Composite diffuse large B-cell lymphoma and precursor B lymphoblastic lymphoma presenting as a double-hit lymphoma with MYC and BCL2 translocation

Double-hit lymphomas (DHL) with concurrent MYC and BCL2 rearrangements are rare entities with an aggressive clinical course and low overall survival. They usually develop de novo and frequently show a morphologic and immunophenotypic overlap with Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL).1 2 The WHO Classification of Tumours of Haematopoietic and Lymphoid Tissue has therefore placed these lymphomas in a provisional category of B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and BL, awaiting further insight into disease course and prognosis.2 We describe the first case of double-hit lymphoma that revealed morphologic and immunophenotypic features of both DLBCL and precursor B-lymphoblastic lymphoma (B-ALL), further highlighting the dilemma in diagnosis and treatment of DHL because of its broad morphologic and immunophenotypic spectrum. A 43-year-old male came to medical attention because of a cough, sore throat, dysphagia and a 20-pound weight loss. Endoscopy revealed a friable mass involving the right epiglottic fold and extending into the false cord. Histologic sections revealed a varied morphology with areas consistent with DLBCL composed of sheets of large pleomorphic cells with mature chromatin and a single prominent nucleolus and other areas more reminiscent of precursor lymphoblastic lymphoma or BL showing monotonous medium-sized cells with fine chromatin (figure 1A–C). In some areas …