Disclosures. Objectives 4/28/2016. Lymphoproliferative Disorders: Challenging Cases from St. Joseph s Hospital. No conflicts of interest.

Size: px

Start display at page:

Download "Disclosures. Objectives 4/28/2016. Lymphoproliferative Disorders: Challenging Cases from St. Joseph s Hospital. No conflicts of interest."

Erin Greene
7 years ago
Views:

1 Lymphoproliferative Disorders: Challenging Cases from St. Joseph s Hospital Disclosures No conflicts of interest. Byron H. Simmons, MD Central Regional Pathology Laboratories Woodbury, Minnesota St. Joseph s Hospital St. Paul, Minnesota April 27, St. Joseph s Hospital St. Paul, Minnesota GOING STRONG FOR 163 YEARS! 2016 Objectives Recognize unusual presentations of lymphoproliferative disorders Understand diagnostic algorithms used to evaluate lymphoproliferative disorders Understand therapeutic implications of uncommon lymphoproliferative disorders Understand limitations of diagnostic tests used in the evaluation of certain lymphoproliferative disorders Cellular Morphology Remains the Cornerstone of Diagnostic Hematopathology Elements of Clinicopathologic Diagnosis in Neoplastic Hematopathology Clinical presentation Routine microscopic evaluation Immunophenotypic characteristics (e.g., immunohistochemistry, flow cytometry) Genetic characteristics (e.g., PCR, FISH, karyotypic analysis) 1

2 Case #1 Peripheral Blood Smear 84-year-old man with weakness and fatigue Physical Examination: Splenomegaly WBC: 75,000 per microliter, >95% lymphoid cells Hemoglobin: 8.6 g/dl MCV: 104 fl Platelet Count: 60,000 per microliter Peripheral Blood Smear Morphologic Differential Diagnosis? Differential Diagnosis Acute lymphoblastic leukemia Chronic lymphocytic leukemia Circulating non-hodgkin lymphoma (e.g., follicular lymphoma) Lymphocytosis, secondary to infection FLOW CYTOMETRY Next Step? 2

3 Cellular Parameters Measured by Flow Cytometric Analysis Size Complexity (cytoplasm, nucleus, membrane) Immunophenotype/Antigenic profile (cytoplasm, nucleus, membrane) Cellular activity (proliferation rate) Flow Cytometry: Systematic Interrogation of Cells in a Sample What subpopulations of cells are represented in the sample? How complex are the cells? How large are the cells? Can subpopulations of cells be separated on the basis of a unique or distinguishing pattern of protein expression? Can cellular activity, biological potential, or response to chemotherapy be predicted on the basis of the immunophenotype? Dx: Atypical Chronic Lymphocytic Leukemia (acll) 7% of cases of CLL, worse prognosis than typical CLL Irregular morphogic, immunophenotypic characteristics, possible variant genetic characteristics Karyotype, CLL (All types): Del 13q14.3 (50%), Trisomy 12 (20%), Del 11q22-23, Del 17p13, Del 6q21 Karyotype, CLL (All types), Adverse Prognosis: Del 11q22-23, Del 17p13, Del 6q21 Other Markers, Adverse Prognosis (All types): high CD38 expression, ZAP-70 expression, IG gene status Dx: Atypical Chronic Lymphocytic Leukemia (acll) Immunophenotypic variations: Loss of CD5, stronger expression of CD23 Genetics: Trisomy 12 most common mutation in acll, prognostic significance unclear Other mutations in acll: t(14;19), mutated IG genes (favorable), unmutated IG genes (unfavorable) 3

4 Case #2 55-year-old woman with abdominal pain and a jejunal mass 63-year-old woman with abdominal mass, history of intermittent diarrhea. Jejunum, Resection Next Step? 4

5 4/28/2016 CD3 (T-cell receptor) Posterior iliac crest, bone marrow biopsy Brain, Right Parietal Lobe, Biopsy CD56 (NCAM) MRI of Head Differential Diagnosis Inflammation (e.g., encephalitis) Recurrent/metastatic lymphoma 5

6 Brain, biopsy CD56 (NCAM) Ki-67 Dx: Enteropathy-Associated T-cell Lymphoma, Metastatic to Brain T-cell neoplasm Presents as intestinal mass, jejunum Type I (classical, polymorphous): Associated with celiac disease/sprue, CD56(-) Type II (monomorphous): No definite association with sprue, CD56(+) CAP 2013, Orlando, Florida: Advanced EATL College of American Pathologists Annual Meeting, October 12 16, 2013 Orlando, Florida CD56-mediated homing of tumor cells to brain. Elevated Ki-67 proliferation index >90% portends aggressive clinical behavior. Bone marrow status has limited predictive value in some patients. Possible role for screening lumbar puncture/csf examination in selected patients. Possible role for early bone marrow transplantation in patients at higher risk for disseminated disease (e.g., due to CD56, high Ki-67) 6

7 4/28/2016 Acknowledgements Archie Defillo, MD Kendall D. Price, MD Eric Nussbaum, MD Alligator Pond, Gaylord Convention Center, Orlando, Florida Lymph node, anatomic compartments Case #3 Lymph Node, Right Groin, Biopsy Reactive lymph node Right Groin Lymph Node, Biopsy 7

8 4/28/2016 CD3 (T-cell receptor) Differential Diagnosis T-cell lymphoma B-cell lymphoma Reactive/Inflammatory (e.g., viral infection) NEXT STEPS? CD20 (B-cell activation molecule) Flow Cytometry: Systematic Interrogation of Cells in a Sample What subpopulations of cells are represented in the sample? How complex are the cells? How large are the cells? Can subpopulations of cells be separated on the basis of a unique or otherwise distinguishing pattern of protein expression? Can cellular activity, potential, or response to chemotherapy be predicted on the basis of immunophenotype? 8

9 Ancillary Studies POSITIVE for T-cell receptor gene rearrangement by PCR NEGATIVE for IgH gene rearrangement by PCR POSITIVE for IgHgene rearrangement by Southern blotting POSITIVE for MYC rearrangement by FISH Final Diagnosis Opinion 1: Composite lymphoma, consisting of diffuse large B-cell lymphoma and angioimmunoblastic T-cell lymphoma Opinion 2: Diffuse large B-cell lymphoma Lymphocytes and Clonality Polyclonal (Benign) Lymphoid Proliferations: broad genetic and immunologic repertoire, capable of responding to wide array of antigenic threats. Monoclonal (Often Malignant, But Not Always): narrow/restricted genetic and immunologic repertoire, very limited range of responses to antigenic threats Immunologic Repertoire assessed by flow cytometry or immunohistochemistry: protein targets Genetic Repertoire assessed by PCR, Southern Blotting, FISH, etc.: nucleic acid targets 9

10 4/28/2016 Second Presentation: Left Axillary Lymph Node, Biopsy Management: Patient Treated for Diffuse Large B-cell Lymphoma 10

11 CD3 CD20 Ki-67 Ancillary Studies POSITIVE for T-cell receptor gene rearrangement (TCR-beta and TCR-gamma regions) NEGATIVE for MYC gene rearrangement by FISH No diagnostic signals detected on PCR analysis for IgH gene rearrangement 11

12 Dx: Composite Angioimmunoblastic T-cell lymphoma, and Diffuse Large B-cell Lymphoma Neoplastic proliferation of CD4(+) T-cells with abundant clear cytoplasm Admixed large B-cells, EBV(+) May present with limited lymphadenopathy and progress over months Rarely, transformation of EBV(+) B-cells to large cell lymphoma TCR and IgH gene rearrangements present R McKenna et.al. Composite Angioimmunoblastic T-cell Lymphoma and Diffuse Large B-cell Lymphoma. Am J Clin Pathol Volume 118: Case #4 57-year-old woman with fatigue WBC: 4.8 thou/microliter Hemoglobin: 12.1 g/dl Platelet Count: 202,000 per microliter Beta-2-microglobulin: 1.63 mcg/ml(wnl) Total protein, 24-hour urine: mg/24 hrs (WNL) Kappa/Lambda free light chain ratio (serum): (Low) Case #4 Peripheral Blood Smear Serum Immunoglobulins (Quantitative): IgG: 668 (Low), Ref. Range: mg/dl IgM: 24 (Low), Ref. Range: mg/dl IgA: 26 (Low), Ref. Range: mg/dl Immunofixation electrophoresis, serum Differential Diagnosis? B-cell lymphoproliferative disorder, immature phenotype B-cell lymphoproliferative disorder, mature phenotype 12

13 4/28/2016 Right and Left Posterior Iliac Crests, Bone Marrow Aspiration and Biopsies Next Step? 13

14 4/28/2016 CD20 CD3 Cyclin-D1 (A cell cycle regulatory protein) Light chain kappa Light chain lambda CD138 (Syndecan-1, plasma cells, epithelium) Final Diagnosis: Multiple Myeloma, light chain lambda-restricted (light chain only) 14

15 Multiple Myeloma: WHO Criteria, Symptomatic Patients M-protein in serum or urine Bone marrow clonal plasma cells or plasmacytoma Related organ or tissue impairment: CRAB hypercalcemia, renal insufficiency, anemia, bone lesions Multiple Myeloma, WHO Criteria, Asymptomatic Patients M-protein in serum or urine at myeloma levels (>30 g/l) AND/OR 10% or more clonal plasma cells in bone marrow No related organ or tissue impairment (no CRAB signs) or myeloma-related symptoms (e.g., acute onset of bone pain, recurrent infections, hyperviscosity syndrome, amyloidosis, etc.) QUESTIONS? Dr. Howard Ratech and Alumni of Hematopathology Fellowship Program, Montefiore Medical Center/Albert Einstein College of Medicine Retirement Dinner, December, 2014, New York, New York Acknowledgements Flow Cytometry Staff, St. Joseph s Hospital: Holly Curtis, Suzanne Chorn, Cheryl Kaup, Kellen Runge HealthEast Medical Laboratory Dr. Joseph P. Leverone, Dr. Kendall D. Price, and Staff Pathologists, Central Regional Pathology Laboratories Dr. James Fink and Staff of Cytogenetics Laboratory, Hennepin County Medical Center Case #5: Bonus Case 55-year-old man with thigh mass 15

16 4/28/2016 Lymph node, anatomic compartments Left Thigh Mass, Biopsy 16

17 Dx: Castleman sdisease, Mixed Hyaline Vascular/Plasma Cell Variant Localized versus Multicentric Absence or presence of constitutional/systemic symptoms (e.g., fever, weight loss) Morphologic characteristics Plasma cells usually are polyclonal, not monoclonal HHV-8(+) variant is aggressive, often associated with HIV infection REFERENCES S Swerdlow et.al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon: International Agency for Research on Cancer J Frater. Typical and Atypical Chronic Lymphocytic Leukemia Differ Clinically and Immunophenotypically. Am J ClinPathol. 2001; 116(5). R McKenna et.al. Composite AngioimmunoblasticT-Cell Lymphoma and Diffuse Large B-Cell Lymphoma. Am J ClinPathol. 2002; 119: LJ Medeiros et.al. Chronic Lymphocytic Leukemia With t(14:19)(q32;q13) is Characterized by Atypical Morphologic and ImmunophenotypicFeatures and Distinctive Genetic Features. Am J ClinPathol. 2011; 135:

Malignant Lymphomas and Plasma Cell Myeloma

Malignant Lymphomas and Plasma Cell Myeloma Dr. Bruce F. Burns Dept. of Pathology and Lab Medicine Overview definitions - lymphoma lymphoproliferative disorder plasma cell myeloma pathogenesis - translocations