LYMPHOMAS H.A MWAKYOMA, MD

Normal lymphoid maturation Requires two major activities The production of a unique antigenic receptor on it's surface The expression of several surface proteins necessary for antigen recognition, cell activation, cell-cell communication. Antigen receptors are generated through the process of "genetic rearrangement"- the random selection and juxtaposition of discontinuous genetic segments encoding the antigen receptor genes

Normal lymphoid maturation B cells Immunoglobulin receptor composed of two heavy and two light chains Select specific heavy chain antigen recognition sequence Select only one of two light chains, kappa or lambda T cells Select one of two heterodimeric receptors Alpha/Beta heterodimer T cell receptor Gamma/Delta heterodimer T cell receptor

Surface antigen production Immune cells require numerous surface molecules for effective immune response, cell-cell communication and regulation Classified into B cell associated, T cell associated, activation associated, cytokine receptors Expression occurs in an orderly sequence in lymphoid maturation Antibodies to these molecules cataloged thru the CD - clusters of differentiation - numerical system Initially developed to characterize monoclonal antibodies detecting proteins whose function was unknown . Now up to CD166. You'll only be tested on 1-130 though (- a joke for you paranoid types.)

STAGES IN LIFE CYCLE OF B-LYMPHOCYTES Maturation in bone marrow with development of functional receptors Stage 2 Testing for and elimination of self-reactive receptors Stage 3 Mature naïve cells move to secondary lymphoid tissues Stage 4 Antigen contact with differentiation into plasma cells and memory cells

Non-Hodgkin’s Lymphoma

Outlines Introduction of lymphoma Classification of lymphoma Symptoms Signs Diagnosis Staging Management Complication of treatment Prognosis Systemic involved non-hodgkin’s lymphoma Stem cell transplantation

Introduction of lymphoma The lymphomas are malignant tumors of lymphoid tissue ,characterized by the abnormal proliferation B or T cells in lymphoid tissue .

Non-Hodgkin’s Lymphoma Non-Hodgkin’s lymphomas (NHL) are a heterogeneous group of malignant lymphomas. There are many different subtypes, every few years the classification is updated. Today, morphology, immunophenotype, molecular, cytogenetics, and other techniques are used for diagnosis. Treatment generally depends on the aggressiveness of the disease (indolent, aggressive, or very aggressive)

Non-hodgkin’s lymphoma This is lymphoma without the presence of Reed-Sternberg cell. B lymphocyte more than T lymphocyte. The extranodal involvement is common,more than HL. Causes of it’s congenital and acquired immunodeficiency e.g drugs , HIV infection, H.pylori infection

Behaviour Lymphomas may be grouped by how quickly they are likely to grow: Indolent (also called low-grade) lymphomas grow slowly. They tend to cause few symptoms. these lymphomas grow slowly. The majority of NHLs are considered indolent. Indolent lymphomas are generally considered incurable with chemotherapy and/or radiation therapy

Behaviour Aggressive (also called intermediate-grade lymphomas) These lymphomas have a rapid growth pattern. They tend to cause severe symptoms. Over time, many indolent lymphomas become aggressive lymphomas This is the second most common form of NHL and are curable with chemotherapy

Behaviour Very Aggressive – (also called High grade lymphoma) These lymphomas grow very rapidly. They account for a small proportion of NHLs and can be treated with chemotherapy. Unless treated rapidly, these lymphomas can be life threatening.

Marginal Zone Lymphoma Indolent Accounts for ~10% of all lymphomas Subcategories MALT Nodal Extra Nodal Splenic

Mantle Cell Lymphoma Aggressive Accounts for ~ 6% of all lymphomas Considered “incurable” with traditional RX Stem cell transplant is offered often as front-line consolidation treatment in “younger” patients

Primary CNS Lymphoma Aggressive Accounts for ~ 1-2% of all lymphomas Different chemotherapy treatments Often requires radiation to the brain: Brain dysfunction in younger patients Dementia in older patients

Anaplastic Large Cell Lymphoma (ALCL) Aggressive Accounts for ~ 2% of all lymphomas Two groups: ALCL ALK-1+ better prognosis, more common in younger patients and children ALCL ALK-1-negative : as bad as any other T-cell lymphoma

Peripheral T-cell Lymphoma Aggressive Accounts for ~ 7% of all lymphomas Worse prognosis, often associated with extranodal presentation Often requiring salvage treatment and transplant

Large Cell Lymphoma Very Aggressive Accounts for ~ 31% of all lymphomas

Classification of lymphomas Subtyping or classification within the two groupings necessary, because different subtypes have Distinct clinical presentations Can require different therapy Have differing prognoses, reflecting different mechanisms of molecular pathogenesis. Unfortunately, rarely unanimous acceptance of any one classification scheme. Intermittent upgrading of classification, with new terminology, reflecting new information and classifier bias Classification often lags behind advances in immunology, research pathology Final result: Difficult area to teach Difficult to remember Job security for me

Classification of lymphoma Hodgkin’s lymphoma Non hodgkin’s lymphoma

Histologic classification of non-Hodgkin’s lymphomas 1. Rappaport - 1966 2. Lukes and Collins - 1974 3. Dorfman - 1974 4. Bennet et al., - 1974 5. Lennert - 1974 6. WHO - 1976 7. Working Formulation - 1982 8. REAL - 1994 9. WHO - 1999

Working Formulation Divided into three "grades" of lymphoma- low, intermediate and high. Low grade = indolent Intermediate and high = aggressive Limitations Purely morphologic classification mixed T and B cell lymphomas together Lumped distinct subtypes of B cell lymphomas together Obscured the biologic, clinical and therapeutic differences Distorted interpretation of clinical trials

Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) 1. Low grade 2. Intermediate grade 3. High grade

Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) Low grade non Hodgkin's lymphomas Small cell lymphocytic Follicular (it is the most common type of lymphoma) Mantle cell Splenic marginal zone lymphoma MALT lymphoma Lymphoplasmacytic NHL

Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) Intermediate grade D. - Follicular, predominantly large cell. E. - Diffuse small cleaved cell. F. - Diffuse mixed, small and large cell. G. - Diffuse large cell.

Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) High grade H. - Large cell immunoblastic. I. - Lymphoblastic. J. - Small noncleaved cell: Burkitt’s

Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) High grade non Hodgkin's lymphomas Diffuse large B cell Diffuse mixed cell lymphoma Burkitt's lymphoma Anaplastic large cell lymphoma

Non-Hodgkin’s lymphomas /NHL/ - clinical features

Non-Hodgkin’s lymphomas-Clinical features 1. Constitutional symptoms (fever, night sweats, weight loss) 2. Lymphadenopathy (cervical, supraclavicular, axillary, inguinal, mediastinal, retroperitoneal, mesenteric, pelvic). 3. Mediastinal adenopathy (T cell lymphoma) 4. Extralymphatic involvement (gastrointestinal, testicular masses, solitary bone lesions, CNS). 5. Unexplained anemia and thrombocytopenia ( bone marrow infiltration).

For the diagnosis of non-Hodgkin’s lymphomas the histological examination of a lymph node is necessary!

Non-Hodgkin’s lymphomas - histological classification

R.E.A.L./W.H.O. Classification WF replaced in 1994 by the Revised European American Lymphoma (REAL) classification, now being modified by the World Health Organization (WHO) REAL/WHO is a "disease” oriented rather than purely morphology oriented classification, based on: Cell lineage: B v T v NK v Histiocytic Stage of maturation of the presumed normal counterpart. Includes immunologic and molecular criteria in addition to purely morphologic criteria of WF

R.E.A.L./W.H.O. Classification—CONT-- Each disease entity may have differing grades of aggressiveness Greatly expanded the list of entities; includes leukemias of lymphoid origin Made teaching to medical students (and in fact all physicians) even more difficult than WF REAL contained a number of “provisional entities” which have been clarified in the upcoming W.H.O. revision.

REAL/WHO classification- backbone B cell neoplasms Precursor B cells-related to acute leukemia (acute lymphoblastic leukemia & (lymphoblastic lymphoma) Peripheral B cell lymphomas- the majority of B cell lymphomas T cell and Natural Killer cell neoplasms Precursor T cells Peripheral T cell and NK neoplasms Hodgkin’s lymphoma

REAL /Revised European-American Lymphoma/-WHO classification of non-Hodgkin’s lymphomas Peripheral B cell lymphomas - Chronic lymphocytic leukemia/lymphocytic lymphoma - Chronic prolymphocytic leukemia - Immunocytoma/lymphoplasmocytic lymphoma - Mantle cell lumphoma - Marginal zone lymphoma /MALT-type/ - Hairy cell leukemia

REAL /Revised European-American Lymphoma/-WHO classification of non-Hodgkin’s lymphomas Peripheral B cell lymphomas /continued/ - Follicle center cell lymphoma - Plasma cell myeloma/plasmocytoma - Diffuse large B cell lymphoma - Burkitt’s lymphoma - Splenic marginal zone B cell lymphoma

REAL /Revised European-American Lymphoma/-WHO classification of non-Hodgkin’s lymphomas Peripheral T cell lymphomas T cell chronic lymphocytic leukemia T cell chronic prolymphocytic leukemia Large granular lymphocyte leukemia /LGL/ Mycosis fungoides /Sézary syndrome Peripheral T cell lymphomas, unspecified

REAL /Revised European-American Lymphoma/-WHO classification of non-Hodgkin’s lymphomas Peripheral T cell lymphomas/continued/ Angioimmunoblastic T cell lymphoma Angiocentric lymphoma Intestinal T cell lymphoma Adult T cell lymphoma/leukemia Anaplastic large cell lymphoma

Very aggressive non-Hodgkin’s lymphomas B-, T-cell acute lymphoblastic leukemia B-, T-cell lymphoblastic lymphomas Burkitt’s lymphoma Adult T cell lymphoma/leukemia

High risk aggressive non-Hodgkin’s lymphomas 1. Age above 60 years. 2. Disease stage III and IV. 3. Extranodal involvement of more than 1 site. 4. Serum LDH concentration >1 x normal. 5. Performance status < 80%.

B cell neoplasms- Precursor B Precursor B cell lymphoblastic leukemia/lymphoma Frozen at lymphoblast cell stage of antigen independent B cell differentiation- normally restricted to bone marrow Usually present as acute leukemia +/- lymph node involvement Can initially present as node or skin disease, with later progression to bone marrow Treated as acute leukemia 80% cure rate in children 20-30% in adults because of "bad" cytogenetics: frequent presence of Philadelphia chromosome t(9;22)

Peripheral B-cell neoplasms Frozen at various stages of antigen dependent B cell maturation and differentiation Small lymphocytic/CLL- the virgin B cell fresh from the marrow Prolymphocytic leukemia- a more clinically aggressive variant of above Lymphoplasmacytic lymphoma- the primary immune response Mantle cell lymphoma- the mantle region surrounding the follicle Follicular lymphoma- the follicle- grades 1-3 Extranodal marginal zone lymphoma- cells at the periphery of the follicle in extranodal sites of lymphoid tissue- Mucosal Associated Lymphoid tissue- such as G.I. tract

Peripheral B-cell neoplasms Nodal marginal zone lymphoma Splenic marginal zone lymphoma- immunologically distinct Hairy cell leukemia- pre-plasma cell Diffuse large B-cell lymphoma- this breaks the ideal of specific cell stage but all represent lymphomas with high replication rate Burkitt lymphoma- very aggressive Plasma cell myeloma- diffuse bone marrow proliferation of plasma cells Plasmacytoma- solitary focus of monoclonal plasma cells, with variable risk of progression to myeloma, depending on site

Mantle cell lymphoma Clinical 6% lymphomas Disease of adults (median age 63) Usually widely disseminated Poor response to all attempted therapies, ? curable with transplant 5yr survival 27% Pathogenesis Due to t(11;14) Upregulates Bcl1 (cyclin D1), a cell cycle regulator

Mantle cell lymphoma Pathology/Diagnosis Benign equivalent is lymphocyte of inner mantle zone Cytology similar to cleaved cell, but nuclear irregularities not as prominent Nodal infiltration diffuse, vaguely nodular or "mantle zone" around residual benign follicles Large cell progression infrequent Immunophenotype: Positive: monoclonal light chain, CD19, CD5, Bcl1 (and Bcl2) Negative CD10, CD23

Follicular lymphoma Mantle cell lymphoma CyclinD1 Bcl2

T cell lymphomas-Precursor T Clinical Disease of teenagers; boys>girls Can present as acute leukemia or mediastinal mass+/- marrow involvement Aggressive lymphoma/leukemia, but curable: ~70% with appropriate multiagent chemotherapy Pathogenesis No single gene culprit, but frequently involve translocation of (onco)genes to site of T cell receptor genes, --> upregulation of proteins

T cell lymphomas-Precursor T Pathology Benign equivalent immature T cells of thymus Histology: Diffuse infiltration of thymus/adjacent lymph nodes Cytology: “Blast cells” of intermediate size with oval to “convoluted” nuclear profiles, fine chromatin and 0-1 nucleolus Again need immunology to distinguish from pre-B

Peripheral T cell lymphomas Predominantly leukemic/disseminated T-cell prolymphocytic leukemia T-cell large granular lymphocytic (LGL) leukemia NK cell leukemia Adult T-cell leukemia/lymphoma

Peripheral T cell lymphomas Predominantly nodal Angioimmunoblastic T-cell lymphoma Peripheral T-cell lymphoma unspecified Anaplastic large cell lymphoma, T/null-cell

Peripheral T cell lymphomas Predominantly extranodal Mycosis fungoides Sezary syndrome Primary cutaneous CD30+ T-cell lymphoproliferative disorders Subcutaneous panniculitis-like T-cell lymphoma NK/T cell lymphoma, nasal and nasal-type Enteropathy-type intestinal T-cell lymphoma Hepatosplenic T-cell lymphoma

Key points regarding T cell lymphomas Clinical Represent 20% all lymphomas More often extranodal than B Can involve skin, midline facial area, liver Very characteristic clinical presentations Most diseases bad: high stage, and poorer response to therapy than B cell lymphomas of all grades

Key points regarding T cell lymphomas Pathogenesis: Characteristic cytogenetic findings associated with several types Anaplastic large cell lymphoma- t(2;5): ALK1 gene Hepatosplenic T cell lymphoma- Isochromosome 7

Key points regarding T cell lymphomas Pathology Cytologic features not as predictive of behavior as B cell lymphomas Anaplastic large cell lymphoma --> better prognosis than most indolent B cell lymphomas- 77% 5 year survival Mycosis fungoides, indolent cutaneous lymphoma, incurable, but with long clinical course

Key points regarding T cell lymphomas Immunophenotypic studies frequently demonstrate Loss of normal T cell associated antigens Antigens associated with Natural Killer cell function Immunology absolutely necessary to recognize

Diagnosis BLOOD: (FBC, Film, ESR, LFT, LDH, Urate , Ca.) Lymph node excision biopsy , image guided needle biopsy. Chest X-ray, CT of thorax, abdominal, pelvis and bone marrow biopsyـــــــstaging of HL

Immunologic Techniques Flow cytometry-automated fluorescent microscopy Immunohistochemistry- in situ immunologic detection through the use of enzyme substrate color deposition Both utilize monoclonal antibodies to detect clonality and unique antigenic patterns

Immunologic Techniques Flow cytometry-automated fluorescent microscopy Immunohistochemistry- in situ detection through the use of enzyme substrate color deposition Examples B cell small lymphocytic lymphoma- Monoclonal light chain, CD19, CD20, CD5, CD23 positive, CD10 negative B cell follicular lymphoma- Monoclonal light chain, CD19, CD20, CD10 positive, CD5 negative

Molecular techniques Detection of antigen receptor clonality Detection of unique cytogenetic rearrangements/translocations Examples Clonal gene rearrangement by Southern blot Bcl2/JH rearrangement by polymerase chain reaction

The End!