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case_images: - A- Asymmetric enlargement of the right cheek; B and C- Surgical exeresis of the intraparotid lymph node; D- Sectioning surface of the lymph node.
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case_images: A 32-year-old caucasian male patient sought the Surgery department at the University Hospital of the University of Sao Paulo, complaining of right cheek swelling for about one year (Figure 1A). The right parotid gland was operated on by trans-node excision in order to preserve the facial nerve (Figures 1B,C). On sectioning surface the tissue showed a light brown color, smooth appearance and elastic consistency (Figure 1D).
case_images: - Photomicrography - Cytologic examination of the intraparotid lymph node aspirate. A- (Papanicolau stain, 400X) large cells (black arrow) with irregular enlarged nuclei and macronucleoli; B- (Dry panotic stain, 1000X) Large atypical cell in a background of small lymphocytes and eosinophils (white arrow).
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case_images: The patient was submitted to a fine needle aspiration (FNA) biopsy and the cytologic analysis revealed scarce cells with large multilobed and convoluted nuclei, with nuclear membrane irregularity and macronucleoli, highly suggestive of Hodgkin lymphoma (HL) diagnostic cells (Figure 2A). These cells were present in a background containing a large number of small polymorphic lymphocytes, frequent eosinophils (Figure 2B) and rare aggregates of histiocytes in an outline of granulomas.
case_images: - Photomicrography - Histologic examination of the intraparotid lymph node. (hematoxilin & eosin) A- Panoramic view (100X) Diffuse, imprecise multinodular lymphoid proliferation, with reactive granulomas (arrow); B- (400X) Large atypical cells (arrow) in a background rich in small lymphocytes.
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case_images: Large cells with the same characteristics observed in the FNA were distributed in a nodular background composed of small lymphocytes and numerous reactive granulomas formed by epithelioid histiocytes (Figures 3A,B).
case_images: - Photomicrography - Immunohistochemistry. A- (400X) positivity for CD20 in the L&H cell (arrow); B- CD68+ reactive granulomas.
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case_images: On immunohistochemistry analysis, the large cells were CD20 positive (Figure 4A), CD15 negative, CD30 negative, CD10 negative, EMA negative and CD3 negative. The reactive histiocytes and granulomas were CD68+ (Figure 4B) and a network of expanded follicular dendritic cells within the nodules was demonstrated by the positivity for CD21.