Surgical Lymph Node Biopsy for the Diagnosis of Lymphoma: A Case Report

Abstract

We report the diagnosis, treatment, and outcomes of a 52-year-old woman who originally presented to her primary care provider with adenopathy. Core needle biopsy (CNB) was inconclusive as it could not distinguish between follicular and diffuse large B-cell lymphomas (DLBCLs). A left axillary surgical lymph node biopsy was performed and demonstrated that the patient had a DLBCL arising from grade 3 follicular lymphoma. We discuss the limitations of CNB and the value of surgical lymph node biopsy in the diagnosis of lymphoma. The patient recovered from the biopsy without complications, and chemotherapy was initiated after the procedure. The patient has now remained in complete remission at 22 months.

Keywords: core needle biopsy; diffuse large b-cell lymphoma (dlbcl); fine-needle aspiration; follicular lymphoma; lymph node excision; lymphoma.

Figure 1. Surgical pathology

Core needle biopsy (a–h) and excisional axillary lymph node biopsy (i–r). i–m of the excisional lymph node biopsy demonstrates a histologic pattern consistent with follicular lymphoma, while n–r of the excisional lymph node biopsy demonstrates a histologic pattern consistent with the diffuse large B-cell lymphoma (DLBCL). (a) 4x and (b) 50x H&E; (c) 20x CD3 stains reactive infiltrating T cells; (d) 20x CD10 stains B cells of follicle center origin (including lymphoma cells in follicular lymphoma and DLBCL); (e) 20x cd20+, marker for B lymphocytes; (f) 20x CD21+, marker for follicular dendritic cells; (g) 20x BCL-2, an anti-apoptotic protein detected in follicular lymphomas and associated with BCL-2 overexpression due to t(14;18) translocations; (h) 20x Ki-67, marker of cell proliferation; (i) 2x H&E follicular areas; (j) 2x CD10+; (k) 2x CD20+; (l) 2x BCL-2; (m) 2x (insert 40x) Ki-67; (n) 2x H&E diffuse large B cell; (o) 2x CD10+; (p) 2x CD20+; (q) 2x BCL-2; (r) 2x (insert 40x) Ki-67.

Figure 2. Radiographic positron emission tomography/computed tomography (PET/CT) imaging

Positron emission tomography/computed tomography (PET/CT) images. Corresponding pairs of images (a, c, e: pretreatment; b, d, f: posttreatment) were acquired before and after treatment. (a, b) supraclavicular, (c, d) axillary, (e, f) lower abdomen/pelvis. The green arrow in images e and f demonstrates decreased size and fluorodeoxyglucose (FDG) avidity after treatment. No new areas of focal avidity were noted after treatment. (g, h) Pre- and posttreatment coronal views. (i, j) Pre- and posttreatment maximum intensity projection (MIP) images. The focus of the FDG uptake involving the left knee was attributed to pre-existing inflammatory arthritis.

Figure 3. Intraoperative and gross pathologic images

(a) Surgical biopsy of the enlarged left axillary lymph node. Placement of a 0 silk suture assists in elevating the lymph node during dissection. An Alexis wound protector (Applied Medical, Rancho Santa Margarita, CA) facilitates exposure and gentle tissue handling. All afferent and efferent lymphatic channels were controlled using surgical clips to avoid postoperative lymphocele formation. (b) Gross surface of the enlarged, firm, tan-red lymph node, measuring 5.2 cm x 3.6 cm x 2.5 cm. (c) The cut surface of the lymph node demonstrated a nodular expansion of uniform tan tissue without hemorrhage or necrosis.

Figure 4. Flow cytometry

Flow cytometry scattergram plots of the B-cell population. (a) Lymphoma cells (denoted as black on the scatter plot) demonstrated lower levels of CD19 positivity than normal B cells (denoted as blue and magenta on the scatter plot). (b) Lymphoma and normal cells were defined by expression on CD19 and/or CD20 positivity, and then gated into the CD10+ and CD10- populations, respectively. (c) Lymphoma cells demonstrated overall higher levels of forward scatter and slightly higher levels of side scatter, suggesting a larger size and cytoplasmic complexity, respectively, compared to normal cells. (d) Lymphoma cells demonstrated nearly exclusively lambda light chain restriction, while normal B cells demonstrated a mixed proportion of lambda and kappa light chain-expressing cells.