lymphomas 1-nhl
TRANSCRIPT
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
Immunophenotyping - IHC
CD20 (L26), a pan-B-cell marker.
CD20 postivity in B-cell neoplasm
Immunophenotyping - IHC
• 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.” !!!!!!
Classification of Lymphomas--History
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
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.
Classification of Lymphomas--History
• 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
Classification of Lymphomas--History
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.
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
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
DLBCL-Intravascular lymphoma
Angiotropic lymphoma, Large B-Cell
DLBCL-Intravascular lymphoma
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
Burkitt’s lymphoma
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
Burkitt’s lymphoma
Burkitt’s lymphoma
Starry sky pattern
BURKITT'S CELL
Burkitt’s lymphoma
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.
Vol 143 No. 1, January 2007
Vol 143 No. 1, January 2007
This 71-year-old woman had a 4month history of generalized dermal plaques and subcutaneous nodules.
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