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DoenDoençça linfoproliferativa B: nova a linfoproliferativa B: nova classificaclassificaçção da OMSão da OMS (WHO 2008)

HIAE, April 2009HIAE, April 2009

Marciano Reis, MD, FRCPCChief, Dept. of Clinical PathologySunnybrook Health Sciences CentreWomen’s College Hospital Chief, Dept. of Laboratory HematologyUniversity Health NetworkAssociate Professor University of Toronto

OverviewOverview

�� Brief history of lymphoma classificationBrief history of lymphoma classification

�� Changes for WHO 2008Changes for WHO 2008

–– Precursor neoplasmsPrecursor neoplasms

–– Small clonal populationsSmall clonal populations

–– Follicular lymphoma issuesFollicular lymphoma issues

–– DLBCL categoriesDLBCL categories

–– Mature T cell neoplasmsMature T cell neoplasms

Need for classificationNeed for classification

�� Diseases must be clearly definedDiseases must be clearly defined–– Diagnosis and treatmentDiagnosis and treatment

�� Need for consensus on terminology and Need for consensus on terminology and definitionsdefinitions–– Essential for both clinical practice and researchEssential for both clinical practice and research

�� Diseases should be clinically distinctiveDiseases should be clinically distinctive–– Mutually exclusive (nonMutually exclusive (non--overlapping categories)overlapping categories)

–– Collectively exhaustive (all diseases should be Collectively exhaustive (all diseases should be identified)identified)

Need for classificationNeed for classification

�� Lumping diverse entities into broad Lumping diverse entities into broad prognostic groups, (i.e. Working prognostic groups, (i.e. Working Formulation)Formulation)–– Obscures distinctive features of rare diseasesObscures distinctive features of rare diseases

–– Distorts data on more common diseasesDistorts data on more common diseases

�� Defining distinct entities facilitates advances Defining distinct entities facilitates advances in:in:–– Pathogenesis, epidemiologyPathogenesis, epidemiology

–– Diagnostic, prognostic, predictive factorsDiagnostic, prognostic, predictive factors

–– Novel approaches to treatmentNovel approaches to treatment

Classification PrinciplesClassification Principles

�� Define distinct disease entities Define distinct disease entities –– Can be recognized by pathologistsCan be recognized by pathologists

–– Have clinical relevanceHave clinical relevance

�� Each entity defined by numerous featuresEach entity defined by numerous features–– Morphology, immunophenotype, genetics and clinical Morphology, immunophenotype, genetics and clinical

featuresfeatures

�� Diseases sorted according toDiseases sorted according to–– Postulated normal counterpartPostulated normal counterpart

–– Stage of differentiation to the extent possibleStage of differentiation to the extent possible

–– Clinical and morphologic similarities Clinical and morphologic similarities

Classification according Classification according to WHOto WHO

–– MorphologyMorphology�� Principal basis for classificationPrincipal basis for classification

�� Often sufficient for diagnosisOften sufficient for diagnosis

–– Immunophenotype and GeneticsImmunophenotype and Genetics�� Important part of the definition of a disease entityImportant part of the definition of a disease entity

�� Objective data permit consensusObjective data permit consensus

�� Immunophenotyping typically used for diagnosis in most Immunophenotyping typically used for diagnosis in most casescases

�� Useful in differential diagnosis and prognosisUseful in differential diagnosis and prognosis

�� Improve reproducibilityImprove reproducibility

–– Clinical findingsClinical findings�� Part of the definition of a disease entityPart of the definition of a disease entity

�� Nodal Nodal vsvs extranodal extranodal

�� Primary site (skin, CNS, GI, mediastinum)Primary site (skin, CNS, GI, mediastinum)

Brief History of Brief History of Lymphoma ClassificationLymphoma Classification

�� 1940s 1940s -- Gall and MalloryGall and Mallory

–– Not clinically usefulNot clinically useful

�� 1950s 1950s -- RappaportRappaport

–– Recognized importance of growth patternRecognized importance of growth pattern

�� 1970s 1970s -- Lukes and Collins, KielLukes and Collins, Kiel

–– Added knowledge that lymphomas are part of Added knowledge that lymphomas are part of

immune system, derived from T and B cellsimmune system, derived from T and B cells

Lancet 1974

History of Lymphoma History of Lymphoma ClassificationClassification

�� 1982 1982 –– Working formulationWorking formulation

– Attempted to unify the complex and confusing lymphoma terminology

– Improve communication between pathologists and clinicians in different parts of the world

– WF – North America, Kiel – Europe


� 1980s and 1990s

– Rapid increase in knowledge of immune system biology

– Immunology and genetics allowed recognition of previously unrecognized types of NHL


� 1994 - Revised European-American Lymphoma (REAL) classification

– ILSG recognized the existence of the new entities and proposed a new classification

– Validated by a multi-institutional study involving 1378 cases (The Non-Hodgkin’s Lymphoma Classification Project)

– Both reproducible and clinically relevant

� Spring pic


�� 2001 2001 –– WHO classificationWHO classification

– Joint project of the Society for Hematopathology and European Association of Hematopathologists

– More comprehensive including myeloid, histiocytic and mast cell neoplasms

– Lymphoma component merely an update of REAL classification with minor changes

WHO 2008 4WHO 2008 4thth EditionEdition

Mature B-cell Neoplasms … (cont.)

WHO 2008: UpdatesWHO 2008: Updates

�� Myeloid neoplasmsMyeloid neoplasms–– New genetic information New genetic information –– new categoriesnew categories

�� Lymphoid neoplasmsLymphoid neoplasms–– Genetic categories of ALL/LBLGenetic categories of ALL/LBL

–– Small clonal lymphoid populations Small clonal lymphoid populations

–– Consensus guidelines for some diseasesConsensus guidelines for some diseases

–– New diseases/subtypes/variants/gradingNew diseases/subtypes/variants/grading

–– Borderline (grey zone) categoriesBorderline (grey zone) categories

Precursor NeoplasmsPrecursor Neoplasms

�� Blastic plasmacytoid dendritic cell neoplasmBlastic plasmacytoid dendritic cell neoplasm–– Formerly Formerly ““blastic NKblastic NK--cell lymphoma/leukemiacell lymphoma/leukemia””

�� Acute leukemias of ambiguous lineage Acute leukemias of ambiguous lineage

–– Acute undifferentiated Acute undifferentiated leukaemialeukaemia (AUL)(AUL)

–– Mixed phenotype acute Mixed phenotype acute leukaemialeukaemia (MPAL) (+/(MPAL) (+/-- recurrent recurrent

genetic abnormalities)genetic abnormalities)

�� TT--lymphoblastic lymphoma/leukemia (Tlymphoblastic lymphoma/leukemia (T--ALL)ALL)

�� BB--lymphoblastic leukemia/lymphoma (Blymphoblastic leukemia/lymphoma (B--ALL)ALL)–– Genetic subtypesGenetic subtypes

Blastic plasmacytoid dendritic cell neoplasmBlastic plasmacytoid dendritic cell neoplasm

BB--lymphoblastic lymphoblastic leukemia/lymphoma (Bleukemia/lymphoma (B--ALL)ALL)

�� B Lymphoblastic Leukemia/Lymphoma, not otherwise B Lymphoblastic Leukemia/Lymphoma, not otherwise

specified specified

�� B lymphoblastic leukemia/lymphoma with recurrent genetic B lymphoblastic leukemia/lymphoma with recurrent genetic

abnormalitiesabnormalities

–– BB-- lymphoblastic leukemia/lymphoma with t(9:22) (q34;q11.2); BCR/Alymphoblastic leukemia/lymphoma with t(9:22) (q34;q11.2); BCR/ABL BL

–– B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearrangeB lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged d

–– B lymphoblastic leukemia/lymphoma with t(12;21) (p13;q22); TEL/AB lymphoblastic leukemia/lymphoma with t(12;21) (p13;q22); TEL/AML1 ML1

(ETV6(ETV6--RUNX1) RUNX1)

–– B lymphoblastic leukemia/lymphoma with hyperdiploidyB lymphoblastic leukemia/lymphoma with hyperdiploidy

–– B lymphoblastic leukemia/lymphoma with hypodiploidy (HypodiploidB lymphoblastic leukemia/lymphoma with hypodiploidy (Hypodiploid ALL) ALL)

–– B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32)(IL3B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32)(IL3--IGH) IGH)

–– B lymphoblastic leukemia/lymphoma with t(1;19)(Q23;P13.3); (E2AB lymphoblastic leukemia/lymphoma with t(1;19)(Q23;P13.3); (E2A--

PBX1; TCF3/PBX1) PBX1; TCF3/PBX1)

Small clonal lymphoid Small clonal lymphoid

populationspopulations

Small clonal lymphoid populationsSmall clonal lymphoid populations

�� Impact of flow cytometryImpact of flow cytometry

–– Detection of small clones of lymphoid Detection of small clones of lymphoid

cells in blood, bone marrow, lymph nodes cells in blood, bone marrow, lymph nodes

of healthy personsof healthy persons

� Have been found in 3.5-5.5% of healthy adults

Rawstron AC. Blood 2002;100:635-639Ghia P. Blood 2004;103:2337-2342

Monoclonal B-cell lymphocytosis

�� Most have immunophenotype of CLLMost have immunophenotype of CLL

�� Smaller percentage CD5Smaller percentage CD5--/CD10/CD10--

�� Absolute lymphocyte count <5.0 x Absolute lymphocyte count <5.0 x

101099/L/L

� No lymphadenopathy, organomegaly and no associated autoimmune or infectious disease

Monoclonal B-cell lymphocytosis

� Very small proportion progresses to clinical disease

– rate of progression approximately 5% over 5 years

– majority occurring >3 years of follow-up

�� ? Analogous to MGUS (MLUS)? Analogous to MGUS (MLUS)

�� ? Early SLL? Early SLL

Follicular lymphoma Follicular lymphoma grading issuesgrading issues

FL grading issuesFL grading issues

�� Grading poorly reproducible Grading poorly reproducible

among pathologistsamong pathologists–– 6161--73% agreement73% agreement

– Variability of field width among different high power objectives

– Identifying centroblasts - large centrocytes and small centroblasts

Blood 1997;89:3909-18

Do we need to grade?Do we need to grade?

� FL1 and FL2 are generally considered to have an indolent behavior

� Clinical course of FL3 is a subject of intense debate

� Different therapeutic approaches are sometimes applied to the indolent(FL1-FL2) and aggressive (FL3) forms

Ganti AK et al. Ann Oncol 2006;17:920-7

Gene expression profiling for FLGene expression profiling for FL

� Glas et al. Blood 2005;105:301-7– Clinical aggressiveness can be associated with specific molecular signatures partially independent from histological grade

– Used a profile of 81 genes to distinguish low-grade from high-grade disease

� Dave et al. N Engl J Med 2004;351:2159-69– Genes that best defined the prognostic signatures in FL were expressed primarily by T cells, macrophages, or dendritic cells, but not by the tumor cells themselves

Gene expression profiling for FLGene expression profiling for FL

� Piccaluga et al. Haematologica 2008; 93(7):1033-38

– Gene expression profile of FL is relatively homogeneous, independent of the histological grade

– FL3b cases constitute a clearly distinct subgroup among FL

� profile closer to FL than to DLBCL

FL grading: WHO 2008FL grading: WHO 2008

�� Suggestion to simplify or eliminate Suggestion to simplify or eliminate

gradinggrading

–– FL 1FL 1--3A: 3A: ““follicular lymphomafollicular lymphoma”” -- one one

disease with no gradesdisease with no grades

–– FL 3B: FL 3B: ““follicularfollicular”” variant of diffuse variant of diffuse

large Blarge B--cell lymphomacell lymphoma


�� Insufficient data at this time to Insufficient data at this time to warrant:warrant:–– Lumping FL3B with DLBCL, or Lumping FL3B with DLBCL, or

–– Eliminating grading altogetherEliminating grading altogether

�� FL1 and FL2 do not differ from one FL1 and FL2 do not differ from one anotheranother–– Could call them both FL1Could call them both FL1

�� FL3A becomes FL2, FL3B becomes FL3FL3A becomes FL2, FL3B becomes FL3

–– What about patients whose tumors have What about patients whose tumors have been classified in WHO 3rd ed and who been classified in WHO 3rd ed and who are still alive and on treatment?are still alive and on treatment?


�� Could change the nomenclatureCould change the nomenclature–– FL low grade (FL 1&2)FL low grade (FL 1&2)

–– FL intermediate grade (FL 3A)FL intermediate grade (FL 3A)

–– FL high grade (FL 3B)FL high grade (FL 3B)�� Not clear that FL3B is more aggressive than Not clear that FL3B is more aggressive than FL3AFL3A

FL grading: WHO 2008FL grading: WHO 2008ConclusionConclusion

�� Grading still based on proportion of Grading still based on proportion of

centroblastscentroblasts

–– FL1FL1--2 = CB rare (2 = CB rare (““low gradelow grade””))

–– FL3A = CB numerous (>15/hpf); FL3A = CB numerous (>15/hpf);

centrocytes still presentcentrocytes still present

–– FL3B = sheets of FL3B = sheets of centroblastscentroblasts

�� Issue will be revisited when more data Issue will be revisited when more data

available from GEP and prognosisavailable from GEP and prognosis

Intrafollicular neoplasia Intrafollicular neoplasia ("In("In--situsitu”” follicular lymphoma)follicular lymphoma)

�� Majority are normal or reactiveMajority are normal or reactive--appearing lymph appearing lymph nodes/lymphoid tissue nodes/lymphoid tissue –– One or more follicles with Bcl2+ CD10+ clonal B cells One or more follicles with Bcl2+ CD10+ clonal B cells

�� Often an incidental finding Often an incidental finding

�� Minority with overt FL elsewhere (earlier, Minority with overt FL elsewhere (earlier, concurrent, later)concurrent, later)

�� Most no FLMost no FL

�� Nodal equivalent of small clones of BCL2+ cells in Nodal equivalent of small clones of BCL2+ cells in blood of normal subjects?blood of normal subjects?–– 22ndnd ““hithit”” required for FLrequired for FL

�� Evaluate for FL, no need for treatmentEvaluate for FL, no need for treatment

Primary Cutaneous Primary Cutaneous Follicle Center LymphomaFollicle Center Lymphoma� Willemze R et al WHO EORTC classification for cutaneous

lymphomas. Blood 105:3768-3785, 2005

� Clinical

– Solitary or grouped plaques and tumors, mainly on scalp, forehead or trunk, rarely legs

– Dissemination to extracutaneous sites is uncommon

– Excellent prognosis regardless of growth pattern (follicular or diffuse), number of centroblasts, or whether localized or multifocal

Primary Cutaneous Primary Cutaneous Follicle Center LymphomaFollicle Center Lymphoma

�� HistologyHistology– Nodular to diffuse infiltrates– Sparing of the epidermis– Follicular growth pattern more common in scalp lesions

– Centrocytes (often large and multilobated), relatively few centroblasts, many reactive T cells

�� ImmunophenotypeImmunophenotype–– CD20+, Bcl6+ CD10CD20+, Bcl6+ CD10--/+ Bcl2/+ Bcl2--/+/+

�� GeneticsGenetics–– BCL2 usually germlineBCL2 usually germline

Primary cutaneous follicle Primary cutaneous follicle center lymphomacenter lymphoma

2x

40x

20x

Pediatric FL and NMZLPediatric FL and NMZL

�� Similar clinical featuresSimilar clinical features

–– Localized in head and neck regionLocalized in head and neck region

–– Median age Median age –– FL 11, NMZL 16FL 11, NMZL 16

–– Male predominance Male predominance –– FL 2:1, NMZL 5:1FL 2:1, NMZL 5:1

–– Good prognosis, some with minimal to no Good prognosis, some with minimal to no

therapytherapy


�� Similar morphologySimilar morphology

–– Follicular hyperplasia, PTGC, follicle lysisFollicular hyperplasia, PTGC, follicle lysis

–– NMZL NMZL –– extrafollicular monocytoid B cellsextrafollicular monocytoid B cells

–– FL FL –– often grade 3often grade 3

�� ImmunophenotypeImmunophenotype

–– NMZL NMZL –– CD20+, Bcl6CD20+, Bcl6--, Bcl2, Bcl2--

–– FL FL –– CD10+, Bcl6+, Bcl2CD10+, Bcl6+, Bcl2--, CD43+/, CD43+/--


�� GeneticsGenetics

–– IgH IgH –– clonally rearrangedclonally rearranged

–– BCL2 BCL2 –– germline, no t(14;18)germline, no t(14;18)

�� Are these truly malignant?Are these truly malignant?

�� Are we doing a Are we doing a favourfavour by making this by making this

diagnosis?diagnosis?

Pediatric NMZLPediatric NMZL

CD20 CD21

CD10 Bcl2

IgD

2x

10x

DLBCL classificationDLBCL classification

Aggressive B cell neoplasmsAggressive B cell neoplasms

�� New categories for DLBCLNew categories for DLBCL

–– primary extranodal sitesprimary extranodal sites

–– viral associatedviral associated

�� Borderline categoriesBorderline categories

–– DLBCL DLBCL –– BLBL

–– PMBC PMBC –– NSHLNSHL

DLBCL categoriesDLBCL categories

� Diffuse large B-cell lymphoma, not otherwise specified

– GCB/ABC, morphologic variants

– T cell/histiocyte rich large B-cell lymphoma

– Primary CNS DLBCL

– Primary cutaneous DLBCL (“ leg type”)

– EBV+ 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 DLBCL

� Plasmablastic lymphoma

� Primary effusion lymphoma

� Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease

Grey zone between BL and DLBCLGrey zone between BL and DLBCL

�� Occasional cases have morphologic features in Occasional cases have morphologic features in between between –– Intermediate to large cells, mitoses, starryIntermediate to large cells, mitoses, starry--sky patternsky pattern

�� 2001 WHO 2001 WHO -- atypical Burkitt lymphomaatypical Burkitt lymphoma

–– Morphologically intermediate between BL and Morphologically intermediate between BL and DLBCLDLBCL�� >95% Ki>95% Ki--67 fraction67 fraction

�� Immunophenotype of BL (CD10+ Bcl6+ Bcl2Immunophenotype of BL (CD10+ Bcl6+ Bcl2--))

�� MYC rearranged, BCL2 germline MYC rearranged, BCL2 germline

–– DxDx made when more likely Burkitt than DLBCLmade when more likely Burkitt than DLBCL

–– Others: classify as DLBCLOthers: classify as DLBCL

Grey zone between BL and DLBCLGrey zone between BL and DLBCL

� Hummel M et al. N Engl J Med 2006;354:2419-30

�� Dave SS et al. Dave SS et al. N Engl J Med 2006;354:2431-42

�� Both looked at GEP to distinguish between BL and Both looked at GEP to distinguish between BL and DLBCLDLBCL

�� Cases called classical BL Cases called classical BL –– all had GEP of BLall had GEP of BL

�� Cases called atypical BL Cases called atypical BL –– 5% not GEP of BL5% not GEP of BL

�� Cases called DLBCL Cases called DLBCL –– 1515--30% GEP of BL30% GEP of BL

�� 20% of cases had GEP between BL and DLBCL 20% of cases had GEP between BL and DLBCL

�� Cases with MYC rearrangement and not GEP of BL Cases with MYC rearrangement and not GEP of BL had worse prognosis than BL or DLBCLhad worse prognosis than BL or DLBCL

ConclusionsConclusions

�� There are cases that cannot be definitively There are cases that cannot be definitively classified as classified as aBLaBL vsvs DLBCLDLBCL

�� May be biologically and clinically differentMay be biologically and clinically different

�� Provisional category: BProvisional category: B--cell lymphoma, cell lymphoma, unclassifiable, intermediate between BL and DLBCLunclassifiable, intermediate between BL and DLBCL–– A heterogeneous category that needs to be further A heterogeneous category that needs to be further

refined; not a distinct entityrefined; not a distinct entity

–– Allows classification of cases not meeting criteria for Allows classification of cases not meeting criteria for classical BL or DLBCLclassical BL or DLBCL

–– Individualized decisions about treatmentIndividualized decisions about treatment

ConclusionsConclusions

�� ImmunophenotypeImmunophenotype–– CD10+ Bcl6+ Bcl2+/CD10+ Bcl6+ Bcl2+/--

–– Ki67 high or intermediateKi67 high or intermediate

�� Genetics Genetics –– MYCMYC, , BCL2BCL2, both (double hit), complex , both (double hit), complex karyotypeskaryotypes

�� Clinical Clinical –– May occur in pts with previous FLMay occur in pts with previous FL

–– Aggressive, short survival (especially double hit Aggressive, short survival (especially double hit cases)cases)

BB--cell lymphoma intermediate between cell lymphoma intermediate between DLBCL (PMBL) and CHL (NSHL)DLBCL (PMBL) and CHL (NSHL)

�� a.k.a. BCLWFIBDLBCLCHLa.k.a. BCLWFIBDLBCLCHL

�� Another grey zone with mediastinal masses, Another grey zone with mediastinal masses,

often in young adults (M>F)often in young adults (M>F)

�� Overlapping histology, immunophenotype Overlapping histology, immunophenotype

and GEPand GEP

–– Large cells, lacunar, RS like, variable sclerosis, Large cells, lacunar, RS like, variable sclerosis,

fibrous bands, inflammatory background fibrous bands, inflammatory background

–– CD45+ CD30+ Pax5+ CD20+/CD45+ CD30+ Pax5+ CD20+/-- CD79a+/CD79a+/--

CD15+/CD15+/-- CD10CD10-- Bcl6Bcl6--/+/+

�� Often aggressive Often aggressive -- ? Treat as DLBC or CHL? Treat as DLBC or CHL

Lymphoma Classification: Lymphoma Classification: Where now?Where now?�� Further assessment of small BFurther assessment of small B--cell neoplasmscell neoplasms

–– Significance of early clonal lesionsSignificance of early clonal lesions

–– Pediatric FL and NMZL: are they really malignant?Pediatric FL and NMZL: are they really malignant?

–– Practical method to risk stratify FL by pathologic featuresPractical method to risk stratify FL by pathologic features

�� Subclassification/risk stratification of DLBCLSubclassification/risk stratification of DLBCL

�� GrayGray--zones: clarifyzones: clarify

�� Further characterization/defining of mature TFurther characterization/defining of mature T--cell neoplasmscell neoplasms

�� Incorporate new information from gene expression profilingIncorporate new information from gene expression profiling–– Panels of antigens for immunophenotyping in classification, Panels of antigens for immunophenotyping in classification,

prognosisprognosis

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