Question 1

A 56 year old man noticed increased fatigue,night sweats,and enlarged lymph nodes in his right axilla.He consulted his physician,a biopsy was done,and a representative section from the biopsy is shown in the accompanying photomicrograph.The right panels show staining for Bcl-2,with a normal lymph node shown in the bottom panel (GC = germinal centre,MZ = mantle zone).Which one of the following is the best diagnosis?

A)Diffuse large B cell lymphoma
B)Follicular hyperplasia
C)Follicular lymphoma
D)Hodgkin's lymphoma
E)Metastatic carcinoma

Follicular lymphoma

Accepted Answer

The follicle-like structures (F)are typical of follicular lymphoma,often involving the perinodal fat.The lymphoma is low grade and grows slowly,but is considered incurable with currently available therapy.Most cases are characterised by a specific chromosomal abnormality,t(14;18),which juxtaposes the immunoglobulin heavy chain (IgH)gene on chromosome 14 with the gene for the anti-apoptotic protein Bcl-2 on chromosome 18.Because IgH is expressed in normal mature B cells,this chromosomal rearrangement results in overexpression of Bcl-2 protein within the tumour cells and so these cells effectively avoid the normal pathway of apoptotic destruction.In normal reactive lymph nodes,the cells of the mantle zone "MZ" are Bcl-2 positive but germinal centre cells "GC" are Bcl-2 negative (c).In contrast,strong Bcl-2 positivity is characteristically seen within the neoplastic follicles "F" in follicular lymphoma (b).

Question 2

An enlarged mesenteric lymph node was removed from the abdomen of a 64 year old man at autopsy after he died in a motor vehicle accident.A representative section is shown in the accompanying photomicrograph.Which one of the following is the best diagnosis?

A)Diffuse large B cell lymphoma
B)Follicular hyperplasia
C)Follicular lymphoma
D)Hodgkin's lymphoma
E)Metastatic carcinoma

Metastatic carcinoma

Accepted Answer

At low power,you can see a tumour (T)replacing normal lymph tissue in the upper half of the node,and distorting the overall architecturE"N" denotes a small area of necrosis,typical of metastatic carcinomas.

Question 3

A 73 year old man complained to his physician about incapacitating back pain.An x-ray of the spine disclosed osteosclerotic lesions throughout the lumbar spine.A biopsy was performed,and a representative section is shown in photomicrograph "a".Photomicrograph "b" shows an immunoperoxidase stain.Antibodies against which one of the following antigens was likely used in the immunoperoxidase stain shown?

A)Albumin
B)Cytokeratin
C)Oestrogen
D)Myosin
E)Prostate specific antigen (PSA)
F)Troponin I

Prostate specific antigen (PSA)

Accepted Answer

Photomicrograph "a" shows an adenocarcinoma with new bone formation (B).Prostate cancer is likely in this age group,and it tends to metastasise to the spinEAdditionally,it usually forms osteosclerotic metastatic lesions.Thus,PSA would be a good antigen to try to detect with immunoperoxidase staining,in order to confirm prostatic origin for the adenocarcinomA

Question 4

A 45 year old man with a previous history of untreated follicular lymphoma developed multiple lymph nodes that were enlarging quickly.Biopsy of one of these nodes was performed,and a representative section is shown in the accompanying photomicrograph.Which one of the following is the best diagnosis?

A)Diffuse large B cell lymphoma
B)Follicular hyperplasia
C)Follicular lymphoma
D)Hodgkin's lymphoma
E)Metastatic carcinoma

Accepted Answer

Diffuse large B cell lymphoma is commonly seen in association with low grade lymphomas,such as chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)or follicular lymphomAThese neoplasms can transform to more aggressive,faster growing diffuse large B cell lymphomas.Ironically,higher grade lymphomas are sometimes easier to treat and cure,because the chemotherapy works better on rapidly dividing cells.

Question 5

A 66 year old man saw his local physician for severe lower back pain.He had tried homeopathy and chiropractic manipulation,but nothing seemed to help.An x-ray of the spine revealed a lytic lesion at the L4 level,with collapse of the vertebral body.A spinal fusion was done,and a biopsy was sent to surgical pathology.A representative section of the biopsy is shown in the accompanying photomicrograph.Which one of the following is the best diagnosis?

A)Follicular lymphoma
B)Metastatic carcinoma
C)Multiple myeloma
D)Normal bone marrow
E)Osteoporosis

Accepted Answer

Most of the cells in the biopsy can be identified as plasma cells,from their peripheral chromatin and the fan-shaped cytoplasm.The lytic lesion of the spine is typical.If serum electrophoresis were available,it would show a monoclonal spike of gamma globulin,due to immunoglobulin synthesis by the neoplasm.

Question 6

A 14 year old boy suffered from a splinter in his right finger,which became infected and inflamed.A large lymph node was found near his elbow,which his mother insisted must be removed.A representative section from the enlarged lymph node is shown at right in the accompanying photomicrograph,along with a normal lymph node that was removed at the same time.Which one of the following is the best diagnosis for the abnormal lymph node?

A)Diffuse large B cell lymphoma
B)Follicular hyperplasia
C)Follicular lymphoma
D)Hodgkin's lymphoma
E)Metastatic carcinoma

Accepted Answer

The history suggests a benign,inflammatory process,which is confirmed by the histological appearancEThe follicles (F)encroach on the medulla,but do not move outside the capsule (as is often the case in follicular lymphoma).

Deck 16: Lymphoid and Haematopoietic Systems