NON HODGKIN LYMPHOMA - APPROACH AND MIMICS

Debdatta Basu, Deepti Jain

Dept. of Pathology
JIPMER, Pondicherry


INTRODUCTION

The lymphomas are a diverse group of malignancies arising from B and T lymphocytes and are generally categorised as either Hodgkin
lymphoma (HL) or non-Hodgkin lymphoma (NHL). NHLs are a heterogeneous group of lymphoproliferative disorders which are mainly
linked by their origin within the lymphoid system and its different cellular components like B-, T-, or natural killer (NK) lymphocytes.
Because NK cells are closely related, and share some immunophenotypic and functional properties with T cells, these two classes of
neoplasms are considered together.


CLASSIFICATION

Over the last forty years there have been numerous efforts to classify lymphoid malignancies culminating in the WHO classification
introduced after much international effort in 2001. It is clear that malignant lymphomas require a sophisticated diagnostic approach based on
clinical features, morphology, immunophenotyping and genetic analysis. It is essential that such an approach underpins the clinical
management of these diseases, many of which are amenable to cure. Clinical care should be delivered by those with expertise and
experience in the area, within a multidisciplinary setting.

In 1956, Rappaport et al. proposed a lymphoma classification based on the pattern of cell growth (nodular or diffuse), and size and shape of
the tumor cells. This classification, though widely used in the Unites States, quickly became outdated with the discovery and existence of
distinct types of lymphocytes (B, T, and NK). The Kiel classification, which divided the lymphomas into low- and high-grade based on
histologic features, became the first and most significant classification to apply this new information to lymphomas. This classification was
widely used in Europe. However, the use of different classification systems in clinical studies made results difficult to compare. Hence, the
International Working Formulation (IWF) for NHLs was developed to standardize the classification of lymphomas.

The IWF classified NHL as either low-, intermediate-, or high-grade based on the morphology and natural history. This classification
divided diffuse large B-cell lymphoma (DLBCL) into intermediate- and high-grade groups. However, these distinctions were not re-
producible. Because this classification did not include immunophenotyping, the categories were not reproducible. In addition, after this
classification was published, many new diseases were described that were not included in the IWF classification.

In 1994, the International Lymphoma Study Group developed the Revised European-American Lymphoma (REAL) classification, which
classified lymphomas based on the cell of origin (B, T, or NK) and included morphology, immunophenotype, genetic, and clinical features
to define diseases. In 1997, the International Lymphoma Classification Project performed a clinical evaluation of the REAL classification in
a cohort of 1403 cases of NHL, confirming the diagnosis of NHL in 1378 (98.2%). The study investigators concluded that the REAL
classification can be readily applied and identifies clinically distinctive types of NHL.

In 2001, the WHO updated the classification of hematopoietic and lymphoid neoplasms to apply the principles of the REAL classification,
representing the first international consensus on classification of hematologic malignancies. The REAL/WHO classification of NHL
includes many entities not recognized by the IWF. After consideration of cell of origin (B, T, or NK), the classification subdivides
lymphomas into those from precursor lymphocytes versus those derived from mature lymphocytes. The classification is further r efined
based on immunophenotype and genetic and clinical features. These considerations have helped define active treatment for specific subtypes
of lymphoma.

In 2008, the International T-Cell Lymphoma Project evaluated the WHO classification of T-cell lymphoma in a cohort of 1314 cases of
PTCL and NK/T-cell lymphomas (NKTCL). The diagnosis of PTCL or NKTCL was confirmed in 1153 cases (88%). The most common
subtypes were PTCL-not otherwise specified (PTCL-NOS; 25.9%); angioimmunoblastic lymphoma (18.5%); NKTCL (10.4%); adult T-cell
leukemia/lymphoma (9.6%); anaplastic large cell lymphoma (ALCL); anaplastic lymphoma kinase (ALK)-positive (6.6%); and ALCL,
ALK-negative (5.5%).15 The findings of this study validated the efficacy of the WHO classification for defining subtypes of T-cell
lymphomas. The WHO classification was updated again in September 2008 to add new diseases and subtypes that have been recognized in
the past decade, and to better define some of the heterogeneous and ambiguous categories based on recent advances.




REAL/WHO CLASSIFICATION 2008

Precursor lymphoid neoplasms
B lymphoblastic leukaemia/lymphoma, NOS
B lymphoblastic leukaemia/lymphoma with recurrent genetic abnormalities
B lymphoblastic leukaemia/lymphoma with t(9:22)(q34;q 11.2): BCR-ABL 1
B lymphoblastic leukaemia/lymphoma with t(v:11q23): MLL rearranged
B lymphoblastic leukaemia/lymphoma with t(12:2 1)(p13;q22): TEL-AMLl (ETV6--RUNX1)
B lymphoblastic leukaemia/lymphoma with hyperdiploidy
B lymphoblastic leukaemia/lymphoma with hypodiploidy (Hypodiploid ALL)
B lymphoblastic leukaemia/lymphoma with t(5; 14)(q31;q32); IL3-IGH
B lymphoblastic leukaemia/lymphoma with t( 1;19) (q23:P13.3): E2A-PBX1(TCF3-PBXI)

T lymphoblastic leukaemia/lymphoma

Mature B-cell neoplasms

Chronic lymphocytic leukaemia/smail Iymphocytic lymphoma
B-cell prolymphocytic leukaemia
Splenic B-cell marginal zone lymphoma
Hairy cell leukaemia
Splenic B-cell Iymphoma/leukaemia, unclassifiable
Splenic diffuse red pulp small B-ceil lymphoma
Hairy cell leukaemia - variant
Lymphoplasmacytic lymphoma
Heavy chain diseases
Gamma heavy chain disease
Mu heavy chain disease
Alpha heavy chain disease
Plasma cell neoplasms
Monoclonal gammopathy of undetermined significance (MGUS)
Plasma cell myeloma
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Monoclonal immunoglobulin deposition diseases
Extranodat marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma)
Nodal marginal zone lymphoma
Pediatric nodal marginal zone lymphoma
Follicular lymphoma
Primary cutaneous follicle centre lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma (DLBCL), NOS
T cell histiocyte-rich large B-cell lymphoma
Primary DLBCL of the CNS
Primary cutaneous DLBCL . leg type
EBV positive DLBCL of the elderly
DLBCL associated with chronic inflammation
Lymphomatoid granulomatosis
Primary mediastinal (thymic) large B-cell lymphoma
Intravascular large B-cell lymphoma
ALK positive large B-cell lymphoma
Plasmablastic lymphoma
Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease
Primary effusion lymphoma
Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and Burkitt lymphoma
B-cell lymphoma, unclassifiable. with features intermediate between DLBCL and classical Hodgkin Lymphoma

Mature T- and NK-cell neoplasms

T-cell prolymphocytic leukaemia
T-cell large granular lymphocytic leukaemia
Chronic Iymphoproliferative disorder of NK cells
Aggressive NK cell leukaemia
Systemic EBVpositive T-cell Iymphoproliferalive disease of childhood
Hydroa vacclniforrne-like lymphoma
Adull T-cell leukaemia/lymphoma
Extranodal NK/T-cell lymphoma. nasal type
Enteropathy -associated T-cell lymphoma
Hepatosplenlc T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
Mycosis fungoides
Sezary syndrome
Primary cutaneous CD30 positive T-cell Iymphoproliferative disorders
Lymphomatoid Papulosis
Primary cutaneous anaplastic large cell lymphoma
Primary cutaneous garnna-delta T-cell lymphoma
Primary cutaneous CD B positive aggressive epidermotropic cytotoxic T-cell lymphoma
Primary cutaneous CD4 positive small/medium T-cell lymphoma
Peripheral T-cell lymphoma. NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma. ALK positive
Anaplastic large cell lymphoma . ALK negative



APPROACH TO THE DIAGNOSIS OF PATIENT WITH LYMPHADENOPATHY

A full blood count with peripheral smear ( and cell marker studies where appropriate), should be carried out before a node bi opsy
to avoid biopsying patients with CLL or acute leukemia
Monospot test in patients < 30years with lymphadenopathy
Consider ENT and FNA examination to exclude epithelial malignancy in patients >40 years with head and neck adenopathy
Excision biopsy of the node is the preferred method: trucut biopsy if the node is not accessible
Node biopsy should send fresh to the laboratory. Fresh material is essential for good quality histology and facilitates the use of
new diagnostic techniques
Which node to biopsy the largest accessible node, if single a whole node biopsy, if generalised lower cervical node is preferred.
To gain the maximum information from a tissue sample suspected of harbouring lymphoma, proper handling of tissue is essential
o Making touch preparations for detailed cytologic assessment
o Snap-freezing tissue for reserve in case frozen section immunohistochemistry or genotypic analysis is required
o Culture, if necessary
o Sending tissue for other studies as required ,e.g. cytogenetic analysis, flow cytometry
o Utmost importance is to leave sufficient tissue for paraffin embedding for diagnostic purposes with good quality
hematoxylin and eosin stained section preferably 2-5m thick
General Morphologic Assessment: The outermost rim of lymph node is often overfixed or subjected to drying, and thus the
lymphoid cells appear deceptively small and dark. The central portion of the node often suffers from delayed fixation which
results in blowing up the nuclei and clearing of the chromatin. Therefore, the intermediate zone is the optimal area for making
detailed cytologic assessment.

Ascertaining that the pathologic process is a lymphoma: Malignant lymphoma can mimic or be mimicked by metastatic
carcinoma or melanoma. Meanwhile, it is most important not to mistake reactive lymphoid proliferations for lymphoma.
Lymphomas especially DLBCL and follicular lymphoma can undergo spontaneous infarction rendering it difficult or impossible
to render a diagnosis of lymphoma in a biopsy specimen. Thus a diagnosis of total lymph node infarction should prompt careful
follow up to rule out lymphoma and repeat biopsy, if appropriate.

Having made a diagnosis of lymphoma, the next step is to classify it according to the cell size, the neoplastic cells can be
compared with reactive histiocytes or endothelial cell nuclei. Apart from cell size, nuclear configuration, cytoplasmic
characterstics, cellular organisation (such as follicular versus diffuse) and other subsidiary features have to be taken into
considerations.

Low magnification approach is a rule: One has to spend maximum time on scanning and low power examination of a lymph
node biopsy to study colours, cellularity, architectural features, size and shape of different compartments, their relationship with
each other and patterns. And also the lymph node involvement may be predominant or may be focal as focal involvement of
lymphomas and acute leukemias in a lymph node biopsy is well known.

Hypercellular lymphomas Lymphomas of small cell type like mantle cell lymphoma, B-CLL/SL, follicular lymphoma.
Others are lymphoblastic lymphoma, Burkitt lymphoma, Hodgkin disease-nodular sclerosis type 2
Normocellular lymphoma Hodgkin disease-mixed cellularity, Hodgkin disease-nodular sclerosis type 1, marginal zone
lymphoma, peripheral T-cell lymphoma
Hypocellular lymphoma Angioimmunoblastic T-cell lymphoma, Histiocyte rich B-cell lymphoma, Histiocyte rich ALCL,
Peripheral T-cell lymphoma

Patterns - Many patterns have been described such as follicular, mantle, marginal zone, sinusoidal, interfollicular, starry sky,
Lennerts (epithelioid histiocytes), fibrous nodular, pseudo follicular. They all denote different lesions. These are best viewed by
altering the intensity of the light, moving condenser, and by changing the power. Different lymphomas may have different
patterns, like mantle cell lymphoma may have either diffuse, nodular or mantle zone patterns

Vascular proliferations are seen commonly in angioimmunoblastic T-cell lymphoma, PTCL (NOS), hyaline vascular type
Castlemans disease, and angioimmunoblastic lymphadenopathy.

Mottling pattern is in T-zone comprising of transformed lymphoid cells, histiocytes, interdigitating dendritic cells. Seen
commonly in reactive nodes, viral infections, SLE, Kikuchis disease and rarely in mycosis fungoides. It has to be differentiated
from the starry sky pattern which is due to histiocytes showing phagocytosis and is seen in viral infections such as infectious
mononucleosis, and Lymphoblastic lymphoma, Burkitts Lymphoma, AML.

Small cell Lymphomas Medium sized Lymphomas
o B-CLL/SLL * Burkitts lymphoma
o Mantle cell lymphoma * Lymphoblastic lymphoma
o Lymphoplasmacytic lymphoma * Blastoid variant of mantle cell lymphoma
o Extranodal marginal zone B-cell lymphoma of MALT type * Blastic transformation of follicular lymphoma
o Splenic marginal zone B-cell lymphoma * Peripheral T-cell lymphoma
o Follicular center lymphoma,predominantly small cell * NK/T-cell lymphoma
* Nodal marginal zone B-cell lymphoma (some
cases)
* Angioimmunoblastic lymphoma
Large sized Lymphomas
o Diffuse large B-cell lymphoma
o Anaplastic large cell lymphoma
o Nodular sclerosis C-HL, syncytial variant
o Lymphocytic depletion C-HL
o Peripheral T-cell and NK/T-cell lymphomas with a high proportion of large cells
o Anaplastic plasmacytoma and plasmablastic large B-cell lymphoma

Immunohistochemical studies :- Immunohistochemical studies play a very important role in modern day evaluation of
lymphoid proliferations, because they permit more detailed and accurate assessment of the disease process. The architecture,
cellular compartments, cell types and even subtle features not obvious on routine microscopy can be clearly highlighted.

IHC staining must be interpreted in the context of the morphologic findings and correlated with the cell populations so one
should determine that which markers are positive in the atypical (neoplastic) cells as many reactive cells present in the
background in many lymphomas. If results are negative, the validity of the stain has to be ascertained by looking for internal
positive controls. Furthermore, the localization of the signal in the cell must be appropriate for the antibody being used,
otherwise the result cannot be considered positive e.g. nucleolar staining for CD20 or diffuse cytoplasmic staining for CD30
should be disregarded.

Cytogenetic and Molecular studies :- Specific translocations have been identified in some lymphoma types so their detection
can sometimes aid in diagnosis. Besides standard cytogenetic techniques, these can be detected by FISH or molecular studies
such as RT-PCR. Molecular studies also helpful in determining the clonality of the lymphoid proliferations, detection of minimal
residual disease after treatment and detection of early relapse. Other than that also helpful in determining the lineage of t he
lymphoid proliferations in controversial cases.

Lymphoma type Specific chromosome translocation
Follicular lymphoma t(14;18)(q32;q21)
Lymphoplasmacytic
lymphoma
t(9;14)(p13;q32)
Extranodal marginal
zone B-cell lymphoma of
MALT type
t(11;18)(q21;q21)
t(1;14)(p22;q32)
Burkitt's lymphoma t(8;14)(q24;q32)
t(8;22)(q24;q11)
t(2;8)(p 12;q24)
Diffuse large B-cell
lymphoma
Translocation involving 3q27 with a
number of chromosome partners
Precursor T -lymphoblastic
lymphoma/leukemia


t(1;14)(p32-34;q11)
Anaplastic large cell
lymphoma, primary
systemic form
t(2;5)(p23;q35)

Variant translocations involving 2p23, e.g.
t(1 ;2), t(2;3), inv(2)(p23;q35)

Classification of NHLs is also important for management of patients and prognostication. There are three major categories of
lymphoma in terms of biologic behaviour: indolent lymphoma, aggressive lymphoma and highly aggressive lymphoma. Except
primary cutaneous anaplastic large cell lymphoma and extra-nodal marginal zone B-cell lymphoma of MALT type. Both of these
have a favourable prognosis and may regress spontaneously or with eradication of the antigenic source.



INDOLENT LYMPOMA
( The good)
AGGRESSIVE LYMPHOMA
(The bad)
HIGHLY AGGRESSIVE
LYMPHOMA
( The ugly)
Prototypic Entities o Follicular lymphoma
o B-CLL/SLL
o Lymphoplasmacytic
lymphoma
o Mantle cell lymphoma
o Splenic marginal zone B-
cell lymphoma
o DLBCL
o PTCL or NK-cell
lymphomas except
mycosis fungoides, T
cell large granular
lymphocytic
lymphoma, Primary
cutaneous anaplastic
large cell lymphoma
o Burkitts lymphoma
o Lymphoblastic
lymphoma
Age Group Older adults Any age Children and young adults
Rate of growth Slow: occasional waxing and waning
course
Fast Very fast ( an oncologic
emergency)
Natural history if
untreated
Indolent course, taking many years
to kill the patient
Killing patient in 1-2years Early dissemination, killing
patients in weeks to months
Response to
treatment
Not curable by chemotherapy or
radiotherapy
Potentially curably by
chemotherapy or radiotherapy
Highly responsive to
chemotherapy

OVERVIEW AND DIFFERENTIAL DIAGNOSIS OF COMMOM NON-HODGKINS LYMPHOMA
1. Precursor Lymphoblastic Lymphoma (LL)

Highly aggressive neoplasm composed of precursor cells of T-,B- or rarely NK cell lineage
Overall 80-90% of all lymphoblastic lymphomas are of T-cell lineage. Most cases of precursor B-cell lymphoblastic neoplasms
present as acute lymphoblastic leukemia and a lymphomatous presentation is rare
T-cell Type : * Most commonly affects adolescents and young adults with male:female ratio- 2:1.
* Most commonly present as large mediastinal mass with symptoms of superior vena cava obstruction, pleural
effusion and supraclavicular lymphadenopathy. Extranodal disease is also common.
* Tendency for early dissemination to the bone marrow and CNS.

B-cell Type: * B-LBL usually occurs over a wide range, from children to older adults with mean age of 32years with slight
female predominance.
* Patients with B-LBL without leukaemia are usually asymptomatic and most have limited stage disease. Head
and neck presentations are particularly common especially in children. Also presents as bony lytic lesions.
Mediastinal involvement is rare.
* Overall survival is better than T-LBL.
Morphology Clues: * Morphologically T-LBL is indistinguishable from B-LBL
* Generally complete effacement of lymphnode architecture or partial involvement with paracortical
involvement and sparing of germinal center may occur. Infiltration of perinodal tissue often produces a
single file pattern
* Sometimes multinodular (pseudofollicular) pattern seen due to stretching of reticulin network or blood
Vessels lead to misdiagnosis of follicular lymphoma
* Key feature is diffuse, dense, monomorphous proliferation of medium sized lymphoid cells with thin
nuclear membranes, delicate chromatin, indistinct nucleoli and a high mitotic count. Nuclei can be round
or convoluted. Cytoplasm typically scanty giving expression of nuclear crowding. Multinucleated tumor
cells almost never found. There may be interspersed tingible body macrophages imparting Starry Sky
Pattern.
Immunophenotype: Defining marker for precursor lymphoblatic neoplasm Tdt- Positive (localized to nuclei). Other less
specific marker for precursor cell neoplasm are CD99, CD34 and CD1a.
T-LBL : CD7 and cytoplasmic CD3 are most often positive. Of these CD3 is lineage specific. CD4 and CD8 frequently co-
expressed on blasts and CD10 may be positive.
B-LBL: Almost always positive for B-cell markers CD19, cytoplasmic CD79a, cytoplasmic CD22
Lymphoblasts positive for CD10, CD24, PAX5 and Tdt. PAX5 considered the most sensitive and specific marker for B
lineage in sections. CD20 and CD34 - +/-. Myeloid antigens CD13 and CD33 may be expressed
Pro- B- CD19+, cytoplasmic CD79a+, cytoCD22+, Tdt+ Common ALL/LBL- CD10+ Mature Pre B-ALL/LBL- cyto
chains +
Differential Diagnosis:-
o Granulocytic Sarcoma :- can mimic LL. Always exclude the possibility if any of these features present- a) Nucleoli
more prominent b) Interspersed eosinophillic myelocytes c) Fine granularity in the cytoplasm d) many nuclei with
reniform contour
o B-CLL/SLL :- Suboptimally fixed material, lymphoblasts may appear shrunken and dark mimicking small
lymphocytes. Young age of the patient and high mitotic count alert the possibility of LL.
o Mantle Cell Lymphoma blastic variant:- LL is Tdt+ and cyclin D1- while MCL shows opposite immunoreactivity
o Follicular Lymphoma:- Multinodular pattern may be mistaken for follicular lymphoma. Nodules in LL are not
genuine follicles but are large collections of neoplastic cells with fibrous framework or blood vessels surround them.
Addition clues are the monomorphous population and high mitotic count
o Burkitts Lymphoma:- Nuclei is usually round but may show nuclear protrusions, prominent nuclear moulding with
squaring of nuclear membrane. Nucleoli is distinct 2-5, definite rim of basophilic to plasmacytoid cytoplasm with
squaring of cytoplasmic membrane. Always B-lineage with Pan B-cell markers positive, CD10+, bcl6+, Tdt- and
very high Ki67 index -100% while LL usually<80%

2. B-cell Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma ( B-CLL/SLL)
Is a neoplastic proliferation of non-activated, mature looking small lymphocytes. Most cases have a leukaemic presentation (B-
CLL) and only rarely have localised disease (B-SLL). The IWCLL definition of SLL requires lymphadenopathy, no cytopenias
due to BM infiltration by CLL/SLL and <5109/L PB B-cells.
Is the most common in western countries with M: F- 1.5-2:1. It accounts for 6.7% of NHL in biopsies. Peripheral blood and BM
usually involved.. Patients are prone to have infection and some may develop autoimmune haemolytic anemia. It is an indolent
lymphoma
B-CLL frequently shows deletions of 13q14 (approximately 50% of cases), which can be homozygous or hemizygous. Deletion
in 11q22-q23 is found in approximately 14% of B-CLL/SLL, and this feature is-"associated with extensive lymph node
involvement and poorer survival.
Variants: * B-CLL/SLL complicated by large B-cell lymphoma:- 3-10% cases can supervene by large B-cell lymphoma
which is composed of large cells, which frequently show significant cellular pleomorphism and bizzare forms,
including RS like cells.
* B-CLL/SLL with RS like cells or superimposed Hodgkins lymphoma:- Rarely isolated large cells resembling
RS cells are dispersed among small lymphoma cells but the inflammatory background typical of HL is lacking.
EBERs and EBV LMP-1 consistently demonstrated in them but not in B-CLL/SLL cells. Sometimes typical HL can
also supervene.
Morphological Clues:- * Generally diffuse effacement of the architecture exceptionally involving the interfollicular regions or B
zones of the node. Perinodal tissue involvement is common.
*Pseudofollicles pattern is pathognomonic i.e. on low power, the dark staining lymphoid infiltrate is
typically punctuated by pale, round foci representing proliferation centers.
* Lymphoma cells are small, with round nuclei, condensed chromatin, inconspicuous nucleoli and scanty
cytoplasm. Mitotic activity is low. Plasma cells are sparse or absent.
* Proliferation centers are typically non-expansile and comprise a mixture of Prolymphocytes and
Paraimmunoblasts interspersed among small lymphocytes.
* Atypical B-CLL (defined as .the presence of > 10% prolymphocytoid cells or >10% cells with cleaved
nuclei or plasmacytoid features), the lymph nodes show much larger proliferation centers, and the
lymphoid cells often exhibit nuclear irregularities. "Paraimmunoblastic variant" is applied when there
are sheets or large aggregates of paraimmunoblasts; these cases are associated with a worse prognosis.
* Sometimes small lymphoid cells show moderate nuclear irregularity leading to differential diagnosis of
mantle cell lymphoma. Some cases show plasmacytoid differentiation.
Immunophenotype:- Pan B markers are positive although CD20 can be weak or even absent. Usually CD5+, CD23+, CD10-,
cyclin D1-, FMC7-, CD79b-, CD43 can be positive.
Ki67 index usually low except in proliferation centers. Ki67 index >25% predicts a less favourable outcome. Reactive T cells
generally sparse in the background.
Atypical immunophenotype CD5- or CD23-, FMC7+ or CD11c+, CD79b+
Differential Diagnosis :-
o N-LPHL : In young patients, N-LPHL must be excluded before a diagnosis of B-CLL/SLL is rendered.
Immunohistochemically, the small lymphocytes of B-CLL/SLL are monotypic and aberrantly express CD5 and
CD43, while those of N-LPHL are polytypic and do not exhibit an aberrant immunophenotype.
o Lymphoblastic lymphoma
o Mantle Cell Lymphoma :- A mantle zone growth pattern and the presence of monotonous lymphoid population
favours a diagnosis of mantle cell lymphoma especially if interspersed with naked nuclei (FDCs). MCL usually
CD23- and cyclin D1+.
o Lymphoplasmacytic Lymphoma:- The presence of many Dutcher bodies is characterstic.
o Follicular Lymphoma :- The prominent proliferation centers seen in some examples of B-CLL/SLL may invite an
erroneous interpretation of follicular lymphoma. In contrast to neoplastic follicles, the proliferation centers are non-
expansile and are usually composed of cells with round nuclei and central nucleoli (prolymphocytes and
paraimmunoblasts). Staining for reticulin will highlight condensed fibers around neoplastic. follicles of follicular
lymphoma but not around proliferation centers. B-CLL/SLL is CD5+, CD10-, while follicular lymphoma is often
CD5- ,CD10+.


3. Mantle Cell Lymphoma (MCL)
Mantle cell lymphoma (MCL) is a B-cell neoplasm composed of monomorphic small to medium sized lymphoid cells with
irregular nuclei which most closely resemble centrocytes/ follicle centre cells and a CCND1 translocation. MCL accounts for 3-
10% of non-Hodgkin lymphomas, occurring predominantly in middle aged or older individuals (median age 63) and a male:
female ratio of 5:1.
Patients usually present with enlarged lymph nodes at multiple sites and frequently a massively enlarged spleen. Bone marrow
involvement with occasional leukaemic spill is present in 80% of patients. Waldeyers Ring and the gastrointestinal tract are
frequent extra-nodal sites of involvement. Lymphomatous polyposis of the gastrointestinal tract is a form of mantle cell
lymphoma and can occur as variably-sized polyps in any part of the gastrointestinal tract.
Median overall survival is 3.5yrs and 5year overall survival rate is only around 30%.
It may show transformation to blastoid form but transformation to DLBCL is extremely rare.
MCL is defined by the presence of the t(11;14)(q13;q32) resulting in juxtaposition of CyclinD1 and the IgH gene which leads to
upregulation of CyclinD1. The translocation can be detected reliably by FISH and in about 40% of cases by PCR.
Morphological Clues:- *Classical MCL is a monomorphic lymphoid proliferation with a vaguely nodular, diffuse, mantle zone
or rarely follicular growth pattern. Infrequent cases may show involvement restricted to inner mantle
zones (in situ MCL).
*Cell population composed of small to medium sized lymphoid cells with slight to markedly irregular
nuclei resembling centrocytes with dispersed chromatin, inconspicuous nucleoli and scanty cytoplasm.
Mitotic activity ranging from low to high.
*Neoplastic transformed cells resembling centroblasts, immunoblasts or paraimmunoblasts and
proliferation centers are absent.
*Hyalinised small vessels are commonly seen with many cases have scattered single epitheliod
histiocytes which occasionally gives a starry sky pattern.
Aggressive Variants:- *Blastoid : Cells resemble lymphoblasts with dispersed chromatin and a high mitotic rate (usually atleast
20-30/10hpf)
*Pleomorphic: Cells are pleomorphic but many are large cells with oval to irregular nuclear contours,
generally pale cytoplasm and often prominent nucleoli in atleast some of the cases.
Other Variants:- *Small cell: Small round lymphocytes with more clumped chromatin, either admixed or predominant,
mimicking SLL.
*Marginal zone like: Prominent foci of cells with abundant pale cytoplasm resembling marginal zone or
monocytoid B-cells mimicking a marginal zone lymphoma; sometimes these paler foci may also
resemble proliferation centers of CLL/SLL.
Immunophenotype: B-cell lineage markers are positive and express intense surface IgM/IgD more frequently with lambda.
CD5+, FMC7+, CD43+ , CD23+/-, CD10-, bcl6-, Cyclin D1+. Cyclin D1 is the hallmark of MCL(>90%).
Cyclin D1 negative MCL: Rare MCL are negative for cyclin D1 and t(11;14) but have an expression profile and other features
indistinguishable from conventional MCL. These cases have high expression of cyclin D2 or cyclin D3. This diagnosis must be
made with grat caution due to many lymphomas that may mimic MCL.
Differential Diagnosis:-
o B-CLL/SLL- Proliferation centers are diagnostic of B-CLL/SLL and cyclin D1
o Marginal zone lymphoma consists of heterogeneous population of cells,with small lymphocytes, centrocyte-like
cells, monocytoid cells, plasma cells, and large lymphoid cells while MCL shows monotonous population of cells
with cyclin D1 +
o Lymphoblastic Lymphoma - Lymphoblastic lymphoma may mimic mantle cell lymphoma because of the irregular
nuclear foldings, but can be distinguished from the latter by the more delicate chromatin; more mitotic figures, high
probability of T-cell immunophenotype, and younger age of the patients. The blastoid variant of mantle cell
lymphoma is practically indistinguishable from lymphoblastic lymphoma;.but it is TdT-.
o Mantle Zone Hyperplasia - Mantle zone hyperplasia sometimes affects a solitary node of young individuals. In
contrast to mantle cell lymphoma with a mantle zone growth pattern, the follicles are localized to the cortex without
architectural effacement, and there is no coalescence of the broadened mantles.
o Castlemans disease of hyaline-vascular type

4. Follicular Lymphoma (FL)
Follicular Lymphoma (FL) is a neoplasm of follicle centre B cells (centrocytes/ cleaved follicle centre cells (FCC) and
centroblasts/ non cleaved FCC) which usually has atleast a partially follicular pattern.
Worldwide FL is the second most frequent subtype of nodal lymphoid malignancies. It accounts for about a third of cases of
adults with NHL in the USA and 22% worldwide. The median age of diagnosis is 59 years with a male: female ratio 1:1.7. It
rarely affects people under the age of 20.
FL predominantly involves lymph nodes but also involves spleen, bone marrow, peripheral blood and Waldeyers ring.
Involvement of non- haematopoietic extra-nodal sites such as skin, gastrointestinal tract, and soft tissues is usually in the context
of widespread nodal disease. Primary follicular lymphoma of the skin (cutaneous follicular lymphoma) is rare but is one of the
commonest cutaneous B- cell lymphomas. Bone marrow involvement is found in 40% of patients at diagnosis and only 30% will
have stage I/II disease. Death usually occurs due to bulky, resistant disease or high grade transformation to diffuse large B-cell
lymphoma (DLBCL).
FL is characterised by the t(14;18)(q32;q21) which involves juxtaposition of the BCL 2 gene and the immunoglobulin heavy
chain locus and is present in 70- 95% of cases leading to upregulation of the anti-apoptotic BCL-2 gene.
Morphological Clues: * Nodal architecture effaced by neoplastic follicles which may extend into perinodal tissue (best to
examine under very low magnification with reduced illumination).
* Four growth patterns can be found in FL (1) follicular (>75% follicular), follicular and diffuse (25-75%
follicular) and minimally follicular (< 25% follicular) and diffuse (0% follicular).
* Neoplastic follicles usually round but can have irregular contours, mostly arranged back to back, vary in
size but usually smaller than reactive follicles. Often poorly demarcated and vague and have attenuated
or absent mantle zones. These follicles lack the polarization typically seen in reactive follicles, tingible
body macrophages absent or very sparse
* Interfollicular spread by neoplastic cells are common and does not constitute a diffuse pattern. A diffuse
area is defined as an area of the tissue completely lacking follicles defined by CD21+/CD23+ FDC.
* Some sclerosis may be present in perinodal tissue or areas of diffuse growth.
* Cytologically composed of two types of B-cells, centrocytes- small to medium sized with angulated or
cleaved nuclei, inconspicuous nucleoli and scant cytoplasm. Centroblast large cells with usually round
or oval, occasional indented nuclei, vesicular chromatin, 1-3 peripheral nucleoli and narrow rim of
cytoplasm
FL is graded on the proportion of centroblasts present and the WHO classification describes three grades based on counting the
absolute number of centroblasts present per 40 x high-power microscopic field/hpf. It is recognised that distinction between
grades 1 and 2 is not clinically useful and the use of a Grade 1-2 (low grade) category is encouraged.
Grade 1 cases have 0-5 centroblasts/hpf
Grade 2 cases have 6-15 centroblasts/hpf
Grade 3 cases have >15 centroblasts/hpf
Grade 3A centrocytes still present
Grade 3B solid sheets of centroblasts
Diffuse areas containing >15 centroblasts/hpf are reported as DLBCL with follicular lymphoma ( Grade 1-2, Grade3A or Grade
3B)
A diagnosis of diffuse FL may be made when lymphoma is composed of cells resembling centrocytes, with a minor component
of centroblasts and an entirely diffuse pattern; both small and large cells must have the immunophenotype of germinal centre
cells or presence of classical t(14;18) should be demonstrated.
Morphological Variants ;
o FL with monocytoid B-cell component: Approximately 9% of follicular lymphomas are accompanied by a
prominent component of neoplastic monocytoid B cells, which are typically distributed as collars around the
neoplastic follicles( composite lymphoma). May be associated with advanced stage disease.
o Signet ring cell type: Some follicular lymphomas are composed partly or entirely of signet-ring cells with the nuclei
displaced to one side by a clear vacuole or eosinophilic PAS-positive globule (Russell body type). The clear vacuoles
often stain for Ig (usually IgG) in the rim. The eosinophilic globules usually stain for IgM,
o FL with rosettes: The rosettes are formed by neoplastic lymphocytes arranged around eosinophilic fibrillary material.
Since the fibrillary material represents entangled cytoplasmic processes, it stains with the various B-lineage markers.
o Floral Variant: When the mantle zone small lymphocytes show prominent inward extension into the neoplastic
germinal centers, the pattern can mimic progressive transformation of germinal centers or N-LPHL. The absence of
reactive follicles in the background, the cytologic composition, and involvement of the perinodal tissues favor a
diagnosis of follicular lymphoma, but immunohistochemical studies may be required to confirm the diagnosis.
o Reverse Variant: Rare follicular lymphomas show reversal of the normal "zonation", with the centers of the follicles
being composed mostly of dark-staining small cells and the rims composed of paler larger cells. This variant may be
mistaken for N-LPHL.
o FL with plasmacytic differentiation: In some follicular lymphomas, a plasma cell population staining for the same
Ig chain as the neoplastic follicles is present in the interfollicular areas or within the follicles. Some such cases are
associated with paraproteinemia. In rare cases, the neoplastic folliclesare composed exclusively of plasma cells
("follicular plasmacytoma").
o Castlemans disease like variant: The neoplastic follicles may rarely be associated with penetrating hyalinised
vessels, mimicking hyaline-vascular Castleman's disease.
o Pediatric FL: Have many features indistinguishable from adults, but demonstrate an increased proportion that are
localised, lack bcl2 protein expression and t(14;18) and are grade 3. Also tend to have large expansile follicles but
good prognosis.
o Intrafollicular neoplasia/in situ FL: Cases occur in which architecturally normal appearing lymph nodes and other
lymphoid tissues have one or more follicles that demonstrate bcl2 overexpressing centrocytes and centroblasts with or
without a monomorphic cytological appearance suggestive of FL. This phenomenon cannot be recognised without
bcl2 staining and the pathology report should indicate that the significance of the finding is unknown and the clinical
evaluation for evidence of overt FL elsewhere is suggested.
Immunophenotype: B-lineage markers are positive ( CD19,CD20, CD22,CD79a). The usual Ig is IgM type. Also bcl2+, bcl6+,
CD10+, CD5-, CD43-, Cyclin D1-. The normal follicular center Bcells are bcl2- while neoplastic follicles, bcl2 express in 85%
of cases. Meshworks of FDC are present in follicular areas but sparse than normal follicles so variably express CD21 and CD23
so both antibodies needed to detect FDC networks. The interfollicular tissue is rich in T cells but when dominated by B-cells
indicative of involvement by FL. Ki67 index usually lower.

Differential Diagnosis:
o Reactive follicular hyperplasia: Follicles in reactive follicular hyperplasia are discrete, well separated, well defined
mantles, follicles exhibit heterogenous population of cells with typically interspersed tingible body macrophages and
cellular polarization into light and dark zones and bcl2-.
o Mantle cell lymphoma with nodular growth pattern: MCL should be seriously considered if the cytologic
composition is monomorphic or IHC can be used.
o Nodal marginal zone B- cell lymphoma with follicular colonization
o N-LPHL: All the large lymphoid nodules are abnormal and lack germinal centers. Nodules are crowded and L&H
cells can be found. The mottled appearance produced by interspersed pink-staining histiocytes is characterstic feature,
if present
o Lymphoblastic lymphoma with nodular growth: Nodules are not genuine follicles but large collections of
neoplastic cells with a fibrous framework or blood vessels stretched around them.
o PTCL with a nodular growth pattern: IHC can help
o Progressive transformation of germinal centers(PTGC): Recognised readily by large dark staining follicles
interspersed among closely reactive follicles. These follicles rich in small lymphocytes but may contain residual
germinal centers.
o C-HL( nodular sclerosis and nodular subtype of lymphocyte rich): neoplastic cells are CD30+,CD15+ and
presence of RS cells.


5. Nodal Marginal Zone Lymphoma
Nodal Marginal Zone Lymphoma is a primary nodal B-cell neoplasm that morphologically resembles lymph nodes involved
by marginal zone lymphoma of extranodal or splenic types, but without evidence of extranodal or splenic disease. Monocytoid
B-cells may be prominent. The disease is rare, comprising <2% of lymphoid neoplasms. Before a firm diagnosis of nodal
marginal zone B-cell lymphoma is made, metastasis from occult or prior extranodal marginal zone B-cell lymphoma should
always be excluded.
In around 20% of cases, the neoplasm can transform into a DLBCL, when the prognosis is worsened.
Patients present with localised (rare) or generalised lymph node involvement. Blood involvement is rare.
Morphological Clues: *Node shows incomplete architectural effacement with reactive lymphoid follicles with well preserved
mantles are almost always scattered in the background. The marginal zone, sinuses, perifollicular region
and interfollicular areas of the lymph node are infiltrated by marginal zone (centrocyte-like) B cells,
monocytoid B-cells, or small B-lymphocytes, with scattered centroblast and immunoblast-like cells
present
* Plasma cell differentiation may be prominent and the differential diagnosis with lymphoplasmacytic
lymphoma or even nodal plasmacytoma may be difficult.
* The presence of remnants of follicular dendritic meshworks suggestive of colonized follicles would
favour the diagnosis of nodal MZL.
Variant: Nodal Marginal zone B-cell lymphoma of splenic type In 17% cases, morphology and immunophenotyping
resemble splenic marginal zone B-cell lymphoma. These are adult patients with lymphadenopathy alone. Survival is favourable.
Immunophenotype: Pan B-cell markers are positive with CD43+ in 50% cases. CD5-,CD23-CD10-,bcl6- and Cyclin D1-.
Bcl2+ in most of the cases. IgD is positive in minority of cases. Tumors mimicking splenic MZL is IgD positive.
Differential Diagnosis:
o Hairy cell leukemia: There is cytologic overlap with hairy cell leukemia, but the clinical setting is totally different.
o Monocytoid B-cell hyperplasia: A variety of reactive lymphoid hyperplasias may be associated with prominence of
monocytoid B cells. The monocytoid B cells are confined to the sinuses and perifollicular zone, and there should not
be obliteration of the normal nodal architecture. The presence of large confluent sheets of monocytoid B cells favors a
diagnosis of neoplasia. Neoplastic monocytoid B cells are more likely to show greater nuclear irregularities, higher
mitotic rate, and more nucleolated forms. In difficult cases, demonstration of light chain restriction, bcl-2
immunoreactivity, or genotypic studies will confirm the diagnosis of lymphoma.
o Systemic mastocytosis: Mast cell disease can mimic extranodal marginal zone B-cell lymphoma by virtue of the
clear cytoplasm and patchy nodal involvement. The presence of sclerosis and eosinophils should raise the possibility
of mastocytosis.
o Peripheral T-cell lymphoma: Clear cells occur commonly in peripheral T -cell lymphomas, and
immunohistochemical studies are required for distinction.

6. Diffuse Large B-cell Lymphoma
Diffuse large B-cel lymphoma is an aggressive, rapidly growing neoplasm composed of lymphoid cells with nuclei comparable
in size to or larger than those of reactive histiocytes. DLBCL accounts for about 30% of cases of non-Hodgkin Lymphoma. The
median age of diagnosis is 64 years with an equal sex ratio
DLBCL can present with nodal or extranodal disease, with up to 40% of cases presenting with extranodal disease. The most
common extranodal site is the gastrointestinal tract (mainly stomach and ileocaecal region) but the disease can present at
virtually any location including skin, central nervous system (CNS), bone, testis, soft tissue, salivary gland, female genital
tract, lung, kidney, liver, Waldeyers ring and spleen.
Primary presentation with bone marrow or peripheral blood involvement is rare. Transformed DLBCL following an indolent
lymphoma such as chronic lymphocytic leukaemia/ small lymphoctic lymphoma (CLL/SLL), follicular lymphoma, marginal
zone B-cell lymphoma or lymphocyte predominant Hodgkin lymphoma is well described.
Underlying immunodeficiency and auto-immune diseases are significant risk factors and are frequently associated with Epstein-
Barr virus (EBV) positivity.
Morphological Clues: * Lymph node demonstrate a diffuse proliferation of large lymphoid cells that have total or partially
effaced the architecture. Partial nodal involvement may be interfollicular and/or less commonly
sinusoidal, The perinodal tissue is often infiltrated.
*Broad or fine strands of sclerosis may be observed. Necrosis is common and the occasional total
infarction may obscure the diagnosis. Some cases may exhibit a starry sky pattern imparted by reactive
histiocytes. Epithelioid cells, histiocytes, plasma cells and eosinophils can be found in the background.
Multinucleated cells resembling RS cells or bizzare cells may be present. Mitotic figures readily found.
Variants: DLBCLs are morphologically diverse including a number of specific subtypes and specific entities and a large number
of cases which are grouped together as DLBCL not otherwise specified (NOS). DLBCL NOS includes the common morphologic
variants centroblastic, immunoblastic and anaplastic. In addition to rare morphologic variants. DLBCL NOS can also be divided
into subgroups based on immunophenotype (CD5+, Germinal centre B cell-like (GCB), non-GCB) or based on gene expression
profile (Germinal center B cell-like (GCB) and activated B cell-like (ABC)) although use of these subgroups
to determine therapy is not currently recommended.
Specific subtypes of DLBCL include T cell/histiocyte rich DLBCL, Primary CNS DLBCL, Primary cutaneous DLBCL (leg type)
and EBV positive DLBCL of the elderly.
Specific DLBCLs with characteristic clinicopathological features include Primary mediastinal large B cell lymphoma,
Intravascular large B cell lymphoma, DLBCL associated with chronic inflammation, Lymphomatoid Granulomatosis, ALK-
positive large B cell lymphoma, Plasmablastic lymphoma, Primary effusion lymphoma and Large B cell lymphoma arising in
HHV-8 associated Castlemans disease.
Centroblastic Variant: Most common variant. Most of the cases, composed entirely >90% of centroblasts.
Immunoblastic Variant: >90% of the cells are immunoblasts with a single centrally located nucleolus and an appreciable
amount of basophilic cytoplasm.
Anapalstic Variant: This variant is characterised by large to very large round, oval or polygonal cells with bizarre pleomorphic
nuclei that may resemble RS cells or anaplastic large cell lymphoma.
Rare cases of DLBCL NOS have a myxoid stroma or a fibrillary matrix. Few cases show pseudo-rosette formation. Occasionally
spindle shaped or signet ring cells also present.
The t(14;18)(q32;q21) occurs in 20-30% of cases. Up to 30% show abnormalities of the 3q27 region involving BCL6.
Microarray studies have shown two major molecular categories of DLBCL with germinal centre (GC) and activated B cell
(ABC) patterns suggestive of malignant transformation at different stages of B-cell development.
Immunophenotype: DLBCL express pan-B markers including CD19, CD20, CD22 and CD 79a. Surface and/or cytoplasmic
immunoglobulin (IgM>IgG>IgA) can be demonstrated in 50-75%. CD30 is expressed in some with anaplastic morphology.
Some cases of DLBCL (<10%) express CD5, most of which represent de novo DLBCL rather than transformation from
CLL/SLL. CD5 +ve DLBCL is cyclin D1 ve, allowing differentiation from blastoid mantle cell lymphoma.
CD10 is expressed in 30-60% of cases, BCL6 in 60-90%, BCL2 in 30-50%, and IRF4/MUM1 in 35-65% of cases (IRF4/MUM1
and BCL6 co-expression may be present). Immunophenotypic subgrouping of DLBCL is based on expression of
CD10/BCL6/IRF4/MUM1. The proliferation fraction, measured by Ki-67 staining is usually high (>40%) and may be greater
than 90% in some cases.
The immunophenotypic profile of GC DLBCL is CD10+ve in >30% cases or CD10-, BCL6+, IRF4/MUM1-and the ABC pattern
is usually CD10-ve, BCL6-ve and BCL2+ve.
Differential Diagnosis:
o Metastatic carcinoma or melanoma: Immunohistochemistry is usually helpful in distinguishing from lymphomas.
o Infectious mononucleosis: the florid immunoblastic proliferation frequently invites an erroneous diagnosis of large
cell lymphoma. Similar, exuberant lymphoid reactions can be seen in other viral infections and hypersensitivity
reactions (e.g. phenytoin). The following clues should raise serious concern for the possibility of infectious
mononucleosis when the initial morphologic impression is that of a large cell lymphoma: young age of the patient,
incomplete effacement of architecture and reactive lymphoid follicles, large activated lymphoid cells generally
lacking definite atypia, large lymphoid cells appearing to show transition to plasmablast and plasma cells.
o Kikuchi's lymphadenitis. Features in favor of this diagnosis over a large cell lymphoma are: occurrence of the
activated cells within circumscribed non-expansile foci in otherwise normal or reactive lymph node tissue; abundance
of karyorrhectic debris; and numerous distinctive phagocytic cells with crescent-shaped nuclei. The cells in the
affected foci represent a mixture of CD3+ cells and CD68+ cells., with very few B cells.
o Burkitt's lymphoma: The following features would favour burkitts lymphoma:- very frequent mitotic figures and
karyorrhectic bodies, squaring off/moulding of the nuclei and cytoplasm, proliferative fraction (Ki67 index) >95%,
CD10 positivity
o Classical HL


7. T cell/histiocyte-rich large B-cell lymphoma
T cell/histiocyte rich large B-cell lymphoma (THRLBCL) is characterised by a limited number of scattered, large, atypical B
cells embedded in a background of abundant T cells (>90%) and frequently histiocytes. It affects mainly middle aged man and
accounts for <10% of all DLBCL. It mainly affects the lymph node but bone marrow, liver and spleen also involved frequently at
diagnosis. It is usually considered an aggressive lymphoma with 5-year survival of only 20%.
Morphologically characterised by isolated or small groups of large lymphoma cells interspersed among sheets of small
lymphocytes. The large cells have round or lobated nuclei and distinct nucleoli and can resemble L&H cells or RS cells. They
should not occur in dense clusters or sheets. They are typically found within clusters of bland-looking non-epitheloid histiocytes
which represent a main and distinctive component of THRLBCL. Eosinophils or plasma cells usually not found. Tcells rossettes
around the tumor cells and remnants of B follicles or clusters of small B lymphocytes are absent.
Immunophenotype: The large atypical cells express Pan B-cell markers and BCL6, variable expression of BCL2 and EMA and
CD15-, CD30- and CD138-. Background is composed of CD68+ histiocytes and CD3+, CD5+ Tcells. There are no FDC
meshworks in the background. EBV is mostly negative
Differential Diagnosis:
o Classical HL, Predominantly diffuse NLPHL- Most difficult to distinguish as marked histology overlap.
Immunohistochemistry is useful. Classical HL is CD15+,CD30+,EMA-, background cells are CD3+ which may form
rossettes around RS cells. The presence of CD20+ large cells within nodules of CD20+ small B cells even if focal, is
diagnostic of N-LPHL. EBV is mostly positive.
o Reactive Immunoblastic Proliferation
o Peripheral T cell Lymphoma

8. ALK+ Large B-cell Lymphoma
ALK+ large B-cell lymphoma is a very rare form of B-cell lymphoma characterized by expression of the ALK protein but
lacking t(2;5) or a variant translocation involving the ALK gene. The patients are adults; there is a marked male predominance.
Patients present with lymph node enlargement, often in multiple sites. Most patients have stage III or IV disease. The clinical
course is aggressive
Morphologically the lymph node architecture is obliterated and there is frequent involvement of the sinusoids. The neoplastic
cells are large, with round vesicular nuclei, central prominent nucleoli, and basophilic cytoplasm with or without a paranuclear
hof.
Immunophenotype: CD45RB+, CD20-, CD79a-, CD3-, EMA+, CD30-, IgA+, suggesting a plasmablastic stage of
differentiation. The ALK immunoreactivity is confined to the cytoplasm, and is due to over-expression of the full-length ALK
protein instead of a chimeric NPM-ALK protein as in ALCL. The Ig genes are rearranged, supporting the B-cell nature of the
neoplasm, and EBV is negative.

9. Plasmablastic Lymphoma
Plasmablastic lymphoma is an uncommon form of large B-cell lymphoma occurring mostly in the setting of AIDS. The tumor is
often limited to the oral cavity and jaw at presentation, although it can spread to distant sites at a later stage. The tumor is highly
aggressive: Plasmablastic lymphoma can also arise in the setting of multicentric Castleman's disease.
Morphologically the diffuse lymphomatous infiltrate is often decorated by tingible-body macrophages, imparting a starry-sky
appearance. The lymphoma cells are large and show a monomorphic cohesive quality. The round to ovoid nuclei are
eccentrically placed and vesicular, with single central large nucleoli or several peripherally located nucleoli. The cytoplasm is
abundant and basophilic to amphophilic, with a prominent paranuclear hof. Apoptosis is prominent, and mitotic activity is brisk.
Immunophenotype: The lymphoma cells usually lack expression of CD45RB, cell surface bilineage markers (such as CD20),
and CD30. CD79a is often focally positive, and cytoplasmic Ig can be demonstrated in some cases. CD138 is positive, while bcl-
6 protein is negative. The Ki-67 index is very high (>90%). For the oral tumors, EBV can be demonstrated in approximately 50%
of cases, and HHV -8 is negative. For plasmablastic lymphoma arising in multicentric Castleman's disease, HHV-8 is positive,
while EBV is negative
Differential Diagnosis: Plasmablastic lymphoma and the plasmablastic type of plasmacytoma/myeloma show many similarities,
but the former is clinically closer to lymphoma than myeloma, is not associated with monoclonal gammopathy.

10. Burkitts Lymphoma
Burkitt lymphoma (BL) is an aggressive lymphoma, which frequently presents at extranodal sites or as acute leukaemia.
Translocation involving MYC is a constant genetic feature and EBV is found in a variable proportion of cases.
The disease is rare with an incidence rate of < 0.2 / 100,000 / year and sporadic BL accounts for 1-2% of lymphomas in Western
Europe and the USA. BL accounts for 30-50% of all childhood lymphomas. The median adult age of onset is 30 years and the
male:female ratio is 2-3:1. Endemic BL occurs in equatorial Africa and Papua New Guinea which corresponds to the distribution
of malaria and has a peak incidence in childhood (4 -7 years). Immunodeficiency associated BL is primarily associated with HIV
infection and is often the AIDS defining illness.
Patients with sporadic BL present with abdominal masses frequently of the ileo-caecal region, a nasopharyngeal mass or
leukaemia. Other presentations include involvement of the ovaries, kidneys and breasts. Retroperitoneal disease may be
associated with spinal epidural compression resulting in paraplegia. Bone marrow involvement in a primarily lymphomatous
presentation is a poor prognostic feature and is found in patients with a high tumour burden. Such patients have a high LDH and
uric acid levels and are at risk of the tumour lysis syndrome.
Morphologically classical BL is composed of medium sized cells, with round nuclei, clumped chromatin and numerous nucleoli.
The cytoplasm is deeply basophilic and usually contains lipid vacuoles. The cells appear to be cohesive but sometimes exhibit
squared-off borders of retracted cytoplasm. There is a high proliferation rate with numerous mitotic figures and starry sky
pattern due to the presence of numerous benign macrophages which have ingested apoptotic tumour cells.
Morphological Variant: BL with plasmacytoid differentiation- In some cases, tumor cells exhibit eccentric basophilic
cytoplasm often with a single central nucleolus. It is more common in immunodeficiency states.
Atypical BL: Some cases of BL show greater nuclear pleomorphism and the nucleoli may be more prominent and fewer in
number.
Burkitt lymphoma is defined by translocation of MYC at band q24 to chromosome 14 q32 (t(8;14)) or less commonly to light
chain loci at 2q11 or 22q11 leading to MYC over-expression. In endemic cases the breakpoint on chromosome 14 involves the
heavy chain joining region (early B-cell) whereas in sporadic cases the translocation involves the Ig switch region (later stage B-
cell). EBV genomes can be demonstrated in most endemic cases, 20-40% of immunodeficiency BL and <30% of sporadic BL
Immunophenotype: Tumour cells express membrane IgM with light chain restriction and B-cell associated antigens such as CD
19, 20 and 22. CD10 and BCL6 are also expressed. The cells are negative for CD5, CD23 and BCL2 ( or weakly positive in 20%
cases). A very high growth fraction is observed and nearly 100% of cells are positive for Ki 67. Infiltrating T-cells are rare. The
blast cells of BL presenting as leukaemia have a mature B-cell phenotype with surface Ig, light chain restriction and expression
of CD10, CD19, CD20, CD22 and CD79a, but not TdT.
Differential Diagnosis:
o Lymphoblastic lymphoma: In BL nuclei is usually round but may show nuclear protrusions, prominent nuclear
moulding with squaring of nuclear membrane. Nucleoli is distinct 2-5, definite rim of basophilic to plasmacytoid
cytoplasm with squaring of cytoplasmic membrane. Always B-lineage with Pan B-cell markers positive, CD10+,
bcl6+, Tdt- and very high Ki67 index -100% while LL usually<80%
o Small B-cell lymphoma: In poorly fixed tissue, the burkitt's lymphoma cells appear shrunken and can be mistaken
for lymphoplasmacytic lymphoma or other small cell lymphomas. The young age of the patient is an important clue to
the correct diagnosis.
o Large cell lymphoma. Distinction between atypical burkitts lymphoma and large cell lymphoma can be very
difficult, because the latter may be composed predominantly of medium-sized cells and show a starry-sky pattern. The
following features would favor the former diagnosis:
a) very frequent mitotic figures and karyorrhectic bodies
b) squaring off/moulding of the nuclei and cytoplasm
c) CDl0 positivity.
d) If bcl-2 protein is expressed ,a diagnosis of Burkitt's or atypical burkitt lymphoma is unlikely.

11. B-cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma
and Burkitt Lymphoma
These are aggressive lymphomas that have morphological and genetic features of both DLBCL and BL, but for biological and
clinical reasons should not be included in these categories. Morphologically some cells that are smaller than typical DLBCL,
resembling BL, and some cells that are larger than typical BL, resembling DLBCL as well as high proliferation fraction, starr y
sky pattern and an immunophenotype consistent with BL. Some cases may be morphologically more typical of BL but have an
atypical immunophenotype or genetic features that preclude a diagnosis of BL.
The diagnosis of this type of unclassifiable B-cell lymphoma category should not be made in cases of morphologically typical
DLBCL that have a MYC rearrangement or in otherwise typical BL in which a MYC rearrangement cannot be demonstrated.
More than half of the patients present widespread often extranodal disease. Bone marrow and peripheral blood may be involved.
Immunophenotypically express B-cell markers, CD19, CD20, CD22 and CD79a and typically sIg. cases that morphologically
resemble BL may be placed in this category when bcl2 is moderately to strongly positive. BCL2 positivity in a case that
otherwise might be classified as BL should suggest the possibility of a double hit lymphoma with both MYC and BCL2
translocations. Ki67 index usually high in these cases but can vary between 50-100%.
Clonal Ig gene rearrangements are present. 35-50% of cases have 8q24/MYC translocation but unlike BL many of these are non
IG-MYC translocations. BCL2 translocation is present in up to 15% of cases and may be associated with MYC (double hit)
and/or BCL6 translocations.


COMMON IHC PANELS
Benign versus malignant lymphoid proliferations
Many benign conditions like viral and bacterial infections, HIV, toxoplasmosis, Kikuchis disease, dermatopathic lymphadeniti s, sinus
histiocytosis with and collagen vascular diseases may mimic a hematolymphoid malignancy. The nodes may be large in size and show a
partial effacement of the architecture with a prominent follicular hyperplasia or/and paracortical T zone expansion. Follicular lysis and
progressive transformation of germinal centres may be evident. Immunoblasts may be prominent both in the follicular as well as in
paracortical zones and may react with LCA and CD30 stains. RS cells, unlike immunoblasts are generally LCA negative. Kikuchi s disease
may resemble DLBCL. Following may be of help in certain circumstances (in addition to morphology)
a) Light chain restriction: by doing kappa and lambda light chains. Excess of kappa-positive cells, or more Kappa than Lambda positive
cells, at least exceeding ratio 10:1 ratio (others prefer 18:1), suggests a neoplastic proliferation.

b) Aberrant expression in B cells:
(i) Co-expression of a B-cell (CD20) marker with CD43 or CD5 (T-cell marker): It can be inferred that this is a neoplastic proliferation.
(ii) Expression of cyclin D1 (bcl-1): It supports a diagnosis of mantle cell lymphoma.

c) Aberrant expression in T cells : Cases of T-cell proliferation (CD3+ve) that extensively express markers not normally expressed by T
cells (such as CD56, CD30, ALK1) or show loss of marker such as CD5 are almost certainly lymphomas. T-cell proliferation that exhibits a
CD4+ CD8+ or CD4- CD8- (double positive or double negative) phenotype is suggestive of NHL.

d) Immature cell phenotype : Large number of lymphoid cells that expressing TdT or CD1a, whether of B or T cell lineage, is indicative
of precursor LL.

e) Sheets of B cells : In nodal and extranodal sites with diffuse small lymphocytic proliferation, presence of diffuse sheets of B cells
(CD20+) suggests a diagnosis of lymphoma.

f) CD10 & bcl-2 expression : is studied for nodular growth patterns and to differentiate Burkitt from DLBCL. BL is CD10+, bcl-2 negative
and Ki67 >95%.

g) CD23 stain : if uncertain as to whether there are neoplastic follicles (subtle follicles or nodules of lymphoid cells) to highlight FDC,
depicting the follicular framework. To differentiate angioimmunoblastic T-cell lymphoma from PTCL (NOS), CD23 demonstrates the FDCs
that occur outside the follicles

h) CD99 (Mic2) : stains lymphoblastic lymphoma, PNET & mesenchymal chondrosarcoma.
i) LCA negative lymphoma : particularly lymphoblastic, plasmablastic, ALCL, PTCL, classical HD and plasma cell neoplasms (even
CD20 negative).


LARGE/INTERMEDIATE CELL MORPHOLOGY ON H&E

LCA BCL2 To provide additional prognostic/
CD20 BCL6 therapeutic information
CD3 CD10
CD5 + Cyclin D1 ( To exclude Blastic Mantle Cell Lymphoma) IRF4/MUM1
CD30
Ki67
TdT

LCA +
CD20 +
CD79a ------------Profile of DLBCL
CD3 -
CD30 -
CD5 -

If CD20+/CD79a+ but proliferative index (Ki67) is high >90%
Consider BURKITT (look for starry sky pattern and BCL2 neg)
Or Intermediate BL/DLBCL. Confirm with molecular testing
For MYC, BCL2, BCL6

If CD20- then do CD79a and CD 138
If CD79a + then consider myeloma ( CD138+) or Myeloid neoplasms ( MPO,CAE)

If LCA-
Consider ALCL (CD30+, ALK+) or non-lymphoid malignancy

If CD20-, CD79a-, CD3+
Consider T-cell Lymphoma, do CD30 and ALK1, CD4, CD8

Potential diagnostic pitfalls for large/intermediate cell morphology
Non-lymphoid malignancy
Germ Cell tumour Carcinoma Melanoma Sarcoma

SMALL CELL MORPHOLOGY ON H&E

a) Nodular/Follicular pattern with small cell morphology b) Nodular/follicular pattern with larger cells or
Follicular Lymphoma atypical morphology consider-
Mantle Cell Lymphoma NLPHL, Lymphocytic rich HL, Nodular Scleosis HL
Marginal Zone Lymphoma
SLL/CLL

Morphology: Small lymphoid cells
1. Benign vs malignant
*Immunoglobulin light chains (kappa and lambda)
*Bcl2 protein in follicles
Kappa/lambda polyclonal or Bcl2- follicles =Reactive
Kappa/lambda monoclonal or Bcl2+ follicles = Small B-cell lymphoma

2. Classification of Small B-cell Neoplasms
CD5+: CLL/SLL vs mantle cell lymphoma
*Cyclin D1-, dim sIg, CD23+ = CLL/SLL *Cyclin D1+, bright sIg, CD23- = Mantle cell lymphoma

CD5-: Follicular lymphoma vs Marginal zone lymphoma(MALT)
CD10+ = Follicular lymphoma CD10- = Marginal zone lymphoma vs CD10- follicular lymphoma
Bcl6+, CD43-, *Bcl2+ follicles = follicular lymphoma Bcl6-, CD43+, Bcl2- follicles = marginal zone lymphoma




b) Non-nodular/ Diffuse pattern with small cell morphology

Lymphoms sub type Pan B-cell
marker
CD5 CD23 IgD Cyclin D1 BCL6/CD10
B-CLL/SLL + + + +
Mantle Cell Lymphoma + + -* + +
Lymphoplasmacytic
Lymphoma
+ -/+
Extranodal marginal zone
B-cell lymphoma of MALT
type
+ -*
Splenic marginal zone B-cell
Lymphoma
+ +
Follicular center Lymphoma
diffuse, predominantly small
cell
+ +/-* +
* Meshworks of follicular dendritic cells are often highlighted by CD23 antibody





OVERVIEW AND DIFFERENTIAL DIAGNOSIS OF COMMON T-CELL/NK CELL LYMPHOMAS

Peripheral T-cell and NK-cell lymphomas account for 10-30% of all NHLs with the lower percentage being observed in
Caucasian populations and the higher percentage being observed in Oriental populations, especially in Japan and northern
Taiwan, where HTLV-1 is endemic.
No single histologic feature is pathognomonic of peripheral T -cell lymphoma (PTCL) or NK-cell lymphoma, although they
should be suspected when two or more of the following features are observed:
a) Predominant involvement of the paracortical regions of the lymph node
b) Prominent high endothelial venules
c) A spectrum of cell sizes and shapes, including small, intermediate-sized, and large cells
d) Irregular nuclear contour, e.g. multilobation and cerebriform nuclei
e) Many cells with pale to clear cytoplasm although some B-cell lymphomas/leukemias (hairy cell leukemia, nodal marginal
zone B-cell lymphoma, some immunoblastic lymphomas) can also exhibit clear cells
f) The presence of many epithelioid histiocytes and/ or eosinophils
g) Extranodal disease with prominent angiocentric growth and necrosis.
There is a poor understanding of molecular pathogenesis of T-cell lymphomas. Definition of these entities based on clinical
grounds, morphology and immunophenotyping.
A diagnosis of peripheral T-cell or NK cell lymphoma should always be confirmed by immunohistochemical staining.
Peripheral T-cell lymphoma (except anaplastic large cell lymphoma) has a much worse prognosis than diffuse large B-cell
lymphoma, even when stratified by the International Prognostic Index, thus it is important to determine the lineage of a
lymphoma, at least for prognostication purposes.

T-Cell Lymphoma -PRESENTATION PATTERNS

Often leukemic or disseminated
o T-cell prolymphocytic leukemia
o T-cell granular lymphocytic leukemia
o Aggressive NK-cell leukemia
o Adult T-cell lymphoma/leukemia (HTLV1 + )
o HepatosplenicT-cell lymphoma

Extranodal/Cutaneous
o Cutaneous TCL
o Extranodal NK/T-cell lymphoma nasal type
o Enteropathy-type T-cell lymphoma
o Subcutaneous panniculitis-like T-cell lymphoma

Mainly nodal
o Peripheral T-cell lymphoma, unspecified
o Angioimmunoblastic T-cell lymphoma
o Anaplastic large cell lymphoma (systemic)




1) Peripheral T-cell Lymphoma, Not Otherwise Specified

It is a heterogenous category of nodal and extranodal mature T-cell lymphomas, which do not correspond to any of the
specifically defined entities of matue T-cell lymphoma in the current classification.
It comprises approximately 30% pf peripheral T-cell lymphoma with most patients are adults. M:F- 2:1. Clinically mostly
present with peripheral lymph node involvement but any site may be affected with often involvement of bone marrow,
spleen, liver and extranodal tissues ( mainly skin and GIT). Peripheral blood sometimes involved but leukaemic
presentation is unusual. Paraneoplastic features such as eosinophilia, pruritis or rarely hemophagocytic syndrome may be
seen. Highly aggressive tumor with poor response to therapy.
Morphologically: PTCL-NOS exhibit diverse histological appearances. In lymph node, shows paracortical or diffuse
infiltrates with effacement of normal architecture. High endothelial venules are prominent and the lymphoid cells may
show trafficking through them. Reactive elements such as eosinophils, plasma cells, histiocytes and epitheliod histiocytes
are commonly seen.
Cytologically spectrum is very broad from highly polymorphous to monomorphous. Cell size ranging from small to
medium sized to large cells or a mixture of these with irregular, pleomorphic, hyperchromatic or vesicular nuclei,
prominent nucleoli and many mitotic figures. Multinucleated cells and RS like tumor cells are not uncommon. Cytoplasm
can be pale, clear, eosinophillic, amphophillic or basophilic.
Extranodal involvement of skin involves infiltration into the dermis and subcutis producing nodules which undergoes
central ulceration. Epidermotropism, angiocentricity and adenexal involvement sometimes seen.
Variants:
Lymphoepitheliod (Lennert Lymphoma): shows diffuse or rarely interfollicular growth. Cytologically consists
predominantly of small cells with slight nuclear irregularities, confluent clusters of epithelioid histiocytes and some larger,
more atypical proliferating blasts. There can be admixed inflammatory cells and scattered RS like cells ( usually EBV+).
High endothelial venules are not prominent. Mostly neoplastic cells are CD8+. It can transform to large cell lymphoma of
T-lineage.
Follicular: Usually consists of atypical clear cells forming intrafollicular aggregates (mimicking follicular lymphoma),
small nodular aggregates in a background of progressively transformed germinal centres (mimicking NLPHL) or enlarged
perifollicular zones/nodular aggregates surrounding hyperplastic follicles (mimicking nodal marginal zone lymphoma).
T-Zone: Characterised by a perifollicular growth pattern throughout the lymph node. Neoplastic cells are predominantly
small with minimal cytological atypia and can be mistaken for benign paracortical hyperplasia. Cells are CD3+, CD4+ and
may show loss of CD5 or CD7.
Immunophenotype: T-lineage markers are positive, e.g. CD2, CD3. A characteristic feature of many PTCLs (80% of
cases) is an aberrant immunophenotype, i.e. loss of one or more T-cell antigens compared with the normal mature T
lymphocytes. Antigens that are most commonly lost are CD7 and CD5 but loss of CD7 has to be assessed with caution
because CD7 normally stains only a subpopulation of T lymphocytes. PTCL-NOS express CD4 much more commonly than
CD8, but both may be absent or coexpressed.
There may be variable expression of activation markers such as HLA-DR, CD25, CD30, and CD134. CD15 expression can
sometimes be seen in the larger cells. Cytotoxic molecules can be expressed in some cases, a feature that is more commonly
seen in extranodal than nodal cases. Unlike AITL, PTCL-NOS usually lacks a follicular T helper phenotype (CD10+,
BCL6+, PD1+ and CXCL13+) with the exception of follicular/perifollicular variant. Ki67 >70% associated with worse
prognosis.


DISEASE IMMUNOPHENOTYPIC PROFILE
PTCL-NOS CD4>CD8, antigen loss frequent (CD7,CD5,CD4/CD8, CD52), CD30-/+,
CD56-/+, CD10-, BCL6-, CLCX13-, PD1-
Angioimmunoblastic Lymphoma CD4+ or mixed CD4/8, CD10+/-, BCl6+/-, CXCL13+, PD1+, hyperplasia of
FDC, EBV+, C020+ B blasts
Adult T cell leukemia/lymphoma CD4+, CD25 , CD7-, CD30-/+, CDl5-/+, FoxP3+/-
Anaplastic large cell lymphoma CD30+. ALK+/-, EMA+. CD25+, cytotoxic granules+, CD4+/-, CD3-/+,
CD43+
T-cell rich large B-cell lymphoma Large CD20+ blasts in background of CD3+ reactive T cells
T zone hyperplasia Mixed CD4/CD8, intact architecture, variable CD25 and CD30, scattered
CD20+ B cells

2) Angioimmunoblatic Lymphoma

Angioimmunoblastic T-Cell Lymphoma, AILT (formerly AILD) is a peripheral T-cell lymphoma characterised by systemic
symptoms, a polymorphous infiltrate involving lymph nodes, with a prominent proliferation of high endothelial venules and
follicular dendritic cells. It occurs in the middle aged and elderly, with an equal incidence in males and females.
Patients usually present with B symptoms, generalised peripheral lymphadenopathy, hepatosplenomegaly, and frequent
skin rash. The bone marrow is commonly involved. Para-neoplastic manifestations are common and include skin rashes,
autoimmune haemolytic anaemia, hypergammaglobulinaemia, eosinophilia, vasculitis, and haemophagocytosis. The
clinical course is aggressive, with a median survival of less than 3 years. The nearly constant association with EBV virus
has been suggested the possible role of virus in etiology.
T-cell receptor genes are rearranged in 75% of cases. Immunoglobulin gene rearrangement is present in 20-30%,
correlating with clonally expanded EBV+ B cells.
Morphologically: The lymph node architecture is partially effaced, often with perinodal infiltration but sparing of
subcapsular sinuses, regressed follicles are often present.
The paracortex is diffusely infiltrated by a polymorphous population of small to medium-sized lymphocytes, usually with
clear to pale cytoplasm and distinct cell membranes. The lymphocytes show minimal cytological atypia, and this form of
lymphoma may be difficult to distinguish from atypical T-zone hyperplasia.
The clear cells often occur in small clusters and produce a highly characterstic mottled pattern at low to medium
magnification. The abnormal lymphoid cells are admixed with small, reactive lymphocytes, eosinophils, plasma cells and
histiocytes. There is marked proliferation of high endothelial venules and follicular dendritic cell meshworks are often
increased. Increased numbers of B immunoblasts are usually present in the paracortex.
A distinctive feature is the frequent presence of irregularly shaped, hypocellular, pale eosinophilic foci comprising fascicles
and whorls of plump spindly cells with abundant cytoplasm, indistinct cell borders, and oval nuclei and delicate chromatin,
representing extrafollicular proliferation of FDCs.
Immunophenotype: Neoplastic T cells express most pan T-cell antigens such as CD3, CD2 and CD5 and majority show
CD4+ although numerous reactive CD8+ cells also present. Characterstically, tumor cells show CD10+. CXCL13+, PD1+
in 60-100% cases. This phenotype is helpful in distinguishing from atypical paracortical hyperplasia. And other peripheral
T-cell lymphomas.
Follicular dendritic cell meshworks expressing CD21, CD23, CD35 and CNA42 expanded usually surrounding the high
endothelial venules. EBV + may be seen
Differential Diagnosis:
o PTCL-NOS: Features favouring AITL are presence of the distinctive clinical features, very prominent
arborizing venules, lymphoid cells, usually with round rather than irregular nuclei, frequent presence of clear
cells, background rich in plasma cells, eosinophils, irregular meshworks of FDCs occurring outside the follicles
and characterstic immunophenotypic profile as mentioned above
o T cell rich large B-cell lymphoma: There may be appreciable number of interspersed large B cells(CD20+)
raising a differential diagnosis with T cell rich large B cell lymphoma. Appreciation that the more atypical cells
including the clear cells are of T lineage and demonstration of polytypic Ig in the large B-cells permit the correct
diagnosis to be made
o Other peripheral T-cell lymphomas

3) Anaplastic Large Cell Lymphoma (ALCL), ALK- positive

ALCL- ALK+ve is a T cell lymphoma consisting of lymphoid cells that are usually large, abundant cytoplasm and
pleomorphic often horse shoe shaped nuclei and characterised by translocation involving the ALK gene, expression of the
ALK protein and CD30.
ALCL accounts for about 3% of adult NHLs and 10-30% of childhood lymphomas. ALK+ve ALCL is most frequent in the
first 3 decades of life and has a M:F ratio of 6:1. It frequently involves both lymph nodes and extra-nodal sites including the
skin (21%), bone (17%), soft tissue (17%), lung (11%) and liver (8%). Involvement of the CNS and gastrointestinal tract is
rare. Marrow involvement occurs in 10% of cases but this increases to 30% if immunohistochemistry for CD30, EMA and
ALK is used.70% of patients present with stage III or IV disease and most have B symptoms, particularly high fevers.
90% of cases show clonal T cell receptor gene rearrangements. Various ALK translocations are described: the most
common, accounting for >80% of cases, is the t(2;5)(p23;p35) translocation involving the ALK gene and the
nucleophosmin gene on 5q25 resulting in nuclear and cytoplasmic ALK protein expression. ALCL ALK+ patients have
better prognosis than ALCL ALK- patients.
Morphologically: Pathological appearance is variable. Lymph node/tissue architecture may be partly effaced and the
disease typically grows within node sinuses. Morphology is variable, ranging from small cell neoplasms to cases with large
anaplastic nuclei. All cases contain cells with eccentric reniform nuclei with an eosinophillic region near the nuclei known
as hallmark cells although the proportion of these cells present is variable.
Morphologic variants include lympho-histiocytic, small cell, and Hodgkin-like patterns. Other histological patterns
include tumors showing cells with monomorphic rounded nuclei, cases rich in multinucleated giant cells or displaying
sarcomatoid features. Occasionally hypocellular appearance with myxoid or edematous background. Capsular fibrosis and
fibrosis associated with tumor nodules may be seen mimicking metastatic non lymphoid malignancy.
Immunophenotype: Cells are CD30+ve with cell membrane and Golgi region pattern. Most cases are EMA positive. CD2,
CD4, CD5 are positive in 70% of cases. Most cases express T cytotoxic associated antigens including TIA-1, perforin and
granzyme B. CD3, CD8, CD15 are negative in most cases.
ALK protein is positive, most cases demonstrating both nuclear and cytoplasmic expression. Variant expression patterns,
cytoplasmic, nuclear and membranous, exist.
Differential Diagnosis:
o DLBCL with immunoblastic/plasmablastic features: These tumors can express ALK protein may
superficially resemble ALCL. ALK+ due to frequent sinusoidal growth pattern. These lymphomas express EMA
but lack CD30 and show a characterstic cytoplasmic restricted granular staining to the ALK protein.
o Metastatic Carcinoma or Melanoma: The sinusoidal growth pattern of ALCL may lead to mistaken diagnosis
of metastatic cancer. ALCL should always be suspected in young patients, especially if the tumor cells display
abundant amphophillic cytoplasm with a prominent golgi zone. Immunohischemistry can also aid in the
diagnosis.
o Classical HL: CD 15 is usually positive with heterogenous staining for CD20. EMA is usually negative
o True Histiocytic Lymphoma and Malignant Histiocytosis
o Reactive Lymphoid Hyperplasia: Some variants of ALCL can be misdiagnosed as reactive lymphadenopathy
as a result of the paucity of large lymphoma cells. The two most important clues to the correct diagnosis are the
young age of the patients and perivascular cuffs of large cells. These findings should prompt careful
immunohistochemical evaluation.
o Primary Cutaneous CD30+ Lymphoma: The clinical features have to be taken into consideration in the
distinction. If the tumor cells are immunoreactive for ALK, the possibility of primary systemic ALCL with
initial presentation in the skin has to be considered.

4) Anaplastic Large Cell Lymphoma, ALK Negative

It is defined as CD30+ T-cell neoplasm that is not reproducible distinguishable on morphological grounds from ALK
positive ALCL. But lacks ALK protein. Mostly it occurs in adults (40-65years) unlike ALCL ALK+. It involves both
lymph nodes and extranodal tissue although the latter sites are less commonly involved than ALCL ALK+. Most patients
present with advanced stage III to IV disease with peripheral and/or abdominal lymphadenopathy and B symptoms.
Morphologically: Nodal or other tissue architecture is effaced by solid, cohesive sheets of neoplastic cells. When
architecture is preserved, neoplastic cells typically grow within sinuses or within T-cell areas showing cohesive pattern
mimic carcinoma. Sclerosis or eosinophils may occur and raise the suspicion of CHL. Neoplastic cells show similar
morphological spectrum to ALCL ALK+. Although a small cell variant not recognised. Typically shows large ,
pleomorphic cells with prominent nucleoli. Hallmark cells are present variably.
Immunophenotype: Strongly positive for CD30, mostly at the cell membrane and golgi region. Staining should be strong
and of equal intensity in all cells which distinguish it from other PTCL. ALK expression is negative. CD2 and CD3 more
often expressed than CD5 and CD45 almost always expressed. CD4>CD8. Many cases express cytotoxic associated
markers TIA1, granzyme B, Perforin. Minority cases are positive for EMA.
Differential Diagnosis:
o PTCL-NOS: In this the abnormal small to medium sized lymphocytes are often admixed with a
morphologically homogenous neoplastic cell population, and the sheet like or sinus pattern of infiltration typical
of ALCL is absent. CD30 is not stongly and uniformly stained the cells especially in the Golgi region and
membrane region and EMA is not positive
o Classic HL: Staining for PAX5 is useful; in CHL show weak expression in the majority of cases while PAX5
negative in all cases of ALCL. CD15 usually positive and EBV expression positivity also raise the suspicion of
CHL.
o Metastatic Carcinoma




IMMUNOPHENOTYPIC AND GENETIC FEATURES OF COMMON T-CELL NEOPLASMS


Neoplasm CD3(S;C) CD5 CD7 CD4 CD8 CD30 TCR NK
16,56
Cytotoxic
Granules
T-Prolymphocytic
Leukemia
+ - + +/- -/+ - - -
T-Large granular
lymphoproliferative
disease
+ - + - + - +,- +
NK Large granular
lymphoproliferative
disease
- - +,- - +/- - - -,+ +
Extranodal NK/T cell
lymphoma
-;+ - -/+ - - - - NA,+ +
Hepatosplenic T-cell
lymphoma
+ - + - - - >> +,-/+ +
Enteropathy T-cell
lymphoma
+ + + - +/- +/- >> - +
Mycosis Fungoides + + -/+ + - - - -
Cutaneous anaplastic
large cell lymphoma
+ +/- +/- +/- - ++ - -/+
Subcutaneous
panniculitis type T-cell
lymphoma
+ + + - + -/+ > -,+/- +
PTCL-NOS +/- +/- +/- +/- -/+ -/+ > -/+ -/+
Angioimmunoblastic T-
cell lymphoma
+ + + +/- -/+ - - NA
Primary systemic
anaplastic large cell
+/- +/- NA -/+ -/+ ++ - +
lymphoma

Key: + = >90% positive; +/- = > 50% positive; -/+ = < 50% positive; - = < 10% positive; Cytotoxic granule = TIA-1, perforin, and/or
granzyme




ATYPICAL LYMPHOID HYPERPLASIA VERSUS NON HODGKIN LYMPHOMA

1. Florid follicular hyperplasia One of the commonest forms of reactive lymphoid hyperplasia seen in an excised lymph node.
Florid follicular hyperplasia needs to be differentiated from Follicular lymphoma. In-situ Follicular lymphoma is also a recently
described entity that should be diagnosed.
2. Progressive transformation of germinal centres Unknown pathogenesis and may be mistaken for Nodular lymphocyte
predominant Hodgkin lymphoma
3. Infectious mononucleosis and immunoblastic proliferations Often may be florid enough to mimic Large cell lymphoma or
Hodgkin lymphoma. The usual problem is interpreting CD 30 positive cells
4. Castleman disease Its a clinical differential diagnosis. The multicentric Castleman disease may also be mistaken for diffuse
high grade lymphoma.
5. Kikuchi Fujimoto lymphadenopathy the early lymphoproliferative phase of this condition can be a mimic of high grade
NHL.
6. Dermatopathic lymphadenitis Reactive lymphoid hyperplasia usually affecting the paracortex. Should be differentiated from
T cell lymphoma and also from infiltration by Mycosis Fungoides.
7. Infectious causes of lymphadenitis Toxoplasmosis and Granulomatous lymphadenitis may at times be a mimic of neoplasms.
Many lymphomas are associated with epithelioid cell proliferations and a florid granulomatous lesion may mask the neoplasm
altogether.