Can J Gastroenterol Vol 21 No 3 March 2007185
A definitive diagnosis of primary Hodgkin lymphoma
on endoscopic biopsy material utilizing in-depth
Garnet Horne MD1, Shaun AC Medlicott MD1, Adnan Mansoor MD1,
Johan Lategan MD2, Raymond Lai MD3, P Beck MD2
1Department of Pathology and Laboratory Medicine; 2Department of Internal Medicine, Peter Lougheed Centre, University of Calgary, Calgary;
3Cross Cancer Institute, University of Alberta, Edmonton, Alberta
Correspondence and reprints: Dr Shaun AC Medlicott, Calgary Laboratory Services, Peter Lougheed Centre, 3500–26 Street North East,
Calgary, Alberta T1Y 6J4. Telephone 403-943-4907, fax 403-291-2931, e-mail firstname.lastname@example.org
Received for publication February 8, 2006. Accepted March 5, 2006
G Horne, SAC Medlicott, A Mansoor, J Lategan, R Lai, P Beck.
A definitive diagnosis of primary Hodgkin lymphoma on
endoscopic biopsy material utilizing in-depth immunohistochemical
analysis. Can J Gastroenterol 2007;21(3):185-188.
The esophagus and stomach can be primary sites for Hodgkin
lymphoma (HL). The pathognomonic feature of HL is the Reed-
Sternberg cell. Because these cells can be rare in HL tumours, biop-
sies obtained via endoscopy are usually inadequate for establishing a
definitive diagnosis. A case of a gastroesophageal junction primary
HL is presented that was diagnosed on endoscopic biopsy material
with the assistance of the immunohistochemical stains PAX5 and
MUM1 which verified the presence of Reed-Sternberg cells. The
patient was effectively treated for HL and avoided traditional
laparotomy or thoracotomy procedures to obtain the diagnosis. This
advanced immunohistochemical approach should be the standard in
the diagnosis of primary gastrointestinal HL. An endoscopy-based
approach should obviate more invasive, open biopsy procedures for
establishing HL diagnosis.
Key Words: Gastroesophageal junction; Hodgkin lymphoma;
Un diagnostic définitif de maladie de
Hodgkin primaire au moyen de l’analyse
immunohistochimique d’un prélèvement
L’œsophage et l’estomac peuvent être des sièges primaires de maladie de
Hodgkin (MH). Les cellules de Reed-Sternberg sont la caractéristique
phatognomonique de la MH. Puisque ces cellules peuvent être rares dans
les tumeurs de MH, les biopsies obtenues par endoscopie ne permettent
généralement pas d’établir un diagnostic définitif. Est présenté un cas de
MH primaire à la jonction gastro-œsophagienne diagnostiqué par co-
loration immunohistochimique PAX5 et MUM1 d’un prélèvement endo-
scopique, qui a démontré la présence de cellules de Reed-Sternberg. Le
patient a subi un traitement efficace contre la MH et évité les interven-
tions diagnostiques classiques par laparatomie ou thoracotomie. Cette
démarche immunohistochimique perfectionnée devrait constituer la
norme pour diagnostiquer la MH gastro-intestinale primaire. Une
démarche endoscopique éviterait les biopsies ouvertes plus effractives
pour confirmer un diagnostic de MH.
he gastrointestinal (GI) tract is a common site for
extranodal non-Hodgkin lymphoma (NHL). However,
primary HL of the stomach or esophagus is an extremely
remote scenario, accounting for fewer than 1% of lymphomas
in these organs (1,2). The diagnosis requires exclusion of
undifferentiated carcinomas, epithelioid sarcomas and
commonly NHLs, especially diffuse large B cell lymphomas
(DLBL), natural killer/T cell lymphomas and anaplastic large
cell lymphomas (ALCL) (3,4). Ancillary studies including
gene rearrangement, flow cytometry and immunohistochemical
analysis of the tumour are critical for confirming the diagnosis.
Most published examples of gastroesophageal HL were
verified only after surgical resection (3,5). We report a gas-
troesophageal junction (GEJ) primary HL and the utilization
of the immunohistochemical markers, PAX5 and MUM1.
These antibodies can help delineate the pathognomonic HL
Reed-Sternberg (RS) cells especially when assessing limited
biopsy material. The most common cause of HL localizing to
the wall of viscera would be contiguous invasion of primary
lymph node disease. However, a positive endoscopic biopsy of
HL may provide credence for a GI tract mucosa origin. We
advocate that transmucosal biopsy material must be diagnos-
tic if HL is to qualify as a GI primary neoplasm.
A previously healthy 33-year-old man developed progressive
dysphagia and had an involuntary weight loss of 4.5 kg over
the past six months. Esophagogastroduodenoscopy identified
an ulcerated mass (45 cm) of the GEJ (Figure 1). The lesion
extended 2 cm into the distal esophagus and provided resist-
ance upon intubating the stomach. Contiguous involvement
of the cardia was obvious on retroflexed views. A computed
tomography scan of the chest and abdomen revealed at least a
6 cm × 6 cm ill-marginated soft tissue mass encasing the distal
esophagus and extending caudally into the stomach cardia
and fundus (Figure 2). The mass was devoid of calcification
and contrast enhancement. The proximal and mid-esophagus,
as well as the distal fundus and antrum, were unremarkable.
©2007 Pulsus Group Inc. All rights reserved
Computed tomography imaging also identified enlarged
lymph nodes of the lesser curve of the stomach and
peripancreatic and subdiaphragmatic periaortic areas. No lym-
phadenopathy was identified in the supraclavicular, axillary
and mediastinal regions. The liver and spleen were normal.
A repeat esophagogastroduodenoscopy one week later
procured tumour for flow cytometry analysis that excluded a B
and T cell monoclonal proliferation, as expected in HL.
A bone marrow biopsy was negative for malignancy. No
immunodeficiency illness or predisposition was discerned on
Histological sections 4 μm thick were stained using the Envision
antimouse and antirabbit antibodies (Dako Canada Inc) and the
diaminobenzidine-Plus kit (Dako Canada Inc). Positive and
negative controls were run in parallel with test material.
Antibodies included: CD45 and ALK-1 (diluted 1:400 and 1:500,
respectively, Zymed Laboratories Inc, USA); CD20, Ki-67, kappa,
lambda, MUM1, CD8, HMB-45, CD117 and epithelial mem-
brane antigen (diluted 1:500, 1:100, 1:10,000, 1:10,000, 1:25,
1:100, 1:200, 1:200 and 1:200, respectively, Dako Canada Inc);
CD30, CD15, bcl-2, vimentin and S-100 were prediluted, AE1/3
(diluted 1:20, Ventana Medical Systems Inc, USA); CD2, CD4
and bcl-6 (diluted 1:100, 1:50 and 1:25, respectively, Vector
Laboratories, USA); CD3 and CD5 (diluted 1:200 and 1:40,
respectively, Lab Vision Co, USA); CD10 (diluted 1:100,
Research Diagnostics Inc, USA); PAX5 (diluted 1:50, Becton
Dickinson and Co, USA); actin (diluted 1:6000, Sigma-Aldrich
Co, USA); cytokeratin 7, cytokeratin 20 and cytokeratin 5/6
(diluted 1:200, 1:20 and 1:25, respectively, Cell Marque Co,
USA); cytokeratin 19 (diluted 1:25, Biogenex, USA); and
In situ hybridization for Epstein-Barr virus encoded RNA
Epstein-Barr virus messenger RNA detection in paraffin
blocks utilized the Dako GenPoint In situ Detection Kit
(Dako Canada Inc) with Epstein-Barr virus encoded RNA
(EBER)-1 and EBER-2 oligonucleotides (Dako Canada Inc, Y017)
as probes. The probes were labelled with diaminobenzidine chro-
mogen. Known positive and negative controls were run in parallel.
The initial endoscopy procured mucosal fragments with
focally intact squamous and oxyntic epithelium of the esoph-
agus and stomach. The lamina propria and submucosa were
expanded by sheets of noncohesive anaplastic cells. Some
cells had reniform nuclei, others had bizarre multilobated
nuclei. Extremely rare cells had bilobed mirror-image nuclei
approaching the classic morphology of RS cells (Figure 3). No
hallmark cells were identified. The process was compatible
with lymphoma. An abundance of anaplastic cells detracted
from a diagnosis of HL but the immunohistochemistry (IHC)
profile of positive CD30 and negative CD45, CD20, ALK-1
and T cell (CD2, CD3, CD4, CD5 and CD8) antibody stain-
ing was complementary. In the absence of CD15 and EMA
staining, a definitive diagnosis was not issued. In situ
hybridization revealed strong nuclear staining for EBER in the
Horne et al
Can J Gastroenterol Vol 21 No 3 March 2007186
Figure 1) Esophagogastroduodenoscopy identified an ulcerating
gastroesophageal junction mass (45 cm) that resisted intubation.
Esophagus (A,B) and stomach (C,D)
Figure 2) Computed tomography scan delineated a bulky ill-defined
mass (arrow) circumscribing the distal esophagus
Figure 3) Small foci of tumour had rare Reed-Sternberg cells (arrows),
circumscribed by reactive lymphocytes, plasma cells and eosinophils.
Hematoxylin and eosin (A); Reed-Sternberg cells are CD45-negative
CD30-positive (C); weakly PAX5-positive (D)
MUM1-positive (E). Original magnification ×400
anaplastic cells. A repeat biopsy procured fresh tissue for flow
cytometry assessment. The subsequent material had similar
tumour morphology, IHC and EBER staining patterns.
Additional IHC analysis revealed positive MUM1 and weakly
positive PAX5 staining of anaplastic cells. Flow cytometry did
not identify a monoclonal B or T cell population. All of these
findings were compatible with HL. Gene rearrangement
analysis by polymerase chain reaction identified a polyclonal
immunoglobulin heavy chain and a T cell receptor pattern,
excluding a B and T cell NHL.
On rendering an initial diagnosis of lymphoma,
chemotherapy was implemented. There was an immediate
improvement in the progressive dysphagia, and tumour bulk
diminished. The patient had a complete radiological response
six months after the diagnosis was established.
We have described a rare case of primary GEJ HL. Lymphoma
is foremost a malignancy of lymph nodes with over 66% of
NHLs and almost all HLs presenting as a lymphadenopathy
(6). The GI tract is the most common site for extranodal
lymphoma, especially in the stomach (6,7). Criteria for the
diagnosis of primary GI lymphoma were established by
Dawson et al (8) in 1961 and are still in use (1,3,7). Criteria
included the location of the bulk of the lymphoma in the
digestive tract, an absence of superficial and mediastinal
lymphadenopathy, an absence of organomegaly, no bone
marrow involvement and a normal peripheral complete blood
Gastric HL is extremely rare, accounting for fewer than 1%
of all gastric primary lymphoma (1,2). The malignancy has a
slight male predominance ratio of 1.2:1, a peak incidence in
the fifth to sixth decades and may have a propensity for the
antrum and pylorus (1,3,7). Presenting symptoms include:
upper abdominal pain, nausea, vomiting, GI bleeding and
weight loss (3,7). Our patient satisfied the criteria for a GI
primary HL, albeit symptoms of dysphagia are not typical for
Because primary gastric HL is a remote entity, the diagno-
sis requires validation through ancillary investigation (1,3,7).
Historically, an accurate diagnosis of gastric HL is not
established on mucosal biopsies procured by endoscopy (3).
Ogawa et al (3) reported that of the 100 gastric HL cases
between 1924 and 1993 (before surgical resection), accurate
diagnoses were established in only three cases. There was no
speculation as to why preoperative diagnostic material was
difficult to ascertain. Despite having original positive mucosal
biopsy material in our case, we requested a second endoscopic
biopsy for ancillary investigations that confirmed the diagno-
sis of HL. Certainly, technological advances in imaging
methodologies, endoscopy and ancillary testing should
accommodate successful tumour sampling by minimally inva-
HL of the esophagus is usually a contiguous extension of an
adjacent lymph node or gastric primary malignancy (5,9).
Primary esophagus HL is an extremely rare lesion with a
propensity for the mid- or proximal one-third (5,9-11). A
variety of clinical presentations include odynophagia/dysphagia,
weight loss, epigastric pain, fullness/bloating, anorexia, nonspe-
cific ‘type B’ symptoms, aneurysmal dilation of the esophagus
and tracheoesophageal fistula (5,9-11). When located in the
lower esophagus, 30% of HLs are complicated by stricture
formation (5). Our patient’s symptoms more accurately
reflected those of a cardia or lower esophageal primary
malignancy. The radiological finding of lymphadenopathy in
neighbouring lymph nodes is compatible with the expected
contiguous dissemination of an HL.
The classic endoscopic appearance of esophageal HL is an
ulcerated mass, often indistinguishable from a carcinoma (5).
Despite the obvious mucosal embarrassment, repeat endo-
scopic biopsy, open biopsy or surgical resection is often
required to establish a diagnosis (5,9). It has been speculated
that endoscopy may be an inadequate procedure for the assess-
ment of HL because the tumour may have an origin deep in
the wall of the viscera (5). However, because GI lymphoid
tissue is almost exclusive to the mucosa and submucosa,
primary lymphoma should be amenable to transmucosal
biopsy procedures. A deep mural origin of HL and/or nondiag-
nostic mucosal biopsy material would confer that primary
disease is actually extramural and/or nodal. If a diagnostic
mucosal biopsy were a required criterion for confirming HL of
GI origin, disease prevalence may be reduced to extremely
rare anecdotal cases.
The RS cell is pathognomonic of HL, regardless of tumour
location (2,6). These large cells can have various
morphologies including uni- or multinucleation, but a
prominent eosinophilic inclusion-like nucleolus is standard
(6). Cells with similar morphology can be present in a number
of processes so that the differential diagnosis of HL includes:
ALCL, adult T cell lymphoma, malignant histiocytosis, poorly
differentiated carcinoma, sarcoma and melanoma (1-3).
Histology and molecular biology analysis are essential for
establishing a definitive diagnosis. PAX5 is a pan-B cell
antibody that facilitates the exclusion of other
lymphoproliferative disorders from HL (12). Specifically,
ALCL and other T cell lymphomas are uniformly negative for
PAX5, while 97% of HL RS cells are weakly positive (12).
Only 4% of DLBL have a weak PAX5 staining pattern because
most are strongly positive (12). MUM1 stains 100% of classic
HL RS cells and is much less sensitive for DLBL (13,14). One
caveat is that large atypical cells of lymphocyte-predominant
HL have been reported to be MUM1-negative (13). Because
mucosal biopsy material may lack architectural landmarks
typical of HL, confirmation of the diagnosis mandates the use of
highly sensitive IHC antibodies for RS cells such as PAX5 and
MUM1 to exclude T cell lymphomas and DLBL, respectively.
Contrary to existing literature, we advocate that the
transmucosal biopsy should provide diagnostic material for a
GEJ HL. Obvious neoplasm in a mucosal biopsy must be a cri-
terion for confirming HL of viscera origin because it detracts
from the possibility that the bulk of the disease is actually
extramural/in a lymph node. Allocating fresh tissue for the
multitude of essential ancillary studies may be jeopardized
when HL is not suspected clinically. Thus, repeat endoscopy
may not be avoidable in the assessment of such a neoplasm.
Architectural features of HL may be limited on mucosal
biopsy material and, thus, highly sensitive IHC antibodies
such as PAX5 and MUM1 must be used to confirm this remote
scenario that could manifest as a gastric or esophageal ulcerat-
ACKNOWLEDGEMENT: This material has been submitted in
abstract form for poster presentation at the 2006 Canadian
Association of Pathologists meeting in St John’s, Newfoundland.
Primary gastroesophageal junction Hodgkin lymphoma
Can J Gastroenterol Vol 21 No 3 March 2007187
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Can J Gastroenterol Vol 21 No 3 March 2007188
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