Diagnostic workup of triple hit lymphoma by fine needle aspiration

Abstract Introduction/Objective Triple-hit lymphomas (THL) represent a rare and aggressive subset of high-grade B-cell lymphomas characterized by a triad of translocations involving MYC, BCL2, and BCL6. Patients with THL face poor outcomes when treated with the standard diffuse large B-cell lymphoma protocol. Thus, intensified regimens have emerged as a frontline strategy for managing these patients. Therefore, accurate diagnosis and molecular subclassification of these lymphomas are essential for guiding therapeutic decisions for these patients. Here, we report a case study detailing the diagnostic assessment of THL utilizing limited diagnostic material obtained through palpation-guided fine-needle aspiration (FNA). Methods/Case Report A 58-year-old male presented with a rapidly enlarging neck mass, accompanied by worsening dysphagia, pain, and fatigue over the course of two months. Laboratory testing showed leukocytosis and imaging studies revealed a partially necrotic, 7.8 x 9.1 x 9.4 cm right jugular nodal mass. The patient was referred to otolaryngology for further evaluation, where FNA of the mass was performed by the cytopathology team. The aspirate was sent for cytology with cell block and flow cytometry. The Romanowsky stain revealed abundant, large, discohesive cells with prominent nucleoli and scant cytoplasm with an abundance of lymphoglandular bodies in the background. Immunohistochemistry (IHC) on the cell block demonstrated BCL-2, BCL-6, and MYC expression, and a Ki-67 proliferation index >95%. Concurrent flow cytometric analyses showed an aberrant B-cell population expressing CD19, CD20, CD22, CD23 and surface lambda light chain. Further fluorescence in situ hybridization (FISH) analysis performed on the cell block confirmed gene rearrangements in BCL2, BCL6 and MYC, thereby classifying this patient’s disease as THL. Results (if a Case Study enter NA) NA Conclusion Diagnosing THL typically demands sufficient tissue for histology, cytology, flow cytometry, IHC, and molecular testing. Herein, we showcase a notable example where the diagnostic evaluation of THL was accomplished using limited material obtained from FNA. This case highlights the efficacy of conducting comprehensive diagnostic studies even when tissue availability is constrained. Utilizing cytologic samples not only streamlines the diagnostic process but also minimizes the need for patients to undergo additional invasive procedures, thus potentially reducing delays in diagnosis and therapeutic intervention.