Lymphomas 1-nhl

Lymphomas

Dr.CSBR.Prasad, M.D.

Lymphoreticular system

Techniques to study the nature of lymphomas (1970 onwards)

• 1-Immunophenotyping• 2-Cytogenetics• 3-Molecular analysis

Immunophenotyping

• Helps to differentiate benign from malignant process

• Helps to differentiate B & T cell neoplasms• Helps to subcategorize B & T cell

lymphomas

Immunophenotyping

• Commonly three methods are used and they yeild similar results.

1-Immunohistochemistry (IHC) 2-Immunofluorescence (IF) 3-Flow cytometry

Immunophenotyping

Attached enzymes (usually horse radish peroxidase or alkaline phosphatase), or a fluorescent substance is tagged to the antibodies

.

Immunophenotyping - IHC

Can you tell them apart? One panel shows the small lymphoid cells from a case of small

lymphocytic lymphoma. The other shows benign small lymphocytes from a reactive lymph node. Which is which?

CD3, a pan-T-cell marker


CD20 (L26), a pan-B-cell marker.

CD20 postivity in B-cell neoplasm


• All lymphoid cells are reactive for CD45 (leukocyte common antigen, or LCA).

• B-cells: are reactive for CD19, CD20 and CD22. Certain low-grade B-cell lymphomas are reactive for two markers otherwise usually found on T-cells: CD5 and CD43. Follicular center cell lymphomas (as well as very different fish, lymphoblastic lymphomas) are frequently CD10(+).

• T-cells: Pan T-cell markers (present on almost all T-cells) include CD2, CD3, CD5, and CD7 (the early childhood markers). Most T-cells mark with either CD4 (helper cells) or CD8 (suppressor cells or cytotoxic cells).

• Natural-killer cells: These are frequently associated with CD16, CD56, or CD57.

Immunophenotyping – IHCCluster Designation Numbers

Immunophenotyping – Flow cytometry

Techniques to study the nature of lymphomas (1970 onwards)

• 1-Immunophenotyping• 2-Cytogenetics• 3-Molecular analysis

Cytogenetics

• Helps to identify translocation, deletions etc.

• Examples: Burkitt’s t(8;14) Mantle cell lymphoma t(11;14) ALCL t(2;5) Follicular lymphoma t(14;18)

Techniques to study the nature of lymphomas

• Molecular analysis is used to find out --Ig gene rearrangement in B-cell

malignancies and --T-cell receptor gene rearrangement in

T-cell malignancies. These rearrangements are too subtle to be

detected by conventional cytogenetics.

Important points regarding lymphoid neoplasms

• There is no benign lymphoid neoplasm.• Lymphomas are diagnosed by histological examination of the

lymphnode or the involved tissue.• Some times it’s necessary to use markers to differentiate reactive

process from lymphomas.• B-cell lymphomas are the most common variety (80-85%).• In patients with lymphomas immune abnormalities are very

common. (infections, autoimmunity and second malignancy).• NHL from the start is a widely disseminated neoplasm.• Spread of NHL is unpredictable where as spread in HD is

predictable.• Clinical presentation: NHL: 2/3 - nodal, 1/3 - extranodal HD: ~100% nodal.

Classification of Lymphomas

Helps in :1-recognising a lymphoma by their features.2-grouping them to understand the biological

principle that underlie their apperance.3-assessing the prognosis and give guidance

in Tx.

Classification of Lymphomas--History1942 Gall & Melory Morphology

1966 Rappaport Morphology

1974 Lukes Immu + Morphology

1975 Kiel Immu+Mor+Grade

1982 Working formula Morphology +Grade

1992 Modified Kiel Mor+IHC+Gra

1994 REAL Mor+IHC+Mol+Clin.prof

1997-2000 WHO Mor+IHC+Mol+Clin.prof

Classification of NHL:1. Non Gall-Rappaport lymphoma2. Non Rappaport-Non-Gall-Lukes Lymphoma3. Non Lukes-Kiel lymphoma4. Non Rappaport-Non Kiel-Non Gall-Non

Lukes lymphoma

Classification of Lymphomas--History

Source: Letter published in ‘The Lancet.’ during late 70s.

• A large study at the NCI looked at 1175 cases of non-Hodgkin's lymphoma with respect to different types of classification.

• “… and concluded that each of the classifications had clinical value but none was clearly superior.” !!!!!!










Working Formulation:• based solely on the morphology of H&E

stained sections• intended to translate among the previous

classifications, not to replace them. • categories do have clinical validity

(therapeutic and prognostic)and are based on relatively simple, reproducible morphologic features.


• The criteria are both architectural (low magnification) and cytological (high magnification):

1. Architectural diffuse proliferation follicular proliferation 1. Cytological Nuclear outline cleaved (indented) non-cleaved Cell size small large mixed small and large


Working FormulaLow Grade Intermediate

GradeHigh Grade

Small lymphocytic Follicular large cell Large cell immunoblastic

Follicular small-cleaved cell

Diffuse small cleaved cell

Lymphoblastic

Follicular mixed small-cleaved and large cell

Diffuse mixed small and large cell

Small non-cleaved cell (Burkitt's and non-Burkitt's type)

Diffuse large cell

• As the years have rolled by, many lymphomas have been distinguished as individual entities with the help of immunologic, cytogenetic and molecular techniques.

• These lymphomas appear to be unique diseases.









WHO classification of lymphomas:

1-The World Health Organization (WHO) classification is a modification of the Revised European-American Lymphoma (REAL) classification.

2-Lymphomas are classified based on Morphology, IHC, Molecular abnormality and Clinical profile.

3-This classification recognizes 3 major categories of lymphoid malignancies based on morphology and cell lineage (B-cell, T/NK cell & Hodgkin’s Lymphoma).

4-Both lymphomas and lymphoid leukemias are included in this classification.

ex: B cell CLL & SLL

Lymphoblastic lymphoma & T-cell acute lymphocytic leukemia

WHO classification of lymphomas

•B-cell neoplasms •Precursor B-cell neoplasms

•Precursor B-cell acute lymphoblastic leukemia (B ALL) •Lymphoblastic lymphoma

•Peripheral B-cell neoplasms •B-cell CLL/small lymphocytic lymphoma •B-cell prolymphocytic leukemia •Lymphoplasmacytic lymphoma/immunocytoma •Mantle cell lymphoma •Follicular lymphoma •Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type •Nodal marginal zone lymphoma (with or without monocytoid B-cells) •Splenic marginal zone lymphoma (with or without villous lymphocytes) •Hairy cell leukemia •Plasmacytoma/plasma cell myeloma •Diffuse large B-cell lymphoma •Burkitt lymphoma

•T-cell and putative NK-cell neoplasms

•Precursor T-cell neoplasms

•Precursor T-cell acute lymphoblastic leukemia (T-ALL)

•Lymphoblastic lymphoma

•Peripheral T-cell and NK-cell neoplasms

•T-cell CLL/prolymphocytic lymphoma

•T-cell granular lymphocytic leukemia

•Mycosis fungoides/Sézary syndrome

•Peripheral T-cell lymphoma, not otherwise characterized

•Hepatosplenic gamma/delta T-cell lymphoma

•Subcutaneous panniculitislike T-cell lymphoma

•Angioimmunoblastic T-cell lymphoma

•Extranodal T-cell/NK-cell lymphoma, nasal type

•Enteropathy-type intestinal T-cell lymphoma

•Adult T-cell lymphoma/leukemia (with human T-cell leukemia virus type 1 [HTLV-1])

•Anaplastic large cell lymphoma, primary systemic type

•Anaplastic large cell lymphoma, primary cutaneous type

•Aggressive NK-cell leukemia

WHO classification of lymphomas

Acute lymphoblastic leukemia--Mostly ALLs with lymphomatous presentation are of

pre T-cell type.--They present as mediatinal masses

(Lymphadenopathy, thymic involvement) and splenomegaly.

--Tdt is positive in 95% of the cases (present in both B & T)

--To differentiate B from T immunotyping is required.--It’s also important to differentiate ALL from myeloid

leukemia.

Cytogenetic defect:90% of ALL have numeric / structural defect.>59% have hyperploidy and polyploidyT(12;21), t(9;22), t(4;11).

Many of these chromosomal aberrations dysregulate the expression of transcription factors essential for normal hemopoietic cell development resulting in arreasted development and accumulation of immature progenitor cells.

Acute lymphoblastic leukemia

Clinical features: Abrupt onset, anemia, fever, bleeding, Bone pain, lymphadenopathy, hepatosplenomegaly, testicular involvement is common in ALL, CNS manifestations.

Prognosis: In ALL is good. 90% achieve CR and 2/3 may be cured.Worse prognosis: -age <2years -Presentation in adolescent and young adults -peripheral blast count >1,00,000 (high tumor burden) -presence of t(9;22)Favourable prognosis: -age between 2 & 10 -Low tumor burden -early pre B-ALL phenotype -t(12;21)

Acute lymphoblastic leukemia

CLL / SLLBoth are identical in morphologically, phenotypically and

genotypically.But differ only in the degree of peripheral blood lymphocytosis (CLL

ab.lym.count >4000/cumm)Histology: 1-Diffuse effacement of architecture of LN 2-populated by small lymphocytes 3-Proliferation centers (by prolymphocytes)PBS & BM: 1-Lymphocytosis 2-Smudge cells 3-Non-paratrabacular aggregates of small lymphocytes.

Peripheral B-cell neoplasms

CLL / SLL

Proliferation center - prolymphocytes

CLL / SLL

Non-paratrabacular infiltration of lymphoma cells

CLL / SLL

Immunophenotyping: B-cell markers CD19, CD20. dim sIg. characteristic CD23Chrmosomal defects: del 13q, 11q, 17q Trisomy 12.CF: >50y, often asymptomatic, Lymphadenopathy, white count >2lakhs. Richter syndromeLab: Hypogammaglobulinemia > infections Autoantibodies > hemolytic anemia, & thrombocytopenia

CLL / SLL

A variant of SLL called "atypical SLL" fails to express CD23; and like mantle cell lymphoma it expresses bright CD20 and surface light chain and FMC7. Often these are the cases with trisomy12.

It may be mistaken for Mantle cell lymphoma (cyclinD1+)

CLL / SLL

CLL/SLL

This lymphoma is very indolent but relentless, with median survivals of almost a decade.

Incurable

Follicular lymphoma

Most common form of NHLMiddle aged malesHistology: Nodular & nodular diffuse growth patterns Two cell types 1-Centrocyte, 2-centroblast BM-Paratrabacular infiltration Liver-portal triad infiltration

A follicular origin may also be inferred from a combination of soft signs: immunophenotype (CD10+), cytogenetic t(14;18), and morphologic (the presence of small cleaved B-cells).

Immunoprofiles: CD19, 20, 10 + sIg+ No CD5 (Differentiates from Mantle cell lymphoma)

BCL-2 over expression (differentiates it from reactive follicle)

Follicular lymphoma

Cytogenetics: Typical t(14;18) Here H Ig gene of chr#14 is translocated to BCL-2 gene on chr#18.

This results in over expression of BCL2 and there by preventing apoptosis.

CF: Indolent lymphoma and is incurable. Survival 7-9yrs Transformation to DLBL may occur (activation of c-Myc)

Follicular lymphoma

Follicular lymphoma

Follicles dispersed throughout the lymphnode with loss of architecture

Follicular lymphoma

Follicular lymphoma

Berard’s grading of FLGrades 1, 2 & 3

Follicular lymphoma

Paratrabacular infiltration of lymphoma cells

Follicular lymphoma

DLBCL

Males >60yrsHistopath: Large cells 4-5x the small lymphocyte Diffuse growth pattern Nucleus is round to oval vesicular with 2-3

nucleoli adjacent to the nuclear membrane. There may be multinulceated giant cells

DLBCL

DLBCL

Several of these cells are excellent examples of the typical cell of large cell lymphoma, the centroblast. It has open (clear) chromatin and several moderately large nucleoli that cling to the nuclear membrane

DLBCL

The WHO classification of DLBCLs takes note of several morphological variants:

• Centroblastic • Immunoblastic • T-cell/histiocyte-rich • Lymphomatoid granulomatosis type • Anaplastic B-cell • Plasmablastic as well as 3 specific subtypes: • Mediastinal (thymic) large B-cell lymphoma • Primary effusion lymphoma • Intravascular large B-cell lymphoma

DLBCL-Intravascular lymphoma

Small blood vessels in the dermis plugged with tumor cells

Large vessel filled with lymphoma cells


Angiotropic lymphoma, Large B-Cell


DLBCL

Centroblastic type

Burkitt’s lymphomaBurkitt's lymphomas come in at least 3 sorts, all of which are more prevalent in

males:

Endemic Burkitt's lymphoma (a WHO classification subtype): a childhood lymphoma prevalent in equatorial Africa and intimately associated with both Epstein-Barr virus infection and a characteristic translocation of the MYC gene.

Sporadic Burkitt's lymphoma (a WHO classification subtype): a world-wide lymphoma affecting slightly older patients, also associated with MYC changes but less so with EBV infection.

Burkitt's-like lymphoma (a WHO classification morphologic variant): a rather different disease affecting an older population and not notably associated with the MYC gene or EBV infection.

All 3 kinds have also been called "small non-cleaved cell lymphoma”

Molecular abnormalities:All forms are associated with translocation of c-myc gene on chr#8. The

partner is usually the IgH locus on chr#14. t(8;14) others t(8;22), t(2;8)Immunophenotyping: CD19, 20 and 10 + BCL-6+

Clinical features: Children and young adults Extranodal sites are most commonly involved Very aggressive But, responds to chemotherapy well.

Burkitt’s lymphoma

Endemic burkitt’s most commonly affects Children and young adults

& Extranodal sites are

most commonly involved


Small non-cleaved cell, high magnification. Most nuclei have 1 or 2 prominent nucleoli. Note the "tingible body" macrophage at the left with debris in its cytoplasm



Starry sky pattern

BURKITT'S CELL


Mycosis fungoides / Sezary syndrome

NHL involving Helper T-cells (CD4+).Has predilection to involve SKIN.It’s an indolent lymphoma.

Stages: Premycotic phase, Plaque phase & Tumor phase.

Mycosis fungoides

Histopathology:• Infiltration of epidermis and upper dermis

by neoplastic T-cells.• These cells have cerebriform nucleus (Sezry

cells)• Extracutaneous spread occurs most

commonly to LN and BM.

Mycosis fungoides

Erythematous patches

Mycosis fungoides

Multiple confluent purple 0.5-2 cm nodules some with overlying crust and scale

Asymptomatic red plaques on chest, abdomen, back and proximal extremities that waxed and waned for several years before they were clinically evaluated and biopsied.

Mycosis fungoides

Diffuse red scaly rash with scattered indurated plaques studded with comedones and follicular pustules.

Mycosis fungoides

There is a dense mononuclear cell infiltrate throughout the dermis with focal epidermal erosion.

Mycosis fungoides

Exocytosis is present (arrow)

.

Mycosis fungoides

Numerous eosinophils and plasma cells are present in the infiltrate.

.

Mycosis fungoides

Another high power view showing prominent lymphocytic exocytosis without spongiosis or keratinocyte hole formation. Also note the coarse collagen fibers in the papillary dermis

Mycosis fungoides

Immunohistochemical staining shows increased

numbers of CD4 positive lymphocytes.

Mycosis fungoides

Sezary syndrome

Features:• Generalized exfoliative erythroderma• No tumefactions• Associated with Leukemia of Sezary cells• Indolent lymphoma with 8-9yrs survival• Transformation to large cell lymphoma can

occur as a terminal event.

Sezary syndrome

Exfoliative erythroderma

Sezary syndrome

This is a cerebriform lymphocyte from a patient with Sezary's syndrome. It is an abnormal lymphocyte. It has super-clumped chromatin with large aggregates or blocks. The cytoplasm is blue and scanty.

Sezary syndrome

Sezary cells are atypical lymphocytes with a grooved or cerebriform nucleus seen both in tissue and blood. The Sézary cell is named after the French dermatologist Sézary A (1880-1956).

Blood criteria to define Sézary syndrome as recently proposed by ISCL are the following:

• An absolute Sézary cell count of 1000 cells/cumm or more • An increase in CD3 or CD4 positive cells resulting in a CD4/CD8

ratio of 10 or more • Aberrant expression of pan T cell markers by flow cytometry,

deficient CD7 expression • Increased relative or absolute lymphocyte counts with evidence of

a T cell clone in the blood by Southern blot or PCR technique

Sezary syndrome

ISCL-International Society for Cutaneous Lymphomas

Diagnosis of Sézary syndrome requires the presence of the triad of

1. Erythroderma, 2. Lymphadenopathy and 3. 10% or more of atypical mononuclear cells in

the peripheral smear. Many experts now consider a circulating Sézary cell

count which exceeds 1000 cells/cumm as characteristic of Sézary syndrome.

Sezary syndrome

Primary Cutaneous ALCL

Vol 143 No. 1, January 2007

Crusted erosions, flaccid bullae with pus, well-circumscribed shallow ulcers, and dusky, erythematous circinate plaques on the

extremities.



This 71-year-old woman had a 4month history of generalized dermal plaques and subcutaneous nodules.

dermatlas.com

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