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广东省2008年1月病理读片会(二)

 


更新时间:2008-01-24 12:05:45  出片单位:广州金域医学检验中心病理诊断部

 

 

病例1 (病理号0749054)
病 史:患者男,52岁,发现右腋窝肿块一个月。全身其它处淋巴结、肝、脾未见异常。
大体所见:灰红多结节组织一堆,总体积7×6×4.5cm,结节直径0.8~2.0cm,包膜完整,切面灰红质脆。
临床诊断:淋巴瘤?


请讨论


病理特点:
⑴ 正常淋巴结结构完全破坏;
⑵ 新生中心细胞与中心母细胞样淋巴细胞弥漫克隆性增生;
⑶ 另有许多上皮样组织细胞成不规则团状散在。

免疫组化:
瘤细胞
阳性:CD20、CD79a、bcl-2
阴性:CD10、CD38、CD3、CD45Ro、CD30、cyclinD1、TdT;
上皮样细胞:CD68(+)、CK(-);CD21、CD23显示片状的FDC;

病理诊断:
(腋窝淋巴结)弥漫性大B细胞淋巴瘤,伴上皮样组织细胞反应(DLBCL—ER)

讨论:本例为DLBCL伴上皮样组织细胞反应,十分少见。国内未见报告,而国外已有50例报告。简介如下:
Centroblastic and centroblastic/centrocytic lymphoma associated with a prominent epithelioid granulomatous response: a clinicopathologic study of 50 cases. (Kojima M et al ,Mod pathol 2002;15(7):750-8)

Background
Diffuse large B-cell lymphoma is a heterogeneous category of lymphoma
Large B-cell lymphoma is sometimes accompanied by a reactive component comprising small lymphocytes, plasma cells, eosinophils, and histiocytes
Centroblastic
Immunoblastic
T-cell/histiocyte rich
Anaplastic
Centroblastic or centroblastic/centrocytic lymphomas with a prominent epithelioid response.

DLBCL-ER?????

MATERIALS AND METHODS

Reviewed 50 patients with LBCL-ER and 167 other (DLBCL) and 94 follicular lymphomas (FL)

RESULTS
Comparied with DLBCL:
LBCL-ER showed a higher age distribution (median 71, P =.03),
A female predominance (M:F = 18:32, P =.001)
Less frequent involvement of extranodal sites >1(P=.004
A bulky mass of the affected lymph nodes in 54% of cases.

Compared with FL:
Older age (P =.0006)
More associated with the aggressive clinical factors such as serum LDH level and International Prognostic Index score

Histological Findings (Low magnification)
Histological features of centroblastic (n=46) or centroblastic/centrocytic lymphomas (n=4) with a prominent epithelioid response.

Nine lesions(18%; displayed a partial follicular growth pattern, and the other 41 (82%) showed a diffuse growth pattern.

At low magnification, thick trabecular fibrosis compartmentalized the lymph node parenchyma in 39 cases, producing a vague nodular pattern even in the diffuse lymphomas

Histological Findings (high magnification)

The majority of the tumor cells had round nuclei with fine nuclear chromatin and two to four small nucleoli,

A small number of immunoblasts,immunoblast-like cells, and medium-sized cells with cleaved nuclei were also seen

A few multilobulated centroblasts and multinucleated cells somewhat resembling Reed-Sternberg cells were observed in two cases

Histological Findings
low-power field of an affected node. Geographic epithelioid granulomatous response occupied 90% of the lymph node. (Case 5).Hematoxylin and eosin (HE), 10 x

Histological Findings
B, low-power field of an affected lymph node. Tubercular fibrosis compartmentalized the parenchyma producing a vague nodular pattern. Note the epithelioid cell accumulation in large and poorly demarcated masses (Case 5). HE 10

Histological Findings
C, high-power field of the affected lymph node. The tumor cells had large round or indented nuclei with small- to medium-sized nucleoli (Case 13). HE 100

D, high-power field of the affected lymph node. Note the binucleated cells. Epithelioid cells are diffusely infiltrating. (Case 24). HE 100 .
 


Immunohistochemistry
Positive for CD20 in every case
CD10 in 43% of the cases
BCL-2 in 56%
Negative for CD5 in the 40 cases
Immunostaining also often highlighted the remnants of the follicular dendritic cell network.
The BCL-2 gene rearrangement was detected in only 19% of the cases

Immunohistochemistry
E, positive membrane staining of tumor cells with CD10 antigens (Case 30).

F, positive membrane staining of mononuclear cells and spindle-shaped cells with CAN.42 antibody (Case 13).

Differential diagnoses
Lymphoepithelioid lymphoma (LeL):
*Small lymphocytes with round or somewhat irregular nuclei are the predominant cell form distributed over the entire lesion
*some medium-sized lymphoid cells and immunoblasts are always present.
*These tumor cells express the helper T cell phenotype.
*Epithelioid cells are usually accumulated in small, well-defined clusters.
*Conspicuous fibrosis of the tumor is absent.
*These features can be regarded as the landmarks that
distinguish LeLs from the present cases.

Differential diagnoses
Cat-scratch disease
Toxoplasmosis
Tuberculosis
The epithelioid cell response is frequently observed in association with the proliferation of the germinal center and/or monocytoid B cells in the granulomatous lymphadenitis

Prognosis
Overall survival for patients with CB and CBCCEP and FLCLEP .
The CBCCEP had a significantly poorer overall survival than those of FLCLEP

Prognosis
Overall survival for patients with CB and CBCCEP and DLBCLEP . The survival curves of both CB and CBCCEP and DLBCLEP are identical.

The survival curve of the cases of LBCL-ER was almost identical with
that of DLBCL and was significantly inferior to that of FL.

Conclusion
LBCL-ER may be regarded as the morphologic variant of DLBCL
Preferentially arising in the aged population
Reflecting the disease progression of FL.

病例2 ( 病理号0762817)
病 史: 患者男,69岁,发现右侧腹股沟肿物2个月,其它处和内脏无异常发现,过去无手术史。
大体所见:灰红碎组织一堆,体积2×1.5×0.5cm。
临床诊断:淋巴瘤,淋巴结结核


请讨论


病理特点:
⑴ 送检组织广泛坏死,其中散在不规则的片状、团状异型细胞,部分区域纤维间质增生分割成巢状;
⑵ 瘤细胞圆形或卵圆形,胞浆丰富,核膜清楚,单个核仁明显,核分裂象易见;

免疫组化:瘤细胞

阳性:CD30、CD20、CD79a、ALK(弱)
阴性:CD3、CD45RO、CK、CEA、 EMA、HMB45、MelanA。

病理诊断:
(右腹股沟)淋巴结间变性大B细胞淋巴 瘤,广泛坏死。

鉴别诊断与讨论
由于瘤细胞成片、巢状,核仁明显,应与下列肿瘤鉴别。
⑴转移性低分化癌;CK(-)、EMA(-)、CEA (-) ;
⑵恶性黑色素瘤:HMB45(-)、MelanA (-)
⑶恶性淋巴瘤:本例确诊为特殊的间变性大B细胞淋巴瘤,因广泛坏死和纤维增生,瘤细胞成巢易误为转移性癌或恶黑,应从中总结经验;
⑷间变性大B细胞淋巴瘤为DLBCL的一种变异型,相对比较少见。

病例
H0774538 男 60岁,发现左侧颌下2×3×3cm肿块3天,余无特殊不适。术中见肿物与周围组织无粘连。
 


弥漫性大B细胞淋巴瘤 vs Burkitt’s 淋巴瘤?

Burkitt’s Lymphoma
Epidemic
Sporadic
Immunodeficiency associated

Variants:
BL with plasmacytoid
Atypical Burkitt’s/Burkitt’s like

Morphology
The medium-sized cells with diffuse monotonous pattern of infiltration

Squared off boarders of retracted cytoplasm after fixation

Round nuclei with clumped chromatin and multiple basophilic
centrally situated nucleoli

Extremely high proliferation rate

Starry sky pattern

Immunohistochemistry
CD19,CD20,CD22, CD10,BCL-6 (+)
CD5,CD23,BCL-2(-)
CD21(+) in Epidemic cases and (-) in sporadic cases
Ki67 nearly 100% positive

Genetics
All cases have a translocation of MYC at band q24 from chromosome 8 to the Ig heavy chain region on chromsome 14 [t(8;14)]

例3 (病理号0754346)

病 史:患者女,25岁,孕39周子宫下段剖宫足月产。术中见左卵巢体积10×8×6cm,卵巢切面囊实性,见多个小囊腔,直径0.2~0.5cm,内含水样物。未提供胃肠道有无确切肿瘤史。
大体所见:灰红肿物一个,已切开,体积11×8×3cm,表面尚光滑。切面灰红、灰黄,囊实性,质中。
临床诊断:左卵巢肿瘤?
 


请讨论


病理特点:
⑴ 卵巢包块,切片中见到卵泡结构;
⑵ 有两种形态的细胞:
●在淋巴管、小血管和间质中有散在成 巢的印戒状瘤细胞浸润;
●弥漫或散在卵圆形、胞质强嗜酸性细胞,核小圆形、深染,无核分裂象,围绕卵泡周边分布。

免疫组化:
瘤细胞CK(+)、EMA(+)、AB/PAS(+);
间质内嗜酸性细胞Inhibin(+),vimentin(+),上皮标记(-)。

病理诊断:
卵巢转移性印戒细胞癌(Krukenberg tumor),伴卵泡膜细胞黄素化。

鉴别诊断与讨论
⑴ 卵巢Krukenberg瘤,最常见于胃癌转移,且双侧较多,但亦有卵巢原发性印戒细胞癌。本例患者为一产妇,临床无胃肠道检查资料。
⑵ 本例另外伴有卵泡膜细胞黄素化的少见改变。黄素化细胞是卵泡膜细胞对孕期绒毛膜促性腺激素的反应性改变。

例4 (病理号0702980)
病 史:患者女, 56岁,左下腹痛4天,左肾区叩击痛明显。入院检查:葡萄糖(GLU)21.7↑(3.85-6.11);尿素氮(BUN)7.0 (1.7-8.2);肌酐(CREA)66(44-133);尿素氮/肌酐 0.106↑(0.055-0.057)。B超:左肾盂内实性占位性病变。CT:1.左肾及肾周感染; 2.左肾占位; 3.双肾结石。手术记录:左肾及左输尿管切除术,术中见左肾重度扩张,吸出脓稠黄色脓液,输尿管无扩张,考虑脓肾。术后检查:葡萄糖(GLU)6.3 (3.85-6.11);尿素氮(BUN)7.0(1.7-8.2);肌酐(CREA)79(44-133);尿素氮/肌酐0.089↑(0.055-0.057)。既往有糖尿病、高血压病史。

大体所见:肾脏一个,表面灰红覆脓苔,体积14×8×8cm,切面灰红、灰黄,可见4个囊腔,直径2~3.5cm,内含脓液,部分区域出血,连一段输尿管,长10cm,直径0.3cm,中段见一直径0.5cm结石。
临床诊断:脓肾

病理特点:
肾实质局部组织结构破坏,见单核、多核组织细胞及少量淋巴细胞、浆细胞弥漫性
浸润,纤维组织增生,似黄色肉芽肿,组
织细胞胞浆中或细胞外见到靶环Michaelis
-Gutmann小体,PAS(+)。

病理诊断:

(右侧)肾软斑病(malakoplakia)

鉴别诊断与讨论
⑴ 主要与黄色肉芽性肾盂肾炎区别:本病在组织细胞内外可见到M-G小体是唯一特点;
⑵ M-G小体的形成,认为是由于巨噬细胞的溶酶体功能障碍,胆碱功能受抑制所致,目前尚不十分清楚;
⑶本例为少见病例,提供给大家参考。

 

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