Primary diagnosis of classic Hodgkin lymphoma by bone marrow aspirate and trephine – an unusual presentation with interesting morphology

Abstract

An 82-year-old gentleman presented with breathlessness and a 3-month history of fevers and night sweats. Past history was remarkable for an unprovoked pulmonary embolism (PE) 10 months prior for which he had 6 months anticoagulation therapy with no specific malignancy diagnosed at that time. Further inpatient investigations revealed a recurrent PE and a subsequent positron emission tomography/computed tomography (PET/CT) scan showed retrocaval lymphadenopathy with fludeoxyglucose (FDG) avid nodes above and below the diaphragm with spleen, liver and marrow involvement. Staging bone marrow aspirate and trephine (BMAT) demonstrated large bilobed Hodgkin Reed-Sternberg (HRS) cells with lymphocyte rosetting. Trephine histology showed focal collections of large HRS cells with an accompanying inflammatory cell infiltrate. The HRS cells were CD15+/CD30+/PAX5(weak) on immunohistochemistry (IHC). A diagnosis of Classic Hodgkin Lymphoma (CHL) was established based on the marrow findings. Hodgkin lymphoma (HL) with bone marrow (BM) involvement is a relatively infrequent finding (∼5% cases of HL)1,2 and the presence of HRS cells in BM aspirate is rare. This case illustrates an unusual clinical presentation of CHL with primary diagnosis attained by BM biopsy. The patient was commenced on chlorambucil, procarbazine, prednisolone and vinblastine (Ch1VPP) chemotherapy and restaging PET/CT after 6 cycles showed marked interval improvement of FDG avid disease.