Non-Hodgkin lymphoma involving lung

Case contributed by Jack Ren
Modality: X-ray

Large unilateral right side pleural effusion can be seen with no fluid on the left. There is no evidence of cardiomegaly. There is an lesion with increased opacity on the peripheral of right upper lung field and another lesion located at the right hilum 

Modality: CT

Hyper-dense lesions surrounded by ground-glass opacity can be seen throughout the right lung. There are also multiples hyder-dense lesion located around right hilum with no occlusion of the bronchus.

Lesions are homogenous in nature and do not enhanced by administration of contrast.

There is pleural effusion in the right lung. Enlarged superior mediastinal lymph nodes around trachea can be seen.

SUPPLEMENTARY REPORT

Immunohistochemistry for tDt is negative. This finding is consistent with the stated diagnosis.
 
CLINICAL HISTORY

Biopsy of superior mediastinal lymph node x2.

 
MACROSCOPIC DESCRIPTION

Specimen container  labelled  'superior  mediastinal lymph  node'. Specimen consists of 4 irregular fragments of yellow tan tissue between 4mm and 7mm.

 
MICROSCOPIC DESCRIPTION

Sections of  the mediastinal  lymph nodes show diffuse effacement of the architecture with extension of the lymphoid infiltrate into adjacent extranodal fat. Some biopsies are affected by crush artefact. In better preserved areas there is a mixed population of lymphocytes, histiocytes and eosinophils,  including increased numbers of large cells with irregular nuclear contours, conspicuous nucleoli and pale vacuolated cytoplasm, forming sheets. No Reed-Sternberg cells are seen.
 
Immunohistochemistry confirms the presence of sheets of CD20 positive, PAX5 positive atypical B cells, admixed with background small CD3 positive T cells. There is patchy  weak CD23 expression. No tDt or CD30 positive cells are seen. CD15 expression is limited to neutrophils. There is non-specific Cyclin D1 expression in endothelial cell nuclei. The Ki67 index of the atypical lymphoid infiltrate is estimated to be about 80%. EBER CISH is negative.
 

Comment:
The features are consistent with a non-Hodgkin lymphoma, favouring either a primary mediastinal large B cell lymphoma or diffuse large B-cell lymphoma. There are morphological features such as compartmentalising sclerosis and cytoplasmic pallor to the tumour cells that favour the former diagnosis, but the immunophenotype does not distinguish between these two entities. Clinicoradiological correlation regarding any previous  history of lymphoma and  whether the disease is limited to the mediastinum  would be helpful to confirm the diagnosis. Ig gene rearrangement studies or flow cytometry would also be useful to confirm clonality.
 

DIAGNOSIS

Superior mediastinal lymph nodes -  non-Hodgkin large B cell lymphoma.

Some features suggest primary mediastinal large B cell lymphoma, but the differential diagnosis also includes diffuse large B cell lymphoma (see comment above).

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Case Information

rID: 29094
Case created: 3rd May 2014
Last edited: 25th Nov 2015
Systems: Chest, Haematology
Inclusion in quiz mode: Included

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