CHRONIC LYMPHOPROLIFERATIVE DISORDERS

PRESENTER- DR. ANKITA BAGHEL

MODERATOR- DR. MANJULA K.

CONTENTS

NORMAL HISTOLOGY WHAT IS CLPD CELL DIFFERENTIATION CLASSIFICATION INDIVIDUAL DISORDERS APPROACH TO DIAGNOSIS CYTOCHEMISTRY IMMUNOPHENOTYPING CYTOGENETICS REFERENCES

NORMAL HISTOLOGY OF LYMPH NODE

CORTEX- Outer most portion- B-cell lymphoid follicles- Primary follicles(small lymphocytes)- Secondary follicle-Germinal center(centroblasts,centrocytes)

PARACORTEX- Below and between the follicle- T-cells, histiocytes, interdigitating Dendritic Cells And Langerhans Cells

MEDULLA

- Deep portion- Plasma cell-rich medullary cords

B CELL DIFFERENTIATION

T CELL DIFFERENTIATION

CHRONIC LYMPHOPROLIFERATIVE DISORDERS(CLPDS) are a heterogeneous group of malignancies characterised by the proliferation of mature B and rarely T lymphoid cells in the peripheral blood, bone marrow and/or lymph nodes/spleen and other lymphoid tissues.

Classification-

1. FAB- MORPHOLOGY+CYTOCHEMISTRY+IMMUNOHISTOCHEMISTRY

2. WHO-• Morphology• Cytochemistry• Immunophenotypic analysis• Cytogenetic and molecular alterations.

WHO CLASSIFICATION

PRECURSOR LYMPHOID NEOPLASM

MATURE LYMPHOID NEOPLASM

HODGKIN’S LYMPHOMA

PRECURSOR LYMPHOID NEOPLASMS

Precursor-B lymphoblastic leukemia/lymphoma

Precursor-T lymphoblastic leukemia/lymphoma

MATURE B-CELL NEOPLASMS1. CHRONIC LYMPHOCYTIC LEUKEMIA/ SMALL LYMPHOCYTIC

LYMPHOMA

2. B- CELL PROLYMPHOCYTIC LEUKEMIA

3. LYMPHOPLASMACYTIC LYMPHOMA

4. SPLENIC MARGINAL ZONE LYMPHOMAS

5. EXTRANODAL MARGINAL ZONE LYMPHOMA

6. MANTLE CELL LYMPHOMA

7. FOLLICULAR LYMPHOMA

8. NODAL MARGINAL ZONE LYMPHOMA

9. HAIRY CELL LEUKEMIA

10.PLASMACYTOMA/PLASMA CELL MYELOMA

11.DIFFUSE LARGE B-CELL LYMPHOMA

12.BURKITT’S LYMPHOMA

13.PLASMABLASTIC LYMPHOMA

14.WALDENSTROM MACROGLOBULINEMIA

MATURE T-CELL & NK-CELL NEOPLASMS1. T-CELL PROLYMPHOCYTIC LEUKEMIA

2. LARGE GRANULAR LYMPHOCYTIC LEUKEMIA

3. PERIPHERAL T-CELL LYMPHOMA

4. UNSPECIFIED ANAPLASTIC LARGE CELL LYMPHOMA

5. ANGIOIMMUNOBLASTIC T-CELL LYMPHOMA

6. ENTEROPATHY-ASSOCIATED T-CELL LYMPHOMA

7. PANNICULITIS-LIKE-T-CELL LYMPHOMA

8. HEPATOSPLENIC T-CELL LYMPHOMA

9. ADULT T-CELL LEUKEMIA/LYMPHOMA

10.AGGRESSIVE NK/T-CELL LYMPHOMA

11.NK-CELL LEUKEMIA

12.SEZARY SYNDROME

13.MYCOSIS FUNGOIDES

HODGKIN’S LYMPHOMA

1. CLASSICAL SUBTYPES-

a. NODULAR SCLEOSIS

b. MIXED CELLULARITY

c. LYMPHOCYTE-RICH

d. LYMPHOCYTE DEPLETION

2. NODULAR LYMPHOCYTE PREDOMINANT

CHRONIC LYMPHOID LEUKEMIA-SUBTYPESB- CELL TYPE

1. B-CELL CLL

• CLL(PROLYMPHOCYTES <10%)

• CLL/PLL(PROLYMPHOCYTES 11-55%)

• RICHTER SYNDROME

2. PROLYMPHOCYTIC LEUKEMIA(PROLYMPHOCYTES >55%)

3. HAIRY CELL LEUKEMIA

4. PLASMA CELL LEUKEMIA, WALDENSTROM MACROGLOBULINEMIA

5. LYMPHOMA SPILL OVER-

• SPLENIC LYMPHOMA WITH VILLOUS LYMPHOCYTES(SLVL)

• MANTLE CELL LYMPHOMA

• OTHER NON-HODGKIN’S LYMPHOMAS

T-CELL TYPE

1. T-CELL PROLYMPHOCYTIC LEUKEMIA

2. LARGE GRANULAR LYMPHOCYTIC LEUKEMIA

3. AGGRESSIVE NK-CELL LEUKEMIA

4. ADULT T-CELL LEUKEMIA/LYMPHOMA

5. MYCOSIS FUNGOIDES/SEZARY SYNDROME

6. PERIPHERAL T-CELL LYMPHOMA

7. ANGIOIMMUNOBLASTIC T-CELL LYMPHOMA

8. ANAPLASTIC LARGE CELL LYMPHOMA ALK +ve

9. ANAPLASTIC LARGE CELL LYMPHOMA ALK -ve

B CELL CHRONIC LYMPHOCYTIC LEUKEMIA

Median age at diagnosis- 70 years Incidence- Males= 2x Women Symptoms related to- Anemia

Thrombocytopenia

Neutropenia Neoplastic cells-

1. Small and mature appearing

2. Scant cytoplasm

3. Nuclei usually round

4. Chromatin regularly clumped(block-type chromatin)

5. Nucleoli inconspicuous

Diagnosis- Lymphocytosis >5 x 109 /L

Prolymphocytes <10%

Smudge cells

Cytogenetic abnormalities-

1. Trisomy 12

2. Del 11q22.3-23.1

3. Del 6q21-23

4. Deletions at 17p13.1(p53 aberrations)

5. 14q abnormalities and complex chromosomal abnormalities

PROLYMPHOCYTIC LEUKEMIA

Aggressive leukemic disorder .Often does not respond to

treatment.Incidence- 10% that of CLL.

Phenotypes-

1.Mature B cell

2.Mature T cell

B CELL PLL

70% cases of PLL. Disease of adults Male:Female-4:1 Lymphocytes-

1. Large cell

2. Moderate amount of pale basophilic cytoplasm

3. Moderately condensed chromatin

4. Single prominent nucleolus

T CELL PLL

Rare disorder of adults Lymphocyte-

1. Medium size

2. Convoluted nuclear outlines

3. Prominent nucleolus

HAIRY CELL LEUKEMIA

Uncommon malignancy of middle age. Male:female-7:1

Presentation-

1. Massive Splenomegaly

2. Extensive bone marrow involvement

3. Pancytopenia

4. WBC count low- Neutropenia And Monocytopenia

Neoplastic cell-

1. Abundant pale staining cytoplasm

2. Circumferential cytoplasmic projections(hairs)

3. Oval or reniform nuclei

4. Fine chromatin

Markers-

1. CD19

2. CD20(strong intensity)

3. CD22

4. CD25

5. CD103

6. CD11c

7. TRAP

Bone marrow aspiration- DRY TAP Bone marrow biopsy- monotonous infiltrate of abnormal

lymphocytes with small nuclei and abundant pale-staining cytoplasm- FRIED EGG APPEARANCE

LARGE GRANULAR LYMPHOCYTIC LEUKEMIA

LYMPHOCYTOSIS-

1. Abundant pale staining cytoplasm

2. Azurophilic cytoplasmic granules

3. Nuclei with mature clumped chromatin

Phenotypes-

1. T LYMPHOCYTE TYPE

2. NK CELL TYPE

T-LGL LEUKEMIA

80% of LGLL Age- 55years

PRESENTATION- Anemia

Neutropenia

Thrombocytopenia

Splenomegaly

NK CELL TYPE

Median age-39 years Acute presentation and aggressive course with

death within 2 months

CUTANEOUS T CELL LYMPHOMA

Primary to skin MYCOSIS FUNGOIDES-most common variant of CTCL SEZARY SYNDROME- Erythroderma + Sezary cells

Sezary cell-

1. Mature memory helper T cell

2. Irregular, convoluted(cerebriform) nuclear outline

3. Finely distributed chromatin

4. CD3+, CD4+, CD7-

SUBGROUP OF CHRONIC LEUKEMIC LYMPHOID MALIGNANCIES

KEY FEATURES MARKERS

1. B CELL CLL LymphocytosisSmudge cellsProlymphocytes <10%

CD19+,CD5+,CD20+ weak intensity, CD23+, FMC-Surface Ig weak intensity

2. B CELL PLL SplenomegalyMarked lymphocytosisProlymphocytes >55%

CD19+,CD20+,CD22+,CD5-/+,FMC-7+Surface Ig strong intensity

3.T CELL PLL SplenomegalySkin lesionsMarked lymphocytosisVaried morphologic appearance

4. HAIRY CELL LEUKEMIA

PancytopeniaCirculating hairy cellsBone marrow dry tapBone marrow fried egg appearance

TRAP+CD19+,CD5-,CD20+ strong intensity,CD22+,CD103+,CD11c+,CD25+Surface Ig strong intensity

5. T CELL LGLL

LymphocytosisAnemiaNeutopeniaThrombocytopeniaRheumatoid factor often presentIndolent course

CD2+,CD3+,CD4-,CD5+,CD7+,CD8+,CD16+,CD56-/+,CD57+/-T Cell receptor clonally rearranged

6. SEZARY SYNDROME

Erythroderma(red skin)Cutaneous T cell lymphomaCirculating malignant cells

CD2+,CD3+,CD4+,CD5+,CD7-,CD8-

MALIGNANT LYMPHOMA

HODGKIN NON-HODGKIN

PARAMETER HODGKIN LYMPHOMA NON-HODGKIN LYMPHOMA

STAGE Usually localized Usually widespread

DISTRIBUTION Usually central nodes Usually involves peripheral nodes

MODE OF SPREAD Contiguous Non-contiguous

EXTRANODAL DISEASE Uncommon Common

PERIPHERAL BLOOD Never involved Can be involved

CELL TYPE Abnormal bizarre cells Resembles normal lymphoid cells

TREATMENT REGIMEN Often ABVD Often CHOP

SMALL LYMPHOCYTIC LYMPHOMA

Tissue equivalent of CLL.

FOLLICULAR LYMPHOMA

Neoplasm composed of cell originating from the germinal center.

Median age-50-60years Presentation-generalized painless lymphadenopathy

peripheral blood involvement

bone marrow involvement Lymph node-infiltrate of lymphoid cells forming poorly

circumscribed nodules Neoplastic follicles diifer from reactive follicle in

lacking apoptosis of lymphocytes Tingible body macrophages Small cleaved cells(CENTROCYTES) and large

cells(CENTROBLASTS)

GRADING OF FOLLICULAR LYMPHOMA

GRADE DEFINITION

1 0-5 centroblasts per defined HPF

2 6-15 centroblasts per defined HPF

3 >15 centroblasts per defined HPF

MANTLE CELL LYMPHOMA

Median age 60 years Male predominance Neoplastic cells-small to intermediate in size with

round to slightly irregular nuclear outlines. Markers-

1. CD19+

2. CD5+

3. CD23-

4. FMC7+

5. sIg+(strong intensity)

6. Cyclin D1

MALT LYMPHOMA

Prsentation-localized extranodal disease A preceding chronic inflammatory

disorder(chronic gastritis,sjogrens,hashimotos) Neoplastic cells-

1. Small lymphocytes

2. Round to slightly cleaved nuclei

BURKITT LYMPHOMA

High grade Non-hodgkin lymphoma High incidence in Africa(ENDEMIC SUBTYPE) 1/3rd of pediatric lymphomas outside

africa(SPORADIC SUBTYPE) Extranodal involvement Endemic-involves facial bones and jaw Sporadic- intestine,ovaries or kidney EBV associated

Biopsy- STARRY SKY APPEARANCE-

• The SKY represents the blue nuclei of the neoplastic lymphocytes

• The STARS formed by scattered pale staining tingible body macrophages.

Infiltrating lymphoid cells are intermediate in size with nuclei approximately the same size as the nuclei of the tingible body macrophages.

Multiple small nucleoli,mitotic figures and apoptotic bodies.

Markers-

1. CD19+

2. sIg+

3. CD10+

4. CD5-

5. t(8;14), t(2;8), t8;22)

HODGKINS LYMPHOMA- CLASSIFICATION

SUBTYPE SCLEROSIS LYMPHOCYTES

TUMOUR CELLSVARIANTS

VARIANTS CELL TYPE

LYMPHOCYTIC PREDOMINANCE

- ++++ + L AND H B-CELL

NODULAR SCLEROSIS

PRESENT ++ ++ LACUNAR UNCERTAIN CELL OF ORIGIN

MIXED CELLULARITY

- ++ ++ - UNCERTAIN CELL OF ORIGIN

LYMPHOCYTIC RICH

- ++++ + - UNCERTAIN CELL OF ORIGIN

LYMPHOCYTIC DEPLETION

-/+ + ++++ - UNCERTAIN CELL OF ORIGIN

ANN ARBOR STAGING OF HODGKIN’SSTAGE FEATURE

STAGE I Involvement of single lymph node region(I) or a single extra lymphatic organ/site(IE)

STAGE II Involvement of two more lymph node regions on the same side of diaphragm(II) orLocalized involvement of an extra lymphatic organ and one more more lymph node regions on the same side of the diaphragm(IIE)

STAGE III

Involvement of lymph node regions on both sides of diaphragm(III), which may also be accompanied by localized involvement of an extra lymphatic organ(IIIE) or involvement of the spleen(IIIS) or both(IIIES)

STAGE IV

Diffuse or disseminated involvement of one or more extra lymphatic organs or tissues with or without associated lymph node enlargement.

SUBCLASSIFICATION

A- without symptoms B- Systemic symptoms:

1. Unexplained fever 38 degree Celsius.

2. Unexplained weight loss 10% body weight in preceding 6 months.

3. Night sweats.

MALIGNANT LYMPHOMA KEY FEATURE

1. FOLLICULAR LYMPHOMA Nodular growth patternLack of tangible body macrophagesCD19+,CD20+,CD5-,CD10+Surface Ig strong intensityt(14;18)BCL-2 protein overexpressionBCL-2 gene rearrangement

2. MANTLE CELL LYMPHOMA Lack of large cellsCD19+,CD20+,CD5+,CD23-,FMC-7+Surface Ig+ strong intensityCyclin-D1 overexpressiont(11;14)BCL-1 rearrangement

3. MALT LYMPHOMA Accompanied by infectious or autoimmune diseaseOften localizedExtranodalLymphoepithelial lesionsBenign folliclesHeterogeneous neoplastic infiltratePhenotype and genotype not specific

4. WALDENSTROM MACROGLOBULINEMIA Lymphoid malignancy with plasmacytic differentiationIgMHypervicosity syndrome

5. BURKITT LYMPHOMA Can be associated with EBVStarry sky growth patternCD19+,CD20+,CD5-,CD10+Strong surface Igt(8;14)C-MYC gene rearrangement

6. ANAPLASTIC LARGE CELL LYMPHOMA Bizarre,anaplastic cells can resemble HDT cell or Null phenotypeLCA+/-,CD30+,CD15-,EMA+/-,EBV-,ALK-1+/-t(2;5)

7. CLASSIC HODGKIN LYMPHOMA Reed-Sternberg cellsLCA-,CD15+,CD30+,ALK-1-Often EBV +

8. LYMPHOCYTIC PREDOMINANT HL Growth pattern frequently nodularL and H cellsLCA+,CD20+,CD15-,CD30-,EBV-

PLASMA CELL DISORDERS

1. PLASMA CELL MYELOMA (MULTIPLE MYELOMA)

2. PLASMACYTOMA

3. PRIMARY AMYLOIDOSIS

4. HEAVY CHAIN DISEASE

5. MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE (MGUS)

KEY FEATURES OF PLASMA CELL DISORDERSNEOPLASM FEATURES

1. MULTIPLE (PLASMA CELL) MYELOMA • LYTIC BONE LESIONS• “M” SPIKE ON SERUM/URINE ELECTROPHORESIS• ROULEAUX ON BLOOD SMEAR• >30% PLASMA CELLS IN BONE MARROW

2. PLAMACYTOMA • LOCALIZED MASS• MONOCLONAL PLASMA CELLS

3. MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE

• MONOCLONAL SERUM PROTEIN• MONOCLONAL PROTEIN <3gm/dl• LYTIC BONE LESIONS ABSENT• BONE MARROW PLASMA CELLS <10%

CRITERIA FOR DIAGNOSIS OF MULTIPLE MYELOMA(SALMON AND DURIE)MAJOR CRITERIA-1. Plasmacytoma on biopsy2. Bone marrow plasmacytosis >30% plasma cells3. M band in serum• IgG >3.5 g/dl OR IgA >2 g/dl• Light chain excretion in urine >/= 1 g/24 HOURS

MINOR CRITERIA-1. Bone marrow plasmacytosis 10-30% plasma cells2. Monoclonal globulin spike IgG <3.5 g/DL, or IgA <2g/DL3. Lytic bone lesions4. Normal IgM <50 mg/dl, IgA <0.1 g/dl OR IgG <0.6 g/dl

CRITERIA FOR MMDiagnossi of myeloma is confirmed when at least-• One major + one minor criteria OR• 3 minor criteria, that must include 1 and 2 of minor criteria.

APPROACH TO DIAGNOSIS OF LYMPHOMA??

CELL SIZE DETERMINATION

Neoplastic cells are compared with the Reactive Histiocytes interspersed among the lymphoma cells.

SMALL- Nuclei smaller than that of reactive histiocytes.

MEDIUM- Nuclei approx. same as that of histiocytes.

LARGE- Nuclei larger than those of histiocytes.

MEDIUM SIZED FOLLICLES-APPROACH TO DIAGNOSIS

MAJOR DIFFERENTIAL DIAGNOSIS

1. Reactive follicular hyperplasia

2. Follicular lymphoma

3. Nodular mantle cell lymphoma

How to distinguish between reactive follicular hyperplasia and follicular lymphoma?FEATURE REACTIVE

FOLLICULAR HYPERPLASIA

FOLLICULAR LYMPHOMA

FOLLICLES Discrete and separeated by interfollicular lymphoid tissue

A pattern of back to back follicles with little interfollicular tissue

TINGIBLE BODY MACROPHAGES

Present Lack

CELLULAR POLARIZATION Into light and dark zones present

Absent

POPULATION Heterogeneous population of follicular cells

Predominance of centrocytes in the follicles

LARGE LYMPHOID NODULES: APPROACH TO DIAGNOSIS

MAJOR DIFFERENTIAL DIAGNOSIS

1. NLPHL

2. N-LRCHL

3. NSHL

4. PTGC

DIFFUSE SMALL B-CELL LYMPHOMAS- APPROACH TO CLASSIFICATION

MAJOR DIFFERENTIAL DIAGNOSIS

1. CLL/SLL

2. Lymphoplasmacytic lymphoma

3. Mantle cell lymphoma

4. Extranodal marginal cell lymphoma

LARGE CELL SCATTERED IN A BACKGROUND OF SMALL LYMPHOCYTES

MAJOR DIFFERENTIAL DIAGNOSIS

1. Reactive lymphoid hyperplasia

2. T-cell/histiocytic rich large B-cell lymphoma

3. Hodgkin lymphoma

Possible diagnosis All large cells show morphologic features acceptable for immunoblasts or centroblasts( nuclear size <x2.5 small lymphocyte nucleus: nuclear contour round to oval)

Large cells are atypical(with irregular nuclear folding or granular chromatin),but most nuclei are <x2.5 small lymphocyte nucleus

Most large cells have nuclei >x3 small lymphocyte nucleus

Reactive lymphoid hyperplasia

+ - -

TCRBCL + + +

Hodgkin’s lymphoma

- - +

CELL IDENTIFICATION BY CYTOCHEMISTRYCYTOCHEMICAL REACTION CELL TYPES

1. NON SPECIFIC ESTERASE • MYELOID CELLS• MONOCYTES• MEGAKARYOCYTES• T LYMPHOCYTES(dot like staining)

2. CHLOROACETATE ESTERASE • MYELOID CELLS• MAST CELLS

3. PEROXIDASE • MYELOID CELLS• EOSINOPHILS• MONOCYTES

4. SUDAN BLACK B • MYELOID CELLS• MONOCYTES

5. METHYL GREEN PYRONINE • PLASMA CELLS• IMMUNOBLASTS

6.PERIODIC ACID-SCHIFF WITH DIASTASE • PLASMA CELLS

7. TARTRATE-RESISTANT ACID PHOSPHATASE • HAIRY CELL LEUKEMIA

PROBLEM TO BE ASSESSED FIRST-LINE ANTIBODIES

B LINEAGE ? CD20( or CD79a, PAX5)

T LINEAGE ? CD3( OR CD2)

NK LINEAGE ? CD56, SURFACE CD3, CYTOPLASMIC CD3, TCR

FOLLICULAR CENTER CELL ? CD10( OR BCL6, HGAL)

FOLLICULAR LYMPHOMA OR HYPERPLASIA ? BCL2, CD10(interfollicular invasion)

CLL ? CD5, CD23

NORMAL MANTLE ZONE CELLS ? IgD

MANTLE CELL LYMPHOMA ? CYCLIN D1, CD5

BURKITT LYMPHOMA ? Ki67, CD10(+/-BCL6), BCL2, MYC

IMMATURE(PRECURSOR LYMPHOBLASTIC)CELL ? TdT

ANAPLASTIC LARGE CELL LYMPHOMA ? CD30, ALK

PLASMA CELL ? CD20- , CD138+

HISTIOCYTE ? CD163( or CD68)

INTERDIGITATIONG DENDRITIC OR LANGERHANS CELL ?

S100( also LANGERIN/ CD207 for the latter cell type)

FOLLICULAR DENDRITIC CELL ? CD21 or CD35

HODGKIN LYMPHOMA ? CD30, CD15, PAX5

MOST USEFUL ANTIBODIES FOR ASSESSMENT OF LYMPHOID PROLIFERATIONS

CHARACTERISTIC CYTOGENETIC FINDINGS IN SPECIFIC LYMPHOMA TYPESLYMPHOMA TYPE SPECIFIC CHROMOSOMAL

TRANSLOCATIONONCOGENE OR TUMOUR SUPPRESSOR GEENE IMPLICATED

Follicular lymphoma t(14;18)(q32;q21) BCL2

Mantle cell lymphoma t(11;14)(q13;q32) CCND1

Extranodal marginal zone lymphoma of MALT type

t(11;18)(q21;q21)t(1;14)(p22;q32)t(14;18)(q32;q21)t(3;14)(p14.1;q32)

API2, MALT1BCL10MALT1FOXP1

Burkitt lymphoma t(8;14)(q24;q32)t(8;22)(q24;q11)t(2;8)(p12;q24)

MYC

T-lymphoblastic lymphoma/leukemia

t(1;14)

RELATIVE FREQUENCIES OF B-CELL LYMPHOMA SUBTYPES IN ADULTS

RELATIVE FREQUENCIES OF MATURE T-CELL LYMPHOMA SUBTYPES IN ADULTS

REACTIVE LYMPADENOPATHIES AND THEIR DISTICTION FROM LYMPHOMA

INFECTIOUS MONONUCLEOSIS AND OTHER VIRAL INFECTIONS

HYPERSENSITIVITY REACTIONS(PHENYTOIN) KIKUCHI LYMPHADENITIS

REFERENCES

MCKENZIE-2ND EDITION,VOLUME 2 WHO CLASSIFICATION OF TUMOURS OF

HAEMATOPOIETIC AND LYMPHOID MALIGNANCIES-4TH EDITION

WINTROBES-11TH EDITION ROBBINS- 18TH EDITION DIAGNOSTIC HISTOPATHOLOGY OF TUMOURS-

FLETCHER 4TH EDITION,VOLUME 2 IOACHIM’S LYMPH NODE PATHOLOGY INTERNET

THANK YOU