We present here a case of a-40-year old Bosnian male that presented hepatosplenomegalia and generalized lymphadenopathy. He was diagnosed with CLL in 2003 followed by two cycles of chemotherapy.  
Sternal punctate as well as bone marrow biopsy findings are presented here.  
Bone marrow showed a nodal proliferation of the population of small, scattered lymphocytes ("centrocyte-like" cells) along with myelo-monocytic proliferation.  
Immunohistochemistry: CD23(negative, stains only follicular dendritic cells), CD43(+), Bcl-2(+), Bcl-6(-), CD20(+), CD10(-), CD5(-), Cyclin D1(-).  
Additional immunohistohemistry (CD34 & CD14) will follow soon and will be updated here.  
Clinical diagnosis: NHL  
Histopathological diagnosis: Marginal zone B-lymphoma?  
Please, give your opinion.

franco 2007-12-15 17:36	Bone marrow seems to be definitively infiltrated by low grade B-cell lymphoma: immunocytochemistry favours a marginal zone origin. I would ask if there is an intrasinusoidal component, not clearly observable in CD20 specimen at this magnification. CD 43 seems to be negative: positive cells can be myeloid.
hurwitz 2007-12-16 17:18	I support Vitos opinion, the findings are strongly suggestive of marginal zone lymphoma. CLL is less likely. On the high power image of the PAS stained section I had the impression to see intrasinusoidal lymphoid cells.   It would be helpful if you could add the PBC. Also a high power image of the CD 20 stain could help to find intrasinusoidal spread, characteristic for SMZL, also the pending CD34 stain will facilitate the detection of intra sinusoidal lymphoid cells, on high power of course.
metz 2007-12-17 02:58	I agree this is probably marginal zone lymphoma rather than CLL. The absence of "smear ceels" in the aspirate film, together with CD5-, CD20 strong (should be weak in CLL) and CD43- make the diagnosis of CLL most unlikely.
diane.c.farhi 2007-12-17 18:40	[comment sent by email] I think the CD23 is positive. It seems to me that the most likely   diagnosis is follicular center cell lymphoma. Does the patient have   lymphocytic leukemia?
anpo 2007-12-17 23:00	Follicular lymphoma would show some CD10 positivity. I agree with previous comments: marginal cell lymphoma is most probable (there is also enlarged spleen), CD23 positivity is probably in a ractive follicle. An alternative diagnosis could be HCL variant but diff. diagn. would need more extensive immunophenotyping (CD103, CD11c, CD25, CD123).
tzankov 2007-12-18 08:18	I agree with the most common opinion that this case is most probably a marginal zone lymphoma (CD23 stains some FDC and not hte noplastic B-cells). It would be of particular importance to study sinus association of the infiltrate and expression of IgM and IgD in order to exculude or confirm splenic marginal zone lymphoma, since in the case of such plenic marginal zone lymphoma the patient may profit from splenectomy even in such "advanced" stage disease.
Mueller-Hermelink 2007-12-18 11:04	As everybody agrees on the diagnosis marginal zone lymphoma ,I almost do not dare to mention a differing opinion:The periostal localization of this infiltration is not typical for marginal zone lymphoma but rather for follicular lymphoma , especially if you have seen FDC in the CD23 stain. CD 10 is sometimes negative in BM , but BCL6 should give an answer.Some toimes it is difficult to see the follicular component that is excvlusively present in the direct periostal area and all the other cells constitute a marginal zone differentiation . It may be helpful to ask for a lymph nopde biopsy.
tzankov 2007-12-19 09:46	I also agree with the arguments of Prof. Müller-Hermelink, but we for several times observed bone marrow infiltrates by MZL (proven in MALT sites and lymph nodes and also accompanied by classical cytogenetic aberations like trisomy 3 and malt1 breaks) with peritrabecular locations and FDC networks, so that considering the phenotype (CD10-, bcl-6-), the morphology, particulalry the high amount of interstitial CD20+ cells, which is rather not a feature of follicular lymphoma in bone marrow, and the clincal history I would still favor MZL. would you please add the CD10 and bcl-6 stains?
Mueller-Hermelink 2007-12-20 18:29	Also the clinical history is not very suggestive of MZL . I believe it would be helpful to see a lymph node biopsy.
diane.c.farhi 2007-12-20 18:40	[comment sent by email] I agree with Dr. Mueller-Hermelink, as in my comment of Dec 17.
nurija 2007-12-24 19:46	CD10 and Bcl-6 were negative
hurwitz 2007-12-27 16:41	Relying on morphology and immunohistochemistry on the bone marrow biopsy, MZL, seems to be the most likely diagnosis,however in view of the clinical history, a lymph node biopsy is recommended to clarify the findings.
nurija 2007-12-28 08:04	I agree with dr Nina
hurwitz 2007-12-29 20:51	For the time being the case can be concluded as:     Bone marrow infiltration by low grade lymphoma, possibly   marginal zone lymphoma.   Because of the clinical presentation, which is unusual for MZL, a lymph node biopsy is recommended for further clarification.
	» Add comment (Login)