We present a new case of the spleen lesion in a 40-year-old Bosnian female that clinically presented as a thrombocytopenia.  
Surgery was performed and her spleen was removed.  
On gross examination, a 11x9 cm large spleen showed areas of micronodular pattern. Hilar lymph node was unremarkable.  
Microscopic analysis revealed the presence of a central dark zone withine the white pulp, composed of small lymphocytes. The white pulp was surrounded by marginal and mantle zone. The red pulp contained dilated sinuses filled with moderately large lymphocytes with monocytoid features.  
Immunohistochemistry:  
Spleen: CD3 positive (predominantly in the red pulp and marginal zone), CD5 (predominantly positive in marginal and mantle zone and single cells within the red pulp), CD43 (predominantly diffuse positivity), CD45RA (B-lymphocytes), Bcl-2 (positive in marginal and mantle zone as well as in sinuses).  
Hilar lymph node: Preserved normal architecture, expansion of marginal and mantle zone of secondary follicles. CD3 positive predominantly in interfollicular areas; CD5 positive in interfollicular areas and sporadically positive within the secondary follicles; CD43 - the same as CD5; CD45RA diffusely positive; Bcl-2 positive in mantle and marginal zone as well as in interfollicular areas.  
Clinical diagnosis: Essential thrombocytopenia  
Histipathological diagnosis: Splenic marginal zone lymphoma (SMZL)?  
Please, give your opinion!

anpo 2007-08-10 11:13	The spleen was really not enlarged (11 cm is within limits) and on HE photos there are somewhat expanded marginal zones but otherwise quite normal pattern. The Bcl-2 stain pattern is normal. Lymph node seems also reactive. I do not see a lymphoma there unless one can prove that there is a monoclonal B-cell population in marginal zones. Do you have any CD20 stain or kappa /lambda?
SergeyN 2007-08-11 23:20	I think the previous comment has fully covered the problem: you need a very strong and objective proof to make the diagnosis of splenic MZL without spleen enlargement and structure effacement.     Well, proving B-cell clonality would do it, otherwise I would think it reactive.     By the way, the diagnosis of immune thrombocytopenia requires lack of splenomegaly.
kunze 2007-08-12 12:30	I agree to the comments of Drs. Porwitt and Nikulshin. The reactive lymphofollicular hyperplasia is compatible with ITP. SMZL seems less likely.
semir 2007-08-14 10:17	Thank you for all your valuable comments. We conclude that there is no SMZL in the spleen, just reactive changes.
hurwitz 2007-08-15 16:13	I agree with all the previous comments.   The case can be concluded as:   Spleen with marked reactive follicular hyperplasia and slight expansion of mantle and marginal zones, compatible with reactive changes in ITP. There is no evidence of splenic marginal zone lymphoma.
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