A 16 years old male patient was referred to us from the surgical side about 8 months back with a right axillary lymph node biopsy report of "Hodgkin’s lymphoma, lymphocytic predominance type". An FNAC from an adjoining LN, also done outside prior to the bx, was reported as NHL, which while reviewing, we found a classical RS cell around plenty of mature lymphocytes (Fig1). He presented to us with :
– Multiple, slowly enlarging swellings in the right axilla for the last 6 years
– Dull aching pain in the back – 6 months
– Progressively increasing weakness of both lower limbs with difficulty in walking – 6 months
– No h/o fever, night sweat or weight loss
On examination, the patient was found to have significant right axillary and cervical lymphadenopathy, mild hepatosplenomegaly, mild pallor and kyphosis of spine with bony tenderness over D12 vertebra; the power of his lower limbs were Grade 4/5 on both sides with absent knee-jerk bilaterally. There was no sensory deficit on both lower limbs or any bladder/ bowel abnormality.
History and examination done to rule in radiculopathy and Koch’s infection (common in our country) were not informative.
We reviewed the lymph node biopsy slides and diagnosed it as Classical HD,lymphocyte-rich variant - there were plenty of mononuclear Hodgkin cells and quite a few Classical RS cells against a background of mature lymphocytes; no L&H popcorn cell was found(Figs 2-5). We sent the paraffin blocks for immunohistochemistry at an outside institute since this facility is not available with us. Meanwhile we did a serum LDH which was raised. We also did X-Ray DL Spine, CT scan of chest & abdomen as also an MRI of DL spine. They revealed erosive changes of D12 vertebra with pre- & paravertebral soft tissue shadowing and evidence of cord compression(Figs 6,7). We did an FNAC from the paravertebral soft tissue mass where we found large, atypical mononuclear and binucleated cells (Fig 8,9).This was followed by a biopsy of the same mass which was initially reported by the pathologist as “suggestive of deposit of lymphoma”. I reviewed the slides, found a classical R-S cell , brought it to the notice of the histopathologist who immediately acknowledged my finding (Figs 10,11). A bone marrow biopsy done revealed features suggestive of infiltration by lymphoproliferative disorder; no R-S cell was found in it. At this stage we diagnosed the patient to be suffering from HD, classical lymphocyte-rich variant, Stage IV and eagerly waited for the immunohistochemistry results. Finally the report came which went like this:
Tumour cells- CD20+,CD30-(repeated twice),CD15- & LCA-ve. Background cells are CD3+. Although the R-S cells are CD30 & 15- in this case, this is unlikely to be anything other than classical HD.
(I do not have the immuno-stained slides; but I have the paraffin block of the LN Bx. I also have the H&E slides of the paravertebral mass and the marrow trephine Bx with me. No other slide or paraffin block is available with me.)
So now we had a lymph node biopsy of HD whose H&E was suggestive of classical lymphocyte-rich variant while the immunohistochemistry was in favour of lymphocyte predominant HD. We started to treat the patient with ABVD regimen. While he was responding well to therapy, he stopped coming back to us after completion of 4 cycles because of economic constraints.
My question: What is the diagnosis in this case? - the H&E suggests HD Classical Lymphocyte-rich variant while the immunohistochemistry is in favour of Lymphocyte predominant HD though the H&E findings were given more importance even in that report
HD