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Unexpected finding on staging bone marrow aspirate for Hodgkin’s lymphoma

Jens Samol¹, Kelly J Susan²

¹ Beatson Oncology Centre, Medical Oncology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, Scotland, G12 0YN, UK
² Wycombe General Hospital, Haematology, Queen Alexander Road High Wycombe, Buckinghamshire HP11 2TT, UK

Correspondence to:
Jens Samol, jens.samol{at}gmail.com

A lady in her seventies with a history of breast cancer and left mastectomy presented in summer 2000 with weight loss, hepatosplenomegaly and abnormal liver functions.

Her chest x ray at that time revealed enlargement of the azygous node and evidence of left mastectomy, in addition to a well known calcified opacity in the left lower lobe (fig 1A). A CT scan confirmed mediastinal lymphadenopathy (fig 1B) and hepatosplenomegaly (fig 1C).

View this figure (49K): in this window | in a new window | PowerPoint for Teaching   Figure 1 A. Chest x ray showing left mastectomy, azygos node and calcified opacity in left lower lobe. B. CT showing mediastinal lymphadenopathy. C. CT showing hepatosplenomegaly.

 

On mediastinal lymph node biopsy a diagnosis of classical nodular sclerosing Hodgkin’s lymphoma (nsHL)¹ was made using immunohistochemical stains including CD15 (fig 2A) and CD30 (fig 2B).

View this figure (92K): in this window | in a new window | PowerPoint for Teaching   Figure 2 A. Immunohistochemical stain demonstrating CD15 positive Hodgkin/Reed–Sternberg (H-RS) cells. B. Immunohistochemical stain demonstrating CD30 positive H-RS cells.

 

Bone marrow aspirate and trephine biopsy were performed as part of the staging procedure. Unexpectedly, the aspirate revealed bone marrow infiltration by malignant Hodgkin/Reed–Sternberg (H-RS) cells. Normally bone marrow infiltration by H-RS cells leads to fibrosis resulting in a dry aspirate and trephine biopsies are the only means by which marrow infiltration is confirmed. Figure 3 shows an aspirate with a particle and three H-RS cells marked with a blue arrow. Figure 4A shows a Hodgkin cell whereas fig 4B shows the same cell at higher power demonstrating the nucleolus. Figure 5A shows one further and fig 5B shows two further H-RS tumour cells demonstrating the typically found prominent nucleoli (Professor Kevin Gatter, Pathology Department, John Radcliffe Hospital, Oxford, UK, personal communication). The surrounding cells in fig 5A are reactive and normal.

View this figure (136K): in this window | in a new window | PowerPoint for Teaching   Figure 3 Bone marrow aspirate at low power. Arrows show tumour cells.

 

View this figure (87K): in this window | in a new window | PowerPoint for Teaching   Figure 4 A. Hodgkin cell at higher power. B. Same tumour cell at higher resolution demonstrating the nucleolus.

 

View this figure (55K): in this window | in a new window | PowerPoint for Teaching   Figure 5 A. Hodgkin/Reed–Sternberg (H-RS) cell at high power resolution with surrounding cells representing reactive cells. B. Two further H-RS tumour cells at high power resolution also demonstrating multiple nucleoli.

 

To our knowledge, this is the first report of H-RS cells being found on a staging bone marrow aspirate.

The patient was treated for stage IV_B nsHL with chlorambucil, vinblastine, procarbazine and prednisolone (CHLVPP) therapy for two courses, changed to adriamycin (doxorubicin), bleomycin, vinblastine and dacarbazine (ABVD), and finished six courses in total.² The hepatosplenomegaly resolved and her liver function tests normalised, confirming the suspected liver infiltration by her Hodgkin lymphoma. She suffered several therapy-related complications, among which neutropenic sepsis and Bleomycin-induced skin toxicity were the most prominent ones.³

She remained in complete remission for nearly 3 years, had only a partial response to retreatment and died of her Hodgkin lymphoma in late 2004.

With a diagnosis of nsHL the presence of H-RS cells on this patient’s bone marrow aspirate were highly unexpected. This was a rare finding, highlighting the importance of not missing H-RS cells in marrow aspirates. Such tumour cells usually are not found as fibrosis prevails but they may also be missed as it is not anticipated to find H-RS cells on a staging bone marrow aspirate.

Competing interests: none.

1. Stein, H. Hodgkin lymphoma. In: ES Jaffe, NL Harries, H Stein, et al, eds. Pathology and genetics of tumours of haematopoietic and lymphoid tissues. Lyon, France: IACS Press, 2001: 237–53.
2. Canellos, GP, Anderson, JR, Propert, KJ, et al. Chemotherapy of advanced Hodgkin’s disease with MOPP, ABVD, or MOPP alternating with ABVD. New Engl J Med 1992; 327: 1478–84.[Abstract]
3. CTCAE Version 3. http://ctep.cancer.gov (accessed 12 November 2008).

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