STEP 1: 63 yrs old woman was operated due to "ACUTE ABDOMEN" symptoms. The hepatosplenomegaly and lymphadenopathy were found. PB: Hb 117, LEU: 4, PLT: 167. LN biopsy was taken.  
HISTO: Difusse small lympho's proliferation (CD3+ >> CD20+) with scattered "paraimunoblasts" with the prominent eo nucleoli, CD23+ focci of medium sized cells in the sinus and cortical projection and reticulin fibrosis in medium sized cell populated areas. Some destructed CD21+ FC's are present by IH. Partially open sinuses with granulocytes and eo's. It's difficult detect and visualize larger CD23+ cells in CD5 amd CD43 cells due to heavy background.  
WORKING FORMULATION: (IMPRESSION OF LOW GRADE LYMPHOMA ARCHITECTURALLY) "atypical diffuse lymphadenopathy: clonality studies are required". Suspitious immunophenotype: CD20+ CD3- CD5/CD43?  
STEP 2: IgH monoclonality was found and threpine biopsy was taken. BM: Infiltration of small B lymphos (diffuse interstitial) 70%.IH: CD20+ CD5+ CD23+ CD43-. II° reticulin fibrosis is present.  
BLOOD: WBC (10*9/l) 4.700; LYM (%) 38.2; HgB (g/l) 123.1  
 
DIAGNOSIS: CLL/SLL with BM and minimal LN involvement (with prominent T cell reaction).  
 
Special quests: 1. Armentarium in detection of small neoplastic cell populations, obscured by reactive major population. 2. Demonstration of architecture or immunophenotype (Photography of several stains), when digital co-localisation of changes is impossible due to cutting and changing contours of the tissue.  
 
Thank you for participation.

tzankov 2008-01-22 13:30	The lymph node architecture is preserved, there are a clear B- and T- zonation and no particular phenotypic abnormalities, the sinus show a "katarrhalic" infiltration by granulocytes, so that I would favor a reactive process. For sure in the paracorex there are larger T- (?) cells, but such changes could also occur under reactive circumstances. CD8:CD4?     Did the lady had an acute abdomen? Sepsis? Is there a sufficient explanation for the hepato-splenomegaly? Stasis?
ugnius 2008-01-22 13:48	Thanx. My thoughts were the same at first, but what to do with larger CD23+ and CD20+ (!) cells? And the first alert for me was difusse fibrosis in VISCERAL nodes it's not so usual with single files of the lymphos.
ugnius 2008-01-22 14:50	The real problem evolve after PGR: IgH monoclonality was found and threpine biopsy was taken.
ugnius 2008-01-22 14:51	So it seems we really deal with monoclonal B (small) population, if the results are adequate.
hurwitz 2008-01-24 20:23	My impression is that the LN architecture is blurred, which can also happen in reactive conditions as well. The clusters of large CD79+ cells with prominent nuclei are somewhat worrying together with the proved monoclonality. The abscess like accumulation of granulocytes could be a red tape. Was the acute abdomen explained by the laparatomy? Lets wait for the BMB. Please be so kind and submit it as well. It is difficult to make up the mind at the present stage.
ugnius 2008-01-25 08:38	Please find a BM findings appended.
tzankov 2008-01-25 11:19	I have to revise my estimation on the lymph node after consideration of the bone marrow findings, since here there a clear cut B-CLL in the latter and, probably, but I do not think that this can be for sure diagnosed on the submitted microphotographs, a minimal lymph node involvement.
ugnius 2008-01-25 11:28	Thank you. You are poright- but really there is nothing to add to photographs in this LN. "Real picture" is similar. So only after PCR and esp. BM biopsy we may consider the possiblity of minimal spread retrospectivelly. So: how the minimal low grade B populations can be detected in T predominant patterns? An extranodal sites(tonsils?) are the another problem with minimal CLL involvement...
hurwitz 2008-01-25 14:00	The lymphoid population has a typical SLL/CLL phenotype. Could you please provide us the PBC differential. To call it CLL there we need to prove an absolute lymphocytosis in the PB.   In reply of your question regarding minimal lymph node involvement by CLL This can be a problem, in particular if the neoplastic cells do not express CD20 on immunohistochemistry, which can happen, because of the typically week CD0 expression in CLL.
erber 2008-01-25 15:25	The bone marrow shows a diffuse interstitial infiltration by small mature lymphocytes with morphology of chronic lymphocytic leukaemia. Phenotyping shows these cells to be CD5, positive B cells. Ig rearrangement confirms clonality.   Favoured diagnosis: Small lymphocytic lymphoma.   This can occur with a normal leucocyte count
ffrenchma 2008-01-28 15:43	I agree with Dr Hurwitz and Dr Erber comments. Diagnosis on lymph node was perhaps polluted by intercurrent inflammation due to abdominal problems. The complete blood count is always important to known in this context
ugnius 2008-01-30 17:44	Thank you all for the comments. Add info: really we have not lymphocytosis: BLOOD: WBC (10*9/l) 4.700; LYM (%) 38.2; HgB (g/l) 123.1.
hurwitz 2008-02-08 00:13	In the absence of lymphocytosis in the PB we can conclude the case as small lymphocytic lymphoma.   Thanks to all participants
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