Blastoid Mantle Cell Lymphoma in the Leukemic Phase: Resolving a Morphological Dilemma Through Flow Cytometry

TL;DR

This paper describes a case where flow cytometry helped diagnose blastoid mantle cell lymphoma, avoiding confusion with acute leukemia.

Contribution

The paper highlights the diagnostic utility of flow cytometry in resolving morphological challenges in blastoid mantle cell lymphoma.

Findings

Flow cytometry distinguished blastoid MCL from ALL based on specific immunophenotypic markers.

The case showed bright CD45 and positivity for CD19, CD20, CD5, and FMC7, but negativity for CD34, CD23, CD200, and CD10.

Accurate diagnosis via flow cytometry ensured appropriate treatment and avoided misdiagnosis as acute leukemia.

Abstract

Leukemic conversion of nodal mantle cell lymphoma (MCL) is most often detected as incidental lymphocytosis on routine blood counts, often mimicking chronic lymphocytic leukemia, with flow cytometric immunophenotyping being the gold-standard test for diagnosis. Blastoid MCL closely mimics acute lymphoblastic leukemia (ALL), thus posing significant diagnostic challenges. Blastoid transformation of MCL is usually associated with TP53 mutations, homozygous deletions of CDKN2A and CDKN2C, amplifications and overexpression of CDK4, and occasionally microdeletions of RB1, and is associated with an aggressive disease course. Equivocal cases require histopathological evaluation, fluorescent in-situ hybridization, or molecular studies for confirmation. We report the case of an 82-year-old female who presented with lower respiratory tract infection and was found to have severe anemia (hemoglobin: 45 g/L) and marked leukocytosis (325 × 10⁹/L) with 63% blastoid-appearing cells on peripheral blood smear, initially suggestive of acute leukemia. Flow cytometric immunophenotyping demonstrated bright CD45 expression with low side scatter and positivity for CD19, CD20, CD38, CD5, CD79b, and FMC7 with negativity for CD34, CD23, CD200, and CD10, suggesting blastoid transformation of MCL rather than de novo ALL. This case highlights the critical role of flow cytometry in distinguishing blastoid MCL from acute leukemia, thereby preventing misdiagnosis and ensuring appropriate therapeutic decision-making.

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