Lymphadenopathy CC + slides Flashcards by Meghan May

Would we call this a reactive or neoplastic lymph node? Why?

Would we expect to see patient with night sweats or a fever?

This is reactive

the tissue structure is still intact and you can see clear morphologic features

a fever, night sweats are assoicated with neoplastic conditions

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Is this lymph node reactive or neoplastic?

What would we see clincally; low grade fever or night sweats?

Neoplastic

we can tell because the morphology is not maintained

You would see night sweats = hematolymphoid symptom (also fatigue)

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55 yo Man comes in with several lumps on neck that have been there for past 6 months.

Afebrile, no night sweats or weight loss nor any recent illness

the nodes are 1 to 2 cm and paplable on both sides, can’t palpate spleen

All labs are normal but CT shows mild splenomegaly and lots of 1 to 3 cm nodes in neck, axilla, mediastium, paraaortic and ingunal.

What is our most likey dx?

Follicular lymphoma

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What are key considerations when deciding beween a benign and neoplastic lymphadenopathy?

– Duration? Growth interval?; fast = neoplastic, slow = indolent
– Size? was growth rapid adn is it over 1 cm
– Location? Extent? axilla, inguinal adn cervical and IG promiment , if you can feel them elsewhere this is concerning
– Tender vs. Nontender? tender is more reactive, nontender more neoplastic
– Fixed vs. mobile? fixed is bad sign

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What do we look at in the histological exam when discerning between neoplastic and benign lymphadenopathy?

– LN architecture? intact = normal and reactive vs effaced for neoplastic
– Dominant cell type? neoplastic tends to be more homogenous while reactive still has all cell types
– Atypia? deviation from normal cytology sign of neoplasm
– Flow cytometry?

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Common causes of reactive lymphadenopathy

– Infectious
– Autoimmune
– Drugs
– Foreign body

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3 causes of neoplastic lymphadenopathy

– Lymphoma
– Leukemic involvement
• Lymphoblastic lymphoma
• Myeloid sarcoma
– Metastatic tumor

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In reactive lymphadenopathy, what do we see on HE in the following conditions?

• Autoimmune, early HIV, toxoplasmosis

– Follicular hyperplasia

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What do we see on HE in EBV, CMV, herpes, drugs

– Paracortical hyperplasia

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What do we see on HE in sinus histiocytosis?

draining tumors

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Follicular Lymphoma

______of all lymphomas; ____ of B-cell lymphomas
• ____median age; slight male predominance
• Nodal ____extranodal involvement

20%

1/3

60 y/o

nodal>

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Most cases of Follicular lymphoma are caused by?

Are indolent or aggresive?

t(14;18)

Indolent

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Follicular lymphoma is

• Generally indolent; however, 40% “transform” to
aggressive lymphomas which are:

– Diffuse large B-cell lymphoma
– Burkitt lymphoma

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What do you see here on HE?

Follicular hyperplasia

lymph nodes are nodular, but they are excessive

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You perform flow cytometry on patient that has follicular hyperplasia

it reveals clonal B cell population w/ low forward scatter and :

CD5-, CD10+ , CD19+, CD20+, CD23-

Doc decides to watchfully wait: 18 months later patient has increased fatigue and see more invovlement on scans. Whats the most appropriate managment now?

Chemotherapy and anti-CD20 monoclonal antiB therapy

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The following are all examples of:

Follicular lymphoma
Diffuse large B-cell lymphoma
Mantle cell lymphoma
Marginal zone lymphoma
Lymphoplasmacytic lymphoma
Burkitt lymphoma

Non hodkgins lymphoma (NHL)

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When Dx B-Cell NHL, what things do we need to consider?

Morphology: Archichecture and tumor cells

Immunophenotype:
– Establish B-lineage
– Small-sized lymphomas: CD5, CD10, CD23
• Cytogenetics
– t(14;18), t(11;14); t(8;14)

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What NHL have SMALL tumor size and are NODULAR or FOLLICULAR?

• Follicular lymphoma

Marginal zone lymphoma
CLL/SLL

Exceptions:

*Mantle Cell is nodular but can be any size

• Lymphoplasmacytic lymphoma is small but not nodular

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What do Diffusse large B cell lymphoma and Burkitt lymphoma have in common?

Both have diffuse architecture and are meduim to large sized

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What small cell NHL are CD5-

Follicular lymphoma

Marginal Zone lymphoma

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What small B celled leukemia/lymphomas are CD5+?

Mantle cell lymphoma CLL/SLL

What small B cell lymphoma has the following markers? CD5+ CD23+

CLL/SLL

What small B cell lymphoma is CD5+ CD23-

Mantle cell lymphoma

What small B cell lymphoma is CD5- CD10-

Marginal zone lymphoma

What small B cell lymphoma is CD5- CD10+

Follicular lymphoma

What is the translocation for Follicular lymphoma?

t(14;18)

What is the translocation for Mantle cel lymphoma

t(11;14)

What is the translocation in Burkitt Lymphoma ~ there are 3

t(8;14) t(2;8) t(8;22)

What is the translocation in Marginal zone lymphoma

t(11;18)

t(14;18) seen in Follicular lymphoma is results in what mutatation?

BCL-2 Prevents cells from apoptosis – Overexpressed in many lymphomas

– t(14;18) • \_\_\_\_\_\_\_\_fusion of follicular lymphoma • Overexpression • Tumor progression due to \_\_\_\_\_\_\_\_ rather than uncontrolled cell proliferation

IgH-bcl-2 inhibition of normal apoptosis,

What is the difference in BCL 2 expression in Follicular lymphoma vs follicular hyperplasia?

Follicular hyperplasia = BCL-2 - Follicular lymphoma = BCL 2 +

Mantle cell lyphoma has t(11;14) which disregulates what key part of cell cycle?

• Cyclin D1

Mantle cell lymphoma: t(11;14) • _______ fusion • Overexpression of cyclin D1 • Detection by cytogenetics and/or immunohistochemistry • Diagnostic for mantle cell lymphoma in neoplastic B-cell processes

Cyclin D1-IgH | (image is CD1 staining)

Burkitt lymphoma has increased \_\_\_\_\_gene expression what gene translocation?

C-Myc t(8;14)

Describe Burkitt lymphoma on HE

starry sky apperance --\> white cells are tumor cells

When would I see a tumor that has c-MYC over expression and BCL2 expression?

IF patient had follicular lymphoma (BLC2 expression) that developled into Burkitts lymphoma (c-MYC) which can happen!

-Chronic lymphocytic leukemia/Small lymphocytic lymphoma – Follicular lymphoma – Marginal zonelymphoma – Lymphoplasmacytic lymphoma these are all high grade or low grade?

all LOW grade

What are my high grade NHL?

• High grade – Diffuse large B-cell lymphoma – Burkitt lymphoma

• Extranodal marginal zone lymphoma – Indolent or aggressive? – Small-sized cells or Large sized cells? – Extranodal sites include what?

indolent small : mainly MALT sites such as gastric, thyroid, lung

IG what are our tx options for low grade NHLs?

– Treatment may consist of antibiotics, resection, radiation, chemotherapy

• Diffuse large B-cell lymphoma is a high grade NHL: – Indolent or Aggressive? – small or large-sized cells?

aggressive large with both nodal adn extranodal invovlement TX = aggresive chemo

Brief summary of T/NK cell lymphomas: • Relatively common or uncommon in the US • Aggressive or indolent tumors (generally)? • Types: **– Peripheral T-cell lymphoma – Anaplastic T-cell lymphoma, ALK(+) – Extranodal NK/T-cell lymphoma**

uncommon in US AGGRESSIVE

**Anaplastic large-cell lymphoma** – Aggressiv _Pediatric_ tumor – \_\_\_\_\_\_T-cell neoplasm – Characterized by\_\_\_\_\_ rearrangements (tyrosine kinase receptor) Most commonly what translocation?

CD8(+) ALK t(2;5)

CD8(+) ALK rearrangements t(2;5) characteristic of what neoplasm?

• Anaplastic large-cell lymphoma

– Mostly NK-cell neoplasm but may be T cell – Formerly mid-line lethal granuloma – Nasal mass with necrosis, extensive destruction, and angioinvasion SEen in adults

Extranodal NK/T-cell lymphoma, nasal type

What clinical variants are there of Burkitt lymphoma

-Sporatic (ileocecal mass) – Endemic (EBV, breast, jaw, ovary masses) – Immunosuppression-related (EBV) – Transformation from follicular lymphoma

Extranodal NK/T-cell lymphoma, nasal type is associated with \_\_\_\_\_\_ is common in what location? aggressive or indolent?

– EBV-associated – More common in Asia, South America – Aggressive (all T/NK cell lymphomas are aggresive)

The follow are all: • Lymphomas (mostly B) – Endemic Burkitt lymphoma – Post-transplant lymphoproliferative disorder – Extranodal NK/T-cell lymphoma, nasal type – Subsets of Hodgkin lymphoma, diffuse large B-cell lymphoma, T-cell lymphomas • Nasopharyngeal carcinoma

EBV-associated neoplasms

35 yo recent African immigrant has rapidly enlarging breast mass. It's biopsied and has a 'stary skied' apperance, what is the mostly likely Pathology explaining this ?

EBV (will cause breast, ovary and jaw masses)

Hodkin lypmphoma: frequently involvems multiple nodes or is localized to single node? Has orderly spread or noncontiguous spread?

Hodkin is more localized to single node often axial groups wil have orderly, contiguous spread

Does the below describe Hodking lymphoma or non-hodking lymphoma: mesenteric nodes and waldyere ring often involved extranodal involvment common BM involvement

Non-Hodkin lymphoma

You do a biopsy and see these cells, the pathologist calls them "Reed Sternberg cells"

Classic Hodkin Lymphoma and MUST be observed to dx HL!

Describe the morphology of Reed-Sternberg cells

Must be observed to diagnose HL and B-lineage neoplastic cells -Large size – Frequent binucleation – Large, eosinophilic nucleoli (“owleye”)

Hodgkin lymphoma is a disease seen in: \_\_\_\_% of all lymphomas

adults 30%

Reed Sternberg cells – Contiguous spread – Lymph node involvement

charcteristics of HL

Lacunar cells or are a varient of Sternberg cells seen in:

Nodular sclerosis HL

L&H (popcorn) variation of Sternberg cells are seen in:

Nodular lymphocyte predominant

Nodular sclerosis is most common HL. Seen in what age and sex? location in body? Common morphology:

Nodular sclerosis is 15-35 yo, M=F located at mediastinum Lacunar cells with dense sclerosis

CD markers in Nodular sclerosis HL

CD15(+), CD30 (+); **CD20(-)**, CD45 (-) the CD20- is surprising bc it's a B cell neoplasm!

Have a 20 yo woman w/ lump in the right side of neck thats grown larger over the past 4 months. Afebrile, no night sweats or weight loss with no meds or smoking. PE: 3.5 cm right anterior cervical node and 1 cm right supraclavicular node Biopsy the node and we se the architecture is effaced. He notes a few obvious cell amidst all the eosinophils in the slide. What is this?

them are Reed Sternberg cells and this chick has HL (B cell neoplastic cells)