The images are from a nasopharyngeal mass in a 78-year-old patient. Diagnosis of Lymphoplasmacytic lymphoma (LPL), or Waldenstrom macroglobulinemia (WM), is challenging given its variable presentation and morphological similarity to other B cell lymphomas, particularly marginal cell lymphoma. Both may appear as diffuse proliferations of small, malignant lymphocytes in the lymph nodes, as shown in this case.1 A key differentiating factor is the presence of intranuclear inclusions, called Dutcher bodies, in which the cytoplasm overlays or invaginates the nucleus (as shown) due to cellular immunoglobulin overproduction.2 Hemosiderin deposition (a golden-brown pigment) is also characteristic of LPL. Interestingly, both Dutcher bodies and hemosiderin deposition are not found to have a direct association with MYD88 status, a mutation present in approximately 90% of LPL cases.

Further LPL testing includes serum analysis for IgM, along with observation of symptoms related to hyperviscosity and slowed blood flow (due to excess immunoglobulin). Such symptoms include blurred vision, visual impairment, bleeding, headaches, sensory neuropathy, and cold sensitivity in the extremities.1 Additionally, molecular assessment for MYD88 as well as CXCR4 mutations is recommended, as CXCR4 mutations occur in up to 40% of patients

Citations

1. Kaseb H, Gonzalez-Mosquera LF, Parsi M, et al. Lymphoplasmacytic Lymphoma. [Updated 2021 Apr 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

2. Jiang N, Qi C, Chang H. Dutcher bodies in multiple myeloma are highly associated with translocation t(4;14) and IgA isotype. Br J Haematol. 2015;171(5):890-892.