VII.

Overview of the lymphoid immune system

A. Lymphocytes evolve from pluripotent stem cells located in the bone

marrow, and differentiate into two major functional cell types:
o 1. B lymphocytes, comprising the humoral immune system, whose
ultimate function is the production of antibodies
o 2. T lymphocytes, comprising the cellular immune system, whose
functions include
a. Direct killing of foreign or intracellularly infected cells,
cytotoxic T cells
b. Fine control of the immune response through the secretion of
cytokines, helper and suppressor T cells.
B. The anatomical organization of the lymphoid immune system can also be
divided into two major functional groups:
o 1. The primary immune organs, which are the sites of initial maturation
from immature precursors into immune competent cells:
a. B cells- bone marrow
b. T cells- thymus
o 2. The secondary immune organs, which are the sites of antigen driven
replication and differentiation into committed effector cells
a. Lymph nodes
b. Spleen
c. Mucosal Associated Lymphoid System (MALT)-lymphoid cells
lining the respiratory and gastrointestinal tracts
d. Everywhere else
C. The lymph nodes, in their totality, are the largest of the secondary immune
organs, and the site of the majority of lymphoid pathology.

VIII. Lymph node anatomy

To recognize lymph node pathology, one has to be familiar with normal lymph node
anatomy and cytology
 Figure 1: Picture of lymph node

A. The lymph node has 7 major subdivisions.

o 1. The lymph node capsule, which surrounds the lymph node
o 2. The subcapsular sinus- the initial entryway of lymphatic fluid into the
node via afferent lymphatics
o 3. The lymph node cortex- beneath the subcortical sinus-the location of
primary and secondary lymphoid follicles
a. In the absence of immune stimulation, the cortical lymphoid
follicles are primary follices, composed of small B lymphocytes
which may be virgin B lymphocytes or recirculating memory B
cells. There is also a fine meshwork or dendritic reticulin cell
cytoplasm, which is invisible without special immunolabelling
techniques
b. With antigenic stimulation, antigen recognizing B cells are
stimulated to replication and differentiation. This converts the
primary follicle into a secondary follicle or germinal center,
surrounded by a mantle zone of transient small lymphocytes, and
a central area containing replicating "follicular center cells" and
their differentiating progeny- see below.
o 4. The paracortex- the region surrounding and beneath the germinal
centers
 o 5. The medulla- deep to the cortex/paracortex, and composed
of medullary cords and medullary sinuses
o 6. Medullary vessels- artery and vein
o 7. Afferent and efferent lymphatic vessels
B. After initial maturation in the primary immune organs, "virgin" B and T
lymphocytes are released into the peripheralblood and home to specific sites
within the lymph node (and theother secondary organs), controlled by
incompletely understood homing receptors. Hence these regions are enriched
for one type of lymphocyte, T or B. The separation of B and T lymphocytes is
not absolute however, and both cell types are present throughout the lymph
node, necessary for coordinated lymphoid immune response.
C. The sites of B cell homing include:
o 1. The primary and secondary follicles of the lymph node cortex-the sites
of antigen presentation to B cells, and subsequent proliferation and
differentiation in response to same
o 2. The medullary cords, where plasma cells aggregate, and release their
immunoglobulins into the efferent lymph
D. The site of T cell homing is the paracortex.
E. Normal lymphocytes recirculate, passing from blood into and through the
lymph nodes, and then into efferent lymphatics, surveilling for the presence of
the antigen for which they have a unique and specific receptor on their surface.
If this antigen is not present, the lymphocytes leave the node.
F. Virgin lymphocytes have a finite lifespan, numbered in weeks, unless they
come in contact with antigen.

IX. Cytology of the lymph node

A. The lymph node is thus a dynamic organ, composed of transient B and T

lymphocytes, antigen processing and presenting cells, replicating B and T
lymphocytes (in response to antigen), persistent and transient final effector
cells. Some of these functional subgroups are cytologically unique, and others
are cytologically indistinguishable. The ultimate microscopic impression, with
practice, is one of cytologic heterogeneity, and histologic organization.
B. Cell types:

o 1. Small lymphocytes
a. Small round dark blue dots. Round nucleus, clumped
chromatin, small or absent nucleolus.
 b. The dullest looking cells hiding the greatest level of functional
heterogeneity. Can be T or B cell, virgin (unexposed to antigen)
or differentiated effector/memory cell. Most likely lineage
guessed by location within the node, but lineage and state of
differentiation must be confirmed by immunologic/molecular
techniques
c. Locations:
(1) B cells- primary follicles, mantle zone of secondary
follicles, medullary cords
(2) T cells- paracortex, minor population within germinal
center.
d. Kinetically, clumped chromatin tells us that the cell is
nonproliferating- not activated to enter the cell cycle and replicate

Figure 2: Follicular center cell types

o 2. Follicular (germinal) center cells- replicating and post-replicating B

cells.

a. Noncleaved cells, large and small

 (1) Replicating populations within the germinal center-
expanding the number of cellsreactive with entrapped
antigen.
(a) Have round nuclei like small lymphocytes, but
larger, with open or vesicular chromatin pattern, and
recognizable nucleoli. Nucleus clear because genetic
material unwound for replication. Size, large or
small based on comparison with nucleus of
macrophage.

b. Cleaved cells, small (and large) - post mitotic

memory cell or plasma cell precursors
(1) Clumped chromatin like small lymphocytes, but
irregular folded and cleaved nuclear profiles.
(2) Nonproliferating population
o 3. Immunoblasts- Proliferating large cells found outside the germinal
centers. May be of B or T cell type. Again have characteristics of
replicating lymphocytes- vesicular chromatin, nucleoli
o 4. Accessory cells
a. Antigen processing cells-process and present antigen to B and T
lymphocytes- invisible innormal lymph node
(1) T cell paracortex- interdigitating reticulin cells
(2) B cell germinal centers- dendritic reticulin cells
b. Macrophages (histiocytes)-
(1) Tingible body macrophages of germinal centers
(2) Main cells of medullary sinuses- Abundant pale
cytoplasm, oval nucleus, single small nucleolus

X. Pathology of lymph nodes

A. Infections
o 1. Bacterial
a. Acute inflammation, abscess formation
o 2. Fungal, mycobacterial
a. Granulomatous, caseous and noncaseous
o 3. Diagnosis by culture, serologies, and/or special stains
a. Some typical histologic patterns
1. Necrotizing granulomatous reactions in cat scratch disease,
tularemia
 2. Sinusoidal and perisinusoidal monocytoid B cells, intrafollicular
granulomas in toxoplasmic lymphadenitis
B. Reactive hyperplasias
o 1. Exaggerations of normal histology. Expansion of all regions or selective
expansion of one. Some types characteristic of certain diseases, but most not
o 2. Follicular hyperplasia- increase in number and size of germinal centers, spread
into paracortex, medullary areas
a. Collagen vascular diseases,
b. Systemic toxoplasmosis,
c. Syphillis
o 3. Interfollicular hyperplasia- paracortex-
a. Skin diseases
b. Viral infections
c. Drug reactions
o 4. Sinus histiocytosis- expansion of the medullary sinus histiocytes-
a. Adjacent cancer
b. Infections
C. Sarcoidosis
D. Metastatic tumors

E. Malignant lymphomas (Non-Hodgkins' lymphomas-NHLs) and Hodgkin's

lymphoma

XI. Non- Hodgkin's Lymphomas

A. Malignancies of the lymphoid system in which the primary manifestations

of disease occur outside the bone marrow, at the sites of normal lymphoid
homing
o 1. Lymph nodes
o 2. Spleen
o 3. M.A.L.T.
o 4. Anywhere
o 5. (Lymphomas outside lymph nodes and spleen are referred to as
extranodal lymphomas)
B. Approximately 40, 000 cases per year, 20,000 deaths
C. Composed of cells frozen at a single stage of normal lymphoid
maturation/differentiation
D. Recapitulate the biologic behavior and immunophenotype of normal cell
they mimic
 E. Since there are several cytologically and immunologically recognizable
stages of normal lymphoid maturation, there are several subtypes of
lymphoma
F. All are clonal malignancies, derived from a single cell that has undergone a
malignant transformation, mutation
G. Best initially conceptualized as two major clinical types
o 1. Indolent lymphomas
o 2. Aggressive lymphomas
H. Indolent lymphomas
o 1. Lymphomas frozen at stages which are not normally replicating, but
may be circulating
o 2. Often widespread throughout the body at diagnosis
o 3. Prolonged natural history, median survivals greater than 5 years
o 4. Will usually respond very well to chemo- or radiation therapy
o 5. Will usually relapse, and currently incurable unless
a. Localized disease (see below) or
b. Marrow ablation with some type of stem cell transplant
o 6. Classification of indolent lymphomas- see below
I. Aggressive lymphomas
o 1. Lymphomas frozen at stages normally characterized by replication
and accelerated growth
o 2. More often localized at presentation than indolent lymphomas; more
often extranodal
o 3. Short natural history; median survival </= 2 years
o 4. Require more aggressive forms of chemotherapy to achieve "clinical
remission"- disappearance of all detectable disease
o 5. Despite aggressive natural history, approximately 30-40% of adults
curable with aggressive therapy, 50-80% children
J. Subtyping within these two common clusters is necessary, because they
have distinct clinical presentations, can require different therapy, and have
differing prognoses, reflecting different mechanisms of molecular
pathogenesis.
K. Classification of lymphomas
o 1. Rarely unanimous acceptance of any one classification scheme.
o 2. Often changing terminology, reflecting classifier bias and new
information
o 3. Often lags behind advances in immunology, research pathology
o 4. From 1982-1994, the classification used in the United States was
called the Working Formulation for Clinical Usage.
 a. Based on the dominant cytologic cell type observed under the
microscope
b. Presence or absence of "follicularity" - mimicking of normal
lymphoid follicle formation
c. The observed clinical history of 1200 patients classified
according to the terminology below

Table 1: Working Formulation for Clinical Usage

Low grade:
ML, small lymphocytic

ML, follicular small cleaved cell

ML, follicular, mixed small and large cell

Intermediate grade:
ML, follicular, large cell

ML, diffuse, small cleaved cell

ML, diffuse, mixed small and large cell

ML, diffuse, large cell

High grade:
ML, large cell, immunoblastic

ML, lymphoblastic

ML, small non-cleaved cell (Burkitt's vs non-

Burkitt's)

Miscellaneous
Miscellaneous (mycosis fungoides, true
histiocytic, etc.)

d. Divided into three "grades" of lymphoma-low, intermediate

and high
1). Low grade = indolent
2). Intermediate and high = aggressive
 e. Microscopic features of malignant lymphomas
1) Low power
a) Loss of normal architectural organization
b) Presence of absence of aberrant follicle
formation
2) High power
a) Replacement of cellular heterogeneity by a
dominant cell type

XI. Non- Hodgkin's lymphoma cont'd

o 5. Working Formulation was replaced in 1994 with the Revised European American Lymphoma
project (REAL) classification, proposed by the International Lymphoma Study Group.
o 6. This is now being modified by the World Health Organization (WHO)
a. Necessary because purely morphologic Working Formulation classification mixed T
and B cell lymphomas together, obscuring the biologic, clinical and therapeutic
differences between them, and distorting clinical trials
b. REAL/WHO is a "disease" oriented classsification based on cell lineage and stage of
maturation of the presumed normal counterpart. Each entity may have differing grades of
aggressiveness
c. Includes immunologic and molecular criteria in addition to purely morphologic criteria
of the Working Formulation
d. Greatly expanded the list of entities,and includes leukemias of lymphoid origin
e. Made teaching to medical students (and in fact all physicians) even more difficult than
previously
f. Finally, REAL contained a number of "provisional entities" which have undergone
further clarification in the upcoming World Health Organization revision.

Table 2: International Lymphoma Study Group Classification (including

provisional WHO categories)
B-Cell Neoplasms T/NK-Cell Lymphoma Hodgkin's Lymphoma
Precursor B-cell lymphoblastic Precursor T cell lymphoblastic Lymphocyte predominance,
leukemia/lymphoma leukemia/lymphoma nodular

Peripheral T-cell and NK-cell

Peripheral B-cell neoplasms Classical HL
neoplasms
Predominantly
B-cell CLL/SLL Lymphocyte rich classical HL
leukemic/disseminated
B-cell prolymphocytic leukemia T-cell prolymphocytic leukemia Nodular sclerosis
T-cell large granular lymphocytic
Lymphoplasmacytic lymphoma Mixed cellularity
(LGL)
Mantle cell lymphoma leukemia Lymphocyte depletion
Follicular lymphoma NK cell leukemia Unclassifiable classical HL
Extranodal marginal zone B-cell
lymphoma, MALT type (+/- Adult T-cell leukemia/lymphoma
monocytoid B cells)
Splenic marginal zone B-cell
lymphoma (+/-villous
lymphocytes)
Hairy cell leukemia
Diffuse large B-cell lymphoma
Burkitt lymphoma
Plasma cell myeloma
Plasmacytoma
Predominantly nodal
Angioimmunoblastic T-cell
lymphoma
Peripheral T-cell lymphoma
unspecified
Anaplastic large cell lymphoma,
T/null-cell
Predominantly extranodal
Mycosis fungoides
Sezary syndrome
Primary cutaneous (CD30+ T-cell
lymphoproliferative disorders)
Subcutaneous panniculitis-like T-
cell lymphoma
NK/T cell lymphoma, nasal and
nasal-type
Enteropathy-type intestinal T-cell
lymphoma
Hepatosplenic T-cell lymphoma
(gamma/delta)
(alpha/beta)

o 7. REAL/WHO classification- backbone

a. B cell neoplasms
1) Precursor B cells-related to acute leukemia
2) Peripheral B cell lymphomas- the majority of B cell lymphomas
b T cell and Natural Killer cell neoplasms
1) Precursor T cells
2) Peripheral T cell and NK neoplasms
c Hodgkin's lymphoma
o 8. B cell neoplasms
a. Precursor B cell lymphoblastic leukemia/lymphoma
1) Frozen at lymphoblast cell stage of antigen independent B cell differentiation-
normally restricted to bone marrow
2) Usually present as acute leukemia+/- lymph node involvement
3) Can initially present as node or skin disease, with later progression to bone
marrow
b. Peripheral B-cell neoplasms- frozen at various stages of antigen dependent B cell
maturation and differentiation
1) Small lymphocytic/CLL- the virgin B cell fresh from the marrow
2) Prolymphocytic leukemia- a more clinically aggressive variant of above
3) Lymphoplasmacytic lymphoma- the primary immune response
4) Mantle cell lymphoma- the mantle region surrounding the follicle
5) Follicular lymphoma- the follicle- grade 1-3
6) Extranodal marginal zone lymphoma- cells at the periphery of the follicle in
extranodal sites of lymphoid tissue- Mucosal Associated Lymphoid Tissue- such
as G.I. tract
7) Nodal marginal zone lymphoma
8) Splenic marginal zone lymphoma- immunologically distinct
 9) Hairy cell leukemia- pre-plasma cell
10) Diffuse large B-cell lymphoma- this breaks the ideal of specific cell stage,
but all represent lymphomas with high replication rate
11) Burkitt lymphoma- very aggressive
12) Plasma cell myeloma- diffuse bone marrow proliferation of plasma cells
13) Plasmacytoma- solitary focus of monoclonal plasma cells, with variable risk
of progression to myeloma, depending on site
c. Why list separately, if most indolent?
1) Differ in clinical presentation, immunology, therapy, prognosis, molecular
pathogenesis, even if all crudely categorized by median survival > two years
2) Examples "indolent" peripheral B
(a). follicular lymphoma- most common type of indolent lymphoma in
US, and second most common type lymphoma overall
(1.) Disease of adults >40 (median age 59)
(2.) Usually widely disseminated at diagnosis, with bone
marrow involvement
(3.) Will respond to "gentle chemotherapy" but will relapse-
cannot be cured short of bone marrow transplant, but overall 5
yr survival 72%
(4.) Benign equivalent is small cleaved cell of germinal center
(5.) Cytology: clumped chromatin and infrequent nucleolus
like small lymphocyte, but irregular nuclear profile, with
nuclear folds or "cleavages"
(6.) Retain follicular structure, but monotonous accumulation
of single cell type
(7.) Over time, additional mutations can occur, producing
progression ("transformation") to large cell lymphoma and
more aggressive clinical course
(8.) Pathogenesis: due to t(14;18), which upregulates
expression of an anti-apoptotic protein Bcl2
(9.) Has characteristic immunophenotype: monoclonal light
chain, CD19, CD10, Bcl2 positive, CD5, Bcl1/Cyclin D1
negative
(b). Imitator: Mantle cell lymphoma- 6% lymphomas
Looks like indolent but behaves aggressively
(1.) Disease of adults (median age 63)
(2.) Usually widely disseminated
(3.) Poor response to all attempted therapies, ? curable with
transplant-overall 5yr survival 27%
(4.) Benign equivalent is lymphocyte of inner mantle zone
(5.) Cytology similar to cleaved cell, but nuclear irregularities
not as prominent
(6.) Nodal infiltration diffuse, or expansion of mantle zone
around residual benign follicles
(7.) Large cell progression not frequent
(8.) Pathogenesis due to t(11;14), which upregulates, Bcl1, a
cell cycle effector
(9.) Immunophenotype: monoclonal light chain, CD19, CD5,
Bcl1 (and Bcl2) positive, CD10 negative

Table X: Indolent B cell lymphomas+imitator

Follicular Small
Marginal zone Mantle cell
Lymphoma (Grade lymphocytic
Lymphoma Lymphoma
I) lymphoma/CLL
Frequency (% all 22% 7 8 6
 lymphomas)
Age of onset-
59 65 61 63
median
Stage at Stage III/IV
Stage IV Stage I Stage III/IV
Presentation (Disseminated)
Good to most
Similar to
Response to treatments, but Poor response to all
Follicular Frequently curable
Therapy incurable short of therapies to date
lymphoma
transplant
5 yr survival 72% 51 74 27
Predominant site
Nodal Marrow/Nodal Extranodal Marrow/nodal
presentation
Pattern of nodal Diffuse or "mantle
Follicular Diffuse Diffuse
Infiltration zone"
Benign cell Germinal center Marginal zone
Virgin B cell Mantle cell
Equivalent small cleaved cell Lymphocyte
Small cleaved cell in Small Mix of small Small cell with
Dominant cell
most cases, but can lymphocytes with lymphocytes, plasma irregular nucleus,
type
be large cell round nucleus cells similar to cleaved
Positive: CD19 CD5,
Positive: Positive: CD19 Positive: CD19 Bcl2
Bcl2
Immuno CD19 CD10, Bcl2+ CD5,CD23
phenotype Negative: CD10,
Negative: CD23,
Negative: CD5 Negative: CD10 CD5
CD10
Molecular
t(14;18) Bcl2/JH Trisomy 12 Trisomy 3 t(11;18) t(11;14) Bcl1/JH
Pathogenesis

3) Examples aggressive B cell lymphoma

(a.) diffuse large B cell lymphoma-30% NHL
(1.) Disease of adults and children- median age 64
(2.) Limited versus widespread disease 1:1
(3.) Approximately 40% curable with aggressive
chemotherapy/ stem cell
transplant- partially predictable by International Prognostic
Index
(4.) Benign equivalent- large replicating cells of germinal
center and paracortex
(5.) Cytology: Oval or cleaved nucleus with vesicular
chromatin and 1-3 nucleoli.
Nucleus larger than that of reactive macrophage, often
necrosis; increased mitotic rate
(6.) Diffuse infiltration of lymph node
(7.) Several cytologic subtypes initially felt to have differing
clinical behavior. Yielded division into intermediate versus
high grade types- now not felt valid or significant.
(8.) Pathogenesis not as clearly defined- several cytogenetic
abnormalities associated with large cell lymphoma, but no
defining one
(9.) Immunophenotype characterized by monoclonal light
chain, CD19 expression, with variable expression of other B
cell associated antigens
 (b) Burkitt's lymphoma- 3% lymphomas
(1) Disease of adults and children- median age 31
(2) Initially recognized in Africa by Thomas Burkitt- noted
association with Epstein Barr
virus infection and localization in jaw
(3) In US, usually presents in ileocecal region of children- 1/3
of all childhood lymphomas
(4) Approximately 40% of adults curable with very aggressive
therapy; 70-80% children
(5) Benign equivalent is replicating small noncleaved cell of
germinal center: cytology: round to oval nucleus, smaller than
that of reactive macrophages with vesicular chromatin and 2-5
nucleoli
(6) Diffuse infiltration of lymph node
(7) Very high mitotic rate, lot of ineffective proliferation;
attracts macrophages to phagocytize and produces a "starry
sky" pattern at low power
(8) Pathogenesis: t(8;14), producing upregulation of myc
oncogene, a cell cytcle regulation gene
(9) Immunophenotype: Monoclonal light chain, CD19, CD10
positive, CD5 negative
o 9. T cell lymphomas
a. Precursor T cell lymphoblastic lymphoma/leukemia
1) Disease of young teenagers; boys>girls
2) Can present as acute leukemia or mediastinal mass+/- marrow involvement
3) Aggressive lymphoma/leukemia, but curable ~70% with appropriate
multiagent chemotherapy
4) Benign equivalent immature T cells of thymus
5) Cytologic features: "Blast cells" of intermediate size with oval to
"convoluted" nuclear profiles, fine chromatin and 0-1 nucleolus
(a) Histology: Diffuse infiltration of thymus/adjacent lymph nodes
(b) Pathogenesis unclear, but frequently involves translocation of oncogenes to
site of T cell receptor genes, and upregulation of protein production
b. Peripheral T cell lymphomas
1) Predominantly leukemic/disseminated
a) T-cell prolymphocytic leukemia
b) T-cell large granular lymphocytic (LGL) leukemia
c) NK cell leukemia
d) Adult T-cell leukemia/lymphoma
2) Predominantly nodal
a) Angioimmunoblastic T-cell lymphoma
b) Peripheral T-cell lymphoma unspccified
c) Anaplastic large cell lymphoma, T/null-cell
3) Predominantly extranodal
a) Mycosis fungoides
b) Sezary syndrome
c) Primary cutaneous CD30+ T-cell lymphoproliferative disorders
d) Subcutaneous panniculitis-like T-cell lymphoma
e) NK/T cell lymphoma, nasal and nasal-type
f) Enteropathy-type intestinal T-cell lymphoma
g) Hepatosplenic T-cell lymphoma
c. Key points regarding T cell lymphomas
1) Represent 20% all lymphomas
2) Tend to involve extranodal sites like skin, midline facial area, liver more than
B cell,
with very characteristic clinical presentations
 3) Cytologic features not as predictive of behavior as B cell lymphomas
(a) One of most aggressive looking, anaplastic large cell
lymphoma,actually has better prognosis than most indolent B cell
lymphomas-77% 5 year survival
4) Most common type in skin, mycosis fungoides, is an indolent lymphoma,
similarly incurable, but with long clinical course
5) Most nodal disease is bad, high stage, and poorer response to therapy than B
cell lymphomas of all grades
6) Immunophenotypic studies frequently demonstrate
(a) Loss of normal T cell associated antigens
(b) Antigens associated with Natural Killer cell function
7) Pathogenesis: Characteristic cytogenetic findings associated with several
types
(a) Anaplastic large cell lymphoma- t(2;5): ALK1 gene
(b) Hepatosplenic T cell lymphoma- Isochromosome 7

XII. Ancillary diagnostic studies

A. Use of immunologic techniques

o 1. Malignant lymphomas reproduce the immunobiology of their benign
counterparts
o 2. This reproduction may be aberrant, and hence distinguishable from
normal
o 3. Normal lymphoid maturation (within the primary lymphoid organs)
requires:
a. The production of a unique antigenic receptor on it's surface,
through the process of genetic rearrangement of discontinuous
segments of the antigen receptor genes
1.) B cells
a.) immunoglobulin receptor composed of two heavy
and two light chains
b.) Selection of only one of two light chains, kappa
or lambda
2.) T cells
a.) Alpha/Beta heterodimer T cell receptor
b.) Gamma/Delta heterodimer T cell receptor
b. The expression of several surface proteins necessary for antigen
recognition, cell activation, cell-cell communication.
1.) Classified into B, T, activation associated, cytokine
receptor thru the CD, clusters of differentiation, numerical
system. Now up to CD166. (You'll only be tested on 1-130
though - a joke for you paranoid types.)
o 4. Expression, normal and aberrant can be used to:
a. Determine lineage, B versus T
 b. Detect clonality- light chain disproportion (normal ratio
kappa/lambda light chain expression in B cells= 2/1)
c. Suspect malignancy- loss of expression, aberrant expression
d. Recognize characteristic patterns associated with certain
subtypes of lymphoma
o 5. Immunologic signals can be detected by
a. Flow cytometry-automated fluorescent microscopy
b. Immunohistochemistry- in situ detection through the use of
enzyme substrate color deposition
o 6. Examples
a. B cell small lymphocytic lymphoma- monoclonal light chain,
CD19, CD20, CD5 positive, CD10 negative
b. B cell small cleaved lymphoma- monoclonal light chain, CD19,
CD20, CD10 positive, CD5 negative
B. Molecular techniques
o 1. Detection of antigen receptor clonality
o 2. Detection of unique cytogenetic rearrangements
o 3. Examples
a. T(14;18) and follicular small cleaved lymphoma- involves
immunoglobulin heavy chain gene, ch.14, and bcl2, chr. 18, an
"oncogene" normally controlling programmed cell death
b. T(8;14) and Burkitt's lymphoma- involves Ig heavy chain gene
and myc oncogene, chr.8, which normally controls entry into cell
cycle

XIII. Clinical features- non-Hodgkin's lymphoma

A. Clinical presentation
o 1. Enlarging mass(es), typically painless, at sites of nodal tissue
o 2. Obstruction, ulceration of hollow organs- MALT- pain
o 3. Interference with normal organ function- solid organ infiltration-
kidneys, liver, bone marrow
B. Clinical staging of lymphomas
o 1. Defines extent of disease; determines therapy and prognosis
o 2. Based on physical, radiologic examination, bone marrow biopsy and
aspiration
o 3. Ann Arbor Staging system
o 4. B symptoms- fever, weight loss > 10% body weight, night sweats

Ann Arbor Staging System

 Stage Distribution of Disease
Involvement of a single lymph node region
I (I) or involvement of a single
extralymphatic organ or site (IE)
Involvement of two or more lymph node
regions on the same side of the diaphragm
II alone (II) or with involvement of limited
contiguous extralymphatic organ or tissue
(IIE)
Involvement of lymph node regions on both
sides of the diaphragm (III), which may
III
include the spleen (IIIs) and/or limited
contiguous
Multiple or disseminated foci of
involvement of one or more extralymphatic
IV
organs or tissues with or without lymphatic
involvement.

C. Therapy
o 1. Seminar cases will also discuss
o 2. Indolent lymphomas, limited stage (5-10% cases) treated with
radiation therapy- can be curative
o 3. Indolent lymphomas, disseminated (90%) treated by
a. Low morbidity limited chemotherapy
1) No expectation of cure
2) Older patients
3) Most will respond totally or partially, with months to
years of disease free survival, but will relapse
4) Many will respond to additional rounds of similar or
alternative regimens
5) Pts will eventually die of their disease, or another
disease of elderly
6) Death from disease due to
a.) Immune suppression- infections
b.) Progression to aggressive lymphoma
b. Bone marrow transplant (allo/auto/peripheral stem cell)
1) Effort at cure-
2) Younger patients
o 4. Aggressive lymphomas treated with multiagent (>/= 4 drugs)
chemotherapy
 a. Complete remission rates 60-80%
b.30-40% cured
c. Therapy determined by prognostic index- see below
o 5. Newer therapies and their roles still being established
a. Autologous bone marrow transplantation/high dose
chemotherapy with peripheral stem cell harvest
b. Immunotherapy
D. Prognosis
o 1. Primarily based on inherent biology of tumor and stage
o 2. Are however additional factors that can be used for prognosis
a. International prognostic index- word recognition
1). Five clinical and laboratory features proven by
regression analysis to best stratify patients with large cell
lymphoma into four risk groups with statistically
different survival rates
2). Used to decide on aggressiveness of therapy
3). Used in evaluation of new therapies
4). Although developed for large cell lymphoma, also has
utility in stratifying indolent lymphomas
b. Cytogenetics/Oncogenes- know they exist
1) Are cytogenetic/molecular abnormalities that predict
more aggressive clinical course
2) Others can predict acceleration/transformation from low
to higher grade lymphoma
3) Not routinely used beyond tertiary care centers;
practicality/cost effectiveness still being established

XIV. Hodgkin's Lymphoma

A. Less common than NHL; approximately 10,000 cases per year

B. Incidence with respect to age bimodal, with one peak in late adolescence,
young adulthood, second peak in sixth decade
o 1. This bimodal curve shifts to younger ages in undeveloped countries
C. Unlike nonHodgkin's lymphomas, diagnosed by the presence of a minor
cellular component, the Reed Sternberg cell, found in the appropriate
microscopic cellular background
D. Classification of Hodgkin's lymphoma has also been recently revised

Rye Classification REAL/WHO Classification

Lymphocyte Lymphocyte predominant,
 predominant-5% nodular

Nodular sclerosis-70% Classical HL

Mixed cellularity-20% Lymphocyte rich classical HL

Lymphocyte depleted-5% Nodular sclerosis

Mixed cellularity

Lymphocyte depletion

Unclassifiable classical HL

E. Classification:

F. Are characteristic patterns of involvement, and characteristic variants of

Reed Sternberg cell associated with different subtypes
o 1. Lymphocyte predominant
a. Usually presents with limited disease in the neck of young
adults
b. Associated with L and H (lymphocytic and histiocytic) cell
(popcorn cell) variant RS RS cell
o 2. Nodular sclerosis
a. Usually presents in the anterior mediastinum and neck of
young adult females
b. Associated with lacunar variant Reed Sternberg cell
o 3 Lymphocyte depleted
a Often presents in retroperitoneum
b Accompanied by sclerosis and pleomorphic RS cell variants
 G. As in NHL, there are ancillary immunologic studies that can assist the dx of
Hodgkins' lymphoma, and distinguish from immunoblast reaction or unusual
variants of NHL
o 1. Expression of CD15 and CD30 antigens in golgi and on cell membrane
by immunohistochemistry.
H. Hodgkin's lymphoma spreads contiguously via lymphatics
I. Staging as in NHL- may or may not include laparotomy/splenectomy
J. Therapy
o 1. Hodgkins lymphoma is a curable malignancy
o 2. Overall cure rate approximately 80%
o 3. With modern therapy, prognosis based more on staging, bulk of
disease, than morphologic subtype. Not true in earlier era, where
prognosis decreased with number of lymphocytes- see C5 above.
o 4. Limited stage, low bulk disease treated with radiation therapy
o 5. Higher stage, symptomatic (IIB-IV) treated with multi-agent
chemotherapy+/- radiation therapy
K. Complications of therapy
o 1. Radiation/chemotherapy effects to lungs, heart, bone marrow
o 2. Sterility
o 3. Splenectomy associated sepsis
o 4. Therapy associated second malignancies
L. Pathobiology
o 1. The etiology of Hodgkins lymphoma is still unknown, and until very
recently, the lineage of the R-S cell was also obscure
o 2. The mixed cellular infiltrate, unusual large cells, clustered familial
cases, and early evidence of immune dysfunction suggest an infectious
etiology
a Approximately 30% of cases/Reed Sternberg cells contain
Epstein Barr virus within the RS cells
o 3. Recent molecular studies, utilizing single cell dissection and PCR
based sequencing of the antigen receptor genes indicate that the Reed-
Sternberg cell in the majority of cases is in fact an altered B cell.
o 4. Therefore Hodgkin's lymphoma is a type of B cell lymphoma, but one
with a very different biology than the other types of B cell lymphoma,
and hence still deserves a separate category in the classification system.
o 5. The molecular abnormalities within the different types of R-S variants
effect the expression of lineage associated antigens
 a. L and H cells of lymphocyte predominant Hodgkin's disease
express B cell antigens, and are clonal proliferations of this cell
type
b. Reed Sternberg cells of other types may express T cell, B cell
and macrophage associated antigens, but at the molecular level,
show B cell gene rearrangements, often with out of frame
mutations.