A 15-year-old male presented to his primary care physician with a one month history of bilateral cervical lymphadenopathy, fever, night sweats, malaise, and weight loss. Subsequent PET scans demonstrated increased metabolic activity in multiple lymph nodes as well as diffuse bone marrow involvement. Hematological parameters were as follows: hemoglobin 13 g/dL, hematocrit 38%, WBC 9,800/mm³, platelets 148,000/mm³. A touch preparation of the bone marrow biopsy revealed the presence of numerous large cells with abundant vacuolated, basophilic cytoplasm and demonstrating pleomorphic nuclear features. Several of the nuclei were embryoid in shape and eccentrically placed, consistent with "hallmark" cells of anaplastic large cell lymphoma i.e. cells with horseshoe nuclei. The majority of malignant cells, however, as shown in this image were rather pleomorphic (see arrows). All cells of interest contain clumped chromatin and prominent nucleoli.