2017 Annual Meeting

Evening Specialty Conference

Hematopathology Challenges: What They Didn't Teach You in Fellowship

March 6 2017, 7:30pm to 9:30pm

James R. Cook, MD, PhD and Tracy George, MD
Robert Ohgami, MD, PhD - Carlos Bueso-Ramos, MD, PhD - Annette Kim, MD, PhD - Magdalena Czader, MD, PhD

Pre-Meeting Materials

Case 1

Robert Ohgami, MD, PhD

Clinical History:

A 32 year old man presents with a 4 month history of isolated left inguinal lymphadenopathy. A physical exam demonstrates no other abnormal findings. The patient has no personal or family history of malignancy. Further workup including CBC, peripheral blood smear and bone marrow biopsy were unremarkable. A biopsy of the left inguinal lymph node was performed and images provided here.

Pertinent Laboratory Data:

  • CBC and differential: WBC: 6.2 K/μL
  • HGB: 14.3 g/dL, PLT: 210 K/μL
  • Neutrophils: 65%
  • Lymphocytes: 30%
  • Monocytes: 3%
Lymph Node:
  • Cytogenetic studies: Normal male karyotype;
  • 46,XY[20].Molecular studies: Negative for T-cell and B- cell clonality

Morphological Findings (click to enlarge):

Figure 1 H&E, 100X
Figure 2 H&E, 100X
Figure 3 H&E, 200X
Figure 4 CD123, 40X
Figure 5 D2-40, 40X
Figure 6 CD3, 100X
Figure 7 CD4, 100X
Figure 8 CD8, 100X
Figure 9 CD99, 100X
Figure 10 TdT, 200X
Figure 11 A keratin immunostain at 100X magnification
Figure 12 An HHV8 immunostain at 100X magnification

Case 2

Carlos Bueso-Ramos, MD, PhD

Clinical History:

Case 46 year-old woman had a clinically aggressive tumor in the anterior mediastinum that was initially diagnosed as a diffuse B-cell lymphoma. She received chemotherapy, but showed no significant improvement. One year later, the patient presented at our institution with pelvic bone metastases. Biopsy specimens of the sacrum lesion and bone marrow were obtained.

Morphological Findings (click to enlarge):

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6

Case 3

Annette Kim, MD, PhD

Clinical History:

he patient is a 56 year old male with a prior diagnosis of acute myeloid leukemia (AML) who now presents with a 5 month history of slowly progressive pink-yellowish papules on the trunk and extremities while on decitabine. The patient was originally diagnosed with AML 10 months prior to this presentation, although thrombocytopenia was noted as early as 5 years previously. A bone marrow biopsy at that time of AML diagnosis identified 80% blasts with the following flow cytometric immunophenotype: positive for CD45(dim), CD13, CD33, CD34, CD117, and HLA-DR, but negative for CD3, CD5, CD7, CD10, CD11b, CD14, CD15, CD19, CD20, CD56, and CD64. Molecular testing at diagnosis was positive for a 36 bp FLT3-ITD as well as the following variants: ASXL1 p.D690fs* (49.6%), IDH1 p.R132C (14.0%), KRAS p.G12R (4.0%), NRAS p.G13C (41.7%), and SRSF2 p.P95L (33.3%). The karyotype was normal. The patient underwent 7+3 induction followed by re-induction due to residual blasts on bone marrow studies performed on days 15 and 28. At the end of re-induction, the patient had less than 5% blasts. Subsequent marrow studies while the patient was on decitabine over the course of 9 months were stable at 5-10% blasts with significant dysmegakaryopoiesis. CBCs during these 9 months were notable for a leukocytosis (up to 55 K/uL) with a monocytosis (up to 32%), thrombocytopenia (12-36 K/uL), and anemia (7.0-10.9 g/dL). A series of 4 skin biopsies were obtained that were examined by morphology, immunohistochemistry, and molecular studies.

Pertinent Laboratory Data:

At the time of presentation to dermatology for his skin lesions, the patient's CBC was: WBC 5.42 K/uL (4% bands, 52% neutrophils, 15% lymphocytes, 20% monocytes, 2% eosinophils, 3% metamyelocytes), HGB 8.3 g/dL, MCV 91.3 fL, and PLT 39 K/uL.

Morphological Findings (click to enlarge):

A representative set of seven images are provided. These include a representative 2x and a 40x view of the H&E slide of one of the skin biopsies. In addition, immunohistochemical studies were performed on the infiltrate. The large cells were largely positive for CD56 (shown) and CD163 (shown) with subset staining for Langerin (shown), CD1a, and S100. Lysozyme (shown) was weakly positive in a granular pattern in a majority of cells, with strong diffuse staining in only a minor subset of cells with higher N:C ratio. The infiltrate was essentially negative for CD34 (shown), CD123, and TCL1. A similar immunohistochemical pattern was seen in the other biopsies, with varying numbers of CD56, Langerin, CD1a, and S100 positive cells.

Figure 1 Skin BxA 2x
Figure 2 Skin BxA 20x CD163
Figure 3 Skin BxA 40x CD34
Figure 4 Skin BxA 40x CD56
Figure 5 Skin BxA 40x Langerin
Figure 6 Skin BxA 40x lyso
Figure 7 Skin BxA 40x

Case 4

Magdalena Czader, MD, PhD

Clinical History:

The patient is a 22 year-old male with a long-standing history of normocytic anemia. The patient was first diagnosed with anemia at 13 years of age and has received occasional transfusions. He has intermittent neutropenia. Platelet counts has been within normal limits or slightly elevated. There is no reported family history of anemia. Bone marrow exam is performed as a follow-up.

Pertinent Laboratory Data:

  • CBC and differential count: WBC 4.8 k/ul
  • RBC: 2.34 million/ul
  • Hemoglobin: 7.3 g/dL
  • Hematocrit: 22.4%
  • MCV: 96 fL
  • RDW: 18.1%
  • Platelet count: 384 k/ul
  • Bands: 1%
  • Segmented neutrophils: 54%
  • Lymphocytes: 38%
  • Monocytes: 7%
  • Cytogenetic study: 46,XY[20]

Morphological Findings (click to enlarge):

Figure 1 Bone marrow biopsy
Figure 2 Bone marrow biopsy
Figure 3 Bone marrow biopsy
Figure 4 Bone marrow biopsy
Figure 5 Reticulin stain, bone marrow biopsy
Figure 6 Tryptase immunohistochemical stain, bone marrow biopsy
Figure 7 Bone marrow aspirate smear 100x
Figure 8 Bone marrow aspirate smear 100x
Figure 9 Peripheral blood smear 100x


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