Excisional Node Biopsy Research Articles

S2212 Diffuse Gastrointestinal Kaposi Sarcoma in a Patient With HHV-8 Associated Multicentric Castleman Disease

Introduction: Castleman disease is a rare non-clonal lymphoproliferative disorder characterized by non-neoplastic lymphadenopathy that can affect any region of the body. Castleman disease adenopathy can either be localized to a single site, or more widespread. In the latter case, Multicentric Castleman Disease (MCD) is further classified as either HHV-8 negative/idiopathic MCD or HHV-8 associated MCD. MCD can present aggressively with systemic manifestations, and treatment differs based on the presence of Kaposi Sarcoma (KS). In this report, we describe a patient with HIV/AIDS that was found to have diffuse gastrointestinal KS and was ultimately diagnosed with HHV-8 associated MCD. Case Description/Methods: A 44 year old male with recently diagnosed HIV/AIDS and cutaneous KS presented with complaints of night sweats, dizziness, weight loss, and diarrhea. He reported waxing and waning lymphadenopathy present for at least one year. Physical examination was notable for diffuse lymphadenopathy and an enlarged spleen. Initial laboratory studies were remarkable for CD4 count of 70, Hgb 6.0g/dL, platelets 91 k/uL, sodium of 121mmol/L. CT of the abdomen and pelvis demonstrated diffuse lymphadenopathy as well as marked splenomegaly. CT of the chest showed thoracic lymphadenopathy, and MRI Brain revealed cervical chain lymphadenopathy. GI was consulted to evaluate for systemic/GI KS or other lesions to guide definitive treatment. EGD and colonoscopy demonstrated nodules in the stomach, ascending colon, and rectum all of which were biopsied and revealed KS. An excisional biopsy of an inguinal lymph node was obtained, pathology revealed Castleman lymphadenopathy, plasma cell variant. Oncology recommended that the patient be started on rituximab and liposomal doxorubicin for treatment of HHV-8 associated MCD with concurrent Kaposi Sarcoma. Discussion: We present a rare case of HHV-8 associated MCD with concomitant KS found diffusely in the GI tract and skin. There was initially significant diagnostic uncertainty until lymph node biopsy was performed. Interestingly, therapeutic recommendations for MCD depend on the presence or absence of KS, and gastrointestinal KS can be present without cutaneous KS. MCD without KS is treated with four weeks of rituximab, and if KS is present, doxorubicin or etoposide is included. This case highlights the potential for GI involvement of KS in MCD, and in particular the need to pursue endoscopy in patients with HH/V-8 associated MCD to evaluate for KS and guide treatment decisions.Figure 1.: Kapsoi Sarcoma in the gastric antrum (a), gastric body (b), sigmoid colon (c), and rectum (d).

S2397 First Reported Case of Kikuchi-Fujimoto Disease in a Crohn’s Disease Patient

Introduction: Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare entity, mostly associated with autoimmune conditions such as SLE. It is benign, focal, self-limited, and despite abundant literature, its pathogenesis remains unknown. We report a unique case of KFD in a patient with coexisting Crohn’s disease. Case description/methods: A 23-year-old female with no medical history was evaluated for Iron deficiency anemia and anorexia. She underwent a colonoscopy which revealed normal colonic mucosa, however, an ulcerated and congested terminal ileum was seen. Biopsies were significant for acute cryptitis and granuloma. Serology was positive for anti–Saccharomyces cerevisiae antibody and fecal calprotectin was elevated. She was initially started on oral corticosteroids and later transitioned to azathioprine and Adalimumab, with a good response. 7 months later, she was planned for a repeat colonoscopy to check for endoscopic healing, however, at her pre-procedure COVID testing, she was noted to have rubbery painless LAD of the right neck. The procedure was postponed and she was immediately asked to discontinue her medications. She was referred to an oncologist. A CT chest was unremarkable and an excisional biopsy of the largest of the lymph node revealed necrotizing lymphadenitis, favoring KFD. Infectious workup was negative. Over the next 2 months, her LAD spontaneously resolved without the need for medications. A repeat colonoscopy was aborted due to poor prep. A follow-up MRE revealed long segment mid and distal Crohn's ileitis, and fecal calprotectin remained elevated. She was started on oral budesonide with plans to restart biological therapy after repeating a colonoscopy. Discussion: KFD may rarely involve the terminal ileum, potentially masquerading as Crohn’s disease. Our patient, however, had histological findings pathognomic for Crohn’s and her ileitis did not resolve with the resolution of LAD. Lymphoma remains a feared adverse outcome of both immunomodulators and Anti-TNF medications, thus necessitating their cessation upon signs of LAD. However negative EBV testing, an unrevealing chest CT, and a benign histological diagnosis of KFD may allow our patient to safely resume these medications to treat her Crohn's.Figure 1.: Excisional Lymph node biopsy specimen demonstrating necrotizing histiocytic lymphadenitis. No infectious organisms were identified (Negative PAS, Warthin-Starry stain, Tuberculosis, HSV 1/2 and EBV immunohistochemistry).

Pulmonary Phaehyphomycosis in Retroviral Disease Patient

Pulmonary phaeohyphomycosis is a rare infection in the lung caused by black fungi containing a cytoplasmic melanin-like pigment. A 42-year-old man with underlying retroviral disease on HAART was investigated for having constitutional symptoms. Despite undetectable viral load and a high CD4 count, he was found to have unexplained significant loss of weight and appetite over a period of 6 months. Clinical examination revealed a cachexic man with multiple inguinal lymphadenopathies. Excisional biopsy of the inguinal lymph node revealed reactive follicular hyperplasia. CT Thorax, Abdomen and Pelvis was arranged to look for occult malignancy or infection and he was found to have multiple non-enhancing subcentimeter lung nodules mainly at the lateral segment of the right middle lobe of his lung. The largest nodule measured about 0.8 x 1.5 x 0.5 (AP x W x CC), with some nodules having an irregular margin with no extension into the adjacent bronchi. Bronchoscopy was done and demonstrated a black patch at the right intermedius, lateral segment of the middle lobe which did not disappear upon bronchial flush or wash. Histopathological examination found focal areas of blackish pigment and the bronchial alveolar lavage sent for fungal culture grew Cladosporium species. The patient was treated with oral Itraconazole with marked clinical improvement. This case highlights an unusual black fungi infection in the lung that stands out not only for its rarity and it's responsiveness to treatment, but also the susceptibility of an RVD positive patient to this infection despite having suppressed viral load and normal CD4 count.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S17

Indolent B-Lineage Precursor Populations Identified by Flow Cytometry and Immunohistochemistry in Benign Lymph Nodes.

In this retrospective study, we report a series of benign lymph nodes showing small populations of normal B-cell precursors characterized by flow cytometry and immunohistochemistry. Ten cases identified during clinical flow cytometry practice were retrospectively reanalyzed with particular attention to hematogone categorization and enumeration. Immunohistochemical staining was performed on five excisional lymph node biopsy specimens to characterize the morphologic correlate. Populations of hematogones ranging from 0.13% to 1.86% (median, 0.51%) of all viable leukocytes were demonstrated in 10 benign lymph node samples from eight different patients ranging in age from 17 to 45 years (median, 37.5). These hematogones showed a characteristic immunophenotype (CD19+/CD10+) and maturational pattern by flow cytometry, with progression from stage 1 (median, 0.03%) to stage 2 (median, 0.19%) to stage 3 (median, 0.26%) seen in all cases. Immunohistochemical staining on five excisional biopsy specimens demonstrated a distinct perisinusoidal distribution of CD10+/CD20+ cells with a subset of TdT+ cells, providing a morphologic correlate. To our knowledge, this is the first study to characterize distinct hematogone populations within benign lymph nodes by both flow cytometry and immunohistochemistry. Recognizing these normal B-cell precursor populations is important to avoid their miscategorization as a CD10+ B-cell neoplasm.

Kedi tırmığı hastalığında F18 FDG PET/BT bulguları: olgu sunumu

Cat-scratch disease is a bacterial infection caused by Bartonella Henselae which affects lymph nodes that drain the sites of inoculation. Axillary, cervical and inguinal lymph nodes are the most common regions being involved. The disease can be considered as an FDG-avid disease, given the granulomatous nature of the infection. We herein report F18 FDG PET/CT findings of a 49-year-old woman, who has abdominal lymphadenopathy revealed on ultrasonography (USG). PET/CT scan demonstrated bilateral axillary and abdominopelvic hypermetabolic enlarged lymph nodes with SUVmax value of 6.2 to 18.5. Moreover, a hypermetabolic hypodense lesion in the spleen with SUVmax value of 11.3 was detected. Excisional biopsy of the axillary lymph node performed. Based on clinical-histopathological findings and the history of being scratched by a cat recently, the patient was diagnosed with cat-scratch disease. In conclusion, cat-scratch disease represents a cause of false-positive results in oncological PET/CT scans. Furthermore, PET/CT may have a role in revealing the applicable biopsy area and showing the additional involvement sites. Keywords: Cat-Scratch Disease, PET-CT, Lymphadenopathy.

CORRIGENDUM

SonographyVolume 8, Issue 3 p. 135-135 CORRIGENDUMFree Access CORRIGENDUM This article corrects the following: Oral Presentations Volume 8Issue S1Sonography pages: 3-28 First Published online: May 20, 2021 First published: 02 September 2021 https://doi.org/10.1002/sono.12273AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL The content of the Oral abstract O082 entitled ‘O082 | Taking the “Kik” out of Kikuchi-Fujimoto Disease- a Case Study’ by Debbie Slade has been replaced.1 The correct content is presented below: Introduction: Kikuchi-Fujimoto disease, more commonly known as Kikuchi's disease or Histiocytic Necrotizing Lymphadenitis, is a rarely encountered, widely misunderstood usually benign pathology that involves unusual swelling of the lymph nodes. The purpose of this presentation is to rectify a shortfall in available literature describing this disease. This case study describes a 42-year old Caucasian woman who presented with a unilateral neck swelling and describes etiology, ultrasound appearances, cytology, diagnosis and treatment. Method: - Ultrasound examination was performed in the region of concern using a Canon (Toshiba) XG unit and 12 MHZ linear array transducer. - Transverse, longitudinal and hilar measurements of the enlarged lymph node were documented. Borders, internal echogenicity and architecture was assessed. Power Doppler was utilized to assess vascularity. - Insonation of the entire neck was performed looking for evidence of additional abnormal lymph nodes or malignancy. - Ultrasound appearances were compared with common lymph node pathology. - Ultrasound guided FNA was performed as was surgical excision in an effort to achieve diagnosis. Results: Ultrasound Appearance: - A single enlarged hypoechoic lymph node with cystic components, lobulated cortex and hyperemic hilar flow was identified in the left anterior triangle (segment 11A). Differential diagnoses of Lymphoma, TB and cat scratch disease were suggested by ultrasound appearances. Conclusion: - FNA results were inconclusive. - Definitive diagnosis of Kikuchi disease was achieved only with excisional node biopsy. Take Home Messages: Consider Kikuchi disease as an ultrasound differential diagnosis for enlarged lymph nodes. Definitive diagnosis of Kikuchi disease can only be made by excisional node biopsy. REFERENCE 1ASA2021 Brisbane Hybrid, 27th Annual International Conference of the Australasian Sonographers Association, 28–30 May 2021. Sonography. 2021; 8(Suppl. 1): 3- 28. https://doi.org/10.1002/sono.12255 Volume8, Issue3September 2021Pages 135-135 ReferencesRelatedInformation

PERIPHERAL LYMPH NODE EXCISIONAL BIOPSY IN CHILDREN: YIELD IN A TERTIARY CARE CENTRE

AIM: To study the pediatric patients in a developing country undergoing peripheral lymph node excision biopsy in terms of demographics and histopathological ndings and evaluate the diagnostic yield of peripheral Lymph node excision biopsy in children. MATERIALS AND METHODS: A retrospective study of 402 patients was done of the children undergoing peripheral lymph node st st excision biopsy in a tertiary care center from 1 January 2013 to 31 December 2018 (6 years). Demographics, histopathological ndings and yields were studied. RESULTS: Out of the 402 patients, 218 (54.2%) were males and 184(45.8%) were females. Male to female ratio 1.18: 1. Maximum patients belonged to the age group of 4-6years (26.87%) followed by the age group of 2-4years of age (22.89%). Most common group of nodes excised were cervical (77.9%) followed by axillary and inguinal lymph nodes (9.2%) each. The most common etiology was reactive lymphoid hyperplasia (63.18%) in our study followed by tuberculous lymphadenitis(31.84%). Specic ndings were seen in 35.58% and non-specic ndings were seen in 64.42% patients. Malignancy was seen in 8 patients (2%). CONCLUSION: Peripheral Lymphadenopathy in pediatric population is always a diagnostic challenge. While FNAC tends to be investigation of choice for adults, in a developing country with limited resources and high prevalence of tuberculosis, peripheral lymph node biopsy is the gold standard with a good diagnostic yield and should always be considered for patients with persistent lymphadenopathy. Clinical significance: The study highlights the importance of excision biopsy in peripheral lymphadenopathy in children in a developing nation with limited resources and high prevalence of infectious diseases.

Hodgkin Lymphoma Presenting With Spinal Cord Compression: Challenges for Diagnosis and Initial Management.

Hodgkin lymphoma (HL) can present with extra-nodal disease, but spinal cord compression is exceptionally rare. We describe a 15-year-old presenting with hip/back pain with normal initial examination. Persistent pain and raised inflammatory markers prompted further investigation with MRI, which revealed an epidural mass causing spinal cord compression. On examination, there was no palpable lymphadenopathy or cauda equina syndrome, but absent lower limb reflexes were noted. Following multidisciplinary discussion, it was determined that cauda equina syndrome was imminent and therefore surgical debulking was undertaken, both to prevent this complication and establish a diagnosis. At surgery, the tumor was highly vascular. Frozen section confirmed lesional material. Following surgery, and given the frozen section findings, a short course of steroids was commenced to reduce any peri-surgical edema. Unfortunately, histopathology was ultimately non-diagnostic, due to failure of immunohistochemistry on technically challenging material. Consequently, ultrasound-guided excision biopsy of a (non-palpable) cervical lymph node was performed five days later; histopathology showed typical effacement of the normal architecture and a conspicuous population of CD15/CD30-positive larger pale cells present, confirming nodular sclerosis classic HL, despite recent steroids. We review the available literature for HL presenting with spinal cord compression and describe the challenges for diagnosis and initial management in such cases.

Toxoplasmosis presenting as isolated cervical lymphadenopathy-A rare case

Lymphadenopathy is not uncommon in toxoplasmosis. Its rare in an immunocompetent patient. We present a case of toxoplasmosis in an asymptomatic lady with isolated cervical lymph node. The diagnosis was confirmed by excision biopsy of lymph node and serology

Kikuchi-Fujimoto Disease: A Rare Cause of Cervical Lymphadenopathy.

Kikuchi-Fujimoto disease (KFD) is a rare benign disease, clinically characterized by fever and tender cervical lymphadenopathy affecting the posterior cervical lymph nodes. This disease is usually accompanied by night sweats, rashes, and headaches. It generally affects young individuals, especially females, of Oriental-Asian origin. The etiology of KFD remains uncertain, but associations have been noted with viral diseases including Epstein-Barr virus (EBV), herpes simplex virus (HSV), and varicella-zoster virus (VZV), as well as autoimmune disorders including systemic lupus erythematosus (SLE) and Sjogren's syndrome. This review points out the etiology of KFD with cervical lymphadenopathy alongside its clinical presentation, histological highlights, lab investigations, complications, and treatment. Accurate diagnosis of this disease depends on lymph node excisional biopsy. Three histological patterns of KFD are recognized: proliferative, necrotizing, and xanthomatous. Distinction from lymphadenopathy-associated alternate disorders (e.g., SLE, malignancy, tuberculosis, or another infectious lymphadenitis) is essential to ensure appropriate therapy. This self-limited condition entails nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief with consideration of corticosteroids and hydroxychloroquine in severe cases.

Kikuchi-Fujimoto disease presenting in a patient with SARS-CoV-2: a case report

BackgroundWe present a yet to be described association of SARS-CoV-2 infection with Kikuchi-Fujimoto disease.Case presentationA 32-year-old physician with history of SARS-CoV-2 infection presented to the emergency department with 2 weeks of fever, chills, and right sided cervical lymphadenopathy. He was treated empirically for presumed folliculitis with worsening of symptoms leading to repeat presentation to the emergency department.Extensive workup was unrevealing of an infectious cause and needle biopsy of the lesion was unrevealing. An excisional lymph node biopsy revealed follicular hyperplasia with necrotic foci showing abundance of histiocytes at the edge of necrosis with CD8 predominance of T-cells. Final diagnosis was deemed to be Kikuchi-Fujimoto disease. Antibiotic therapy was discontinued, and the patient’s symptoms resolved with steroid therapy and expectant management.ConclusionsThis is the first report of a patient developing Kikuchi-Fujimoto disease following SARS-CoV-2 infection. Clinicians should be aware of Kikuchi-Fujimoto disease as a possibility when approaching patients with hyper-inflammatory states who present with cervical lymphadenopathy.

Diffuse Large B-Cell Lymphoma With a Background of Extensive Granulomatous Inflammation: A Potential Pitfall for Misdiagnosis

Granulomatous inflammation has been reported to be associated with Hodgkin and non-Hodgkin lymphomas. Here, we report a case of recurrent diffuse large B-cell lymphoma (DLBCL) with extensive granulomatous inflammation that was initially misdiagnosed as granulomatous lymphadenitis. In 2019, a 75-year-old Caucasian male presented to our hospital with an enlarged right supraclavicular lymph node. He had a medical history of prostate cancer (in 2004), DLBCL (initially diagnosed in 2009), and rectal adenocarcinoma (in 2017), all of which responded well to treatment. In 2018, the patient had experienced right axillary adenopathy, weight loss, and intermittent night sweats. An excisional biopsy of a right axillary lymph node, performed at another institution, was diagnosed as granulomatous lymphadenitis. In 2019, at our hospital, an excisional biopsy of a right supraclavicular lymph node showed DLBCL in a background of granulomatous inflammation. A review of the prior right axillary lymph node biopsy also showed DLBCL with a background of extensive granulomatous inflammation. Chemotherapy was initiated and the patient’s follow-up showed a good response. We report this case to raise awareness that granulomatous inflammation may obscure the diagnosis of some neoplasms, such as DLBCL, which are less commonly known to have granulomatous inflammation. This may result in delayed treatment and may ultimately affect outcomes.

Intrathoracic calculous cholecystitis due to delayed iatrogenic diaphragmatic hernia

Iatrogenic diaphragmatic hernias is rare complications of abdominal or thoracic surgery. Depending on the location and size of the defect retroperitoneal or intra-abdominal organs and tissues can prolapse into thoracic cavity due to the negative intra-thoracic pressure. This can cause risk of obstruction or strangulation of abdominal contents, and may ischemia and perforation. We present a case of delayed presentation of a patient with iatrogenic diaphragmatic herniation of liver and gallbladder with stones into the thorax. A 62-year-old female was visited our hospital for complaining of right sided thoracic back pain during 3month. The pain had not been treated with analgesics. Three years ago, she has been diagnosed right diaphragmatic metastatic nodule from ovarian cancer. She was operated excisional biopsy of intrathoracic lymph nodes and parietal pleural by VATs (video-assisted thoracic surgery). A computed tomography-scan showed intrathoracic displacement of her liver and chronic cholecystitis with multiple stones. The patients underwent laparotomy via an abdominal approach with subcostal incision. Intraoperative findings confirmed that right diaphragmatic focal defect and liver and gallbladder herniated into the thoracic cavity. The organs were placed back into the thoracic cavity. A cholecystectomy was performed, and the defect in the diaphragm measuring 13 cm × 10 cm, was repaired with a Gortex graft. Postoperative recovery was uneventful. The patient was discharged seven days after the surgery without any problems.

Diffuse peritoneal lymphomatosis or abdominal tuberculosis: a clinico-radiological conundrum

Primary extra nodal lymphoma occurs in approximately 25% to 40% of patients and is more common in patients with NHL. Diffuse large B-cell lymphoma (DLBCL) is the dominant histological subtype. A 60-year-old gentleman presented to our hospital with pain abdomen associated with abdominal distension since a month, few constitutional symptoms with bilateral axillary and inguinal lymphadenopathy. Blood investigations showed high total count with significantly high LDH levels. Provisional diagnosis of tubercular Abdomen/Malignant Ascites with Unknown primary was made. CT Abdomen showed large bowel wall thickening with parietal peritoneal lesions with omental cake. Excision biopsy of inguinal lymph node showed lymphoid follicles with poorly defined attenuated mantle zones having centrocytes and centroblasts. Immunohistochemistry was positive for markers, which confirmed the diagnosis of Stage 4B DLBCL, germinal center B-cell type. Sepsis and acute kidney injury occurred and the patient expired, 6 days after diagnosis. To conclude, Peritoneal lymphomatosis is an extremely rare condition. This case highlights the need to have a high index of suspicion for malignancy, when a given case is clinically diagnosed with tuberculosis as and when new findings appear during investigation.

The Diagnostic Yield of Excisional Biopsy in Cervical Lymphadenopathy: A Retrospective Analysis of 158 Biopsies in Adults.

Cervical lymph nodes are the most common site of peripheral lymphadenopathy. The underlying etiologies are usually benign and self-limiting but may include malignancies or other severe life-threatening diseases. The aim of the current study was to investigate the various underlying pathologies of cervical lymphadenopathy as assessed by the diagnostic yield of excisional lymph node biopsies of the neck in a tertiary adult practice. The evaluation was performed in light of previous literature and regional epidemiological patterns. Retrospective analysis of hospital charts of 158 adult patients who underwent an excisional biopsy for suspected cervical lymphadenopathy at a tertiary referral head and neck service between January 2017 and December 2019. The most common underlying pathology was unspecific and/or reactive lymphadenitis in 44.5% of specimens, followed by malignant disease in 38.6% of cases. An age above 40 years was significantly correlated with an increased likelihood of malignant disease. Lower jugular and posterior triangle lymph nodes showed higher malignancy rates than other groups (100% and 66.7%, respectively). The overall surgical complication rate was 2.5%. The results of the current study serve as an indicator of the variety of etiologies causing cervical lymphadenopathy. In particular, given the increasing incidence of malignant diseases in recent decades, the findings should alert physicians to the importance of lymph node biopsy for excluding malignancy in persistent cervical lymphadenopathy especially in older adults. The findings emphasize the value of excisional lymph node biopsy of the neck as a useful diagnostic tool in adult patients with peripheral lymphadenopathy.

A Rare Case of T-Cell Histiocyte Rich Large B-Cell Lymphoma of the Thyroid in a Patient With Hashimotos

Introduction: T-cell/histiocyte-rich large B-cell lymphoma (THRLBCL) is a rare form of large B-cell lymphoma, which usually involves the lymph nodes exclusively. We describe a patient with Hashimoto’s thyroiditis who was discovered to have THRLBCL arising from the thyroid. Clinical Case: A 78-year-old female with a history of Hashimoto’s thyroiditis noted increase in the size of her left thyroid lobe for two months despite normal TSH on Levothyroxine, prompting an ultrasound which revealed several enlarged left sided cervical lymph nodes and an enlarged left thyroid gland. Cytology from an FNA of a left level 3 lymph node showed atypical lymphoid infiltrate featuring scattered large atypical cells in a background of small lymphocytes. Immunohistochemical testing was PAX5+, CD30- and CD15-. Cytology from an FNA of left thyroid revealed identical changes and immunohistochemistry demonstrated PAX5+ and CD20+. Concurrent flow cytometric studies demonstrated increased CD4 to CD8 ratio among T cells. Excisional biopsy of a left cervical lymph node confirmed a diagnosis of THRLBCL. PET/CT exhibited lymphadenopathy above her diaphragm and splenic involvement. Her bone marrow biopsy was negative for involvement. She was deemed Stage III with international prognostic index (IPI) of 2 corresponding with low-intermediate risk. She was commenced on chemotherapy R-CHOP with plan to complete 6 cycles. Discussion: THRLBCL is characterized by scattered atypical B lymphocytes on a background of T lymphocytes and histiocytes. Usually, T-cells are predominantly CD8+, in contrast to our patient. Some studies identified cases of predominant CD4+ and PD1+ T cells. Cytology revealed scattered small B-cells and large B-cells, a feature that is not typically seen in THRLBCL. A diagnosis of diffuse transformation of nodular lymphocyte predominant Hodgkin lymphoma was considered but the diffuse proliferation outside of CD21+ and involvement of the thyroid is not compatible with such diagnosis. Similarly, a diagnosis of follicular helper T-cell lymphoma with admixed large B-cells was considered but while PD1+ CD4+ T cells are present, there was no aberrant antigen expression by flow cytometry or T cell clonality. THRLBCL mainly involves lymph nodes and presents at advanced Ann Arbor stages with high IPI. Malignant lymphomas of the thyroid gland are exceedingly rare, accounting for 2% of thyroid cancers, out of which the literature reveals a single case report of THRLBCL arising from the thyroid. THRLBCL represents an aggressive form of lymphoma and is treated according to stage-matched DLBCL, although the effects of Rituximab in this population is variable. Conclusion: Hashimoto’s is considered a risk for thyroid lymphoma usually diffuse large B-cell lymphoma and MALT lymphoma. We present a rare case of THRLBCL occurring in the setting of Hashimoto’s with acute thyroid gland enlargement.

P06. First do no harm: Reducing morbidity from excision biopsy of axillary lymph nodes

Background: Often no guidelines exist within a hospital for the appropriate pathway for unexplained axillary lymphadenopathy. Excision biopsy of axillary lymph nodes is a morbid procedure. It is frequently done on the emergency list by the on call surgical registrar or at the end of a busy breast list. We should think again.

Lennert Lymphoma (lymphoepithelioid lymphoma) with Extensive Necrosis: A Case Report

Lennert lymphoma (lymphoepitheloid lymphoma) is an extremely rare variant of peripheral T-cell lymphoma, not otherwise specified. Here we report a case of Lennert lymphoma diagnosed in a 57-year-old woman. She had a three-year history of waxing and waning lymphadenopathy with a rapid increase in size in the past four months before presentation. A needle biopsy and a fine needle aspiration were non-diagnostic due to extensive necrosis. The patient underwent a right neck lymph node excisional biopsy which showed the lymph node architecture was effaced by numerous and sometimes confluent clusters of epithelioid histiocytes and infiltration of small lymphocytes. Extensive necrosis was present. Immunohistochemical stains revealed a mixed population of B- and T-cells with the T-cells showing diminished T-cell markers CD3, CD5, and CD7. Flow cytometric analysis detected a small population (7% of total lymphocytes) of CD4-positive T-lymphocytes with loss of CD3, CD5, and CD7 expressions. PCR-based T-cell receptor gene rearrangement studies showed positive results (clonal peaks) in both gamma and beta genes. Stains for microorganisms were negative. The overall findings indicate Lennert lymphoma. To our knowledge, this is the first reported case of Lennert lymphoma with extensive necrosis. The patient is undergoing chemotherapy. The diagnosis of Lennert lymphoma can be challenging, particularly in cases with extensive necrosis. Our case highlights that adequate sampling is important in the investigation of patients with suspected Lennert lymphoma. A careful pathologic examination with ancillary studies including flow cytometry, immunohistochmistry, and cytogenetic and molecular studies leads to the accurate diagnosis.

Primary cutaneous T-cell lymphomas in childhood and adolescence.

Primary cutaneous lymphomas are extranodal non-Hodgkin lymphomas of T- or B- cell origin, that predominantly affect older patients but have been reported in all age groups and as early as in the first years of life. Diagnosis of cutaneous lymphomas is challenging and requires high clinical suspicion and close collaboration between dermatologists, pediatric oncologists and pathologists. Skin involvement of non-Hodgkin lymphomas in children or adolescents can either be primary cutaneous or secondary due to an underlying nodal lymphoma. The most common primary cutaneous lymphomas encountered in children are of T-cell origin, with mycosis fungoides being the most prevalent cutaneous T-cell lymphoma, followed by CD30+ lymphoproliferative disorders. While cutaneous lymphomas share clinicopathologic characteristics between juvenile and adult forms, there are important differences in terms of clinical presentation, diagnosis and treatment. The hypopigmented variant of mycosis fungoides seems to be overrepresented in the pediatric age group. Prognosis and treatment of mycosis fungoides are stage dependent. The majority of children present with early-stage disease and respond well to topical corticosteroids and phototherapy.

A woman with visual loss, amenorrhoea and polyuria: the first reported case of nodular lymphocyte-predominant Hodgkin lymphoma presenting with hypopituitarism.

SummaryA 34-year-old woman presented 18 months post-partum with blurred vision, polyuria, amenorrhoea, headache and general malaise. Comprehensive clinical examination showed left superior temporal visual loss only. Initial investigations revealed panhypopituitarism and MRI demonstrated a sellar mass involving the infundibulum and hypothalamus. Lymphocytic hypophysitis was suspected and high dose glucocorticoids were commenced along with desmopressin and thyroxine. However, her vision rapidly deteriorated. At surgical biopsy, an irresectable grey amorphous mass involving the optic chiasm was identified. Histopathology was initially reported as granulomatous hypophysitis. Despite the ongoing treatment with glucocorticoids, her vision worsened to light detection only. Histopathological review revised the diagnosis to partially treated lymphoma. A PET scan demonstrated avid uptake in the pituitary gland in addition to splenic involvement, lymphadenopathy above and below the diaphragm, and a bone lesion. Excisional node biopsy of an impalpable infraclavicular lymph node confirmed nodular lymphocyte-predominant Hodgkin lymphoma. Hyper-CVAD chemotherapy was commenced, along with rituximab; fluid-balance management during chemotherapy (with its requisite large fluid volumes) was extremely complex given her diabetes insipidus. The patient is now in clinical remission. Panhypopituitarism persists; however, her vision has recovered sufficiently for reading large print and driving. To the best of our knowledge, this is the first reported case of Hodgkin lymphoma presenting initially as hypopituitarism.Learning pointsLymphoma involving the pituitary is exceedingly rare and, to the best of our knowledge, this is the first reported case of nodular lymphocyte-predominant Hodgkin lymphoma presenting as hypopituitarism.There are myriad causes of a sellar mass and this case highlights the importance of reconsidering the diagnosis when patients fail to respond as expected to appropriate therapeutic intervention.This case highlights the difficulties associated with managing panhypopituitary patients receiving chemotherapy, particularly when this involves large volumes of i.v. hydration fluid.