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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.