Epidemiology of NHL 4% of all cancers 4% of all deaths 8.5 cases / 100.000 / year 65 M:F 1.8 65 ...
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Transcript of Epidemiology of NHL 4% of all cancers 4% of all deaths 8.5 cases / 100.000 / year 65 M:F 1.8 65 ...
Epidemiology of NHLEpidemiology of NHL 4% of all cancers4% of all cancers 4% of all deaths4% of all deaths 8.5 cases / 100.000 / year <658.5 cases / 100.000 / year <65 69 cases / 100.000 / year >6569 cases / 100.000 / year >65 M:F 1.8 <65 1.3 > 65M:F 1.8 <65 1.3 > 65 higher incidence in Western than higher incidence in Western than
developing countriesdeveloping countries incidence increased 3 fold 1975-95incidence increased 3 fold 1975-95
NHL : etiologic factorsNHL : etiologic factors
Immunodeficiency : primary and acquired Immunodeficiency : primary and acquired (HIV, post-tansplant)(HIV, post-tansplant)
Virus: HTLV-1, EBVVirus: HTLV-1, EBV Helicobacter PyloriHelicobacter Pylori Autoimmune disordersAutoimmune disorders Occupational exposures (pesticides, Occupational exposures (pesticides,
solvents, dyes)solvents, dyes) Other (weak association):Other (weak association): diet (milk, meat), diet (milk, meat),
blood transfusions, familialblood transfusions, familial
Ann Arbor Staging Ann Arbor Staging I: a single lymphatic region or extranodal siteI: a single lymphatic region or extranodal site II: two or more regions on the same side of II: two or more regions on the same side of
diaphragm or one extranodal site and one or diaphragm or one extranodal site and one or more lymphaticmore lymphatic
III: Involvement on both sides of diaphragmIII: Involvement on both sides of diaphragm IV: disseminated to liver, lung, BM, pleura, IV: disseminated to liver, lung, BM, pleura,
bone, skinbone, skin
Diagnostic proceduresDiagnostic procedures History (B symptoms)History (B symptoms) physical examinations (lymph nodes, physical examinations (lymph nodes,
hepatosplenomegaly, Waldeyers ring etc)hepatosplenomegaly, Waldeyers ring etc) Lab.: complete blood count, LDH, bLab.: complete blood count, LDH, b22--
microglobulin, renal and liver functionmicroglobulin, renal and liver function Chest X-ray, abdominopelvic CT scanChest X-ray, abdominopelvic CT scan bilateral BM biopsies and PB smearbilateral BM biopsies and PB smear
Hematopathology Lab.Hematopathology Lab. Processing and diagnosis of bone marrow, Processing and diagnosis of bone marrow,
blood, lymph nodes, tonsils, thymus, spleen blood, lymph nodes, tonsils, thymus, spleen and other tissues with suspect lymphomaand other tissues with suspect lymphoma
Methods:Methods: routine histopathologyroutine histopathology immunohistochemistry on frozen and paraffin immunohistochemistry on frozen and paraffin
sectionssections flow cytometryflow cytometry DNA analysisDNA analysis molecular biologymolecular biology
Routine histopathologyRoutine histopathology
Fixatives:Fixatives: B5 and formalineB5 and formaline StainingsStainings Htx-eosineHtx-eosine GiemzaGiemza PASPAS Gordon-SweetGordon-Sweet
frozen
B5 form.
flow
imprints: DNA
LYMPHOMA LYMPHOMA CLASSIFICATIONSCLASSIFICATIONS
Kiel classification 1974, rev. 1992Kiel classification 1974, rev. 1992 Lukes and Collins classification 1974Lukes and Collins classification 1974 Working Formulation 1984Working Formulation 1984 REAL (Revised European-American REAL (Revised European-American
Classification) Harris et al.Classification) Harris et al.
Blood, 1994, 84, 1361-1392Blood, 1994, 84, 1361-1392
B-cell lymphomasB-cell lymphomas Postulated normal counterparts:Postulated normal counterparts:
stemcell
BM B cellprecursor
B-precursorALL/NHLnullcommonpre-B
AUL
Peripheral B-cells
Lymph nodes
Peripheralblood
Mucosa associatedlymphatic tissue
B-cell lymphomasB-cell lymphomas Postulated normal counterparts:Postulated normal counterparts:• Peripheral B-cellsPeripheral B-cells
small lymphocyte
GC
Mt
Mz
Marginal zone
Mantle zone
FCC
Lymph node
Burkitt?
Large cell NHL
Lpl/ICPC
CLL
CB
CC
HCL??? Proliferating B-cell
recirculating B-cell
Ig producingB-cell
REAL ClassificationREAL Classification
B cell neoplasmsB cell neoplasms I. B-precursor neoplasmsI. B-precursor neoplasms
lymphoblastic leukemia/lymphomalymphoblastic leukemia/lymphoma
II. Peripheral B-cell neoplasmsII. Peripheral B-cell neoplasms
REAL ClassificationREAL Classification II. Peripheral B-cell neoplasmsII. Peripheral B-cell neoplasms 1. B-CLL1. B-CLL 2.Lymphoplasmocytoid lymphoma -2.Lymphoplasmocytoid lymphoma -
immunocytomaimmunocytoma 3.Mantle cell lymphoma3.Mantle cell lymphoma 4.Hairy cell leukemia4.Hairy cell leukemia 5.Plasmacytoma/myeloma5.Plasmacytoma/myeloma
NHL : Flow cytometry NHL : Flow cytometry
Morphology: Lymphocytic lymphomaMorphology: Lymphocytic lymphoma
Immunophenotype: CD19+, kappa+, CD5+, Immunophenotype: CD19+, kappa+, CD5+, CD23+, CD20-, mCD22-, CD10-CD23+, CD20-, mCD22-, CD10-
NHL : Flow cytometryNHL : Flow cytometry ImmunocytomaImmunocytoma Monoclonal k, CD19+, CD20+, CD22+, CD5-, Monoclonal k, CD19+, CD20+, CD22+, CD5-,
CD10-, CD23-CD10-, CD23-
60% B cells,80% B cells CD5- Monocl. kappa
NHL : Flow cytometry NHL : Flow cytometry Morphology: Mantle cell lymphomaMorphology: Mantle cell lymphoma
CD19+ CD5 dim
CD5 dimCD23-
NHL : Flow cytometryNHL : Flow cytometry HAIRY CELL LEUKEMIAHAIRY CELL LEUKEMIA CD19+ cells have characteristic scatter, CD5-, CD19+ cells have characteristic scatter, CD5-,
CD10- (some cases +)CD10- (some cases +)
CD19PE
CD5FITC
NHL : Flow cytometryNHL : Flow cytometry HAIRY CELL LEUKEMIAHAIRY CELL LEUKEMIA CD19+ cells are Bly7+, CD11c+, CD25+CD19+ cells are Bly7+, CD11c+, CD25+
NHL : Flow cytometryNHL : Flow cytometry Myeloma - plasmocytoma:Myeloma - plasmocytoma: CD19-, CD20-, CD22-, CD23-, CD5-, CD19-, CD20-, CD22-, CD23-, CD5-,
CD10-CD10-
R4
CD38 bright,CD45neg CD56+
REAL ClassificationREAL Classification II. Peripheral B-cell neoplasmsII. Peripheral B-cell neoplasms 6. Follicle Center Cell (FCC)6. Follicle Center Cell (FCC) grades: I (small cell), II (mixed small and large cell), III grades: I (small cell), II (mixed small and large cell), III
(large cell)(large cell)
7. Marginal zone B-cell7. Marginal zone B-cell extranodal (MALT +/- monocytoid cells)extranodal (MALT +/- monocytoid cells) nodal (+/- monocytoid cells)nodal (+/- monocytoid cells) splenic marginal zone (+/- villous lymphocytes)splenic marginal zone (+/- villous lymphocytes)
NHL : Flow cytometry NHL : Flow cytometry Morphologic diagnosis : Morphologic diagnosis : Low grade Marginal zone NHLLow grade Marginal zone NHL Triple staining FITC/ PE/ CD20PerCPTriple staining FITC/ PE/ CD20PerCP
R1
64% B cells Monocl.
NHL : Flow cytometry NHL : Flow cytometry Morphologic diagnosis : Morphologic diagnosis : Low grade Marginal zone NHLLow grade Marginal zone NHL Tripple stainings CD23 F/CD5 PE/ CD19TRI and Tripple stainings CD23 F/CD5 PE/ CD19TRI and
CD22 F/CD10PE/CD19 TRICD22 F/CD10PE/CD19 TRI
Most B-cellsexpress CD22 dimand are CD10-
14% B cells CD23+4%B cells CD23+/5+7% of B cells CD5+
Localizations of MALT lymphomasLocalizations of MALT lymphomas conjunctiva inc. orbitconjunctiva inc. orbit salivary glandssalivary glands Waldeyer's ringWaldeyer's ring larynxlarynx thyroid glandthyroid gland breastbreast lunglung GI tractGI tract urogenital tracturogenital tract
NHL : Flow cytometryNHL : Flow cytometry MALT lymphoma, gastric mucosa pxMALT lymphoma, gastric mucosa px B cells were CD20+, CD22+, CD5-, CD10-, B cells were CD20+, CD22+, CD5-, CD10-,
CD23- CD23-
60%B cells
NHL : Flow cytometry NHL : Flow cytometry Morphology: FCC type IIMorphology: FCC type II Partial involvement (confirmed by bcl-2 IH)Partial involvement (confirmed by bcl-2 IH)
R5
45% B-cells
ratio:0,5
NHL : Flow cytometry NHL : Flow cytometry Morphology: FCC II (CB/CC foll&diff)Morphology: FCC II (CB/CC foll&diff) A CD19 dim population was presentA CD19 dim population was present
NHL : Flow cytometry NHL : Flow cytometry Morphology: FCC II (CB/CC foll&diff)Morphology: FCC II (CB/CC foll&diff) The medium/large sized cell population is monoclonal The medium/large sized cell population is monoclonal
for for
NHL : Flow cytometry NHL : Flow cytometry Morphology: FCC II (CB/CC foll & diff)Morphology: FCC II (CB/CC foll & diff) The medium/large sized cell population is CD10+ and CD22 The medium/large sized cell population is CD10+ and CD22
dim, CD5-, CD23-dim, CD5-, CD23-
REAL ClassificationREAL Classification II. Peripheral B-cell neoplasmsII. Peripheral B-cell neoplasms 8. Diffuse Large B-Cell 8. Diffuse Large B-Cell include various subtypesinclude various subtypes one defined: mediastinal (thymic) B-NHLone defined: mediastinal (thymic) B-NHL
9. Burkitt´s lymphoma9. Burkitt´s lymphoma 10. High-grade Burkitt-like10. High-grade Burkitt-like
NHL : Flow cytometry NHL : Flow cytometry Large cell B-NHL (CB polym. diff.)Large cell B-NHL (CB polym. diff.) Staining CD5F/CD19PE/CD3PerCPStaining CD5F/CD19PE/CD3PerCP CD20-, mCD22-, CD23-, CD10-CD20-, mCD22-, CD23-, CD10- some cells positive for in large cell-gatesome cells positive for in large cell-gate
32% of cells in large-cell gate83% CD19+
NHL : Flow cytometryNHL : Flow cytometry Lymphoblastic lymphoma Burkitt-likeLymphoblastic lymphoma Burkitt-like
R1
L3Scatter
78% B cellsCD19+. CD20dim,m CD22 neg
NHL : Flow cytometryNHL : Flow cytometry
Lymphoblastic lymphoma Burkitt-likeLymphoblastic lymphoma Burkitt-like
CD10+CD22 neg
CD19+, CD5-
T-cell lymphomasT-cell lymphomas Postulated normal counterparts:Postulated normal counterparts:
stemcell
AUL
BMTHYMUS
T ALLcyt.CD3+/TdT+
m3-/4-/8-
m3-/4+/8+
4+ or 8+
T-cellprecursors
Peripheral T-cells
skinMF, SS
Mucosa, bowelIntest. T cell NHL
Lymph node
sinus
Peripheral T NHL
ANLC
REAL ClassificationREAL Classification T cell neoplasmsT cell neoplasms I. Precursor T-cellI. Precursor T-cell lymphoblastic leukemia/lymphomalymphoblastic leukemia/lymphoma
II. Peripheral T cell and NK-cell II. Peripheral T cell and NK-cell neoplasmsneoplasms
REAL ClassificationREAL Classification II. Peripheral T cell and NK-cell II. Peripheral T cell and NK-cell
neoplasmsneoplasms 1. T CLL1. T CLL 2. Large granular lymphocyte (LGL) 2. Large granular lymphocyte (LGL)
leukemialeukemia
T-cell type NK-cell typeT-cell type NK-cell type 3.Mycosis fungoides/Sezary syndrome3.Mycosis fungoides/Sezary syndrome
REAL ClassificationREAL Classification II. Peripheral T cell and NK-cell II. Peripheral T cell and NK-cell
neoplasmsneoplasms 4. Peripheral T cell lymphoma4. Peripheral T cell lymphoma cytologic categories: medium sized, mixed medium cytologic categories: medium sized, mixed medium
and large cell, large cell-lymphoepithelioid celland large cell, large cell-lymphoepithelioid cell 5. Angioimmunoblastic T-cell 5. Angioimmunoblastic T-cell
lymphoma AILDlymphoma AILD 6. Angiocentric lymphoma6. Angiocentric lymphoma
REAL ClassificationREAL Classification II. Peripheral T cell and NK-cell II. Peripheral T cell and NK-cell
neoplasmsneoplasms 7. Intestinal T cell lymphoma7. Intestinal T cell lymphoma (+/- enteropathy associated)(+/- enteropathy associated)
8. Adult T cell lymphoma/leukemia8. Adult T cell lymphoma/leukemia 9.Anaplastic large cell lymphoma9.Anaplastic large cell lymphoma CD30+, T-and null cell typesCD30+, T-and null cell types
NHL : Flow cytometryNHL : Flow cytometry Peripheral T cell NHLPeripheral T cell NHL mCD3-, cytCD3+, CD4+, CD8-,mCD3-, cytCD3+, CD4+, CD8-, CD7+, CD2+,CD5+, HLA-DR neg.CD7+, CD2+,CD5+, HLA-DR neg.
84% T cells mCD3-/CD4+
NHL : Flow cytometryNHL : Flow cytometry Peripheral T cell NHLPeripheral T cell NHL 80% of CD4+ cells were CD45RA, Leu8dim+80% of CD4+ cells were CD45RA, Leu8dim+
gated on CD4/SSC
*TRC V g 1.3 rearrangement
Dermatopatisk lymphadenopathyDermatopatisk lymphadenopathy
CD4/CD8 ratio 15:1CD4/CD8 ratio 15:1 All T cells positive for mCD3, CD5, CD2, CD7All T cells positive for mCD3, CD5, CD2, CD7 Activation of CD4 cellsActivation of CD4 cells
Dermatopatisk lymphadenopathyDermatopatisk lymphadenopathy CD4 positive cells not clonal (no TCR or CD4 positive cells not clonal (no TCR or
rearangement)rearangement) Cd45RA:CD45R0 0,35Cd45RA:CD45R0 0,35 predominance of CD62L+predominance of CD62L+
ImmunohistochemistryImmunohistochemistry
Frozen sections:Frozen sections: skin biopsies, bone marrow biopsiesskin biopsies, bone marrow biopsies APAAP methodAPAAP method Paraffin sectionsParaffin sections lymph nodes and other tumorslymph nodes and other tumors Immunoperoxidase methodImmunoperoxidase method Ventana Ventana
ImmunohistochemistryImmunohistochemistry
Panel of antibodiesPanel of antibodies B T OtherB T Other CD20 CD3 MIB-1CD20 CD3 MIB-1 CD79 UCHL-1 CD45CD79 UCHL-1 CD45 k/l CD43 CD68k/l CD43 CD68 LN1 CD4/CD8 CD30,CD15LN1 CD4/CD8 CD30,CD15
FLow cytometryFLow cytometry
Multiparameter analysisMultiparameter analysis Triple immunofluorescence:Triple immunofluorescence: CD14CD14//GPAGPA//CD45CD45
B TB T lambdalambda//kappakappa//CD20CD20 CD4CD4//CD8CD8//CD3CD3 CD22CD22//CD10CD10//CD20 CD20 CD7CD7//CD2CD2//HLA-DRHLA-DR CD23CD23//CD5CD5//CD19 CD19 CD16CD16//CD56CD56//CD3CD3
Flow cytometryFlow cytometry Other panelsOther panels
T cells Hairy cell leukemiaT cells Hairy cell leukemia
CD25/CD25/CD56CD56//CD3 CD3 CD103/ CD103/CD19CD19//CD20CD20 CD45RA/CD45RA/CD45ROCD45RO//CD4CD4 CD11c/ CD11c/CD19CD19//CD20CD20 CD45RA/CD45RA/CD45ROCD45RO//CD8 CD8 CD25/ CD25/CD19CD19//CD20CD20 CD62L/CD62L/CD4CD4//CD8CD8
Other methodsOther methods
DNA indexDNA index Feulgen staining on imprintsFeulgen staining on imprints PI staining by flowcytometryPI staining by flowcytometry Molecular methodsMolecular methods TCR rearrangementTCR rearrangement Heavy chain rearrangementHeavy chain rearrangement PCR for translocationsPCR for translocations
Chromosomal abnormalities in Chromosomal abnormalities in some NHL entitiessome NHL entities
CLL B tri 12, abn. 13qCLL B tri 12, abn. 13q mantle cell t(11;14) mantle cell t(11;14) bcl-1bcl-1 FCC t(14;18) FCC t(14;18) bcl-2 bcl-2 BurkittBurkitt t(8;14),t(8;22),t(2;8) t(8;14),t(8;22),t(2;8) C-mycC-myc CLL T inv.14(q11;32), tri.8CLL T inv.14(q11;32), tri.8 low grade T tri.3, 5 or +Xlow grade T tri.3, 5 or +X large cell anaplastic t(2;5)large cell anaplastic t(2;5)
Future clinical trialsFuture clinical trials Aggressive lymphomasAggressive lymphomas Dose intensity and dose sizeDose intensity and dose size High dose sequential therapyHigh dose sequential therapy
Indolent lymphomasIndolent lymphomas nucleoside analogs (CDA)nucleoside analogs (CDA) immunotherapyimmunotherapy monoclonal antibodiesmonoclonal antibodies antisense nucleotidesantisense nucleotides
Bone marrow ref.Bone marrow ref.
Tumors of the Bone MarrowTumors of the Bone MarrowBrunning R.D., McKenna R.W.Brunning R.D., McKenna R.W.
Armed Forces Institute of Pathology, Fasc. 9Armed Forces Institute of Pathology, Fasc. 9
Bethesda, MD, 1994Bethesda, MD, 1994
Pathology of Bone MarrowPathology of Bone MarrowNaeim F.Naeim F.
Igakuy-Shoin, New york, Tokyo 1992Igakuy-Shoin, New york, Tokyo 1992
Lymphomas ref.Lymphomas ref. Atlas of Lymphoid Hyperplasia and LymphomaAtlas of Lymphoid Hyperplasia and LymphomaFerry JA., Haris NL.Ferry JA., Haris NL.
WB. SAuders Co, Philadelphia, London etc. 1997WB. SAuders Co, Philadelphia, London etc. 1997
Extranodal LymphomasExtranodal LymphomasIsaacson PG., Norton AJ.Isaacson PG., Norton AJ.
Churchill Livingstone, Edinburgh, London etc., 1994Churchill Livingstone, Edinburgh, London etc., 1994
Thymus, Lymph Nodes, Spleen and LymphaticsThymus, Lymph Nodes, Spleen and LymphaticsHenry K., Symmers W.St C.Henry K., Symmers W.St C.
Churchill Livingstone, Edinburgh, London etc., 1992Churchill Livingstone, Edinburgh, London etc., 1992