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A 57-year-old male is referred for further evaluation regardi ng general ized lymphade-nopathy and leukocytosis. Patien t reports general ized fatigue and nigh t sweats for the precedi ng 2 mon ths. Physical examination reveals bilateral cervical and axi llary lymph-adenopathy. No palpable hepatosplenomegaly is elicited . Laboratory workup shows leukocyte count of 38,000/ ,LLL. hemoglobin of 12.8 g/d l, and platelet count of 1 57,000/ ,LLL. Peripheral b lood smear is shown below.
Flow cytometry of peripheral blood is performed and reveals expression of CD 1 0, CD 1 9 , and CD20 and lack of expression of CDS and CD23. Bone marrow aspiration and biopsy are obtained. Bone marrow biopsy is shown below.
What is the most likely diagnosis?
- Follicular lymphoma (FL)
- Small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL)
- Hairy cell leukemia (HCL)
- Mantle cell lymphoma (MCL)
- Burkitt lymphoma/leukemia (BL)
Medicine
A. Peripheral blood smear reveals increased number of mature-appearing lymphocytes with condensed chromatin and exhibiting nuclear clefts, "buttocks cells:' Flow cytometry reveals lack of expression of CDS and CD23 with positive expression of CDIO, and bone marrow biopsy reveals a paratrabecular infiltrate characteristic of follicular lymphoma involvement. Bone marrow involvement is reported in 40% to 70% of patients with FL, and 33% also have peripheral blood involvement. Lack of CDS and CD23 expression in addition to the pattern of bone marrow involvement make SLL/CLL less likely. MCL typically lacks expression of CD23 while being positive for CDS.
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