Diagnostika lymfomů Extranodální lymfomy Doc. MUDr. L. Boudová, Ph. D.

Contents WHO Classification 2008

Lymphomas Clonal disorders of lymphoid cells at various stages of differentiation HODGKIN L. NON-HODGKIN L. immature cells (precursors) mature cells B T Distinction clinical histological Note: Hodgkin lymphoma is also a (mature)B-cell lymphoma.

Lymphoid malignancies Epidemiology 90%: B; FL+ DLBCL – 60% 4% of all new cancers each year Incidence increasing per 100 000: 34 lymphoid neoplasms

Lymphoma diagnosis Sample Lymph node Bone marrow Spleen, extranodal tissue Cerebrospinal fluid

Lymphoma diagnosis Histology, cytology Immunohistochemistry Ag detected in tissue slides Molecular biology Clonality, lineage – gene rearrangements Translocation detection, mutations Flow cytometry Clinicopathological correlation, esp. T-cell lymphomas difficult to diagnose

Lymphoma diagnosis molecular biology Gene rearrangement (PCR, Southern blot) Clonality and lineage B-cells: IgH T-cells: T-cell antigen receptor Characteristic translocations Mantle cell lymphoma t(11;14) Follicular lymphoma, diffuse large B-cell l. t(14;18) Anaplastic large cell lymphoma t(2;5) Burkitt lymphoma t(8;14)

B-cell lymphoma Clonal disorders of B-cells at various stages of differentiation of immature cells - lymphoblasts B-acute lymphoblastic leukaemia - frequent, children B-lymphoblastic lymphoma - rare of mature B-cells most common: diffuse large B-cell lymphoma, follicular; plasma cell myeloma

Mature B-cell lymphomas Chronic lymphocytic leukemia/small lymphocytic lymphoma; B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma Hairy cell leukemia Plasma cell myeloma Monoclonal gammopathy of unknown significance Solitary plasmacytoma of bone Extraosseous plasmacytoma Extranodal marginal zone B-cell lymphoma= MALT Nodal marginal zone B-cell lymphoma Splenic marginal zone lymphoma

Mature B-cell lymphomas Follicular lymphoma Mantle cell lymphoma Diffuse large B-cell lymphoma Mediastinal (thymic) large B-cell lymphoma Intravascular large B-cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukaemia

T-cell lymphoma Precursor T-cell lymphomas T-acute lymphoblastic leukaemia T-lymphoblastic lymphoma Mature T-and NK cell neoplasms uncommon –10% of all NHL Most frequent : peripheral T-cell lymphoma, unspecified large cell anaplastic lymphoma often difficult to diagnose

Most common T-cell lymphomas 1. Leukaemic/disseminated adult T-cell leukaemia - HTLV 1 2. cutaneous - mycosis fungoides, Sezary syndrome, primary cut. anaplast. lymphoma 3. other extranodal - extranod. NK/T - nasal, enteropathy assoc. 4. nodal - peripheral T-cell lymphoma, NOS, anaplastic large cell lymphoma

NK/T-cell lymphoma of nasal type EBV, angiocentric, destructive South America, Asia Lethal midline granuloma NK/T-cell l. Wegener granulomatosis Cocaine abuse

Diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma aggresive, potentially curable COMMON! 1/3 of all lymphomas of adults (med. 64 ys) nodal OR extranodal (1/3) GIT, skin, CNS, testis bone, soft tissue, salivary glands, Waldeyer ring, lung, kidney, liver, spleen, female genital tract

Diffuse large B-cell lymphoma Primary OR secondary Chronic lymphocytic leukemia Follicular lymphoma Marginal zone B-cell lymphoma Nodular lymphocyte predom. Hodgkin l. Risk factor: immunodeficiency (often EBV+)

Diffuse large B-cell lymphoma Morphologic variants Centroblastic Immunoblastic Plasmablastic DLBCL subtypes T-cell/histiocyte rich CNS Skin- leg type EBV positive - elderly

Special lymphomas of large B-cells Mediastinal (thymic) Intravascular Chronic inflammation Lymphomatoid granulomatosis ALK positive plasmablastic Arising in HHV8 Castleman dis. Primary effusion

Diffuse large B-cell lymphoma, Giemsa

Diffuse large B-cell lymphoma Differential diagnosis Tumors Haematological: lymphomas – peripheral - B, T precursors - B, T myeloid neoplasm Non-haematological: carcinoma, sarcoma, GIST, melanoma, seminoma, glial tumors Reactive disorders: infectious mononucleosis, Kikuchi

T-cell /histiocyte rich B-cell lymphoma CD20 Diffuse/ vaguely nodular diffuse large B-cell lymphoma neoplastic B-cells scarce majority reactive T-cells, histiocytes Small B-cells rare BUT areas with increased numbers of small B-cells  associated NLPHL ?

T-cell /histiocyte rich B-cell lymphoma Differential diagnosis 1. Hodgkin lymphoma - classical - NLPHL (nodular paragranuloma) 2. T-cell lymphoma 3. Reactive disorders – T/HRBCL interfollicular

Diffuse large B-cell lymphoma clinicopathological subtypes mediastinal

Mediastinal DLBCL Thymus Female, 30 ys Anterior mediastinal mass Superior vena cava syndrome Clinicopathological differential diagnosis?

Mediastinal DLBCL Compartmentalising fibrosis Polymorphic large cells, abundant pale cytoplasm CD20, CD23, CD30, CD45

Mediastinal DLBCL – differential diagnosis Problems 1. small biopsies, crushed cells, small areas for IH 2. background: small ly, eosinophils; RS cells 3. clinicopathological features – med. mass, young woman Traverse-Glehen : Mediastinal Gray Zone Lymphoma. The Missing Link Between Classic Hodgkin Lymphoma And Mediastinal Large B-Cell Lymphoma. Am J Surg Pathol, Nov. 2005, 29, 1411-1421 GRAY ZONE

Classical Hodgkin lymphoma Nodular sclerosis

Borderline cases

BCLUWFIBDLBCLACHL

BCLUWFIBDLBCLACHL DLBCL vs. CHL morphology, IHC Garcia, Histopathology 2005

BCLUWFIBDLBCLACHL DLBCL vs. CHL morphology, IHC Traverse-Glehen AJSP 2005

Differential diagnosis versus DLBCL Differential diagnosis versus Burkitt lymphoma

Burkitt lymphoma 1. endemic (Africa) 2. sporadic (young, rare) 3. immune deficiency-associated - HIV! t(8;14) starry sky

BCLUWFIBDLBCLABL

BCLUWFIBDLBCLABL DLBCL versus Burkitt morphology, IHC, genetics Chuang AJCP

Extranodal lymphomas the primary tumor is extranodal (not nodal) The biggest mass is extranodal at the time of the diagnosis Diagnosis may be nmore difficult than in the LN – other tumours may be more common in extranodal localizations (carcinomas..) – think of the possibility of a lymphoma Most common: GIT, skin, Waldeyer,CNS, testis, bone soft tissue, salivary glands, lung, kidney, liver, spleen, female genital tract Histological types: DLBCL, MALT l.

Gastrointestinal lymphomas most common extranodal lymphomas 50%

Klinické symptomy často necharakteristické! pokročilé: tumor v břiše, srůsty kliček, perforace lymfadenopatie hepatosplenomegalie KO: lymfocytóza,  LDH endoskopický nález

GI lymphomas Site Type B DLBCL, MALT MCL, FL T EATL Stomach Intestines (ileocaec., jejunum, duodenum)

Diffuse large B-cell lymphoma of the stomach

DLBCL HE CD20

MALT lymphoma versus DLBCL Gastric DLBCL de novo transformation of a low-grade lymphoma clonal progression in time Independent coexistence of 2 clones: low /high grade component DO NOT USE “HIGH-GRADE MALT LYMPHOMA“

MALT lymphoma chronic antigenic stimulation - Helicobacter pylori stomach, intestine (IPSID) chronic antigenic stimulation - Helicobacter pylori Regulation: specific activated T-cells Slow progression- 90%: stage IE, IIE (bone marrow involvement: rare, 10%)

Helicobacter pylori Chronic gastritis

Diseases associated with Helicobacter pylori infection Chronic gastritis Peptic ulcer Gastric carcinoma Gastric MALT lymphoma Disease Association Chronic gastritis Strong causal association Peptic ulcer disease Gastric carcinoma Gastric MALT lymphoma* Definitive etiologic role

MALT lymphoma of the stomach

MALT lymphoma Different sites common features Architecture Cytology Immunophenotype extrafolik. infiltráty folikulární kolonizace lymfoepiteliální léze monocytoidní, plazmat. buňky

Macroscopy: often noncharacteristic Microscopy: Wotherspoon criteria - spectrum 0 normal mucosa 1 chronic active gastritis 2 chronic active gastritis with lymphoid follicles 3 suspicious lymphoid infiltrate, probably reactive 4 suspicious lymphoid infiltrate, probably lymphoma 5 MALT lymphoma

MALT lymphoma Immunohistochemistry No specific MALT lymphoma marker Positivity: CD20, CD79a; Ig light chains; Ig heavy chains: IgM; CD43 Negativity: CD5, CD10, bcl6, IgD, cyclin D1 CD21, CD10, Ki-67: residual lymphoid follicles

Differential diagnosis of MALT lymphoma HP gastritis Wotherspoon criteria spectrum 0-5 other lymphomas: DLBCL, MCL, FL… Integrated approach favoring MALT lymphoma: dense lymphoid infiltrate prominent LEL Dutcher bodies infiltration of muscularis mucosae atypia of lymphoid cells B - cell monoclonality

B-cell monoclonality detection Imunohistochemistry - Ig light chains Molecular biology - PCR - IgH rearrangement Polyclonal IgH rearrangement Monoclonal IgH rearrangement

repeat the biopsy; sampling It is often not possible to establish a clear diagnosis in a single biopsy. repeat the biopsy; sampling ? MALT lymphoma/gastritis? Large cell component? Correct diagnosis and treatment Interdisciplinary communication Repeated biopsies, specialized methods

MALT lymphoma after therapy Response: regression of lymphoid infiltrate and LEL Gastric mucosa: atrophy, intestinal metaplasia, empty, fibrotic, basal lymphoid aggregates Always assess Helicobacter pylori B-cell clonality assessment by PCR: not clear

Průkaz monoklonality Imunohistochemie lehké řetězy Ig Molekulární genetika PCR přestavba genu IgH CDR III

Gastric MALT lymphoma Recurrent genetic abnormalities t(11;18)(q21;q21)/ API2-MALT1 usually the sole genetic abnormality, 25% of g. MALT l., H. p. neg., no response to ATB t(14;18)(q32;q21)/ IgH-MALT1 non-gastric t(1;14)(p22;q32)/ IgH-BCL10; t(1;2)(p22;p12) Different strains of Helicobacter pylori

MALT l. in other sites than the stomach Eye – Chlamydia psittaci Skin – Borrelia burgdorferi IPSID – Campylobacter jejuni Salivary, thyroid, lung, orbit, breast, skin Localized; disseminated (30%, after a long period) 5 y OAS: 90%

Multiple lymphomatous polyposis Mantle cell lymphoma Follicular lymphoma MALT lymphoma

Mantle cell lymphoma Multiple lymphomatous polyposis M60 bad prognosis imunohistochemistry genetics WHO

Mantle cell lymphoma - localisation Lymph nodes, Waldeyer; bone marrow Extranodal sites: GIT, skin, others GIT: multiple lymphomatous polyposis (MCL, FL, MALT l.)

Mantle cell lymphoma CD5 Cyclin D1

MALT? MCL? FISH t(11;14)(q13;q32)

Enteropathy-associated T-cell lymphoma Proximal jejunum Very rare x most common GI T-cell lymphoma Acute abdomen (40%) – emergency surgery Obstruction/perforation, peritonitis, sepsis, death Non-acute: pain, weight loss, malabsorption Age 60, M=F

Enteropathy-associated T-cell lymphoma Striking association with celiac disease Histology and immunomorphology Anaplastic/pleomorphic (80%) Celiac dis.+, enteropathy +, CD56- Monomorphic (20%) Celiac dis.-, enteropathy+/-, CD56+ Half of the patients die soon after the manifestation

Enteropathy-associated T-cell lymphoma CD3 T-cells, plasma cells, eosinophils Anaplastic

TCR gamma - PCR ABI PRISM TGGE

Testicular lymphomas

Lymfomy varlete Primární x sekundární 1% všech NHL 2% nádorů varlete ! nejčastější nádor varlete u mužů 50 let !

I. Dospělí: DLBCL MALT lymfom, folikulární lymfom T-lymfomy T/NK – lymfomy, nosní typ plasmocytom II. Děti: před pubertou Sek. (5% systém.): Burkitt, DLBCL, lymfoblastické nádory Primární: folikulární lymfom

Infiltrace varlete parciální celková Zvětšení unilaterální bilat. současné

DLBCL Intertubulární růst

Destrukce tubulů, difúzní růst

Stadium IE Cytologické rysy Nejčastěji: dif. velkobuněčný B-lymfom - CB, IB - CD20+, CD79a+

Lymfom varlete (DLBCL) ! nejčastější nádor varlete u mužů 50 let ! primární diagnózy: 10% chybné („seminom“)

Většinou diagnostikován v KLIN. ST. IEA Prognóza nemocných není tak dobrá, jako u odpovídající rizikové skupiny nodálního DLBCL Pozdních relapsy: CNS, druhostranné varle, zejména u nemocných nedostatečně léčených v úvodu

The mysterious link between the brain and the testis

CNS lymphomas

Primární lymfomy CNS pouze v CNS mozek 1% intrakraniálních nádorů – 1% NHL imunodeficientní x imunokompetentní

Multifokální, periventrikulární or unifocal mass MR Multifokální, periventrikulární or unifocal mass

Perivask. manžety CD20 RETIKULIN

Predispozice imunitní deficity AIDS EBV-LMP

Vzácné prezentace lymfomů v NS Lokalizace Oko Dura mater Mícha, extradurální expanze Lymphomatosis cerebri Kraniální a periferní nervy Typ lymfomu T-lymfom, ALCL intravask. lymfom SLL, MgZL, FL, PTLD

Závěr: primární lymfom CNS svébytná nádorová jednotka histopatologická diagnóza stereotaktická biopsie

Intravaskulární B-lymfom

Intravaskulární B-lymfom

Lymfoproliferace u imunodeficitů

immunodeficiencies Associated tumors Skin, urogenital tract, lymphomas

Stavy se sníženou imunitou 1. iatrogenic immunosuppression after transplantation (posttransplantation lymphoproliferative disease, PTLD) 2. autoimmune diseases (RA, SLE) 3. HIV 4. primary immune deficiencies 5. senile EBV-related B-cell lymphomas

PTLD Posttransplantation lymphoproliferative disease Clinicopathological spectrum 1. Histol. Iniciální - časné 2. Polymorfní 3. Monomorfní 4. Hodgkinův lymfom, PTLD podobná Hodgkinově lymfomu

Etiopatogeneze imunosuprese infekce EBV chronická antigenní stimulace štěpem další infekční agens?

Klesající imunitní odpověď Vliv EBV Reaktivní T-buňky „IM“ Polymorfní PTLD Monomorfní PTLD HL Polyklonální lymfoidní proliferace Klonální populace Sekundární genetické změny EBV Plazmocytární hyperplazie Klesající imunitní odpověď

PTLD – potransplantační lymfoproliferace Early – up to 1 year – EBV - strong role Late – after 1 year

Frekvence PTLD: 1-10% - typ a stupeň imunosuprese, - EBV status Lokalizace: často extranodální Nejvíce: 1. rok po transplantaci PTLD časná x pozdní Mortalita: Tx solidních orgánů: 60% kostní dřeně: 80% Reverzibilita: u některých PTLD Původ: příjemce (solidní) x dárce (BMT)

EBV Infectious mononucleosis Burkitt lymphoma Hodgkin lymphoma B-cell lymphomas in immunosuppressed patients (HIV, transplantation) Nasopharyngeal carcinoma

HIV and lymphomas 1 st most frequent tumor: Kaposi sarcoma Lymphoma - AIDS defining illness 3% of patients with AIDS

Lymfomy u HIV pozitivních lidí agresívní B-lymfomy, často extranodální; heterogenní (GIT, CNS) patogenetické faktory: herpesviry: EBV (v 50%), Kaposi Sarcoma Human Virus/HHV 8 (primary effusion lymphoma) chronická antigenní stimulace genetické abnormality poruchy cytokinové regulace prognóza závisí na tíži imunodeficience

Lymphomas associated with HIV Incidence increased: 60-200 x (versus noninfected population) Incidence decreases with HAART, ↑CD4 Hodgkin lymphoma: AIDS: risk 10 x higher

Lymfomy u HIV+ 1. lymfomy postihující také imunokompetentní pacienty časté: Burkittův (klasický, plazmacytoidní, atypický), DLBCL (často v CNS!) vzácnější: extranodální B-lymfom z marginální zóny, periferní T-lymfom, klasický Hodgkinův lymfom 2. lymfomy specifické pro HIV+ pacienty primary effusion lymphoma, plazmoblastický lymfom ústní dutiny 3. léze vyskytující se i u jiných imunodeficiencí - polymorfní "PTLD"

Lymfoproliferativní choroby u primárních imunodeficiencí rare More than 60 PID Heterogenous Manifestattion highly variable Ataxia teleangiectasia Wiskott Aldrich sy CVID SCID XLP…

Lymfoproliferativní choroby u primárních imunodeficiencí hlavně u dětí, častěji u chlapců; (x common variable immunodeficiency: dospělí) většinou extranodální (GIT, CNS) většinou B-lymfoproliferace: fatální infekční mononukleóza, DLBCL, lymfomatoidní granulomatóza, Hodgkinův lymfom; T-lymfomy /leukémie

Senile EBV+ lymphoproliferations no other overt ID, only the age… Oyama AJSP 2003

EBV + senile lymphoproliferations Rare Asia over 50 Various histological appearance