non Hodgkin lymphoma, Classification of NHL, Burkitt lumphoma

1. NON HODGKIN
LYMPHOMA
Dr Vijay Shankar S

2. LEARNING OBJECTIVES
 Introduction
 Classification systems
 B cell lymphomas
 Burkitt lymphoma

3. Classification Systems
 Recognized as neoplasms in early 1900
 Chaotic terminology
 Descriptive vs cell lineage classification systems
Classification based on:
 Morphology (H&E)
 Clinical Outcomes
 Morphology + markers + Molecular techniques

4. Lymphoma Classification
 Morphology
 Morphology + Clinical outcomes + ? Markers
 Morphology + Immunophenotype + Chromosome data
 Morphology + IPX + Molecular studies + Chr (biologic subgroups)
 Morphology + Clinical + IPX + Mol. Sty + Gene arrays
 +Proteomics
1900 2010
Reticulum
Cell
Tumors &
HD
Lymphoma Rappaport
1950
WF / NCI
1982
REAL
-
WHO

5. Morphology
Markers
CD1, CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11,
CD14, CD15, CD19, CD20, CD21, CD25, CD30, CD33,
CD79A, CD99, CD117 etc.
Molecular
T & B cell gene rearrangement studies
In-situ (FISH etc.), HUMARA,
Gene/tissue arrays, CGH, Proteomics etc.

6. Classification Criteria - WF-NCI Classification (1982)
Criteria
 Pattern of Growth
 Cells & Cellular
Features
 Prognostic Categories
Classification
 Low Grade
 Intermediate Grade
 High Grade
Pathology - 1180 cases independently reviewed by panel of
hematopathologists (US, Europe and Japan)
Clinical data – Survival/response analyzed by statisticians
NCI funded study, 1982

7. Small Cells Intermediat
e
Large Cells
Pathologic / Morphologic Criteria – WF/NCI Classification, 1982
Nodular / Follicular Diffuse

8. Small Cells Intermediate Large Cells

9. Lymphoma Classification
Working Formulation (WF-NCI) Classification
 Pattern of Growth
 Follicular or Diffuse
 Cells
 Cell size - Small, medium
& large
 Lymphocytes, plasma cells,
immunoblasts
 Prognostic Categories
 Low grade
 Intermediate & High
grade
 Low Grade
 A. Small cell
 B. Follicular small cell cleaved
 C. Follicular mixed small and large
 Intermediate Grade
 D. Follicular large cell
 E. Diffuse small cell cleaved
 F. Diffuse mixed small & large cell
 G. Diffuse large cell
 High Grade
 H. Immunoblastic
 I. Lymphoblastic
 J. Small cell non-cleaved

10. WF-NCIClassification (1982)
 Limitations
 Works well for B-cell lymphomas
 Mixed small and large cell lymphomas ?
 IPX, Flow & molecular data not applicable
 Marginal zone (MALT) and mantle types not
classifiable
 Newer subtypes (T, NK cell etc.) cannot be
adequately classified under WF-NCI system
 Strengths
 Grading system and high clinical acceptance
 Many Rx protocols are based on WF-NCI

11. Revised European & American
Lymphoma Classification (1996)
 WF-NCI system enhanced by Ancillary studies ?
 IHC
 Flow, cytogenetic
 Several sub-categories
 All neoplastic entities of reticuloendothelial system
 Includes tissue based, BM and peripheral blood neoplasms
 Grading system not used
 Currently modified by Society of Hematopathology,
European association of Hematopathology
 Recent WHO publication (2001)

12. Criteria for WF-NCI and REAL/WHO
REAL-WHO
 Cells
 Pattern
 Immunophenotype
 Grade (not graded*)
*grading is under development
WF-NCI
 Pattern
 Cells
 Grade

13. REAL-WHO, 2001
Cells and Cellular Features
 Cell size (S, M & L), cleaved
 Lymphoblasts, large/small
lymphocytes, mantle cells,
monocytoid B-cells (marginal
zone), immunoblasts, lymph-
plasma cells
Pattern of Growth
 Follicular or diffuse
Immunophenotype
 IHC, Flow & Genotype
 Lymphoid (B, T, NK),
histocyte, myeloid and
macrophages
Several Categories
 B-cell Neoplasms
 T-cell Neoplasms
 Hodgkin’s disease
 Histiocytic/Dendritic
cell neoplasms
 Acute leukemia
 Lymphoid or myeloid
 Myelodysplasia
 Chronic
myeloproliferative
disorders

14. REAL-WHO – 2001: Classification – Biologic Groups ?
 Precursor B-cell
 ALL / lymphoblastic
lymphoma
 Mature (peripheral) B-cell
 CLL / SLL
 B-prolymphocytic leukemia
 Lymphoplasmacytic leukemia
 Splenic marginal zone (SLVL)
 Hairy cell leukemia
 Plasma cell myeloma
 Extranodal MALT
 Nodal MALT
 Follicular lymphoma
 Diffuse large B-cell lymphoma
 Burkitt lymphoma/leukemia
 Precursor T-cell
 ALL / lymphoblastic lymphoma
 Blastoid NK-cell lymphoma
 Mature (peripheral) T-cell
 T-cell prolymphocytic
 T-cell large granular lymph
 Aggressive NK-cell leuk
 ATLL (HTLV1+)
 Extranodal NK/T-cell lymphoma
 Enteropathy associate T lymp
 Hepatosplenic lymphoma
 Subcutaneous panniculitis T-cell
lymphoma
 MF/SS
 Primary cutaneous large lymph
 Angioimmunoblastic lymphoma
 Primary systemic anaplastic large
cell lymphoma (ALCL)

15. Relative Frequency of Lymphomas REAL .. N. Harris et al
 B-cell > 85%
 T-cell < 15%
Types
 Diffuse large B-cell – 31%
 Follicular lymphoma – 22%
 MALT lymphoma 8%
 Mature T-cell lymphoma – 8%
 CLL/SLL – 7%
 Mantle cell lymphoma – 6%
 Mediastinal large B-cell lymphoma – 2%
 Anaplastic large cell lymphoma – 2%
 Burkitt lymphoma – 2%
 Nodal marginal zone lymphoma – 2%
 Precursor T lymphoblastic – 2%
 Lymphoplasmacytic lymphoma – 1%
 Other types – 7%

16. WHO Classification of Hematopoietic
and Lymphoid Tumors: B-cell Neoplasms
Indolent
 Chronic lymphocytic
leukemia (CLL)/small
lymphocytic lymphoma
 Lymphoplasmacytic/
Waldenstrom’s
macroglobulinemia (WM)
 Hairy cell leukemia
 Marginal zone lymphoma
 Extranodal mucosa-
associated lymphoid
tissue (MALT)
 Nodal
 Splenic
 Follicle center lymphoma,
follicular, grade I-II
Aggressive
 Prolymphocytic leukemia
 Plasmacytoma/
multiple myeloma
 Mantle cell
 Follicle center lymphoma,
follicular, grade III
 Diffuse large B-cell
lymphoma (DLBCL)
 Primary mediastinal large
B-cell lymphoma
Very Aggressive
 Precursor
B-lymphoblastic
lymphoma/leukemia
 Burkitt lymphoma/
B-cell acute leukemia
 Plasma cell leukemia
Jaffe E, et al. IARC Press, World Health Organization, 2001.

17. B-Cell Lymphoma (85%)
 B-Cells help make antibodies, which are proteins that
attach to and help destroy antigens
 Lymphomas are caused when a mutation arises during
the B-cell life cycle
 Various different lymphomas can occur during several
different stages of the cycle
 Follicular lymphoma, which is a type of B-cell lymphoma is
caused by a gene translocation which results in an over
expressed gene called BCL-2, which blocks apoptosis.

19. Precursor B or T Lymphoblastic
Leukemia/lymphoma
 High grade B or T cell
neoplasm
 Common in children
 Leukemic or
lymphomatous phase
 CD19+, CD79a+,
CD10+, CD24+, tDt+
(precursor B)
 CD3+, CD5+, tDt+
(precursor T)

20. B-Cell Small Lymphocytic /
CLL
 Small lymphoid cells &
“pseudo growth centers”
 Immunophenotype
 CD20+ dim, CD19+,
CD5+, CD23+, k or l+ dim
 Indolent process
 Prolymphocytes (<30%)
 High grade B-cell
lymphoma (Richter’s
transformation)
SLL
SLL
CLL

21. Follicular Lymphoma
 Most common form of NHL
 Middle age. M:F:: 1:1
 Rare in Asian population
 Neoplastic cells resemble normal Germinal
center B cells

22. Follicular Lymphoma
 Predominantly follicular,
focal diffuse or pure diffuse
 Small cleaved cells
(centrocytes)
 Larger cells ( centroblasts)
 Mixed small and large cells
 Grade I, II & III a/b
 Nodal or extranodal
 BM + (85%)
Small Cell Cleaved Follicular Lymphoma
Grade I

23. Follicular Lymphoma
Histopathology
Centrocytes:Small cells with irregular / cleaved nuclear contours
& scant cytoplasm
Centroblasts: larger cells with open nuclear chromatin, several nucleoli
& moderate cytoplasm
Centrocytes
Centroblasts

24. •Bone marrow involvement occurs in 85 % of cases
•Characteristically takes the form of paratrabecular
aggregates
bcl2 positivity of bone marrow neoplastic cellsParatrabecular bone marrow infiltration
by Follicular lymphoma

25. Immunophenotype
CD19+, CD20+, CD10+, k or l +, CD 5-, CD23+/-
Also expresses bcl-2 protein in more than 90 %
of cases.
Cytogenetics & Molecular Genetics
Hallmark of follicular lymphoma is a (14 ;18 ) translocation that
juxtaposes the IgH locus on Chr 14 and the bcl-2 locus on Chr 18

26. Clinical features.
 Painless, generalised lymphadenopathy
 Indolent waxing and waning course
 Incurable
 Median survival- 7-9 yrs
 Histologic transformation to DLBCL in 30% -
50% of cases., rarely into burkitt like lymphoma.
 Survival less than 1 yr after transformation

27. Diffuse large B-cell lymphoma
 most common type of “aggressive” lymphoma
 usually symptomatic,presents with rapidly
enlarging, mass at a single nodal or extranodal site
 extranodal involvement is common
 cell of origin: germinal center B-cell
 treatment should be offered
 curable in ~ 40 – 50%.

28. Diffuse Large Cell Lymphoma (B-
cell)
 Diffuse pattern of
growth.
 Large cell size(4 -5
times the diameter of
a small lymphocyte.
 R-S like cells may be
seen in more
anaplastic variants.
Large cell Lymphoma
Immunoblastic Lymphoma

29. BURKITT LYMPHOMA
 Aggressive B- cell neoplasm
 Types
1. African ( Endemic) Burkitt lymphoma
2. Sporadic ( Non Endemic) Burkitt lymphoma
3. Aggressive lymphomas in individuals infected with HIV
 EBV infection related. t(8;14)

30. Died 23 Mar 1993 (born 28 Feb 1911)
Irish surgeon and medical researcher who
first identifiedBurkitt's lymphoma.
In 1957, in Uganda, Burkitt found several
children suffering from fast-spreading
tumours in the head and neck. When they
died within weeks, Burkitt recognised this
was a previously undescribed cancer
disease. He showed that these and all cases
were characterized by infiltration of the
affected tissues by lymphocytes. With
colleagues Edward Williams and Clifford
Nelson, he plotted the geographical
incidence of the disease, and found it in
the same areas endemic with malaria. This
survey is regarded as one of the pioneering
studies of geographical pathology. Burkitt
helped to develop chemotherapy for the
disease. Later, he championed high fibre
diets.
Dr Denis (Parsons) Burkitt

31. A group of Burkitt's Lymphoma cases in Dr Burkitt's care.
Mulago Hospital, Kampala, Uganda, in 1960

32. Clinical features
Both endemic & sporadic are found in children and young adults.
Endemic Burkitt lymphoma : often present as a mass involving mandible
Unusual prediliction for abdominal viscera(kidneys, ovaries, adrenals).
Sporadic Burkitt lymphoma: Most often presents as an
abdominal mass involving the ileocecum and peritoneum

33. Morphology

34. Immunophenotype: Mature B cell markers – Surface IgM, CD19,
CD20,CD10.
Cytogenetic Features
In most of the cases of Burkitt's lymphoma, a reciprocal translocation
has moved the proto-oncogene c-myc from its normal position on chromosome 8
to a location close to the enhancers of the antibody heavy chain genes on chromosome 14.
T(8;14)

35. prognosis
 Very aggressive , but responds well to short-
term, high dose chemotherapy.
 Most children and young adults can be cured.
 Outcome guarded in older adults.

36. THANK YOU