Pathology of Lymph Nodes

Big Picture
• As with other organs, lymph nodes, and more globally, the
immune system, can be the site of infectious, immune and
neoplastic disease, the latter either primary or metastatic
• The clinical manifestations of diseases of the lymph nodes are:
– Local enlargement, tender on nontender, +/_
– Compression of adjacent structures +/_
– Release of cytokines producing "systemic" symptoms of
fever, weight loss and night sweats
• Infectious organisms can stimulate the same acute, chronic or
granulomatous reactions in the draining lymph nodes as they
characteristically stimulate at other sites
 Big Picture 2
• Several types of immune stimuli can cause "reactive"
enlargement of the entire lymph node, or selective expansion
of cortical, paracortical or medullary regions
• Metastatic tumors spread to the lymph nodes primarily via
lymphatic drainage from adjacent solid organs
• Primary neoplasms of the lymph nodes are all malignant
• They are divided into malignant non-Hodgkin's lymphomas
(NHL), and Hodgkin lymphoma
 Big Picture 3
• NHL's are more common, and can be simply divided into
indolent, or slow growing types, and aggressive types
• Malignant lymphomas represent clonal malignancies in
which mutational events have caused the majority of
progeny cells to freeze at a single stage of normal
lymphocyte differentiation
– Lymphomas frozen at a stage associated with high
replication --> aggressive lymphomas;
– Lymphomas frozen at stages associated with
recirculation or final function --> indolent lymphomas
 Big Picture 4
• The diagnosis of malignant lymphomas is based on the
microscopic recognition of the dominant cytologic cell
type, supplemented by immunologic and molecular
techniques
• The treatment and prognosis of lymphomas are based on
– The dominant cell type (and it's inherent biologic
behavior),
– The extent of spread (Stage)
– The underlying health of the patient
• All of the previous statements are complicated by the fact
that indolent lymphomas can further mutate and transform
to aggressive types
 Big Picture 5
• Hodgkin lymphoma is a less common nodal disease whose
diagnosis is based on the detection of a characteristic cell, the
Reed Sternberg cell, in the appropriate histologic setting
• There are several (five) histologic subtypes, but prognosis is
based primarily on extent of disease
• Hodgkin lymphoma is a more curable disease than non-
Hodgkin lymphomas
• Now watch me confuse this relatively straightforward
information with the details.
 Overview of the lymphoid immune
system
• Lymphocytes evolve from pluripotent stem cells --> two
major functional cell types:
– B lymphocytes, comprising the humoral immune -->
production of antibodies
– T lymphocytes, comprising the cellular immune
system, -->
• Direct killing of foreign or intracellularly infected
cells, cytotoxic T cells
• Fine control of the immune response through the
secretion of cytokines, helper and suppressor T
cells.
 Anatomical organization
• The anatomic organization of the lymphoid immune system
divided into two major functional regions:
– The primary immune organs, sites of initial maturation -->
immune competent cells:
• B cells- bone marrow
• T cells- thymus
– The secondary immune organs, sites of antigen driven
replication and differentiation into committed effector cells
• Lymph nodes
• Spleen
• Mucosal Associated Lymphoid System (MALT)- lymphoid
cells lining the respiratory and gastrointestinal tracts
• Everywhere else
• The lymph nodes, in their totality, represent the largest secondary
organ, and the major site of lymphoid pathology
 Lymph node anatomy

• To recognize
lymph node
pathology,
one has to
be familiar
with normal
lymph node
anatomy
and cytology
 Lymph node variation
• Lymph node histology
is dynamic: follicles
– In the absence of
immune stimulation,
primary follicles

– In the presence of
immune stimulation,
secondary follicles or
germinal centers
 Lymphocyte homing
• After initial maturation in the primary • The site of T cell homing is the
immune organs, "virgin" B and T paracortex
lymphocytes --> peripheral blood --> • The separation of B and T lymphocytes
home to specific sites within the lymph not absolute,
node (and the other secondary • Both cell types present throughout
organs), lymph node, necessary for coordinated
lymphoid immune response.
• The sites of B cell homing include:
– The primary and secondary
follicles of cortex-the sites of
• antigen presentation
• proliferation and
differentiation in response to
same
– The medullary cords -->plasma
cells aggregate--> release their
immunoglobulins into the efferent
lymph
 Lymphocyte recirculation
• Normal lymphocytes recirculate, passing from blood -->
lymph nodes --> efferent lymphatics
– Allows constant surveillance for the presence of the antigen
for which the lymphocyte has a unique and specific
receptor on it's surface.
• If antigen not present, lymphocytes leave the node and
recirculate
• Virgin lymphocytes have a finite lifespan, numbered in weeks,
unless they come in contact with antigen
 Cytology of the lymph node
• The normal or reactive lymph node is thus a dynamic organ
• Composed of
– Transient B and T lymphocytes
– Antigen processing and presenting cells
– Replicating B and T lymphocytes (in response to antigen)
– Persistent and transient final effector cells
– Macrophages
• Some of these functional subgroups are cytologically unique,
others cytologically indistinguishable
• The ultimate microscopic impression, with practice, is one of
cytologic heterogeneity, and histologic organization
 Cell types I
• Small lymphocytes
– Small round dark blue dots. Round
nucleus, clumped chromatin, small or
absent nucleolus.
– The dullest looking cells hiding the
greatest level of functional
heterogeneity.
• Can be T or B cell, virgin
(unexposed to antigen) or
differentiated effector/memory cell.
• Most likely lineage, B or T,
guessed by location within the
node, but lineage and state of
differentiation must be confirmed
by immunologic/molecular
techniques
– Locations:
• B cells- primary follicles,
mantle zone of secondary
follicles, medullary cords
• T cells- paracortex, minor
population within germinal
center.
– Kinetically, clumped
chromatin tells us that the cell is
not proliferating- not activated
to enter the cell cycle and
replicate
 Cell types 2:Follicular (germinal)
center cells
• Replicating and post-replicating B cells – Small cleaved cells-
– Noncleaved cells, small and large • Nonreplicating population
• Replicating populations- • Post mitotic memory or plasma
expanding antigen responsive cell precursors
cells. • Clumped chromatin
• Round nuclei but larger than • Irregular folded and cleaved
resting small lymphocyte nuclear profiles
• Open or vesicular chromatin
• Recognizable nucleoli.
– Nucleus clear -->genetic
material unwound for
replication.
• Size, large or small compared
nucleus of macrophage.
 Cytology of lymph node 3
• Immunoblasts
– Replicating large cells found
outside the germinal centers.
– May be of B or T cell type
– Have nuclear characteristics of
replicating lymphocytes-
• Vesicular chromatin
• Nucleoli
• Accessory cells
– Antigen processing cells
• Interdigitating reticulin cells- T cell
paracortex
• Dendritic reticulin cells- B cell germinal
centers
• Process and present antigen to B and T
lymphocytes
• Invisible in normal lymph node
– Macrophages (histiocytes)-
• Phagoctytic cells of lymph node
• Tingible body macrophages of germinal
centers
• Medullary and subcapsular sinus
macrophages-
• Abundant pale cytoplasm
• Oval nucleus, single small nucleolus
 Pathology of lymph nodes 1

• Infections
• Reactive hyperplasias
• Sarcoidosis
• Metastatic tumors
• Malignant lymphomas
– Non-Hodgkin’s lymphoma-NHL
– Hodgkin’s lymphoma
 Pathology of lymph nodes 2
• Infections
– Bacterial
• Acute inflammation, abscess formation
– Granulomatous, caseous and noncaseous
– Diagnosis by culture, serologies, and/or special stains
 Reactive hyperplasias
• Exaggerations of normal histology.
– Expansion of all regions or selective expansion
– Some types characteristic of certain diseases, but most not
• Follicular hyperplasia- increase in number and size of germinal centers,
spread into paracortex, medullary areas
– Collagen vascular diseases
– Systemic toxoplasmosis
– Syphillis
• Interfollicular hyperplasia- paracortex
– Skin diseases
– Viral infections
– Drug reactions
• Sinus histiocytosis- expansion of the medullary sinus histiocytes-
– Adjacent cancer
– Infections
 Malignant lymphomas
(Non-Hodgkin's lymphomas-NHLs)
• Malignancies of the lymphoid system which primarily
manifest themselves outside the bone marrow, at the sites
of normal lymphoid homing
– Lymph nodes
– Spleen
– M.A.L.T.
– Anywhere
(Lymphomas outside lymph nodes and spleen are
referred to as extranodal lymphomas)
• Approximately 40, 000 cases per year, 20,000 deaths
 Clinical presentation
• Enlarging mass(es), typically painless, at sites of nodal tissue
• Compression, infiltration of hollow organs
– Pain, obstruction, perforation
• Interference with normal organ function-
– Solid organ infiltration- kidneys, liver, bone marrow
• Systemic symptoms
– Fever
– Night sweats
– Weight loss
• If marrow infiltrated, can have leukemic component
 NHL 2
• Composed of cells that have lost the ability to pursue the full
range of lymphoid differentiation, and are frozen at a single
stage of the normal maturation/differentiation sequence
• Recapitulate the biology and immunophenotype of normal cell
counterpart
• Several cytologically and immunologically recognizable stages
of normal lymphoid maturation --> several subtypes of
lymphoma
• Clonal malignancies, derived from a single cell that has
undergone a malignant transformation, mutation
• Best initially conceptualized as two major clinical types
– Indolent lymphomas
– Aggressive lymphomas
 NHL 3 Indolent lymphomas
• Lymphomas frozen at stages not normally replicating, but may
be circulating
• Diseases of slow accumulation, due to defective apoptosis
• Often widespread at diagnosis
• Prolonged natural history, median survivals >5 years
• Will usually respond to chemo- or radiation therapy
• Will usually relapse, but respond to same or alternative tx
• Currently incurable unless
– Localized disease or
– Marrow ablation with some type of stem cell transplant
• Classification of indolent lymphomas- later
 Aggressive lymphomas
• Lymphomas frozen at stages characterized by replication and
accelerated growth
• Diseases of defective cell cycle control
• More often localized at presentation than indolent lymphomas
• More often extranodal
• Shorter natural history; median survival </= 2 years
• Require more aggressive therapy to achieve "clinical
remission"- disappearance of all detectable disease
• Despite short natural history, curable disease in some with
aggressive therapy
– Approximately 30-40% of adults
– 50-80% children
• All childhood lymphomas of this type
 Classification of lymphomas
• Subtyping or classification within the two groupings necessary,
because different subtypes have
– Distinct clinical presentations
– Can require different therapy
– Have differing prognoses, reflecting different mechanisms of
molecular pathogenesis.
• Unfortunately, rarely unanimous acceptance of any one classification
scheme.
• Intermittent upgrading of classification, with new terminology, reflecting
new information and classifier bias
• Classification often lags behind advances in immunology, research
pathology
• Final result:
– Difficult area to teach
– Difficult to remember
– Job security for me
 WorkingFormulation for Clinical
Usage
• From 1982-1994, the classification used
in the United States
• Based on:
– The observed clinical history of
1200 patients classified according to
the terminology to right
– Microsopic examination alone,
utilizing
• Loss of normal nodal
architecture
• The dominant cytologic cell
type observed under the
microscope
• Presence or absence of
"follicularity" - mimicking of
normal lymphoid follicle
formation
• Low grade
• ML, small lymphocytic
• ML, follicular small cleaved cell
• ML, follicular, mixed small and large
cell
• Intermediate grade:
• ML, follicular, large cell
• ML, diffuse, small cleaved cell
• ML, diffuse, mixed small and large cell
• ML, diffuse, large cell
• High grade
• ML, immunoblastic
• ML, lymphoblastic
• ML, small non-cleaved cell (Burkitt's vs
non-Burkitt's)
• Miscellaneous (mycosis fungoides,
true histiocytic, etc.)
 Working Formulation
• Divided into three "grades" of lymphoma- low, intermediate and high. As
stated above,
– Low grade = indolent
– Intermediate and high = aggressive

• Limitations
– Purely morphologic classification mixed T and B cell lymphomas
together
– Lumped distinct subtypes of B cell lymphomas together
– Obscured the biologic, clinical and therapeutic differences
– Distorted interpretation of clinical trials
 R.E.A.L./W.H.O. Classification
• WF replaced in 1994 by the Revised European American Lymphoma
(REAL) classification, now being modified by the World Health
Organization (WHO)
• REAL/WHO is a "disease” oriented rather than purely morphology
oriented classification, based on:
– Cell lineage: B v T v NK v Histiocytic
– Stage of maturation of the presumed normal counterpart.
– Includes immunologic and molecular criteria in addition to purely
morphologic criteria of WF
– Each disease entity may have differing grades of aggressiveness
– Greatly expanded the list of entities; includes leukemias of
lymphoid origin
– Made teaching to medical students (and in fact all physicians) even
more difficult than WF
• REAL contained a number of “provisional entities” which have been
clarified in the upcoming W.H.O. revision.
B-Cell Neoplasms
Precursor B-cell lymphob last ic
leuke mia/lympho ma
Periphe ral B-cell neop lasms
B-cell C LL/SLL
B-cell prolymphocyt ic leuke mia T- cell prolymphocyt ic leuke mia
Lymphop lasmacytic lympho ma T- cell l arge g ranu lar lymphocyt ic
Mant le cell l ympho ma
Folli cular lympho ma
Ext ranoda l marginal zone B -
cell l ympho ma, MALT type (+/-
monocyto id B ce lls)
Noda l marginal zone B -cell
lympho ma (+/-monocyto id B
cells)
Splenic marginal zone B -cell
lympho ma (+/-villous
lymphocytes )
Hairy cell l euke mia
Diffuse large B -cell l ympho ma Seza ry synd rome
Burkitt lympho ma
Plasma cell myeloma
Plasmacyto ma
T/NK-Cell Neoplasms Hodg kin's Lymphoma
Precursor T cell lymphob last ic Lymphocyte p redo minance,
leuke mia/lympho ma nodu lar
Periphe ral T- cell and NK-cell Class ical HL
neop lasms
Predo minantly Lymphocyte rich class ical HL
leukemic/ dissemi nated
Nodu lar sclerosis
Mixed cellularity
(LGL ) leuke mia
NK cell l euke mia Lymphocyte dep letion
Adu lt T- cell l euke mia/lympho ma Unclass ifiable class ical HL
Predo minantly nodal
Ang ioimmunob last ic T- cell
lympho ma
Periphe ral T- cell l ympho ma
unspec ified
Anap last ic large ce ll l ympho ma,
T/null- cell
Predo minantly extranodal
Mycosis fungo ides
Primary cutaneous (CD30+ T- cell
lymphop roliferative d isorders)
Subcutaneous pann iculitis-like T-
cell l ympho ma
NK/T cell l ympho ma, nasa l and
nasa l-type
Ente ropathy -type intest inal T- cell
lympho ma
Hepatosp lenic T- cell l ympho ma
g/d (gamma/de lta)
a /b (alpha/beta )
REAL/WHO classification- backbone
• B cell neoplasms
– Precursor B cells-related to acute leukemia
– Peripheral B cell lymphomas- the majority of B
cell lymphomas
• T cell and Natural Killer cell neoplasms
– Precursor T cells
– Peripheral T cell and NK neoplasms
• Hodgkin’s lymphoma
Frequency of lymphomas
 Indolent versus aggressive
• Indolent • Aggressive
– Small lymphocytic
lymphoma/CLL – Prolymphocytic leukemia
– Follicular lymphoma, Grades 1/2 – Large B cell lymphoma
– Extranodal Marginal zone – Burkitt lymphoma
lymphoma of MALT type
– Nodal marginal zone lymphoma – Mantle cell lymphoma
– Splenic marginal zone – Anaplastic large cell
lymphoma lymphoma
– Hairy cell leukemia
– Lymphoplasmacytic lymphoma
– All peripheral T cell
– Plasma cell myeloma
lymphomas
– Plasmacytoma
– Cutaneous T cell lymphoma
– Cutaneous CD30+ anaplastic
large cell lymphoma

Divides B and T
 B cell neoplasms- Precursor B
• Precursor B cell lymphoblastic leukemia/lymphoma
– Frozen at lymphoblast cell stage of antigen independent B
cell differentiation- normally restricted to bone marrow
– Usually present as acute leukemia +/- lymph node
involvement
– Can initially present as node or skin disease, with later
progression to bone marrow
– Treated as acute leukemia
• 80% cure rate in children
• 20-30% in adults because of "bad" cytogenetics: frequent
presence of Philadelphia chromosome t(9;22)
 Peripheral B-cell lymphomas
Lymphomas frozen at various stages of antigen dependent B cell maturation and
differentiation
 Peripheral B-cell neoplasms
• Frozen at various stages of antigen dependent B cell maturation and
differentiation
– Small lymphocytic/CLL- the virgin B cell fresh from the marrow
– Prolymphocytic leukemia- a more clinically aggressive variant of above
– Lymphoplasmacytic lymphoma- the primary immune response
– Mantle cell lymphoma- the mantle region surrounding the follicle
– Follicular lymphoma- the follicle- grades 1-3
– Extranodal marginal zone lymphoma- cells at the periphery of the follicle in
extranodal sites of lymphoid tissue- Mucosal Associated Lymphoid tissue-
such as G.I. tract
– Nodal marginal zone lymphoma
– Splenic marginal zone lymphoma- immunologically distinct
– Hairy cell leukemia- pre-plasma cell
– Diffuse large B-cell lymphoma- this breaks the ideal of specific cell stage
but all represent lymphomas with high replication rate
– Burkitt lymphoma- very aggressive
– Plasma cell myeloma- diffuse bone marrow proliferation of plasma cells
– Plasmacytoma- solitary focus of monoclonal plasma cells, with variable
risk of progression to myeloma, depending on site
 Example Indolent Lymphoma:
Follicular lymphoma Grade I
• Clinical • Pathogenesis:
– Most common type of indolent lymphoma in – Due to t(14;18)(q32, q21)
US; second most common type lymphoma • Upregulates expression of an anti-
overall apoptotic protein Bcl2
– Disease of adults >40 (median age 59) • Immortalizes lymphoma cells
– Usually widely disseminated at diagnosis,
incl. bone marrow
– Will respond to “gentle chemotherapy” but
will relapse
• Incurable short of bone marrow
transplant unless rare limited disease
– Overall 5 yr survival 72%
– Over time, additional mutations -->
progression (“transformation”) to large cell
lymphoma --> aggressive clinical course
– Although Gr.1 is most common presentation,
some patients present with predominance of
large cells within follicles -->more aggressive
clinical course
 Follicular lymphoma Grade I
• Pathology/diagnosis
– Benign equivalent: small cleaved cell of
germinal center
– Clumped chromatin and infrequent
nucleolus like small lymphocyte
– Irregular nuclear profile, with nuclear
folds or "cleavages"
– Retain follicular structure, but
monotonous accumulation of single cell
type
– Characteristic immunophenotype:
• Positive:Monoclonal light chain,
CD19, CD10, Bcl2
• Negative: CD5, Cyclin D1/Bcl1
– Can also detect translocation by
cytogenetics and/or polymerase chain
reaction
 Table X: Indolent B cell lymphomas
Follicular Marginal zo ne Small lymphocytic
Lymphoma Lymphoma lymphoma/CLL
(Grade I)
Frequency (% 22% 8 7
all ly mphomas
Age of onset 59 61 65
median
Stage at Stage III/I V Stage I Stage IV
Presentation Disseminated
Response to Good to most Frequently Similar to
Therapy treatments, curable Follicular
but incurable lymphoma
short of
transplant
5 yr survival 72% 74% 51%

Predominant si te Nodal Extranodal Marrow/nodal

presentation
Pattern of nodal Follicular Diffuse Diffuse
Inf iltration
Benign cell Germinal Marginal zo ne Virgin B cell
Equivalent center Lymphocyte
small cle aved
cell
Dominant cell Small cl eaved Mix o f small Small
type cell i n most lymphocytes, lymphocytes
cases, but can plasma cells with round
be large cell nucleus
Im muno pheno Positive: CD19 Positive: Positive:
-type CD10, Bcl2+ CD19, Bcl2 CD19, CD5
Negative: CD5- Negative: CD23
CD10, CD5 Negative:
CD10
Molecular t(14;18) t(11;18), Trisomy 1 2
Pathogenesis Bcl2/JH Trisomy 3
Examples: aggressive B cell lymphoma-Diffuse
large B cell lymphoma

• Clinical
– Most common lymphoma- 30% NHL
– Disease of adults and children, but median age 64
– Limited versus widespread disease ~1:1
– Presents with rapidly enlarging masses
– Approximately 40% curable with aggressive chemotherapy/
stem cell transplant
• Partially predictable by International Prognostic Index (later)

• Pathogenesis
– Not as clearly defined as previous examples- several
cytogenetic abnormalities associated with large cell lymphoma,
but no defining one
 Diffuse Large B cell lymphoma
• Pathology
– Benign equivalent- large replicating B
cells of germinal center and paracortex
– Diffuse infiltration of lymph node
– Often necrosis; increased mitotic rate
– Cytology: Oval or cleaved nucleus with
vesicular chromatin and 1-3 nucleolus
– Nucleus larger than that of reactive
macrophage
– Several cytologic subtypes initially felt to
have differing clinical behavior.
– Yielded division into intermediate versus
high grade types- now not felt valid or
significant without
immunologic/molecular evidence
– Immunophenotype characterized by
monoclonal light chain, CD19
expression,with variable expression of
other B cell associated antigens
 Burkitt's lymphoma
• Clinical • Pathogenesis:
– 3% lymphomas – t(8;14), producing upregulation of
– Disease of adults and children- myc oncogene, a cell cycle
median age 31 regulation gene
– Initially recognized in Africa by
Thomas Burkitt
• Association with Epstein Barr
virus infection
• Localization in jaw
– In US, usually presents in ileocecal
region of children
– 1/3 of all childhood lymphomas
– Earlier eras, very aggressive and
rapidly fatal
• Now, ~70-80% children curable
• 40% of adults
 Burkitt's lymphoma
• Pathology
– Benign equivalent is replicating small
noncleaved cell of germinal center:
– Diffuse infiltration of lymph node
– Very high mitotic rate, lot of
ineffective proliferation;
– Attracts macrophages to
phagocytize> starry sky pattern at
low power
– Cytology: round nucleus, smaller
than that of reactive macrophage
– Vesicular chromatin and 2-5 nucleoli
– Immunophenotype:
• Positive: Monoclonal light chain,
CD19, CD10
• Negative: CD5
 Mantle cell lymphoma
• Clinical
– 6% lymphomas
– Disease of adults (median
age 63)
– Usually widely disseminated
– Poor response to all
attempted therapies,
– ? curable with transplant
– 5yr survival 27%

• Pathogenesis
– Due to t(11;14)
– Upregulates Bcl1 (cyclin
D1), a cell cycle regulator
 Mantle cell lymphoma
• Pathology/Diagnosis
– Benign equivalent is lymphocyte of
inner mantle zone
– Cytology similar to cleaved cell, but
nuclear irregularities not as
prominent
– Nodal infiltration diffuse, vaguely
nodular or "mantle zone" around
residual benign follicles
– Large cell progression infrequent
– Immunophenotype:
• Positive: monoclonal light
chain, CD19, CD5, Bcl1 (and
Bcl2)
• Negative CD10, CD23
Follicular lymphoma Mantle cell lymphoma

CyclinD1

Bcl2
 Table X: Indolent B cell lymphomas
Follicular Marginal zo ne Small lymphocytic Mantle cell
Lymphoma Lymphoma lymphoma/CLL Lymphoma
(Grade I)
Frequency (% 22% 8 7 6
all ly mphomas
Age of onset 59 61 65 63
median
Stage at Stage III/I V Stage I Stage IV Stage III/IV
Presentation Disseminated
Response to Good to most Frequently Similar to Poor response to
Therapy treatments, curable Follicular all therapies
but incurable lymphoma to date
short of
transplant
5 yr survival 72% 74% 51% 27%

Predominant si te Nodal Extranodal Marrow/nodal Nodal

presentation
Pattern of nodal Follicular Diffuse Diffuse Diffuse,
Inf iltration nodular
or
Òmantle zoneÓ
Benign cell Germinal Marginal zo ne Virgin B cell Mantle cell
Equivalent center Lymphocyte
small cle aved
cell
Dominant cell Small cl eaved Mix o f small Small Small cell
type cell i n most lymphocytes, lymphocytes wi th irregular
cases, but can plasma cells with round nucleus,
be large cell nucleus similar to
cleaved
Im muno pheno Positive: CD19 Positive: Positive: Positive:
-type CD10, Bcl2+ CD19, Bcl2 CD19, CD5 CD19, CD5,
Negative: CD5- Negative: CD23 Bcl2
CD10, CD5 Negative: Negative:
CD10 CD10
Molecular t(14;18) Trisomy 3 Trisomy 1 2 t(11;14)
Pathogenesis Bcl2/JH Bcl1/JH
 T cell lymphomas-Precursor T

• Clinical
– Disease of teenagers; boys>girls
– Can present as acute leukemia or mediastinal mass+/- marrow
involvement
– Aggressive lymphoma/leukemia, but curable: ~70% with
appropriate multiagent chemotherapy
• Pathogenesis
– No single gene culprit, but frequently involve translocation of
(onco)genes to site of T cell receptor genes, --> upregulation of
proteins
 T cell lymphomas-Precursor T
• Pathology
– Benign equivalent
immature T cells of
thymus
– Histology: Diffuse
infiltration of
thymus/adjacent lymph
nodes
– Cytology: “Blast cells”
of intermediate size with
oval to “convoluted”
nuclear profiles, fine
chromatin and 0-1
nucleolus
– Again need immunology
to distinguish from pre-B
 Peripheral T cell lymphomas
• Predominantly
leukemic/disseminated
– T-cell prolymphocytic leukemia
– T-cell large granular
lymphocytic (LGL) leukemia
– NK cell leukemia
– Adult T-cell leukemia/lymphoma
• Predominantly nodal
– Angioimmunoblastic T-cell
lymphoma
– Peripheral T-cell lymphoma
unspecified
– Anaplastic large cell lymphoma,
T/null-cell
• Predominantly extranodal
– Mycosis fungoides
– Sezary syndrome
– Primary cutaneous CD30+ T-
cell lymphoproliferative
disorders
– Subcutaneous panniculitis-like
T-cell lymphoma
– NK/T cell lymphoma, nasal and
nasal-type
– Enteropathy-type intestinal T-
cell lymphoma
– Hepatosplenic T-cell lymphoma
 Key points regarding T cell
lymphomas
• Clinical
– Represent 20% all lymphomas
– More often extranodal than B
• Can involve skin, midline facial
area, liver
• Very characteristic clinical
presentations
– Most diseases bad: high stage, and
poorer response to therapy than B
cell lymphomas of all grades
• Pathogenesis:
– Characteristic cytogenetic findings
associated with several types
• Anaplastic large cell lymphoma-
t(2;5): ALK1 gene
• Hepatosplenic T cell lymphoma-
Isochromosome 7
• Pathology
– Cytologic features not as predictive of
behavior as B cell lymphomas
• Anaplastic large cell lymphoma -->
better prognosis than most indolent B
cell lymphomas- 77% 5 year survival
• Mycosis fungoides, indolent cutaneous
lymphoma, incurable, but with long
clinical course
– Immunophenotypic studies frequently
demonstrate
• Loss of normal T cell associated
antigens
• Antigens associated with Natural Killer
cell function
• Immunology absolutely necessary to
recognize
 Ancillary diagnostic studies
• Use of immunologic/molecular techniques
• Malignant lymphomas reproduce the immunobiology of their benign
counterparts
• This reproduction may be aberrant, and hence distinguishable from
normal
• Expression, normal and aberrant can be used to:
– Determine lineage, B versus T versus NK
– Detect clonality
– Suspect malignancy- loss or aberrant expression of expected
antigens
– Recognize characteristic patterns of antigenic expression
associated with certain subtypes of lymphoma
 Normal lymphoid maturation
• Requires two major activities – B cells
– The production of a unique • Immunoglobulin receptor
antigenic receptor on it's surface composed of two heavy and
– The expression of several surface two light chains
proteins necessary for antigen – Select specific heavy
recognition, cell activation, cell- chain antigen
cell communication. recognition sequence
– Antigen receptors are generated – Select only one of two
through the process of "genetic light chains, kappa or
rearrangement"- the random lambda
selection and juxtaposition of – T cells
discontinuous genetic segments • Select one of two
encoding the antigen receptor heterodimeric receptors
genes
– Alpha/Beta heterodimer
T cell receptor
– Gamma/Delta
heterodimer T cell
receptor
 Normal lymphoid maturation
• Requires two major activities
– The production of a unique antigenic receptor on it's surface
– The expression of several surface proteins necessary for antigen
recognition, cell activation, cell-cell communication.
• Antigen receptors are generated through the process of "genetic
rearrangement"- the random selection and then juxtaposition of
discontinuous genetic segments encoding the antigen receptor genes
– B cells
• Immunoglobulin receptor composed of two heavy chains and two
light chains
– Select specific heavy chain gene sequences
– Select only one of two light chains, kappa or lambda
– T cells
• Select one of two heterodimeric receptors
– Alpha/Beta heterodimer T cell receptor
– Gamma/Delta heterodimer T cell receptor
Antigen receptor selection- B cell
 Surface antigen production
• Immune cells require numerous surface molecules for effective
immune response, cell-cell communication and regulation
• Classified into B cell associated, T cell associated, activation
associated, cytokine receptors
• Expression occurs in an orderly sequence in lymphoid maturation
• Antibodies to these molecules cataloged thru the CD - clusters of
differentiation - numerical system
– Initially developed to characterize monoclonal antibodies
detecting proteins whose function was unknown .
– Now up to CD166. You'll only be tested on 1-130 though (- a
joke for you paranoid types.)
B cell antigen expression
T cell antigen expression
 Immunologic Techniques
• Flow cytometry-automated
fluorescent microscopy
• Immunohistochemistry- in situ
immunologic detection
through the use of enzyme
substrate color deposition
• Both utilize monoclonal
antibodies to detect clonality
and unique antigenic patterns
 Immunologic Techniques
• Flow cytometry-automated fluorescent microscopy
• Immunohistochemistry- in situ detection through the use of
enzyme substrate color deposition
• Examples
– B cell small lymphocytic lymphoma-
• Monoclonal light chain, CD19, CD20, CD5, CD23
positive, CD10 negative
– B cell follicular lymphoma-
• Monoclonal light chain, CD19, CD20, CD10 positive,
CD5 negative
 Molecular techniques
• Detection of antigen receptor clonality
• Detection of unique cytogenetic
rearrangements/translocations
• Examples
– Clonal gene rearrangement by Southern blot
– Bcl2/JH rearrangement by polymerase chain
reaction
 Clinical presentation
• Enlarging mass(es), typically painless, at sites of nodal tissue
• Obstruction, ulceration of hollow organs- pain, perforation
• Interference with normal organ function-
– Solid organ infiltration- kidneys, liver, bone marrow
• Systemic symptoms
– Fever
– Night sweats
– Weight loss
• If marrow infiltrated, can have leukemic component
 Clinical staging of lymphomas
• Defines extent of disease; determines therapy and prognosis
• Based on physical, radiologic examination, bone marrow biopsy and
aspiration
• Ann Arbor Staging system
• B symptoms- fever, weight loss > 10% body weight, night sweats
Staging table
 Prognosis
• International prognostic index
– Aggressive lymphomas
• Cytogenetics
• Oncogenes
 International Prognostic Index 1

• Clinical features
identifying prognostic
subsets of diffuse
large cell lymphoma
• Identified through
retrospective
statistical analysis of
large set patients
• Assigned 1 point for
each bad feature
 Therapy I Indolent lymphomas
• Seminar cases will also discuss – "Bone marrow transplant"-
• Limited stage (5-10% cases) • Effort at cure
– Radiation therapy • Reserved for younger patients <60
– Can be curative • High dose chemotherapy and allogeneic
• Disseminated indolent/low grade lymphomas (90%) transplantation
– No therapy • High dose chemotherapy and autologous
– Low morbidity limited chemotherapy peripheral stem cell collection/reinfusion
• Older patients • Increased morbidity
• No expectation of cure
• Most will respond totally or partially, with
months to years of disease free survival, but
will relapse
• Many will respond to additional rounds of
similar or alternative regimens
• Pts will die of disease, or interceding disease
of elderly
• Death from disease due to
– Immune suppression- infections
– Progression to aggressive lymphoma
 Therapy II- Aggressive lymphoma

• Limited disease localized disease treated with irradiation plus

limited cycles multiagent chemotherapy
• More extensive disease with more cycles multiagent (>/= 4
drugs) chemotherapy
– Complete remission rates 60-80%
– 30-40% cured
• Newer therapies and their roles still being established
– Bone marrow transplantation
• Allogeneic
• Autologous
– Immunotherapy
 Hodgkin's lymphoma
• Less common than NHL; ~
10,000 cases per year
• Age incidence bimodal, with one
peak in late adolescence, young
adulthood, second peak
beginning in sixth decade
– Bimodal curve shifts to
younger ages in poorer
countries
• Unlike NHL, HL diagnosed by the
presence of a minor cellular
component, the Reed-Sternberg
cell, found in the appropriate
microscopic cellular background
Hodgkin's lymphoma classification
Rye Classification REAL/WHO Classification

Lymphocyte predominant-5% Lymphocyte predominance,

nodular
Nodular sclerosis-70%

Mixed cellularity-20% Classical HL

Lymphocyte depleted-5% Lymphocyte rich classical HL

Nodular sclerosis

Mixed cellularity

Lymphocyte depletion

Unclassifiable classical HL
 Hodgkin's Histologic subtypes

• Are characteristic patterns of

involvement, and characteristic
variants of Reed Sternberg cell
associated with different subtypes
• Nodular sclerosing HL
– Most common type Hodgkin's
lymphoma in US/Europe
– Usually presents in the anterior
mediastinum and neck of young
adult females
– Characterized by fibrotic capsule
and bands subdividing tissue and
– Lacunar variant Reed Sternberg
cell
 Histologic
subtypes 2
• Lymphocyte predominant
– Usually presents with limited disease in the
neck of young adults
– Associated with L and H (lymphocytic and
histiocytic) or "popcorn cell" variant RS cell
• Mixed cellularity
– More extensive disease
– Older patients than NS and LP
– More R-S cells, eosinophils, plasma cells
– Mononuclear variant R-S cells
– Inherently more aggressive disease
• Lymphocyte depleted
– Often presents in retroperitoneum, older
patients
– Accompanied by loss lymphocytes,
sclerosis and pleomorphic RS cell variants
– Also more aggressive disease
 Ancillary studies
• Ancillary immunologic studies assist the dx of Hodgkins' lymphoma
• Distinguish HL from
– Immunoblast reactions
– Unusual variants of NHL
• CD15 and CD30 antigens in golgi and on cell membrane of R-S cells
most useful
 Patterns of spread
• Hodgkin's lymphoma spreads contiguously via
lymphatics
• Staging as in NHL- may or may not include
laparotomy/splenectomy
 Therapy
• Limited stage, low bulk disease treated with radiation
therapy
• Higher stage, B symptoms (IIB-IV) treated with multi-
agent chemotherapy+/- radiation therapy
• Complications of therapy
– Radiation effects to lungs, heart, bone marrow
– Sterility
– Splenectomy associated sepsis
– Therapy associated second malignancies
 Prognosis
• Hodgkin's lymphoma is a curable malignancy
• Overall cure rate approximately 80%
• With modern therapy, prognosis based more on
staging, bulk of disease, than morphologic subtype
• Not true in earlier era, where prognosis decreased
with number of lymphocytes; lymph depleted HL had
a terrible prognosis
 Pathobiology
• The etiology of HL is still unknown
• The lineage of the R-S cell was also obscure until recently
• The mixed cellular infiltrate, unusual large cells, clustered familial cases,
and early evidence of immune dysfunction suggest an infectious
etiology+/- an inherited predisposition
• In approximately 30% of cases, Epstein Barr virus found within the RS cells
• Molecular studies, utilizing single cell dissection and PCR based
sequencing of the antigen receptor genes indicate that the R-S cell in the
majority of cases is an altered B cell.
• Thus HL is a type of B cell lymphoma, but with a very different biology
from the other types of B cell lymphoma
• Still deserves a separate category in the classification system
 Molecular information
• The molecular abnormalities within the different types of
R-S variants effect the expression of lineage associated antigens
– L and H cells of lymphocyte predominant HL express B cell antigens,
and are clonal proliferations of this cell type
– RS cells of other types may express T cell, B cell and macrophage
associated antigens, but usually fail to express antigen receptors
• At the molecular level, show B cell gene rearrangements with out of
frame mutations or.
• Mutations in transcription/translation systems so no antigen receptor
proteins transported to surface
Additional figures
Large cells