Numerous Reed–Sternberg cells in bone marrow aspirate from a patient with the syncytial variant of nodular sclerosis classical Hodgkin lymphoma

A 54-year-old male presented with poor appetite, 10 kg weight loss, and dull periumbilical pain for 1 month. Computed tomography (CT) scans revealed hepatosplenomegaly and cervical, axillary, mediastinal, and abdominal lymphadenopathy, suggesting a lymphoid neoplasm. His full blood count showed: hemoglobin 11.1 g/dL, mean corpuscular volume 76.6 fL, mean corpuscular hemoglobin 27.9 pg, white cells 1.7 × 10⁹/L, and platelets 120 × 10⁹/L. Blood chemistry showed abnormal concentrations of lactate dehydrogenase 2,309 IU/L, albumin 3.2 g/dL, total bilirubin 1.65 mg/dL, serum glutamic oxaloacetic transaminase 181 IU/L, serum glutamic pyruvate transaminase 128 IU/L, and alkaline phosphatase 496 IU/L. A cervical lymph node biopsy was performed, and the patient was diagnosed with syncytial variant of nodular sclerosis classical Hodgkin lymphoma (HL) based on histologic features and the results of immunohistological staining as follows: CD30⁺, CD15⁻, CD3⁻, CD5⁻, BCL2⁺, BCL6⁻, CD20⁺, CD79a⁺, and BOB1⁻. Bilateral examination of the bone marrow aspirate to stage HL showed numerous giant-sized cells with one or more nuclei containing large nucleoli and abundant basophilic cytoplasm (Fig. 1a–c). These cells were consistent with Hodgkin and Reed–Sternberg (HRS) cells, whose proportions on bone marrow aspirate are 9.4 and 9.9 % for the left and right sides, respectively. Trephine biopsy showed diffuse infiltration with an inflammatory background by HRS cells (Fig. 1d), which were found to express the CD30⁺, CD15⁻, and ALK⁻ profile using immunohistochemistry (Fig. 1e, f). Although the expression of CD15, the classic marker for HL, was not observed in either the cervical lymph node or bone marrow in this case, this finding can be observed as the frequency of CD15 expression in HL was 66–84.4 % according to previous reports [1, 2]. Thus, the negative expression of that did not have a decisive effect on the diagnosis of HL. Bone marrow infiltration has been reported in only 4.8–5.2 % of patients with HL [3, 4]. Moreover, numerous Reed–Sternberg cells (RS) in bone marrow aspirate have rarely been reported. This is probably due to related bone marrow fibrosis or scattered focal lesions, which may not be aspirated during a single attempt. Bone marrow involvement in patients with proven HL can be diagnosed if typical RS cells are found in the bone marrow based on the Ann Arbor histologic criteria, thus diagnosis of stage 4 HL was established in this case. The patient is currently receiving standard combination chemotherapy [ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine)] and has shown a good clinical response.

Fig. 1

a Hodgkin and Reed–Sternberg cells in the bone marrow aspirate (Wright–Giemsa stain, ×200). b, c Reed–Sternberg cells in the bone marrow aspirate (Wright–Giemsa stain, ×1000). d Reed–Sternberg cells in the trephine biopsy (hematoxylin–eosin stain, ×1000). e Immunohistochemistry result for CD30 is positive in Hodgkin and Reed–Sternberg cells (×400). f Hodgkin and Reed–Sternberg cells reveal negative reaction to ALK stain (×400)