approach to nhl

8/6/2019 Approach to NHL

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G. Swarnalata

Senior Consultant Pathologist

Apollo Hospitals, Jubilee Hills,

HyderabadE mail: [email protected]

A pattern based approach tonodal lymphoma : The critical role

of histology


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WHO classification of lymphoma (2001)Non- Hodgkin lymphoma

y

B cellPrecursor B cell

Mature B cell

B cell proliferation of uncertain

malignant potential

y Hodgkin lymphomaNodular lymphocyte predominant

Classical Hodgkins lymphoma

Nodular lymphocyte rich

Nodular sclerosis

Mixed cellularity

Lymphocyte depleted

y Histiocytic and dendritic cellneoplasms

y Mastocytosis

y

T cell and NK cellPrecursor T cell

Peripheral T and NK cell

T cell proliferation ofuncertain malignant potential


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B cell non-Hodgkin lymphomay Precursor B cell neoplasms

Lymphoblastic

y Mature B cell neoplasms

Chronic lymphocytic leukemia/ small lymphocytic lymphoma

B- prolymphocytic leukemia

Lymphoplasmacytic lymphoma

Mantle cell lymphoma

Follicular lymphoma

Splenic marginal zone lymphoma

Marginal zone lymphoma

Hairy cell leukemia

Diffuse large cell lymphoma

Mediastinal large B-cell lymphoma

Intravascular large B-cell lymphoma

Primary effusion lymphoma

Burkitts lymphoma

Plasmacytoma/ plasma cell myeloma

Solitary plasmacytoma of bone


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Analysis of nodal lymphoma1994 2008 : 692 cases

Apollo Hospitals, Jubilee Hills, Hyderabad


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Analysis of nodal lymphoma1994 2008 : 692 cases


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Scope of the symposium

Topics not covered

y Common lymphomasy Approach to diagnosis

y Histology

y Immunohistochemistry

y Uncommon lymphomas

y Extranodal lymphoma

y

Variant patterns of the common lymphomasy Cytogenetics

y Molecular studies

y Limitations of IHC


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Indolentlymphomathe good

Aggressivelymphomathe bad

Highlyaggressivelymphomathe bad

Entities FollicularlymphomaCLL/SLL

Marginal zone

Diffuse large BcellPeripheral T

cell

BurkittslymphomaLymphoblastic

Age group Older adults Any age Children andyoung adults

Rate of growth Slow; waxingand waning Fast Very fast

Stage atpresentation

Usually highstage

Evenlydistributedthrough the

stages

Usually highstage


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Indolentlymphomathe good

Aggressivelymphomathe bad

Highlyaggressivelymphomathe bad

Natural history ifuntreated

Indolent course Kills in 1 to 2years

Kills in weeks tomonths

Response to

treatment

Often not

curable

Potentially

curable

Highly

responsive toaggressivechemotherapy

Clinical outcome Repeatedrelapses

70 to 80%completeremission

Cure in earlystage disease

Survival curve


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Approach to lymphomas

y Nodular / diffuse

y

Small lymphocyticy Medium lymphocytic or blastoid

y Large lymphocytic

y Mixed small and large


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Reactive follicular hyperplasia versusfollicular lymphomaDiscrete separated follicles

Variable in size and shape

Well defined mantles


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Follicular lymphomaBack-to back arrangement of follicles

Mantles lacking

Follicles in perinodal tissue


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Reactivehyperplasia

y Heterogeneouspopulation

y Tingible bodymacrophages

y Polarisation


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Follicular lymphoma

y Predominantlycentrocytes

y Lack of tingiblebody macrophages

y Loss of polarisation


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Grade 1

15/hpf

Grading of follicular lymphoma

Number of centoblasts per high power field

At least 20 fields of neoplastic follicles counted


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Nodular growth pattern inlymphomas

y Follicular lymphoma

y Mantle cell lymphoma

y Extranodal marginal zone lymphomay Nodular lymphocyte predominant Hodgkins

y Classic Hodgkins

y Lymphoblastic lymphoma


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Mantle cell lymphomaMantle zone pattern

Mantle cell nodular

Diffuse

Starry sky


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y Small to mediumsized

y Slight/ moderatenuclear irregularities

y Open nuclearchromatin

y

Small inconspicuousnucleoli

y Scant cytoplasm

y Prominent mitoses


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Starry sky pattern in mantle cell lymphoma


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Marginal zone lymphoma


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y Small to mediumsized

y Irregular necleoli

y Absent nucleoli

y Pale nucleoli


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Diffuse small cell lymphoma

y B-CLL/SLL

y Mantle cell lymphoma

y Marginal zone lymphoma


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Small lymphocytic lymphoma

Dark staining infiltrate punctuatedby pale proliferation centres


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Follicular pattern in smalllymphocytic lymphoma


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Proilferation centres or pseudofollicles

Small lymphocytes,prolymphocytes and

paraimmunoblasts


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Follicular Mantle cell

Small lymphocytic


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Medium sized/ blastoidlymphomas

y Lymphoblastic lymphoma

y Burkitts lymphomay Blastoid mantle cell lymphoma

y Blastic NK cell lymphoma


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Lymphoblastic lymphoma


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Burkitts lymphoma


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Round to convoluted nuclei

Delicate chromatin

Inconspicuous nucleoli

Scant cytoplasm

Multiple distinct nucleoli

Moderate deeply basophilic cytoplasm


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Diffuse large cell proliferations

y Lymphoma

y Diffuse large B cell ( DLBCL)

y

Anaplastic large cell (ALCL)y Classic Hodgkin, syncytial variant

y Classic Hodgkin, lymphocyte depleted

y Peripheral T cell

y

Metastatic carcinomay Metastaic melanoma

y Metastatic sarcoma


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Diffuse large cell lymphoma


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y Non cohesive

y Nuclear moulding

y Nuclear streaming

y Nuclear membranefolding

y Cytoplasmbasophilic/amphophilic


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Immunoblastic lymphoma Plasmablastic lymphoma


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Anaplastic large cell

T cell rich B cell


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Metastatic carcinoma

y Cohesive islands oftumour

y Sharp boundary withstroma


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Metastatic signet cell carcinoma Metastatic poorly differentiated carcinoma


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Metastatic melanoma

y Cohesively non

cohesivey Individual cells

falling off withinislands


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Peripheral T cell lymphoma


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Pointers to a peripheral Tcell lymphoma

y Paracortical expansion

y Prominent high

endothelial venulesy Mixed inflammatory

infiltrate

y Lymphocytes ofvarying size

y Clear cells

y Multinucleate and ReedSternberg like cells


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Algorithm for lymph node diagnosis

Lymph node

Follicular Diffuse

Small LargeMediumReactive Lymphoma

Lymphoid Non-lymphoid

LBL Burkitt

Small cleavedFollicular Mantle SLL

Small round

DLBCL variants

DLBCL ALCL,

PTCL

Hodgkin


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The importance of a goodquality H & E stained section


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Poor fixation


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Poor processing


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Shattered sections


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Careful and critical histologic

examination remains the mostimportant first diagnostic step inthe evaluation of lymph nodes

and the determination of whatancillary tests are required toreach a final diagnosis.

approach to nhl

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