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Difficulty: HardPathology and Biopsy Interpretation

Match each of the following synoptic pathology descriptions and immunohistochemical profiles from lymph node or bone marrow biopsies to the most appropriate definitive hematolymphoid diagnosis.

  • Diffuse architectural effacement by medium-sized lymphoid cells with frequent mitoses and interspersed tingible-body macrophages; positive for CD10 and BCL6, negative for BCL2.Burkitt lymphoma
  • Nodular growth pattern composed of a mixture of centrocytes and centroblasts; positive for CD10, BCL6, and strongly positive for BCL2.Follicular lymphoma
  • Diffuse infiltrate of small-to-medium lymphoid cells with irregular nuclear contours; positive for CD5 and Cyclin D1, negative for CD23.Mantle cell lymphoma
  • Nodular and interstitial infiltrates of small, mature-appearing lymphocytes; positive for CD5 and CD23, negative for Cyclin D1.Chronic lymphocytic leukemia / Small lymphocytic lymphoma (CLL/SLL)
  • Rare, large, binucleated cells with prominent eosinophilic nucleoli surrounded by a dense mixed inflammatory infiltrate; positive for CD15 and CD30, negative for CD45 and CD20.Classic Hodgkin lymphoma

Answer

Burkitt lymphoma matches the BCL2-negative starry sky pattern. Follicular lymphoma matches the BCL2-positive nodular pattern. Mantle cell lymphoma matches the CD5+/CD23-/Cyclin D1+ profile. CLL/SLL matches the CD5+/CD23+ profile. Classic Hodgkin lymphoma matches the CD15+/CD30+/CD45- binucleated cells.
Definitive hematolymphoid diagnoses require integrating cellular morphology, growth patterns, and specific immunophenotypes. Burkitt lymphoma presents with a 'starry sky' pattern and is definitively BCL2 negative. Follicular lymphoma classically expresses BCL2 due to its defining t(14;18) translocation. Mantle cell lymphoma is driven by a t(11;14) translocation leading to Cyclin D1 overexpression, demonstrating a CD5+/CD23- profile. CLL/SLL uniquely co-expresses CD5 and CD23. Finally, Classic Hodgkin lymphoma is characterized by Reed-Sternberg cells that express CD15 and CD30 but lack the common leukocyte antigen CD45.

Step-by-Step Solution

1
Analyze the first profile featuring a high mitotic rate and a lack of BCL2 expression.
Identified as Burkitt lymphoma.
Burkitt lymphoma is a rapidly dividing germinal center tumor (CD10+) that uniquely lacks BCL2, which differentiates it from follicular lymphoma.
2
Evaluate the nodular architecture exhibiting CD10, BCL6, and BCL2 positivity.
Identified as Follicular lymphoma.
The strong aberrant BCL2 expression in a nodular follicular pattern is pathognomonic for the t(14;18) translocation seen in Follicular lymphoma.
3
Examine the two CD5-positive profiles to accurately differentiate Mantle cell lymphoma from CLL/SLL.
The CD5+/CD23-/Cyclin D1+ profile maps to Mantle cell lymphoma; the CD5+/CD23+ profile maps to CLL/SLL.
CD23 and Cyclin D1 are the most reliable immunophenotypic markers to distinguish these two common CD5+ B-cell lymphomas.
4
Identify the large cells lacking CD45 and CD20 but expressing CD15 and CD30.
Identified as Classic Hodgkin lymphoma.
Classic Reed-Sternberg cells typically lose standard B-cell markers and pan-leukocyte markers while aberrantly expressing CD15 and CD30 within a reactive inflammatory background.

Key Concept

Accurate interpretation of lymph node and bone marrow pathology relies on synthesizing morphological features with specific immunohistochemical panels to differentiate overlapping hematolymphoid malignancies.
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Topics

Pathology and Biopsy Interpretation

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