Transcript Case Study

Case Study 42
Henry Armah, M.D., M.Phil.
Question 1
Clinical history: 80-year-old male with past medical
history of malignant non-Hodgkin’s lymphoma, diffuse
large B-cell type, of the left flank soft tissue and
abdominal wall post chemotherapy 10 months prior. He
also had past medical history significant for status post
pacemaker placement, colorectal carcinoma, aortic valve
replacement, diabetes mellitus, chronic obstructive
pulmonary disease and coronary artery disease. He
presented with confusion and unsteady gait. MRI was not
done because the patient had a pacemaker. Describe the
abnormal findings of this cranial CT scan with contrast?
Ax CT+C
Answer
Bilateral thalamic and mesial temporal contrast enhancing
masses.
Question 2
What are your differential diagnoses based on the
patients’ age, past medical history, and the radiological
findings?
Answer
1. Malignant Lymphoma
2. High-grade Glioma
3. Metastatic carcinoma
4. Abscess
Question 3
The neurosurgeon performs a CT-guided stereotactic
biopsy of the mass, and requested an intraoperative
consultation. Describe the microscopic findings on this
touch preparation slide?
Click here to view slide.
Answer
Blood and scattered atypical cells.
Question 4
What is your intraoperative diagnosis? (A: Category such
as Defer, Reactive/Non-neoplastic, or Neoplastic; B: More
specific diagnosis or statement)
Answer
A. Defer
B. Atypical cells with hemorrhage
Question 5
The permanent section has returned from histology.
Describe the microscopic findings on this H&E slide?
Click here to view slide.
Answer
Fragments of brain tissue extensively and diffusely
infiltrated by angiocentric dense atypical lymphoid
infiltrates. The majority of the lymphoid cells are large with
moderate pleomorphism and occasional mitosis. The
interface between the diffuse lymphoid infiltrate and the
adjacent brain parenchyma show reactive gliosis.
Question 6
What additional studies would you need to confirm the
final diagnosis in this case?
Answer
1. CD20 (L26)
2. CD5
3. CD10
4. BCL-2
5. MUM-1
6. Ki-67 (MIB-1)
7. CD3
8. Cyclin D1
9. CD21
10.EBER (EBV Insitu Hybridization)
Question 7
What do you see on this CD20 (L26) immunostain slide?
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Answer
CD20 (L26) is strongly and diffusely positive in the
neoplastic lymphoid cells.
Question 8
What do you see on this CD5 immunostain slide?
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Answer
CD5 is strongly and diffusely positive in the neoplastic
lymphoid cells.
Question 9
What do you see on this CD10 immunostain slide?
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Answer
CD10 is strongly and diffusely positive in the neoplastic
lymphoid cells.
Question 10
What do you see on this BCL-2 immunostain slide?
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Answer
BCL-2 is strongly and diffusely positive in tumor cells.
Question 11
What do you see on this MUM-1 immunostain slide?
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Answer
MUM-1 is strongly and diffusely positive in tumor cells.
Question 12
What do you see on this Ki-67 (MIB-1) immunostain
slide?
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Answer
Ki-67 (MIB-1) is positive in the nuclei of greater than 90%
of the neoplastic lymphoid cells.
Question 13
What do you see on this CD3 immunostain slide?
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Answer
CD3 is negative in the neoplastic lymphoid cells, but
highlights scattered reactive T-lymphocytes at the
interface between the lesion and the adjacent brain
parenchyma.
Question 14
What do you see on this Cyclin D1 immunostain slide?
Click here to view slide.
Answer
Cyclin D1 is negative in the neoplastic lymphoid cells, but
highlights rare admixed lesional cells most probably
infiltrating reactive lymphocytes.
Question 15
What do you see on this CD21 immunostain slide?
Click here to view slide.
Answer
CD21 is negative in the neoplastic lymphoid cells.
Question 16
What do you see on this EBER (EBV Insitu Hybridization)
slide?
Click here to view slide.
Answer
EBER (EBV Insitu Hybridization) is negative in the
neoplastic lymphoid cells.
Question 13
What is your final diagnosis in this case?
Answer
Malignant Non-Hodgkin’s Lymphoma, Diffuse Large BCell Type