From www.bloodjournal.org by guest on February 20, 2017. For personal use only.

bloodwork

IMAGES IN HEMATOLOGY

Double hit, triple hitlook for it

c Rudolf Benz, Kantonsspital Munsterlingen;

and Joelle Tchinda, Childrens
Hospital Zurich

A 68-year-old patient was admitted to our hospital with a short history of constipation and dyspnea. Cytology of the pleural effusion
revealed large blastoid B cells. Positron emission tomography/computed tomography scan showed extensive uorodeoxyglucose
activity. In the bone marrow aspirate, large blasts with deeply basophilic cytoplasm and numerous vacuoles resembling Burkitt cells
(panel A) were present. Cytogenetic and uorescence in situ hybridization analysis showed MYC, BCL2 (double hit), and BCL6 (triple
hit) rearrangements within a complex karyotype (panel B), seen in about 5% to 15% of diffuse large B-cell lymphomas (DLBCL). It was
therefore classied according to the World Health Organization as a B-cell lymphoma unclassiable with features intermediate between
DLBCL and Burkitt lymphoma due to the distinct cytogenetic alterations. Because of the aggressive behavior of the disease, we treated
with 3 cycles of rituximab hyper-CVAD/rituximab high-dose methotrexate and 6 intrathecal chemoprophylaxes. Positron emission
tomography/computed tomography scan showed complete resolution and the patient was well. However, disease recurrence was
documented shortly after. The patient died despite reinduction with rituximab-DHAP.
Double- and triple-hit lymphomas are chemosensitive aggressive B-cell lymphomas, but unlike Burkitt lymphoma and DLBCL they have
a very high recurrence rate and are almost always fatal. Proper molecular characterization of lymphomas to determine prognosis is very
important for patient advice and treatment decision.

For additional images, visit the ASH IMAGE BANK, a reference and teaching tool that is
continually updated with new atlas and case study images. For more information visit
http://imagebank.hematology.org.

BLOOD, 28 MARCH 2013 x VOLUME 121, NUMBER 13 2383

 From www.bloodjournal.org by guest on February 20, 2017. For personal use only.

2013 121: 2383

doi:10.1182/blood-2012-10-451716

Double hit, triple hitlook for it

Rudolf Benz and Joelle Tchinda

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