Diffuse Large B-Cell Lymphoma with Anaplastic Clear Cells: A Rare Variant

doi:10.4236/ojpathology.2012.24028

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Open Journal of Pathology, 2012, 2, 150-154

Published Online October 2012 (http://www.SciRP.org/journal/ojpathology)

http://dx.doi.org/10.4236/ojpathology.2012.24028

Diffuse Large B-Cell Lymphoma with Anaplastic Clear

Cells: A Rare Variant

Mónica Belinda Romero-Guadarrama1*, Leslie Elizmara Aguilar-Ayala1, German Ott2,

Jorge Pérez-Espinosa1

1Unit Pathology, Hospital General de México, OD and Medicine School, Autonomous National University of Mexico, Mexico City,

Mexico; 2Department of Clinical Pathology, Robert-Bosch-Hospital, Stuttgart, Germany.

Email: *[email protected]

Received June 20th, 2012; revised July 26th, 2012; accepted August 6th, 2012

ABSTRACT

Introduction: Diffuse Large B-Cell Lymphoma (DLBCL) is a heterogeneous group conformed by morphological and

clinical varieties of neoplasms; it originates from peripheral B-cells and is distinguished into three groups: germinal

center (GC), activated B lymphocyte (ABL), and the third type. The existence of DLBCL with anaplastic morphology

and expression of CD30 without t (2, 5) translocation is rare. The aim of the present article is to describe this morphol-

ogic variant in a 54-year-old woman and a 74-year-old man, respectively. Materials and Methods: Patients diagnosed

with DLBCL with anaplastic variant were identified from the surgical pathology records. Results: Out of 357 biopsies

with this diagnosis, 11 (3%) corresponded to the anaplastic variant, 2 presented morphological clear cells; they became

visible because of an increase in volume in the cervical area of 4 months of evolution, usually associated to diaphoresis

and weight loss with clinical fulminating progression. An autopsy study was performed to one patient and it showed

infiltration in supraclavicular lymph nodes, thyroid, and lung. The neoplastic cells presented abundant clear cytoplasm

and pleomorphic nuclei that expressed CD20, CD30 and CD45. Conclusion: This variation is rare. The clinical presen-

tation and prognosis are controversial; we present the morphological and immunophenotype changes of this variant.

The differential diagnosis from other clear cell neoplasms should be made.

Keywords: B-Cell Anaplastic Lymphoma with Clear Cells

1. Introduction

Anaplastic large-cell lymphoma with immunophenotype

B (ALCL-B) is a morphological variant of the diffuse

large B-cell lymphoma (DLBCL), according to the clas-

sification established by WHO in 2008 [1]; it was recog-

nized by its expression of the Ki-1 antibody, now CD30.

Neoplastic cells that expressed CD30 derived from

T-cells and they were denominated Ki-1 Lymphomas. It

is now recognized that there is a small number of cases

with the B immunophenotype [2].

This type of lymphoma appears in lymph nodes and is

identical to its counter part T-cell lymphoma. It had not

been identified for a long time [3-5] and it is character-

ized by the presence of large cells from abundant to

scarce cytoplasm and with round, oval and pleomorphic

nuclei. Some cells can be gigantic, they express B mark-

ers such as CD19 or CD20, among others, and CD30 as

the activation marker. They can be morphologically in-

distinct from carcinomas because of their histological

appearance.

There are few cases published and its frequency re-

mains unknown. However, in the study performed by

Weisenburger and colleagues, it represented 3.4% of

total non-Hodgkinlymphomas [6].

Clinical presentation and prognosis are similar to other

types of diffuse large B-cell lymphoma. However, in a

study performed by the French group GELA, a small

number of cases of this type of lymphomas, badly pre-

dicted [7] was reported.

The aim of the present article is to present the clinical,

morphological, and immunophenotypic characteristics of

this variation with cells that present a clear cytoplasm.

2. Materials and Methods

Case Selection

During a period of eight years, we studied 357 DLBCL

from the surgical pathology records in the Pathology

Unit of the General Hospital of Mexico; 11 (3.0%) of

these cases corresponded to an anaplastic morphology, 2

cases were selected out of these 11 due to the presence of

clear cells. In every case, clinical records and histo-

*Corresponding author.

Diffuse Large B-Cell Lymphoma with Anaplastic Clear Cells: A Rare Variant 151

logical sections were verified.

The histological sections were cut at 4-μm thickness

and they were stained with hematoxylin-eosin and peri-

odic acid-Schiff stain. Representative sections were cho-

sen in order to perform manually the immunoperoxidase

technique. The technique consisted in using avidin-bio-

tin-peroxidase with previous antigenic recuperation, for

this reason, citrate buffer was used at 99˚C, for 10 min-

utes in a pressure cooker.

Monoclonal antibodies were CD20 (L-26 clone Da-

koCytomation), CD3 (rabbit monoclonal antibodies; Da-

koCytomation), CD10 (clone 56C; Novocastra Labo-

ratories), bcl2 (clone 124; DakoCytomation), bcl6 (clone-

PGB6p; DakoCytomation), MUM 1 protein (clone-

MUM1p; DakoCytomation), LMP-1 (clone Zebra/Dako-

Cytomation), CD30/Ki-1 (DakoCytomation), epithelial

membrane antigen (DakoCytomation), cytokeratins 10/

13 (DakoCytomation), Lysozyme (DakoCitomation),

CD1a (DakoCytomation and PS100 (DakoCytomation).

For their microscopic evaluation, they were developed

with diaminobenzidine.

EBER (in situ hybridization for Epstein-Barr virus)

technique was performed to determine the presence of

Epstein-Barr virus (EBV) in the nuclei of neoplastic cells;

for this, tests of labinized peptide nucleicacid of fluoro-

cyanate were used to determine the presence of nuclear-

encoded RNA. Alkaline phosphatase-conjugated, rabbit

antibodies and anti-fluorescein isothiocyanate were added,

followed by 4-nitroblue tetrazolium/5-bromo-4-chloro-

3-indolyl phosphate (NBT/BCIP; Roche Diagnostics,

Indianapolis, IN, USA). It was contrasted with Gill’s

hematoxylin and the final procedure was followed just

like in the immunoperoxidase technique, already de-

scribed. We used a nasal NK/T-cell lymphoma sample as

a positive external control.

3. Results

3.1. Description of Cases

3.1.1. C as e 1

A 54-year-old woman with progressive increase of cer-

vical lymphadenopathies of 4 × 3 cm of 4 months of

evolution, presence of diaphoresis, asthenia, adynamia,

and 10 kg weight loss. Biopsy was performed. Clinical

follow: The patient was lost due to institutional change

for treatment.

Macroscopic findings

We received an ovoid sample of 3 × 2 cm, gray-white

color and consistency of rubber, the surface of the sec-

tion was homogeneous. It was fixed in 10% formalde-

hyde.

3.1.2. C as e 2

A 74-year-old man with a progressive increase in volume

of the left side of the neck of 4 months of evolution; as-

thenia and adynamia were added. The physical examina-

tion showed the increase in volume of the left side of the

neck of 10 × 15 cm that affected submandibular and cer-

vicallymph nodes. Laboratory tests revealed LDH of 418

and 611 U/L.

Computed axial tomography, abdominal-thoracic re-

gion with no alterations, and bone marrow biopsy was

performed. Treatment was established by CHOP. Subse-

quently, he presented respiratory difficulties, tonic-clonic

convulsions, and died. Autopsy was done.

3.2. Macroscopic Findings

The sample obtained from the lymph node conglomera-

tion corresponded to several tissue fragments of irregular

form and of gray-white color of 2 × 2 cm. They were

fixed in 10% formaldehyde.

The autopsy study revealed the presence of a left sided

lymph node conglomeration of 16 × 12 × 14 cm, with a

“fish/meat” aspect, gray and white color that infiltrated

into de soft tissues of the neck and muscles, cartilage,

trachea and larynx wall. A neoplastic infiltration was

observed in the lower-left pole of the thyroid and in

lungs. The rest of the organs were found irrelevant.

3.3. Histopathology

Both samples corresponded to cervical lymph nodes, in

which a neoplasm constituted by a capsule of connective

tissue with large cells of abundant clear cytoplasm was

observed; the large cells were negative in the presence of

glycogen with PAS stain. The nuclei of cells were ovoid,

irregular, some cells with two nuclei, with lobes and

evident nucleoli. We observed small reactive lympho-

cytes and sclerosis among the neoplastic cells (Figures 1

and 2). Immunohistochemical reactions demonstrated

Figure 1. Diffuse proliferation of large cells with clear cyto-

plasm (H-E 10×).

Diffuse Large B-Cell Lymphoma with Anaplastic Clear Cells: A Rare Variant

152

Figure 2. Cells with clear cytoplasm and pleomorphic nuclei

(H-E 40×).

CD20, CD45, and CD30 positivity (Figures 3 and 4).

Other markers tested, such as: antigen of epithelial mem-

brane, lysozyme, CD 1ª, Ps-100, cytokeratins, CD 10,

bcl2, bcl6, Mum-1, and EBER, were all negative.

4. Discussion

Anaplastic DLBCL is characterized by a cellular prolif-

eration with pleomorphic or anaplastic morphology and

by expression of the CD30 marker. In the past, it used to

be diagnosed as immunoblastic lymphoma or malignant

histiocytosis. Anaplastic DLBCL can also simulate ma-

lignant melanoma and undifferentiated carcinoma. The

present report describes a rare variant of DLBCL with

morphological characteristics of cells showing a clear cy-

toplasm, localized in cervical lymph nodes. The B-lym-

phoma that constantly presents cells with clear cytoplasm

is originated in the mediastinum, and the initial reports

appeared in the early 1980s. It as a tumor different from

lymphoblastic T-cell lymphoma, thymiccarcinoma, or

sarcomas [8,9].

This B-lymphomais located in the mediastinum, in the

anterior superior area; it is frequently associated to scle-

rosis with dissemination through different places. It is

presumed to be originated from thymic B-cells situated

around the vessels between the cortex and medulla of the

organ [10]; some immunophenotypic characteristics of

neoplastic cells indicate that they are originated from

terminal B-cell and gene expression profiling showed a

unique expression profile [11]. It is infrequent and re-

presents about 2.4% of all types of lymphoma [1,12].

Contrary to the reported cases in the present article;

clinically, it is present in young women between 36 and

39 years of age and, as mentioned before, it initially oc-

curs in the anterior mediastinum and disseminates th-

rough extranodal areas such as kidney, adrenal gland,

Figure 3. CD20 is positive in the cytoplasmic membrane of

the neoplastic cells (Immunoperoxidase 10×).

Figure 4. Expression of CD30 in most of the cells is shown

(Immunoperoxidase 10×).

liver and central nervous system [13].

In our patients, the initial area for the clinical presenta-

tion was the cervical lymph node. The autopsy study re-

vealed local infiltration into cervical soft tissues, thyroid

gland, and lung. The bone marrow was not infiltrated.

This DLBCL variant has not been sufficiently studied

because it has been reported only in a small percentage

of cases (less than 20%) [14,15].

The cells are morphologically large with abundant cy-

toplasm, giant cells. The so called decoy cells (hallmark

cells) can be observed with an increasing diffuse pattern

or sinus condition. Other morphological types described

are small and fusiform cells [1]. In this study, we ob-

served large cells of abundant clear cytoplasm and ir-

regular, fissured, lobed nuclei and, occasionally, with

Diffuse Large B-Cell Lymphoma with Anaplastic Clear Cells: A Rare Variant 153

visible nucleolus. Among neoplastic cells, small lym-

phocytes and limited collagen fibers were observed. De-

coy cells were not visible in any of the two samples. By

definition, neoplastic cells display expression of B mark-

ers such as CD19, CD20, and CD22 combined with

CD30 expression, this last marker is changeable and it

can be in the cytoplasmic membrane of the cells or in the

cytoplasm. In the cases presented in this report, CD30

expression occurred in both the cytoplasmic membrane

and the cytoplasm with paranuclear distribution. Other

activation markers that can be considered in this type of

lymphoma are CD23, CD21, CD38, CD71, CD25, and

CD45 [3,16].

Unfortunately, we did not performa molecular study;

however, it has been informed previously about the

clonal IgH rearrangement in 3 of 5 cases by Southern

blot hybridization [16]. Using other methods, like poly-

merase chain reaction (PCR), it was possible to notice

the IgH gene rearrangement in 59% of anaplastic lym-

phomas with B-immunophenotype [17]. Average muta-

tion observed in this lymphoma is 13%, similar to other

cases of DLBCL, follicular lymphoma and Hodgkin’s

lymphoma. Somatic mutations suggest that this lym-

phoma comes from B-cells of the germinal center or

post-germinal [17]. By immunophenotype, we were not

able to reveal expression of markers, the germinal center,

or the activated lymphocyte; for this reason, we believe

that this variant corresponds to the so-called third type.

The presence of the Epstein-Barr virus (EBV) has been

analyzed showing variable results, using several tech-

niques. In the cases here presented, it was not possible to

observe such an association. In the Japanese study group,

an association of EBV with the lymphoma in 35% of 17

cases studied was found [18,19]. In another series of 16

cases, an association frequency of 19% was observed

[20]. This piece of information must be taken carefully,

because many types of lymphoma exist that are associ-

ated with the presence of this virus.

Differential diagnosis must be performed in regard to

B-immunoblastic lymphoma with the presence of clear

cells, from T-anaplastic lymphoma, associated or not to

the expression of ALK (Anaplastic lymphoma kinase)

and from metastatic carcinoma that presents clear cells

similar to kidney cells. Immunohistochemistry markers

have a relevant role in the differential diagnosis [1].

In conclusion, we presented two rare cases of diffuse

large B-cell lymphoma, an anaplastic morphological

variant, where most of the cells presented clear cyto-

plasm in two adults older than 50 years, not associated to

Epstein-Barr virus and with fulminant clinical course.

We consider important the description of this variant in

order to know better its biology and morphological as-

pect for further studies.

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Abreviations

DLBCL = Diffuse Large B Cell- Lymphoma

GC = Germinal Center

ALCL-B = Anaplastic Large-Cell Lymphoma with Im-

munophenotype B

WHO = World Health Organization

GELA = French Group

EBER = In Situ Hybridization for Epstein-Barr Virus

PCR = Polymerase Chain Reaction