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Alina Nicolae MD, PhD
CASE 2
The 11th International Course
on the Pathology of the
Digestive System
Clinical History
20-year-old female patient
Jan 2016 - acute right lower quadrant abdominal
pain, nausea, vomiting, fever
Ultrasonography – enlargement of the appendix,
no other lesions
Laparotomy - appendectomy has been performed
Macroscopically: 5cm long vermiform appendix, with
pseudomembranes on serosal surface
Dg: Acute appendicitis with periappendiceal abscess
Imaging (CT, TEP-scan):
mesenteric mass 19cm (SUV-18)
nodules (3-5 cm) peritoneal,
perihepatic, Douglas’s pouch
diffuse GI wall hyperfixation (SUV-
11) (stomach, jejunum)
thyroid nodules
inferior vena cava thrombosis,
ascites
March 2017
Rapid increase of abdominal
circumference, epigastric & lumbar pain
Biologically: hepatic cytolysis,
cholestasis, increase lipase & LDH
Clinicians asked for a retrospective
histopathological review of the
appendix
Some reflections….
What is your dg? How many of you would agree
with the dg of acute appendicitis ?
Would you ask for further IHC?
If yes, which antibodies?
CD5
CD20
CD5
CD20
Bcl-6 CD10
MUM1 Hans’ algorithm
Bcl-
2
cMyc
Ki-67 p53 p21
FISH studies
NO MYC/8q24; BCL2/18q21, BCL6/3q27 gene rearrangments
Primary appendicular DLBCL, NOS
GC phenotype (Hans’ algorithm)
FISH 8q24 break-apart probe
Absence of MYC translocation,
fusion signal pattern
BL/DLBCL morphology
BL-like phenotype
BL
HGBCL, NOS
DLBCL, NOS
HGBCL w R
MYC+BCL2+/-BCL6
Revised diagnosis
Apr 2017: Core needle biopsies of mesenteric
mass were performed to confirm the dg
CD3 CD20
Further clinical work-up
Flow cytometry peripheral blood and bone
marrow - negative for lymphoma
Bone marrow biopsy – absence of infiltration
Cytology LCR - negative
Ann Arbor Stage IV
(digestive, peritoneal)
aaIPI – 2 (LDH, Stage)
Apr 2017: COP treatment for debulking (remarkable
regression of tumor mass) R-COPADEM, FISH results
neg switched to R-CHOP 14 (GAINED study)
No ovarian cortex cryopreservation (emergency treatment)
Follow-up
May 17
Aug 17
PET scan Sept
2017 CR
CR – 13 months
after ASCT
Rare, <250 cases, 1.7% of appendiceal tumors
Mean age 48y (range 4-70), M:F - 1.5:1, most White
Most pts no relevant medical history, immunocompetent
Non-specific clinical findings, often signs and symptoms
suggestive of acute appendicitis
Right hemicolectomy confers no survival benefit over
appendectomy CHT primary treatment modality
Journal of Surgical Research 2017
Markedly homogeneous
enlargement (2.5-4cm) of the
appendix
Usually preserved vermiform
morphology
Stranding of the
periappendiceal fat :
superimposed inflammation
or tumor extension
Coexisting abdominal LAD or
aneurysmal dilatation of the
appendiceal lumen specific
for lymphoma
Pickhardt et al AJR Am J Roentgenol. 2002
CT scan
Axial images from
unenhanced CT
Contrast enhanced CT
Pathological examination
Diffuse, circumferential wall
thickening w obliteration of the lumen
Diffuse lymphocytic infiltration of the
appendiceal wall
Periappendiceal inflammation,
necrosis, and/or lymphomatous
extension into adjacent fat
Lymphoma types: DLBCL (34%), BL
(26%, young age), FL (15%)
Pickhardt et al AJR Am J Roentgenol. 2002
Ayud et al. J Surg Res 2017
Primary lymphomas of the appendix exist and can
affect young pts
All appendectomies should be sent for HP dg
Appendix with >2.5 cm diameter suspicious for
neoplasm extensive sampling
Awareness is crucial to achieve the correct dg;
clinical signs of appendicitis, young age and acute
inflammation are pitfalls in recognizing lymphomatous
appendiceal involvement
Take home message