J Yeungnam Med Sci.  2023 Nov;40(Suppl):S113-S122. 10.12701/jyms.2023.00584.

Classical Hodgkin lymphoma following follicular lymphoma: a case report

• Kim B

• KMID: 2548352
• DOI: http://doi.org/10.12701/jyms.2023.00584

Abstract

The simultaneous, composite, or sequential occurrence of follicular lymphoma (FL) and classical Hodgkin lymphoma (HL), both of which originate from germinal center B-cell, is rare. Questions have been raised with regard to the type of tests that pathologists should perform when observing the presence of a “large-cell lymphoma” following an FL and what are the most critical pathological points for diagnosis. Here, we present a case of a classical HL following an FL after administering rituximab-bendamustine (R-Benda) chemotherapy. Furthermore, we also summarized the literature and compared this case with other HLs that followed FLs. A 55-year-old woman was diagnosed with a grade 3A FL of the breast and axillary lymph node masses. She completed six R-Benda chemotherapy cycles for stage IV FL. Twenty-three months after the diagnosis, follow-up image studies showed an increase in the size and number of the lesions. Biopsies of the neck lymph node and liver were performed, and the diagnosis was classical HL. Sequential or composite FL and HL may sometimes develop from the same clone because they share the same genetic alterations, such as B-cell lymphoma (Bcl)-2 or Bcl-6 translocation. When a large-cell lymphoma is found after the treatment of FL, classical HL should be considered a pathological differential diagnosis, and histological, immunohistochemical, or molecular investigations must be considered during the diagnostic process.

Keyword

Follicular lymphomas; Hodgkin disease; Immunoglobulin heavy chain genes; Proto-oncogene protein c-bcl-2

Figure

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  Fig. 1. Chest computed tomography (CT) images display multiple subcutaneous enhanced masses (arrows) measuring (A) 29 mm at the right lower back, (B) 17 mm at the mid-back, and (C) 12 mm at the left breast. (D) No abnormal findings are observed in the neck CT.

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  Fig. 2. Microscopic findings of the left breast. (A) Low-power magnification revealing a proliferation of neoplastic follicles with slight size variation and attenuated mantle zone (hematoxylin and eosin [H&E] stain, ×40). (B) Abnormal follicular growth patterns extending to the fatty tissue outside the lymph node through the lymph node capsule (H&E stain, ×40). (C) Neoplastic follicles predominantly composed of centroblasts, consistent with follicular lymphoma, grade 3A. Tingible body macrophages are absent (H&E stain, ×400). (D) CD21 immunohistochemistry highlighting follicular dendritic cell meshworks inside and outside the lymph node (CD21 immunohistochemistry, ×40). (E) Anti-CD20 (CD20 immunohistochemistry, ×40) and (F) anti-Bcl-6 antibodies reacting to tumor cells (Bcl-6 immunohistochemistry, ×100). (G) Sparse CD10-positive cells observed in neoplastic follicles (CD10 immunohistochemistry, ×100). (H) Bcl-2 expression in neoplastic follicles (Bcl-2 immunohistochemistry, ×100). (I) The Ki67 labeling index with 50% of tumor cells ratio (Ki-67 immunohistochemistry, ×400).

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  Fig. 3. Positron emission tomography (PET) images. (A) Stage workup revealing fluorodeoxyglucose uptake in bilateral posterior shoulder, back, flank, bilateral breast, left axilla, and diaphragmatic lesions. (B) PET during regular check-up after the diagnosis of follicular lymphoma shows a new lesion in the left supraclavicular, mediastinal, and left axillary lymph nodes. (C) Enlarged lymph nodes of the right supraclavicular area and lateral neck, exhibiting internal necrosis (arrow). (D) Abdomen computed tomography displaying multiple small low-density nodules in both livers (arrows).

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  Fig. 4. Microscopic findings of the supraclavicular lymph node and liver. (A) Lymph node effaced by the proliferation of large histiocytoid cells with extensive necrosis (hematoxylin and eosin [H&E] stain, ×40). (B, C) High magnification view showing scattered Reed-Sternberg cells admixed with histiocytes (H&E stain, ×400). (D) CD30 immunohistochemistry revealing positive staining in Reed-Sternberg cells (CD30 immunohistochemistry, ×400). (E) Weaker to PAX-5 antibody reactivity in large cells compared to strongly positive non-neoplastic B-cells (PAX-5 immunohistochemistry, ×400). (F) MUM1 expression in the nuclei of tumor cells (MUM1 immunohistochemistry, ×400). (G) Weak expression of Bcl-6 in the nuclei of tumor cells (Bcl-6 immunohistochemistry, ×400). (H) Liver biopsy showing a nodular proliferation of lymphoid cells with fibrosis (H&E stain, ×100). (I) High-power view of the liver biopsy, revealing Reed-Sternberg cells and histiocytes identical to that of the lymph node biopsy (H&E stain, ×400).

Reference

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