Pathology of Lymph Nodes

Norman Levy, MD
Big Picture
Aswithotherorgans,lymphnodes,andmoreglobally,the
immunesystem,canbethesiteofinfectious,immuneand
neoplasticdisease,thelattereitherprimaryormetastatic
Theclinicalmanifestationsofdiseasesofthelymphnodesare:
Localenlargement,tenderonnontender,+/_

Compressionofadjacentstructures+/_

Releaseofcytokinesproducing"systemic"symptomsof

fever,weightlossandnightsweats
Infectiousorganismscanstimulatethesameacute,chronicor
granulomatousreactionsinthedraininglymphnodesasthey
characteristicallystimulateatothersites
Big Picture 2
Severaltypesofimmunestimulicancause"reactive"
enlargementoftheentirelymphnode,orselective
expansionofcortical,paracorticalormedullaryregions
Metastatictumorsspreadtothelymphnodesprimarilyvia
lymphaticdrainagefromadjacentsolidorgans
Primaryneoplasmsofthelymphnodesareallmalignant
TheyaredividedintomalignantnonHodgkin's
lymphomas(NHL),andHodgkinlymphoma
Big Picture 3
NHL'saremorecommon,andcanbesimplydividedinto
indolent,orslowgrowingtypes,andaggressivetypes
Malignantlymphomasrepresentclonalmalignanciesin
whichmutationaleventshavecausedthemajorityof
progenycellstofreezeatasinglestageofnormal
lymphocytedifferentiation
Lymphomasfrozenatastageassociatedwithhigh

replication>aggressivelymphomas;
Lymphomasfrozenatstagesassociatedwith

recirculationorfinalfunction>indolentlymphomas
BigPicture4
Thediagnosisofmalignantlymphomasisbasedonthe
microscopicrecognitionofthedominantcytologiccell
type,supplementedbyimmunologicandmolecular
techniques
Thetreatmentandprognosisoflymphomasarebasedon
Thedominantcelltype(andit'sinherentbiologic

behavior),
Theextentofspread(Stage)

Theunderlyinghealthofthepatient

Allofthepreviousstatementsarecomplicatedbythefact
thatindolentlymphomascanfurthermutateand
transformtoaggressivetypes
BigPicture5
Hodgkinlymphomaisalesscommonnodaldisease
whosediagnosisisbasedonthedetectionofa
characteristiccell,theReedSternbergcell,inthe
appropriatehistologicsetting
Thereareseveral(five)histologicsubtypes,butprognosis
isbasedprimarilyonextentofdisease
Hodgkinlymphomaisamorecurablediseasethannon
Hodgkinlymphomas
Nowwatchmeconfusethisrelativelystraightforward
informationwiththedetails.
Overviewofthelymphoid
immunesystem
Lymphocytesevolvefrompluripotentstemcells>two
majorfunctionalcelltypes:
Blymphocytes,comprisingthehumoralimmune>

productionofantibodies
Tlymphocytes,comprisingthecellularimmune

system,>
Directkillingofforeignorintracellularlyinfected
cells,cytotoxicTcells
Finecontroloftheimmuneresponsethroughthe
secretionofcytokines,helperandsuppressorT
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 histology
 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
The sites of B cell homing include: lymphoid immune response.
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
Normallymphocytesrecirculate,passingfromblood>
lymphnodes>efferentlymphatics
Allowsconstantsurveillanceforthepresenceofthe

antigenforwhichthelymphocytehasauniqueand
specificreceptoronit'ssurface.
Ifantigennotpresent,lymphocytesleavethenodeand
recirculate
Virginlymphocyteshaveafinitelifespan,numberedin
weeks,unlesstheycomeincontactwithantigen
Cytologyofthelymphnode
Thenormalorreactivelymphnodeisthusadynamicorgan
Composedof
TransientBandTlymphocytes

Antigenprocessingandpresentingcells

ReplicatingBandTlymphocytes(inresponsetoantigen)

Persistentandtransientfinaleffectorcells

Macrophages

Someofthesefunctionalsubgroupsarecytologicallyunique,others
cytologicallyindistinguishable
Theultimatemicroscopicimpression,withpractice,isoneof
cytologicheterogeneity,andhistologicorganization
 CelltypesI
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. Locations:
Can be T or B cell, virgin
B cells- primary follicles,
(unexposed to antigen) or
differentiated effector/memory cell. mantle zone of secondary
follicles, medullary cords
Most likely lineage, B or T, guessed
by location within the node, but T cells- paracortex, minor
lineage and state of differentiation population within germinal
must be confirmed by center.
immunologic/molecular techniques Kinetically, clumped
chromatin tells us that the cell is
not proliferating- not activated
to enter the cell cycle and
replicate
 Celltypes2:Follicular(germinal)
centercells
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.
Reactive germinal center
MZ

LZ

DZ
 Cytologyoflymphnode3
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
Pathologyoflymphnodes1
Infections
Reactivehyperplasias
Sarcoidosis
Metastatictumors
Malignantlymphomas
NonHodgkinslymphomaNHL
Hodgkinslymphoma
Pathologyoflymphnodes2
Infections
Bacterial

Acuteinflammation,abscessformation
Granulomatous,caseousandnoncaseous
Diagnosisbyculture,serologies,and/orspecialstains
Reactivehyperplasias
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
Malignantlymphomas
(NonHodgkin'slymphomasNHLs)
Malignanciesofthelymphoidsystemwhichprimarily
manifestthemselvesoutsidethebonemarrow,atthesites
ofnormallymphoidhoming
Lymphnodes

Spleen

M.A.L.T.

Anywhere

(Lymphomasoutsidelymphnodesandspleenare
referredtoasextranodallymphomas)
Approximately40,000casesperyear,20,000deaths
Clinicalpresentation
Enlargingmass(es),typicallypainless,atsitesofnodaltissue
Compression,infiltrationofholloworgans
Pain,obstruction,perforation
Interferencewithnormalorganfunction
Solidorganinfiltrationkidneys,liver,bonemarrow
Systemicsymptoms
Fever
Nightsweats
Weightloss
Ifmarrowinfiltrated,canhaveleukemiccomponent
NHL2
Composedofcellsthathavelosttheabilitytopursuethefull
rangeoflymphoiddifferentiation,andarefrozenatasingle
stageofthenormalmaturation/differentiationsequence
Recapitulatethebiologyandimmunophenotypeofnormalcell
counterpart
Severalcytologicallyandimmunologicallyrecognizablestagesof
normallymphoidmaturation>severalsubtypesoflymphoma
Clonalmalignancies,derivedfromasinglecellthathas
undergoneamalignanttransformation,mutation
Bestinitiallyconceptualizedastwomajorclinicaltypes
Indolentlymphomas

Aggressivelymphomas
NHL 3 Indolent lymphomas
Lymphomasfrozenatstagesnotnormallyreplicating,but
maybecirculating
Diseasesofslowaccumulation,duetodefectiveapoptosis
Oftenwidespreadatdiagnosis
Prolongednaturalhistory,mediansurvivals>5years
Willusuallyrespondtochemoorradiationtherapy
Willusuallyrelapse,butrespondtosameoralternativetx
Currentlyincurableunless
Localizeddiseaseor

Marrowablationwithsometypeofstemcelltransplant

Classificationofindolentlymphomaslater
Aggressivelymphomas
Lymphomasfrozenatstagescharacterizedbyreplicationand
acceleratedgrowth
Diseasesofdefectivecellcyclecontrol
Moreoftenlocalizedatpresentationthanindolentlymphomas
Moreoftenextranodal
Shorternaturalhistory;mediansurvival</=2years
Requiremoreaggressivetherapytoachieve"clinicalremission"
disappearanceofalldetectabledisease
Despiteshortnaturalhistory,curablediseaseinsomewith
aggressivetherapy
Approximately3040%ofadults

5080%children

Allchildhoodlymphomasofthistype
Classificationoflymphomas
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
 WorkingFormulationfor
ClinicalUsage
From19821994,theclassificationused
intheUnitedStates
Basedon:
Theobservedclinicalhistoryof
1200patientsclassifiedaccordingto
theterminologytoright
Microsopicexaminationalone,
utilizing
Lossofnormalnodal
architecture
Thedominantcytologiccell
typeobservedunderthe
microscope
Presenceorabsenceof
"follicularity"mimickingof
normallymphoidfollicle
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.)
 WorkingFormulation
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.
REAL/WHOclassification
backbone
Bcellneoplasms
PrecursorBcellsrelatedtoacuteleukemia
PeripheralBcelllymphomasthemajorityofB
celllymphomas
TcellandNaturalKillercellneoplasms
PrecursorTcells
PeripheralTcellandNKneoplasms
Hodgkinslymphoma
Frequency of lymphomas
Indolent versus aggressive
Indolent Aggressive
Small lymphocytic lymphoma/CLL
Follicular lymphoma, Grades 1/2
Prolymphocytic
Extranodal Marginal zone leukemia
lymphoma of MALT type
Nodal marginal zone lymphoma
Large B cell lymphoma
Splenic marginal zone lymphoma Burkitt lymphoma
Hairy cell leukemia
Lymphoplasmacytic lymphoma
Mantle cell lymphoma
Plasma cell myeloma Anaplastic large cell
Plasmacytoma lymphoma
Cutaneous T cell lymphoma
Cutaneous CD30+ anaplastic large
All peripheral T cell
cell lymphoma lymphomas

Divides B and T
BcellneoplasmsPrecursorB
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)
 PeripheralBcelllymphomas
Lymphomas frozen at various stages of antigen dependent B cell maturation and
differentiation
PeripheralBcellneoplasms
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 zone Small lymphocytic
Lymphoma Lymphoma lymphoma/CLL
(Grade I)
Frequency (% 22% 8 7
all lymphomas
Age of onset 59 61 65
median
Stage at Stage III/IV 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 site Nodal Extranodal Marrow/nodal

presentation
Pattern of nodal Follicular Diffuse Diffuse
Infiltration
Benign cell Germinal Marginal zone Virgin B cell
Equivalent center Lymphocyte
small cleaved
cell
Dominant cell Small cleaved Mix of small Small
type cell in most lymphocytes, lymphocytes
cases, but can plasma cells with round
be large cell nucleus
Immunopheno 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 12
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'slymphoma
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
Mantlecelllymphoma
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
Follicularlymphoma Mantlecelllymphoma

CyclinD1

Bcl2
 Table X: Indolent B cell lymphomas
Follicular Marginal zone Small lymphocytic Mantle cell
Lymphoma Lymphoma lymphoma/CLL Lymphoma
(Grade I)
Frequency (% 22% 8 7 6
all lymphomas
Age of onset 59 61 65 63
median
Stage at Stage III/IV 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 site Nodal Extranodal Marrow/nodal Nodal

presentation
Pattern of nodal Follicular Diffuse Diffuse Diffuse,
Infiltration nodular
or
mantle zone
Benign cell Germinal Marginal zone Virgin B cell Mantle cell
Equivalent center Lymphocyte
small cleaved
cell
Dominant cell Small cleaved Mix of small Small Small cell
type cell in most lymphocytes, lymphocytes with irregular
cases, but can plasma cells with round nucleus,
be large cell nucleus similar to
cleaved
Immunopheno 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 12 t(11;14)
Pathogenesis Bcl2/JH Bcl1/JH
 TcelllymphomasPrecursorT
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
 TcelllymphomasPrecursorT
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
PeripheralTcelllymphomas
Predominantly Predominantly extranodal
leukemic/disseminated
Mycosis fungoides
T-cell prolymphocytic leukemia
T-cell large granular lymphocytic
Sezary syndrome
(LGL) leukemia Primary cutaneous CD30+ T-
NK cell leukemia cell lymphoproliferative
Adult T-cell leukemia/lymphoma disorders
Subcutaneous panniculitis-like
Predominantly nodal T-cell lymphoma
Angioimmunoblastic T-cell NK/T cell lymphoma, nasal
lymphoma and nasal-type
Peripheral T-cell lymphoma Enteropathy-type intestinal T-
unspecified cell lymphoma
Anaplastic large cell lymphoma, Hepatosplenic T-cell
T/null-cell lymphoma
 KeypointsregardingTcell
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
Ancillarydiagnosticstudies
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

Normallymphoidmaturation
Requires two major activities B cells
The production of a unique Immunoglobulin receptor
antigenic receptor on it's composed of two heavy and
surface two light chains
Select specific heavy
The expression of several
chain antigen recognition
surface proteins necessary for sequence
antigen recognition, cell
Select only one of two
activation, cell-cell light chains, kappa or
communication. lambda
Antigen receptors are T cells
generated through the process Select one of two
of "genetic rearrangement"- the heterodimeric receptors
random selection and Alpha/Beta heterodimer T
juxtaposition of discontinuous cell receptor
genetic segments encoding the Gamma/Delta
antigen receptor genes heterodimer T cell
receptor
Normallymphoidmaturation
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
ImmunologicTechniques
Flowcytometryautomatedfluorescentmicroscopy
Immunohistochemistryinsitudetectionthroughtheuseof
enzymesubstratecolordeposition
Examples
Bcellsmalllymphocyticlymphoma

Monoclonallightchain,CD19,CD20,CD5,CD23
positive,CD10negative
Bcellfollicularlymphoma

Monoclonallightchain,CD19,CD20,CD10
positive,CD5negative
Moleculartechniques
Detectionofantigenreceptorclonality
Detectionofuniquecytogenetic
rearrangements/translocations
Examples
ClonalgenerearrangementbySouthernblot
Bcl2/JHrearrangementbypolymerasechain
reaction
Clinicalpresentation
Enlargingmass(es),typicallypainless,atsitesofnodal
tissue
Obstruction,ulcerationofholloworganspain,perforation
Interferencewithnormalorganfunction
Solidorganinfiltrationkidneys,liver,bonemarrow
Systemicsymptoms
Fever
Nightsweats
Weightloss
Ifmarrowinfiltrated,canhaveleukemiccomponent
Clinicalstagingoflymphomas
Definesextentofdisease;determinestherapyandprognosis
Basedonphysical,radiologicexamination,bonemarrowbiopsyand
aspiration
AnnArborStagingsystem
Bsymptomsfever,weightloss>10%bodyweight,nightsweats
Stagingtable
Prognosis
Internationalprognosticindex
Aggressivelymphomas
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
Survival curves
 TherapyIIndolentlymphomas
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
Disseminated indolent/low grade lymphomas (90%) High dose chemotherapy and
No therapy allogeneic transplantation
Low morbidity limited chemotherapy High dose chemotherapy and
Older patients autologous peripheral stem cell
No expectation of cure collection/reinfusion
Most will respond totally or partially, with months to Increased morbidity
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
TherapyIIAggressive
lymphoma
Limiteddiseaselocalizeddiseasetreatedwithirradiationplus
limitedcyclesmultiagentchemotherapy
Moreextensivediseasewithmorecyclesmultiagent(>/=4drugs)
chemotherapy
Completeremissionrates6080%

3040%cured

Newertherapiesandtheirrolesstillbeingestablished
Bonemarrowtransplantation

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
AncillaryimmunologicstudiesassistthedxofHodgkins'lymphoma
DistinguishHLfrom
Immunoblastreactions

UnusualvariantsofNHL

CD15andCD30antigensingolgiandoncellmembraneofRScells
mostuseful
Patternsofspread
Hodgkin'slymphomaspreadscontiguouslyvia
lymphatics
StagingasinNHLmayormaynotinclude
laparotomy/splenectomy
Therapy
Limitedstage,lowbulkdiseasetreatedwithradiation
therapy
Higherstage,Bsymptoms(IIBIV)treatedwithmulti
agentchemotherapy+/radiationtherapy
Complicationsoftherapy
Radiationeffectstolungs,heart,bonemarrow

Sterility

Splenectomyassociatedsepsis

Therapyassociatedsecondmalignancies
Prognosis
Hodgkin'slymphomaisacurablemalignancy
Overallcurerateapproximately80%
Withmoderntherapy,prognosisbasedmoreon
staging,bulkofdisease,thanmorphologicsubtype
Nottrueinearlierera,whereprognosisdecreased
withnumberoflymphocytes;lymphdepletedHL
hadaterribleprognosis
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
The End!
Additional figures
Reed Sternberg cells
Large cells