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Virtual case of the month
Tonsillar follicular large B-cell lymphoma with IRF4 rearrangement causing sleep apnoea
  1. Yu-Ting Yu1,
  2. Seiji Sakata2,
  3. Kengo Takeuchi2,
  4. L Jeffrey Medeiros3,
  5. Kung-Chao Chang4
  1. 1 Pathology, National Cheng Kung University, Tainan, Taiwan
  2. 2 Division of Pathology, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
  3. 3 Hematopathology, UT MD Anderson Cancer Center, Houston, Texas, USA
  4. 4 Pathology, National Cheng Kung University Hospital, Tainan, Taiwan
  1. Correspondence to Professor Kung-Chao Chang, Pathology, National Cheng Kung University Hospital, Tainan 70428, Taiwan; changkc{at}mail.ncku.edu.tw

https://doi.org/10.1136/jclinpath-2019-205915

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    Clinical question

    An 8-year-old boy, without underlying disease, presented to the otolaryngologist with sleep apnoea and snoring. Physical examination showed bilateral tonsillar and adenoid hypertrophies and he underwent bilateral tonsillectomy and adenoidectomy. Review the high quality, interactive digital Aperio slide at http://virtualacp.com/JCPCases/jclinpath-2019-205915/ and consider your diagnosis.

    What is your diagnosis?

    1. Follicular hyperplasia.

    2. Paediatric-type follicular lymphoma.

    3. Conventional follicular lymphoma.

    4. CD10-MUM1+follicular lymphoma.

    5. Large B cell lymphoma with IRF4 rearrangement.

    Discussion

    Pathologically, the follicles in the tonsils are numerous but only a subset is arranged in a back-to-back pattern (online supplementary figure S1). No abnormal follicle is found in the adenoid. These abnormal follicles show attenuated mantle zones, loss of polarity and starry-sky appearance (figure 1A), and are composed predominantly of medium-sized blasts (figure 1A, inset). Immunohistochemically, the cells in the abnormal follicles are positive for CD20, BCL-6 (figure 1B), BCL-2 (figure 1C) and MUM1/IRF4 (figure 1D) with a Ki-67 proliferative index of 20% to 30% (figure 1E). CD10 is however negative. An initial impression of paediatric-type follicular lymphoma was considered but the strong expression of MUM1/IRF4 suggests the alternative entity ─ follicular form of large B-cell lymphoma with IRF4 rearrangement.1 We, thus, performed a detailed fluorescence in situ hybridisation study using three-colour probes of mixed 6p25.3 region (IRF4) dual colour split …

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    Footnotes

    • Handling editor Iskander Chaudhry.

    • Correction notice This paper has been corrected since it was published Online First. New hyperlinks for the digital slides have been added.

    • Contributors YTY collected the clinical data and wrote the paper; SS, KT performed and analysed the FISH studies; LJM clinically reviewed and revised the paper; KCC conducted the whole study and revised the paper.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Parental/Guardian consent obtained.

    • Provenance and peer review Commissioned; internally peer reviewed.