Simultaneous Follicular Lymphoma and Myelofibrosis: Report of a Case with Review of the Literature

Figures & data

Table 1 The Laboratory Findings

CRP	CRP	35.19mg/L↑
CBC	WBC	1.36×10^9/L↓
	NE	0.88×10^9/L↓
	LY	0.32×10^9/L↓
	EO	0.01×10^9/L↓
	RBC	1.93×10^12/L↓
	Hb	57.00g/L↓
	PLT	59.00×10^9/L↓
ESR	ESR	97mm/h↑
Coagulation	Fbg	4.35g/L↑
	DD	1.93mg/L FEU↑
Coombs test	Direct Coombs test	Negative
	Indirect Coombs test	Negative
β2 microglobulin	β2-MG	4.58ug/mL↑
ANA	ANA	Weak positive 1:100
RCT	RCT%	3.16%↑
Biochemistry	T.P	63.4g/L↓
	GLOP	19.8g/L↓
	ALP	125.8U/L↑
	LDH	488.1U/L↑
	HBD	360.4U/L↑
	Mb	77ng/mL↑
	FBG	7.16mmol/L↑
	P	1.74mmol/L↑
	Mg	0.73mmol/L↓
	Uric acid	506.5umol/L↑
	TG	1.85mmol/L↑
	HDL	0.70mmol/L↓
	Apo A1	0.93g/L↓
Serum iron metabolism	Fer	581.4ng/mL↑
	UIBC	55.00umol/L↑
Interleukin-6	IL-6	17.10pg/mL↑

Notes: ↑Denotes above the upper limit of the reference range, ↓denotes below the lower limit of the reference range.

Abbreviations: CBC, complete blood count; CRP, C-reactive protein; WBC, white blood cell; NE, neutrophil; LY, lymphocyte; Eo, eosinocyte; RBC, red blood cell; Hb, hemoglobin; PLT, plate; ESR, erythrocyte sedimentation rate; Fbg, fibrinogen; DD, Ddimer; RCT, reticulocyte; T.P, total protein; GLOB, globulin; ALP, alkaline phosphatase; LDH, lactate dehydrogenase; HBD, hydroxybutyrate dehydrogenase; Mb, myoglobin; GLU, FBG, fasting blood glucose; TG, triglyceride; HDL, high density lipoprotein; Apo A1, Apolipoprotein A1; Fer, ferritin; UIBC, unsaturated iron binding capacity; IL-6, interleukin-6.

Figure 1 The changes of β2-MG, IL-6, VEGF, LDH. The series of β2-MG, IL-6 are drawn on the primary axis, and the series of VEGF, LDH are drawn on the secondary axis.

Figure 2 Flow cytometry of peripheral blood. (A–F) Before chemotherapy, the aberrant lymphocytes population expressed CD19, CD20, CD10, cKappa; (H–M) after three courses of chemotherapy, these became negative.

Figure 3 The immunostaining of right cervical lymph node for cytokines. (A) (b-FGF;×200), positive; (B) (IL-1β;×200), positive; (C) (IL-2;×200), positive; (D) (IL-6;×200), positive; (E) (IL-10,×200), positive; (F) (MUM-1×200), positive; (G) (PDGF×200), positive; (H) (TGF-β×200), positive; (I) (TNF-α×200), positive; (J) (VEGF×200), positive; (K) HE, ×40.

Figure 4 The immunostaining of bone marrow before treatment. (A) (b-FGF;×200), positive; (B) (CD20;×100), positive; (C) (CD61×100), positive; (D) (IL-10;×200), positive; (E) HE 100×; (F) (IL-1β;×200), positive; (G) (PDGF×200), positive; (H) (TGF-β×200), positive; (I) (VEGF×200), positive; (J) reticular fiber staining revealed diffuse fibrosis (MF-3) 100×; (K) (IL-2;×200), positive; (L) (IL-6;×200), positive; (M) (TNF-α×200), positive.

Figure 5 PET/CT finding. (A–C) Before chemotherapy. (The largest lymph nodes was in the lower abdominal mesenteric region 68mm x 42mm, SUVmax =8.2). (D–F) After three courses of chemotherapy (The spleen reduced obviously, whose metabolism was normal (SUVmax=2.6)). (A) Widespread lymph node enlargement and hypermetabolism, splenomegaly, kidney hypermetabolism (blue arrows) and diffuse bone marrow hypermetabolism. Its inferior border approached the upper margin of pelvis (SUVmax= 2.9); (B) spinal hypermetabolism (blue arrow); (SUVmax =9.0); (C) iliac hypermetabolism (blue arrows); (D) no abnormal lymph nodes were found. The volume of spleen was smaller than before, and the metabolism of bone marrow, kidney metabolism were normal (red arrows); (E) normal spine metabolism, (SUVmax =3.3) (red arrow); (F) normal ilium metabolism (red arrows).

Figure 6 Fluorescence interphase in situ hybridization on lymph node biopsy. (A) IGH-BCL2 dual-colour dual-fusion probe displays two fused green and red signals, one isolated green and one isolated red signal in most of tumour nuclei with t(14;18) (q21;q32)/IGH-BCL2. Arrow indicates positive nuclei. (B) BCL2 dual-colour break-apart (BAP) probe shows one co-localised green and red signal, one isolated green and one isolated red signal in most of tumour nuclei; (C) BCL6 dual-colour break-apart (BAP) probe shows two co-localised green and red signal; (D) MYC dual-colour break-apart (BAP) probe shows one co-localised green and red signal.

Table 2 The Analysis of Peripheral Blood

	Before Treatment	After First Course	After Second Course	After Third Course
RBC	1.93×10^12/L	3.29×10^12/L	4.01×10^12/L	4.04×10^12/L
Hb	57.00g/L	97.00g/L	125.00g/L	122.00 g/L
WBC	1.36×10^9/L	3.33×10^9/L	4.12×10^9/L	5.04×10^9/L
PLT	59.00×10^9/L	135×10^9/L	214×10^9/L	175×10^9/L

Note: The pancytopenia is responding well to treatment.

Figure 7 The immunostaining of bone marrow after one course of chemotherapy. (A) (b-FGF;×200), positive; (B) (CD19;×200), negative; (C) (CD117×200), negative; (D) (IL-1β;×200), positive; (E) (IL-2;×200), positive; (F) (IL-6;×200), positive; (G) (IL-10;×200), positive; (H) (PDGF×200), positive; (I) (TGF-β×200), positive; (J) (TNF-α×200), positive; (K) (VEGF×100), positive; (L) reticular fiber staining ×200, MF-1.

Figure 8 The immunostaining of bone marrow after two courses of chemotherapy. (A) (b-FGF;×200), negative; (B) (CD19;×200), negative; (C) (CD117;×200), negative; (D) (IL-1β;×200), negative; (E) (IL-2;×100), negative; (F) (IL-6;×200), negative; (G) (IL-10;×200), negative; (H) (PDGF×200), negative; (I) (TGF-β×200), negative; (J) (TNF-α×200), negative; (K) (VEGF×100), positive; (L) reticular fiber staining 100×, MF 0–1.