1. LYMPHOMAS
H.A MWAKYOMA, MD

2. 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

3. 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

4. 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 though (- a joke for you paranoid types.)

5. 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

6. Non-Hodgkin’s Lymphoma

7. 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

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

9. 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)

10. 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

11. 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

12. 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

13. 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.

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

15. 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

16. 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

17. 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

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

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

20. 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

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

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

23. 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

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

25. 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

26. 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.

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

28. 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

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

30. 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).

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

32. Non-Hodgkin’s lymphomas - histological classification

33. 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

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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%.

42. 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)

43. 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

44. 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

45. 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

46. 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

47. Follicular lymphoma
Mantle cell lymphoma
CyclinD1
Bcl2

48. 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

49. 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

50. 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

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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. The End!