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ANALYTICAL REPORT
Year : 2012  |  Volume : 8  |  Issue : 3  |  Page : 457-459

Value of bone marrow examination in Hodgkin lymphoma: Report of three cases with review of literature


1 Department of Pathology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
2 Department of Medical Oncology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Date of Web Publication17-Nov-2012

Correspondence Address:
Jyoti R Kini
Department of Pathology, Kasturba Medical College, Mangalore - 575001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.103535

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 > Abstract 

Bone marrow involvement by Hodgkin lymphoma is rare with an average incidence of 10%. However, the incidence of bone marrow involvement has been shown to be less than 1% in patients with clinical stage IA or IIA disease. The involvement of the marrow in a patient with Hodgkin lymphoma represents stage IV disease. We report our experience wherein three cases of marrow involvement were picked up on bone marrow aspirates/ -imprints and confirmed on trephine biopsy. In this paper we wish to highlight the significance of bone marrow examination in the initial diagnosis and staging of even clinically early stage Hodgkin lymphoma. Staging investigations performed at the time of diagnosis for patients with Hodgkin lymphoma are vital for determining the appropriate treatment and prognosis.

Keywords: Bone marrow aspirate, Hodgkin lymphoma, trephine biopsy


How to cite this article:
Kini JR, Suresh PK, Sinha R, Sahu KK, Kumar S, Prasad K. Value of bone marrow examination in Hodgkin lymphoma: Report of three cases with review of literature. J Can Res Ther 2012;8:457-9

How to cite this URL:
Kini JR, Suresh PK, Sinha R, Sahu KK, Kumar S, Prasad K. Value of bone marrow examination in Hodgkin lymphoma: Report of three cases with review of literature. J Can Res Ther [serial online] 2012 [cited 2019 Nov 12];8:457-9. Available from: http://www.cancerjournal.net/text.asp?2012/8/3/457/103535


 > Introduction Top


Hodgkin lymphoma (HL) is a malignant neoplasm of the lymphoid tissue found in the lymph nodes, spleen, liver, bone marrow, and other sites. Infiltration of the bone marrow at the time of diagnosis is rare, usually focal, and almost always associated with extensive disease, systemic symptoms, and unfavorable histology.

Here we report a case of HL which was diagnosed on bone marrow aspirate (BMA). In the second case, a diagnosis of HL was made based on BMA findings and subsequent fine needle aspirate cytology of cervical lymph node. We also present a case wherein bone marrow infiltration was picked up on bone marrow imprint smear itself thereby helping in the early detection of stage IV disease.


 > Case Reports Top


Case 1

A 19-year-old girl presented with 3 month history of low grade fever and evening rise in temperature. She also gave a history of significant weight loss, malaise, and lassitude. On physical examination, she had severe pallor and a single, non-matted, non-tender 1.5 × 1.0 cm left cervical lymph node of firm consistency. There was no organomegaly, no bony tenderness, or any other systemic examination findings. Routine blood investigations revealed pancytopenia with hemoglobin of 52 g/L, total leukocyte count (TLC) of 1.2 × 10 9 /L, and platelet count (PC) of 83 × 10 9 /L. A concurrent bone marrow aspiration and biopsy followed by a lymph node biopsy were done as a work up for pancytopenia and pyrexia of unknown origin. BMA revealed a cellular marrow with few large binucleate cells having moderate cytoplasm and prominent nucleoli suggestive of Reed Sternberg (RS) cells [Figure 1] in a polymorphous background. A diagnosis of HL was rendered. The bone marrow biopsy (BMB) showed cellular marrow composed of neutrophils, lymphocytes, eosinophils, plasma cells, RS cells, and also few epithelioid granulomas [Figure 2]. The diagnosis of HL was confirmed. The lymph node biopsy revealed HL- mixed cellularity. Immunohistochemistry done on the lymph node biopsy showed CD 15 and CD 30 positivity in the neoplastic cells. The patient was started on chemotherapy and she is currently in remission.
Figure 1: BMA smear shows a characteristic diagnostic reed sternberg cell (arrow) (Leishman stain, × 400), inset magnifi ed view (Leishman stain, × 1000)

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Figure 2: BMB shows a typical RS cell (arrow) in a polymorphous background (H and E, × 100), inset magnified view (H and E, × 400)

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Case 2

A 55-year-old male presented with 6 month history of low grade fever and evening rise in temperature. He also gave history of weight loss along with on and off cough. On physical examination, he had pallor and a single, discrete, non-tender 1.8 × 1.5 cm right cervical lymph node of firm consistency. There was no organomegaly, no bony tenderness, or any other systemic examination findings. Routine blood investigations revealed hemoglobin of 86 g/L, TLC of 4.2 × 10 9 /L, and PC of 155 × 10 9 /L. His erythrocyte sedimentation rate (ESR) was 68 mm at the end of 1 h. A concurrent BMA and BMB followed by fine needle aspiration cytology (FNAC) of the lymph node were done to rule out tuberculosis and evaluate for pyrexia of unknown origin. BMA revealed a cellular marrow with occasional RS cells and mononuclear forms in a polymorphous background. A diagnosis suggesting the possibility of HL was offered. The FNAC of lymph node offered a diagnosis suspicious of HD. BMB confirmed the involvement by HL. On histological examination of the lymph node biopsy, a final diagnosis of HL- mixed cellularity was put forward and confirmed by immunohistochemistry.

Case 3

A 28-year-old male with history of fever of one month duration had left cervical and bilateral axillary lymphadenopathy on examination. He also had mild hepatosplenomegaly (liver 2 cm, spleen just palpable). The routine hemogram showed hemoglobin of 138 g/L, TLC of 4.3 × 10 9 /L, and PC of 280 × 10 9 /L. The lymph node biopsy showed HL-lymphocyte predominant. Immunohistochemistry done on the lymph node biopsy showed the neoplastic cells were CD 15 and CD 30 positive. BMB was performed for staging of the disease. The imprint smears revealed a cellular marrow with typical RS cells. BMB confirmed involvement of the bone marrow by HL.


 > Discussion Top


HL involving the bone marrow is rare, ranges between 2% to 32% with an average incidence of 10%. [1] However, the incidence of bone marrow involvement has been shown to be less than 1% in patients with clinical stage IA or IIA disease. [2] The involvement of the marrow in a patient with HL represents stage IV disease. Thus, staging investigations performed at the time of diagnosis for patients with HL are considered crucial for determining the appropriate treatment and prognosis.

Trephine biopsy, usually unilateral is the recommended method to evaluate bone marrow involvement. The value of this procedure is however controversial. BMB is more frequently performed by clinical hematologists than oncologists in the United Kingdom. [3] In addition, there is little consensus about the impact of bone marrow infiltration on prognosis. [4],[5] Even, when the bone marrow is involved, it is extremely rare for the tumor cells to be detected in the BMA. The higher sensitivity of the trephine biopsy in the detection of metastatic neoplasms including HL has been reported in recent studies. [1,2] Certain authors envisage that BMA has a minimal role, if any, in detecting involvement of bone marrow by HL. [2],[4],[6],[7],[8] The focal pattern of infiltration may be the cause for negative bone marrow aspiration. They advocate that clinical stage IA and IIA patients do not need bone marrow examination.

HL is sometimes diagnosed from trephine biopsy histology. [9] The presence of RS cells which were detected in the aspirates and imprints of our patients suggest the possibility of early detection and diagnosis of HL especially in patients presenting with pyrexia of unknown origin and cytopenias. Thus, the concept of abandoning bone marrow aspiration and biopsy in early stage HL needs to be revised as suggested by some authors. [1],[5],[10]

The trephine biopsy and histopathological evaluation play a vital role in uncovering marrow involvement by HL. Although reports of neoplastic cells in BMAs are rare, our cases stress the value of aspirates and imprints especially when a diligent assessment of the smears is combined with high index of suspicion.

 
 > References Top

1.Subramanian R, Basu D, Badhe B, Dutta TK. Role of Bone marrow trephine biopsy in the diagnosis of marrow involvement in Hodgkin's disease. Indian J Pathol Microbiol 2007;50:640-3.  Back to cited text no. 1
[PUBMED]    
2.Howell SJ, Grey M, Chang J, Morgenstern GR, Cowan RA, Deakin DP, et al. The value of bone marrow examination in the staging of Hodgkin's Lymphoma: A review of 955 cases seen in a regional cancer center. Br J Haematol 2002;119:408-11.  Back to cited text no. 2
[PUBMED]    
3.Howard MR, Taylor PRA, Lucraft HH, Taylor MJ, Proctor SJ. Bone marrow examination in newly diagnosed Hodgkin's disease: Current practice in the United Kingdom. Br J Cancer 1995;71:210-2.  Back to cited text no. 3
    
4.Cavalieri E, Anselmo AP, Gianfelici V, Frattarelli N, Pescarmona E, Foa R, et al. Is bone marrow trephine biopsy always mandatory in Hodgkin's disease? Haematologica 2005;90:134-6.  Back to cited text no. 4
    
5.FrancoV, Tripodo C, Rizzo A, Stella M, Florena AM. Bone marrow biopsy in Hodgkin's lymphoma. Eur J Haematol 2004;73:149-55.  Back to cited text no. 5
    
6.Moid F, DePalma L. Comparison of relative value of bone marrow aspirates and bone marrow trephine biopsies in the diagnosis of solid tumor metastasis and Hodgkin lymphoma. Arch Pathol Lab Med 2005;129:497-501.  Back to cited text no. 6
[PUBMED]    
7.Vassilakopoulos TP, Angelopoulou MK, Constantinou N, Karmiris T, Repoussis P, Roussou P, et al. Development and validation of a clinical prediction rule for bone marrow involvement in patients with Hodgkin lymphoma. Blood 2005;105:1875-80.  Back to cited text no. 7
[PUBMED]    
8.Abrahamsen AF, Jakobsen E, Langholm R, Abrahamsen JF, Kvaloy S, Nome O. Bone marrow examination in Hodgkin's disease. Acta Oncol 1992;31:41-2.  Back to cited text no. 8
    
9.Bain BJ. Bone marrow trephine biopsy. J Clin Pathol 2001;54:737-42.  Back to cited text no. 9
[PUBMED]    
10.Kar R, Dutta S, Tyagi S. Clinically unsuspected Hodgkin's lymphoma diagnosed primarily from bone marrow trephine biopsy: Report of six cases. Indian J Pathol Microbiol 2008;5:186-9.  Back to cited text no. 10
[PUBMED]  Medknow Journal  


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