A pattern based approach to

nodal lymphoma : The critical role

of histology

G. Swarnalata
Senior Consultant Pathologist
Apollo Hospitals, Jubilee Hills,
Hyderabad
E mail: swarnalata@apollohospitals.com
WHO classification of lymphoma (2001)
Non- Hodgkin lymphoma
 B cell  T cell and NK cell
Precursor B cell
Precursor T cell
Mature B cell
B cell proliferation of uncertain
Peripheral T and NK cell
malignant potential T cell proliferation of
 Hodgkin lymphoma uncertain malignant potential
Nodular lymphocyte predominant
Classical Hodgkins lymphoma
Nodular lymphocyte rich
Nodular sclerosis
Mixed cellularity
Lymphocyte depleted
 Histiocytic and dendritic cell neoplasms
 Mastocytosis
B cell non-Hodgkin lymphoma
 Precursor B cell neoplasms

Lymphoblastic
 Mature B cell neoplasms

Chronic lymphocytic leukemia/ small lymphocytic lymphoma

B- prolymphocytic leukemia
Lymphoplasmacytic lymphoma
Mantle cell lymphoma
Follicular lymphoma
Splenic marginal zone lymphoma
Marginal zone lymphoma
Hairy cell leukemia
Diffuse large cell lymphoma
Mediastinal large B-cell lymphoma
Intravascular large B-cell lymphoma
Primary effusion lymphoma
Burkitt’s lymphoma
Plasmacytoma/ plasma cell myeloma
Solitary plasmacytoma of bone
Analysis of nodal lymphoma
1994 – 2008 : 692 cases

Apollo Hospitals, Jubilee Hills, Hyderabad

Analysis of nodal lymphoma
1994 – 2008 : 692 cases
 Scope of the symposium
Common lymphomas
Approach to diagnosis
Histology
Immunohistochemistry
Topics not covered
Uncommon lymphomas
Extranodal lymphoma
Variant patterns of the common lymphomas
Cytogenetics
Molecular studies
Limitations of IHC
 Indolent Aggressive Highly
lymphoma lymphoma aggressive
“the good “the bad” lymphoma
“the bad”

Entities Follicular Diffuse large B Burkitt’s

lymphoma cell lymphoma
CLL/SLL Peripheral T Lymphoblastic
Marginal zone cell

Age group Older adults Any age Children and

young adults

Rate of growth Slow; waxing Fast Very fast

and waning

Stage at Usually high Evenly Usually high

presentation stage distributed stage
through the
stages
 Indolent Aggressive Highly
lymphoma lymphoma aggressive
“the good “the bad” lymphoma
“the bad”

Natural history if Indolent course Kills in 1 to 2 Kills in weeks to

untreated years months

Response to Often not Potentially Highly

treatment curable curable responsive to
aggressive
chemotherapy
Clinical outcome Repeated 70 to 80% Cure in early
relapses complete stage disease
remission

Survival curve
Approach to lymphomas
Nodular / diffuse

Small lymphocytic
Medium lymphocytic or blastoid
Large lymphocytic
Mixed small and large
Reactive follicular hyperplasia versus
follicular lymphoma
Discrete separated follicles
Variable in size and shape
Well defined mantles
Follicular lymphoma
Back-to back arrangement of follicles
Mantles lacking
Follicles in perinodal tissue
Reactive hyperplasia
Heterogeneous
population
Tingible body
macrophages
Polarisation
Follicular lymphoma
Predominantly
centrocytes
Lack of tingible
body macrophages
Loss of polarisation
Grade 1 Grade 2 Grade 3
<5/hpf 5 -15/hpf >15/hpf
Grading of follicular lymphoma
Number of centoblasts per high power field
At least 20 fields of neoplastic follicles counted
 Nodular growth pattern in
lymphomas

Follicular lymphoma
Mantle cell lymphoma
Extranodal marginal zone lymphoma
Nodular lymphocyte predominant Hodgkins
Classic Hodgkins
Lymphoblastic lymphoma
Mantle cell lymphoma
Mantle zone pattern
Mantle cell nodular
Diffuse
Starry sky
 Small to medium
sized
 Slight/ moderate
nuclear irregularities
 Open nuclear
chromatin
 Small inconspicuous
nucleoli
 Scant cytoplasm
 Prominent mitoses
Starry sky pattern in mantle cell lymphoma
Marginal zone lymphoma
Small to medium
sized
Irregular necleoli
Absent nucleoli
Pale nucleoli
 Diffuse small cell lymphoma

B-CLL/SLL
Mantle cell lymphoma
Marginal zone lymphoma
Small lymphocytic lymphoma
Dark staining infiltrate punctuated
by pale proliferation centres
‘Follicular’ pattern in small
lymphocytic lymphoma
Proilferation centres or pseudofollicles

Small lymphocytes,
prolymphocytes and
paraimmunoblasts
Follicular Mantle cell

Small lymphocytic
Medium sized/ blastoid
lymphomas

Lymphoblastic lymphoma
Burkitt’s lymphoma
Blastoid mantle cell lymphoma
Blastic NK cell lymphoma
Lymphoblastic lymphoma
Burkitt’s lymphoma
Round to convoluted nuclei Multiple distinct nucleoli
Delicate chromatin Moderate deeply basophilic cytoplasm
Inconspicuous nucleoli
Scant cytoplasm
 Diffuse large cell proliferations

Lymphoma
Diffuse large B cell ( DLBCL)
Anaplastic large cell (ALCL)
Classic Hodgkin, syncytial variant
Classic Hodgkin, lymphocyte depleted
Peripheral T cell
Metastatic carcinoma
Metastaic melanoma
Metastatic sarcoma
Diffuse large cell lymphoma
Non cohesive
Nuclear moulding
Nuclear streaming
Nuclear membrane
folding
Cytoplasm
basophilic/amphop
hilic
Immunoblastic lymphoma Plasmablastic lymphoma
Anaplastic large cell
T cell rich B cell
Metastatic carcinoma

Cohesive islands of
tumour
Sharp boundary with
stroma
Metastatic signet cell carcinoma Metastatic poorly differentiated carcinoma
Metastatic melanoma

Cohesively non
cohesive
Individual cells
falling off within
islands
Peripheral T cell lymphoma
Pointers to a peripheral T
cell lymphoma

 Paracortical expansion
 Prominent high
endothelial venules
 Mixed inflammatory
infiltrate
 Lymphocytes of
varying size
 Clear cells
 Multinucleate and Reed
Sternberg like cells
 Algorithm for lymph node diagnosis

Lymph node

Follicular Diffuse

Reactive Lymphoma Small Medium Large

Follicular Mantle SLL

Small cleaved Small round
Lymphoid Non-lymphoid

LBL Burkitt Hodgkin

DLBCL ALCL,
PTCL
DLBCL variants
The importance of a good
quality H & E stained section
Poor fixation
Poor processing
Shattered sections
Careful and critical histologic
examination remains the most
important first diagnostic step in
the evaluation of lymph nodes
and the determination of what
ancillary tests are required to
reach a final diagnosis.