Cytologically Yours: CoW: 20131202

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Contents

Clinical Summary

The patient is an 60 year old male with a remote history of an abdominal melanoma that was excised with negative margins. The patient has been experiencing lower back pain for the past several months and has received epidural injections. As a part of the workup, the patient had a CT which revealed retroperitoneal lymphadenopathy. A CT guided fine needle aspiration and biopsy of a paracaval lymph node was performed.

Past Medical History

  • 2003 Melanoma
  • Diabetes
  • Hypertension

Past Surgical History

  • 2013 Arthroscopic knee surgery
  • 2003 Excision of melanoma
  • 2002 Discectomy


Clinical Plan

The differential diagnosis for otherwise asymptomatic lymphadenopathy in this patient is melanoma, lymphoma, or occult malignancy.

Radiology

  • PET CT showed hypermetabolic activity with an SUV of 12.7.
  • CT of abdomen and pelvis showed adenopathy adjacent to the aorta and inferior to the vena cava at the level of the right kidney. The largest node measured 4 cm in greatest dimension.


Pathology

Cytology


Resident Questions


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Final Diagnosis

Cytology

  • Positive for malignancy, the differential diagnosis includes melanoma and Hodgkin lymphoma.


Biopsy

Biopsy Diagnosis

  • Classical Hodgkin lymphoma, favor mixed type.
    • CD15 Positive in tumor cells
    • CD30 Positive in tumor cells
    • PAX5 Weakly positive
    • CD20 Positive in background lymphocytes
    • CD3 Positive in background lymphocytes
    • S100 Negative
    • Mart1 Negative
    • HMB45 Negative

Discussion

The features of Hodgkin lymphoma include atypical (Hodgkin cells) and Reed-Sternberg cells. The nucleus should be 3-4x the size of a small lymphocyte. In classic Hodgkin lymphoma, scattered eosinophils, plasma cells, histiocytes, and a predominately CD3+ lymphocyte population will be seen in the background. The immunophenotype of classic Hodgkin lymphoma shows CD15, CD30, MUM1, and weak PAX5 positivity. Histology is usually needed to subtype Hodgkin lymphoma.