brief discussion on approach to diagnosis of lymph node via cytology-this part specially focuses on malignancy

1. APPROACH TO LYMPH NODE
CYTOLOGY-2
DR KAMALESH LENKA
MODERATOR DR SWAGATIKA AGARWAL

2. CLASSIFICATION OF LYMPHOMA 2016 WHO

3. 2008 WHOLymphoma classification
• Mature
Follicular lymphoma
Pediatric follicular lymphoma*
B-cellneoplasms •
Primary cutaneous follicle centre lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma (DLBCL), NOS
T-cell/histiocyte rich large B-cell lymphoma
Primary DLBCL of the CNS
Primary cutaneous DLBCL, leg type
EBV-positive DLBCL of the elderly*
DLBCL associated with chronic inflammation
Lymphomatoid granulomatosis
Primary mediastinal (thymic) large B-cell lymphoma
Intravascular large B-cell lymphoma
ALK-positive large B-cell lymphoma
Plasmablastic lymphoma
Large B-cell lymphoma arising in HHV8-associated multicentric Castleman
disease
Primary effusion lymphoma
Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large
B-cell lymphoma and Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large
B-cell lymphoma and classical Hodgkin lymphoma
Mature T-cell and NK-cell neoplasms
T-cell prolymphocytic leukemia
T-cell large granular lymphocytic leukemia
Chronic lymphoproliferative disorder of NK cells*
Aggressive NK-cell leukemia
Systemic EBV-positive T-cell lymphoproliferative disease of childhood
Hydroa vacciniforme-like lymphoma
Adult T-cell leukemia/lymphoma
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
Mycosis fungoides
Sézary syndrome
Primary cutaneous CD30+ T-cell lymphoproliferativedisorders
Lymphomatoid papulosis
Primary cutaneous anaplastic large cell lymphoma
Primary cutaneous γδ T-cell lymphoma
Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma*
Primary cutaneous CD4+ small/medium T-cell lymphoma*
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma, ALK-positive
Anaplastic large cell lymphoma, ALK-negative*
Hodgkin lymphoma
Nodular lymphocyte predominant Hodgkin lymphoma
Classical Hodgkin lymphoma
Nodular sclerosis classical Hodgkin lymphoma
Lymphocyte-rich classical Hodgkin lymphoma
Mixed cellularity classical Hodgkin lymphoma
Lymphocyte-depleted classical Hodgkin lymphoma
Histiocytic and dendritic cell neoplasms
Histiocytic sarcoma
Langerhans cell histiocytosis
Mature B-cell neoplasms
Chronic lymphocytic leukemia/small lymphocytic
lymphoma
B-cell prolymphocytic leukemia
Splenic marginal zone lymphoma
Hairy cell leukemia
Splenic lymphoma/leukemia, unclassifiable*
Splenic diffuse red pulp small B-cell
lymphoma*
Hairy cell leukemia variant*
Lymphoplasmacytic lymphoma
Waldenström macroglobulinemia
Heavy chain diseases
α Heavy chain disease
γ Heavy chain disease
μ Heavy chain disease
Plasma cell myeloma
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Extranodal marginal zone lymphoma of mucosa-
associated lymphoid tissue (MALT lymphoma)
Nodal marginal zone lymphoma
Pediatric nodal marginal zone lymphoma*

4. What prompted the change……….
• NGS
• New clinical, pathological and genetic/molecular data concerningthe
“small B-cell” lymphomas.
• Cooperative Multicentric trials

5. WHO CLASSIFICATION 2016
• Mature B-cell neoplasms
• Mature T and NK neoplasms
• Hodgkin lymphoma
• Posttransplant lymphoproliferative disorders (PTLD)
• Histiocytic and dendritic cell neoplasms

6. • MATURE B-CELL NEOPLASMS
• Chronic lymphocytic leukemia /small lymphocytic lymphoma
• Monoclonal B-cell lymphocytosis*
• B-cell prolymphocytic leukemia
• Splenic marginal zone lymphoma
• Hairy cell leukemia
• Splenic B-cell lymphoma/leukemia, unclassifiable
• Splenic diffuse red pulp small B-cell lymphoma
• Hairy cell leukemia-variant
• Lymphoplasmacytic lymphoma
• •waldenstorm macroglobulinemia
• Monoclonal gammopathy of undetermined significance (MGUS), IgM*
• Mu heavy chain disease
• Gamma heavy chain disease
• Alpha heavy chain disease
• Monoclonal gammopathy of undetermined significance (MGUS), IgG/A*
• Plasma cell myeloma
• Solitary plasmacytoma of bone
• Extraosseous plasmacytoma
• Monoclonal immunoglobulin deposition diseases*
• Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

7. • Nodal marginal zone lymphoma
• Pediatric nodal marginal zone lymphoma
• Follicular lymphoma
• Insitu follicular neoplasia
• Duodenal type follicular lymphoma

8. • Pediatric-type follicular lymphoma*
• Large B-cell lymphoma with IRF4 rearrangement*
• Primary cutaneous follicle center lymphoma
• Mantle cell lymphoma
• • In situ mantle cell neoplasia
• Diffuse large B-cell lymphoma (DLBCL), NOS
• • Germinal center B-cell type
• • Activated B-cell type
• T cell/histiocyte-rich large B-cell lymphoma
• Primary DLBCLof the CNS
• Primary cutaneous DLBCL, leg type
• EBV positive DLBCL, NOS*
• EBV+ Mucocutaneous ulcer*

9. • DLBCLassociated with chronic inflammation
• Lymphomatoid granulomatosis
• Primary mediastinal (thymic) large B-cell lymphoma
• Intravascular large B-cell lymphoma
• ALK positive large B-cell lymphoma
• Plasmablastic lymphoma
• Primary effusion lymphoma
• HHV8 positive DLBCL, NOS*
• Burkitt lymphoma
• Burkitt-like lymphoma with 11q aberration*
• High grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements*
• High grade B-cell lymphoma, NOS*
• B-cell lymphoma, unclassifiable, with features intermediate between DLBCLand classical
Hodgkin lymphoma

10. HODGKIN
LYMPHOMA
Nodular lymphocyte predominant Hodgkin lymphoma
Classical Hodgkin lymphoma
Nodular sclerosis classical Hodgkin lymphoma
Lymphocyte-rich classical Hodgkin lymphoma
Mixed cellularity classical Hodgkin lymphoma
Lymphocyte-depleted classical Hodgkin lymphoma

11. Posttransplant lymphoproliferative disorders (PTLD)
Plasmacytic hyperplasia PTLD
Infectious mononucleosis PTLD
Florid follicular hyperplasia PTLD*
Polymorphic PTLD
Monomorphic PTLD (B- and T-/NK-cell types)
Classical Hodgkin lymphoma PTLD

12. Histiocytic and dendritic cell neoplasms
• Histiocytic sarcoma
• Langerhans cell histiocytosis
• Langerhans cell sarcoma
• Indeterminate dendritic cell tumor
• Interdigitating dendritic cell sarcoma
• Follicular dendritic cell sarcoma
• Fibroblastic reticular cell tumor
• Disseminated juvenile xanthogranuloma
• Erdheim-Chester disease

13. APPROACH TO DIAGNOSIS

14. FNA LYMPHOID
POPULATIONS
Monotonous Heterogenous Pleomorphic

15. monotonus
Small
medium
large
Predominant cell
type

16. SMALL MONOTONUS POPULATION
• Sm lymphocytic lymphoma
• Mantle cell lymphoma
• Follicular lymphoma (grade 1)
• Marginal zone lymphoma (uncommon)
• Peripheral T or NK/T cell lymphoma
• Lymphocyte-rich Hodgkin lymphoma
• T cell/histocyte rich B cell lymphoma
• Quiescent (minimally active) small node

17. MEDIUM MONOTONUS POPULATION
• Burkitt Lymphoma
• Lymphoblastic lymphoma
• Blastoid mantle cell lymphoma
• T or NK/T cell lymphomas

18. LARGE MONOTONUS POPULATION
• Diffuse large B, Peripheral T or NK/T lymphomas
• Plasmablastic lymphoma

19. HETEROGENOUS
MAINLY SMALL
CELL
MAINLY LARGE
CELL

20. HETEROGENOUS PREDOMINANTLY SMALL
CELL
• Reactive hyperplasia
• Follicular lymphoma (low grade)
• Marginal zone lymphoma
• Lymphoplasmacytic lymphoma
• Sm lymphocytic lymphoma (uncommon)

21. HETEROGENOUS LARGE CELL POPULATION
• Reactive immunoblastic proliferation
• Follicular lymphoma (grade 3)/large B cell
• Peripheral T cell lymphoma
• Classic Hodgkin lymphoma
• T cell/histocyte rich B cell lymphoma

22. PLEOMORPHIC CELL POPULATION
• Anaplastic large cell lymphoma
• 'Large cell' pleomorphic lymphomas (T, NK and B cell)
• Lymphocyte-depleted Hodgkin lymphoma
• Histiocytic Sarcoma
• Anaplastic plasmacytoma

23. Hodgkin lymphoma
• Hodgkin lymphoma accounts for approximately 30% of all lymphomas
• It is comprised of two entities: nodular lymphocyte predominant HL
and classic HL.
• The subtypes of classic HL are
• nodular sclerosis
• mixed cellularity,
• lymphocyterich
• lymphocyte depleted.

24. • 1. atypical mononuclear cells (‘Hodgkin cells’); nucleus is 3–4 × the
• size of a small lymphocyte,
• 2. Reed-Sternberg cells,
• 3. a variable number of eosinophils, plasma cells and histiocytes,
• 4. a background population of lymphocytes,

25. • 5. immunophenotype: classic Hodgkin lymphoma, Reed-Sternberg
• cells CD30, CD15, MUM1,weak PAX5; small lymphocytes usually
• predominantly CD3,
• 6. nodular lymphocyte predominant type, Reed-Sternberg cells
• CD20, CD79a, BCL6, OCT-2, BOB1, CD45, EMA; small lymphocytes
• usually predominantly CD20.9,69

26. REED STERNBERG CELL
• Reed–Sternberg cells are large (30–50 microns)
• either multinucleated or have a bilobed nucleus
• prominent eosinophilic inclusion-like nucleoli
• thus resembling an "owl's eye" appearance
• Reed–Sternberg cells are CD30 and CD15 positive, usually negative for
CD20 and CD45

27. REED STERNBERG CELL

28. TYPES OF R –S CELL

29. • They can also be found in reactive lymphadenopathy (such as
infectious mononucleosis immunoblasts which are RS like in
appearance,
• carbamazepine associated lymphadenopathy)
• very rarely in other types of non-Hodgkin lymphomas

30. Binuclear Reed-Sternberg cells and
mononuclear Hodgkin cells in a background of
mainly small lymphocytes
and/or granulocytes
Varying basophilia

31. Many scattered binuclear or multilobated Reed-Sternberg cells with a background of lymphocytes

32. Characteristic CD30 positivity

33. Examples of Reed-Sternberg cells from different cases; multiple or multilobated large
nuclei with very large nucleoli; reticulate chromatin; pale cytoplasm

34. Other examples of Reed-Sternberg giant cells

35. Recurrent Hodgkin lymphoma; atypical mononuclear cell
forms only

36. Multinucleated ‘popcorn’ cell in a background of small B
lymphocytes and some histiocytes

37. Clusters of numerous
large atypical lymphoid cells dominate smears focally; some
are of
Reed-Sternberg

38. Reed-Sternberg-like cells in infectious mononucleosis(A) Multilobated
giant cell (MGG, IP); (B) Binucleate cell with very large
nucleoli (MGG, HP), from two different cases of infectious mononucleosis

39. Reed-Sternberg-like immunoblasts (A) Large binucleate cell in
case of angioimmunoblastic T-cell lymphoma; (B) Binucleate cell in
toxoplasma lymphadenitis

40. Reed-Sternberg-like cells in peripheral T-cell lymphoma
Pleomorphic T-cell lymphoma with Reed-Sternberg-like cells (

41. Large cell anaplastic
lymphoma, CD30 positive; differential diagnosis of Hodgkin
lymphoma is a
common problem in ALK negative cases

42. Reed-Sternberg-like cells in metastatic carcinoma (A) Large
binucleate cells with large nucleoli in metastatic nasopharyngeal
carcinoma;
note eosinophils in the background; (B) Large binucleate cell in
lymph node
metastasis from squamous cell carcinoma of floor of mouth

43. Reed Sternberg-like cell in dendritic follicular cell
sarcoma
Large binucleate cell with large nucleoli

44. NON HODKINS LYMPHOMA

45. Small B-cell lymphomas
LYMPHOMA
TYPE
CD5 CD 10 CD 23 CYCLIN D1 CYTOGENETCS
Small
lymphocytic
+ - + - TRISOMY 12
Mantle cell + - - + t(11;14)
Follicular (low
grade)
- +/- -/+ - t(14;18)
Lymphoplasmac
ytic
- + - - non-specific
Marginal zone
(nodal)
- + - - Trisomies 3,7,18

46. SMALL LYMPHOCYTIC LYMPHOMA/CHRONIC
LYMPHOCYTIC
LEUKAEMIA (SLL/CLL)
• 1. a monotonous population of small lymphoid cells,
• 2. mainly round nuclei slightly larger than those of normal small
• lymphocytes,
• 3. characteristically coarse granular nuclear chromatin (‘grumelé’,
highlighted by Pap staining); nucleoli absent,
• 4. a varying number of prolymphocytes: larger size, more cytoplasm,
• pale chromatin, single central nucleolus,
• 5. large paraimmunoblasts with prominent nucleolus and gray-blue
• cytoplasm,

47. Monotonous population of slightly enlarged lymphocytes with coarsely granular chromatin (grumelé
pattern) particularly obvious in Pap-stained smears

48. • 6. Rare tingible-body macrophages,
• 7. immunophenotype: CD19, CD20, faint SIg, CD5, CD23 (CD10 and
• FMC7 negative) (Fig. 5.30),
• 8. aberrant immunophenotype: CD5 or CD23 negative69 (rarely CD
• 10 positive),
• 9. genetics: trisomy 12 (20%), deletion 13q (50%).

49. presence of many large cells with a single nucleolus (polymphocytes)
representing
proliferation center, especially in slightly understained cells

50. Lymphoplasmacytic lymphoma (LPL)
• 1. a mixed population of lymphocytes, plasma cells and occasionally
• some blasts,
• 2. a variable number of lymphocytes with plasmacytoid features and
• Dutcher bodies,
• 3. may occasionally have amyloid,

51. Predominantly small lymphocytes, some with plasmacytoid cytoplasm, and a single large blastic
cell (MGG, HP) (Reproduced with permission from van Heerde et al.9);
(B) Lymphoplasmacytic lymphoma with obvious plasma cell component
(MGG, HP).

52. • 4. immunophenotype: strong SIg and CIg, CD19, CD20, CD79a (CD5
• and CD23 negative),
• 5. aberrant immunophenotype: occasionally CD5 and/or CD23
• positive (rarely CD10),
• 6. genetics: no specific abnormality in node.

53. Plasmacytoma
• 1. cells resembling mature or immature (nucleoli-containing) plasma
• cells,
• 2. eccentric nuclei, condensed chromatin or blastic-like, condensed
• cytoplasm,
• 3. immunophenotype: CD38, CD79a, CD138, OCT-2, CIg; CD 20 and
• Pax 5 very often negative,
• 4. aberrant immunophenotype: CD56, CD10, CD117, cyclin D1.

54. Pure population of well-differentiated plasma
cells

55. Follicular lymphoma
• 1. lymphoid population composed of a mixture of centrocytes and
• centroblasts,
• 2. centroblasts with large round or slightly irregular nuclei, small
• nucleoli and basophilic cytoplasm,
• 3. centrocytes, small to medium-sized, with irregular or cleaved
• nuclei, inconspicuous nucleoli and little cytoplasm with a
• tendency to form clusters,

56. Predominance of medium sized
cells with irregular, sometimes cleaved nuclei; a few
centroblasts with
multiple nucleoli. Relatively few small lymphocytes

57. Kappa/lambda staining in cytospin preparation showing
lambda monoclonality

58. • 4. usually a relatively low number of small lymphocytes (Fig. 5.37A),
• 5. immunophenotype: monotypic SIg (Fig. 5.37B,C), CD19, CD20,
• CD10 (in 60–90% of cases), Bcl-2, Bcl-6, CD23 sometimes,
• 6. aberrant immunophenotype: CD5 (floral variant),
• 7. genetics: t(14;18) in over 90%.

59. Cytocentrifuge preparation;
centrocytes showing cleaved nuclei; one centroblast

60. Dendritic reticulum cells may be prominent in follicular lymphomas; predominance of centrocytes(A, MGG,
B, Pap, HP).

61. Mantle cell lymphoma (MCL)
• 1. monotonous population of small centrocyte-like cells with
• occasional histiocytes,
• 2. blastoid variant cells resemble lymphoblasts,
• 3. immunophenotype: CD19, CD20, SIg, CD5, FMC7, Cyclin-D1 (cell
• block or CNB); CD10 and CD23 negative,
• 4. aberrant immunophenotype: CD5 negative, CD5 and CD10
• positive, CD23 weakly positive,19,20,69
• 5. genetics: t(11;14) almost all cases

62. Nuclei a little larger than those of
lymphocytes irregular shape, finely granular chromatin
without distinct
nucleoli. A few normal lymphocytes present.

63. Central histiocyte for size comparison

64. Immunostaining with CD5: strongly positive reactive T
cells
and moderate positivity in malignant lymphoma cells

65. Marginal zone lymphoma (MZL)
• 1. heterogeneous population of cells (uncommonly monomorphous
• population),
• 2. small up to medium atypical cells with irregular nuclei,
• 3. mature small lymphocytes, plasma cells, large transformed cells,
• 4. variable numbers of monocytoid cells with clear cytoplasm;
• difficult to identify

66. • 5. immunophenotype: CD19, CD20, CD79a, FMC7 (CD5, CD10, CD23
• negative),
• 6. aberrant immunophenotype: CD5 or CD10 (rarely),
• 7. genetics: nodal – trisomies 3,7,18; extranodal – t(11;18), t(3;14),
• t(14;18).

67. Diffuse large B-cell lymphoma
• There are three common variants
• centroblastic,
• immunoblastic
• anaplastic (pleomorphic).

68. Centroblastic variant
• 1. a population of mainly centroblasts,
• 2. characteristically round nuclei with multiple small nucleoli (Fig.
• 5.41),
• 3. a variable proportion of indented/cleaved or even multilobated
• nuclei often present (Fig. 5.42–5.43),
• 4. immunoblasts with abundant basophilic cytoplasm and large
• central nucleoli may be present in the ‘polymorphous subtype

69. immunoblastic variant
• 1. a pleomorphic cell population dominated by large blasts;
• sometimes extreme pleomorphism and multinucleated cells,
• 2. unevenly distributed nuclear chromatin; prominent, usually
• single central nucleoli; occasionally multiple nucleoli; frequent
• mitoses,
• 3. abundant blue cytoplasm (MGG); perinuclear pale zone (Fig.
• 5.44A),
• 4. tingible body macrophages

70. Anaplastic variant
• 1.cells resemble Hodgkin and/or Reed-Sternberg cells,
• 2. may resemble cells of anaplastic large cell lymphoma

72. Diffuse large B-cell lymphoma,NOS
• 1. immunophenotype: CD19, CD20; often SIg, sometimes
• CIg; variable expression CD10, BCL6, BCL2 and
• MUM1; CD 30 most likely in anaplastic variant,
• 2. aberrant immunophenotype: CD5positve (10%); rarely
• cyclin D1 focal positivity,
• 3. genetics: t(14;18) in 30%, MYC rearrangement up to
• 10%,

73. Predominance of large centroblastic lymphoid cells with pale nuclei, scanty cytoplasm and multiple, often
peripheral, nucleoli

74. Diffuse large B-cell lymphoma, NOS Cytocentrifuge
preparation of cerebrospinal fluid showing pronounced
irregularity of
nuclear contour (MGG, HP).

75. Diffuse large B-cell lymphoma, NOS. Polymorphous. Centroblasts, immunoblasts and large centrocytic cells,
particularly distinct in Pap-stained preparations

76. Predominantly large lymphoid cells with large round nuclei, large nucleoli
and abundant basophilic cytoplasm

77. Predominance of large lymphoid cells with large vesicular round
nuclei and
large central nucleoli

78. T-cell/histiocyte-rich large B-cell
lymphoma
• 1.smears dominated by small mature lymphocytes, over 90%,
• 2. variable numbers of epithelioid histiocytes,
• 3. scattered large cells mimicking Hodgkin or Reed-Sternberg cells,
• centroblasts, immunoblasts and ‘popcorn cells’,
• 4. immunophenotype: small cells, CD3, CD5, CD8; large cells, CD20,
• CD79a, BCL6 (CD15, CD30 negative),
• 5. genetics: non-specific.

79. Scattered large abnormal lymphoid cells with a background of reactive lymphocytes

80. The neoplastic B cell highlighted by immunostaining for
CD20

81. Plasmablastic lymphoma
• 1. monotonous cellular smear with cells resembling immunoblasts
• or a mixture of large nuclei, coarse chromatin, small nucleoli and
• smaller plasmacytic cells,
• 2. immunophenotype: CD138, CD38, MUM1, CD79a (positive
• 50–85%),
• 3. genetics: frequent IG/MYC translocations and gains in multiple
• chromosomal loci.

82. Uniform large cells with vesicular nucleus, prominent nucleoli and
moderate cytoplasm-resembling immunoblasts

83. CD138 positive

84. Burkitt lymphoma
• 1. usually a relatively uniform cell population with a high mitotic
• rate,
• 2. rounded nuclei of variable but predominantly intermediate size,
• 3. granular or speckled chromatin pattern, multiple (2–5) small but
• prominent nucleoli,
• 4. variable, mostly thin rim of dense blue cytoplasm with small lipid
• vacuoles (MGG),

85. • 5. starry-sky macrophages often prominent with a ‘dirty’
• background,
• 6. immunophenotype: SIgM, CD19, CD20, CD10, BCL6 (negative for
• BCL2, TdT); proliferative index (MIB1) nearly 100%,
• 7. genetics: t(8;14) in 80%, t(2;8) and t(8;22)

86. Rounded lymphoid cells; some variation in
nuclear size; distinct nucleoli; granular chromatin; dense blue
cytoplasm
with lipid vacuoles and some starry-sky macrophages

87. Blastic cells with round nuclei of varying size
and small amount of cytoplasm; occasional starry-sky macrophages

88. Dual-color FISH with break-apart c-MYC
probes ( 5’c-MYC probe orange and 3’c-MYC probe green)
showing nuclei
in which one pair of probe signals (yellow) is split apart due to
a c-MYC
region rearrangement.

89. B-lymphoblastic leukemia/ lymphoma
• 1. a homogeneous population of cells of similar type.
• 2. round nuclei mainly of intermediate size, occasionally showing
• considerable variation in size,
• 3. finely granular or ‘speckled’ nuclear chromatin with multiple small
• nucleoli,
• 4. moderately basophilic, fragile cytoplasm

90. • 5. starry-sky macrophages may be present (Fig. 5.51A),
• 6. immunophenotype: CD19, CD79a, CD10, PAX5, TdT (CD34, CD20
• variable expression),
• 7. genetics: many with variable genetic abnormalities having
• prognostic significance

91. Rounded nuclei of variable, mainly
intermediate size; speckled nuclear chromatin; small but distinct
nucleoli.
Starry sky macrophages may be presen

92. T-lymphoblastic leukemia/lymphoma
• 1. a relatively uniform cell population with a high mitotic rate,
• 2. intermediate-sized nuclei, often prominent anisonucleosis,
• 3. variable number of convoluted (unipolar deeply indented) nuclei,
• 4. dense, finely granular chromatin; mostly inconspicuous nucleoli,
• 5. scanty, pale, fragile cytoplasm,

93. • 6. immunophenotype: TdT, most often CD3 (cytoplasmic) and CD7;
• often CD4 and CD8 double positive or double negative; variable
• positivity with CD1a, CD34, CD10,
• 7. genetics: 50–70% abnornal karyotype

94. Note unipolar indentation (convolution) in some cells. Anisokaryosis, dense chromatin without distinct
nucleoli, many mitoses. TdT positivity.

95. Mature T and NK-Cell neoplasms

96. Angioimmunoblastic T-cell lymphoma
• 1. heterogeneous cell population,
• 2. small to medium irregular lymphocytes,
• 3. variable number of large cells – including immunoblasts and at
• times pleomorphic cells (resembling Reed-Sternberg cells),
• 4. reactive background of small round lymphocytes, eosinophils,
• plasma cells, epithelioid and nonepithelioid histiocytes, dendritic
• cells,

97. • 5. immunophenotype: CD3, CD4, BCL6, CD10 , CXCL13, PD1,
• 6. PCR: T-cell gene rearrangement detectable in 75–90% of cases;
• clonal immunoglobulin gene rearrangement in 25–30% of cases,
• 7. genetics: trisomy 3 or 5 most common

98. Heterogeneous population of
cells with small, medium and large lymphocytes,
neutrophils, eosinophils
and plasmacytoid cells

99. Anaplastic large cell lymphoma (ALCL), ALK
positive
• 1. large cells with pleomorphic nuclei,
• 2. some Reed-Sternberg-like large cells,
• 3. irregular nuclei; horseshoe shaped (hallmark cells), donut,
• multinucleated with one or more prominent nucleoli,
• 4. cytoplasm abundant and may be vacuolated,
• 5. few lymphoglandular bodies,
• 6. cell clustering at times

100. • 7. immunophenotype: CD30, ALK, EMA, one pan T-cell marker
• usually positive (null cell at times), perforin; variably positive for
• CD45 (CD15 and PAX5 negative),
• 8. genetics: t(2;5) in 84% of cases.

101. Large polymorphous cells
with abundant cytoplasm; pseudoepithelial arrangement;
multinucleation;
distinct nucleoli.

102. Occasional ‘hallmark’ cells with horseshoe/boomerang
nuclear forms.

103. DONUT CELL

104. CD30 (Ki-1) positive

105. PROBLEMS AND DIFFERENTIAL
DIAGNOSIS
• distinction from reactive lymphadenopathy,
• NHL with few neoplastic cells in a dominant population of reactive
lymphoid cells, e.g. T-cell/histiocyte rich B lymphoma
• small cell anaplastic carcinoma and other small cell tumors,
particularly versus low-grade follicular (centrocyte
dominant),lymphoblastic and Burkitt lymphomas
• large cell malignancies, undifferentiated carcinoma, melanoma,
seminoma, myeloid sarcoma versus large cell lymphoma,
• including anaplastic large cell lymphoma

106. Diffuse large cell lymphoma, NOS, with reactive lymphocytes
Scattered neoplastic cells with very large nuclei with a
dominant
background population of reactive lymphocytes

107. Such clusters may
simulate small cell anaplastic carcinoma or adenocarcinoma; this
problem
mainly occurs in follicular lymphomas and large cell anaplastic
lymphomas

108. Small cell anaplastic (neuroendocrine) carcinoma This
example of a FNB smear from a lung tumor closely mimics
anaplastic large
cell lymphoma: dispersed cells with large eccentric nuclei
and a thin rim of
blue cytoplasm

109. Metastatic large cell
undifferentiated carcinoma with solitary tumor cells may
mimic large cell
lymphoma

110. Metastatic melanoma mimicking lymphoma (A) Dispersed malignant cells with eccentric
nuclei and pale cytoplasm; lymphoid globules absent
(Pap, HP). (B) Amelanotic melanoma showing dense smooth chromatin and characteristic
paranuclear dark area in tumor cells

111. tumor cytoker
atin
Melan a s100 Cd 45 cd15 Cd 30 alk Cd 20 oct4 mpo
DLBCL - - - + - +/- - + - -
CARCINO
MA
+ - -/+ - -/+ +/- - - - -
MELANO
MA
- + + - - - - - - -
SEMINOM
A
- - - - - - - - + -
CHL - - - -/+ +/- + - -/+ - -
ALCL - - - +/- - + +/- - - -
SEMINOM
A
- - - +/- +/- - - - - +

112. Histiocytic sarcoma
• A very pleomorphic cell population
• with multilobed nuclei and multinucleated cells which
• may resemble Reed-Sternberg cells should make one think of this
possibility.
The main differential diagnosis includes
• large cell non-Hodgkin lymphomas (especially ALCL), HL,
• pleomorphic carcinoma and melanoma

113. • immunophenotype: monocyte/macrophage markerslike CD68,
CD163, CD14 and lysozyme;
• absence of T- and B-cell characteristics; myeloperoxidase, CD33 and
CD34 negative
• PCR: lacks IgH or TCR rearrangement
• genetics: non-specific

114. Metastatic lymph node disease
• Lymph nodes enlarged by metastatic tumour spread often show
• diffuse involvement, therefore an FNA from an involved node
• will almost invariably result in diagnostic cells
• Such ‘foreign’ cells are in most instances readily identifi ed in a
background of lymphoid cells.

115. M etastatic epithelial tumours
• Squamous carcinoma
• Squamous carcinomas often yield a mixed pattern
• well-differentiated type, keratinised cells with blue cytoplasm
• These cells have hyperchromatic nuclei and may show squamous
pearl formation
• The cellular atypia can be minimal

116. Metastatic squamous cell carcinoma. (A) There are several atypical squamous cells with
hyperchromatic nuclei and blue cytoplasm (MGG). (B) Same
aspirate alcohol fi xed and Papanicolaou stained

117. Adenocarcinoma
• These metastases will often disclose their nature by acinar structures
or gland formation
• their site of origin may be diffi cult to determine
• additional features might be helpful
• mucin production is often seen in gastrointestinal and lung CA.
• Cells with pale grey vacuolated large cytoplasm (MGG) and a nucleus
with a central nucleolus are suggestive of a renal cell carcinoma

118. Metastatic adenocarcinoma. The glandular
arrangement of
the malignant epithelial cells is obvious. This is a
deposit from a welldifferentiated
prostatic carcinoma

119. Small cell carcinoma of undifferentiated type
• crowded clusters of tumour cells showing moulding
• scanty cytoplasm,
• coarse chromatin,
• frequent mitoses and
• a background of necrosis
• resemble lymphoma cells,

120. M etastatic malignant melanoma
• polymorphic dissociated cells which may rarely contain fi ne pigment
granules staining darkly on MGG
• the cytoplasm often shows vacuoles only and this is referred to as ‘
negative pigmentation ’ .
• The nuclei have large nucleoli which occasionally may be replaced by
cytoplasmic invaginations into the nucleus

121. Metastatic malignant melanoma. In this case the
aspirate consists
of dissociated relatively monotonous round cells. This
rare variant is diffi cult
to differentiate from other round cell tumours

122. M etastatic sarcomas
• The fi ndings in FNA material mirror the diversity of histological
appearances encountered in primary sarcomas of different types.
Metastatic sarcoma. Lymph node deposit of
abnormal spindle
cells from a Kaposi’s sarcoma occurring in an HIV-
positive patient

123. RECENT ADVANCES

124. CD30 EXPRESSION IN FOLLICULAR T CELL
LYMPHOMA
• In many cases, neoplastic T cells form rosettes around Hodgkin–
Reed–Sternberg-like cells
• Frequently, the immunophenotype of rosetting neoplastic T cells
differed from the bulk neoplastic cells with less numerous T-follicular
helper cell markers expressed, suggesting a modulation of T-follicular
helper cell marker expression in the neoplastic T cells.
• In 75% of the cases, variable CD30 expression was encountered in the
neoplastic T cells

125. • Hodgkin–Reed–Sternberg-like cells in follicular T cell lymphoma
cannot reliably be differentiated from the Hodgkin–Reed–Sternberg
cells of classical Hodgkin lymphoma based on their
immunophenotype.
• In contrast, demonstration of a T-follicular helper cell phenotype with
CD10 and frequent CD30 expression in the neoplastic T cell
population can help to establish the diagnosis of follicular T cell
lymphoma, and may even indicate CD30 as a therapeutic target for
these patients.

126. THANK YOU