Case 654 -- An 86 year-old female with a history of hematolymphoid neoplasia

Contributed by Lin Liu, MD, PhD and Miroslav Djokic, MD


CLINICAL HISTORY

The patient is an 86 year-old female with a history of hematolymphoid neoplasia diagnosed in 2007. She last received chemotherapy in 2007. She now presents with leukocytosis and thrombocytopenia.

The peripheral blood smear was reviewed (Figure 1).

RED BLOOD CELL MORPHOLOGY: Mild anisocytosis, occasional ovalocytes and occasional teardrop cells (Figure 1).

WHITE BLOOD CELL MORPHOLOGY: Numerous blasts with high N/C ratio, cup-shaped nuclei, fine chromatin pattern, and distinct nucleoli are present (Figure 2). A distinct population of atypical lymphocytes with bipolar tuft-like cytoplasmic projections is also present (Figure 3). Neutrophils are markedly decreased and without overt dysplastic change.

PLATELETS are decreased.

BONE MARROW: The touch imprints are adequate for evaluation (2 touch imprints reviewed) (Figures 6 and 7). The marrow biopsy is adequate for interpretation.

The bone marrow is markedly hypercellular (95%). The bone marrow architecture is completely effaced by extensive leukemic infiltrate (Figure 4). The blast morphology is identical to that described in peripheral blood (Figures 5, 6 and 7). Several small lymphoid aggregates with crush artifact are also noted (Figure 8). Erythroid and myeloid cell lines are rarely seen and difficult to evaluate. Bony trabeculae are unremarkable. Rare megakaryocytes are noted. Reticulin stain shows focally moderate fibrosis (Figure 9).

PARAFFIN SECTION IMMUNOHISTOCHEMISTRY

To further characterize the small lymphoid aggregates, paraffin section immunohistologic studies were performed on the marrow biopsy. The following results were found (Figure 10):

FLOW CYTOMETRY

Flow cytometric immunophenotypic studies performed on the bone marrow aspirate demonstrate abnormal blasts population comprising approximately 90% of the total cells analyzed with the following immunophenotype; CD45 dim positive, CD34 negative, HLA-DR negative, CD117 dim positive, CD7 negative, CD56 positive, CD33 positive, CD14 negative, CD19 negative (Figures 11 and 12). A second distinct population of lambda restricted B-cells that comprises 4% of the total cells is seen. The B-cells have the following phenotype: CD20 positive, CD22 positive, CD19 positive, CD38 negative, CD5 negative, CD10 negative (Figures 13 and 14). Also present are a few heterogeneous T-cells, a few granulocytes and rare monocytes.

CYTOGENETIC STUDIES

46, XX
Apparently normal female bone marrow chromosome analysis.

FINAL DIAGNOSIS


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