Best Practice in Lymphoma Diagnosis and Reporting Specific disease appendix

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1 Best Practice in Lymphoma Diagnosis and Reporting Specific disease appendix This is a companion to the guideline on best practice in Lymphoma diagnosis and reporting that can also be found on the BCSH website. British Committee for Standards in Haematology Royal College of Pathologists Address for correspondence: BCSH Administrator British Society for Haematology 100 White Lion Street London N1 9PF Writing group: Parker A 1, Bain B 2, Devereux S 3, Gatter K 4, Jack A 5, Matutes E 6, Rooney N 7, Ross F 8, Wilkins B 9, Wotherspoon A 10, Ramsay A. 11 Guideline update and changes: This guideline is an updated version of the 2008 guideline, revised to take into account the 2008 WHO guidelines as they apply to the lymphoproliferative disorders. There have been no changes to the sections on histiocytic and dendritic cell neoplasms. The pathology of posttransplant lymphoproliferative disorder is dealt with in the BCSH guideline on this topic. This appendix does not include all diagnoses. Review date: April 2012 (first published in April 2010). Disclaimer While the advice and information in these guidelines is believed to be true and accurate at the time of going to press, neither the authors, the British Society for Haematology nor the publishers accept any legal responsibility for the content of these guidelines. 1 Anne Parker, (BCSH Lead), Consultant Haematologist, Glasgow Royal Infirmary, Glasgow 2 Barbara Bain, Consultant Haematologist, St Marys Hospital, Paddington 3 Steve Devereux, Consultant Haematologist, Kings College Hospital, London, 4 Kevin Gatter, Professor of Pathology, John Radcliffe Hospital, Oxford 5 Andrew Jack, Consultant Histopathologist, Leeds General Hospital, Leeds 6 Estella Matutes, Consultant Haematologist, The Royal Marsden, London 7 Nick Rooney, Consultant Histopathologist, Southmead Hospital, Bristol 8 Fiona Ross, Consultant Clinical Scientist, Wessex Regional Genetics Laboratory, Salisbury, 9 Bridget Wilkins, Consultant Histopathologist, Royal Victoria Infirmary, Newcastle upon Tyne 10 Andrew Wotherspoon, Consultant Histopathologist, The Royal Marsden, London, 11 Alan Ramsay, Consultant Histopathologist (RCPath Lead), University College Hospital, London

2 Index for Disease Specific Appendix Mature B Cell neoplasms 1. Chronic lymphocytic leukaemia (CLL) and small lymphocytic lymphoma (SLL) (p02) 2. B-cell prolymphocytic leukaemia (B-PLL) (p11) 3. Lymphoplasmacytic lymphoma / Waldenström macroglobulinaemia (p16) 4. Splenic B-cell marginal zone lymphoma (p20) 5. Hairy cell leukaemia (p27) 6. Plasma cell myeloma and other plasma cell neoplasms (p32) 7. Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (p43) 8. Nodal marginal zone lymphoma (p48) 9. Follicular Lymphoma (p52) 10. Mantle cell lymphoma (p57) 11. Diffuse large B cell lymphoma (p63) a. Mediastinal B cell lymphoma b. Plasmablastic lymphomat-cell/ histiocyte-rich large B cell lymphoma c. ALK positive DLBCL d. Intravascular lymphoma e. Primary effusion lymphoma 12. Non-endemic Burkitt lymphoma (p75) Mature T- and NK-cell neoplasms 13. Extranodal NK/T cell lymphoma, nasal type (p81) 14. Enteropathy-associated T-cell lymphoma (p85) 15. Hepatosplenic T-cell lymphoma (p88) 16. Angioimmunoblastic lymphoma (p92) 17. Anaplastic large cell lymphoma, ALK-positive and ALK-negative (p96) 18. Peripheral T-cell lymphoma, not otherwise specified (p101) 19. T-lymphoblastic leukaemia/ lymphoma (p106) 20. T-cell prolymphocytic leukaemia (p110) 21. T-cell large granular lymphocytic leukaemia (p115) 22. Aggressive natural killer-cell leukaemia (p120) 23. Adult T-cell luekaemia/ lymphoma (p124) Hodgkin Lymphoma 24. Classical Hodgkin Lymphoma (p129) 25. Nodular lymphocyte predominant Hodgkin lymphoma (p133) Histiocytic and Dendritic cell neoplasms 26. Histiocytic Sarcoma (p137) 27. Langerhans cell histiocytosis (p140) 28. Langerhans Cell Sarcoma (p144) 29. Interdigitating dendritic cell sarcoma/ tumour (p147) 30. Follicular dendritic cell sarcoma/ tumour (p150) 31. Dendritic cell tumour not otherwise specified (p 153)

3 1 Chronic lymphocytic leukaemia (CLL) and small lymphocytic lymphoma (SLL) 1.1 Disease and Clinical Features This is a clonal disorder of mature B lymphocytes with a variable clinical course in which there is accumulation of neoplastic cells in the bone marrow, peripheral blood and secondary lymphoid tissues. The clinical features result from immunological dysfunction, lymph node and organ infiltration and, later in the course of the disease, bone marrow failure. 1.2 Peripheral blood Peripheral blood lymphocyte count > 5 x 10 9 /l in CLL Peripheral blood lymphocyte count may be < 5.0 x 10 9 /l, these cases being referred to as monoclonal B lymphocytosis with CLL phenotype or, if there is significant tissue infiltration, as small lymphocytic lymphoma. Typical morphology: Small lymphocytes, scanty cytoplasm, clumped chromatin, indistinct or absent nucleoli

4 1.3 Bone marrow Examination of the bone marrow is not routinely required in CLL but may be indicated in the following situations:- where there is diagnostic difficulty, as a prognostic indicator, to document the response to therapy, to assess haemopoietic reserve (particularly when autoimmune cytopenia is suspected) or as a research investigation. Bone marrow aspirate morphology is similar to that of the peripheral blood Trephine biopsy histology typically reveals mixed nodular and interstitial infiltration of intertrabecular spaces, rarely diffuse ( packed marrow pattern) with small lymphocytes. Nodules may be based on proliferation centres containing para-immunoblasts (histological equivalents of prolymphocytes) but only rarely on pre-existing, non-neoplastic follicles. In untreated patients, paratrabecular infiltration is almost never found. 1.4 Lymph node & spleen Lymph node biopsy is seldom necessary in CLL. However, it may be performed if there is persistent enlargement of a single lymph node group after therapy or when high grade transformation is suspected. The usual context for lymph node biopsy is in diagnosis of small lymphocytic lymphoma in the absence of features of CLL. The usual pattern is of diffuse effacement of lymph node structure with variable numbers of proliferation centres (sometimes called pseudofollicles). Transformation to a diffuse, high grade B-cell lymphoma (Richter s transformation) and Hodgkin lymphoma may occur. EBV has been implicated in some of these cases. As a result of immunosuppression, high grade lymphoma can also develop in B lymphocytes that are not part of the neoplastic clone. 1.5 Immunophenotype The typical immunophenotype of CLL is given below in table 1.1. Additional antigens such as CD38 (Damle, et al 1999) and ZAP70 (Crespo, et al 2003, Orchard, et al 2004, Rassenti, et al 2004, Wiestner, et al 2003) have been shown to have prognostic significance in B-CLL but are not required for diagnosis.

5 Similarly, demonstration of p53 dysfunction by FACS immunophenotyping following in vitro exposure of cells to ionising radiation is prognostically valuable although not currently essential for diagnosis (Lin, et al 2002, Carter, et al 2004). Table 1.1 CLL immunophenotype scoring system (Delgado, et al 2003) Marker Score points 1 0 Smlg Weak Strong CD5 Positive CD23 Positive FMC7 Positive CD22 or CD79b Weak Strong Score = or > 4 in 92% of cases of CLL If <= 3 then exclude mantle cell lymphoma by one or both of: (i) Immunostaining of bone marrow trephine sections or lymph node for nuclear cyclin D1 (ii) FISH for t(11:14) using blood, BM or lymph node. Other lymphoproliferative disorders such as marginal zone, follicular and lymphoplasmacytic lymphomas can usually be distinguished by their immunophenotype. In problematic cases, lymph node or other tissue biopsy may be appropriate if the distinction is clinically important. 1.6 Cytogenetics & molecular genetics Conventional cytogenetic studies are frequently not informative because of a failure of CLL cells to divide in vitro. FISH studies are useful in differentiating mantle cell lymphoma from CLL. Perform FISH for t(11;14) with specific CCND1/IGH probes or CCND1 breakapart probe in all cases of CLL with atypical morphology or a score of 3 or less. If

6 a bone marrow trephine biopsy or lymph node specimen is available, immunohistochemistry for cyclin D1 should also be performed. Cytogenetic abnormalities have been shown to correlate with prognosis; deletion of 13q14 being associated with a good prognosis, trisomy 12 and deletion of 6q with an intermediate and deletion of 17p (TP53) and 11q (ATM)with a poor prognosis (Dohner, et al 2000). The loss of TP53 is strongly associated with poor response to alkylating agents and purine analogues. (Stilgenbauer and Dohner 2002) However, finding these abnormalities by FISH does not provide any diagnostic information as all are common in many subtypes of lymphoma. 1.7 Prognostic markers Clinical factors Staging systems based on the extent of lymphadenopathy and the presence of anaemia and/or thrombocytopenia (excluding that with an auto-immune basis) are the simplest and best validated predictors of outcome in CLL. These systems do not predict disease progression in early stage disease; however those with progressive stage A disease have a similar outcome to stage B patients. Males with CLL generally have a worse prognosis than females regardless of clinical stage (Catovsky, et al 1989). Table 1.2 Binet staging system for CLL (Binet et al. 1981) Stag Features % Median survival e (months) A < 3 lymphoid areas* B = or > 3 lymphoid areas C Haemoglobin < 100 g/l or platelets < x 10 9 /l *The five lymphoid areas comprise unilateral or bilateral cervical, axillary and inguinal lymphadenopathy, hepatomegaly and splenomegaly Biological markers

7 In addition to easily measurable clinical variables, a number of other biomarkers correlate with outcome in CLL and these are summarised below (adapted from Oscier, et al 2004) Table 1.3. Biological variables that correlate with prognosis in CLL Factor Outcome Reference Trephine biopsy Diffuse pattern worse than nondiffuse (Montserrat, et al 1996) Lymphocyte doubling time <12 months worse than >12 months (Montserrat, et al 1986) Serum markers High lactate dehydrogenase, 2 (Di Raimondo, et al microglobulin, soluble thymidine kinase, soluble CD23 worse 2001, Hallek, et al 1999, Knauf, et al 1997, Schwarzmeier, et al 2002) CD38 >20-30% CD38+ve worse (Damle, et al 1999) Genetic del 17p worse than del 11q worse (Dohner, et al 2000) abnormalities than trisomy 12 worse than del 13q. del 17p resistant to therapy except corticosteroids and alemtuzumab IG V H status Unmutated immunoglobulin variable genes (>98% germline) (Damle, et al 1999, Hamblin, et al 1999) worse Using the threshold of 98% to divide mutated from unmutated cases, patients with Vh3.21 fall into the mutated group but nevertheless have a poor prognosis (Tobin, et al 2002). P53 expression Poor response to chemotherapy, response to Alemtuzumab (Cordone, et al 1998, Lozanski, et al 2004)

8 ZAP 70 Correlates (partially) with unmutated IG V H status (Crespo, et al 2003, Orchard, et al 2004, Rassenti, et al 2004, Wiestner, et al 2003) 1.8 Pitfalls Cytology in peripheral blood and aspirated marrow is variable and not a reliable guide to diagnosis. Atypical morphological features include presence of >10% but <55% prolymphocytes (also called CLL-PL) and >15% lymphoplasmacytic cells +/- cells with cleft nuclei (Bennett, et al 1989). Immunophenotyping is occasionally atypical, with absence of expression of CD5 or CD23 (rarely both). In such atypical variants, marrow trephine biopsy or lymph node histology may be helpful and is recommended; immunohistological phenotyping can reveal weak expression or a proportion of cells expressing CD5/CD Differential diagnosis The main differential diagnosis is between other types of non-hodgkin lymphoma with blood overspill. These include the following Mantle cell lymphoma B-cell prolymphocytic leukaemias Follicular lymphoma Marginal zone lymphomas Recommendations Recommendations for diagnosis of CLL Diagnostic criteria Peripheral blood lymphocyte count > 5 x 10 9 /l Peripheral blood immunophenotype score = or > 4 Histology demonstrating CD5/CD23 if no blood involvement. Level of evidence Grade C level IV

9 Cases with score < 4 should have FISH for t(11:14) and cyclin D1 immunohistochemistry to exclude MCL. Cases requiring treatment should have FISH or functional studies done for investigation of TP53 mutations 1.11 References Bennett, J.M., Catovsky, D., Daniel, M.T., Flandrin, G., Galton, D.A., Gralnick, H.R. & Sultan, C. (1989) Proposals for the classification of chronic (mature) B and T lymphoid leukaemias. French-American-British (FAB) Cooperative Group. J Clin Pathol, 42, Binet, J.L., Auquier, A., Dighiero, G., Chastang, C., Piguet, H., Goasguen, J., Vaugier, G., Potron, G., Colona, P., Oberling, F., Thomas, M., Tchernia, G., Jacquillat, C., Boivin, P., Lesty, C., Duault, M.T., Monconduit, M., Belabbes, S. & Gremy, F. (1981) A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer, 48, Carter, A., Lin, K., Sherrington, P.D., Pettitt, A.R. (2004) Detection of p53 dysfunction by flow cytometry in chronic lymphocytic leukaemia. Br J Haematol, 127, Catovsky, D., Fooks, J. & Richards, S. (1989) Prognostic factors in chronic lymphocytic leukaemia: the importance of age, sex and response to treatment in survival. A report from the MRC CLL 1 trial. MRC Working Party on Leukaemia in Adults. Br J Haematol, 72, Crespo, M., Bosch, F., Villamor, N., Bellosillo, B., Colomer, D., Rozman, M., Marce, S., Lopez-Guillermo, A., Campo, E. & Montserrat, E. (2003) ZAP-70 expression as a surrogate for immunoglobulin-variable-region mutations in chronic lymphocytic leukemia. N Engl J Med, 348, Cordone, I., Masi, S., Mauro, F.R., Soddu, S., Morsilli, O., Valentini, T., Vegna, M.L., Guglielmi, C., Mancini, F., Giuliacci, S., Sacchi, A., Mandelli, F. & Foa, R. (1998) p53 Expression in B-Cell Chronic Lymphocytic Leukemia: A Marker of Disease Progression and Poor Prognosis. Blood, 91, Damle, R.N., Wasil, T., Fais, F., Ghiotto, F., Valetto, A., Allen, S.L., Buchbinder, A., Budman, D., Dittmar, K., Kolitz, J., Lichtman, S.M., Schulman, P., Vinciguerra, V.P., Rai, K.R., Ferrarini, M. & Chiorazzi, N. (1999) Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia. Blood, 94,

10 Delgado, J., Matutes, E., Morilla, A.M., Morilla, R.M., Owusu-Ankomah, K.A., Rafiq-Mohammed, F., del Giudice, I. & Catovsky, D. (2003) Diagnostic significance of CD20 and FMC7 expression in B-cell disorders. Am J Clin Pathol, 120, Di Raimondo, F., Giustolisi, R., Lerner, S., Cacciola, E., O'Brien, S., Kantarjian, H. & Keating, M.J. (2001) Retrospective study of the prognostic role of serum thymidine kinase level in CLL patients with active disease treated with fludarabine. Ann Oncol, 12, Dohner, H., Stilgenbauer, S., Benner, A., Leupolt, E., Krober, A., Bullinger, L., Dohner, K., Bentz, M. & Lichter, P. (2000) Genomic aberrations and survival in chronic lymphocytic leukemia. N Engl J Med, 343, Hallek, M., Langenmayer, I., Nerl, C., Knauf, W., Dietzfelbinger, H., Adorf, D., Ostwald, M., Busch, R., Kuhn-Hallek, I., Thiel, E. & Emmerich, B. (1999) Elevated serum thymidine kinase levels identify a subgroup at high risk of disease progression in early, nonsmoldering chronic lymphocytic leukemia. Blood, 93, Hamblin, T.J., Davis, Z., Gardiner, A., Oscier, D.G. & Stevenson, F.K. (1999) Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia. Blood, 94, Knauf, W.U., Ehlers, B., Mohr, B., Thiel, E., Langenmayer, I., Hallek, M., Emmerich, B., Adorf, D., Nerl, C. & Zwingers, T. (1997) Prognostic impact of the serum levels of soluble CD23 in B-cell chronic lymphocytic leukemia. Blood, 89, Lin, K., Sherrington, P.D., Dennis, M., Matrai, Z., Cawley, J.C., Pettitt, A.R. (2002) Relationship between p53 dysfunction, CD38 expression, and IgV(H) mutation in chronic lymphocytic leukemia. Blood, 100,: (Erratum in: Blood 2002, 100, 2291.) Lozanski, G., Heerema, N.A., Flinn, I.W., Smith, L., Harbison, J., Webb, J., Moran, M., Lucas, M., Lin, T., Hackbarth, M.L., Proffitt, J.H., Lucas, D., Grever, M.R. & Byrd, J.C. (2004) Alemtuzumab is an effective therapy for chronic lymphocytic leukemia with p53 mutations and deletions. Blood, 103, Montserrat, E., Sanchez-Bisono, J., Vinolas, N. & Rozman, C. (1986) Lymphocyte doubling time in chronic lymphocytic leukaemia: analysis of its prognostic significance. Br J Haematol, 62, Montserrat, E., Villamor, N., Reverter, J.C., Brugues, R.M., Tassies, D., Bosch, F., Aguilar, J.L., Vives-Corrons, J.L., Rozman, M. & Rozma, C. (1996) Bone marrow assessment in B-cell chronic lymphocytic leukaemia: aspirate or biopsy? A comparative study in 258 patients. Br J Haematol, 93, Orchard, J.A., Ibbotson, R.E., Davis, Z., Wiestner, A., Rosenwald, A., Thomas, P.W., Hamblin, T.J., Staudt, L.M. & Oscier, D.G. (2004) ZAP-70 expression and prognosis in chronic lymphocytic leukaemia. Lancet, 363,

11 Oscier, D., Fegan, C., Hillmen, P., Illidge, T., Johnson, S., Maguire, P., Matutes, E. & Milligan, D. (2004) Guidelines on the diagnosis and management of chronic lymphocytic leukaemia. British Journal of Haematology, 125, Rassenti, L.Z., Huynh, L., Toy, T.L., Chen, L., Keating, M.J., Gribben, J.G., Neuberg, D.S., Flinn, I.W., Rai, K.R., Byrd, J.C., Kay, N.E., Greaves, A., Weiss, A. & Kipps, T.J. (2004) ZAP-70 compared with immunoglobulin heavy-chain gene mutation status as a predictor of disease progression in chronic lymphocytic leukemia. N Engl J Med, 351, Schwarzmeier, J.D., Shehata, M., Hilgarth, M., Marschitz, I., Louda, N., Hubmann, R. & Greil, R. (2002) The role of soluble CD23 in distinguishing stable and progressive forms of B-chronic lymphocytic leukemia. Leuk Lymphoma, 43, Stilgenbauer, S. & Dohner, H. (2002) Campath-1H-Induced Complete Remission of Chronic Lymphocytic Leukemia despite p53 Gene Mutation and Resistance to Chemotherapy. N Engl J Med, 347, Tobin, G., Thunberg, U., Johnson, A., Thorn, I., Soderberg, O., Hultdin, M., Botling, J., Enblad, G., Sallstrom, J., Sundstrom, C., Roos, G. & Rosenquist, R. (2002) Somatically mutated Ig V(H)3-21 genes characterize a new subset of chronic lymphocytic leukemia. Blood, 99, Wiestner, A., Rosenwald, A., Barry, T.S., Wright, G., Davis, R.E., Henrickson, S.E., Zhao, H., Ibbotson, R.E., Orchard, J.A., Davis, Z., Stetler-Stevenson, M., Raffeld, M., Arthur, D.C., Marti, G.E., Wilson, W.H., Hamblin, T.J., Oscier, D.G. & Staudt, L.M. (2003) ZAP-70 expression identifies a chronic lymphocytic leukemia subtype with unmutated immunoglobulin genes, inferior clinical outcome, and distinct gene expression profile. Blood, 101,

12 2 B-cell prolymphocytic leukaemia (B-PLL) 2.1 Definition and clinical features B-PLL is a rare clonal disorder of mature B cells with prolymphocytic morphology characterised by high peripheral blood white count, little lymphadenopathy and marked splenomegaly. Patients are generally elderly; there is a male predominance and often a more aggressive course than in CLL. About 20% of cases of B-PLL have been reported to have a t(11;14) translocation but these probably represent a leukaemic variant of mantle cell lymphoma. (Ruchlemer, et al 2004) 2.2 Peripheral blood Total white cell count is usually >100 x 10 9 /l, although it may be lower in patients with slowly progressive disease. Anaemia and thrombocytopenia may be present due to hypersplenism and/or bone marrow failure. Prolymphocytes comprise > 55% of circulating cells. These are intermediate sized cells with relatively small volume, mildly basophilic cytoplasm and round nuclei with moderately condensed chromatin and a prominent nucleolus. 2.3 Bone marrow Bone marrow aspirate shows heavy infiltration by prolymphocytes. Bone marrow trephine biopsy histology shows a diffuse intertrabecular or mixed diffuse and interstitial infiltrate of small to medium-sized lymphoid cells, with prominent single nucleoli, corresponding closely with the cytological appearances. Nuclear cyclin D1 staining is seen in some cases in association with the t(11;14) abnormality, emphasising the possibility that they are variants of, or closely related to, MCL. Immunohistochemistry for CD5 and CD23 yields varying results. 2.4 Lymph node & spleen Lymphadenopathy is not prominent, but nodes show diffuse infiltration by prolymphocytes. Proliferation centres (pseudofollicles) are generally not seen.

13 Histology of the spleen shows infiltration of both red and white pulp with prolymphocytes. 2.5 Immunophenotype Table 2.1 Recommended Panel for diagnosis of B-PLL Marker SmIg CD5 CD23 FMC7 CD22 or CD79b CD20 Cyclin D1 Reaction Strong Positive in 33% of cases Usually negative Strong Strong Strong 2.6 Cytogenetics & molecular genetics Cytogenetic abnormalities appear to be similar to those in CLL (Lens, et al 1997, Lens, et al), but prognostic associations have not been proven. Early reports suggest that about 20% of cases of possible B-PLL have a t(11;14), but these probably represent a leukaemic variant of mantle cell lymphoma (Ruchlemer, et al 2004). Abnormalities of the TP53 gene are found in more than 50% of cases (Lens, et al 1997). 2.7 Prognostic factors Advanced age, the presence of anaemia and TP53 abnormalities predict a poor prognosis (Hercher, et al 2001). 2.8 Pitfalls Cases of diffuse high grade B-cell lymphoma may present with bone marrow and peripheral blood involvement. The morphology and immunophenotype may be

14 similar to B-PLL and differentiation may require correlation with the clinical picture and tissue biopsy findings. There may be clinical and cytomorphological overlap with either CLL or mantle cell lymphoma, making immunophenotyping essential and genetic investigations advisable in all cases. If cyclin D1 expression is identified this should be considered to be mantle cell lymphoma. The immunophenotype may be variant and should be interpreted with caution. 2.9 Differential diagnosis Leukaemic and blastoid variants of mantle cell lymphoma may be confused with B-PLL in peripheral blood and lymph node respectively. Atypical CLL (CLL-PL) can also be confused with B-PLL Recommendations Recommendations for diagnosis of B-PLL Diagnostic criteria Lymphocytosis with more than 55% prolymphocytes Level of evidence Grade C level IV Immunophenotype SmIgM/D strong, CD20 strong, CD22/CD79b strong, FMC7+, CD5+ in 33% patients. CD23 usually negative. Immunohistochemistry for Cyclin D1 in all cases to exclude MCL and/or FISH for t(11;14) References Hercher, C., Robain, M., Davi, F., Garand, R., Flandrin, G., Valensi, F., Vandeputte, H., Albert, A., Maynadie, M., Troussard, X., Simon, G.H., Lespinasse, J., Portefaix, G. & Merle-Beral, H. (2001) A multicentric study of 41 cases of B-prolymphocytic leukemia: two evolutive forms. Leuk Lymphoma, 42, Lens, D., De Schouwer, P.J., Hamoudi, R.A., Abdul-Rauf, M., Farahat, N., Matutes, E., Crook, T., Dyer, M.J. & Catovsky, D. (1997) p53 abnormalities in B-cell prolymphocytic leukemia. Blood, 89, Lens, D., Matutes, E., Catovsky, D. & Coignet, L.J. (2000) Frequent deletions at 11q23 and 13q14 in B cell prolymphocytic leukemia (B-PLL). Leukemia, 14,

15 Ruchlemer, R., Parry-Jones, N., Brito-Babapulle, V., Attolico, I., Wotherspoon, A.C., Matutes, E. & Catovsky, D. (2004) B-prolymphocytic leukaemia with t(11;14) revisited: a splenomegalic form of mantle cell lymphoma evolving with leukaemia. Br J Haematol, 125,

16 3 Lymphoplasmacytic lymphoma / Waldenström macroglobulinaemia 3.1 Definition and clinical features Lymphoplasmacytic lymphoma (LPL) is a slowly progressive, clonal disorder of mature B cells, with features of plasma cell differentiation. Paraproteinaemia (usually IgM) is common, and may give rise to hyperviscosity. In some patients this can be associated with peripheral neuropathy. Splenomegaly is frequent but not usually massive and lymphadenopathy, when present, is not usually prominent. WM is the term used to describe cases of LPL in which there is an IgM paraprotein, which may be associated with hyperviscosity. 3.2 Peripheral blood Peripheral blood films typically show marked rouleaux formation and variable numbers of small lymphocytes, lymphoplasmacytoid cells and plasma cells, the latter rarely present in high numbers. Anaemia, neutropenia and thrombocytopenia may occur because of hypersplenism and/or bone marrow failure. 3.3 Bone marrow Bone marrow aspirate morphology is similar to that found in peripheral blood. Trephine biopsy histology shows irregular nodular and paratrabecular infiltrates, with or without additional diffuse interstitial infiltration. Intrasinusoidal infiltration is uncommon, in contrast with splenic marginal zone and mantle cell lymphomas. Plasma cells may contain PAS-positive inclusions of immunoglobulin, which may appear in the cytoplasm (Russell bodies) or indenting the nucleus (Dutcher bodies). The proportions of lymphocytes, lymphoplasmacytoid cells and plasma cells vary widely. There may also be scattered larger blast cells but no true paraimmunoblasts or proliferation centres. Accompanying reactive mast cells are often abundant (Wilkins, et al 2001). 3.4 Lymph node

17 The lymph nodes contain diffuse or vaguely nodular infiltrates of mixed lymphoid cells encompassing the spectrum described above. Absence of neoplastic follicles, expanded marginal zones or infiltrates of monocytoid B cells is important in differentiating lymphoplasmacytic lymphoma from other types of small B-cell lymphoma (Nathwani, et al 2001). 3.5 Immunophenotype Table 3.1 Recommended Panel for Diagnosis of Lymphoplasmacytic Lymphoma Marker Reaction SmIg Positive. Usually IgM+IgD+/- rarely IgG or IgA CD5 (rare atypical cases +) CD10 CD23 (rare atypical cases +) CD19, CD20, Positive CD22, CD79a Positive CD25, CD27 Positive CD103, CD138 BCL2, PAX5 Positive BCL6 3.6 Cytogenetics & molecular genetics It has been reported that a t(9;14)(p13;q32) involving PAX5 and IGH occurs in about 50% of LPL cases (Iida, et al 1996) but no confirmation from other groups has been found. Waldenström macroglobulinemia cases do not usually have translocations involving IGH but frequently have a deletion of 6q (Schop and Fonseca 2003). This is seen in many types of lymphoma and has neither diagnostic nor prognostic value in this group. In cases with an atypical immunophenotype, FISH to exclude t(11;14) and t(14;18) may be helpful. 3.7 Prognostic features A variety of clinical and laboratory parameters have been correlated with a poor prognosis including: advanced age, male sex, weight loss, the presence of one

18 or more cytopenias, raised beta 2 microglobulin level, high IgM paraprotein level and low serum albumin (Johnson, et al 2006). 3.8 Pitfalls Cases with little evidence of plasma cell differentiation may be confused with other small B-cell lymphomas; immunophenotyping can exclude CLL, MCL and follicular lymphoma but not splenic or extranodal marginal zone lymphomas (Berger et al 2005). 3.9 Differential diagnosis CLL Follicular lymphoma Plasma cell myeloma Splenic marginal zone lymphoma/slvl Node-based and extranodal (MALT-type) marginal zone B cell lymphoma Mantle cell lymphoma 3.10 Recommendations Recommendations for diagnosis of Lymphoplasmacytic Lymphoma Diagnostic criteria Level of evidence IgM (or other) monoclonal gammopathy of any Grade C level IV concentration Bone marrow infiltration by small lymphocytes showing plasmacytoid and/or mature plasma cell differentiation Nodular, interstitial or paratrabecular pattern of bone marrow infiltration Immunophenotype: Sm IgM+ CD5- CD10- CD19+ CD20+ CD22+ CD23- CD25+ CD27+ FMC7+ CD103- CD138-. Additional investigations

19 Plasma viscosity, tests of renal and hepatic function Direct antiglobulin test, cold agglutinin titre and cryoglobulins Beta 2 microglobulin 3.11 References Berger, F., Traverse-Glehen, A., Felman, P., Callet-Bauchu, E., Baseggio, L., Gazzo, S., Thieblemont, C., Ffrench, M., Magaud, J.P., Salles, G., Coiffer, B. (2005) Clinicopathologic features of Waldenstrom's macroglobulinemia and marginal zone lymphoma: are they distinct or the same entity? Clin Lymphoma, 5, Iida, S., Rao, P.H., Nallasivam, P., Hibshoosh, H., Butler, M., Louie, D.C., Dyomin, V., Ohno, H., Chaganti, R.S. & Dalla-Favera, R. (1996) The t(9;14)(p13;q32) chromosomal translocation associated with lymphoplasmacytoid lymphoma involves the PAX-5 gene. Blood, 88, Johnson, S.A., Birchall, J., Luckie, C., Oscier, D.G. & Owen, R.G. (2006) Guidelines on the management of Waldenstrom macroglobulinaemia. Br J Haematol, 132, Nathwani, B.N., Harris, N.L., Weisneberger, D., Isaacson, P.G., Piris, M.A., Berger, F., Muller-Hermelink, H.K. & Swedlow, S.H. (2001) Follicular Lymphoma. In: Pathology & Genetics: Tumours of haematopoietic and lymphoid tissues (ed. by E.S. Jaffe, N.L. Harris, H. Stein & J.W. Vardiman), pp IARC Press, Lyon. Schop, R.F. & Fonseca, R. (2003) Genetics and cytogenetics of Waldenstrom's macroglobulinemia. Semin Oncol, 30, Wilkins, B., Buchan, S., Webster, J. & Jones, D. (2001) Tryptase-positive mast cells accompany lymphocytic as well as lymphoplasmacytic lymphoma infiltrates in bone marrow trephine biopsies. Histopathology, 39,

20 4 Splenic B-cell marginal zone lymphoma 4.1 Definition and Clinical features Splenic B-cell marginal zone lymphoma (SMZL) is a slowly progressive, clonal disorder of mature B lymphocytes, in which there is usually marked splenomegaly, little lymphadenopathy and, in about 30% of cases, a low level (often IgG) paraproteinaemia. When abnormal cells are found in the peripheral blood or bone marrow, the term splenic lymphoma with villous lymphocytes (SLVL) is often used. Transformation to high-grade non-hodgkin lymphoma occurs in about 10% of cases (Oscier, et al 2005; Iannitto, et al 2004, Dogan & Isaacson, 2003, Audouin, et al 2003, Parry-Jones, et al 2003, Thieblemont,et al 2003, Chacon, et al 2002, Catovsky & Matutes 1999). 4.2 Peripheral blood Variable, but frequently low numbers of small to medium sized mature lymphoid cells with faintly basophilic cytoplasm, moderately clumped chromatin and indistinct nucleoli are found in the peripheral blood. Some have plasmacytoid features and polar cytoplasmic villous projections. Pancytopenia due to hypersplenism and/or bone marrow infiltration may be present. Selective monocytopenia is not a feature of this disorder. 4.3 Bone marrow In contrast to classical hairy cell leukaemia, the bone marrow is usually easy to aspirate. Infiltration may be minor, and the cytological features of the abnormal cells are similar to those of the peripheral blood. Bone marrow trephine biopsy appearances vary from subtle, interstitial and/or intrasinusoidal infiltration (Franco, et al 2001, Franco, et al 2004), that may not be visible with standard histological stains, to very extensive nodular and paratrabecular infiltration. If nodular or paratrabecular infiltrates are present, it is exceptional not to find interstitial infiltration in addition. Nodules in some cases strongly resemble reactive lymphoid follicles and may show germinal centre formation. These are believed to represent colonisation of pre-existing nonneoplastic follicles by the lymphoma cells. The latter are usually small

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