A young woman with relapsed/refractory anaplastic large cell lymphoma in leukemic phase

Our readers continue to provide us with interesting and informative cases about cell morphology. This week’s case was sent to us by Beth Ward, MT ASCP at Cincinnati Children’s Hospital Medical Center in Ohio, USA. Here is her story:

Patient history
This is a story about a young woman with relapsed/refractory anaplastic large cell lymphoma in leukemic phase. The patient had very high risk anaplastic large cell lymphoma (ALK+) with progressive CNS and systemic disseminated disease.

PET scan revealed major systemic progression of disease outside CNS; primarily intrabdominal periarotic nodes and massive increased splenic involvement with ALCL. Progressive systemic marrow disease with ALCL leukemic phase.

MRI on brain showed stable brain parenchyma. Persistent confluent areas of signal abnormality within the white matter as well as some persistent subtle enhancement of the left frontal leptomeninges. Essentially stable enhancement abnormality within the orbits. There is enhancement within the right greater than left intraconal space and surrounding the optic nerve sheaths as well as some questionable enhancement within the optic nerves themselves. No new orbital mass lesion is demonstrated.

Chemotherapy was initiated and she received a high dose dexamethasone for acute management of progressive disease symptoms and rapid taper in face of early response to crizotinib.

Interpretation of the peripheral blood showed anaplastic large cell lymphoma in leukemic phase. Below you find images captured on a CellaVision DM96 of the ALCL leukemic blasts as well as some images of her neutrophils, lymphocytes, and monocytes.

CBC/Diff results as follows:

WBC 22.1 (H) 4.5 – 13.0 K/mcL
RBC 3.53 (L) 3.80 – 5.20 M/mcL
HGB 10.8 (L) 11.7 – 15.7 gm/dL
HCT 30.3 (L) 35.0 – 47.0 %
MCV 85.7 80.0 – 96.0 fL
MCH 30.7 26.0 – 34.0 pg
MCHC 35.8 31.0 – 36.0 gm/dL
RDW 16.3 (H) <=15.2 %
PLATELET 29 (C) 135 – 466 K/mcL
SEGS 38 (L) 40 – 70 %
BANDS 0 0 – 4 %
LYMPHS 20 (L) 34 – 42 %
MONOCYTE 10 (H) 0 – 8 %
EOSINOPHIL 0 0 – 5 %
BASOPHILS 0 0 – 1 %
BLASTS 30 % 0%
NEUTROPHIL ABSOLUTE 8.40 (H) 1.80 – 8.00 K/mcL
LYMPH ABSOLUTE 4.64 1.20 – 5.20 K/mcL
MONO ABSOLUTE 2.21 (H) 0.00 – 0.60 K/mcL
EOSINOPHIL ABS 0.00 0.00 – 0.60 K/mcL
BASO ABSOLUTE 0.00 0.00 – 0.10 K/mcL

Thank you Beth Ward for sharing your case with us!


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