A 55-year-old female presented with a 6-month history of a slow growing mass in her right neck and unexplained 20-lb weight loss. An excision biopsy showed a lymph node measuring 1.5 cm in widest diameter. On light microscopy, in addition to a nodular appearance, a floral architecture was appreciated (Image 1). The normal nodal architecture was effaced by a monotonous population of large CD20+ lymphocytes forming abnormally shaped follicles. These follicles had centers composed of large cells infiltrated by small lymphocytes coming from the surrounding mantle zones (Image 2), forming an unusual serpiginous pattern. Immunohistochemistry showed the large cell were CD20+ (Image 3), CD3− (Image 4), CD5−, CD10−, bcl-2−, and cyclin D1− . Kappa and lambda light chain staining revealed scattered positive plasma cells, but the large cells were negative. The final diagnosis was floral variant of follicular grade 3B non-Hodgkin lymphoma. Subsequent staging workup showed that she had no residual disease after the excision biopsy and therefore was considered to be stage IB. As she became asymptomatic, no further therapy was given.
First described in 1987, the floral variant is a rare but distinct morphological entity that can be seen in all grades of follicular lymphoma . Only a limited number of cases have been reported to date. This entity can mimic progressive transformation of germinal center, which can occur as a feature of reactive lymphoid hyperplasia or in association with lymphocyte predominance Hodgkin lymphoma and nodal marginal zone lymphoma with floral follicles [2,4]. The floral variant does not appear to alter the prognosis of follicular lymphoma and is currently not listed as a distinct clinical entity in the World Health Organization lymphoma classification.