Differentiating lymphoblastic lymphoma and Ewing's sarcoma: Lymphocyte markers and gene rearrangement

We encountered a child with an intraosseous small round cell tumor that was negative for LCA, CD20 (L26), and CD3 and positive for vimentin, CD99 (MIC -2), and periodic acid-Schiff. The tumor exhibited rosette-like formations. This case was initially interpreted as Ewing's sarcoma (ES); however, addi tional studies revealed positivity for CD79a, CD43, and TdT expression, and an immunoglobulin heavy chain gene rearrangement (IgH-R) by polymerase cha in reaction (PCR) established this to be a precursor B-lymphoblastic lympho ma. Because the differential diagnosis of ES and lymphoblastic lymphoma can be difficult and the differential diagnostic value of leukocyte antigens a nd immunoglobulin heavy chain gene rearrangement studies have not been full y evaluated, we conducted a more extensive investigation on 33 (21 soft tis sue and 12 intraosseous) ES cases. Cases were retrieved from the files of t he Department of Pathology at Georgetown University and from the Soft Tissu e Registry of the Armed Forces Institute of Pathology. The cases were studi ed by light microscopy, immunohistochemistry, and PCR for IgH-R and T cell receptor gamma chain gene rearrangement (T gamma -R). There were 17 females and 16 males; the mean age was 29.3 years. Locations included the extremit ies (n = 17) and trunk (n = 16). All cases fit the ES spectrum by light mic roscopy and immunohistochemistry, as previously determined, and were negati ve for lymphoid markers (LCA, CD3, CD20, CD43, CD79a, and TdT), CD10 and CD 34. CD99 was positive in 31/33 and bcl-2 was weakly positive in 13/33 cases . All 21 cases studied for gene rearrangements by PCR were negative for IgH -R and T gamma -R. Distinction of intraosseous lymphoblastic lymphoma from ES may be difficult because lymphomas may occasionally exhibit unexpected m orphologic and immunophenotypic properties including LCA, CD3 and CD20 nega tivity and cytokeratin positivity. Additional analysis using CD79a, CD43, T dT, and PCR should be performed to avoid misdiagnosis. True ES is negative for lymphoid markers including CD79a, CD43, and TdT, as well as for IgH-R a nd T gamma -R.