Lymphoma Diagnosis Flashcards
Riddle me this…
81 yo femaile
Feels well
Lump in left and right groin
- Present for long time - severl months
- Fimr confluent mass up to 3cm
- No rashes, no signs of infect
Full blood picture unremarkable
- WCC 8.7
Prolonged nature and size
- Sent for biopsy
Small lymphocytes
- Unremarkable - maybe low grade
Shitt tonne of germinal centers
- Abnormal shapes
Few T cells
Negative cyclingD1
Flow cytometry (normal)
- Clonal (lambda light chain restricted
- B cell (CD19, CD20)
- CD10
Histology
- Follicular pattern
- B cell (CD20), germinal center (BCL6, CD10)
- Abberant BCL2 expression
Could be:
Small lymphocytic lymphoma/leukaemia (SLL/CLL)
- Similar to chronic lymph
Follicular Lymphoma
- Germinal center expansion
Mantle cell lymphoma
- Overexpression of cyclin D1
FOLLICULAR LYMPHOMA
- But what is grade?
What can you do with a fresh lymph node?
Triage in lab for
- Micobio
- Flow cutometry
- Histo (PRIORITY if limited tissue)
- Possibly, frozen, FISH cytogenetics
Whats one of the first things you do?
Scrape onto slide and rapid H+E stain
What is the processfor a fresh node triage?
Cut surface smear + rapid H+E
Granulomas/necro = micro next
Anaplastic cells = electron micro
mixed small lymph - flow
high grade lymph - fish
limited tissue - histo only
What does CD20 stain?
B cells
What does CD3 stain?
T cells
What does CD10 stain?
Germinal center (membrane)
What does BCL6 stain?
Germinal center (nucleus)
How can you tell if normal germinal centers?
Send off to test for clonality via flow cytometry or gene rearrangement studies
Can test for aberrant immunophenotype
- Flow or immunohistochemical stains
What is BCL2?
Anti-apoptotic marker
What expresses BCL2?
Normal T cells, resting B cells
B cells down regulate
How can you tell if its actually B cells expressing BCL2, not just T cells chilling in germinal center?
Compare BCL2 stain with CD3 stain of same node
If not may T cells, then it is abberant expression of BCL2
Rekt
How do you test for the more aggressive mantle cell lymphoma?
cyclinD1 via immunohistochemistry
If +, mantle cell lymphoma
What are kappa and lambda light chains?
Compose immunoglobulin of antibody (light chains)
Each B cell expressing only one class of light chain
Typically kappa lambda ratio is 3:1 in serum
If significantly higher chain than other, probably malignant condition e.g. lymphoma
What does CD21 stain for?
Stains to see if Follicles have retained networks
Stains follicular dendritic cells
That there is no bleedthrough in, forming DLBCL
- Diffuse large B cell lymphoma
Used in grading of follicular lymphoma
How are lymphoma graded to do with centroblasts?
Depending on ratio of centroblasts to centrocytes
Neoplastic cells are mostly centroblasts
What is a centroblast?
An activated B cell that is enlarged and proliferating
Large number means malignancy
Larger looking cell
What is MIB1?
Proliferation marker
What happens after you tell docs its a follicular lymphoma?
PET Scan
Picks up metabolically active areas
What does staging involve for hodgkin and non hodgkin lymphoma?
The spread of the lymhpoma
Renal liver function HIV, Hep Bone marrow trephine CT scan - mass lesions PET scan - metabolic activity Performance status
What does indolent mean?
Causing little or no pain
Is follicular lymphoma curable?
No
Generally indolent though
When would you treat follicular lymphoma?
Generally left untreated unless
- Progressive disease or bulky
- Organ dysfunction
- Systemic B symptoms
- Cytopenias (marrow infiltration)
What is a cytopenia?
Low blood cell count (any blood cell)
What is the common genetic fusion in follicular lymphoma?
t(14;18)(q32;q21)
BCL2-IgH fusion
= 90% of FL
BCL2 - antiapoptopic proten
Upregulated by IgH
What happens genetically if follicular lymphoma progresses to double hit lymphoma?
Additional MYC or BCL6-breakapart associated with transformation and poor prognosis
MYC = pro proliferation
BCL and MYC = rekt
How is DLBCL treated?
R-CHOP
- Retuximab (anti-CD20)
- Cyclophosphamide
- Doxorubicin
- Vincristine
- Prednisone
Palliative radiation therapy
Whow is double hit follicular lymphoma treated?
More intese
HyperCVAD
Riddle me this one fewl….
29yo male
Neck swelling slowly progressing
Night sweats
Weight loss (10kg), fevers
No travel
CT showed extensive lymphadenopathy
Lymph node biopsy followed by PET
- Lots of node involvment
Macro:
- Nodular appearence to naked eye with fibrosis
Micro:
Many histiocytes - send to micro
- Granulomas
Large atypical lymphs
Histo:
Fibrotic node
Red large cell with large nuc
- Red steenberg
- Large irregular membrane
- Typically binucleated
Keep checking
Flow Cytometry:
- No monoclona B cell or aberrant T cell population
Immunohisto:
- CD20 - (on large cells)
- CD3 -ve (on large cell)
- CD30+ve
- CD15 weak/neg (usually hodgkin is positive)
- CD45 -ve on large cells
- PAX5 weak+ve
- EBER+ve (EBV related to hodg)
Classical hodgkin lymphoma
Nodular sclerosis subtype
What does CD45 stain?
All cells except steenberg cells
pan lymphocytic marker
What is PAX5?
Usually B cell marker
Hodgkins thought of as crippled B cell
RSB typically bind PAX5
What does EBER test for?
Presence of EBV - linked to hodgkins
What would the clinical symptoms be of hodgkins lymphoma?
B symptoms
What would the morphology be of hodgkins?
R-S cell variants
Fibrosis, heterogenous background
What would the immunophenotype be of hodgkins?
CD30+ (binds randshit on RS) CD15- CD45- CD20- CD3- PAX5 weak+ EBER+
What other types of hodgkins lymphoma are there?
Nodular sclerosis
Lymphocyte rich
Mixed cellularity
Lymphocyte deplete
What % of lymphomas are hodgkin?
10%
When does hodgkins typically strike?
bimodal - 20 years and 65 years
How is hodgkin lymphoma staged?
PET +/- consider bone marrow traphine
How is hodgkin lymphoma treated?
ABVD
What is the cure rate for hodgkin lymphoma?
Below 75%
