Figure 1: Low power H&E Morphology of Double Hit Lymphoma
Low power image (on the left) demonstrates circumscribed infiltrate of cells within the lamina propria and extending through the full thickness beyond the muscularis propria in some areas. At higher power (pictured on the right), the infiltrate is diffuse.
Figure 2: Intermediate Power H&E Morphology of Double Hit Lymphoma
The lymphoma cells are infiltrating through the muscularis propria with starry sky pattern noted on the second image (on the right). The latter pattern is reflective of all high grade proliferative processes and may be seen in Burkitt lymphoma and lymphoblastic processes, in addition.
Figure 3: High Power H&E Image of Double Hit Lymphoma
At high-power, there is starry sky appearance with medium sized blastoid lymphoma cells with dispersed nuclear chromatin and scattered mitoses.
Figure 4: CD20 and CD3 in Double Hit Lymphoma
The lymphoma cells are positive for CD20 (left side image) with only scattered T-cells on CD3 (right side image).
Figure 5: CD10 and MYC Immunostain in Double Hit Lymphoma
The lymphoma cells are strongly positive for CD10 (membranous staining, left side image) with diffuse positivity for MYC by immunohistochemistry (90%; >40% considered positive, right side image).
Figure 6: BCL-2 and Ki-67 Immunostain in Double Hit Lymphoma
BCL-2 is strongly positive in the lymphoma cells (100%; >50% consider positive, left side image). Likewise, Ki-67 highlights numerous proliferative lymphoma cells (90%, right side image).
Figure 7: PD–L1 Immunostain in Double Hit Lymphoma
The lymphoma cells are negative for PD–L1. Occasional internal control histiocytes demonstrate moderate membranous staining for PD–L1.
Figure 8: FISH for MYC and BCL2 in Double Hit Lymphoma
The separated colors in each of the probes indicate breaks in the MYC and BCL2 genes consistent with rearrangements in these genes.
