LYMPHORETICULAR PATHOLOGY

Haematopathology Slide Seminar FRCPath Part 2 Surgical Pathology Course, Manchester Dr A Chaturvedi /Dr L Menasce GM-HCDP, Consultant Histopathologist, Christie Hospital, Manchester, UK

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Neoplastic Haematopathology– clinical & laboratory considerations and their diagnostic/ therapeutic implications (1,2,3) Role of the histopathologist– 1. establish diagnosis (consider pitfalls) exclude non-neoplastic haematolymphoid processes inflammatory (dermatopathic LA); immunological (Kikuchi; lupus); infection (infectious mononucleosis (IM) in nodes, toxoplasma); megaloblastic anaemia in trephines (not covered – refer to extra slides); significance of granulomas (assess background lymphoid tissue), and, exclude non-haematolymphoid pathology [ e.g. metastasis- signet] 2. Guide/direct further management (e.g. advise on repeat sampling; material for flow-cytometry; local practices – FNA vs core vs excision) 3. Efficiency – time (rapid turnaround), cost See Ref. 1 (a&b): RCPath documents Ref. 2: IOG guidance Ref. 3: BLPG

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Overview Clinical information •

Age / Sex / Ethnic origin

• • •

Clinical presentation Site(s), Size and distribution of enlarged lymph nodes/ spleen/ cutaneous/ other Course of disease

• • • •

Area of residence/history of travel Drug history Past medical history Presence of or absence of immunosuppression HIV status/ History of transplant/ Autoimmune disorders/ Drugs/ Concurrent diseases

• •

Haematological laboratory findings - increased or decreased counts/ abnormal forms Serological studies- autoantibodies

•

Clinical differential diagnosis The Christie NHS Foundation Trust

Clinical context matters!

MIB1 CD20

CD20

EBV The Christie NHS Foundation Trust

Reference books

Swerdlow SH, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised Fourth Edition, Volume 2. Lyons: (IARC), 2017.

Elder DE, et al. WHO Classification of Skin Tumours. Fourth Edition, Volume 11. Lyons: (IARC), Sept 2018.

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Histological assessment • Systematic approach • Thorough understanding of the normal cellular compartments and architecture (lymph node/ skin/ spleen/ mucosa/ bone marrow/other)

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lymph node : Size/ Capsule Architecture Sinus Follicles (B-cells) inter-follicular or paracortex (T-cells) Medulla (vessels), stromal elements etc.

(vessels)

Follicles: Germinal centre (B cells)

Mantle zone (B cells) Marginal zone (B cells)

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Types of Architectural patterns • • • • • • •

Diffuse (effaced) Nodular/ follicular Mantle Marginal Inter-follicular/paracortical Sinusoidal Heterogeneous

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‘Non-specific’/ Reactive lymph node patterns

• FOLLICULAR AND NODULAR PATTERNS Follicular Hyperplasia

Autoimmune Disorders (Rheumatoid Arthritis) Castleman’s Disease, Hyaline Vascular Type (Angiofollicular Lymphoid Hyperplasia) Progressive Transformation of Germinal Centers

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Reactive lymph nodal patterns ‘Non-specific’ • PREDOMINANTLY SINUS PATTERN Sinus Histiocytosis

Histiocytic Expansion Due to a Specific Cause (Storage Disease, Lymphangiogram, Prosthesis, Whipple’s Disease) Vascular Transformation of Sinuses Hemophagocytic Lymphohistiocytosis

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Reactive/ ‘Non-specific’ lymph nodal patterns INTERFOLLICULAR OR MIXED PATTERNS Paracortical Hyperplasia and Dermatopathic Reaction Granulomatous Lymphadenitis Immunoglobulin G4–Related Lymphadenopathy (IgG4 plasma cells (>100 per high-power field) and IgG4/IgG ratio (>40%))

Kimura’s Disease Toxoplasmic Lymphadenitis Systemic Lupus Erythematosus Kikuchi’s Lymphadenitis (Kikuchi-Fujimoto Lymphadenitis, Histiocytic Necrotizing Lymphadenitis) Kawasaki’s Disease (Mucocutaneous Lymph Node Syndrome) Inflammatory Pseudotumor Bacillary Angiomatosis The Christie NHS Foundation Trust

Reactive lymph nodal patterns ‘Non-specific’ DIFFUSE PATTERN Infectious Mononucleosis

Cytomegalovirus Infection Herpes Simplex Lymphadenitis Dilantin-Associated Lymphadenopathy

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Reactive lymph nodal patterns ‘Non-specific’ • Follicular hyperplasia • Mantle zone expansion • Marginal zone expansion/ monocytoid B-cell collections • Paracortical hyperplasia • Reactive immunoblastic proliferations • Sinus histiocytosis • Plasma cell infiltrates

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Assessment •

Differential diagnosis

•

Ancillary studies

1.

2.

3.

4.

Histochemical stains (rare) Immunohistochemistry Cytogenetics and molecular studies Flow cytometry

• Definitive diagnosis depends on morphological findings, clinical context and ancillary studies

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LR2 – 5648-09 • 30 years; male

• Persistent lymphadenopathy • HIV+

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LR2 – 5648-09

• HIV-associated lymphadenopathy • florid follicular hyperplasia with follicle lysis

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LR2 – 5648-09 • HIV-associated lymphadenopathy (contd) • StagesType A: florid follicular hyperplasia Type B: florid follicular hyperplasia with follicle lysis Type C: lymphocyte depletion • p24 antigen by IHC in dendritic cells

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LR6 – 674-08 • 20 years; Female

• Groin lymph node

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LR6 – 674-08 • Reactive lymph node with follicular and paracortical hyperplasia • Dermatopathic-lymphadenitis-like changes

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LR6 – 674-08 • “Dermatopathic-lymphadenitis-like changes” • Paracortical hyperplasia – IDC’s (S100+), LC’s (S100, CD1a, CD207 +) and melanin-laden macrophages • Consider TCR gene-rearrangement clonality testing [early involvement by MF/SS)

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LR13-1 • Female 31; • persistent palpable left posterior triangle lymph node

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• CD3 The Christie NHS Foundation Trust

• MPO

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Kikuchi-Fujimoto lymphadenopathy (Histiocytic Necrotizing Lymphadenitis) •

Predominance in young adults (esp., women and Far east Asian descent)

• •

Cervical lymph nodes; Mild systemic symptoms (fever, sore throat, myalgia) Benign course, spontaneous remission

• • • • •

Lymph node slightly enlarged, partly preserved architecture, patchy necrosis, marked apoptosis, nuclear debris Proliferative, necrotising, xanthomatous phases Aggregates of histiocytes with crescentic nuclei (MPO+) Activated T lymphocytes (immunoblasts), predominant cytotoxic CD8+ Plasmacytoid dendritic cells (CD123 positive)

•

Absence of neutrophils and eosinophils

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Other example proliferative The Christie NHS Foundation Trust

Other example - necrotic

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Other example xanthomatous The Christie NHS Foundation Trust

Kikuchi-Fujimoto lymphadenopathy differential diagnosis • Systemic lupus lymphadenitis

• Necrotising granulomatous lesions (TB, histoplasmosis, leprosy, cat-scratch) • Acute EBV infection • Allergic reactions • Necrosis in lymphoma • Non-Hodgkin lymphoma The Christie NHS Foundation Trust

LR 14 - 2 • Male 31y; inguinal lymph node

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HSV

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Herpes simplex virus lymphadenitis • Usually associated with disseminated infection and rash • More common in immunosupressed persons • Rarely localised, mainly inguinal • Viral inclusions

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LR9

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LR9 • Toxoplasmosis

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Toxoplasmosis vs HIV adenopathy • • • •

Geographic lymphoid follicles are seen in both.

Monocytoid B-cell hyperplasia are seen in both.

Intrafollicular microgranulomas commoner in toxoplasmosis.

Paracortical polykaryons in some cases of HIV.

• • • •

Loss of IgM, IgD positive mantle in HIV. Reversal of CD4:CD8 ratio in HIV. HIV p24 staining of FDC meshworks in HIV. Antitoxoplasma immunohistochemistry is of no value in toxoplasmic lymphadenitis, and cysts are v. v. v. rare!

• Coincident pathologies in HIV. • Some patients with HIV are infected with toxoplasma!

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LR5 – 1290-10 • 35 years; male

• Right posterior triangle lymph nodes

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LR5 – 1290-10 • Tuberculous lymphadenitis.

• AFB identified on ZN stain

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Granulomatous lymphadenopathy • • • • • •

Tuberculosis Sarcoidosis Lymphogranuloma venereum Tularaemia Cat Scratch disease Toxoplasmosis

Neoplastic • Lymphoma – T-cell lymphoma -Hodgkin lymphoma -Other lymphomas • Non-haematologic malignancies – seminoma etc

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LR16 - 4 • Female 44y; • mediastinal mass ?thymoma

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• CD21

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IgM

IgD

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Castleman lymphadenopathy hyaline vascular type • • • •

More common Younger patients Frequently asymptomatic Isolated lymph node mass (Often mediastinal)

• Numerous small lymphoid follicles • Lollipop follicle • Hyaline deposits in germinal centres; expanded FDCs meshworks; atypia in FDCs (clonal abnormalities have been detected at molecular level) • Concentric layering of lymphocytes • Interfollicular vascular hyperplasia; hyaline sclerosis The Christie NHS Foundation Trust

Castleman’s Disease Hyaline-Vascular variant

Plasma Cell variant

•

• • •

• •

•

Younger patients (children and young adults) Isolated lymph node mass (unicentric) Often mediastinal (abdominal, retroperitoneal) Frequently asymptomatic

• •

•

Pathogenesis: FDC abnormalities: Increased local VEGF EGFR expression by FDC Clonal cytogenetic abnormalities FDC dysplasia / sarcoma

•

Management: Excision, RT

•

Mixed type? Some overlapping morphological features

•

Age variable Multicentric > unicentric Peripheral and/or central lymphadenopathy Systemic symptoms usually present Pathogenesis “IL6 syndrome” (human IL6, viral IL6, VEGF, others?)

Plasma cell disorders (myeloma, POEMS) HHV8, “Plasmablastic variant” Autoimmune diseases; Unknown Management varies according to clinical syndrome immunomodulation,anti-IL6, anti-CD20, HAART, CT, PSCT

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Castleman’s disease Plasma cell variant Separate example

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LR 15 - 3 • Female 67y; • lymph node right posterior triangle; • enlarged neck lymph nodes plus swelling post nasal space

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S100 protein The Christie NHS Foundation Trust

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman) • Mean age 20 (new born-elderly) • Usually cervical lymphadenopathy but other sites including extra-nodal disease • Lymphadenopathy of long duration, usually spontaneous regression • Dilatation of sinuses • Large histiocytic cells(CD68, S100+) with abundant eosinophilic cytoplasm containing vacuoles with engulfed lymphocytes (emperipolesis) • Numerous polyclonal plasma cells • ?aetiology; defective phagocytosis? subset familial syndrome (mutation in SLC29A3) The Christie NHS Foundation Trust

LR4 – 4647-09 • 61 years; female

• Swelling submental region; • 6 months duration; • painless and slowly growing

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CD23

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LR4 – 4647-09 Positive • • • •

CD20 CD5 CD23 BCL2

Negative • CD3 • CD10 • Cyclin D1

Ki-67 ~ 5%

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LR4 – 4647-09 • Chronic lymphocytic leukaemia / small lymphocytic lymphoma

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CLL - Transformation • Richter transformation (~3%) • Clonally related or unrelated (about a half each)

• Classic DLBCL-type • Hodgkin lymphoma-like (~0.5%) • Prolymphocytic transformation (frequency not known)

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Related discussion LYMPHOID NEOPLASMS

NHL Mature B-cell neoplasms Indolent CLL/SLL, FL (incl. cutaneous), Extra-nodal MZL of MALT(other MZL) LPL, HCL Plasma cell neoplasms [MGUS/PC Myeloma/others], Intermediate Mantle CL

High grade DLBCL, NOS (GC vs. post GC), variants Plasmablastic L, PEL Burkitt lymphoma (and similar entities)

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LYMPHOID NEOPLASMS NHL : Mature B-cell neoplasms; CLL/SLL, FL (incl. cutaneous), MantleCL, MZL

CLL/SLL small lymphocyte, round nucleus, clumped chromatin inconspicuous nucleolus

Follicular Lymphoma

Marginal Zone Lymphoma

two cell types: centrocytes and centroblasts

Small bland ‘monocytoid’ Exclude other indolent NHL CD43; IRTA1, MNDA; clonality

Mantle Cell Lymphoma (MCL) N.B. : Transformation in all indolent NHL (i.e. block and assess entire node) 1. CLL - Richter’s 2. FL grade : centroblasts/hpf: 0-5,6-15, >15 (+/centrocytes); follicular/ diffuse 3. Blastoid var MCL

uniform population small to medium, cleaved nuclei

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LYMPHOID NEOPLASMS (contd) NHL : Mature B-cell neoplasms;

CLL/SLL, FL (incl. cutaneous), MantleCL, MZL

CLL: •‘nodular’ • Proliferation centres •Use of CD21/CD23- dendritic markers

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LR3 – 101-08 • 40 years; male

• Right cervical lymph node

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CD5

CD3

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Cyclin D1 The Christie NHS Foundation Trust

Cyclin D1 The Christie NHS Foundation Trust

LR3 – 101-08 Positive • • • •

CD20 CD5 Cyclin D1 BCL2

Negative • • • •

CD3 CD23 CD10 p53

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LR3 – 101-08 • Mantle cell lymphoma

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Mantle Cell Lymphoma • Most are associated with t(11;14) and overexpression of cyclin D1.

• A small proportion of cases are cyclin D1 negative; these show overexpression of cyclin D2 and cyclin D3.

• SOX11

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Mantle Cell Lymphoma • malignancy of naïve B-cells.

• associated with a relatively poor prognosis.

• a small proportion have mutations in the Ig gene - these patients have better prognosis.

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Mantle Cell Lymphoma • Patterns: Nodular, mantle zone and diffuse.

• Variants:  Blastoid variant (>10 mitosis/ 10hpf  Pleomorphic blastoid  CLL-like

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Case LR8 • 50 years; male

• lymph node left groin enlarged

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Case LR8 Positive • • • • •

CD20 CD10 BCL6 CD23 BCL2

Negative • CD3 • CD5 • CD21

Ki-67 <25%

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Case LR8 • Follicular lymphoma, grade 1

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Follicular Lymphoma Centrocytes + Centroblasts Number of centroblasts/hpf <5

6-15

Only Centroblasts

Follicular grade 3b

>15

1 2 3a Follicular grade

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Related discussion - LYMPHOID NEOPLASMS NHL : Mature B-cell neoplasms;

CLL/SLL, FL (incl. cutaneous), MantleCL, MZL

Follicular Lymphoma (FL) from Follicular Hyperplasia Characteristic

Specificity for FL

Frequency in FL

Centrocytes Diagnostic predominate in follicles

High

Centrocytes present between follicles

Diagnostic

High

Diagnostic

Moderate

Highly suggestive

High

Highly suggestive

Moderate

Vascular invasion by centrocytes Close packing of follicles Diffuse areas or sclerosis

Follicles extend beyond Highly suggestive nodal capsule

High

Mantle zone absent

Suggestive

High

“Starry sky” cells absent in follicles

Suggestive

High

Mantle zone present

Not helpful

Low

Some reactive follicles present

Not helpful

Low

Size, shape, uniformity of follicles

Not helpful

—

“Cracking” artefact or compression of reticulin

Not helpful

—

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LR10 – 4461-10 • 31 years; male

• Left axillary lymphadenopathy

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LR10 – 4461-10 Positive • • • •

CD20 EMA BCL2 Lambda light chain restriction

Negative • • • • •

CD15 CD30 CD3 IgD EBV-LMP-1

Prominent CD57 positive T-cell infiltrate in the background; rosettes

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LR10 – 4461-10 • Nodular lymphocyte predominant Hodgkin lymphoma

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Nodular Lymphocyte Predominant HL - A Distinct Entity •

Unimodal age distribution - usually 4th or 5th decades

•

Male predominance

•

Stage I or Stage II disease

•

B-symptoms – uncommon

•

Cervical and inguinal lymph node involvement is common

•

Mediastinal involvement is uncommon

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Nodular Lymphocyte Predominant HL – A Distinct Entity • Associated with progressively transforming germinal centres • About 3-5% progress to NHL - diffuse large B-cell type • Frequent multiple relapses • Good survival • ‘Wait & Watch’ in stage I

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LR1 – 309-10 • 22 years; female

• Right neck node

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LR1 – 309-10 Positive • • • •

CD20 (uneven) CD15 CD30 BCL2

Negative • CD45 • CD3 • EBV-LMP-1

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LR1 – 309-10 • Nodular Sclerosis Classical Hodgkin lymphoma, BNLI grade 1

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Sub-classification of Nodular sclerosis classical Hodgkin Lymphoma BNLI 1985 • Grade I – • Lymphocyte predominance or • mixed cellularity without pleomorphic RS cells • predominance of bland fibrohistiocytes with a minority of RS cells • Grade II – • mixed cellularity with pleomorphic RS cells • 25% of nodules with a high proportion of RS cells and variants • lymphocyte depletion

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Hodgkin Lymphoma Nodular Lymphocyte Predominant HL

Classical HL Mixed Cellularity

Grade 1 Nodular Sclerosis Grade2 Lymphocyte-rich Lymphocyte Depleted

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Diagnostic Criteria -

Hodgkin Lymphoma Classical type

Nodular LP •

Classical RS cell not seen; “popcorn” cells seen

•

Classical RS cell often seen

•

Background cells - admixture of Bcells and T-cells OR predominantly B-cells; T cells rosettes

•

Background cells - activated T cells; T cell rosettes

•

Eosinophils & plasma cells scanty

•

Eosinophils & plasma cells often seen

•

Often rich in histiocytes

•

Histiocytes less conspicuous

Positive

1.

2.

3.

4.

5.

CD45+ CD20+ Oct-2+ BOB.1+ MUM-1+/–

Negative

1.

2.

3.

4.

5.

CD15− CD30− BCL2− CD10− EBV−

Positive

Negative

1.CD30 (>90%) 2.CD15 (75%-85%) 3.BSAP (PAX5) 4.IRF4/MUM-1 5.CD20 −/+ 6.LMP-1 (20%-50%)

1.CD45 2.EMA 3.ALK1 4.CD79a (rarely +) 5.BOB.1 6.Oct-2 −/+

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LR7 – 8941-09 • 38 years; Male

• HIV+ • Left axillary mass

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LR7 – 8941-09 Positive • • • • •

CD20 CD79a CD10 BCL6 EBER

Negative • • • • •

CD3 CD5 CD138 MUM1 BCL2

Ki-67 ~ 100% IGH/MYC and CMYC rearrangement positive; no evidence of IGH/BCL2 and BCL6 rearrangement

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LR7 – 8941-09 • Burkitt lymphoma

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Related discussion -LYMPHOID NEOPLASMS NHL :Mature B-cell neoplasms –

DLBCL, NOS (GC vs. post GC) and variants;; Burkitt lymphoma

Burkitt’s lymphoma

DLBCL

large vesicular nuclei, prominent nucleoli, basophilic cytoplasm and easily found mitotic figures; heterogeneous cell population

medium-sized, monotonous and somewhat uniform appearance; starry sky

feature

BL

Expression of CD19, Positive CD20, CD22, CD79a

Most cases positive

CD10 expression

Positive

Variably positive; defines GCB subtype of DLBCL

BCL6 expression

Positive

Most cases positive

Negative

60%-70% positive, mostly within ABC subtype

Bright CD38

Positive

CD38 may be positive, but often dim

EBV-EBER

Positive (15%- Usually 30%)† negative

Cytogenetics

t(8;14) or variant

BCL2 expression

CD10− CD10+

BCL6+ IRF4/MUM-1−

Germinal center B-cell type (GCB)

BCL6+ IRF4/MUM-1+

BCL6−

Non–germinal center Bcell type (non-GCB)

DLBCL

+, expression in >30% of tumor cells Hans Algorithm Molecular

MYC rearrangement to IG partner

MYC translocation in 5%-8% of de novo DLBCLs

LR18 - 6 • Female 18y; axillary lymph node

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• CD30

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• EMA

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• ALK

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Anaplastic large cell lymphoma Alk positive • Young adults • Peripheral lymph nodes affected; Skin can be involved

• Partial nodal involvement • Paracortical areas (T- zone) and sinuses involvement • Follicles and germinal centres spared • Cohesive cells, cords and sheets, anaplastic large cells, pleomorphic bizarre, reniform; wreath-like, embryo-like nuclei (hallmark cell) • T- cell phenotype (often CD3 -) • Translocation t(2; 5)(p23;q35) • Chimeric protein NPM– ALK detected by antibody ALK-1(nuclear and cytoplasmic staining) • variants The Christie NHS Foundation Trust

LR19 - 7 • Female 86y; bx right supraclavicular node.

Previous bx, mostly necrotic; ? metastatic

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EMA

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CD79a

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CD20

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Kappa

Lambda

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EBER The Christie NHS Foundation Trust

ALK

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ALK positive large B-cell lymphoma • Rare (less than 1% of DLBCL) • Mainly involves lymph nodes; may present as a mediastinal mass or involve extranodal sites • Most patients present with advanced stage disease (III/IV)

• Sinusoidal growth pattern; large immunoblast-like cells, plasmablastic, atypical multinucleated cells • • • • •

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Differential diagnosis • • • •

Metastatic carcinoma Metastatic seminoma Metastatic melanoma Plasmablastic lymphoma

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LR20 - 8 Female 66y;lump right forearm, known CLL

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LCA/CD45

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CD20

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CD3

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LYSOZYME

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CD11c

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PGM-1 The Christie NHS Foundation Trust

S-100

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Melan-A

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Myeloid sarcoma • Tumour mass of myeloid blasts with or without maturation at a site other than the bone marrow • Syn.: Extra-medullary myeloid tumour, granulocytic sarcoma, chloroma • Skin, lymph node, GI, bone, soft tissue, testis • Myeloblasts with or without features of promyelocytic or neutrophilic maturation • IHC panel: CD68, lysozyme, CD43, MPO, CD117, CD34, CD56, glycophorin, CD4, CD14, CD11c, CD163, CD45 CD30; CD123 • May occur de novo, precede or coincide with AML or represent blastic transformation of MDS, MPN, MDS/MPN The Christie NHS Foundation Trust

Differential diagnosis • Non-Hodgkin lymphoma • Melanoma, neuroendocrine carcinoma

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Case xxx • Female 50Y • enlarged inguinal lymph node

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CD3

CD2

CD79a

CD7

CD20

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CD4

CD8

PD1

EBER

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Angioimmunoblastic T cell lymphoma • Peripheral T-cell lymphoma • CD4 positive follicular helper T cell • Frequent association with EBV • Clinical: Systemic disease at presentation (advanced stage); generalised lymphadenopathy; hepato-splenomegaly; skin rash; pruritus; pleural effusion; arthritis; ascites;

polyclonal hypergammaglobulinaemia; circulating immune complexes; haemolytic anaemia; positive rheumatoid factor; and anti–smooth muscle antibodies The Christie NHS Foundation Trust

Angioimmunoblastic T-cell lymphoma • Lymph node architecture often partially effaced and peripheral cortical sinuses may be spared

• Marked proliferation of arborising high endothelial venules; increased follicular dendritic cell meshworks • Polymorphic infiltrate, small, medium sized; pale cytoplasm (PD1, CD10,CX CL13, FOXP3 +); reactive lymphocytes, eosinophils, plasma cells and histiocytes; Reed-Sternberglike cells

• Expansion of B-immunoblasts in the paracortex; EBV positive; may progress to EBV positive DLBCL. The Christie NHS Foundation Trust

Other example Peripheral T-cell lymphoma NOS The Christie NHS Foundation Trust

Peripheral T-cell lymphoma NOS- CD3 The Christie NHS Foundation Trust

Peripheral T-cell lymphoma CD15 The Christie NHS Foundation Trust

Peripheral T-Cell Lymphoma, Not Otherwise Specified • All mature T-cell neoplasms lacking specific features that would allow categorization in any better-defined WHO classification subtype of postthymic T-cell lymphoma/leukemia • Other categories of T-cell lymphoma must be excluded before a diagnosis of PTCL, NOS is established • Unlikely to constitute only one entity

• Rare overall but represent the most common PTCL category in North America and Europe • Affect older adults (median age, 60 years), but children can also be affected • Most patients present with nodal involvement, but any site may be affected.

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Peripheral T cell lymphoma NOS • CD3+, CD4+ > CD8+, TCRαβ+ neoplastic T cells • Aberrant T-cell immunophenotype • Cytotoxic immunophenotype uncommon Molecular Genetics • Monoclonal TCR gene rearrangements in 90% to 100% of cases • Monoclonal or oligoclonal IgH gene rearrangement may be present Cytogenetics • Complex clonal chromosome aberrations frequent • Rare recurrent translocations, t(5;9) (SYK-ITK), in the follicular variant

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Lymphoepithelioid variant

T-zone variant

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Fellowship tumour pathology The Christie School of Oncology The Christie, Manchester UK • • • • • • •

Haemato-lymphoid Urology Soft Tissue Skin tumours Gynaecological GI Neuroendocrine lia.menasce@christie.nhs.uk, patrick.Shenjere@christie.nhs.uk • pedro.oliveira@christie.nhs.uk • Anshuman.chaturvedi@christie.nhs.uk The Christie NHS Foundation Trust

Extra slides

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Tumours of Haematopoietic and lymphoid tissues (ref.4) MYELOID NEOPLASMS - Myeloproliferative Neoplasms (CML,PV, ET, PM, mastocytosis. others) -

Myeloid & Lymphoid neoplasms with eosinophils & PDGFR/ FGFR abnormality

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Myelodysplastic/MPN (CMML and others)

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MD Syndromes/ neoplasms (RCUD, RCMD, RARS, RAEB, isolated 5q, others)

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Acute myeloid leukaemia (recurrent genetic abn. [APML]/ MDS-/ Therapyrelated, AML-NOS, myeloid sarcoma, Blastic plasmacytoid dendritic)

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Acute leukaemia, ambiguous lineage See Ref. 4: WHO blue book

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Tumours of Haematopoietic and lymphoid tissues (ref.4) LYMPHOID NEOPLASMS NHL Precursor lymphoid neoplasms (B- and T- Lymphoblastic leukaemia/lymphoma, NOS; other) Mature B-cell neoplasms INDOLENT= CLL/SLL, FL (incl. cutaneous), Mantle CL, Extra-nodal MZL of MALT(other MZL), LPL,HCL, Plasma cell neoplasms [Myeloma/others] HIGH-GRADE= DLBCL, NOS (GC vs. post GC) – subtypes, variants incl. Plasmablastic L, Primary effusion lymphoma Burkitt lymphoma (and similar entities) Mature T-cell neoplasms Extranodal NK/ T-cell lymphoma, nasal type (and others) Enteropathy-associated T-cell lymphoma, Cutaneous T-cell neoplasms including - MF, Sezary syndrome , Primary cut. CD-30 positive lymphoproliferative disorders (and others) Angioimmunoblastic T-cell lymphoma, ALCL (ALK positive and negative) , PTCL-NOS HL NLPHL cHL (NS-cHL, MC-cHL, LR-cHL, LD-cHL) Immunodeficiency associated lymphoproliferative disorders (HIV associated, PTLD, others)

HISTIOCYTIC AND DENDRITIC CELL NEOPLASMS LCH, Dendritic cell sarcoma and others

The Christie NHS Foundation Trust See Ref. 4: WHO blue book

Histopathology - laboratory issues (1) 1.

2.

3.

4.

Bone marrow, Nodal and Extra-nodal neoplasia (tissue processing) Special stains – Trephine biopsy (Reticulin, Perl’s, Giemsa) Immunohistochemistry- CD markers (Initial panel); controls; uss Lymph nodes and trephines LCA : ?role (HL); CD20 (vs CD79a), CD3: B- & T-cell lineages CD21/ CD23: Dendritic meshwork; BCL-2: Follicle centre (role in FL vs reactive; other) Ki-67: G.C. polarity; proliferation (Burkitt’s vs DLBCL) ‘other’ NHL: CD5, CD23, cyclin-D1, CD10, BCL6, CD43, kappa, lambda, CD138 (CD56), TdT HL: CD30, CD15 ‘additional’ markers: CD4, CD8, CD7, CD56, Perforin, Granzyme, Alk-1, BOB-1, OCT-2, tryptase, DBA.44, CD103, CD2, CD25, PAX-5 , LMP-1, EBER-ISH Trephines MPO (myeloid), glycophorin (erythroid), vWF/ CD31, CD34 (monoblasts may be negative), CD117, TdT Genetics (specific translocations/ clonality studies): conventional cytogenetics (?role), FISH, RT-PCR

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See Ref. 1 (a&b): RCPath documents

LYMPHOID NEOPLASMS NHL Mature T-cell neoplasms Extranodal NK/ T-cell lymphoma, nasal type (and others) Enteropathy-associated T-cell lymphoma, Cutaneous T-cell neoplasms including – MF, Sezary syndrome , Primary cut. CD-30 positive lymphoproliferative disorders (and others) Angioimmunoblastic T-cell lymphoma, ALCL (ALK positive and negative) , PTCL-NOS

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LYMPHOID NEOPLASMS NHL : Mature T-cell neoplasms Extranodal NK/ T-cell lymphoma, nasal type (and others) broad cytologic spectrum - small medium or large blastic frequent necrosis, angiocentric growth, cytotoxic phenotype, strong association with Epstein-Barr virus (EBV) IHC: CD2+, surface CD3−, cytoplasmic CD3ε+, and CD56+ CD43 and CD45RO are commonly positive, and CD7 is occasionally expressed.

CD4, CD5, CD8, TCRαβ, and TCRγδ are usually negative Ki-67 immunostaining is usually high (>50%) nearly consistent association with EBV- LMP1, EBER

Anaplastic large cell lymphoma (ALCL) usually large and have abundant cytoplasm and pleomorphic, often horseshoe-shaped nuclei. t(2;5)(p23;q35); variant translocations By definition, all ALCLs are positive for CD30. variably positive for CD45 and CD45RO one or more T-cell or natural killer (NK)-cell antigens; null-type CD3 negative in more than 75% ALK staining may be cytoplasmic, nuclear, and nucleolar,

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LYMPHOID NEOPLASMS NHL : Mature T-cell neoplasms EATL: tumour of intraepithelial lymphocytes varying degrees of transformation Usually large lymphoid cells classic form of EATL and the type II, or monomorphic, variant complication of celiac disease (gluten-sensitive enteropathy) / sporadically positive for CD3, CD7, CD103, and granzyme B; negative for CD4 and CD8 [type II EATL - tumour cells express CD3, CD8, CD56, and granzyme B]

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OTHER LYMPHOID NEOPLASMS • Immunodeficiency associated lymphoproliferative disorders (HIV associated, PTLD, others) HISTIOCYTIC AND DENDRITIC CELL NEOPLASMS • LCH, Dendritic cell sarcoma and others

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Primary Cutaneous Lymphomas

Swerdlow SH, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised Fourth Edition, Volume 2. Lyons: (IARC), 2017.

Elder DE, et al. WHO Classification of Skin Tumours. Fourth Edition, Volume 11. Lyons: (IARC), Sept 2018.

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Primary Cutaneous T-Cell Lymphomas

Quintanilla-Martinez L, et al. Non–Mycosis Fungoides Cutaneous T-Cell Lymphomas. Report of the 2011 Soc for Hematopathology/Eur Assoc for Haem Wkshp. Am J Clin Pathol 2013;139:491-514

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Primary Cutaneous T-Cell Lymphomas

Mycosis fungoides & Sézary syndrome - two closely related conditions; neoplastic T cells infiltrate the skin & circulate in peripheral blood

Jaffe E, et al (ed). Ch39. Mycosis Fungoides and Sézary Syndrome. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous T-Cell Lymphomas

Mycosis fungoides - patch stage

Note: The diagnosis of mycosis fungoides is best established with the collaboration of a knowledgeable clinician, unless the histopathologic findings are unequivocal.

Jaffe E, et al (ed). Ch39. Mycosis Fungoides and Sézary Syndrome. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous T-Cell Lymphomas Mycosis fungoides – patch and tumour stage

Note: CD30+ cells occur in some plaques of mycosis fungoides, but mostly in tumors that have anaplastic large cells; when CD30 is expressed on lesional lymphocytes that have undergone large cell transformation, it does seem to have prognostic significance

Jaffe E, et al (ed). Ch39. Mycosis Fungoides and Sézary Syndrome. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous T-Cell Lymphomas (Non-mycosis fungoides)

Three types of primary cutaneous CD30+ lymphoproliferative disorders (LPDs) are recognized in the World Health Organization classification: • primary cutaneous anaplastic large cell lymphoma (C-ALCL), • lymphomatoid papulosis (LyP), and • borderline lesions.

Quintanilla-Martinez L, et al. Non–Mycosis Fungoides Cutaneous T-Cell Lymphomas. Report of the 2011 Soc for Hematopathology/Eur Assoc for Haem Wkshp. Am J Clin Pathol 2013;139:491-514

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Diagnostic challenges

Note: LyP and C-ALCL can coexist and probably represent a continuum of lesions.

Detection of clonality does not indicate lymphoma as it occurs in LyP and pityriasis lichenoides.

Histologic distinction of LyP from lymphoma can be extremely difficult, making clinical correlation imperative.

The diagnosis is often obvious when one sees the patient.

The correct diagnosis of LyP is essential to avoid overtreatment.

Quintanilla-Martinez L, et al. Non–Mycosis Fungoides Cutaneous T-Cell Lymphomas. Report of the 2011 Soc for Hematopathology/Eur Assoc for Haem Wkshp. Am J Clin Pathol 2013;139:491-514

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Diagnostic challenges

Quintanilla-Martinez L, et al. Non–Mycosis Fungoides Cutaneous T-Cell Lymphomas. Report of the 2011 Soc for Hematopathology/Eur Assoc for Haem Wkshp. Am J Clin Pathol 2013;139:491-514

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Diagnostic challenges

Quintanilla-Martinez L, et al. Non–Mycosis Fungoides Cutaneous T-Cell Lymphomas. Report of the 2011 Soc for Hematopathology/Eur Assoc for Haem Wkshp. Am J Clin Pathol 2013;139:491-514

The Christie NHS Foundation Trust

Diagnostic challenges

Quintanilla-Martinez L, et al. Non–Mycosis Fungoides Cutaneous T-Cell Lymphomas. Report of the 2011 Soc for Hematopathology/Eur Assoc for Haem Wkshp. Am J Clin Pathol 2013;139:491-514

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Primary Cutaneous B-cell Lymphomas - classification

in the revised WHO 2016 classification, PCFCL and PCDLBCL, LT are included as separate entities, as defined in the WHO-EORTC classification

Jaffe E, et al (ed). Ch20. Primary Cutaneous B-Cell Lymphomas. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous B-Cell Lymphomas

Jaffe E, et al (ed). Ch20. Primary Cutaneous B-Cell Lymphomas. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous B-Cell Lymphomas

Primary cutaneous marginal-zone lymphoma.

A, Typical clinical presentation with multiple nodules on the back.

B, Dense infiltrates throughout the dermis are shown.

C, CD79a staining showing a predominance of B cells and reactive germinal centers D, Monotypic immunoglobulin G, kappa-positive plasma cells in the superficial dermis (kappa staining).

E, Negative staining for lambda light chains.

Jaffe E, et al (ed). Ch20. Primary Cutaneous B-Cell Lymphomas. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous B-Cell Lymphomas

• Primary Cutaneous Follicle-Center Lymphoma

• 10% of all cutaneous lymphomas and about 50% of primary CBCLs • indolent clinical course • perivascular and periadnexal, nodular or diffuse infiltrates with almost constant sparing of the epidermis • Variable European and US data: do not express BCL2 protein or show faint BCL2 staining in a minority of neoplastic B cells do not or rarely show the interchromosomal (14;18) translocation

Jaffe E, et al (ed). Ch20. Primary Cutaneous B-Cell Lymphomas. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Primary Cutaneous B-Cell Lymphomas

Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type (A), Clinical presentation with large tumors on the right lower leg (20% other sites) (B), Diffuse proliferation of centroblasts and immunoblasts (C) Tumor cells show strong reactivity for CD20 [note- activated B-cell (ABC)-type DLBCL]

(D) immunoglobulin M and (E) MYC

Jaffe E, et al (ed). Ch20. Primary Cutaneous B-Cell Lymphomas. In, Hematopathology (2nd edition) - Elsevier, 2017.

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Bone marrow trephine reporting Adequacy – at least 1.5 cm in length and obtained at right angles to the cortical bone (caveats)

Cellularity - 30:70 and 70:30 Marrow: fat :: hyper/hypocellular Myeloid: erythroid :: wide range

Myeloid lineagelocalisation, differentiation, maturation Erythroid lineagelocalisation, maturation Megakaryocyteslocalisation, number, morphology Other-haematopoetic cells Lymphoid, Plasma cells, mast cells Non-haematopoetic cells Metastases Bony trabeculae ; vessels Special stains- Reticulin (Perls, Giemsa)

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Bone marrow trephine reporting Semi-quantitative Grading of Bone Marrow Fibrosis Grade

Description

0

Scattered linear reticulin fibers with no intersections (crossovers), corresponding to normal bone marrow

1

Loose network of reticulin with many intersections, especially in perivascular areas

2

Diffuse and dense increase in reticulin with extensive intersections, occasionally with focal bundles of collagen or focal osteosclerosis

3

Diffuse and dense increase in reticulin with extensive intersections and coarse bundles of collagen, often associated with osteosclerosis

The Christie NHS Foundation Trust Ref. Jaffe E, et al. Haematopathology. Elsevier, 2011.

Bone marrow trephine reporting MYELOID NEOPLASMS Myeloproliferative Neoplasms (CML,PV, ET, PM, mastocytosis,others) Common characteristics hypercellular ; progression with time to acute leukaemia; increasing fibrosis

• CML- CP : Marked granulocytic differentiation (inc. var. increased eosinophils, basophils); left-shift; Megakaryocytes increased smaller hypolobate BCR-ABL1

• PV : prominent erythroid differentiation Florid megakaryocytic proliferation- larger hypo-hyperlobated, loose clusters Large dilated sinuses filled with red blood cells JAK2V617F

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Bone marrow trephine reporting MYELOID NEOPLASMS Myeloproliferative Neoplasms (CML,PV, ET, PM, mastocytosis,others) Common characteristics hypercellular ; progression with time to acute leukaemia; increasing fibrosis

•

Essential Thrombocythemia (ET): megakaryocytic proliferation - giant forms with nuclear atypia (less pleomorphic than PV/PM) , ‘staghorn’ nuclei , clusters, near sinuses JAK2V617F, MPL

•

Primary Myelofibrosis: prefibrotic and fibrotic stages well-vascularized fibrosis bizarre megakaryocytes; ‘cloud-like’, bare nuclei, dense clusters, adjacent to endosteum/sinusoids JAK2V617F

•

Mast Cell Disease paratrabecular/ perivascular infiltrates or intertrabecular nodules multifocal, dense infiltrates (>15m.c. in aggregate) atypical or spindle shaped (>25%) IHC (CD117, CD2, CD25, tryptase) KIT-mutation D816V

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Bone marrow trephine reporting MYELOID NEOPLASMS MD Syndromes/ neoplasms (RCUD, RCMD, RARS, RAEB, isolated 5q, others) Myelodysplastic features (all three/two/one cell line affected) • Erythroblasts: Nuclear abnormalities- binucleate/ megaloblastic ; disrupted colonies, single stage of maturation • Myeloid: Nuclear abnormalities and decreased granularity ALIPs • Megakaryocytes: Micro-/ Mononuclear/Naked nuclei paratrabecular • Background haemosiderin The Christie NHS Foundation Trust

Bone marrow trephine reporting MYELOID NEOPLASMS - MD Syndromes/ neoplasms

Dyshematopoietic features

dyserythropoiesis & increase in immature mononuclear cells

(ref. images - dako)

dyserythropoiesis, increase in immature cells (presumably of myeloid lineage) (arrows) and granular deposits of hemosiderin

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Bone marrow trephine reporting MYELOID NEOPLASMS - MD Syndromes/ neoplasms

Dyshematopoietic features

aggregates of abnormally localized immature precursor (ALIP) cells

Grouped dysmorphic (hypolobated) megakaryocytes (arrow),

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Bone marrow trephine reporting PITFALLS HIV Marrow •MDS-like features (all three lineages)- in 3/4th •Other changes (kaposi’s sarcoma)

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Bone marrow trephine reporting MYELOID NEOPLASMS Myelodysplastic/MPN (CMML and others) CMML: Monocyte count absent specific cytogenetic abN (BCR-ABL/PDGFR) dysplasia or clonal abN or persistent unexplained monocytosis CD123, CD163

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Bone marrow trephine reporting MYELOID NEOPLASMS Acute myeloid leukaemia (recurrent genetic abn. [APML]/ MDS-/ Therapy-related, AML-NOS, myeloid sarcoma, Blastic plasmacytoid dendritic)

• 20% blasts in marrow • Specific cytogenetic abnormality • APML t(15,17)

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Bone marrow trephine reporting PITFALLS Megaloblastic Marrow

giant metamyelocytes and small megakaryocytes with hyperlobated nuclei

Aplastic Anemia • D/D Hypocellular MDS/AML look at the cells - blasts

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Bone marrow trephine reporting LYMPHOID NEOPLASMS Acute Lymphoblastic Leukemia PITFALLmonotonous, ‘small’ B-cell and T-cell markers Ki-67 TdT Lineage markers

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Bone marrow trephine reporting LYMPHOID NEOPLASMS Context: • • • •

CLL

Staging marrows (n.b. discordance) Primary diagnosis Splenomegaly, FBC/ peripheral smear WNL

Patterns of infiltration: Normal Interstitial (CLL ) Nodular (CLL ; d/d reactive) Intra-sinusoidal Paratrabecular (FL) Diffuse/ packed (advanced stage with dense infiltrate)

Hairy cell leukemia: Annexin1, CD123, CD103, CD68 and DBA.44, BRAF V600E mutations

FL

HCL

Lymphoplasmacytic lymphoma: range of differentiation between lymphocytes and plasma cells; dutcher bodies

Plasma cell neoplasm: >10% Plasma cells, clonal

LPL Other NHL’s: DLBCL etc HL: staging ; levels for mononuclear cells; appropriate background The Christie NHS Foundation Trust

Bone marrow trephine reporting PITFALLS Benign vs neoplastic lymphoid aggregates in the bone marrow

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