HL-447 Lymphoma Diagnosis Delay: Biopsy Strategy Insights

• Published in: Clinical lymphoma, myeloma and leukemia Vol. 24; p. S448
• Main Authors: Godin, Shea-Lee, El Warrack, Samantha, Meleveedu, Kapil
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.09.2024
• Subjects: excisional biopsy; follicular lymphoma; Hodgkin lymphoma; lymphoma; HL; follicular lymphoma; case; lymphoma; excisional biopsy; Hodgkin lymphoma
• ISSN: 2152-2650
• DOI: 10.1016/S2152-2650(24)01466-6

Follicular lymphoma (FL) is an indolent lymphoma and is the second most common cause of non-Hodgkin lymphoma (NHL) after diffuse large B-cell lymphoma (DLBCL). Histological transformation of FL to DLBCL occurs in 2-3% of patients annually. The European Society of Medical Oncology recommends surgical excision biopsy of lymph nodes to diagnose lymphoma whenever possible. We present a patient in whom excisional biopsy was deferred, resulting in late diagnosis and subsequent treatment. A 55-year-old female with a history of asthma and nephrolithiasis was evaluated for an incidental adrenal adenoma after presenting with recurrent nephrolithiasis. CT abdomen revealed upper abdominal retroperitoneal lymphadenopathy and mildly enlarged mesenteric lymph nodes. Core needle biopsy (CNB) was consistent with follicular lymphoma, CD10+, CD20+, Bcl2+, BCL6+, and cyclin D1-. FISH testing for BCL-2, BCL6, and Myc was negative. A subsequent PET scan showed retroperitoneal disease. She initially underwent surveillance monitoring, given her low disease burden. However, persistent B symptoms, including fevers and night sweats, resulted in treatment with single-agent rituximab despite stable disease on interval imaging, which did not result in symptomatic improvement. A subsequent CT scan revealed new splenomegaly and multiple enlarged mesenteric lymph nodes with subtle thoracic sclerosis suspicious for metastatic disease. PET scan showed hypermetabolic left cervical, mediastinal, bilateral hilar, retroperitoneal, mesenteric, and pelvic lymphadenopathy, as well as extensive osseous disease. Excisional biopsy was finally pursued and was not consistent with FL; instead, it showed CD30-positive lymphoma favoring Hodgkin lymphoma with atypical features. FL has a distinctly nodular growth pattern and is comprised of a mixture of centrocytes and centroblasts. Fine needle aspiration should be avoided for tissue diagnosis because it cannot determine the typical growth pattern and grading, making it difficult to classify the disease. Although CNB provides a definite diagnosis in 92.3% of cases with suspected lymphoma, it is less conclusive than surgical excision, which provides a definite diagnosis in up to 98.1% of cases. CNB has proven to be inferior to surgical excision in providing a definite diagnosis in lymphoma workup; therefore, the latter should be considered early in diagnosing and timely managing the disease.