Disorders of Hematopoietic System Lymphoproliferative Neoplasms

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1 Disorders of Hematopoietic System Lymphoproliferative Neoplasms Vishala Neppalli, M.D Assistant Professor of Oncology, Hematopathology Roswell Park cancer Institute

2 Learning Objectives Introduction to lymphoid system - Anatomic distribution - Physiology Introduction to pathobiology Introduction to neoplastic lymphoid proliferations- clinical Presentation Overview of diagnostic concepts (pathology)

3 Subdivision of Hematopoietic Tumors Anatomic distribution Bone marrow Blood Liquid Thymus Lymph nodes spleen Tissue

4 Lymphoid System: Physiology Important component of immune system Cellular components and functions: - B-lymphocytes and plasma cells: antibody mediated defense. - T-lymphocytes and Natural Killer cells: cell mediated defense, and support B-lymphocyte function. Deregulation of function: - Immunodeficiency, - Autoimmune disorders - Malignancy

5 Lymphoid System: Pathobiology Lymphocyte development is a complex process that occurs in discrete steps B stem cell Pro B cell B cell Plasma cell T stem cell Prothymocyte T cell Lymphoid stem cell Pluripotent stem cell DC stem cell NK cell Mature dendritic cell Myeloid series Monocytes Macrophages Neutrophils Myeloid stem cell

6 Lymphoid System: Pathobiology Lymphocytes Undergo Genomic Alterations During Normal Development Genome instability and mutation Despite the oncogenic dangers associated with genomic instability and mutation lymphoid cells purposely alter their DNA during development to maximize the diversity and effector functions of their antigen receptors Tsai AG, Lieber MR. BMC Genomics. 2010;11(suppl):S1.

7 T-Cell Gene Rearrangements: Genetic Permutations and Combinations Leukemia (2003) 17,

8 Lymphoid System: Pathobiology Stages of T-cell development are defined by surface antigen expression Prothymocyte Cortical thymocyte Medullary thymocyte T cell cytoplasmic surface CD7 CD2/CD5 CD3 CD4 CD8 TDT* *Terminal deoxynucleotidyl transferase. Swerdlow SH et al, eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon, France: IARC; 2008.

9 Lymphoid System: Pathobiology Lymphoma subtypes arise from different stages of T-cell development 1,2 Pro/thymocyte Innate immunity Acquired immunity Bone marrow/thymus Tissues Blood Tissues T lymphoblastic leukemia/ lymphoma Hepatosplenic TCL Cutaneous γδ TCL Adult T- cell leukemia/ lymphoma, HTLV1 PTCL- NOS, ALCL, AITL, enteropathy- associated TCL, subcutaneous panniculitis- like TCL, mycosis fungoides 1. Swerdlow SH et al, eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon, France: IARC; de Leval L et al. Histopathology. 2011;58(1):49-68.

10 Lymphoid System: Pathobiology Stages of B-cell development are defined by surface antigen expression 1-3 B stem cell Pro B cell B cell Plasma cell CD19 CD20 CD21 CD22 CD38 CD40 1. Orkin SH et al. Cell. 2008;132(4): Uckun FM. Blood. 1990;76(10): Swerdlow SH et al, eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon, France: IARC; 2008.

11 Lymphoid System: Pathobiology Lymph Node Section: Hematoxylin and Eosin Stain Germinal Center (lymphoma) Mantle zone (lymphoma) Marginal zone (lymphoma) T zone (lymphoma)

12 W.H.O. classification Incorporates morphology, immunophenotype, genetic and clinical features Non- Hodgkin s Lymphoma B cell neoplasms (20 types) Small lymphocytic lymphoma/ chronic lymphocytic leukemia B cell prolymphocytic leukemia Lymphoplasmacytic lymphoma Splenic marginal zone lymphoma Hairy cell leukemia Plasma cell myeloma Monoclonal gammopathy of uncertain significance Solitary plasmacytoma of bone Extraosseous plasmacytoma Primary amyloidosis Heavy chain diseases Extranodal marginal zone B cell lymphoma MALT Nodal marginal zone lymphoma Follicular lymphoma Mantle cell lymphoma Diffuse large B-cell lymphoma Mediastinal (thymic) large B-cell lymphoma Intravascular large B-cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukemia T cell neoplasms (16 types) T-cell PLL T-cell LGL leukemia Aggressive NK leukemia Adult T-cell leukemia/lymphoma Mycosis fungoides Sezary syndrome 1 cutaneous ALCL Lymphomatoid papulosis Blastic NK cell lymphoma Extranodal NK/T-cell lymphoma, nasal type Enteropathy-type T-cell lymphoma Hepatosplenic T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Angioimmunoblastic lymphoma Peripheral T-cell lymphoma, unspecified Anaplastic large cell lymphoma Hodgkin Lymphoma Classical HL NLPHL No simple way to remember this

13 Frequency and distribution of lymphoproliferative neoplasms B-NHL: 88% T/ NK NHL: 12% B-FL 22% DLBCL 31% Peripheral T-cell lymphoma, not otherwise specified Cutaneous T-cell lymphoma Anaplastic large cell lymphoma Angioimmunoblastic T-cell lymphoma NK-cell lymphoma 4% of all Cancers Information presented in the World Health Organization Classification of Tumors: Tumors of Hematopoietic and Lymphoid Diseases :

14 Clinical Presentation Unexplained/unintentional weight loss Unexplained fever Night sweats Rash Painless lymphadenopathy Skin rash

15 Enlargement of lymph nodes in lymphoma Biopsy of suspected Lymph node for diagnosis

16 Examples of Skin Rash

17 Clinical Approach to Lymphoma Diagnosis Physical examination Complete blood count, peripheral blood smear review Chemistry: lactate dehydrogenase, beta 2 macroglobulin Radiology: X-ray, Ct scan PET scan Tissue biopsy Bone marrow biopsy

18 Peripheral Blood Review

19 Radiology Cervical lymph nodes CT scan PET scan Fused PET-CT Mediastinal mass Enlarged spleen

20 Open biopsy Lymph Node Biopsy

21 Tissue Biopsies Cassettes Tissue Blocks

22 Tissue Biopsy: Microscopic Evaluation

23 Diagnostic Tests Hematopathologists conduct diagnostic evaluation using special tests CD20 CD79a Immunohistochemistry

24 Diagnostic Tests Hematopathologists conduct diagnostic evaluation using special tests

25 Diagnostic Tests: FISH JMD May 2006, Vol. 8, No. 2

26 Diagnostic Tests: FISH JMD May 2006, Vol. 8, No. 2

27 Lymphoma Classification : Clinical behavior Mature High Grade B-cell Neoplasms Diffuse Large B-cell Lymphoma Burkitt Lymphoma B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and Burkitt lymphoma

28 Heterogeneity of Diffuse Large B-cell Lymphoma Clinical Presentation Morphology Immunophenotype Molecular/ Cytogenetic features Response to treatment

29 Heterogeneity of Diffuse Large B-cell Lymphoma Clinical Presentation - Nodal Disease -Extra-nodal disease - Skin, soft tissue, bone, GI tract, CNS, organ involvement, mediastinum - Immunosuppression related

30 Diffuse Large B-cell Lymphoma: Gross LN Spleen Leg Forms a mass. Can be associated with necrosis in large lesions.

31 Relationship of DLBCL Subgroups to Normal B- Lymphocyte Differentiation and Activation CD21 BCL6 CD10 c-myc BCL2 IRF4 NATURE VOL FEBRUARY 2000

32 Subtypes of DLBCL and Survival Characteristics NATURE VOL FEBRUARY 2000

33 Follicular Lymphoma B-FL pattern: Absence of TM, proliferation of centroblasts/centrocytes

34 CD3 and CD20 Pattern CD3: T-cell CD20: B-cell B-FL pattern: Absence of TM, proliferation of centroblasts/centrocytes

35 Dignostic Approach: Immunohistochemistry CD10: Folliclular centre cell B-cells BCL-2: antiapoptotic BCL-6: nuclear stain, follicular centre B-cell B-FL: CD3-; CD20+, BCL2+, CD10+, BCL-6 +

36 Marginal zone lymphoma

37 Marginal zone pattern CD21: FDC

38 Marginal zone pattern CD3: T-cells

39 Marginal zone pattern CD79a: B-cells

40 Marginal zone pattern BCL2

41 Marginal zone pattern Pan keratin

42 Metastatic/ sinusoidal pattern

43 Metastatic/ sinusoidal pattern

44 Burkitt Lymphoma

45 Treatment Combination chemotherapy Monoclonal therapy: Rituximab Transplant

46 Thank You

Non-Hodgkin s Lymphoma

Non-Hodgkin s Lymphoma Luis Fayad, MD Assistant Professor Clinical Medical Director Lymphoma/Myeloma Department Non-Hodgkin s Lymphoma Non-Hodgkin s lymphomas (NHL) are a heterogeneous group of malignant