case_images: PMC5428247_01
case_images: Histologic features of the patient's excisional biopsy performed in 2012. (A) and (B) Hematoxylin-eosin sections at x100 and x400 magnification, respectively, showing effacement of lymph node architecture by neoplastic follicles containing centroblasts and centrocytes. Immunohistochemical studies confirm the diagnosis of follicular lymphoma, showing that the lymphocytes are B cells (CD20+) that express CD10 and BCL2. Ki67, the proliferation antigen, is expressed in 40% to 50% of B cells.
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case_images: The largest of nodal areas measured 6.2 cm x 2.5 cm, and an excisional biopsy of a lymph node from the neck demonstrated grade 3A FL (Figure 1).
case_images: (A) Positron emission tomography with computerized tomographic (PET/CT) coronal image: fused arrows point to enlarged left cervical, bilateral axillary, retroperitoneal nodes, and spleen with severely increased 2-deoxy-2-[fluorine-18] fluoro-d-glucose uptake. (B) and (C) CT-PET sagittal spine and coronal images: intensely increased and diffuse marrow uptake, with resolution of multifocal sites of bulky adenopathy above and below the diaphragm, as well as complete resolution of splenic involvement.
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case_images: A subsequent positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with CT (18F-FDG PET/CT) showed widespread adenopathy with increased uptake in the neck, chest, abdomen, and pelvis with diffuse splenic involvement and marrow involvement of C2, T10, and L3 vertebral bodies (Figure 2A). A restaging 18F-FDG PET/CT in January 2016 showed increased diffuse marrow uptake most notably involving vertebral bodies T7, T8, and T11 with the area of SUVmax in the right aspect of T8 of 11.4 (Figure 2B and 2C).
case_images: Histologic features of the patient's bone marrow biopsy in 2016. Replacement of the bone marrow by lymphoma (hematoxylin-eosin, original magnification x100 and x400). Wright-Giemsa-stained slide showing atypical lymphoid cells with some small- to intermediate-sized cells with round nuclei, fine chromatin, and small amounts of basophilic cytoplasm with vacuoles (x1000). Immunohistochemical studies showed that the tumor cells express PAX5 and partial terminal deoxynucleotidyl transferase (TdT) and c-MYC and are negative for CD20 and CD34.
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case_images: The large atypical cells expressed PAX5, CD10, BCL2, and c-MYC and were negative for CD20, MPO, CD34, CD30, and BCL6 (Figure 3).