病理报告结论不一致怎么办呢？

橙色雨丝

Luckymirror 发表于 2022-9-29 16:24
谢谢您！我也是这么觉得的，又放心一点点……老天保佑

我结合周教授和高教授的报告分析一下：切了一个疑似淋巴瘤的淋巴结，首先看结构是否破坏，根据描述，有一定的异常，但没有完全破坏，只是有较多的淋巴细胞增生；这时候要判断是反应性增生，还是肿瘤性增生；周教授根据FDC网和IgM的染色，倾向于是肿瘤性增生，因为反应性增生中IgM的染色是有一定规律的，现在不符合规律了；那么，有B有T，哪个是肿瘤呢？TCR重排阳性，所以倾向于是T；外周T淋巴瘤各个分型中只有血管免疫母细胞淋巴瘤（AITL）最难确诊，因为肿瘤细胞数量相对较少，而且背景中总是有个头较大，核异常（核大，甚至双核或多核，很像霍奇金的RS细胞）的免疫母细胞，但是这些细胞通常不是肿瘤细胞，而是被EB病毒感染的B细胞，周教授看到了这样的细胞，高教授没有看到；除了免疫母细胞，AITL还有一个特征是HEV（高内皮小静脉）增生（所以叫做血管免疫母细胞淋巴瘤），这个周教授和高教授都没有看到；但是有一部分细胞表达滤泡辅助性T细胞（AITL的肿瘤细胞）标记物CXCL-13和ICOS，不排除是肿瘤性的；最后，高教授根据患者自身免疫性疾病的病史，认为淋巴瘤证据不足，而周教授认为是外周T细胞淋巴瘤，自身免疫性疾病的患者本身就是淋巴瘤高发人群，一方面免疫紊乱，另一方面长期服用免疫抑制性药物也增大淋巴瘤风险，所以这样判断也有一定依据；总之，由于激素的使用，给病理诊断带来很大困难，目前情况不明，建议观察，如果是肿瘤性病变，早晚还会出现异常情况的。

Luckymirror

橙色雨丝 发表于 2022-09-30 07:45
我结合周教授和高教授的报告分析一下：切了一个疑似淋巴瘤的淋巴结，首先看结构是否破坏，根据描述，有一定的异常，但没有完全破坏，只是有较多的淋巴细胞增生；这时候要判断是反应性增生，还是肿瘤性增生；周教授根据FDC网和IgM的染色，倾向于是肿瘤性增生，因为反应性增生中IgM的染色是有一定规律的，现在不符合规律了；那么，有B有T，哪个是肿瘤呢？TCR重排阳性，所以倾向于是T；外周T淋巴瘤各个分型中只有血管免疫母细胞淋巴瘤（AITL）最难确诊，因为肿瘤细胞数量相对较少，而且背景中总是有个头较大，核异常（核大，甚至双核或多核，很像霍奇金的RS细胞）的免疫母细胞，但是这些细胞通常不是肿瘤细胞，而是被EB病毒感染的B细胞，周教授看到了这样的细胞，高教授没有看到；除了免疫母细胞，AITL还有一个特征是HEV（高内皮小静脉）增生（所以叫做血管免疫母细胞淋巴瘤），这个周教授和高教授都没有看到；但是有一部分细胞表达滤泡辅助性T细胞（AITL的肿瘤细胞）标记物CXCL-13和ICOS，不排除是肿瘤性的；最后，高教授根据患者自身免疫性疾病的病史，认为淋巴瘤证据不足，而周教授认为是外周T细胞淋巴瘤，自身免疫性疾病的患者本身就是淋巴瘤高发人群，一方面免疫紊乱，另一方面长期服用免疫抑制性药物也增大淋巴瘤风险，所以这样判断也有一定依据；总之，由于激素的使用，给病理诊断带来很大困难，目前情况不明，建议观察，如果是肿瘤性病变，早晚还会出现异常情况的。

谢谢雨丝大神！太感谢您对我病理的专业分析。我昨天也电话请教了周教授助手，我不知道自己理解的对不对，她说看过好多遍这个淋巴结结构是破坏了，不是正常的，加上我的分子诊断是T细胞单克隆，再加上其他专业的分析吧，所以综合考虑下的结论。
针对我上周CT淋巴结变小变少（我昨天才给，因为是寄片之后才拍的），认为是好事。所以报告后加了一句：如果临床表现不像，请结合临床。
所以，现在都是说继续观察。有医生建议隔两个月拍一次PETCT，不知道有这个必要吗？那个辐射好大

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byjz

至于连T细胞，还是B细胞都分不清楚么？

JJKKPPAAYHY

请问是怎么找这么多医院做病理的？是直接去医院挂号吗？

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Luckymirror

JJKKPPAAYHY 发表于 2022-10-01 15:10
请问是怎么找这么多医院做病理的？是直接去医院挂号吗？

一般不用的 之家可以帮忙联系 我这是临床医生帮忙联系的

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JJKKPPAAYHY

Luckymirror 发表于 2022-10-01 16:49
一般不用的 之家可以帮忙联系 我这是临床医生帮忙联系的

好的 非常感谢答复 一起加油

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Luckymirror

@橙色雨丝 @战斗先生
时间好快，距离去年来这里已有一年之久。首先衷心祝各位老师别来无恙身体健康万事顺意。
在去年病理结论不一致以后，我2022年10月重新做了PET-CT，显示左颈部淋巴结大部分消失并无摄取值，胸腺肿物尺寸变小摄取值从19降为7。而后在中肿再做会诊，结论是免疫性非典型性增生，密切随访。
2023年8月一年复查CT，胸腺肿物尺寸又变大了，左侧脖子淋巴较2022年9年增多增大，直到现在左锁骨可以摸到浅表淋巴结。我昨天又取了脖子淋巴结做活检，3个，0.5—1cm大小。目前在忍痛等结论。

我们通过医院申请了香港陈GuoZhang教授做会诊，包括把2015年胸腺手术组织、2022年淋巴结、胸腺穿刺全部送过去，刚刚收到陈教授的报告。还请大神们@橙色雨丝 @战斗先生 帮忙看看给点意见。


2015 mediastinum (thymus) excision/biopsy specimen  1512115

The thymus excision specimen shows features typical of thymic extranodal marginal zone lymphoma (MALT lymphoma). The extensive cystic transformation of the thymic epithelium, dense infiltration of small lymphoid cells and plasma cells,  prominent lymphoepithelial lesions and presence of pale monocytoid cells in the vicinity of the epithelium are all characteirstic. [Unstained paraffin sections are not available to further characterize the nature of the neoplastic cells, such as IgA production.]

Comment: Thymic MALT lymphomas most typically / frequently occurs in  patients with Sjogren syndrome, which this patient did have. This is a highly indolent tumor with excellent prognosis. The tumor most commonly secretes IgA, and IgA paraproteinemia may be present in some patients. (We do not have unstained paraffin sections for immunostaining to prove that the neoplastic plasma cells secrete IgA and are monotypic.).



2022 mediastinal core biopsy   2214844

The biopsy shows strips of tissue densely infiltrated by small lymphoid cells, monocytoid cells and plasma cells. There are bands of interspersed cytokeratin+ epithelium (thymic epithelium), and lymphoepithelial lesions are present. There are  moderate numbers of CD20+ B cells, and many CD3+ T cells are present. We have performed immunostaining for immunoglobulins; the neoplastic cells express IgA, and exhibit kappa light chain restriction. Thus the mediastinal biopsy shows persistence or recurrence of thymic extranodal marginal zone lymphoma.

Comment:  It is unclear from the clinical records whether the 2015 thymic excision was a complete excision; so the 2022 biopsy may represent either residual or recurrent thymic MALT lymphoma. This time, we manage to demonstrate that this neoplasm is IgA-kappa positive, which can help us further track the nature of other biopsies. NGS studies on this sample  (1DNA) shows mutations in several genes, including EP300, which is known to be implicated in some MALT lymphomas.



2022 neck lymph node needle biopsy  2214362

The lymph node core biopsy shows strips of tissue populated mostly by small lymphoid cells, plasma cells and occasional large cells. The morphology is rather nonspecific. Immunostaining shows that there are not many CD20+ B cells, but moderate numbers of CD3+ T cells. While the findings are nonspecific (reactive versus neoplastic), we have nonetheless performed IgA, Kappa and lambda immunostains, and can convincingly demonstrate presence of IgA-kappa-restricted cells, indicating the presence of subtle involvement by the extranodal marginal zone lymphoma.

Comment:  The demonstration by NGS of similar genetic alterations (specimen 2DNA) in comparison with the mediastinal biopsy further supports involvement of the lymph node by the same tumor, albeit with a lower allelic frequency (suggesting presence of tumor in a lower percentage in this specimen).



2022 neck lymph  node excision   948691  

The lymph node shows distorted but still preserved architecture – sinuses are intact and often distended by histiocytes and/or lymphoid cells. Lymphoid follicles are inconspicuous. The paracortex is expanded, with a spectrum of lymphoid cells (small and large) that do not show frank nuclear atypia; there are also focal collections of monocytoid cells. Scattered histiocytes and epithelioid histiocytes are present. Immunostaining shows nodular aggregates of CD20+ B cells plus small numbers of CD20+ cells in between. Many CD3+ cells are present, including small and large cells; and they represent a mixture of CD4+ and CD8+ cells. We have performed IgA, Kappa and lambda immunostains, and can demonstrate a minor population of IgA-kappa-restricted cells, indicating the presence of subtle involvement by the extranodal marginal zone lymphoma (even more subtle than in the neck lymph node needle biopsy). I believe the background lymph node shows reactive changes, presumably a reaction to the lymphoma or a manifestation of the underlying autoimmune disease (Sjogren syndrome).

Comment:  NGS studies (3DNA) show similar genetic mutations, at a very low tumor allelic frequency, suggesting that the thymic MALT lymphoma cells are present as a minor population – either the disease is regressing or there is a sampling error or the excised lymph node is not the same as the biopsied lymph node. I note in one of the reports that clonal TCRG rearrangement is demonstrated in this specimen; I cannot fully explain this – there might be minor T-cell clones in the background of lymphoid hyperplasia.

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橙色雨丝

Luckymirror 发表于 2023-10-28 13:18
@橙色雨丝 @战斗先生
时间好快，距离去年来这里已有一年之久。首先衷心祝各位老师别来无恙身体健康万事顺意。
在去年病理结论不一致以后，我2022年10月重新做了PET-CT，显示左颈部淋巴结大部分消失并无摄取值，胸腺肿物尺寸变小摄取值从19降为7。而后在中肿再做会诊，结论是免疫性非典型性增生，密切随访。
2023年8月一年复查CT，胸腺肿物尺寸又变大了，左侧脖子淋巴较2022年9年增多增大，直到现在左锁骨可以摸到浅表淋巴结。我昨天又取了脖子淋巴结做活检，3个，0.5—1cm大小。目前在忍痛等结论。

我们通过医院申请了香港陈GuoZhang教授做会诊，包括把2015年胸腺手术组织、2022年淋巴结、胸腺穿刺全部送过去，刚刚收到陈教授的报告。还请大神们@橙色雨丝 @战斗先生 帮忙看看给点意见。


2015 mediastinum (thymus) excision/biopsy specimen  1512115

The thymus excision specimen shows features typical of thymic extranodal marginal zone lymphoma (MALT lymphoma). The extensive cystic transformation of the thymic epithelium, dense infiltration of small lymphoid cells and plasma cells,  prominent lymphoepithelial lesions and presence of pale monocytoid cells in the vicinity of the epithelium are all characteirstic. [Unstained paraffin sections are not available to further characterize the nature of the neoplastic cells, such as IgA production.]

Comment: Thymic MALT lymphomas most typically / frequently occurs in  patients with Sjogren syndrome, which this patient did have. This is a highly indolent tumor with excellent prognosis. The tumor most commonly secretes IgA, and IgA paraproteinemia may be present in some patients. (We do not have unstained paraffin sections for immunostaining to prove that the neoplastic plasma cells secrete IgA and are monotypic.).



2022 mediastinal core biopsy   2214844

The biopsy shows strips of tissue densely infiltrated by small lymphoid cells, monocytoid cells and plasma cells. There are bands of interspersed cytokeratin+ epithelium (thymic epithelium), and lymphoepithelial lesions are present. There are  moderate numbers of CD20+ B cells, and many CD3+ T cells are present. We have performed immunostaining for immunoglobulins; the neoplastic cells express IgA, and exhibit kappa light chain restriction. Thus the mediastinal biopsy shows persistence or recurrence of thymic extranodal marginal zone lymphoma.

Comment:  It is unclear from the clinical records whether the 2015 thymic excision was a complete excision; so the 2022 biopsy may represent either residual or recurrent thymic MALT lymphoma. This time, we manage to demonstrate that this neoplasm is IgA-kappa positive, which can help us further track the nature of other biopsies. NGS studies on this sample  (1DNA) shows mutations in several genes, including EP300, which is known to be implicated in some MALT lymphomas.



2022 neck lymph node needle biopsy  2214362

The lymph node core biopsy shows strips of tissue populated mostly by small lymphoid cells, plasma cells and occasional large cells. The morphology is rather nonspecific. Immunostaining shows that there are not many CD20+ B cells, but moderate numbers of CD3+ T cells. While the findings are nonspecific (reactive versus neoplastic), we have nonetheless performed IgA, Kappa and lambda immunostains, and can convincingly demonstrate presence of IgA-kappa-restricted cells, indicating the presence of subtle involvement by the extranodal marginal zone lymphoma.

Comment:  The demonstration by NGS of similar genetic alterations (specimen 2DNA) in comparison with the mediastinal biopsy further supports involvement of the lymph node by the same tumor, albeit with a lower allelic frequency (suggesting presence of tumor in a lower percentage in this specimen).



2022 neck lymph  node excision   948691  

The lymph node shows distorted but still preserved architecture – sinuses are intact and often distended by histiocytes and/or lymphoid cells. Lymphoid follicles are inconspicuous. The paracortex is expanded, with a spectrum of lymphoid cells (small and large) that do not show frank nuclear atypia; there are also focal collections of monocytoid cells. Scattered histiocytes and epithelioid histiocytes are present. Immunostaining shows nodular aggregates of CD20+ B cells plus small numbers of CD20+ cells in between. Many CD3+ cells are present, including small and large cells; and they represent a mixture of CD4+ and CD8+ cells. We have performed IgA, Kappa and lambda immunostains, and can demonstrate a minor population of IgA-kappa-restricted cells, indicating the presence of subtle involvement by the extranodal marginal zone lymphoma (even more subtle than in the neck lymph node needle biopsy). I believe the background lymph node shows reactive changes, presumably a reaction to the lymphoma or a manifestation of the underlying autoimmune disease (Sjogren syndrome).

Comment:  NGS studies (3DNA) show similar genetic mutations, at a very low tumor allelic frequency, suggesting that the thymic MALT lymphoma cells are present as a minor population – either the disease is regressing or there is a sampling error or the excised lymph node is not the same as the biopsied lymph node. I note in one of the reports that clonal TCRG rearrangement is demonstrated in this specimen; I cannot fully explain this – there might be minor T-cell clones in the background of lymphoid hyperplasia.

陈教授的结论是胸腺MALT淋巴瘤，颈部淋巴结有少量肿瘤细胞的累及，以及T细胞的增生，但是不足以下结论说增生的T细胞是肿瘤性的。

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Luckymirror

橙色雨丝 发表于 2023-10-28 13:40
陈教授的结论是胸腺MALT淋巴瘤，颈部淋巴结有少量肿瘤细胞的累及，以及T细胞的增生，但是不足以下结论说增生的T细胞是肿瘤性的。

谢谢大神。我也是一直处于t细胞重排的阴影之中那您觉得边缘区淋巴瘤是否可以解决我身上的这些疑问呢？接下来还是要有个方向治疗啊

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橙色雨丝

Luckymirror 发表于 2023-10-28 13:45
谢谢大神。我也是一直处于t细胞重排的阴影之中那您觉得边缘区淋巴瘤是否可以解决我身上的这些疑问呢？接下来还是要有个方向治疗啊

肿瘤的发生和发展是需要一个过程的，以外周T为例，先是增生，然后是单克隆的增生，最后是T细胞淋巴瘤，现在应该可以说最多只发展到单克隆增生的阶段，会不会继续发展，谁也说不好，解决MALT淋巴瘤的问题对T细胞增生也是有抑制作用的。

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Luckymirror

橙色雨丝 发表于 2023-10-28 13:50
肿瘤的发生和发展是需要一个过程的，以外周T为例，先是增生，然后是单克隆的增生，最后是T细胞淋巴瘤，现在应该可以说最多只发展到单克隆增生的阶段，会不会继续发展，谁也说不好，解决MALT淋巴瘤的问题对T细胞增生也是有抑制作用的。

妈呀还是好可怕π_π

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