A 71 year old gentleman comes into clinic with a 2 month history of lethargy, decreased appetite and marked weight loss. He has no past medical history of note, but had a brother who had died of lymphoma.
Examination reveals mild bilateral cervical and axillary lymphadenopathy with no palpable organomegaly.
Routine investigations such as CBC, BMP, and LFTs are normal. He does have an elevated globulin gap with a polyclonal increase in gamma-globulins. However, myeloma was excluded when serum protein electrophoresis detected no monoclonal band.
CT reveals widespread lymphadenopathy involving the neck, axillae, chest/mediastinum, abdomen and pelvis with mild to moderate splenomegaly.
Excision biopsy of an axillary node reveals the following:
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