LINFOMAS B AGRESIVOS

Lluís Colomo

Hospital Clínic, Barcelona

Linfomas Indolentes y Agresivos Características histopatológicas

• Células pequeñas

• Baja actividad proliferativa

• Crecimiento no destructivo

• Respuesta a influenciasreguladoras

• Células grandes

• Actividad proliferativa alta

• Crecimiento destructivo

• Crecimiento Autonomo

Indolente (Bajo grado) Agresivos (Alto grado)

• Curso clinical indolente

• Supervivencia larga

• No curable con quimioterapia

• Ausencia de “plateau” en las curvas de supervivencia

• Curso clinical agresivo

• Supervivencia corta sin tto

• Posible larga superviencia(curación)

• “Plateau” en las curvas de supervivencia

Linfomas Indolentes y Agresivos Características Clínicas

Indolente (Bajo grado) Agresivos (Alto grado)

REAL/WHO Classification

Histological distribution

2%

8%

6%

36%1% 2%

7%

7%

7%

24%

LymphocyticLymphoplasmocytoidMALTFollicularMantle-cellDiffuse large-cellBurkittAnaplasticPeripheral T-cellOther

NHL Classification Project, 1997

N=1.403

BURKITT LYMPHOMA

• Highly aggressive

• Extranodal or acute leukemia

• Monomorphic medium-sized B-cells

• High number of mitotic figures

• Translocation MYC

• Epstein-Barr virus frequent WHO, 2001

ENDEMIC

• Equatorial Africa, New Guinea

• Children (4-7 years)

• M:F 2-3:1

• Jaws, orbit 50-60%• Ovary (bilateral)• Ileo-coecal region, omentum, breast, kidney

• EBV+ 95%• Malaria as cofactor

SPORADIC

• Elsewhere (North Africa, South America)

• Median age 30 years(younger)

• Abdominal tumors (ileo-coecal region)• Ovary, breast, kidney

• EBV+ 20% (60-80%)

IMMUNODEFICIENCY

• HIV infection

• Nodal• Bone marrow

• EBV+ 30-40%

BURKITT LYMPHOMA - Clinical Variants

• Extranodal

• Depend on involved site ? CNS involvement

• Bulky Disease ? very short doubling time

• Acute Leukemia

• High LDH and Uric acid ? renal failure

• Stages III-IV 70%

BURKITT LYMPHOMA - Clinical Features

BL with plasmacytoid differentiation

BURKITT LYMPHOMA - Variants

Atypical BL / Burkitt-like• Immunodeficiency

• Monotypic cIg

• Ki-67 ~ 100%

• MYC translocation

PLASMA CELL

NAIVE -BLYMPHOCYTE

MCLt(11;14)CCND1

CLL

FLt(14;18)

bcl-2

MEMORY CELL

BLt(8;14)c-myc

MALTt(11;18)API2-MLTALL/LBL

LCLt(3q)bcl-6

CLLMCL

BL has the phenotype of a germinal center cell

CD20 CD10

bcl-2 Ki-67

CD20

CD10

bcl-2

Ki-67

CD3

bcl-6

EBERs

BURKITT LYMPHOMA - Phenotype

• CD19, CD22, CD79a

• sIg (IgM > IgG, IgA)

• cIg (plasmacytoid variant)

• T-cell markers negative

• CD5-, CD23-

• TdT-, CD34-

• LMP1- / EBERs+ (Latency pattern I)

Translocation involving MYC is a constant genetic feature in BL

14q32 (IgH)

Fusion Translocation Probes Break Apart Rearrangement Probes

normal t(8;14)

t(8;14)(q24;q32)

8q24 (c-myc)

normal

8q24 (c-myc)

Blum, K. A. et al. Blood 2004;104:3009-3020

Direct and indirect consequences of c-Myc overexpression in Burkitt lymphoma

• Prolonged ALL-like regimens are ineffective

• Early-stages ? CR rates of 100%

• Advanced stages ? CR 85-90%

• Relapse occurs within first year

• Radiotherapy has not primary role in BL treatment

BURKITT LYMPHOMA - Treatment

AIDS-Related Burkitt’s Lymphoma vs.Diffuse Large B-cell Lymphoma

HAART EraPre–Highly Active Antiretroviral

Therapy (HAART)

J Clin Oncol 2005;23:4430

Diffuse Large B-Cell LymphomaHeterogeneous Disease

• Clinical Characteristics

• Morphology

• Phenotype

• Genetic Alterations

• Oncogenic alterations

CD5CD10

Diffuse Large B-Cell Lymphoma

• Large B-cells (size equal to macrophage nuclei or more than twice of lymphocytes)

• Diffuse growth• 30-40% of adult NHL• Extranodal 40%

(gastrointestinal / any site)• Tumor mass in extranodal sites• De novo or progression of a

low grade lymphoma

Diffuse Large B-cell LymphomasMorphologic Variants

CENTROBLASTIC

IMMUNOBLASTIC

T-CELL/HISTIOCYTIC RICH

ANAPLASTIC LARGE CELL LYMPHOMA

PLASMABLASTIC LYMPHOMA

FULL-LENGTH ALK POSITIVE

Cb

TCR ALCLB ALK

Imb

PBL

PrimaryMediastinal Intravascular

PrimaryEffusion

HHV-8

Diffuse Large B-cell LymphomasSubtypes (clinico-pathological entities)

Centroblastic monomorphic

Immunoblastic

Diffuse Large B-cell LymphomasMorphologic Variants

Centroblastic multilobated

Centroblastic polymorphic

T-Cell/Histiocyte rich B-Cell Lymphoma

CD79a

CD57CD3

T-Cell/Histiocyte rich B-Cell Lymphoma

• Age <60 years

• Stages III-IV?75%

• High LDH ?50-60% DLBCL (GELA)

• Hepatomegaly 30% 12%• Splenomegaly 60% 17%• Bone marrow + 35% 26%

• CR after treatment 58% 73%5-year follow-up• Event Free Survival 58% 52%• Overall Survival 63% 66%

Rüdiger, Ann Oncol 2002;13(S1):44-51

Anaplastic Large Cell Lymphoma

CD20 CD30

Plasmablastic Lymphoma of the Oral Cavity

• HIV+ (15/16)• Monomorphic blasts • CD45, CD20 -/w; VS38c+• No serum M-component• EBV+ (60%)• Unfavorable outcome

Delecluse et al., Blood 1997;89:1414-20

Monomorphic Polymorphic

PLASMABLASTIC LYMPHOMAMorphologic heterogeneity

kappa lambda

CD45 CD20 CD79a

CD3

EBER

MUM1BCL6

CD138

Plasmablastic Lymphoma/DifferentiationA term for many uses

Morphological Differentiation- Large Cell Lymphomas with secretory/plasmacytic

differentiation- Dedifferentiated/Plasmablastic Myeloma

Phenotypical Differentiation

- Large Cell Lymphomas with terminal B-celldifferentiation profile (CD20- CD38/CD138 +)

Different Disease Entities- PBL oral cavity- PBL Castleman disease/HHV-8 associated

PBL of “Oral Mucosa type”23 cases (19M / 4F)

Age 48y (11-86)HIV+ 73% (16/22)

Other: 2 postTx / 1 steroids (SLE) / 2 >80y

Sites:11 oral 5 maxillary sinus

12 extraoral 1 skin / 1 anal / 1 soft tissues

3 nodal / 1 bone marrowEBV + 17/23 (74%)

HHV8 + 0/19 (0%)

8/10 high stage at presentation / 7 DOD (1-28 months)

Am J Surg Pathol 2004;28:736–747

CD138

• Morphological plasma cell differentiation

• Nodal & Extranodal

• HIV + (33%)Other immunodeficiencies

• EBV 60%

• Similar to extramedullary highgrade plasma cell tumors

• Extensive bone dissemination, occasional IgG M component

Plasmablastic Lymphoma with Plasmacytic Differentiation

EBER

DLBCL with Terminal Differentiated B-cell Phenotype A heterogeneous spectrum

Immunosupressed patients (HIV+/ HIV-)? Plasmablastic Lymphomas

- Oral cavity type

- PBL with plasmacytic differentiation

? HHV-8 Associated Large B-Cell Lymphomas- Primary effusion lymphoma

- Extracavitary (Solid) variant of PEL

- HHV-8 +/Castleman associated plasmablastic lymphoma

Immunocompetent patients? Extramedullary presentation of Plasma cell neoplasms (Multiple

Myeloma, Plasmacytoma)

? DLBCL expressing ALK

Differential Diagnosis? Pyothorax associated lymphoma

? DLBCL with secretory/plasmablastic differentiation

PRIMARY EFFUSION LYMPHOMA

• Rare

• Pleural, peritoneal and pericardial cavities

• No lymphadenopathy or organomegaly

• Associated with HHV8 infection

• Coinfection with EBV in most cases

• HIV infection >> elderley males

• Associated with Kaposi sarcoma, Castleman disease

PRIMARY EFFUSION LYMPHOMA

Tran

sfor

med

SS

C

Forward Scatter0 64 128 192 256

064

128

192

256

CD

45

->

CD30 ->100 101 102 103 104

100

101

102

103

104

CD

19

->

CD30 ->100 101 102 103 104

100

101

102

103

104

CD

5->

CD20 ->100 101 102 103 104

100

101

102

103

104

CD

56

->

CD38 ->100 101 102 103 104

100

101

102

103

104

CD

10

->

CD45 ->100 101 102 103 104

100

101

102

103

104

Lam

bd

a ci

top

l->

Kappa citopl ->100 101 102 103 104

100

101

102

103

104

CD

79

aci

top

l->

CD3 citopl ->100 101 102 103 104

100

101

102

103

104

INMUNOFENOTIPO

Grandes CD45débil CD30++ CD38++ CD138- CD2- CD3-/+ CD5- CD7-CD19- CD20- CD10- CD79a- ?&? – CD56- CD15- EMA+

The neoplastic cells are positive for HHV8/KSHV in

all cases (WHO,2001)

Ladd

er

Case

Cont

rol

-Co

ntro

l +H 2

O

LANA-1

*

Blood, 2003

Solid Extracavitary PEL

• Before, concomitant with or after PEL

• HIV+ / HHV8 + / EBV +

• Immunoblastic ? polymorphic

• B-cell markers (4/8 patients)

• Aberrant CD3 expression

• LN ? disseminated disease (stages III-IV)

Beaty, Am J Surg Pathol 1999;23:992Chadburn, Am J Surg Pathol 2004;28:1401

HHV-8

k l

IgM

HHV-8

HHV-8 is associated with a plasmablastic variant of Castleman disease that is linked to HHV-8-positive plasmablastic lymphoma

Dupin N, Diss TL, Kellam P, Tulliez M, Du MQ, Sicard D, Weiss RA, Isaacson PG, Boshoff C Blood 2000;95:1406-12

Extramedullary Plasmablastic Plasma Cell Neoplasms (Multiple Myeloma, Plasmacytoma)

Ki-67

CD56 Ciclina D1 CD117

• Young males

• Immunocompetent

• Generalized LN

• ALK-1+

• EMA, CD138

• IgA+

• CD30-

• t(2;19); t(2;5)

• Poor prognosis

DLBCL With Expression of ALK

ALK-1

EMACD138

Pyothorax-associated Lymphoma

• History of chronic pyothorax

• Adults (median age 64 years)

• Thoracic pain + fever

• Pleural 80% (tumoral mass)

• Immunoblastic large cells

• Most cases CD20+

• Association with EBV (latency III pattern)

• 5-year survival rate ?20%

Nakatsuka et al, J Clin Oncol 2002;20:4255

CD20

LMP1

DLBCL with Terminal Differentiated B-cell Phenotype A heterogeneous spectrum

Immunosupressed patients (HIV+/ HIV-)? Plasmablastic Lymphomas

- Oral cavity type

- PBL with plasmacytic differentiation

? HHV-8 Associated Large B-Cell Lymphomas- Primary effusion lymphoma

- Extracavitary (Solid) variant of PEL

- HHV-8 +/Castleman associated plasmablastic lymphoma

Immunocompetent patients? Extramedullary presentation of Plasma cell neoplasms (Multiple

Myeloma, Plasmacytoma)

? DLBCL expressing ALK

Differential Diagnosis? Pyothorax associated lymphoma

? DLBCL with secretory/plasmablastic differentiation

MORPHOLOGIC VARIANTS CentroblasticImmunoblasticT-cell Rich B-cell LymphomaPlasmablastic LymphomaALK positive DLBCLLymphomatoid Granulomatosis

SUBTYPES

Primary Mediastinal B-cell Lymphoma

Intravascular Lymphoma

Primary Effusion Lymphoma

DLBCL (WHO)

B95-8039

Primary Mediastinal (Thymic)Large B-cell Lymphoma

•5% of aggressive lymphomas

•Young females (median 30-35 years)

•Anterior mediastinal mass involving the thymus with local agressive growth

•Vena cava syndrome 30%

•Localised disease ? rare distant spread

•Disseminate to extranodal sites (kidney, adrenal, liver, skin, brain)

•EBV-

Primary Mediastinal (Thymic)Large B-cell Lymphoma

CK

Primary Mediastinal (Thymic)Large B-cell Lymphoma

• Asteroid medullary B-cell population

• CD19, CD20, CD79

• DO NOT EXPRESS s/c Ig

• CD10-/+, Bcl-6+/-, MUM1+/-, CD138-

• CD30w+, CD15-

• Bcl-2+, CD21-• BOB.1+, Oct-2+ • PAX5+, PU.1+ • MAL protein 70%

• Somatic IgVH mutations and BCL6mutations

Primary Mediastinal (Thymic) Large B-cell Lymphoma

Lack of HLA class I products is the cause of the low levels of ß2-microglobulin in serum

Primary Mediastinal B-cell Lymphoma Distinct Gene Expression Profile

Rosenwald, J Exp Med 2003

CD30

Mediastinal Gray Zone Lymphoma

Classic HL?

CD15PMBL?

• cHL-NS or PMBL with unusual features

• Composite and metachronous

CD20

Savage, Blood 2003;102:3871Rosenwald, J Exp Med 2003;198:851

PMBL transcriptional profile resembles that of cHL

Mediastinal Gray Zone Lymphoma

• Intermediate between PMBL and cHL

• Lack of Ig expression

• Low levels of BCR signalling molecules

• Activation of the NF-kB pathway

• Similar gene expression profiles

• Common genomic aberrancies (2p15-REL, 9p24-JAK2 )

• B-cell transcription factor expression resemble PMBL

Environmental factors could play a favourable roleClinical studies are necessary

García, Histopathology 2005;47:101Poppema, Eur J Haematol Suppl. 2005;66:45

Traverse-Glehen, Am J Surg Pathol 2005;29:1411

INTRAVASCULAR LARGE B-CELL LYMPHOMA

• Uncommon (<1% of NHL)

• Adults (median age 70 years)

• Extranodal (brain, skin > other sites)

• High LDH, B symptoms

• Hepatosplenic involvement (26%)

• Bone marrow infiltration (32%)

• Disseminated at diagnosis

• Overall survival usually poor

Ferreri, Br J Haematol, 2004;127:173

CD20

INTRAVASCULAR LARGE B-CELL LYMPHOMA

• Large cells in small vessels

• CD19, CD20, CD22, CD79a

• CD5+, CD10+ few cases

• Rarely T-cell phenotype

• Abnormal or absent expressionof adhesion molecules

• IgH rearrangement

INTRAVASCULAR LARGE B-CELL LYMPHOMA - Variants

CUTANEOUS

• Localised

• Younger patients

• Better prognosis

ASIATIC

• Haemophagocytic syndrome

• Liver, spleen

• Bone marrow CD20 CD68

Ferreri, Br J Haematol, 2004;127:173

CD20

Retroperitoneal mass

Brain tumor

Extravascular infiltration

Diffuse Large B-Cell LymphomaHeterogeneous Disease

• Clinical Characteristics

• Morphology

• Phenotype

• Genetic Alterations

• Oncogenic alterations

CD5CD10

LNH AGRESIVOSINDICE PRONÓSTICO INTERNACIONAL (IPI)

Supervivencia global a 5 años, estratificados por grados de riesgo

Shipp. N Engl J Med. 1993;329:987

100

75

50

25

0

0 2 4 6 8 10

H

HILI

L

Pac

ient

es(%

)

Años

5 años5 años

Alizadeh A, et al. Nature 2000;403:503-511

Gene expression–defined DLBCL also likely represent different mechanisms of malignant transformation and

distinct tumor biology

Lossos, JCO 2005

DLBCL Subgroups Recognized by Microarray May Correspond to Different Entities

Rosenwald, NEJM 2002;346:1937-1947

NEJM 2002;346:1937-1947

N=235

DLBCL Subgroups are Genetically Distinct

Beà, Blood 2005;106:3183-90

CD10 Bcl-6

MUM-1 CD138

CD10 -

+ GC

Bcl-6

Non GC

MUM-1

GC

Non GC

-

+ -

+

Diffuse Large B-Cell LymphomaImmunophenotypical approach

Germinal Center profile

Non GC profile

Hans et al. Blood. 2004;103:275

Chang et al. Am J Surg Pathol 2004;28:464

Tzankov et al. J Clin Pathol, 2003;56:747–752

Diffuse Large B-Cell LymphomaImmunophenotypical approach

CD10 -

+ GC

Bcl-6

Non GC

MUM-1GC

Non GC

-

+ -

+

Diffuse Large B-Cell Lymphoma Phenotype as prognostic factor

GC-like DLBCL

“Centroblastic”

CD10+ / bcl6+

Bcl2+ t(14;18)

Bcl6 expression not useful

CD5-

Extranodal

BETTER PROGNOSIS ?

ABC-like DLBCL

“Immunoblastic”

MUM1+ / CD138?

Bcl2+ BCL2 amplification

Bcl6 expression not useful

CD5+

Nodal / Specific sites

POOR PROGNOSIS ?

Linderoth et al. Clin Cancer Res 2003.better76%CD40

Drillenburg et al. Leukemia 1999.worse76%CD44

Harada et al. Leukemia 1999.Linderoth et al. Clin Cancer Res 2003.worse

17%9%CD5

Hermine et al. Blood 1996.Hill et al. Blood 1996.Colomo et al. Blood 2003.

worse45%55%59%

Bcl-2

Years

Prob

abili

ty

.2

.4

.6

.8

1

0 2 4 6 8 10 12 14

Bcl-2-negative

Bcl-2-positive

Mounier et al. Blood 2003

p=0.004

Bcl-2 +R-CHOP

CHOP

Diffuse Large B-Cell Lymphoma Phenotype as prognostic factor

Location in Lymphoma Classification

• Primary mediastinal large B-cell lymphoma

• Primary cutaneous large B-cell lymphoma

• DLBCL of Immnunoprivileged sites (SNC, testes)

• Follicular lymphoma

– Children

– Extranodal sites

– Duodenum (IgA)

• Skin T-cell lymphomas

• Cell of origin

• Site related immunological function

• Tumor- host Interaction

Conclusions and Perspectives

• New information has clarified different categories and suggestedpotential new variants and entities

• Broad categories still remain heterogeneous and need additional progress

• New concepts are emerging that may be important in future efforts to define new disease entities

- Anatomic site as a parameter for classification- Identification of new entities based on expression profiles- Identification of new markers useful for the daily practice

• New information regarding pathogenesis will have significant implications for the design of clinical trials and the development of new therapeutic approaches

http://www.ncbi.nlm.nih.gov/entrez/query.fcgihttp://www.ncbi.nlm.nih.gov/gquery/gquery.fcgi

http://www.hlda8.org/HLDAtoHCDM.htm

http://mpr.nci.nih.gov/prow/

http://www.nordiqc.org/

http://www.uscap.org/http://www.hematology.org/

LINKS