Diagnostika lymfomůExtranodální lymfomy

Doc. MUDr. L. Boudová, Ph. D.

Contents

WHO Classification

2008

LymphomasClonal disorders of lymphoid cells at various stages of differentiation

HODGKIN L.

NON-HODGKIN L.immature cells (precursors)mature cellsBT

Note:Hodgkin lymphoma is also a (mature)B-cell lymphoma.

Distinctionclinicalhistological

Lymphoid malignanciesEpidemiology

90%: B; FL+ DLBCL – 60%

4% of all new cancers each yearIncidence increasing

per 100 000:34 lymphoid neoplasms

Lymphoma diagnosis

Sample

Lymph node

Bone marrow

Spleen, extranodal tissue

Cerebrospinal fluid

Lymphoma diagnosis

Histology, cytologyImmunohistochemistry Ag detected in tissue slidesMolecular biologyClonality, lineage – gene rearrangementsTranslocation detection, mutations

Flow cytometryClinicopathological correlation, esp. T-cell

lymphomas difficult to diagnose

Gene rearrangement (PCR, Southern blot)

Clonality and lineage B-cells: IgHT-cells: T-cell antigen receptor

Characteristic translocations

Mantle cell lymphoma t(11;14)

Follicular lymphoma, diffuse large B-cell l. t(14;18)

Anaplastic large cell lymphoma t(2;5)

Burkitt lymphoma t(8;14)

Lymphoma diagnosismolecular biology

B-cell lymphomaClonal disorders of B-cells at various stages of differentiationof immature cells - lymphoblastsB-acute lymphoblastic leukaemia - frequent, childrenB-lymphoblastic lymphoma - rareof mature B-cells

most common: diffuse large B-cell lymphoma, follicular; plasma cell myeloma

Mature B-cell lymphomasChronic lymphocytic leukemia/small lymphocytic

lymphoma; B-cell prolymphocytic leukemiaLymphoplasmacytic lymphomaHairy cell leukemiaPlasma cell myelomaMonoclonal gammopathy of unknown significanceSolitary plasmacytoma of boneExtraosseous plasmacytomaExtranodal marginal zone B-cell lymphoma=

MALT Nodal marginal zone B-cell lymphomaSplenic marginal zone lymphoma

Mature B-cell lymphomasFollicular lymphoma

Mantle cell lymphoma

Diffuse large B-cell lymphoma

Mediastinal (thymic) large B-cell lymphoma

Intravascular large B-cell lymphoma

Primary effusion lymphoma

Burkitt lymphoma/leukaemia

T-cell lymphoma

• Precursor T-cell lymphomas - T-acute lymphoblastic leukaemia- T-lymphoblastic lymphoma

– Mature T-and NK cell neoplasms• uncommon –10% of all NHL • Most frequent : peripheral T-cell lymphoma,

unspecified• large cell anaplastic lymphomaoften difficult to diagnose

Most common T-cell lymphomas• 1. Leukaemic/disseminated

adult T-cell leukaemia - HTLV 1• 2. cutaneous - mycosis fungoides, Sezary

syndrome, primary cut. anaplast. lymphoma• 3. other extranodal - extranod. NK/T - nasal,

enteropathy assoc.• 4. nodal - peripheral T-cell lymphoma, NOS,

anaplastic large cell lymphoma

NK/T-cell lymphoma of nasal type

• EBV, angiocentric, destructive

• South America, Asia

Lethal midline granuloma

NK/T-cell l.

Wegener granulomatosis

Cocaine abuse

Diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma

aggresive, potentially curable

COMMON!

1/3 of all lymphomas of adults (med. 64 ys)

nodal OR extranodal (1/3)

GIT, skin, CNS, testisbone, soft tissue, salivary glands, Waldeyer ring, lung, kidney, liver, spleen, female genital tract

Diffuse large B-cell lymphoma

Primary OR secondary

Chronic lymphocytic leukemiaFollicular lymphomaMarginal zone B-cell lymphomaNodular lymphocyte predom. Hodgkin l.

Risk factor: immunodeficiency (often EBV+)

Diffuse large B-cell lymphoma

Morphologic variants

Centroblastic

Immunoblastic

Plasmablastic

DLBCL subtypes

T-cell/histiocyte rich

CNS

Skin- leg type

EBV positive - elderly

Special lymphomas of large B-cells

Mediastinal (thymic)

Intravascular

Chronic inflammation

Lymphomatoid granulomatosis

ALK positive plasmablastic

Arising in HHV8 Castleman dis.

Primary effusion

Diffuse large B-cell lymphoma, Giemsa

Diffuse large B-cell lymphomaDifferential diagnosis

TumorsHaematological: lymphomas – peripheral - B, T

precursors - B, Tmyeloid neoplasm

Non-haematological: carcinoma, sarcoma, GIST, melanoma, seminoma, glial tumors

Reactive disorders: infectious mononucleosis, Kikuchi

T-cell /histiocyte rich B-cell lymphoma

diffuse large B-cell lymphoma

neoplastic B-cells scarcemajority reactive T-cells, histiocytes

Small B-cells rare BUT areas with

increased numbers of small B-cells

associated NLPHL ?

CD20Diffuse/ vaguely nodular

T-cell /histiocyte rich B-cell lymphomaDifferential diagnosis

1. Hodgkin lymphoma

- classical

- NLPHL (nodular paragranuloma)

2. T-cell lymphoma

3. Reactive disorders – T/HRBCL interfollicular

Diffuse large B-cell lymphomaclinicopathological subtypes

• mediastinal

Mediastinal DLBCLThymus

Female, 30 ys

Anterior mediastinal mass

Superior vena cava syndrome

Clinicopathological differential diagnosis?

Mediastinal DLBCLCompartmentalising fibrosis

Polymorphic large cells, abundant pale cytoplasm CD20, CD23, CD30, CD45

Mediastinal DLBCL – differential diagnosisProblems1. small biopsies, crushed cells, small areas for IH2. background: small ly, eosinophils; RS cells3. clinicopathological features – med. mass, young woman

Traverse-Glehen : Mediastinal Gray Zone Lymphoma. The Missing Link Between Classic Hodgkin Lymphoma

And Mediastinal Large B-Cell Lymphoma.

Am J Surg Pathol, Nov. 2005, 29, 1411-1421

GRAY ZONE

Classical Hodgkin lymphoma

Nodular sclerosis

Borderline cases

BCLUWFIBDLBCLACHL

BCLUWFIBDLBCLACHLDLBCL vs. CHLmorphology, IHC

Garcia, Histopathology 2005

BCLUWFIBDLBCLACHLDLBCL vs. CHLmorphology, IHC

Traverse-Glehen AJSP 2005

DLBCL

Differential diagnosis versus

Burkitt lymphoma

Burkitt lymphoma

1. endemic (Africa)

2. sporadic (young, rare)

3. immune deficiency-associated - HIV!

t(8;14)

starry sky

BCLUWFIBDLBCLABL

BCLUWFIBDLBCLABLDLBCL versus Burkitt

morphology, IHC, genetics

Chuang AJCP

Extranodal lymphomas

the primary tumor is extranodal (not nodal)The biggest mass is extranodal at the time of the diagnosisDiagnosis may be nmore difficult than in the LN – other tumours

may be more common in extranodal localizations (carcinomas..) – think of the possibility of a lymphoma

Most common: GIT, skin, Waldeyer,CNS, testis, bone

soft tissue, salivary glands, lung, kidney, liver, spleen, female genital tract

Histological types: DLBCL, MALT l.

Gastrointestinal lymphomas

most common extranodal lymphomas

50%

Klinické symptomy často necharakteristické!

• pokročilé: tumor v břiše, srůsty kliček, perforace

• lymfadenopatie

• hepatosplenomegalie

• KO: lymfocytóza, LDH

• endoskopický nález

GI lymphomasType B

DLBCL, MALT

MCL, FL T

EATLSite Stomach Intestines (ileocaec., jejunum, duodenum)

Diffuse large B-cell lymphoma of the stomach

DLBCLHE CD20

MALT lymphoma versus DLBCL

Gastric DLBCL de novotransformation of a low-grade lymphoma

clonal progression in timeIndependent coexistence of 2 clones:

low /high grade component

DO NOT USE “HIGH-GRADE MALT LYMPHOMA“

MALT lymphoma

stomach, intestine (IPSID)

chronic antigenic stimulation

- Helicobacter pylori

Regulation: specific activated T-cells

Slow progression- 90%: stage IE, IIE

(bone marrow involvement: rare, 10%)

Helicobacter pylori

Chronic gastritis

Diseases associated with Helicobacter pylori infection

• Chronic gastritis• Peptic ulcer

• Gastric carcinoma• Gastric MALT lymphoma

MALT lymphoma of the stomach

MALT lymphomaDifferent sitescommon featuresArchitectureCytologyImmunophenotypeextrafolik. infiltráty

folikulární kolonizace

lymfoepiteliální léze

monocytoidní, plazmat.

buňky

Macroscopy: often noncharacteristic

Microscopy: Wotherspoon criteria - spectrum

0 normal mucosa

1 chronic active gastritis

2 chronic active gastritis with lymphoid follicles

3 suspicious lymphoid infiltrate,

probably reactive

4 suspicious lymphoid infiltrate,

probably lymphoma

5 MALT lymphoma

MALT lymphoma

Immunohistochemistry

No specific MALT lymphoma markerPositivity: CD20, CD79a; Ig light chains; Ig

heavy chains: IgM; CD43Negativity: CD5, CD10, bcl6, IgD, cyclin D1

CD21, CD10, Ki-67: residual lymphoid follicles

Differential diagnosis of MALT lymphomaHP gastritis Wotherspoon criteria

spectrum 0-5

other lymphomas: DLBCL, MCL, FL…

Integrated approachfavoring MALT lymphoma:dense lymphoid infiltrate prominent LELDutcher bodiesinfiltration of muscularis mucosaeatypia of lymphoid cellsB - cell monoclonality

B-cell monoclonality detection

Monoclonal IgH rearrangement

Polyclonal IgH rearrangement

Imunohistochemistry - Ig light chains

Molecular biology - PCR - IgH rearrangement

It is often not possible to establish a clear diagnosis in a single biopsy.

repeat the biopsy; sampling

? MALT lymphoma/gastritis?

Large cell component?

Correct diagnosis and treatment

Interdisciplinary communication

Repeated biopsies, specialized methods

MALT lymphoma after therapy

• Response: regression of lymphoid infiltrate and LEL

• Gastric mucosa: atrophy, intestinal metaplasia, empty, fibrotic, basal lymphoid aggregates

• Always assess Helicobacter pylori

• B-cell clonality assessment by PCR: not clear

Průkaz monoklonality

• Imunohistochemie

lehké řetězy Ig

• Molekulární genetika PCR

přestavba genu IgH CDR III

Gastric MALT lymphomaRecurrent genetic abnormalities

• t(11;18)(q21;q21)/ API2-MALT1

usually the sole genetic abnormality, 25% of g. MALT l., H. p. neg., no response to ATB

• t(14;18)(q32;q21)/ IgH-MALT1

non-gastric• t(1;14)(p22;q32)/ IgH-BCL10; t(1;2)(p22;p12)

• Different strains of Helicobacter pylori

MALT l. in other sites than the stomach

• Eye – Chlamydia psittaci

• Skin – Borrelia burgdorferi

• IPSID – Campylobacter jejuni

• Salivary, thyroid, lung, orbit, breast, skin

• Localized; disseminated (30%, after a long period)

• 5 y OAS: 90%

Multiple lymphomatous polyposis

Mantle cell lymphoma

Follicular lymphoma

MALT lymphoma

Mantle cell lymphoma

Multiple lymphomatous polyposis

M60 bad prognosis imunohistochemistry genetics WHO

Mantle cell lymphoma - localisation

Lymph nodes, Waldeyer; bone marrow

Extranodal sites: GIT, skin, others

GIT: multiple lymphomatous polyposis

(MCL, FL, MALT l.)

Mantle cell lymphoma

CD5 Cyclin D1

MALT? MCL? FISH t(11;14)(q13;q32)

Enteropathy-associated T-cell lymphoma

Proximal jejunum Very rare x most common GI T-cell lymphoma

Acute abdomen (40%) – emergency surgeryObstruction/perforation, peritonitis, sepsis, death

Non-acute: pain, weight loss, malabsorption

Age 60, M=F

Enteropathy-associated T-cell lymphoma

Striking association with celiac disease

Histology and immunomorphology

Anaplastic/pleomorphic (80%)

Celiac dis.+, enteropathy +, CD56-Monomorphic (20%)

Celiac dis.-, enteropathy+/-, CD56+

Half of the patients die soon after the manifestation

Enteropathy-associated T-cell lymphoma

Anaplastic T-cells, plasma cells, eosinophils

CD3

TCR gamma - PCR

TGGE

ABI PRISM

Testicular lymphomas

Lymfomy varlete• Primární x sekundární

• 1% všech NHL

• 2% nádorů varlete

! nejčastější nádor varlete

u mužů 50 let !

I. Dospělí:DLBCLMALT lymfom, folikulární lymfom T-lymfomyT/NK – lymfomy, nosní typplasmocytom

II. Děti: před pubertouSek. (5% systém.): Burkitt, DLBCL,

lymfoblastické nádory

Primární: folikulární lymfom

Infiltrace varleteparciální

celková

Zvětšeníunilaterálníbilat. současné

Intertubulární růst

DLBCL

Destrukce tubulů,difúzní růst

Cytologické rysy

Nejčastěji: dif. velkobuněčný B-lymfom - CB, IB - CD20+, CD79a+

•Stadium IE

Lymfom varlete (DLBCL)

! nejčastější nádor varlete

u mužů 50 let !

primární diagnózy: 10% chybné („seminom“)

• Většinou diagnostikován v KLIN. ST. IEA

• Prognóza nemocných není tak dobrá, jako u odpovídající rizikové skupiny nodálního DLBCL

• Pozdních relapsy: CNS, druhostranné varle, zejména u nemocných nedostatečně léčených v úvodu

The mysterious link

between

the brain

and

the testis

CNS lymphomas

Primární lymfomy CNS

• pouze v CNS

• mozek

• 1% intrakraniálních nádorů – 1% NHL

• imunodeficientní x imunokompetentní

Multifokální, periventrikulární or unifocal mass

MR

Perivask.

manžety

RETIKULIN

CD20

Predispozice

imunitnídeficity

AIDS

EBV-LMPEBV-LMP

Vzácné prezentace lymfomů v NS

• LokalizaceOko

Dura materMícha, extradurální expanzeLymphomatosis cerebriKraniální a periferní nervy

• Typ lymfomuT-lymfom, ALCLintravask. lymfomSLL, MgZL, FL, PTLD

Závěr:primární lymfom CNS

svébytná nádorová jednotka

histopatologická diagnóza

stereotaktická biopsie

Intravaskulární B-lymfom

Intravaskulární

B-lymfom

Lymfoproliferace u imunodeficitů

immunodeficiencies

• Associated tumors

• Skin, urogenital tract, lymphomas

Stavy se sníženou imunitou

1. iatrogenic immunosuppression after transplantation(posttransplantation lymphoproliferative disease, PTLD)

2. autoimmune diseases (RA, SLE)3. HIV4. primary immune deficiencies5. senile EBV-related B-cell lymphomas

PTLDPosttransplantation

lymphoproliferative disease

Clinicopathological spectrum1. Histol. Iniciální - časné

2. Polymorfní

3. Monomorfní

4. Hodgkinův lymfom, PTLD podobná Hodgkinově lymfomu

Etiopatogeneze

• imunosuprese

• infekce EBV

• chronická antigenní stimulace štěpem

• další infekční agens?

EBVPolyklonální lymfoidní proliferace

Klonální populace

Sekundární genetické změny

„IM“

Plazmocytární hyperplazie

Polymorfní PTLD Monomorfní PTLD HL

Reaktivní T-buňky

Klesající imunitní odpověď

Vliv EBV

PTLD – potransplantační lymfoproliferace

Early – up to 1 year – EBV - strong role

Late – after 1 year

• Frekvence PTLD: 1-10% - typ a stupeň imunosuprese, - EBV status

• Lokalizace: často extranodální

• Nejvíce: 1. rok po transplantaci

PTLD časná x pozdní

• Mortalita: Tx solidních orgánů: 60%

kostní dřeně: 80%

• Reverzibilita: u některých PTLD

• Původ: příjemce (solidní) x dárce (BMT)

EBV• Infectious mononucleosis

• Burkitt lymphoma

• Hodgkin lymphoma

• B-cell lymphomas in immunosuppressed patients (HIV, transplantation)

• Nasopharyngeal carcinoma

HIV and lymphomas

• 1 st most frequent tumor: Kaposi sarcoma

• 2nd: lymphomas

• Lymphoma - AIDS defining illness

• 3% of patients with AIDS

Lymfomy u HIV pozitivních lidíagresívní B-lymfomy, často extranodální;

heterogenní (GIT, CNS)patogenetické faktory:

herpesviry: EBV (v 50%), Kaposi Sarcoma Human Virus/HHV 8 (primary effusion lymphoma)

chronická antigenní stimulace

genetické abnormality

poruchy cytokinové regulaceprognóza závisí na tíži imunodeficience

Lymphomas associated with HIV

Incidence increased: 60-200 x

(versus noninfected population)

Incidence decreases with HAART, ↑CD4

Hodgkin lymphoma: AIDS: risk 10 x higher

Lymfomy u HIV+1. lymfomy postihující také imunokompetentní

pacienty

časté: Burkittův (klasický, plazmacytoidní, atypický), DLBCL (často v CNS!)

vzácnější: extranodální B-lymfom z marginální zóny, periferní T-lymfom, klasický Hodgkinův lymfom

2. lymfomy specifické pro HIV+ pacienty

primary effusion lymphoma, plazmoblastický lymfom ústní dutiny

3. léze vyskytující se i u jiných imunodeficiencí - polymorfní "PTLD"

Lymfoproliferativní chorobyu primárních imunodeficiencí

rare• More than 60 PID• Heterogenous• Manifestattion highly variable• Ataxia teleangiectasia• Wiskott Aldrich sy• CVID• SCID• XLP…

Lymfoproliferativní chorobyu primárních imunodeficiencí

hlavně u dětí, častěji u chlapců;

(x common variable immunodeficiency: dospělí)

většinou extranodální (GIT, CNS) většinou B-lymfoproliferace: fatální

infekční mononukleóza, DLBCL, lymfomatoidní granulomatóza, Hodgkinův lymfom; T-lymfomy /leukémie

Senile EBV+

lymphoproliferationsno other overt ID,

only the age…

Oyama AJSP 2003

EBV + senile lymphoproliferations

• Rare

• Asia

• over 50

• Various histological appearance