EPISODE 1 2006 07 20: 56 yrs old female presents with lymphadenopathy (PREVIOUS CASE IN HEMATOPATHOLOGY GROUP- follow the link below).  
Diagnosis was: "...NH (marginal?)lymphoma possible. Molecular evaluation and repeated biopsy is recomended."  
 
EPISODE 2 2006 09 28: Repeated biopsy (slips throw the fingers to another pathologist...):  
Diagnosis PERIPHERAL T CELL LYMPHOMA.  
 
HISTO: The T/paracortical zone is expanded by small- medium cells with the pale eo cytoplasm and irregular nuclei. Scattered RS like cells. IH: CD3+ CD4+ CD8- CD56- GranzymB-. Ki67 prolif. activity in nonfollicullar area: 30%. Some epithelioid cell clusters. Some irregular FDC proliferations. Some NONFOLLICULAR CD20+ population forms protrusions and nodules, immitating FC. Admixture of CD20+ cells and faint CD20+ areas in paracortical zone (aberrant CD20 expression on T cells?). Some strange lymphoid nodules without architecture of normal FCs("strange follicles").  
IN PROGRESS: Some double CD20/CD3 stains, EBV, CD30, etc.  
BACK TO PRIMARY BIOPSY- the same features are seen here too with less prominent T zone expansion and histiocyte clustering, but CD20+ cell admixture in "marginal" or paracortical zone is slightly obscuring the picture...  
 
QUESTION: 1. Interpretation of NH lymphoma: peripheral T NOS (T zone) or early AILT or ???  
2. Interpretation of these "pale" CD20+ cells imitating follicles.  
Thank you for continuous participation.  

Mueller-Hermelink 2007-09-15 17:00	I agree with the other comments and believe that there is a remarkable extrafollicular activation and Plasmacytopoiesis. The Bcl2 stain is quite peculiar ( not staining the mantle zone , some activity within the follicles where no T cells are stained and low proliferative activity of follicles) Could you stain for CD 10 and kappa/lambda ? There is no typical aspect for T cell lymphoma.
ugnius 2007-09-17 12:21	Thank you. Please find some add photos. DOOUBLE CD20 (BROWN)/CD3(RED). Kappa/ lambda are pending. "Strange" follicles and nodules consists of faintly CD20+ cell clusters (mantle zones intensivelly are CD20+++). Paracortex consists of mixture of interstitial T cells, interstitial and clustering CD20+ cells and CD68+ macrophages. EBV LMP1 single cells+.
ugnius 2007-09-17 13:07	Bcl6/CD10+ FC's are scattered. A lot of "pale" nodules or "strange follicles" are CD10/Bcl6 (-). But the reactivity of CD10/Bcl6 still remains on the single FC's...
diane.c.farhi 2007-09-20 17:01	I believe that the two biopsies are essentially identical. There is an interfollicular infiltrate, with a background of follicular hyperplasia. The follicles are reactive and not part of the disease. The interfollicular pattern is characteristic of peripheral T cell lymphoma and Hodgkin lymphoma. In either case, accompanying plasma cells, eosinophils, neutrophils, and histiocytes are to be expected. The key to this case lies in the examination of the large atypical cells in the infiltrate. One picture shows a RS-like cell with a double nucleus, but this is not at all conclusive. I would pay more attention to these cells. Mitoses in this area and positive staining of the large cells for T cell markers would favor T cell lymphoma. Positive staining of the large cells for CD15 would favor HL. You might want to try EBV staining and see if the large cells are positive; this would favor HL, but I wouldn't use it as a major criterion. As an aside, PTCL with epitheloid histiocytes has been termed Lennert's lymphoma; however, I can't tell from the pix just how many histiocytes vs lymphoma cells are in the infiltrate. More remote possibilities are mast cell disease and Langerhans histiocytes; these can be evaluated with the appropriate immunostains.
torlakovic 2007-09-21 03:11	This case is very difficult to evaluate from the images alone. However, I will comment on few observation I made. First, I agree with Dr. Mueller-Hermelink that Bcl-2 staining does not look normal even if technically suboptimal, if these nodular structures (at least most of them) are really ordinary follicles with germinal centers and mantles. One could see from the FDC pattern that most of the small rounded clusters are not really follicles but follicles (mostly primary) are pushed on a side by some cells. These cells are difficult to evaluate from the images, but it seems to me that some (that are clearly CD4+/CD3+ are clusters of small T-cells (also thought of plasmacytoid monocytes, but these should not be CD3+), and in others which express CD20, could be clusters of marginal zone cells. The interfollicular infiltrate may represent interfollicular Hodgkin, interfollicular reactive infiltrate or so-called "Hodgkinoid lymphadenopathy" (which may recur), or other. In one image it also seems that some large interfollicular cells may be Bcl-6 positive, which would be informative, but I cannot tell if that is actually distorted follicle. Therefore, I overall somewhat favor a reactive condition, but am not able to fully evaluate this biopsy and am not able to make a diagnosis here.
ugnius 2007-09-25 14:20	Thank you all for comments. Please find some photo attached: kappa, lambda, IgM, IgD. It seems that it's really B cell proliferation. I'm waiting T and B clonality studies from both parafin materials.
ugnius 2007-09-27 13:14	THE LAST IH: CD15- (except granulocytes), single CD117+ mastocytes, single CD138+ sinus plasmacytes, single CD1a+ cells, some S100 histiocytes. The last photos: CD43.
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