Available online at www.annclinlabsci.org 262 Annals of Clinical & Laboratory Science, vol. 41, no. 3, 2011

Intravascular Large B-cell Presenting as Cholecystitis and Pancytopenia: Case Report with Literature Review

Xiuzhen Duan, Angelo Lapus, Robert E. Brown, Lei Chen

Department of Pathology and Laboratory Medicine, the University of Texas Health Science-Medical School at Houston, Houston, Texas, USA

Abstract. Intravascular large B-cell lymphoma (IVLBCL) is a rare variant of extranodal diffuse large B- cell lymphoma with only a few more than 300 cases reported. It is characterized as lymphoma cells con- fined to the lumina of small vessels, so patients usually do not present with masses or lymphadenopa- thy. Clinical presentations of these patients are non-specific and the pathologic changes may be subtle, which often leads to delayed diagnoses and, in many instances, a postmortem diagnosis. IVLBCL can essentially involve the vessels of any organ, but it is quite rare for the gallbladder to serve as the ini- tial presenting site; there are only four such cases reported in the English literature. Furthermore, IV- LBCL of the gallbladder with peripheral blood involvement is even less common. We report a recent case of IVLBCL presenting as acute cholecystitis and pancytopenia. The patient underwent a simple cholecystectomy. Examination of the gallbladder showed clusters of large lymphoma cells within lumina of small vessels in the gallbladder wall. These cells were positive for CD5/CD20 and negative for CD3, CD10, and TdT. Based on these findings, a diagnosis of IVLBCL was made. Coincidently, circulating lymphoma cells were identified in the peripheral blood and confirmed by flow cytometric analysis (posi- tive for CD19/CD20/CD5, without light chain expression). The patient was started on chemotherapy but subsequently died of chemotherapy related multi-organ failure 10 days after the initial diagnosis.

Keywords: Intravascular large B-cell lymphoma, gallbladder, flow cytometry

Introduction ant are skin and (CNS) while patients with the Asian variant present more According to the recent WHO classification, IV- often with a hemophagocytic syndrome [3]. In LBCL is defined as a rare variant of extranodal dif- spite of the intravascular infiltrate, IVLBCL in- fuse large B-cell lymphoma [1] with approximately volving the peripheral blood is seen in only 25% 300 cases reported to date [2]. It tends to occur of Asian and in 5% of Western variant cases [3]. in elderly patients with an almost equal gender Gallbladder involvement is extremely rare, with distribution. In general, this disease may involve only four cases identified in the English literature any organ and its clinical presentation is nonspe- [4-7]. Here, we report a case of IVLBCL of the cific. Two main clinical variants were recognized gallbladder presenting as cholecystitis and pancy- at the International Consensus Meeting in 2007: topenia. The diagnosis of IVLBCL was made based the so-called Western and Asian variants [3]. The on the gallbladder findings, and peripheral blood most commonly involved sites in the Western vari- involvement was confirmed by flow cytometry.

Clinical History

Address correspondence to Lei Chen, MD,Department of Pathology and Laboratory Medicine,University of Texas A 51 year old obese Hispanic woman with longstanding Health Science Center–Houston 6431 Fannin Street, MSB diabetes presented to the emergency room with a five 2.136,Houston, TX 77030, USA; tel 713 566 4690; fax 713 566 day history of fever, abdominal pain and nausea. Re- 5285; e-mail [email protected] view of systems revealed chronic symptoms of fatigue,

0091-7370/11/0300-262. © 2011 by the Association of Clinical Scientists, Inc. Intravascular Large B-cell Lymphoma 263

to large in size with a high nuclear/cytoplas- mic ratio, vesicular chromatin and small nucleoli (Figure 1B). Atypical mitoses were also noted. A panel of immunohistochemical stains was performed, revealing positivity of atypical lymphoid cells Figure 1. Hematoxylin-eosin (H&E) section of gallbladder showing mucosa and submucosal vessels filled with for CD5 and CD20 atypical lymphoid elements (arrows); Higher power to illustrate atypical nature of intravascular lymphoid elements (A, x200; B, x400). (Figure 2), as well as general weakness, and a 50 pound weight loss over one for Bcl-6, and nega- year. CT and ultrasound examinations were consistent tivity for CD3, cyclin D1, and pancytokera- with acute cholecystitis. An uncomplicated laparo- tin. The proliferation index by Ki-67 was up to scopic cholecystectomy was performed with success- 90%. Collectively, these results established the ful removal of an edematous and inflamed gallbladder; diagnosis of IVLBCL involving the gallbladder. other abdominal organs were noted to be grossly unre- Concurrently, evaluation of the peripheral blood markable during the operation. The specimen was sent smear revealed rare circulating large atypical lym- to the pathology department for routine examination. phoid cells (Figure 3), which were suspicious for Routine lab tests were performed, including complete lymphoma. Thus, a peripheral blood sample was sent blood count (CBC), liver, renal, and routine chemistry panels. Pancytopenia was identified (hemoglobin 10.7- to the flow cytometry lab for immunophenotyping, 11.5 g/dl; WBC 2.2-3.2 x 109/L; 43-96 x109/L; which confirmed an aberrant B-cell population absolute count persistently low, 400-600/ without light chain expression. Large lymphoid cells dl). The patient’s (LDH) was showed CD5/CD20 co-expression, were positive markedly elevated at 4539 U/L (reference range 100- for CD19 and negative for CD3, CD10, and TdT. 190 U/L) and her liver aspartate transaminase This immunophenotype coincided with the im- was high at 72-105 U/L (reference 15-37U/L); alanine munohistochemical stain results of the gallbladder. transaminase was normal. Hypoalbuminemia with a se- The patient’s post-operative recovery was compli- rum albumin of 2.1-2.5 g/dl (reference 3.4-5.0 g/dl) was cated by fever, bilateral pulmonary basilar atelec- found. The patient’s renal panel was normal. A periph- tasis with bilateral pleural effusions, and mental eral blood smear review was requested by the clinician. status changes. With a diagnosis of IVLBCL, the Materials and Methods

An acalculous gallbladder was received in surgical pathol- ogy and representative H&E sections were obtained. A peripheral blood smear was performed using the Wright stain. A peripheral blood sample was also submitted for flow cytometric analysis based on the morphologic evaluation. No biopsy was performed.

Results

Histological sections of the gallbladder revealed non-specific chronic cholecystitis, cholesterolosis, and many dilated small vessels in the gallbladder wall, filled with clusters of atypical lymphoid cells Figure 2. Immunohistochemical stain. Lymphoma cells positive for (Figure 1A). These were medium CD20 (x100). 264 Annals of Clinical & Laboratory Science, vol. 41, no. 3, 2011

respiratory failure twenty days after the diagno- sis. No postmortem examination was performed.

Discussion

It is exceedingly rare for the gallbladder to serve as the initial presenting site of an extranodal non- , with only 35 cases reported in the English literature; more than half were MALT lymphoma (20 cases), followed by diffuse large B- cell lymphoma (6 cases) and other variants of B-cell lymphoma (5 cases). Only four cases of IVLBCL involving the gallbladder were reported; two cases were retrieved from two separate studies (DiGi- useppe et al, 10 cases, and Ferreri et al, 38 cases) [4, Figure 3. Atypical large lymphoid cell in peripheral blood smear (Wright 5]. The general features of IVLBCL of the gallblad- stain, x500). der identified from the literature and our case are summarized in Table 1. One Western variant pa- patient was transferred to the unit for tient did not have any clinical information [5]. In initiation of chemotherapy. During her hospital- two Western variant patients CNS symptoms were ization, extensive radiologic exams were performed present in addition to symptoms of cholecystitis. on head, chest, abdomen and pelvis which were However, skin manifestations were not mentioned essentially unremarkable with exception of pleu- in any patients. As a common finding in the Asian ral effusions and pulmonary atelectasis. No skin variant, was present in the bone biopsy or bone marrow staging was performed. marrow [6]. Overall, the diagnosis of IVLBCL was After the first round of chemotherapy, the pa- made antemortem in four Western patients and tient’s pancytopenia worsened and she de- postmortem in the Japanese patient. Based on the veloped sepsis with multidrug-resistant original article [6], this Japanese patient presented Pseudomonas and fungal infections. Despite che- with fever and upper abdominal pain. A diagnosis motherapy cessation, the patient’s status continued of ‘mild cholecystitis’ was rendered on the gallblad- to decline, and she subsequently died of renal and Table 1. General features of intravascular large B-cell lymphoma of gallbladder.

Author/ Age/ Variant Skin CNS Peripheral blood Immuno- Diagnosed Survival Year Gender phenotype premortem

DiGuseppe/1994 85/F Western No No N/A Yes 1 month

Ferreri/2004 N/A* Western N/A N/A N/A N/A Yes 5 months

Kurodu/2007 79/M Asian No No pancytopenia CD5- No 4 months CD10-

Vazquez/2007 64/F Western No Yes anemia CD5- Yes 5 days CD10-

Duan/2010 51/F Western No Yes pancytopenia CD5+ Yes 20 days CD10-

Note: *Case 2: without detail clinical information mentioned by original paper Case 3: large B-cell lymphoma was diagnosed on bone marrow. Patient died after 4 months of chemotherapy. IVLBCL was diag nosed on gallbladder retrospectively. Intravascular Large B-cell Lymphoma 265

Table 2. Common Abnormal Laboratory Findings in Intravascular Large B-cell Lymphoma

Hemoglobin WBC LDH Albumin* b-MGN**

Result <12 g/dl <4 x 109/L <150 x109/L high low high

Note: LDH: lactate dehydrogenase *Hypoalbuminemia in 84% of Asian cases; 18% of Western cases (3) **b-microglobulin is seen in 82% of Western cases (5) der after cholecystectomy. Four months after the - 9% of patients [3]. Among the abnormal labora- cholecystectomy, the patient developed high fe- tory results, anemia and markedly increased serum ver and pancytopenia. A diagnosis of ‘large B-cell LDH are the most common findings [3]. Common lymphoma’ with hemophagocytosis was made on a abnormal laboratory results retrieved from review bone marrow biopsy and confirmed with flow -cy of the literature are listed in Table 2 [2, 3, 5]. By tometry. This patient achieved a partial remission immunophenotyping, IVLBCL demonstrates a B- after chemotherapy; however, he died of respiratory cell lineage with expression of CD19 (85%), CD20 failure. IVLBCL of the gallbladder was diagnosed (96%), and CD79a (100%). The majority are posi- retrospectively as part of the autopsy examination. tive for MUM1/IRF4 (95%). A subset is positive Review of two detailed reports on gallbladder IV- for CD5 (38%) and CD10 (13%) [2]. Lymphoma LBCL [6, 7], plus the findings in our case dem- cells in all cases of gallbladder IVLBCL were nega- onstrated that the abnormal laboratory findings of tive for CD10 while our case was positive for CD5. IVLBCL involving the gallbladder were similar to The cause of the unpredictable biologic behavior of IVLBCL involving other organs. Anemia is the most this tumor is unclear. Ponzoni and colleagues sug- common finding, followed by an elevated LDH. gested a deficiency of CD29 or CD54 in tumor cells Furthermore, both our patient and the Japanese [8]; other authors postulated a role of molecular ad- patient shared similar presentations: cholecystitis- hesion or homing receptors necessary for migration like symptoms and pancytopenia, and diagnoses into extravascular regions [9]. Nevertheless, due to were both confirmed by flow cytometric analysis. its extremely variable clinical presentation, it is of- These observations emphasize the role of peripheral ten referred to as ‘the great imitator’ by oncologists blood smear review and flow cytometric analysis [10]. Overall, the variable clinical manifestations, for a prompt and accurate diagnosis in these pa- the rarity of this lymphoma, and the subtle patho- tients if pancytopenia or leucopenia are present and logic changes are factors which all contribute to a there is suspicion of IVLBCL. IVLBCL is consid- delayed diagnosis and poor outcome in IVLBCL ered a disseminated disease without tumor masses patients. Indeed, more than half of the IVLBCL cas- or lymphadenopathy [3]. We believe the heteroge- es discussed here were diagnosed postmortem [11]. neous manifestations are caused by obstruction of There is no standard approach to the diagnosis of the circulating tumor cells within the blood vessels IVLBCL. A suggested modality for the workup of in certain organ/sites; however, gallbladder involve IVLBCL was proposed at the International Con- ment as the initial presentation is rare. In the larg- sensus Meeting in Locarno, Switzerland in 2005 est series of cases involving the Western variant [5], and includes ‘physical examination with emphasis the most commonly involved sites of IVLBCL were on nervous system and skin; routine blood stud- skin (40%), CNS (39%), bone marrow (32%), liver ies (especially hepatic, pulmonary, renal or thy- or (26%), lung (19%), and endocrine glands roid functional tests); peripheral blood smear; or kidney (16%). Moreover, liver, spleen, lung, en- contrasted total-body computerized tomography docrine gland and bone marrow served as a part of scan; contrasted whole- magnetic resonance multiple organ system involvement in these cases imaging; CSF cytology and biochemical examina- [5]. Despite its intravascular infiltrative pattern, tion; bone marrow biopsy’ [3]. 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