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3 different cases of lymphoma

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Dr. Maruf Rumi

Phase-B resident

Dept. of Haematology

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CASE-1

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  • Mr. Abdul Karim 63 year old male presented with the complaint of-
          • Fever &
          • Weight loss for 3 months
          • abdominal lump for 1 month
        • O/E-
          • anaemia+
          • jaundice+
          • midline incision scar mark
          • epigastric lump
          • no LN
          • no organomegaly

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06/12/21

13/12/21

20/12/21

28/12/21

Hb

8 gm/dl

9.3 g/dl

10.2

11.2 g/dl

ESR

115

110

103

25 mm/hr

TWC

MCV 72

MCH 22.5

75

23

75

24

​

​

09 × 109 /L

N 90%

L 5%

M 5%

PLT

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​

​

180 × 109 /L

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MHA

​

NNA

AA

Iron

11ug/dl

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​

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Tsat

6.21%

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​

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Ferritin

4743 ng/ml

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28/12/21

08/12/21

07/12/21

Bilirubin

2.2 mg/dl (T) 1.45 (D)

2.1

2.2

SGPT

10 U/L

60

64

SGOT

30 U/L

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​

ALP

1151 U/L

1344

1347

Albumin

3.3 g/dl

2.6

2.9

Calcium

7.7 mmol/L

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Creatinine

0.64 mg/dl

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LDH

312 U/L

​

338

Reticulocyte

2.5%

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Coomb’s D & I

negative

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CRP

228.4 mg/dl

procalcitonin

0.82 ug/l

Blood culture

no growth

ICT malaria

negative

ICT kala-azar

negaative

Stool R/E, Urine R/E, OBT

negative

BMS

Myeloid hyperplasia

Endoscopy upper GIT

Erosive gastritis

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  • CT whole abdomen

pleomorphic multiple lymph node enlargement (6.25×5.14cm) porta hepatis, lesser curvature, pre verebral, pre & para aortic region

  • CT guided FNAC para aortic LN (31/10/21)

medium to large sized atypical lymphoid cells, round to oval nuclei, multiple prominent nucleoli, mostly mononucleated & few binucleated R-S cells with background mature lymphocytes, plasma cell, epitheloid histiocytes & blood-

Hodgkin Lymphoma

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Biopsy mesenteric tissue (18/11/21)-

    • atypical lymphoid proliferation

IHC (30/11/21)

    • CD3, CD20, CD10 positive in normal distribution
    • BCL2 negative in germinal centre
    • Ki67% <50%
            • ractive hyperplasia

review report (11/12/21)

    • lymphatic vascular proliferation with lymphoid hyperplasia. no malignant cell

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Core biopsy abdominal LN-

  • large atypical lymphoid cells present diffusely mixed with small lymphocytes & epitheloid histiocytes. PAS negative.
              • High grade NHL

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      • IHC
        • CD30 positive
        • CD 15 negative
        • PAX5 weakly positive
        • CD3 negative
        • CD20 negative
        • CD79a negative
        • LMP1 positive

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      • Classical HL, mixed cellularity

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  • Diagnosis?
  • Obstructive jaundice?
  • Chemotherapy?

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CASE-2

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  • Mr. Sumon 34 years old male
          • difficulty in breathing & swallowing
          • change of voice
          • epistaxis for 1 month
  • General & systemic exam- NAD

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Hb

12.5 g/dl

ESR

57 mm/hr

TWC

14 × 109 /L

N 70%

L 20%

M 5%

PLT

350 × 109 /L

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Bilirubin

0.5 mg/dl

SGPT

36 U/L

SGOT

83 U/L

Albumin

4.2 g/dl

Calcium

2.2 mmol/L

Na

135 mmol/L

K

4.4 mmol/L

Creatinine

0.64 mg/dl

Uric acid

4.8 mg/dl

LDH

1185 U/L

RBS

4.8 mmol/L

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  • Large lobuated enhancing soft tissue mass (4.0×5.2×5.2 cm) in nasopharynx occupying whole of the airway, mildly extending anteriorly with obstruction of posterior rares. intramedullary signal intensity on T1W1 & hyperintense on T2W1. After contrast mild hetergenous enhancement of the mass.
  • Multiple enhancing LN left side of neck
  • ?Lymphomatous lesion

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HPR of nasopharyngel mass-

Poorly differentiated carcinoma consistent with undifferentiated non keratinized carcinoma- Nasopharyngeal type.

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              • D/D- DLBCL

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  • ENT consultation
        • no surgical intervention
        • Radiotherapy
  • Oncology consultation
        • Nasopharyngeal carcinoma
        • IHC

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  • IHC-
      • CD20- positive
      • CD7- negative
      • BCL2- positive
      • BCL6- negative
      • MUM1- positive
      • cMYC- negative
      • Pancytokeratin- negative
      • Ki-67- positive 80%
      • DLBCL- ABC type

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  • Diagnosis?
  • Treatment?

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CASE-3

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  • Mr. Imran 24 year old male presented with the complaints of-
        • change of voice for 1 & 1/2 month
        • occasional cough
        • H/O high grade fever
        • generalized skin lesion for 1 & 1/2 year

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  • change of voice, hoarseness of voice
  • cough- ×productive ×haemoptysis ×chest pain ×SOB
  • fever- not documented
  • skin lesion-
        • upper & lower limb→ trunk→ face
        • multiple, hyperpigmented lesion, variable size (<1 cm), some are flat, some are eleveted, with some ulcertion and nectrosis
        • itchy
        • non tender
        • no oral ulcer, hair loss

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  • not anaemia or icteric
  • no lymphadenopathy
  • no bony tenderness
  • hepatomegaly+
  • splenomegaly++

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Hb

10.5 g/dl

ESR

10 mm/hr

TWC

4.7 × 109 /L

N 78%

L 28%

M 4%

PLT

180 × 109 /L

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Bilirubin

0.5 mg/dl

SGPT

36 U/L

SGOT

83 U/L

Albumin

1.6 g/dl

Calcium

2.0 mmol/L

Na

133 mmol/L

K

4.7 mmol/L

Creatinine

0.64 mg/dl

Uric acid

3.0 mg/dl

LDH

1185 U/L

RBS

6.8 mmol/L

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  • minimal heterogenous contrast enhancing soft tissue dense area noted in anterior mediastinum, paratracheal, pre and subcarinal region displacing and compressing vital structures.
  • Liver enlarged in size with multiple hypodense area
  • Spleen grossly enlared with multiple hypodense lesion

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FNAC superior mediastinal mass-

  • spindle shaped cell in sheets and cluster with mild to moderate pleomorphism, background shows polymorphs, lymphocytes & histicytes

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Bone marrow examination-

    • normocellular
    • increased M:E ratio
    • hyperactive granulopoiesis with predominance of eosinophilic myelocytes and myelocytes

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skin tissue Histopathology-

    • hyperkeratosis, parakeratosis, mild acanthosis, fibroplasis with less dense mononuclear cells and some neutrophils.
    • no malignant cell is seen
    • mycosis fungoides

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core biopsy of mediastinal mass-

    • almost necrotic tissue
    • small viable area of lymphoid cells
    • IHC CD2, CD20 positive but scattered (inconclusive)

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clinically deteriorating

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repeat biopsy

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chemotherapy

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