Hematopathology Laboratory

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Hematopathology Laboratory

• Dr. Gilberts lab

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CASE 1

• Explanation
• Review this case before looking at subsequent
  cases. On low power, note the architecture
  (compare to the diagram) and identify the
  following capsule, subcapsular sinus, lymphoid
  follicles with germinal centers, interfollicular
  region, paracortical region, and medullary areas.
  Although some features of the architecture are
  subtle, they are distinctly different from the
  effaced lymph node architecture found with
  lymphomas.

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Slide 1.1The low power microscopic appearance of
the normal lymph node is shown here with the
capsule at the top.
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Slide 1.2The medium power microscopic appearance
of the normal lymph node is shown here with a
follicle containing a germinal center.
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Slide 1.3The medium power microscopic appearance
of the normal lymph node with immunoperoxidase
stain utilizing antibody to CD-20, a B-cell
marker, is shown here.
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Slide 1.4The medium power microscopic appearance
of the normal lymph node with immunoperoxidase
stain utilizing antibody to CD-45-RO, a T-cell
marker, is shown here.
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CASE 1 Normal benign reactive lymph node
The diagnosis is normal (slightly reactive) lymph node. Refer back to this image of a normal node when looking at other cases and note the differences. A diagrammatic representation of the normal nodal architecture is shown below                                                                            A - Afferent lymphatic channels B - Subcapsular sinus C - Follicle D - Sinuses E - Paracortical region F - Medullary cords G - Efferent lymphatic channel
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CASE 2

• History
• A 64 year old man noticed lumps in his neck and
  axillae for approximately one year. These lumps
  had disappeared and then had recurred. He was
  otherwise asymptomatic. On physical examination,
  the patient had several non-tender, movable,
  rubbery 1 to 3 cm lymph nodes palpable in both
  sides of the neck and in the axillae. On
  abdominal examination, the spleen was also
  palpable. A CBC showed WBC count 7700/microliter,
  Hgb 11.9 g/dL, Hct 36, MCV 85 fL, and platelet
  count 207,000/microliter. An axillary lymph node
  biopsy was performed.

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Slide 2.1Note the pattern of the follicles at
low power in this microscopic appearance of the
lymph node.
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Slide 2.2At medium power, the follicles in this
lymph node are seen to be crowded.
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Slide 2.3At higher power, the monomorphous
nature of the lymphocytes comprising the
follicles and interfollicular zones can be
appreciated.
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Slide 2.4Note the appearance of the lymphocytes
at high power in this microscopic appearance of
the lymph node.
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Questions

1. On low power, how does the architecture differ
   from that of the normal lymph node?
2. Under high magnification, how do the lymphocytes
   in the follicles appear as compared to those in a
   normal lymph node?
3. What is your diagnosis?

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CASE 2 Malignant lymphoma, small cleaved type

1. On low power, how does the architecture differ
   from that of the normal lymph node? Under low
   power, notice that the normal nodal architecture
   is replaced by tumor cells which form a
   follicular pattern. In contrast to the benign
   lymph node in Case 1, there are many more
   follicles (with a "back- to-back" arrangement)
   with the normal mantle zone absent.
2. Under high magnification, how do the lymphocytes
   in the follicles appear as compared to those in a
   normal lymph node? Under higher power, the
   follicles (nodules) are composed of a uniform
   population of small cleaved lymphocytes. The
   nuclei of these neoplastic lymphocytes have
   twisted or cleaved contours. In contrast to the
   benign reactive germinal centers of Case 1 in
   which there is a mixture of cells, the malignant
   lymphoma seen here has only one cell population
   present. In this case, the malignant cells are
   mostly small cleaved lymphocytes.
3. What is your diagnosis? The diagnosis is
   Malignant lymphoma, small cleaved cell type,
   follicular (also known as Malignant lymphoma,
   poorly differentiated lymphocytic type, nodular).
   This is histologically a low grade lymphoma, but
   it tends to involve more lymph node groups and,
   thus, have a higher stage.

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CASE 3

• History
• A 64 year old man noticed several lumps in his
  neck and axillae developing over a period of
  about one year. On physical examination, he had a
  palpable spleen and multiple medium-sized,
  rubbery lymph nodes palpable in both sides of his
  neck, axillae, and inguinal regions. A CBC showed
  WBC count of 4800/microliter, Hgb 12.6 g/dL, Hct
  37.8, MCV 88 fL, and platelet count
  169,000/microliter. A biopsy of an axillary lymph
  node was performed.

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Slide 3.1Note the pattern at low power in this
microscopic appearance of the lymph node.
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Slide 3.2Note the pattern at medium power in
this microscopic appearance of the lymph node.
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Slide 3.3Note the lymphocytes at high power in
this microscopic appearance of the lymph node.
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Questions

1. What is the pattern of the lymph node observed
   under low power magnification?
2. Under high power magnification, compare the
   appearance of the neoplastic cells to the few
   remaining normal lymphocytes present.
3. What is your diagnosis in this case?

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CASE 3 Malignant lymphoma, small lymphocytic type

1. What is the pattern of the lymph node observed
   under low power magnification? The pattern is
   diffuse and no lymphoid follicles are identified.
   Note that the normal architecture of the lymph
   node is obliterated.
2. Under high power magnification, compare the
   appearance of the neoplastic cells to the few
   remaining normal lymphocytes present. Under
   higher power, the lymph node is replaced by an
   infiltrate of small (mature-appearing) neoplastic
   lymphocytes, and the infiltrate extends through
   the capsule of the lymph node and into the
   surrounding fat.
3. What is your diagnosis in this case? The
   diagnosis is Malignant lymphoma, small
   lymphocytic type, diffuse (also known as
   "Well-differentiated" lymphocytic lymphoma). This
   is histologically a low grade lymphoma, but it
   tends to involve more lymph node groups and,
   thus, have a higher stage.

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CASE 4

• History
• A 65 year old woman had symptoms of abdominal
  pain and weight loss for several months. Physical
  examination revealed no palpable peripheral
  lymphadenopathy. There was no hepatosplenomegaly.
  An abdominal CT scan revealed an 8 x 10 cm
  retroperitoneal mass. A CBC revealed a WBC count
  of 8850/microliter, Hgb 13.1 g/dL, Hct 40.0, MCV
  96 fL, and platelet count 287,000/microliter. A
  biopsy of the mass was performed.

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Slide 4.1Note the pattern at low power in this
microscopic appearance of the lymph node.
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Slide 4.2Note the pattern at high power in this
microscopic appearance of the lymph node.
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Questions

1. Is this a diffuse or nodular pattern?
2. AT high magnification, compare the neoplastic
   cells to the few remaining normal lymphocytes
   present.
3. What is your diagnosis in this case?
4. What special studies could be done with this
   tissue to arrive at a more definitive diagnosis?

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CASE 4 Immunoblastic lymphoma

1. Is this a diffuse or nodular pattern? This is a
   diffuse pattern.
2. At high magnification, compare the neoplastic
   cells to the few remaining normal lymphocytes
   present. At higher power, the malignant
   lymphocytes are much larger than the few
   remaining small lymphocytes in this lesion. The
   neoplastic lymphocytes have a moderately abundant
   cytoplasm, and the nuclei are round to ovoid with
   prominent eosinophilic nucleoli.
3. What is your diagnosis in this case? The
   diagnosis is Diffuse malignant lymphoma, large
   cell type (also known as immunoblastic
   lymphoma). This is histologically a high grade,
   aggressive lymphoma, but it tends to be localized
   and have a low stage. It is potentially curable
   in some patients.
4. What special studies could be done with this
   tissue to arrive at a more definitive diagnosis?
   The major differential diagnosis in this case
   would be a metastatic carcinoma. The presence of
   monoclonal immunoglobulin as demonstrated by
   immunoperoxidase technique would help to confirm
   this lesion as a malignant lymphoma. If
   immunoperoxidase staining demonstrated
   cytokeratin positivity, then this would be
   evidence for a carcinoma. Cytokeratin is present
   in most carcinomas, but not in lymphomas.
   Electron microscopy may aid in differentiating
   carcinoma from lymphoma.

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CASE 5

• History
• A 27 year old woman presented to you, her
  physician, with a month-long history of chest
  pain. On physical examination, she has no
  lymphadenopathy or hepatosplenomegaly. She does
  have plethora of the head and neck. You order a
  routine chest radiograph. A CBC shows a WBC count
  of 6350/microliter, Hgb 13.1 g/dL, Hct 39.5, MCV
  91 fL, and platelet count 215,000/microliter. A
  lesion is found and resected.

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Slide 5.1In the PA view of a chest radiograph
ahove, there is a large anterior mediastinal
mass. There is also an elevated left
hemidiaphragm from left phrenic nerve invasion by
the mass.
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Slide 5.2Note the pattern at low power in this
microscopic appearance of the lymph node.
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Slide 5.3Note the pattern at medium power in
this microscopic appearance of the lymph node.
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Slide 5.4Note the pattern at high power in this
microscopic appearance of the lymph node.
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Questions

1. What does the chest radiograph reveal?
2. What histologic features are noted at low power?
3. What type of cells are present in the nodules?
   What surrounds the nodules?
4. What is your diagnosis in this case?
5. What is the prognosis in this case?

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CASE 5 Hodgkin's disease, nodular sclerosis type

1. What does the chest radiograph reveal? There is
   an anterior mediastinal mass. A mass in this
   location may have produced some superior vena
   cava obstruction to produce the plethora noted on
   physical examination. At thoracotomy a 5 x 8 cm
   mass was resected.
2. What histologic features are noted at low power?
   Under low power, the capsule is markedly
   thickened and the lymph node parenchyma is
   traversed by bands of collagen, dividing the node
   into nodules. The normal nodal architecture is
   obliterated by this process.
3. What type of cells are present in the nodules?
   What surrounds the nodules? At higher power, you
   can see that small lymphocytes are mixed with
   some large cells with lobulated nuclei, or with
   multinucleated cells that have prominent
   nucleoli. Some of these large cells appear to be
   lying in a space (lacunar Reed-Sternberg cells).
4. What is your diagnosis in this case? The
   diagnosis is Hodgkin's disease, nodular
   sclerosis type.
5. What is the prognosis in this case? Nodular
   sclerosis is the most common type of Hodgkin's
   disease (the others being lymphocyte depletion,
   mixed cellularity, and lymphocyte predominance).
   NSHD often involves the mediastinum and it is
   generally associated with a good prognosis. More
   than 80 of patients with Hodgkin's disease can
   be cured, particularly the younger patients.

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CASE 6

• History
• A 66 year old man had been complaining of back
  pain for several months, for which he had taken
  non-steroidal anti-inflammatory medications. This
  is a bone marrow biopsy from the posterior iliac
  crest of a 66 year old man. He had been treated
  for approximately six months for low back pain.
  Radiographs revealed a lytic bone lesion in the
  right posterior iliac crest as well as multiple
  lytic lesions of the skull and vertebral column.
  His CBC showed WBC count 4890/microliter, Hgb
  10.8 g/dL, Hct 32.2, MCV 89 fL, and platelet
  count 135,000/microliter. A serum chemistry panel
  showed sodium 140 mmol/L, potassium 4.0 mmol/L,
  chloride 98 mmol/L, CO2 24 mmol/L, urea nitrogen
  32 mg/dL, creatinine 2.9 mg/dL, glucose 79 mg/dL,
  AST 30 U/L, ALT 23 U/L, alkaline phosphatase 249
  U/L, total bilirubin 0.9 mg/dL, albumin 3.5 g/dL,
  and total protein 9.6 g/dL. A posterior iliac
  crest bone marrow biopsy was performed.

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Slide 6.1Note the "punched out" circular lytic
lesions in the skull.
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Slide 6.2Note the rounded lesions in the skull.
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Slide 6.3Note the pattern at low power in this
bone marrow biopsy. Is this normal cellularity?
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Slide 6.4Note the pattern at medium power in
this microscopic section of a bone marrow biopsy.
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Slide 6.5Note the pattern at high power in this
bone marrow smear. What is the predominant cell
type?
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Questions

1. What is the predominant cell type present in the
   bone marrow?
2. What other laboratory studies should be done in
   order to arrive at a definitive diagnosis?
3. What is your diagnosis in this case?

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CASE 6 Multiple myeloma

1. What is the predominant cell type present in the
   bone marrow? The bone marrow is nearly replaced
   by plasma cells and is virtually 100 cellular,
   rather than the 40 expected at this site for the
   patient's age. The myeloid, erythroid, and
   megakaryocytic cell lines are difficult to find,
   explaining his pancytopenia.
2. What other laboratory studies should be done in
   order to arrive at a definitive diagnosis? The
   high total serum protein with low normal albumin
   suggests increased globulins, which could be
   monocolonal. To confirm the diagnosis, you should
   order serum and urine protein electrophoresis.
   These will show a monoclonal spike of abnormal
   gamma globulin secreted by the neoplastic plasma
   cells (in only rare cases will the plasma cells
   not secrete an identifiable globulin).
3. What is your diagnosis in this case? The
   diagnosis is multiple myeloma, which accounts for
   over 95 of cases in which a monoclonal
   gammopathy is present. The plasma cells can
   produce lytic bone lesions, such as those seen in
   the skull.

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CASE 7

• History
• A 39 year old male is known to be HIV positive
  and has had bouts of Pneumocystis carinii
  pneumonia in the past two years. He was recently
  diagnosed with cytomegalovirus retinitis. He has
  been on highly active anti-retorviral therapy
  (HAART) that included zidovudine (AZT) for one
  year, but had to stop. He developed abdominal
  pain with bowel obstruction. A laparotomy was
  performed and a 20 cm segment of ileum was
  resected. This section is from one of several
  mass lesions ranging from 1 to 3 cm in size and
  located on the mucosal surface extending into
  muscularis of the bowel.

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Slide 7.1Note the gross appearance of the mass
lesion in the small intestine.
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Slide 7.2Note the low power microscopic
appearance of the mass lesion in the small
intestine.
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Slide 7.3Note the high power microscopic
appearance of the mass lesion in the small
intestine.
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Questions

1. What is the predominant cell type in this mass
   lesion?
2. What is the diagnosis and how does this relate to
   his history?
3. What would a peripheral lymphocyte count (with
   subsets) probably demonstrate?
4. Why did he have to stop the zidovudine?

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CASE 7 Burkitt's lymphoma

1. What is the predominant cell type in this mass
   lesion? There are large lymphocytes with nuclei
   having clumped chromatin.
2. What is the diagnosis and how does this relate to
   his history? This is Burkitt's lymphoma and is
   typical of one kind of high grade lymphoma (the
   other is large cell, or immunoblastic, lymphoma)
   seen with AIDS.
3. What would a peripheral lymphocyte count (with
   subsets) probably demonstrate? He would have a
   lymphopenia and a CD4 lymphocyte count probably
   under 200/microliter. His HIV-1 RNA level would
   likely be elevated.
4. Why did he have to stop the zidovudine?
   Zidovudine (AZT) suppresses bone marrow, and he
   probably had severe pancytopenia.