EPISODE 1: 59yrs old male with diagnosis of cHL (MC) in 2007 (CD30+ CD15- CD20- CD3-) from supraclavicular node (clin. suspition of mts). An appropriate therapy was administered. THE MATERIAL IS NOT ACCESSIBLE FOR REVIEW FOR A MOMENT.  
HISTO(DECRIPTION ONLY): LN with obliterated architecture: vague T nodules/zones between residual B follicles and B cell agregates. Interstitial multiple mediom- large sized CD30+ cells with vesiculated/lobated nuclei. CD21+ FDC oval networks in B follicles: giant cells focally occupate these follicles in mantle pattern.  
IH description: Giant cells: CD30 (+/+++)(cytopl.- membr. Golgi) 90%, CD15/EMA/EBV LMP1(-), Mum1 (+/++) 10% (nuclear), Bcl6(+/++) 40% (nuclear); FDC networks CD21+; Multiple CD138+/EMA+/Mum1+ plasmocytes, esp. in the sinuses in periphery of tumor; INFILTRATION OVERALL: CD3+ >CD20+; Bcl2+ mantle zones and aprt of T population (20%); CD3+ T population: CD4/CD8 ~2/1.  
 
EPISODE 2: Nowadays (2009 february): LN biopsy from the groin region.  
HISTO: Difuse T pleomorphic infiltration with medium-sized CD30+CD15- cells.  
PCR: IgH/IgKapa: CLONAL. TCR gama/beta: CLONAL.  
IH: CD30(+/+++)(citopl.- Golgi r.- membr.) medium-large sized cells: 10% population: CD15(+/+++) 20% (membr.- citopl.- Golgi r. r-ja), EBV EBER/EBV LMP1(-), LCA? (difficult interpretation, most probasbly +), CD20(+/+++) 80% (membr.), ALK1(-), CyclinD1(-), Bcl6(++) 100% (nuclear).  
INFILTRATE OVERALL: LCA(++/+++) 90% (membr.- cytopl.), CD3(+++) 75% (cytopl.), CD20/CD79a (+++)(cytopl.)(in periphery of T "nodules") 10%. CD138+/CD79a+ > CD20+ plasmoid cells about 15%: Ig kappa(++)(cytopl.)/Ig lambda apie 4/1 (!). Ki67 about 30% (+++)(nuclear).  
T POPULATION: CD3/CD2/CD5(+++) 100% (cytopl.), CD4/CD8+ about 2-3/1, CD7+ 30%. GranzymB+ ~ 20% (++)(dot cytopl.). CD10+ lymphos ~5%. CD57+ lymphos with irregular nuclei ~30%.  
Prominent nodular and irregular FDC proliferation: CD21+>CD21+.  
 
PROPOSAL: Peripheral T lymphoma NOS/AILT vs cHL (MC).  
QUEST: 1. Interpretation of clonality studies.  
 
Thank you for collaboration.

Mueller-Hermelink 2009-02-15 09:06	The most important step is to establish the exact phenotype of HD-cells in the initial biopsy,in order to see whether it was indeed classical HL or a greyzone -lymphoma with ALCL , HL-like:In our experience Perforin is the best marker and Pax5 :H-cells and RS-like cells should be Pax5 negative and Perforin positive. If so , the T cell clonality would be easy to understand ( but the lymphoma still difficult to classify). If the case was such a ALCL, HL-like lymphoma , the B cell clonality would be the real problem , I would first start to look for EBV- lymphoproliferation by LMP and EBER, if negative, you would have to find other explanatoions ( pseudoclonality ? etc. )
ugnius 2009-02-16 10:33	Thank you. To date I have only previuos description. Nowadays HE picture is fully T peripheral NHL or AILT like with scattered HL like cells. EBV EBER and LMP1 are negative. PCR results are more compatible with AILT with minor B clone in my mind. I will provide IH pictures in a moment...
tzankov 2009-02-16 10:48	HE and the virtual slides are in favor of T-NHL: the small subcapsular B-cell rims, the pronounced T-cell predominance, the atypical T-cells... AILT would probably best explain the presence of both clonal B- and T-cells. would you add CD21 or CD23 stained slides?
ugnius 2009-02-16 11:38	CD21/CD23, CD20, Pax5, CD3 are placed in...
tzankov 2009-02-17 13:37	CD23, CD79a and CD20b are well consistent with AILT. As mentioned above, presence of clonal B-cells is a rather common phenomenon in AILT.
hurwitz 2009-02-18 21:25	I support Dr.Tzankovs opinion that an AILT has to be considered. In addition AILT can be easily misinterpreted as HL, and this might have happened on the first biopsy.
ugnius 2009-02-21 17:42	Thank you. My thoughts are the same, but unfortunatelly I cannot find primary biopsy for review. In the case of success I will immediatelly inform you.
SergeyN 2009-02-22 22:34	Dear Ugnius, did you stain the old-fashioned PAS and Gomori here? Just to make the case perfect
torlakovic 2009-03-17 17:44	I also think that this is AITL. Previous biopsy was most likely the same. I have seen such cases of AITL that were previously called cHL because of the incomplete work up. However, monoclonal B-cell proliferations are EBV+. Since your EBV studies were negative, I wonder if this is an exception from the rule, technical problem, or "hit and run" (in case you ever get a previous biopsy try doing EBV studies there; I have seen one such case in which EBV was first positive, but lost in the follow up biopsy).
ugnius 2009-03-17 18:19	Thank you. PAS and GSPS are placed in. appologies for delays and techinical problems. Your feedback and remarks on opening of virtual slides and other technical things (IH and digital photo quality) will be appreciated too. Thank you once more time.
tzankov 2009-03-18 12:57	Considering the tenor of all above comments, the morphology and the clonality reports, with presence of both clonal B- and T-cells, we can close this cases as (most probably) mature T-cell lymphoma, especially AILT.     Considering the fine borders between cHL and AILT, I refer to the excellent paper of Dr. Naresh:     'Precursors' of classical Hodgkin lymphoma in samples of angioimmunoblastic T-cell lymphoma. Naresh et al. Br J Haematol. 2008 Apr;141(1):124-6.
	» Add comment (Login)