Professional Documents
Culture Documents
Norman Levy, MD
Big Picture
Aswithotherorgans,lymphnodes,andmoreglobally,the
immunesystem,canbethesiteofinfectious,immuneand
neoplasticdisease,thelattereitherprimaryormetastatic
Theclinicalmanifestationsofdiseasesofthelymphnodesare:
Localenlargement,tenderonnontender,+/_
Compressionofadjacentstructures+/_
Releaseofcytokinesproducing"systemic"symptomsof
fever,weightlossandnightsweats
Infectiousorganismscanstimulatethesameacute,chronicor
granulomatousreactionsinthedraininglymphnodesasthey
characteristicallystimulateatothersites
Big Picture 2
Severaltypesofimmunestimulicancause"reactive"
enlargementoftheentirelymphnode,orselective
expansionofcortical,paracorticalormedullaryregions
Metastatictumorsspreadtothelymphnodesprimarilyvia
lymphaticdrainagefromadjacentsolidorgans
Primaryneoplasmsofthelymphnodesareallmalignant
TheyaredividedintomalignantnonHodgkin's
lymphomas(NHL),andHodgkinlymphoma
Big Picture 3
NHL'saremorecommon,andcanbesimplydividedinto
indolent,orslowgrowingtypes,andaggressivetypes
Malignantlymphomasrepresentclonalmalignanciesin
whichmutationaleventshavecausedthemajorityof
progenycellstofreezeatasinglestageofnormal
lymphocytedifferentiation
Lymphomasfrozenatastageassociatedwithhigh
replication>aggressivelymphomas;
Lymphomasfrozenatstagesassociatedwith
recirculationorfinalfunction>indolentlymphomas
BigPicture4
Thediagnosisofmalignantlymphomasisbasedonthe
microscopicrecognitionofthedominantcytologiccell
type,supplementedbyimmunologicandmolecular
techniques
Thetreatmentandprognosisoflymphomasarebasedon
Thedominantcelltype(andit'sinherentbiologic
behavior),
Theextentofspread(Stage)
Theunderlyinghealthofthepatient
Allofthepreviousstatementsarecomplicatedbythefact
thatindolentlymphomascanfurthermutateand
transformtoaggressivetypes
BigPicture5
Hodgkinlymphomaisalesscommonnodaldisease
whosediagnosisisbasedonthedetectionofa
characteristiccell,theReedSternbergcell,inthe
appropriatehistologicsetting
Thereareseveral(five)histologicsubtypes,butprognosis
isbasedprimarilyonextentofdisease
Hodgkinlymphomaisamorecurablediseasethannon
Hodgkinlymphomas
Nowwatchmeconfusethisrelativelystraightforward
informationwiththedetails.
Overviewofthelymphoid
immunesystem
Lymphocytesevolvefrompluripotentstemcells>two
majorfunctionalcelltypes:
Blymphocytes,comprisingthehumoralimmune>
productionofantibodies
Tlymphocytes,comprisingthecellularimmune
system,>
Directkillingofforeignorintracellularlyinfected
cells,cytotoxicTcells
Finecontroloftheimmuneresponsethroughthe
secretionofcytokines,helperandsuppressorT
cells.
Anatomical organization
The anatomic organization of the lymphoid immune system divided
into two major functional regions:
The primary immune organs, sites of initial maturation --> immune
competent cells:
B cells- bone marrow
T cells- thymus
The secondary immune organs, sites of antigen driven replication
and differentiation into committed effector cells
Lymph nodes
Spleen
Mucosal Associated Lymphoid System (MALT)- lymphoid cells
lining the respiratory and gastrointestinal tracts
Everywhere else
The lymph nodes, in their totality, represent the largest secondary
organ, and the major site of lymphoid pathology
Lymph node anatomy
To recognize
lymph node
pathology,
one has to
be familiar
with normal
lymph node
anatomy
and cytology
Lymph node histology
Lymph node variation
Lymph node histology
is dynamic: follicles
In the absence of
immune stimulation,
primary follicles
In the presence of
immune stimulation,
secondary follicles or
germinal centers
Lymphocyte homing
After initial maturation in the primary The site of T cell homing is the
immune organs, "virgin" B and T paracortex
lymphocytes --> peripheral blood --> The separation of B and T lymphocytes
home to specific sites within the lymph not absolute,
node (and the other secondary Both cell types present throughout
organs), lymph node, necessary for coordinated
The sites of B cell homing include: lymphoid immune response.
The primary and secondary
follicles of cortex-the sites of
antigen presentation
proliferation and
differentiation in response to
same
The medullary cords -->plasma
cells aggregate--> release their
immunoglobulins into the efferent
lymph
Lymphocyte recirculation
Normallymphocytesrecirculate,passingfromblood>
lymphnodes>efferentlymphatics
Allowsconstantsurveillanceforthepresenceofthe
antigenforwhichthelymphocytehasauniqueand
specificreceptoronit'ssurface.
Ifantigennotpresent,lymphocytesleavethenodeand
recirculate
Virginlymphocyteshaveafinitelifespan,numberedin
weeks,unlesstheycomeincontactwithantigen
Cytologyofthelymphnode
Thenormalorreactivelymphnodeisthusadynamicorgan
Composedof
TransientBandTlymphocytes
Antigenprocessingandpresentingcells
ReplicatingBandTlymphocytes(inresponsetoantigen)
Persistentandtransientfinaleffectorcells
Macrophages
Someofthesefunctionalsubgroupsarecytologicallyunique,others
cytologicallyindistinguishable
Theultimatemicroscopicimpression,withpractice,isoneof
cytologicheterogeneity,andhistologicorganization
CelltypesI
Small lymphocytes
Small round dark blue dots. Round
nucleus, clumped chromatin, small or
absent nucleolus.
The dullest looking cells hiding the
greatest level of functional
heterogeneity. Locations:
Can be T or B cell, virgin
B cells- primary follicles,
(unexposed to antigen) or
differentiated effector/memory cell. mantle zone of secondary
follicles, medullary cords
Most likely lineage, B or T, guessed
by location within the node, but T cells- paracortex, minor
lineage and state of differentiation population within germinal
must be confirmed by center.
immunologic/molecular techniques Kinetically, clumped
chromatin tells us that the cell is
not proliferating- not activated
to enter the cell cycle and
replicate
Celltypes2:Follicular(germinal)
centercells
Replicating and post-replicating B cells Small cleaved cells-
Noncleaved cells, small and large Nonreplicating population
Replicating populations- Post mitotic memory or plasma
expanding antigen responsive cell precursors
cells. Clumped chromatin
Round nuclei but larger than Irregular folded and cleaved
resting small lymphocyte nuclear profiles
Open or vesicular chromatin
Recognizable nucleoli.
Nucleus clear -->genetic
material unwound for
replication.
Size, large or small compared
nucleus of macrophage.
Reactive germinal center
MZ
LZ
DZ
Cytologyoflymphnode3
Immunoblasts Accessory cells
Replicating large cells found Antigen processing cells
outside the germinal centers. Interdigitating reticulin cells- T cell paracortex
May be of B or T cell type Dendritic reticulin cells- B cell germinal centers
Have nuclear characteristics of Process and present antigen to B and T
replicating lymphocytes- lymphocytes
Invisible in normal lymph node
Vesicular chromatin
Macrophages (histiocytes)-
Nucleoli
Phagoctytic cells of lymph node
Tingible body macrophages of germinal
centers
Medullary and subcapsular sinus
macrophages-
Abundant pale cytoplasm
Oval nucleus, single small nucleolus
Pathologyoflymphnodes1
Infections
Reactivehyperplasias
Sarcoidosis
Metastatictumors
Malignantlymphomas
NonHodgkinslymphomaNHL
Hodgkinslymphoma
Pathologyoflymphnodes2
Infections
Bacterial
Acuteinflammation,abscessformation
Granulomatous,caseousandnoncaseous
Diagnosisbyculture,serologies,and/orspecialstains
Reactivehyperplasias
Exaggerations of normal histology.
Expansion of all regions or selective expansion
Some types characteristic of certain diseases, but most not
Follicular hyperplasia- increase in number and size of germinal centers,
spread into paracortex, medullary areas
Collagen vascular diseases
Systemic toxoplasmosis
Syphillis
Interfollicular hyperplasia- paracortex
Skin diseases
Viral infections
Drug reactions
Sinus histiocytosis- expansion of the medullary sinus histiocytes-
Adjacent cancer
Infections
Malignantlymphomas
(NonHodgkin'slymphomasNHLs)
Malignanciesofthelymphoidsystemwhichprimarily
manifestthemselvesoutsidethebonemarrow,atthesites
ofnormallymphoidhoming
Lymphnodes
Spleen
M.A.L.T.
Anywhere
(Lymphomasoutsidelymphnodesandspleenare
referredtoasextranodallymphomas)
Approximately40,000casesperyear,20,000deaths
Clinicalpresentation
Enlargingmass(es),typicallypainless,atsitesofnodaltissue
Compression,infiltrationofholloworgans
Pain,obstruction,perforation
Interferencewithnormalorganfunction
Solidorganinfiltrationkidneys,liver,bonemarrow
Systemicsymptoms
Fever
Nightsweats
Weightloss
Ifmarrowinfiltrated,canhaveleukemiccomponent
NHL2
Composedofcellsthathavelosttheabilitytopursuethefull
rangeoflymphoiddifferentiation,andarefrozenatasingle
stageofthenormalmaturation/differentiationsequence
Recapitulatethebiologyandimmunophenotypeofnormalcell
counterpart
Severalcytologicallyandimmunologicallyrecognizablestagesof
normallymphoidmaturation>severalsubtypesoflymphoma
Clonalmalignancies,derivedfromasinglecellthathas
undergoneamalignanttransformation,mutation
Bestinitiallyconceptualizedastwomajorclinicaltypes
Indolentlymphomas
Aggressivelymphomas
NHL 3 Indolent lymphomas
Lymphomasfrozenatstagesnotnormallyreplicating,but
maybecirculating
Diseasesofslowaccumulation,duetodefectiveapoptosis
Oftenwidespreadatdiagnosis
Prolongednaturalhistory,mediansurvivals>5years
Willusuallyrespondtochemoorradiationtherapy
Willusuallyrelapse,butrespondtosameoralternativetx
Currentlyincurableunless
Localizeddiseaseor
Marrowablationwithsometypeofstemcelltransplant
Classificationofindolentlymphomaslater
Aggressivelymphomas
Lymphomasfrozenatstagescharacterizedbyreplicationand
acceleratedgrowth
Diseasesofdefectivecellcyclecontrol
Moreoftenlocalizedatpresentationthanindolentlymphomas
Moreoftenextranodal
Shorternaturalhistory;mediansurvival</=2years
Requiremoreaggressivetherapytoachieve"clinicalremission"
disappearanceofalldetectabledisease
Despiteshortnaturalhistory,curablediseaseinsomewith
aggressivetherapy
Approximately3040%ofadults
5080%children
Allchildhoodlymphomasofthistype
Classificationoflymphomas
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
WorkingFormulationfor Low grade
Limitations
Purely morphologic classification mixed T and B cell lymphomas together
Divides B and T
BcellneoplasmsPrecursorB
Precursor B cell lymphoblastic leukemia/lymphoma
Frozen at lymphoblast cell stage of antigen independent
involvement
Can initially present as node or skin disease, with later
transplant
Partially predictable by International Prognostic Index (later)
Pathogenesis
Not as clearly defined as previous examples- several cytogenetic
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
Follicularlymphoma Mantlecelllymphoma
CyclinD1
Bcl2
Table X: Indolent B cell lymphomas
Follicular Marginal zone Small lymphocytic Mantle cell
Lymphoma Lymphoma lymphoma/CLL Lymphoma
(Grade I)
Frequency (% 22% 8 7 6
all lymphomas
Age of onset 59 61 65 63
median
Stage at Stage III/IV Stage I Stage IV Stage III/IV
Presentation Disseminated
Response to Good to most Frequently Similar to Poor response to
Therapy treatments, curable Follicular all therapies
but incurable lymphoma to date
short of
transplant
5 yr survival 72% 74% 51% 27%
involvement
Aggressive lymphoma/leukemia, but curable: ~70% with
Detect clonality
antigens
Recognize characteristic patterns of antigenic expression
Monoclonallightchain,CD19,CD20,CD5,CD23
positive,CD10negative
Bcellfollicularlymphoma
Monoclonallightchain,CD19,CD20,CD10
positive,CD5negative
Moleculartechniques
Detectionofantigenreceptorclonality
Detectionofuniquecytogenetic
rearrangements/translocations
Examples
ClonalgenerearrangementbySouthernblot
Bcl2/JHrearrangementbypolymerasechain
reaction
Clinicalpresentation
Enlargingmass(es),typicallypainless,atsitesofnodal
tissue
Obstruction,ulcerationofholloworganspain,perforation
Interferencewithnormalorganfunction
Solidorganinfiltrationkidneys,liver,bonemarrow
Systemicsymptoms
Fever
Nightsweats
Weightloss
Ifmarrowinfiltrated,canhaveleukemiccomponent
Clinicalstagingoflymphomas
Definesextentofdisease;determinestherapyandprognosis
Basedonphysical,radiologicexamination,bonemarrowbiopsyand
aspiration
AnnArborStagingsystem
Bsymptomsfever,weightloss>10%bodyweight,nightsweats
Stagingtable
Prognosis
Internationalprognosticindex
Aggressivelymphomas
Cytogenetics
Oncogenes
International Prognostic Index 1
Clinical features
identifying prognostic
subsets of diffuse
large cell lymphoma
Identified through
retrospective
statistical analysis of
large set patients
Assigned 1 point for
each bad feature
Survival curves
TherapyIIndolentlymphomas
Seminar cases will also discuss "Bone marrow transplant"-
Limited stage (5-10% cases) Effort at cure
Radiation therapy
Reserved for younger patients <60
Can be curative
Disseminated indolent/low grade lymphomas (90%) High dose chemotherapy and
No therapy allogeneic transplantation
Low morbidity limited chemotherapy High dose chemotherapy and
Older patients autologous peripheral stem cell
No expectation of cure collection/reinfusion
Most will respond totally or partially, with months to Increased morbidity
years of disease free survival, but will relapse
Many will respond to additional rounds of similar or
alternative regimens
Pts will die of disease, or interceding disease of elderly
Death from disease due to
Immune suppression- infections
Progression to aggressive lymphoma
TherapyIIAggressive
lymphoma
Limiteddiseaselocalizeddiseasetreatedwithirradiationplus
limitedcyclesmultiagentchemotherapy
Moreextensivediseasewithmorecyclesmultiagent(>/=4drugs)
chemotherapy
Completeremissionrates6080%
3040%cured
Newertherapiesandtheirrolesstillbeingestablished
Bonemarrowtransplantation
Allogeneic
Autologous
Immunotherapy
Hodgkin's lymphoma
Less common than NHL; ~ 10,000
cases per year
Age incidence bimodal, with one
peak in late adolescence, young
adulthood, second peak beginning
in sixth decade
Bimodal curve shifts to younger
Nodular sclerosis
Mixed cellularity
Lymphocyte depletion
Unclassifiable classical HL
Hodgkin's Histologic subtypes
Are characteristic patterns of
involvement, and characteristic
variants of Reed Sternberg cell
associated with different subtypes
Nodular sclerosing HL
Most common type Hodgkin's
lymphoma in US/Europe
Usually presents in the anterior
mediastinum and neck of young
adult females
Characterized by fibrotic capsule
and bands subdividing tissue and
Lacunar variant Reed Sternberg
cell
Histologic
subtypes 2
Lymphocyte predominant
Usually presents with limited disease in the
neck of young adults
Associated with L and H (lymphocytic and
histiocytic) or "popcorn cell" variant RS cell
Mixed cellularity
More extensive disease
Older patients than NS and LP
More R-S cells, eosinophils, plasma cells
Mononuclear variant R-S cells
Inherently more aggressive disease
Lymphocyte depleted
Often presents in retroperitoneum, older
patients
Accompanied by loss lymphocytes,
sclerosis and pleomorphic RS cell variants
Also more aggressive disease
Ancillary studies
AncillaryimmunologicstudiesassistthedxofHodgkins'lymphoma
DistinguishHLfrom
Immunoblastreactions
UnusualvariantsofNHL
CD15andCD30antigensingolgiandoncellmembraneofRScells
mostuseful
Patternsofspread
Hodgkin'slymphomaspreadscontiguouslyvia
lymphatics
StagingasinNHLmayormaynotinclude
laparotomy/splenectomy
Therapy
Limitedstage,lowbulkdiseasetreatedwithradiation
therapy
Higherstage,Bsymptoms(IIBIV)treatedwithmulti
agentchemotherapy+/radiationtherapy
Complicationsoftherapy
Radiationeffectstolungs,heart,bonemarrow
Sterility
Splenectomyassociatedsepsis
Therapyassociatedsecondmalignancies
Prognosis
Hodgkin'slymphomaisacurablemalignancy
Overallcurerateapproximately80%
Withmoderntherapy,prognosisbasedmoreon
staging,bulkofdisease,thanmorphologicsubtype
Nottrueinearlierera,whereprognosisdecreased
withnumberoflymphocytes;lymphdepletedHL
hadaterribleprognosis
Pathobiology
The etiology of HL is still unknown
The lineage of the R-S cell was also obscure until recently
The mixed cellular infiltrate, unusual large cells, clustered familial
cases, and early evidence of immune dysfunction suggest an infectious
etiology+/- an inherited predisposition
In approximately 30% of cases, Epstein Barr virus found within the
RS cells
Molecular studies, utilizing single cell dissection and PCR based
sequencing of the antigen receptor genes indicate that the R-S cell in
the majority of cases is an altered B cell.
Thus HL is a type of B cell lymphoma, but with a very different
biology from the other types of B cell lymphoma
Still deserves a separate category in the classification system
Molecular information
The molecular abnormalities within the different types of
R-S variants effect the expression of lineage associated antigens
L and H cells of lymphocyte predominant HL express B cell