Non Hodgkin’s Lymphoma

B-cell type
Presenter :Dr. Ashok Singh
 Why to classify
• Diseases must be described ,defined and
named.
• To enable to diagnose ,treat, and study.
• Classification has two aspects
• Class discovery: process of identifying
categories of diseases.
• Class prediction: process of determining which
category an individual case belongs to.
 WHO Classification

• Based on principles initially defined by REAL

Classification.
• The driving force is an attempt to define “real”
diseases that can be recognized.
• Relies on building a consensus among experts.
• The current WHO classification lists the
lymphoid neoplasm
- first according to differentiation
stage (precursor or mature)
- then lineage (B or T/NK)
- specific disease entities according
to predominant clinical presentation
World Health Organization Classification of
Non-Hodgkin's Neoplasms
• PRECURSOR B- cell neoplasm
Precursor B-lymphoblastic leukemia/lymphoma
• Precursor T-lymphoblastic leukemia/lymphoma
• MATURE B-CELL NEOPLASMS
• Chronic lymphocytic leukemia/small lymphocytic
lymphoma
• B-cell prolymphocytic leukemia
• Lymphoplasmacytic lymphoma/Waldenstrom
macroglobulinemia
• Splenic marginal zone B-cell lymphoma
• Hairy cell leukemia
World Health Organization Classification of
Non-Hodgkin's Neoplasms
• Plasma cell neoplasms:
Plasma cell myeloma
Plasmacytoma

• Monoclonal immunoglobulin deposition diseases

• Heavy chain diseases
• Extranodal marginal zone B-cell lymphoma (MALT
lymphoma)
• Nodal marginal zone B-cell lymphoma
• Follicular lymphoma
• Mantle cell lymphoma
tosis
World Health Organization Classification of
Non-Hodgkin's Neoplasms
• Diffuse large B-cell lymphoma
• Mediastinal (thymic) large B-cell lymphoma
• Intravascular large B-cell lymphoma
• Primary effusion lymphoma
• Burkitt lymphoma/leukemia
• Lymphomatoid granuloma
 Precursor B cell neoplasm
• Highly aggressive neoplasm of B, T,NK cell
lineage.
• Lymphoblastic lymphoma and acute
lymphoblastic leukemia different ends of the
spectrum of same disease.
• Arbitrary criteria <25% lymphoblasts in
marrow.
• 80-90% are T cell lineage.
• B cell presents as acute lymphoblastic
leukemia, lymphomatous presentation is rare.
• Wide age range ,mean age – 32 years.
• Prominent lymphadenopathy, skin lesions,
lytic lesions in the bones.
• Lineage not predictable from the histologic
findings.
• Diffuse , dense, monomorphic infiltrate of
medium size lymphocytes.
• Nuclei round to oval, inconspicous nucleoli.
• Immunohistochemically – positive for Tdt-
defining marker.
• CD99 a less specific marker.
• Lineage assignment can be problematic with
absence of CD 20, cd3.
• Biphenotypic cases reported.
 Genetics
• Shows rearrangement of Ig heavy chain genes
in 100% cases.
• 20-30% of cases shows concurrent
rearrangement of TCRβ chain genes.
• T(9,22)(q34;p11),t(1,19)(q23;p13),t(4,11)
(q21;q23) associated with unfavourable
prognosis.
• Hyperdiploidy,>50 chromosomes ,favourable
prognosis.
 Peripheral B cell lymphomas
• Includes (mature)B cell lymphomas of
- naïve B cells
- follicular /germinal center cells
- post germinal center cells
- memory B cells.
 B-CLL/SLL
• Neoplastic proliferation of non-
activated ,mature small lymphocytes.
• Most cases have a leukemic presentation.
• Typically seen in older persons.
• Generalized lymphadenopathy,
splenomegaly,bone marrow involved
commonly.
 B-CLL/SLL
• Indolent ,asymptomatic patients observed
without therapy.
• Lymph node shows complete
effacement,spills in perinodal tissue.
• Dark staining areas punctuated by pale round
foci of proliferations-pathognomonic.
• Lymphoma cells are small, with round nuclei,
condensed chromatin.
B-CLL/SLL
B-CLL/SLL: Paraimmunoblasts, prolymphocytes
• Proliferation centres comprises of a mixture of
prolymphocytes and paraimmunoblasts..
• They are also interspersed among small
lymphocytes.
• Hall mark of B-CLL/SLL.
• Atypical B-CLL –presence of >10%
prolymphocytoid cells, lymph node shows
larger proliferation centers.
• Paraimmunoblastic variant –sheets of of large
aggregates of paraimmunoblasts are seen,
associated with worse prognosis.
• IHC- pan B markers are positive.CD5+, CD10-,
CD23+
• Ki-67 index low
IMMUNOPHENOTYPING
 Genetic features
• Previously thought to have unmutated Ig
genes.
• Recently shown derived from antigen
experienced B lymphocytes that differ in level
of Ig V gene mutation.
• Postulated to be derived from marginal B cell
• 50% shows unmutated Ig genes,50% shows
somatic hypermutation.
Chiorazzi N,et al 2005,Nejm 352:804-815
• Gene expression profiling studies shows a
homogenous phenotype resembling memory
B cells.
• Zap 70 surrogate marker of unmutated status.
• Shows deletion of 13q14(50%), del 11q22-
q23, 17p13 ,mutation p53,associated with
poor survival.
• In proportion of B-CLL/SLL a large B cell
lymphoma can supervene.
B-CLL/SLL: Richter syndrome (DLBCL)
• It can be clonally related to B-CLL/SLL ,or can
occur as new neoplastic event in a
predisposed person.
• B-CLL/SLL with RS like cells or superimposed
HL have been reported.
• EBV plays a key role in the genesis of large
cells.
• Superimposed HL is seen with increased use
of Fludarabine for B-CLL/SLL.
B-CLL/SLL with Reed Sternberg cells
 D/D
• N-LPHL- polytypic. No aberrant
immunoexpression.
• Follicular lymphoma CD5-,CD10+
 Lymphoplasmacytic lymphoma
• Uncommon,low grade lymphoma
• Small lymphoid cells with variable degree of
plasmacytic differentiation.
• Diagnosis of exclusion.
• Disease of middle aged.
• Lymphadenopathy, splenomegaly,
hyperviscosity .
• Marrow involvement frequent, Coomb’s
positive hemolytic anemia.
• Indolent relapsing course.
• Transformation to large B cell lymphoma can
occur.
 Pathology
• Nodal architecture is totally effaced.
• Sinuses distended with proteinaceous fluid.
• Small lymphocytes mixed with
lymphoplasmacytoid cells and plasma cells,
Dutcher bodies commonly seen.
 IHC
• B lineage markers are positive(CD20,CD79a)
• On flow cytometry CD 23 shows dim positivy
in 61% of cases.
• Genetics- Ig genes are rearranged.
• Deletion of 6q21 is the most common (non-
specific alteration)
• D/D- Lennert lymphoma-plasma
cells,plasmacytoid cells.
 Mantle cell lymphoma
• B cell lymphoma of mantle zone or primary
follicle lymphocytes.
• Cyclin D1 expression is the hall mark.
• Occurs in middle aged to old.
• Male preponderance (7:1)
• Lymphadenopathy, extranodal involvement also
commonly seen.
• Gastrointestinal presentation- lymphomatous
polyposis.
 Pathology
• Diffuse infiltration, vaguely nodular to
nodular.
• Proliferation centres generally absent.
• Large transformed cells absent or only focally
present.
• Scattered solitary epithelioid histiocytes
commomly present – diagnostic feature.
• Monotonous cell population.
MCL – diffuse growth pattern
Mantle cell lymphoma: nodularity
• Slightly larger than small lymphocytes.
• Nuclei show indentation and angulation.
• Mitotic count is variable.
• Blastoid variant- resembles lymphoblasts, fine
chromatin,mitotic figures frequent.
• Pleomorphic(anaplastic) variant-
heterogenous population of large tumor cells,
chromatin moderately condensed.
Mantle cell lymphoma: blastoid
Mantle cell lymphoma: pleomorphic
• In situ mantle cell lymphoma-rare variant-
neoplastic cells confined to the mantle zone.
• IHC- B lineage markers are positive.
• Surface Ig is commonly IgM-/+IgD .
• λ light chain is more commonly expressed .
• CD5+, CD23-,CD10-, bcl-6-,cyclin D1+(90%)
Immunophenotyping
• Upto 7% of cases mantle cell lymphoma
negative for cyclin D1 ,definitive diagnosis
rests on typical morphology.
• Genetics- Ig genes are rearranged ,unmutated
in 70-80%.
• Suggested that MCL may not be naïve B cell
neoplasm, rather derived from a marginal
zone or peripheral memory B cell
Bertoni F et al2004,Br J Heamt124;289-298.
• Approx. 50-65% cases exhibit t(11;14)
(q13;q32), juxta poses the BCL-1 oncogene on
11Q13 with IGH.
• Secondary cytogenetic alterations are
common- loss of chr.13,and Y,del 1p,2p11,
6q,8p,11q22-33.
 Follicular lymphoma
• Neoplasm composed of follicular centre B
lymphocytes, showing a follicular
arrangement.
• Most common NHL(22-40%)
• Predominantly in middle-aged and older
persons.
• Presentation –painless enlargement of lymph
nodes, splenomegaly is common.
• Almost always diagnosed in stage III/IV, BM
involvement is common.
• Buttock cells are seen in many cases.
• Flow cytometry can detect clonal population
even in absence of morphologic evidence.
• Indolent course with multiple recurrences
• Practically incurable.
• Localised- primary cutaneous follicular
lymphoma.
• Bcl-2 immunoreactivity and BCL-2
rearrangement –low frequency.
• Follicular lymphoma in children
- rare
- stage I/II
- head and neck region involved
- curable.
- Bcl-2 expression is uncommon.
 Pathology
• Nodal architecture is effaced by neoplastic
follicles.
• Lack cellular polarisation typically seen in
reactive follicles.
• Macrophages are not seen.
• Cellular composition is variable
-centrocytes- folded
elongated,nuclei
• Cells may simulate small lymphocytes.
• Mixed population ,difficult to diagnose
simulates reactive follicles.
• In interfollicular areas presence of atypical
lymphoid cells –supports the diagnosis of
follicular lymphoma.
• Sclerosis is seen in retroperitoneal and groin
region cases.
• Sclerosis most prominent in perinodal tissue
and areas of growth.
• Infiltration of walls of veins is highly
characteristic of follicular lymphoma.
• BM infiltration is paratrabecular.
• Grading of Follicular lymphoma
• Mann and Berard
Grade Equivalent terminology Criteria(no. of large
nucleolated cells/hpf
1 Predominantly small ≤5
cleaved cells.
2 Mixed small and large cells 5-15
3 3a Predominantly large cells >15,some centrocytes still
3b Large cells Exclusively large nucleated
cells
LYMPH NODE BIOPSY
FL FL
Benign vs Malignant
FL: Bcl-2
Vein wall invasion
 Morphologic variants
• Marginal zone differentiation
• 9%
• Prominent neoplastic marginal zone
component.
• Marginal zone cells don’t express cd10,Bcl2
• Poor prognosis.
FL with marginal differentiation
 Morphological variants
• Signet ring cell type
• Partly or entirely composed of signet ring cells.
• Follicular lymphoma with eosinophilic
precipitate.
• Follicular lymphoma with rosettes.
• Reverse variant- reversal of normal zonation.
• Centre composed of dark cells and rim of paler
large cells
Follicular lymphoma - Signet ring cell type
FL Reverse variant
• Pleomorphic variant(anaplastic)
• Cerebriform- very irregularly
folded ,cerebriform nuclei.
• Follicular immunoblastic –plasmablastic
• Follicular lymphoma with plasmacytic
differentiation.
• T cell rich variant.
• In situ follicular lymphoma
• Lymph node shows usual reactive follicular
hyperplasia.
• Germinal centres harbor strongly bcl2+
follicular centre cells.
• Studies shown cells to be clonal –may
represent early colonisation of reactive
germinal centre by follicular lymphomas.
 IHC
• B lineage markers are positive.
• Ig isotype is IgM.
• Bcl2+, CD10+, bcl6+, CD5-, CyclinD1-.
• genetics :
• Somatic hypermutations and ongoing
mutations.
• Characteristic t(14;18)(q32;q21) seen in 70-
80% of cases.
• Translocation results in overexpression of bcl2
protein(anti-apoptotic).
• Rearrangement of Bcl6 genes are seen in 5-15%
of cases- higher risk of transformation to LCL.
• Microarray studies have shown it shares gene
expression profile of normal germinal center B
cell, some genes upregulated, some
downregulated.
• Husson H et al 2002;blood99:282-289.
•
• Progression to DLBCL.
• >50% on long follow up.
• Seems to be part of natural history rather
than consequence.
• Associated with aggressive clinical course.
• No. of genetic changes observed-p53
mutation, bcl-2 somatic mutation, RAS
mutation.
• Diffuse follicular center lymphoma
• Composed of centrocytes, admixed with
centroblasts.
• Uncommon entity
• Diagnosis impossible on morphologic grounds.
• Positive for CD10, Bcl6, Bcl2 gene
rearrangement.
 Extranodal Marginal zone B cell
lymphoma
• Indolent lymphoma
• Architectural and cytologic homology to
extranodal and mucosal lymphoid tissues.
• Most commonly seen in GIT, Thyroid, salivary
gland.
• Predisposing conditions- chronic
inflammation, Hashimoto,s thyroiditis.
• Recent study suggest systemic dissemination
is frequent.
• Prognosis is highly favorable.
• 9-30 % of cases large cell lymphoma can
supervene.
• 70-80% of gastric lymphomas with h.pylori
gastritis can be treated with anti-Helicobacter
therapy.
• It suppress the Helicobacter associated T cell
proliferation, which terminates the CD40
mediated stimulus to B cell.
 pathology
• Unifocal to multifocal involvement of
extranodal tissue.
• Infiltrate is diffuse, interfollicular, or
perifollicular.
• IHC- b lineage markers are positive.Ig is
usually IgM, IgA, IgG.
• Negative for CD5,CD 10,CD23,Cyclin D1.
• Genetics- Ig genes are rearranged.
Extra nodal marginal zone lymphoma in
stomach
LYMPHOEPITHELIAL LESION
• Evidence of ongoing mutation.
• Rearrangements of BCL-1, BCL2 and BCL6 are
lacking.
• Large cell transformation has been observed
commonly.
Nodal marginal zone B cell lymphoma
• Uncommon lymphoma.
• Slight female preponderance.
• Presents with,
lymphadenopathy,paraproteinemia.
• BM involvement more common than
extranodal.
• Transformation to LCL seen in 20% of cases.
• Incomplete effacement.
• Mixed population of cells-small lymphocytes
, monocytoid B cells, plasma cells and large
cells.
• Wreathed epithelioid histiocytes are seen
surrounding clusters of lymphoma cells.
• IHC- similar to extranodal type.
Lymph node biopsy
 DLBCL
• Aggressive , rapidly growing neoplasm
• Composed of lymphoid cells having nuclei
larger than reactive histiocytes.
• Usually arises de novo, can transform from
low grade lymphoma.
• Etiology unknown.
• Slight male preponderance.
• Usually presents with lymphadenopathy.
• Constitutional symptoms may be seen.
• Generally diagnosed in stage IV.
• Potentially curable with chemotherapy.
PATHOLOGY
• Diffuse destructive infiltrate in lymph nodes.
• Infiltration of perinodal tissue and blood
vessels common.
• Cells vary considerably in size from case to
case.
• Nuclei larger than those of reactive
histiocytes.
• Single to multiple nucleoli are seen.
• Mitotic figures readily seen, atypical forms
seen.
• Cannot be differentiated reliably from Tcell
lymphoma morphologically.
DLBCL VARIANTS
• Myxoid variant.
• Lymphoma with rossettes.
• Lymphoma with spindle cells.
• Signet ring cell lymphoma.
• Clear cell variant.
• Sinusoidal large cell variant.
• Interfollicular variant.
• Multilobated large cell lyphoma
• Anaplastic large cell
DLBCL with sclerosis
DLBCL with rosettes
DLBCL with spindling
DLBCL clear cell type
DLBCL multilobated type
DLBCL Anaplastic type
 IHC
• B lineage markers are positive, aberrant
expression not uncommon.
• CD10+ in 40%,bcl6+in 60%,bcl2+ in 50%.
• Bcl2 + cases are resistant to chemotherapy.
Genetics
• Ig genes rearranged, somatic hypermutation
seen.
• Apart from bcl2, bcl6 rearrangements, C-MYC
rearrangement is seen on 10% of cases.
• REL protooncogene amplification seen.
• Hypermutations in PIM1, RhoH/TTF and PAX5
seen in > 50% of cases.
 Intravascular LBCL
• Exclusive intravascular proliferation of
neoplastic cells.
• No circulating lymphoma cells.
• Presentation is with bizzare neurologic
symptoms.
• Non cohesive lymphoma cells plug the lumina
of vessels.
• Majority are B cell lineage.
 Lymphomatoid granulomatosis
• Originally described by Leibow et al in lungs.
• Affects skin, cns, kidneys, .
• Lymphomatoid granulomatosis of lung was
found to be EBV+ Bcell proliferation .
• Median age of presentation is 5th to 6th
decade.
• Commonly presents with pulmonary lesions.
Pathology
• Triad of - 1) atypical lymphoid cells
2) vascular invasion
3) prominent coagulative necrosis
• Infiltrate of small lymphocytes, large atypical
cells and histiocytes.
IHC
• CD20+ in large atypical cells.
• Background of T lymphocytes.
• EBV demonstrated in most of the large cells.
• Shows spontaneous regression in 1/3 of the
cases.
• Rx with steroids and chemotherapy.
 Primary effusion lymphoma
• Occurs almost exclusively in AIDS patients.
• Presents with pleural, pericardial, peritoneal
effusion.
• Highly aggressive tumor.
• Neoplastic cells are large, with basophilic
cytoplasm,highly pleomorphic nuclei.
• CD45RB+, CD20-, CD22-, CD3-.
• B cell nature supported by Ig gene
rearrangement.
Pericardial effusion showing features of Primary
effusion lymphoma
 ALK+ Large B cell lymphoma
• Very rare.
• Adult males
• Marked lymph node enlargement.
• Architecture obliterated.
• Large cells.
IHC
• Immunophenotype suggests plasmablastic
differentiation.
• ALK staining is cytoplasmic, granular.
• Ig gene are rearranged.
• EBV –ve.
• ALK expression results from t(2;17)(p23;q23)
 Plasmablastic lymphoma
• No consensus for this identity.
• Uncommon, highly aggressive variant.
• Morphologic and immunophenotype suggest
B cell differentiation.
• Seen in immunocompromised patients.
• Local and systemic dissemination early in
disease
• Poor prognosis.
Pathology
• Large blastic cells.
• Monomorphic cells.
• Starry sky appearance is seen.
• Negative for CD20 and PAX5,CD45RB,CD79a,
Ig expressed in 50%.
• Ig genes rearranged,.
• EBV demonstrated in 50-74% of cases.
Plasmablastic lymphoma
 PLASMCTYOMA
• Tumorous collection of neoplastic plasma
cells.
• Most commonly seen in upper aerodigestive
tract, bone, soft tissue.
• Lymph node architecture partially or
completely effaced.
• Plasma cells appear monotonous.
 Burkitt’s lymphoma
• Aggressive neoplasm.
• First characterized as round cell sarcoma of
jaw.
• Three types-
1) Endemic
2) Sporadic
3) AIDS associated.
Pathology
• Diffuse pattern of growth.
• Starry sky appearance is characteristic but not
pathognomonic.
• Monotonous infiltrate of medium sized
cells,having multiple nucleoli.
• Atypical variant
-greater variation in size and shape of nuclei.
LYMPH NODE BIOPSY
 IMMUNOPHENOTYPING

CD 79a CD10
• Prominent nucleoli
• Less stary sky appearance.
IHC
• Pan B markers positive.
• CD10 +ve,bcl6+ve.
• CD21 expression is variable.
Genetics
• Ig genes are rearranged, somatic mutations
seen.
• t(8;14)(q24;q32) most common translocation.
• Less commonly seen t(2;8)(p12;q24), t(8;22)
(q24;q11).
• C-myc oncogene is translocated to the Ig
heavy or light chainon chr.2, 4, 22.
• Key molecular event in genesis of Burkitt
lymphoma is C-MYC deregulation,
• p53 mutation seen in 35-50%.
Gene expression profiling
• high level of C-MYC expression
• Low expression of MHC class I genes
• NFЌB expression is low.
 Immunophenotype of Chronic B Cell Leukemias/Lymphomas

Disease entity sIg CD5 CD10 CD11c CD19 CD20 CD22 CD23 CD25 CD103

Chronic +/– ++ – –/+ + +/– –/+ ++ –/+ –

lymphocytic
leukemia
Prolymphocytic ++ + – –/+ + +/– + +/– – –
leukemia

Hairy cell +/– –/+ – ++ + + ++ –/+ + ++

leukemia
Mantle cell + ++ – – + + + –/+ – –
lymphoma
Splenic marginal + –/+ –/+ + + + +/– –/+ – –
zone lymphoma

Lymphoplasmac +/– –/+ – – + +/– +/– –/+ +/– –

ytoid lymphoma

Follicular center + – + – + ++ + –/+ – –

lymphoma
Thank you