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LETTER TO EDITOR  
Year : 2015  |  Volume : 58  |  Issue : 2  |  Page : 261-262
Follicular lymphoma evolving into diffuse large B-cell lymphoma with Reed-Sternberg like cells


1 Department of Pathology, TATA Medical Center, Kolkata, West Bengal, India
2 Department of Laboratory Haematology and Molecular Genetics, TATA Medical Center, Kolkata, West Bengal, India
3 Department of Clinical Haematology, TATA Medical Center, Kolkata, West Bengal, India

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Date of Web Publication17-Apr-2015
 

How to cite this article:
Sancheti S, Arora N, Sawaimoon S, Chakrapani A. Follicular lymphoma evolving into diffuse large B-cell lymphoma with Reed-Sternberg like cells. Indian J Pathol Microbiol 2015;58:261-2

How to cite this URL:
Sancheti S, Arora N, Sawaimoon S, Chakrapani A. Follicular lymphoma evolving into diffuse large B-cell lymphoma with Reed-Sternberg like cells. Indian J Pathol Microbiol [serial online] 2015 [cited 2020 Jun 3];58:261-2. Available from: http://www.ijpmonline.org/text.asp?2015/58/2/261/155354


Editor,

Lymphomas are a diverse group of malignancies and include both Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). [1] Reed/Sternberg (RS) cells are hallmark cells of HL but rarely these cells have been described in NHL and in a few reactive conditions like infective mononucleosis. When seen in cases of NHL they constitute a diagnostic challenge for the pathologists. We describe here a case of follicular lymphoma (FL) evolving into a diffuse large B-cell lymphoma (DLBCL) with scattered RS like cells that has been rarely documented in the literature.

A middle-aged female patient presented with 2 months history of painless swelling over right groin and in the left cervical region. She further complained of weight loss and general weakness. There was no history of fever. Patient had a fine-needle aspiration cytology done from cervical lymph node elsewhere which was found to be atypical and hence she was referred to us. Laboratory studies done at presentation showed hemoglobin of 11.7 g/dl, total leukocyte count of 7500/cmm and platelet count of 250,000/cmm. Serum lactate dehydrogenase levels were 358 U/L (<300 U/L). Serum creatinine, blood urea nitrogen, blood glucose and liver enzymes were within normal limits.

Cervical lymph node biopsy showed effacement of architecture by a predominantly follicular infiltrate (60%) with focal diffuse areas (30-40%) as shown in [Figure 1]a. These diffuse areas were composed predominantly of large cells with round to oval large vesicular nuclei and prominent nucleoli at places with pale eosinophilic cytoplasm. Frequent mitotic figures were seen. Interspersed were scattered large, multinucleate cells with multilobated nuclei having prominent eosinophilic nucleoli resembling RS like cells as shown in [Figure 1]b.
Figure 1: (a) (H and E) shows lymph node with replacement by predominantly nodular and diffuse areas. (b) Interspersed are many large multinucleate Hodgkin Reed/Sternberg like cells. (c) CD20 immunostain highlights the follicular and diffuse areas. (d) These follicles are BCL2 positive


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Immunohistochemistry revealed the follicular areas to be positive for CD20, BCL2 and BCL6 immunostains [Figure 1]. The large cells in the diffuse areas were positive for CD20, CD45, MUM-1, OCT-2, and BOB-1. The interspersed RS like cells were positive for CD20, CD30, and Epstein-Barr virus (EBV)-encoded RNA in situ hybridization. In addition, these RS like cells were positive for CD45, OCT-2, BOB-1, MUM-1, and BCL6 [Figure 2]. All large cells are negative for CD3, CD10, and CD15. The proliferation index (Ki-67) was 80-90% in the diffuse areas. A final diagnosis of FL evolving into a DLBCL with Hodgkin/RS like cells was made.
Figure 2: The Hodgkin Reed/Sternberg like cells within diffuse areas express (a) CD30 (b) Epstein-Barr virus-encoded RNA in situ hybridization (c) OCT-2 and (d) BOB-1 immunostains


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Follicular lymphoma is a low-grade B-cell lymphoma composed of neoplastic centrocytes and centroblasts. [2] During the course of the disease, FL is known to transform to high-grade lymphoma, commonly DLBCL and less commonly to Burkitt's lymphoma (typically with acquisition of translocation involving MYC gene). Rarely FL may precede, follow or occur synchronously with HL having RS cells. [3] Transformation of FL into DLBCL along with the presence of RS like cells is rarely described in the published literature, and it is likely to be missed or misdiagnosed as HL.

To the best of our knowledge only a single similar case has been described earlier. This case published by Menon et al. showed an EBV-positive Hodgkin like transformation of grade 3A FL. [4] The immunoprofile described is similar to what we observed in this case but in addition the RS like cells described by Menon et al. demonstrated p53 positivity. [4] Due to a rare occurrence and lack of large cohort trials, it is difficult to predict clinical behavior of such cases. It will be interesting to know whether these EBV-positive RS like cells originate from the same progenitor cells or are de novo in origin. Documentation of these rare cases is important as these cases can be easily missed and may be misdiagnosed as HL or NHL. This patient was treated as DLBCL with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy and is well off 5 months after the diagnosis was made.

 
   References Top

1.
Arora N, Manipadam MT, Nair S. Frequency and distribution of lymphoma types in a tertiary care hospital in South India: Analysis of 5115 cases using the World Health Organization 2008 classification and comparison with world literature. Leuk Lymphoma 2013;54:1004-11.  Back to cited text no. 1
    
2.
Montoto S, Fitzgibbon J. Transformation of indolent B-cell lymphomas. J Clin Oncol 2011;29:1827-34.  Back to cited text no. 2
    
3.
Harris NL, Jaffe ES, Harris NL, de Leval L, Ferry JA. Follicular lymphoma. In: Jaffe E, editor. Haematopathology. 1 st ed. St. Louis: Elsevier Saunders; 2011. p. 267-90.  Back to cited text no. 3
    
4.
Menon MP, Hutchinson L, Garver J, Jaffe ES, Woda BA. Transformation of follicular lymphoma to Epstein-Barr virus-related Hodgkin-like lymphoma. J Clin Oncol 2013;31:e53-6.  Back to cited text no. 4
    

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Correspondence Address:
Dr. Neeraj Arora
Department of Laboratory Haematology and Molecular Genetics, TATA Medical Centre, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.155354

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