EBV-Positive Diffuse Large B-Cell Lymphoma vs Classic Hodgkin Lymphoma

Lessons From the Friday Unknowns

The infiltrate is composed of scattered large cells in a background of histiocytes, small lymphocytes, plasma cells and scattered eosinophils.

Some large cells have distinct eosinophilic nucleolus (Hodgkin-like cells).

In many areas, there is a significant angiocentric and angiodestructive pattern with large cells invading and disrupting the blood vessel wall.

Scattered multinucleated giant cells are also identified.

The large cells are positive for CD20 (small subset), CD30, CD79a, MUM1, OCT2, and PAX5 by immunohistochemical stains. They are negative for CD15, CD45 and BOB1. Anti-CD3 highlights background small T cells.

Epstein-Barr encoded RNA (EBER) by in situ hybridization is positive in many large neoplastic cells.

The differential diagnosis includes Classic Hodgkin lymphoma (CHL) and EBV-positive diffuse large B-cell lymphoma (DLBCL). The morphology and part of the immunophenotype (negativity for CD20 and CD45 in neoplastic cells) are suggestive of CHL.

However, this morphology is not specific and can also be seen in EBV+ DLBCL. Bright PAX5 positivity and positivity for CD79a are also not typical for CHL.

In addition, the clinical presentation is not usual for CHL (patient initially presented with a large duodenal mass with several mildly enlarged lymph nodes in adjacent areas. This initial presentation was consistent with EBV positive mucocutaneous ulcer rather than CHL, which is a nodal based disease). The presence of angiocentric/angiodestructive pattern and monotypic plasma cells in the current specimen is also in favor of EBV-positive DLBCL.

Links to digital slides: https://bit.ly/3vJ2rLb | Slides labeled case 3

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Siba El Hussein, MD

Hematopathology | Cytopathology | Molecular pathology | Digital pathology | Data science | Machine learning