Bone Marrow-Liver-Spleen Type of Large B-Cell Lymphoma Associated with Hemophagocytic Syndrome: A Rare Aggressive Extranodal Lymphoma

Recently, an unusual subtype of large B-cell lymphoma (LBCL) with distinctive clinicopathologic features has been recognized; it is characterized by involvement of bone marrow with or without liver and/or spleen, but no lymph node or other extranodal sites, usually associated with fever, anemia, and hemophagocytic lymphohistiocytosis (HLH). Because of this distinctive clinical presentation, it has been designated “bone marrow-liver-spleen” (BLS) type of LBCL. To date there is only one series of 11 cases of BLS type of LBCL with detailed clinical, pathologic, and cytogenetic data. Herein, we describe a case of BLS type LBCL presenting with associated HLH in a 73-year-old female. The bone marrow core biopsy showed cytologically atypical large lymphoma cells present in a scattered interstitial distribution and hemophagocytosis and infrequent large lymphoma cells were seen in the bone marrow aspirate smears. Circulating lymphoma cells were not seen in the peripheral blood smears. The patient underwent treatment with chemotherapy (R-CHOP) but unfortunately passed away 2 months after initial presentation. BLS type of LBCL is a very rare and clinically aggressive lymphoma whose identification may be delayed by clinicians and hematopathologists due to its unusual clinical presentation and pathologic features

Post-transplant lymphoproliferative disorder presented as small bowel intussusception in adult liver transplant patient

Intestinal obstruction after liver transplant is a rare complication, with diverse clinical manifestations. Intestinal adhesion is the most common cause. However, internal hernia, abdominal wall hernia, and neoplasm are also reported. Intussusception is another rare cause of intestinal obstruction, which has been reported primarily in pediatric patients. Herein, we report a case of intestinal obstruction from intussusception in an adult liver transplant patient associated with post-transplant lymphoproliferative disorder

Intra-observer reproducibility of whole slide imaging for the primary diagnosis of breast needle biopsies

Background: Automated whole slide imaging (WSI), also known as virtual microscopy is rapidly becoming an important tool in diagnostic pathology. Currently, the primary utilization of the technique is for transmission of digital images, for second opinion consultation, as well as for quality assurance and education. The high-resolution of digital images along with the refinement of technology could now allow for WSI to be used as an alternative to conventional microscopy (CM) as a first line diagnostic platform. However, the accuracy and reproducibility of the technology for the routine histopathologic diagnosis has not been established yet. This study was undertaken to compare the intra-observer variability of WSI and CM in the primary diagnosis of breast biopsies. Materials and Methods: One hundred and three consecutive core needle biopsies of breast were selected for this study. Each slide was digitally scanned and the images were stored in a shared file. Three board-certified pathologists independently reviewed the glass slides by CM first, and in an interval of 2-3 weeks for the 2nd time to establish their baseline CM versus CM reproducibility. They then reviewed the digital images of all cases following the same interval of time to compare the reproducibility of WSI versus CM for each observer. The diagnostic categories included the typical range of benign and malignant mammary lesions. Results: The intra-observer variability for CM versus CM was 4%, 7%, and 0% for observers 1, 2, and 3 respectively. The diagnostic variability for WSI versus CM was 1%, 4%, and 1% for the same observers. All diagnostic disagreements were between ductal hyperplasia and atypical ductal hyperplasia. There was no intra-observer disagreement in the diagnosis of benign versus malignant disease. Conclusions: The intra-observer variability in the diagnosis of the core needle biopsies of the breast by high-resolution, WSI was the same as conventional glass slide microscopy. These results suggest that, WSI could be used similar to CM for the initial diagnosis of breast biopsies

Intra-observer reproducibility of whole slide imaging for the primary diagnosis of breast needle biopsies

BACKGROUND: Automated whole slide imaging (WSI), also known as virtual microscopy is rapidly becoming an important tool in diagnostic pathology. Currently, the primary utilization of the technique is for transmission of digital images, for second opinion consultation, as well as for quality assurance and education. The high-resolution of digital images along with the refinement of technology could now allow for WSI to be used as an alternative to conventional microscopy (CM) as a first line diagnostic platform. However, the accuracy and reproducibility of the technology for the routine histopathologic diagnosis has not been established yet. This study was undertaken to compare the intra-observer variability of WSI and CM in the primary diagnosis of breast biopsies. MATERIALS AND METHODS: One hundred and three consecutive core needle biopsies of breast were selected for this study. Each slide was digitally scanned and the images were stored in a shared file. Three board-certified pathologists independently reviewed the glass slides by CM first, and in an interval of 2-3 weeks for the 2(nd) time to establish their baseline CM versus CM reproducibility. They then reviewed the digital images of all cases following the same interval of time to compare the reproducibility of WSI versus CM for each observer. The diagnostic categories included the typical range of benign and malignant mammary lesions. RESULTS: The intra-observer variability for CM versus CM was 4%, 7%, and 0% for observers 1, 2, and 3 respectively. The diagnostic variability for WSI versus CM was 1%, 4%, and 1% for the same observers. All diagnostic disagreements were between ductal hyperplasia and atypical ductal hyperplasia. There was no intra-observer disagreement in the diagnosis of benign versus malignant disease. CONCLUSIONS: The intra-observer variability in the diagnosis of the core needle biopsies of the breast by high-resolution, WSI was the same as conventional glass slide microscopy. These results suggest that, WSI could be used similar to CM for the initial diagnosis of breast biopsies

Bone Marrow-Liver-Spleen Type of Large B-Cell Lymphoma Associated with Hemophagocytic Syndrome: A Rare Aggressive Extranodal Lymphoma

Recently, an unusual subtype of large B-cell lymphoma (LBCL) with distinctive clinicopathologic features has been recognized; it is characterized by involvement of bone marrow with or without liver and/or spleen, but no lymph node or other extranodal sites, usually associated with fever, anemia, and hemophagocytic lymphohistiocytosis (HLH). Because of this distinctive clinical presentation, it has been designated “bone marrow-liver-spleen” (BLS) type of LBCL. To date there is only one series of 11 cases of BLS type of LBCL with detailed clinical, pathologic, and cytogenetic data. Herein, we describe a case of BLS type LBCL presenting with associated HLH in a 73-year-old female. The bone marrow core biopsy showed cytologically atypical large lymphoma cells present in a scattered interstitial distribution and hemophagocytosis and infrequent large lymphoma cells were seen in the bone marrow aspirate smears. Circulating lymphoma cells were not seen in the peripheral blood smears. The patient underwent treatment with chemotherapy (R-CHOP) but unfortunately passed away 2 months after initial presentation. BLS type of LBCL is a very rare and clinically aggressive lymphoma whose identification may be delayed by clinicians and hematopathologists due to its unusual clinical presentation and pathologic features

Chlamydia Psittaci negative MALT Lymphomas of the Ocular Adnexa Are Characterized by Biased Use of the VH4 Family and Evidence for Antigen Selection

Abstract Abstract 2644 Mucosa-associated lymphoid tissue (MALT) lymphomas are the most common lymphomas in the ocular adnexa. Similar to extranodular MALT lymphomas in other tissues, ocular adnexa MALT lymphomas (OAMALTL) are frequently characterized by an indolent clinical course and often remain localized for many years. While chronic infection (e. g. Helicobacter pylori) or autoimmune diseases (e.g. Hashimoto's thyroiditis and Sjogren's syndrome) frequently precede and predispose patients to develop MALT lymphomas in the stomach, thyroid and salivary glands, respectively, the etiology and pathogenesis of OAMALTL are still controversial. An Italian group and investigators from several other geographic regions demonstrated Chlamydia psittaci (C. psittaci) DNA present in OAMALTL, suggesting that this pathogen may be implicated in the development of these lymphomas. However, similar studies performed by us and other investigators on US-based patients have failed to corroborate this finding. Furthermore, DNA from other bacteria was also not detected by us, thus not supporting a bacterial etiology in US-based patients. Since non-bacterial antigens may predispose patients to OAMALTL, we have examined immunoglubulin (Ig) heavy chain variable region (VH) usage and mutations in the largest to date cohort of C psittaci negative OAMALTL originating from a single institution. DNA was extracted by standard techniques from 68 fresh OAMALTL tissues and used for direct PCR or PCR followed by cloning and sequencing using family specific VH leader and JH primers. To control for potential PCR error, all patient samples were evaluated by 2 independent PCR reactions and sequencing and only cases with identical CDR3 regions in the independent PCR runs were defined as clonal. Using this definition, clonal rearranged VHDJH sequences were identified in 44 (64.7%) tumors originating from the orbit (19), conjunctivae (19) and lacrimal gland (6). Forty seven clonal VH gene sequences were detected (3 of the patients had 2 clonal sequences) with 46 potentially functional and 1 harboring an out-of-frame junction with a stop codon. In 14 (31.8%) cases the PCR product could be sequenced directly, whereas in 30 (68.2%) cases PCR amplicons had to be subcloned to identify the VH gene. The 46 potentially functional VH were derived from 4 of the 7 human VH gene families with the following distribution: VH1, 13.1%; VH2, 2.2%; VH3, 39.1%; VH4, 45.6%, demonstrating a biased overrepresentation of the VH4 gene family (p=0.001). The most frequently encountered genes were VH4-34 (n=8), VH3-30 (n=6), VH3-23 (n=5) and VH4-30 (n=4). VH4-34 represented 17% of all the potentially functional VH genes identified in this study in contrast to its usage in 4–7% in adult peripheral B lymphocytes. Only 3 VH gene sequences were unmutated. The average percent homology to the germ line sequence in the 43 functional mutated sequences was 93.2% (range 71.5–99.6). Multinomial algorithm for antigen selection revealed evidence for positive selection in the CDR in 15 sequences, negative selection in the FR in 17 sequences, and selection in both CDR and FR (in the same sequence) in 7 sequences. Selection analysis using the focused binomial test demonstrated evidence of selection in the FR in 12 sequences and in the CDR in only 4 sequences. Selection was detected in 5 of the 8 functional VH4-34 sequences. Analysis of the tumor-derived CDR3 sequences revealed low similarity and an absence of stereotyped sequences with no homology to antibacterial and other previously published antibodies. The average CDR3 isoelectric point was 5.91±1.89 (SD). The average CDR3 length was 15.73±13.62 (SD) amino acids, with 19 sequences harboring 15–19 amino acids and 7 CDR3 sequences longer than 19 amino acids. Intraclonal variation was assessed by extensive molecular cloning in 8 potentially functional VH gene isolates from 8 randomly selected tumor specimens. Confirmed ongoing mutations were detected in the 6 of the 8 analyzed sequences. Overall our findings demonstrate that C. psittaci negative OAMALTL exhibit biased usage of VH families and genes with evidence for intraclonal heterogeneity and antigen selection in multiple tumors, implicating immunological stimulation in the pathogenesis of these lymphomas. The nature of the antigens potentially playing role in these processes is currently unknown and requires further studies. Disclosures: No relevant conflicts of interest to declare

Diagnosis and treatment of diffuse large B-cell lymphoma in an orangutan (Pongo pygmaeus)

Lymphoma is a common malignancy observed in companion animals. This type of naturally occurring neoplasia has been uncommonly reported in great apes. Diffuse large B-cell lymphoma was diagnosed in an 8-yr-old captive orangutan (Pongo pygmaeus) with gastrointestinal disease by histologic and immunohistochemical methodologies. The orangutan was treated with three cycles of combination chemotherapy (intravenous Rituxan, cyclophosphamide, doxorubicin, and vincristine). The primate has been in good health and exhibiting normal behaviors for more than 15 mo following treatment

Biased use of the IGHV4 family and evidence for antigen selection in Chlamydophila psittaci-negative ocular adnexal extranodal marginal zone lymphomas

Extranodal marginal zone lymphomas (EMZL) are the most common lymphomas in the ocular adnexa. The etiology and potential role for antigenic stimulation in these lymphomas are still controversial. We have examined IGHV gene usage and mutations in 67 Chlamydophila psittaci-negative ocular adnexal EMZL. Clonal IGHV gene sequences were identified in 43 tumors originating from the orbit (19), conjunctivae (18) and lacrimal gland (6). Forty four potentially functional clonal IGHV gene sequences were detected with overrepresentation of the IGHV4 family and IGHV4-34 gene. All but 3 sequences were mutated with the average percent homology to the germ line of 93.5±6.1. Multinomial model and Focused binomial test demonstrated evidence for positive and/or negative antigen selection in 59% of the potentially functional IGHV genes. Intraclonal variation was detected in 8 of 11 tumor specimens. Overall our findings demonstrate that C. psittaci-negative ocular adnexal EMZL exhibit biased usage of IGHV families and genes with evidence for intraclonal heterogeneity and antigen selection in multiple tumors, implicating B-cell receptor-mediated antigen stimulation in the pathogenesis of these lymphomas