1. Lymphoma : Malignancy of Lymphocytes Lymphocytes B-cells T-cells NK-cells (Natural Killer Cells)

2. Definition The term "malignancy" refers to cancerous cells that have the ability to invade and destroy tissues, and / or to metastasize to other sites in the body. There may also be changes to the physiology of the organism. Malignant cells tend to have fast, uncontrolled growth due to changes in their genetic makeup.

3. A malignant clone is a clone of cell that have genomic changes that leads to the malignant state. However not all genomic changes result in malignant clones.

4. Clonal evolution is the further changes in the genome which may result in progression of disease relapse after treatment resistence to standard therapy.

5. Lymphomas 10-20 new case per 100,000 per year Deaths 8 per 100,000 per year Commonest: Diffuse Large B-cell lymphoma Follicular lymphoma CLL Mantle cell lymphoma

6. Rappaport Lymphoma Classification 1966 Well-differentiated diffuse lymphocytic lymphoma Poorly differentiated diffuse lymphocytic lymphoma Well differentiated nodular lymphocytic lymphoma Poorly differentiated nodular lymphocytic lymphoma Nodular Histiocytic lymphoma (= large cell lymphoma) Diffuse Histiocytic lymphoma (=large cell lymphoma) Mixed cell lymphoma MORPHOLOGY ONLY

7. Non-Hodgkin’s lymphoma Lukes and Collins USA Dorfman Kiel (Lennert) Germany WHO Geneva UK Hodgkin’s lymphoma Lukes-Butler Rye Nodular sclerotic Lymphocyte predominent Mixed cellularity Lymphocyte depleted

8. Lukes and Collins (1974) I. Unidentified Cell Type II. T-cells Mycosis fungoides and Sezary, convoluted lymphocyte Immunoblastic sarcoma of T-cells. III. B-cells Small lymphocytic Plasmacytoid lymphocyte Follicular center cell (FCC types; follicular, diffuse, follicular and diffuse, sclerotic) small cleaved large cleaved small non-cleaved Large non-cleaved Immunoblastic IV Histiocytic type V Unclassifiable

9. Updated Kiel B- cell Low Grade Lymphocytic- CLL, prolymphocytic,hairy cell lymphoma Lymphoplasmacytic/lymphoplasmactoid Medium Grade Plasmacytic Centrocytic Centroblastic/centroblastic High Grade Centroblastic Immunoblastic Large cell anaplastic Burkitt’s lymphoma Lymphoblastic Rare types T-cell Lymphocytic CLL, prolymphocytic Lymphoepitheloid Angioimmunoblastic T-zone Pleomorphic small cell Pleomorphic medium and large Immunoblastic Large cell naplastic Lymphoblastic Rare types

10. Working Formulation Low Grade  Malignant Lymphoma, small lymphocytic (chronic lymphocytic leukemia)chronic lymphocytic leukemia  Malignant Lymphoma, follicular, predominantly small cleaved cellfollicularcleaved cell  Malignant Lymphoma, follicular, mixed (small cleaved and large cell)follicularlarge cell Intermediate grade  Malignant Lymphoma, follicular, predominantly large cellfollicular  Malignant Lymphoma, diffuse, small cleaved cell  Malignant Lymphoma, diffuse, mixed small and large cell  Malignant Lymphoma, diffuse, large cell High grade  Malignant Lymphoma, large cell, immunoblasticimmunoblastic  Malignant Lymphoma, lymphoblasticlymphoblastic  Malignant Lymphoma, small non-cleaved cells (Burkitt's lymphoma)Burkitt's lymphoma Miscellaneous  Composite  Mycosis fungoides Mycosis fungoides  Histiocytic Histiocytic  Extramedullary plasmacytoma Extramedullary plasmacytoma  Unclassifiable

11. Immunophenotyping

15. Cytogenetics Normal Karyotype

16. t(9:22) Philadelphia chromosome

17. Fluorescent In Situ Hybridisation (FISH)

18. The Revised European American Lymphoma Classification (REAL) 1994 I. Precursor B-cell neoplasm: Precursor B-lymphoblastic leukemia/lymphoma II. Mature (peripheral) B-cell neoplasms B-cell chronic lymphocytic leukemia / small lymphocytic lymphoma B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma Splenic marginal zone B-cell lymphoma (+/- villous lymphocytes) Hairy cell leuekmia Plasma cell myeloma/plasmacytoma Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type Nodal marginal zone lymphoma (+/- monocytoid B-cells) Follicle center lymphoma, follicular, Mantle cell lymphoma Diffuse large cell B-cell lymphoma Mediastinal large B-cell lymphoma Primary effusion lymphoma Burkitt's lymphoma/Burkitt's cell leukemia  T-Cell and Natural Killer Cell Neoplasms I. Precursor T cell neoplasm: Precursor T-lymphoblastic lymphoma/leukemia II. Mature (peripheral) T cell and NK-cell neoplasms T-cell prolymphocytic leukemia T-cell granular lymphocytic leukemia Aggressive NK-Cell leukemia Adult T cell lymphoma/leukemia (HTLV1+) Extranodal NK/T-cell lymphoma, nasal type Enteropathy-type T-cell lymphoma Hepatosplenic gamma-delta T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphomapanniculitis Mycosis fungoides/Sézary's syndrome Anaplastic large cell lymphoma, T/null cell, primary cutaneous type Peripheral T cell lymphoma, not otherwise characterized Angioimmunoblastic T cell lymphoma Anaplastic large cell lymphoma, T/null cell, primary systemic type  Hodgkin lymphoma (Hodgkin Lymphoma) Nodular lymphocyte predominance Hodgkin's lymphoma Classical Hodgkin's lymphoma Nodular sclerosis Hodgkin's lymphoma Lymphocyte-rich classical Hodgkin's lymphoma Mixed cellularity Hodgkin's lymphoma Lymphocyte depletion Hodgkin's lymphoma

19. WHO classification 2002  Mature B cell neoplasms Chronic lymphocytic leukemia/Small lymphocytic lymphoma Chronic lymphocytic leukemiaSmall lymphocytic lymphoma B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma (such as Waldenström macroglobulinemia) Lymphoplasmacytic lymphomaWaldenström macroglobulinemia Hairy cell leukemia Splenic marginal zone lymphoma Extranodal marginal zone B cell lymphoma, also called MALT lymphoma Extranodal marginal zone B cell lymphomaMALT lymphoma Nodal marginal zone B cell lymphoma (NMZL) Nodal marginal zone B cell lymphoma Follicular lymphoma Mantle cell lymphoma Diffuse large B cell lymphoma Mediastinal (thymic) large B cell lymphoma Mediastinal Intravascular large B cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukemia  Mature T cell and natural killer (NK) cell neoplasms T cell prolymphocytic leukemia T cell large granular lymphocytic leukemia Aggressive NK cell leukemia Adult T cell leukemia/lymphoma Adult T cell leukemia Extranodal NK/T cell lymphoma, nasal type Enteropathy-type T cell lymphoma Hepatosplenic T cell lymphoma Blastic NK cell lymphoma Mycosis fungoides / Sezary syndrome Mycosis fungoidesSezary syndrome Primary cutaneous CD30-positive T cell lymphoproliferative disorders Primary cutaneous anaplastic large cell lymphoma Lymphomatoid papulosis Angioimmunoblastic T cell lymphoma Peripheral T cell lymphoma, unspecified Anaplastic large cell lymphoma  Hodgkin lymphoma Classical Hodgkin lymphomas:Hodgkin lymphomas Nodular sclerosis Mixed cellularity Lymphocyte-rich Lymphocyte depleted or not depleted Nodular lymphocyte-predominant Hodgkin lymphoma  Immunodeficiency-associated lymphoproliferative disorders Associated with a primary immune disorder Associated with the Human Immunodeficiency Virus (HIV)HIV Post-transplant Associated with methotrexate therapymethotrexate Primary central nervous system lymphoma occurs most often in immuno-compromised patients, in particular those with AIDS, but it can occur in the immunocompetent as well. It has a poor prognosis, particularly in those with AIDS. Treatment can consist of corticosteroids, radiotherapy, and chemotherapy, often with methotrexate. Primary central nervous system lymphomaAIDS corticosteroidsradiotherapychemotherapymethotrexate

20. WHO Classification 2008 98 lymphoma entities

21. Burkitt’s Lymphoma Endemic Sporadic

23. c-myc oncogene Regulator of 15% of genes, some of which are involved in cell replication.

24. Chronic Lymphocytic Leukemia Small lymphocytic lymphoma CD20 weak IgM weak FMC7 neg CD5 pos CD 23 pos CD 38 prognostic marker ZAP-70 prognostic marker

25. CLL Staging Stage 0 (LOW RISK) Lymphocytosis >5,000/mm3 without adenopathy (enlarged lymph nodes), hepatosplenomegaly (enlarged spleen), anemia (low red blood cells), or thrombocytopenia (low platelets). Stage I (INTERMEDIATE RISK) lymphadenopathy Stage II (INTERMEDIATE RISK) hepatomegaly or splenomegaly with or without lymphadenopathy Stage III (HIGH RISK) Hb < 11.0 g/dL, Stage IV (HIGH RISK) low platelets < 100,00/mcL

26. FISH 17 p- 32 mths 11q- 79 mths Normal 111 mths Trisomy 12 114 mths 13q- 133 mths 6q- Good prognosis 14q32 Poor prognosis

27. Low-risk CLL People in this group are often diagnosed based on a high lymphocyte count in the blood but otherwise have normal blood counts and do not have enlarged lymph nodes or organs. The prognosis (outlook) for people in this group is often very good, with long survival expected. Most people can be observed with careful and frequent follow-up exams. Treatment is considered if there are signs that the leukemia is progressing or if a person develops bothersome symptoms. When needed, initial treatment is usually chemotherapy (chemo) often combined with a monoclonal antibody targeting CD20 like rituximab (Rituxan).

28. Patients with high-risk CLL (stages III and IV) are more likely to need immediate treatment. When treatment is needed, there are many options. What treatment is used will depend on factors like the patient's health, possible side effects, the reason treatment is needed, and any need for a rapid response. Commonly used treatments include: ■FCR: fludarabine (Fludara), cyclophosphamide (Cytoxan), and rituximab ■Bendamustine (sometimes with rituximab) ■FR: fludarabine and rituximab ■CVP: cyclophosphamide, vincristine, and prednisone (sometimes with rituximab) ■CHOP: cyclophosphamide, doxorubicin, vincristine (Oncovin), and prednisone ■Chlorambucil ■PCR: pentostatin (Nipent), cyclophosphamide, and rituximab ■Alemtuzumab (Campath) Anti-CD52 ■Fludarabine (alone)

29. Prolymphocytic leukemia FMC7 pos

30. Lymph node

32. Mantle cell lymphoma CD5 +ve

37. MC treatment CHOP (hyper VCAD) Proteosome inhibitors Stem cll transplant

38. Follicular lymphoma WelI differentiated germinal centre lymphoma CD 5 –ve CD 10 +ve

40. Bcl-2

41. Lymphoma staging Ann Arbor A No symptoms B Symptoms Sweats, Unexplained fever Weight loss

42. FL treatment CLL type combinations FMDR Fludarabine Mitoxanthrone Dexamethasone Rituxamab

43. Diffuse Large B-cell Lymphoma 30% - 40% lymphomas Poorly Differentiated Germinal Centre Lymphoma Bcl-6 +ve (Chr 3q.27) (Myc, Bcl-2, cyclin D2, CyclinD3,MUM-1) Poorly differentiated non-germinal centre lymphomas May be cured by CHOP cyclophosphamide adriamycin vincristine prednisone

44. Marginal cell lymphomas Mucosa-associated lymphoid tissue MALT-oma Splenic marginal zone lymphoma Nodal marginal zone lymphoma

45. Gastric MALTOMA Helicobactor pylori nearly always present. Virulence factor CagA may be required for the continued growth of the lymphoma Japanese have shown triple antibiotic therapy for H. pylori will result in regression of the lymphoma. (amoxicillin, clarithromycin, omeprazole)

46. Other Maltomas Associated with Autoimmune Disease Thyroid Maltoma with Hashimoto’s thyroiditis Lacrimal and Salivary gland Maltoma associated with Sjrogen’s disease.

47. MALT FISH PANEL t(11;18) in gastric Maltoma t(14,18) in lacrimal/salivary gland Maltoma t(3;14) in thyroid Maltoma t(1;14) in lymph node marginal zone lymphomas

48. Hairy cell leukemia B memory cell Red pulp of spleen Often bone marrow Tartrate-resistent acid phosphatase positive CD103 positive CD11c, CD25 DBA-44 positive in paraffin sections Cures with α-interferon adenosine-deaminase inhibitors deoxycorfomycin 2-chlorodeoxyadenosine

49. Immunoglobulin Secreting Disorders Primarily bone marrow diseases 1. Lymphoplasmacytic lymphoma Waldenstom’s Macroglobulinaemia IgM > Hyperviscosity MYD-88 L265P mutation 2013 2. Plasma cell IgG, IgA, (IgD, IgE rare)

50. Plasma cell disorder WHO 2008 1. M-protein < 30g/L <10% plasma cells No symptoms = MGUS Monoclonal gammopathy of uncertain significance 2. M-protein > 30g/L and/or >10% plasma cells No symptoms = Smouldering multiple myeloma 3. M-protein and/or clonal plasma cells Symptoms CRAB hypercalcaemia renal impairment anaemia bone lesions = Multiple myeloma

51. Cytogenetics Hyperdiploid or not hyperdiploid Translocations Cyclin D1 and Cyclin D3 Good Cyclin D2 Poor

52. Treatment of Myeloma Bortezomib, cyclophosphamide, dexamethasone Thalidomide PSCT

54. T-cell Large Granular Lymphocytic Leukemia T 8 lymphoproliferative disorder. Indolent. Sometimes associated with rheumatoid arthritis. In RA patients is due to chronic inflammation involving T8-cells May cause severe neutropenia due to cytotoxic action on neutrophils Diagnosed by T-cell receptor gene rearrangement studies.

55. T-cell Prolymphocytic Leukemia Spleen, lymph nodes, liver, skin,effusions Survival < 1 yr

56. Adult T-cell leukemia-lymphoma Endemic: Central Africa, South-west Japan, Carribean Vertical transmission of HTLV-1 sexual promiscuity drug addicts Leukemia, lymph nodes, abdominal, skin and bone marrow with hypercalcemia Survival < 1 yr.

57. Mycoses fungoides

58. Enteropathy-associated T-cell lymphoma Associated with refractory coeliac disease Patient is positive for HLA-DQ2 or DQ8 Associated dermatitis herpatiformis and hyposplenism. Aggressive T lymphoma with poor prognosis

59. Peripheral T-cell lymphomas (NOS) Lymph node, bone marrow, liver, spleen, Other organs Low 5 year survival rate

60. Anaplastic Large cell Lymphoma ALK-positive Immunophenotype CD30, ALK Cytogenetics t(2;5)

61. Hodgkin’s Lymphoma CD30, CD15 PAX-5

62. Virus associated Lymphomas EBV Burkitt’s lymphoma Nasal type NK cell lymphoma Post-transplant lymphoproliferative disorders AIDS associated lymphomas Some classical type Hodgkin’s disease HTLV-1 HHV-8 Causes multicentric Castleman’s disease

63. Case Studies Mr. JC 67 yrs Kaitaia March 2009 1 month of feeling tired. Hb 139 WCC 156 Pl 77 Bone marrow : high grade lymphoma cells CSF: Clear

65. Flow cytometry :CD19, CD20, CD22 +ve CD10, CD 5 Lambda light chain FISH, c-myc bcl-2 bcl-6 all detected

66. Received CHOP, methotrexate, etopiside Remission in June 2009 September 2009 Headache, drowsiness CSF relapse Died

67. “Burkitt-like Lymphoma” Heterogenous population of large cells New Classification 2008 “B-cell lymphoma, unclassifiable, with features between DLBCL and Burkitt lymphoma”

68. AH. From Kaitaia Long standing CLL. Blood film changes

70. 55 yr old man presents with cervical lymphadenopathy Hb 149 WCC 12.9 7.0x10 9 /L Pl 166 Cervical lymph node biopsy June 2012

71. Lymphocytes CD 19 CD20 weak CD5, CD 23 pos Lamba light chain weak CD 38 pos FISH Trisomy 12