J Cancer Res Clin Oncol (1981) 101:23-27 doumal of

Cancer Research and

Clinical Oncology @ Springer-Verlag 1981

Heterogeneity of Lymphoblastic Malignancies in Children

J.A. Habeshaw 1 and the United Kingdom Childhood Cancer Study Group

t st. Bartholomew's Hospital, West Smithfield, London EC1A7BE, England

Summary. Lymphocyte surface markers show that lymphoblastic lymphomata in children are a heterogeneous but related group of diseases. Lymphoblastic lymphomas of T cell type fall into at least three subgroups: (1) HTLA positive, E rosette negative, TdT positive phenotype, with characteristically high levels of TdT and some associated expression of C-ALL antigen on a small propor- tion of cells. (2) E rosette positive lymphoblasts with intermediate range of TdT positivity, and which express antigens specific fo r thymic cortical lymphocytes. (3) E rosette positive and C3d positive T lymphoblasts with low levels of TdT enzyme. B lymphoblastic lymphomas show a major subgroup characterised by surface IgM expression, with or without detectable cytoplasmic IgM, and which may express ALL antigen. A minor subgroup of B lymphoblastic disease, of pre- dominantly nodal presentation, expresses surface IgM with some expression of C3d receptors. Therefore at least 3 T cell, and 2 B cell subgroups of lympho- blastic lymphoma can be described.

Key words: Lymphoma in children - Classification - Phenotypic subgroups

Lymphoblastic lymphoma is the most common type of non-Hodgkin's lymphoma in children. Until recently, these tumors were thought to represent a narrow range of histologically defined entities, undifferentiated lymphoblastic lymphoma, Stern- berg sarcoma and Burkitts lymphoma. More recent evidence indicates a rather close relationship of lymphoblastic lymphoma to acute lymphoblastic leukaemia, on the basis of cytochemical and surface phenotyping studies. As in acute lym- phoblastic leukaemia, phenotyping studies indicate heterogeneity of lymphoblastic lymphoma in two of the three main histological groups of this disease. In this sum- mary the phenotypes of 37 cases of lymphoblastic lymphoma are presented as ev- idence of the phenotypic heterogeneity of Null cell, T-lymphoblastic and B-lym- phoblastic lymphoma. These cases were contributed from the United Kingdom Child Cancer Study Group series of non-Hodgkin's lymphomas. Material from

0171-5216/81/0101/0023/$1.00

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Table 1. Lymphoblastic lymphoma of Null cell type

J. A. Habeshaw et aI.

Age Presentation E Fc 7 C3 lgm SIg HTLA ALL TdT Ia

46/12 Retroperitoneal 8 3 3 0 0 Neg ND ND ND 5 Mesenteric 15 0 0 0 0 12 ND 55 ND

10 Mediastinal < 1 6 7 < 1 11 Neg Positive 48 + 4 NodesandMarrow 2 7 4 0 < 1 Neg Positive 96 +

14 Nodesand Blood 3 2 1 <1 < 1 3 43 ND 75 3 Nodes and Blood 9 6 1 < 1 3 0 61 Pos. 44

patients with lymphoblastic lymphoma was submitted to the Imperial Cancer Re- search Fund Medical Oncology Unit for phenotyping studies from the following centres: Hospital for Sick Children Great Ormond Street (London), St. Bar- tholomew's Hospital (London), Children's Hospital Ladywood (Birmingham), Royal Hospital for Sick Children (Bristol), Welsh National School of Medicine, Depar tment of Child Health Llandough Hospital (Penarth), Royal Hospital for Sick Children Yorkhill (Glasgow), Royal Manchester Childrens Hospital (Man- chester), Our Lady's Hospital for Sick Children, Crumlin (Dublin), Childrens Hos- pital (Sheffield), Alder Hey Childrens Hospital (Liverpool) and The Royal Mars- den Hospital (Sutton).

Material was submitted as single cell suspensions containing malignant cells prepared from involved tissue, in appropriate tissue culture medium. Specimens were received and processed within 24 h of operation in most cases.

Phenotyping

In all cases, cells were tested for the following markers: T-cells - H T L A antiserum, E rosetting; B cells, surface immunoglobulin, Fcy rosettes, Fcla rosettes, C3d ro- settes; ALL antigen, Ia antigen were detected with rabbit antisera (R anti-ALL, R ant i -h) or with monoclonal antibodies (J5 anti-ALL, DA/2 anti-HLA-D). TdT ac- tivity was assessed biochemically, or with anti-TdT antiserum. In addition, cells were studied for cytoplasmic immunoglobulin expression. The histological classi- fication in most cases was reviewed by Dr. A.G. Stansfeld.

Results

Lymphoblastic lymphoma of Null cell type (Table 1) (malignant lymphoma, lym- phoblastic, undifferentiated) was seen in six patients. In three patients circulating lymphoblasts were present, and marrow was involved in one patient. None of the cells marked with T- or B-cell specific markers but ALL antigen was present on the cells in four tested cases. TdT actiyity was high in four cases, and four cases expressed Ia antigen. Three patients clearly showed a phenotype of ALL + Ia + TdT + cells. These data suggests that lymphoblastic lymphoma of undifferentiated type is phenotypically similar to common acute lymphoblastic leukaemia. In no case was cytoplasmic Ix chain detected.

Heterogeneity of Lymphoblastic Malignancies in Children 25

Table 2. T-Cell lymphoblastic malignancies: presenting with mediastinal mass and node enlargement

Age Presentation E FW Fcg C3d SIg TdT HTLA ALL

Category 1 E - HTLA + 8 With leukaemia I9 0 0 0 8 ND 60 15 7 Pleural effusion 0 1 0 0 5 54 90 1 3 With leukaemia 4 0 0 0 7 82 70 1

15 With leukaemia 5 17 < 1 9 8 16 80 3 6 Marrow involved 5 10 < 1 18 10 19 78 0

Category 2 E+HTLA+ 3 Marrow 25% blasts 36 13 1 15 0 20.3 + - 8 Marrow clear 62 1 0 3 5 15 + - 6 Marrow+ 72 0 0 0 12 ND 80 0

11 Marrow clear 48 0 0 2 4 ND 60 0 4 Marrow clear 54 < 1 < 1 < 1 2 8.5 + -

14 Pleural effusion 66 < 1 0 < 1 0 22.5 + - 9/12 Marrow clear 70 < 1 < 1 7 7 ND 70 4

13 Marrow+ 58 0 0 0 0 Pos. 60 ~ 1

Category 3 HTLA/E+C3d+ 7 Marrow clear 19 12 0 50 2 3.8 90 0 4 Marrow clear 73 4 0 48 1 0.2 80 0 4 Effusion 53 14 17 64 4 Neg. 75 0

T-lymphoblastic lymphomas (Table 2) showed three major phenotypic subgroups: 1. E r o s e t t e - H T L A + , TdT + 2. E rosette + H T L A + TdT + and 3. E rosette_+, H T L A + , C3d + .

Category 1 tumors appear to be related to A LL in two principal features: TdT ac- tivity is generally high, and some A LL ant igen expressing cells are found as a minor par t of the tumor popula t ion in most cases. Four of five cases in this group were leukaemic. Category 2 tumors showed strong E rosetting, and TdT was positive in all tested cases; in only two cases were any A LL positive cells detected, and these were a minor par t of the tumor cell popula t ion. Category 3 tumors were less strongly E rosetting, and were TdT negative, but expressed H L T A ant igen in con- j unc t ion with C3d receptor. AL L antigen positive cells were no t found in these ma- lignancies.

B-lymphoblastic Malignancies (Tables 3a and 3b)

Twelve category I B lymphoblast ic malignancies showed c o m m o n phenotypes (3a) being S I g + , with no expression of C3d receptor. SIg was IgM only in 10 of the 12 cases, and in six cases monoc lona l cytoplasmic Ig s taining could be detected. In five cases, some ALL antigen positive cells were present, bu t in two cases 70% and 90% of cells, respectively, showed weak but definite s taining for A LL antigen. In most cases presentat ion was extranodal , in three cases bone mar row involve- men t was present.

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Table 3a. Category (I) B-lymphoblastic lymphoma

J. A. Habeshaw et al.

Age Presentation E Fc IgM C3 SIg Class Cylg ALL

2/12 Retroperitoneal 0 1 0

26/,2 Ileocaecal marrow 4 7 0 Skin

6/12 Scalp mass 0 < 1 0

4 Jaw 5 1 0 Bowel

6 Marrow 19 9 7 Node

? Retroperitoneal 3 1 0 Ascites

7 Abdominal mass 6 3 0

9 Retroperitoneal 0 0 0 mass

11 Scalp tumor 4 0 2 Spine D5-D9 Marrow

12 Omentum Ascites 3 1 0

14 Tonsil 6 2 < 1 Cervical nds Supraclavicular nds Inguinal rids

10 Retropharyngeal 0 2 0 tumor

1 84 MK POS 10% ND

3 97 MDK 0 ND

0 46 ML POS 30% ND

2 77 ML ND 70%

11 60 MK POS 60% ND

3 75 ML 0 18%

< 1 98 MK POS 12% ( g only)

0 78 MK POS (10%; 10% K only)

4 75 MGK 0 0

3 75 ML POS (2%) 0

< 1 38 MK 0 0

0 90 MK 0 90%

Table 3b. Category (2) B-lymphoblastic lymphoma

Age Presentation E Fc IgM C3 SIg Class Cylg ALL

4 Mandibular nds 26 1 0 28 33 G 0 0 Axilliary nds Inguinal rids Cervical nds

4 Cervical node 24 4 < 1 36 48 MK 0 ND

2 Supraclavicular nd 24 < 1 < 1 30 37 MK 0 0 Cervical nd Inguinal nds Blasts 2% in marrow

An additional three cases in category 2 (Table 3b) showed phenotypes reminis- cent of adult follicular lymphoma - but with no evidence of follicle formation. These cases all presented as primary lymph node disease, and all showed substan- tial (20%) T-cell populations in conjunction with a SIg+ C3d + monoclonal B cell population. Cytoplasmic Ig was not detected in these tumors, and ALL antigen was not present in the cases examined.

Heterogeneity of Lymphoblastic Malignancies in Children 27

Discussion

On the basis of these results, it is suggested that lymphoblastic tumors can be di- vided into: 1. A L L + T d T + I a + undifferentiated tumors with the phenotype of common-

ALL, 2. E rosette and HTLA positive T-cell tumors with pre thymic (E-HTLA + TdT +

and occasional ALL + cells). Thymic cortical (E + HTLA + TdT +) and foetal thymic (E + HTLA + C3d + TdT - ) phenotypes, and

3. B-cell tumors with Sig + CyIg+ and ALL + phenotype. An additional small category of B-lymphoblastic lymphomas in lymph nodes express SIg+ C3d + phenotype, are phenotypically similar to the follicular lymphoma encountered in adults, but are not obvious follicular tumors. The phenotypic heterogeneity found in lymphoblastic lymphomas in children

indicates that further studies will be needed before an entirely adequate histological and phenotypic classification of these malignancies can be achieved.

This work was presented at Kid on behalf of the U.K. Child Cancer Study Group whose members supplied the material and clinical data on which this work was done. The author is also indebted to Dr. Mel Greaves, ICRF Membrane Im- munology Unit, Lincoln's Inn Fields for supplies of ~HTLA ~ALL antiserum and anti-TdT; to Dr. G. Janossy, Department of Immunology, Royal Free Hospital for ~HTLA and ~Ia antiserum, and to Professor V. Hoffbrand and K. Ganeshaguru for TdT estimations.

Received January 9, 1981/Accepted March 23, 1981