INTERESTING CASE

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INTERESTING CASE
PRESENTED BY NICOLE BAILEY SUNY UPSTATE MEDICAL
UNIVERSITY CYTOTECHNOLOGY 2008
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PRIMARY DIFFUSE LARGE B-CELL LYMPHOMA OF THE
BREAST
CASE PRESENTED IN GENEVA GENERAL HOSPITAL OF
GENEVA, NEW YORK
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CLINICAL PRESENTATION

• 75 YEAR OLD FEMALE
• ROUTINE MAMMOGRAM SHOWED AN AREA OF INCREASED
  DENSITY IN UPPER QUADRANT OF RIGHT BREAST
• 4.2 X 3.4 X 5 CM PALPABLE MASS WITH IRREGULAR
  BORDERS DISCOVERED ON FOLLOW UP ULTRASOUND EXAM
• FNA PROCEDURE PERFORMED ON MASS
• CT SCAN OF CHEST, ABDOMEN AND PELVIS SHOWED NO
  OTHER LESIONS OF CONCERN

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CYTOLOGY/HISTOLOGY

• FNA
• 2 FIXED SLIDES AND 10 ML OF PINKISH FLUID WERE
  RECEIVED IN PATHOLOGY LABORATORY
• PROCESSING
• FIXED SLIDES WERE STAINED WITH PAPANICOLAOU(PAP)
  STAIN
• SUREPATH WAS DONE ON FLUID AND PAP STAINED
• 5-14 GAUGE CORE BIOPSY SAMPLES WERE PREPARED AND
• STAINED WITH HEMATOXYLIN AND EOSIN (HE)
• CORE BIOPSY SLIDES WERE SUBMITTED FOR
  IMMUNOSTAINS

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CYTOLOGY FINDINGS

• ALL CYTOLOGY SLIDES REVEALED A VERY CELLULAR AND
  DIFFUSE PATTERN OF LYMPHOCYTES

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(No Transcript)
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HISTOLOGY FINDINGS

• FAT AND FIBROUS TISSUE INFILTRATED BY
  LYMPHOCYTES

• FOLLICLES AND GERMINAL CENTERS NOT FORMED

• MEDIUM TO LARGE SINGLE LYMPHOCYTES THAT HAVE
  ABNORMAL AND LOBULATED NUCLEI WITH APPARENT
  NUCLEOLI AND RARE MITOSIS

• NO EPITHELIAL OR REED-STERNBERG CELLS
  IDENTIFIED

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IMMUNOSTAINS
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IMMUNOSTAINS
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DIAGNOSIS
ALONG WITH CYTOLOGY, HISTOLOGY, AND RADIOLOGY
FINDINGS
PRIMARY DIFFUSE LARGE B-CELL LYMPHOMA OF THE
BREAST
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BACKGROUND INFO ON DLBCL
(DIFFUSE LARGE B-CELL LYMPHOMA)

• AGGRESSIVE NON-HODGKINS LYMPHOMA
• MOST COMMON OF NON-HODGKINS LYMPHOMAS 30-40
  INCIDENCE AMONG THESE LYMPHOMAS
• BOTH GENDERS AFFECTED, MEN SLIGHTLY HIGHER THAN
  WOMEN
• MEDIAN AGE IS ABOUT 57 YEARS OLD, RANGE 10-88
  YEARS
• INCIDENCE INCREASES WITH AGE
• GENERALLY BECOMES METASTATIC, AFFECTING THE GI,
  TESTES,THYROID,SKIN, BREAST,SPLEEN,BONES, AND
  CNS.

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DLBCL CONT...

• NO KNOWN CAUSE
• LINK OF GENETIC FACTORS INCLUDING BCL-2 AND BCL-6
  GENE REARRANGEMENT
• ANCILLARY TESTING (IMMUNOSTAINS) ARE THE BEST
  FORM OF TESTING FOR THE DIAGNOSIS

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CYTOLOGICAL CRITERIA

• DIFFUSE PROLIFERATION OF ABNORMAL LYMPHOCYTES
• NUCLEI CAN HAVE ABNORMAL AND/OR LOBULATED
  CONTOURS
• PROMINENT NUCLEOLI

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INTERESTING CASE
PRIMARY FOR DLBCL

• UNCOMMON TO ARISE IN THE BREAST BECAUSE
  THERE IS NOT AS MUCH CONTACT WITH LYMPH NODES
• MORE COMMON TO ARISE IN THE
  GASTROINTESTINAL TRACT, THE SPLEEN, OR ADRENAL
  GLANDS.

ONLY ABOUT 2 DLBCL CASES ARE BREAST PRIMARIES
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DIFFERENTIALS

• SMALL BLUE CELL TUMORS

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Differential Diagnosis Small blue cell tumors
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DIFFERENTIAL DIAGNOSIS
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TREATMENT/THERAPY

• CHOP-14 FOR YOUNGER PATIENTS
• CHOP-21 FOR OLDER PATIENTS
• RITUXIMAB TARGETS CD-20 LYMPHOMAS

• 40 LONGTERM SURVIVAL RATE WITH THIS TREATMENT

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FOLLOW UP

• MARCH 10TH FOLLOW UP CT SCAN TO REVIEW
  NEOPLASTIC LESION AND METASTASIS

• THE LOBULATED MASS HAD DECREASED TO 2.1 x 1.1 cm
  COMPARED TO THE 6.1 x 4.4 cm MASS BEFORE.
• THE SIZE OF THE ANXILLARY LYMPH NODES DECREASED
• STILL NO OTHER SIGNS OF METASTASIS TO ANY OTHER
  SITE IN THE BODY.

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WORKS CITED
1. Diffuse Large B-Cell Lymphoma. Available at
http//www.thedoctorsdoctor.com/diseases/lymphoma_
dlbcl.htm. 2. STATdxPATHIQ IMMUNOQUERY
IDENTIFICATION. Available at www.immunoquery.com2
008. 3. Non-Hodgkin's Lymphoma Defined.
Available at www.rituxan.com2008. 4. Diffuse
Large Cell Lymphoma. Available at
www.lymphomainfo.net2008. 5. Berglund M,
Thunberg U, Amini R. Evaluation of
immunophenotype in diffuse large B-cell lymphoma
and its impact on prognosis. Modern Pathology.
200518113-1120. 6. Chang CC, McClintock S,
Cleveland RP, et al. Immunohistochemical
expression patterns of germinal center and
activation B-cell markers correlate with
prognosis in diffuse large B-cell lymphoma. Am J
Surg Pathol. 200428464-470. 7. Cox MC, Nofroni
I, Laverde G, et al. Absolute lymphocyte count is
a prognostic factor in diffuse large B-cell
lymphoma. Br J Haematol. 2008141265-268. 8.
Koss,Leopold G., MD, Dr.h.c., Hon. FRCPATHOL
(UK), Melamed, Myron R., MD, eds. Koss'
Diagnostic Cytology. 2005 No. 2. 9. Ryan G,
Martinelli G, Kuper-Hommel M, et al. Primary
diffuse large B-cell lymphoma of the breast
Prognostic factors and outcomes of a study by the
international extranodal lymphoma study group.
Ann Oncol. 200819233-241. 10. Zwick C,
Gleissner B, Pfreundschuh M. Aspects of
chemotherapy schedules in young and elderly
patients with aggressive lymphoma. Clin Lymphoma
Myeloma. 20078 Suppl 2S43-9.
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THANK YOU
SUE STOWELL, BETH WALSH, LUMI MARINESCU, THE
GENEVA GENERAL CYTOTECHS, AND MY CLASSMATES FOR
ALL OF THEIR HELP AND SUPPORT ON THIS
PRESENTATION!