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Submandibular mass (404635)
Submandibular massnew
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munafdesai
2012-02-04 16:11
INCTR - EBMWG Hematopathology Online
F/64 yrs, mass in rt submandibular region,  no relevant medical history, no cervical or axillary lymphadenopathy, 5x5x4cm irregular soft tissue piece received, ZN & PAS are stain negative, CD 20, CD5 and CD10 are negative,  CD3 positive, images of CD15 and CD30 are submitted
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vrugt
2012-02-06 08:40
Based on the submitted images the tumour could represent a Hodgkin-like ALCL. Especially the strong CD30 expression of all tumor cells favor this diagnosis. The CD15 is negative (lot of non-specific background). The only problem is the the apparent expression for CD3, which is negative in the majority of these lymphomas. I would extend IHC with an EMA, CD2, CD4 and ALK.
tzankov
2012-02-06 12:10
I agree with Bart that this is a partially necrotic, probably lymphoid, tumor of the submandibular lymph node or gland. In order to extablish the lymphoid nature, CD45, CD2, CD4, CD4, CD8 or CD7 (would you please show the CD3 staining?) as well as a CD79a stainings would be helpful. For prognostic purposes, ALK1 would be important. There is lot of hemophagocytosis within the tumor, are there any clinical signs of hemophagocytosis? Staining for EBV (EBER) would be very informative!
munafdesai
2012-02-06 16:29
I have added EBV and CD3 images.
vrugt
2012-02-06 18:13
The CD3 is clearly positive which is unusual for an ALCL, at least in the majority of cases. Additional IHC including the other T cell markers, in particular CD2 and CD4, ALK (or Bcl-2) and EMA is recommended. Because of the absence of a nuclear stainingpattern I regard the EBER to be negative which supports the proposed diagnosis (ALCL are consistently negative for EBER).
munafdesai
2012-02-07 07:20
EMA is negative
vrugt
2012-02-07 08:18
The absence of EMA immunoreactivity indicates that you are probably dealing with an ALK-negative ALCL. In contrast to the ALK+ counterpart the ALK negative variant is almost always negative for this marker. To my opinion the staining for CD15 is negative (background). Together with the negative staining for EBV as well as the morphology a classical Hodgkin can be excluded. What about CD2, CD4 and ALK?
tzankov
2012-02-07 08:39
Is the EBV staining EBER or LMP?
munafdesai
2012-02-07 12:38
It is LMP.
vrugt
2012-02-07 15:03
Sorry, I presumed you performed an EBER. I have no experience with LMP but in the few cases that crossed my eyes only part of the cells were positive with a membranous staining pattern. In this case the staining shares much resemblance with the CD15. Is it specific or just background? Alexander, could you make a commment on this?
tzankov
2012-02-08 07:44
I suppose that this LMP staining is unspecific. Nevertheless with the probable T-cell origin, necrosis, hemophagocytosis and CD30 in mind, you have to stain if for EBER. ALK1 shoudl be stained as well. Other markers like CD45 or CD43 as well as T-cell and cytotoxic markers may round up your work-up.  
 
ALK and EBER are essential since Asparaginase or Crisotinib treatment might be considered.
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Last modified: 2012-02-04 17:55:42