jiwan_lymphoma_cyto.pptx
-
Upload
narendra-bhattarai -
Category
Documents
-
view
216 -
download
0
Transcript of jiwan_lymphoma_cyto.pptx
-
7/28/2019 jiwan_lymphoma_cyto.pptx
1/51
Cytopathology presentation
Dr. Jiwan Kshetry
2070/2/30
-
7/28/2019 jiwan_lymphoma_cyto.pptx
2/51
One Giemsa stained slide
Left supraclavicular lymph node of a 40 years
old male
-
7/28/2019 jiwan_lymphoma_cyto.pptx
3/51
Slide description
Low power
Predominantly dispersed cells with some areas of
clustering
Background shows blood
-
7/28/2019 jiwan_lymphoma_cyto.pptx
4/51
High power:
Predominantly composed of lymphoid cells, nearly
uniformly dispersed in a background of blood,
slightly increased in size (~1.5 times normallymphocyte)
These cells have scant amount of cytoplasm in one side
of the nucleus
Nuclei of some of these are cleaved while most cells
have round, non-cleaved nuclei
Chromatin is condensed with inconspicuous nucleoli
-
7/28/2019 jiwan_lymphoma_cyto.pptx
5/51
Larger cells are present in small number
These cells have finer chromatin but nucleoli are
inconspicuous
Mitosis are frequent among the larger cells
Necrosis and apoptosis are absent
Tingible body macrophages are absent but some
dendritic reticulum cells are seen.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
6/51
The cell clusters are composed of poorly
preserved cells whose morphology is not clear
(pseudo-clustering)
Background also shows plenty of bare nuclei andlymphoglandular bodies
Small lymphocytes and neutrophils are also seen.
Some of the neutrophils show finely vacuolated
bluish cytoplasm
-
7/28/2019 jiwan_lymphoma_cyto.pptx
7/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
8/51
Approach to diagnosis
Cytomorphology ( pap stain missing)
Flow cytochemistry
Immunocytochemistry Molecular cytogenetics
A complete blood count can also be useful.Presence of enlarged lymph nodes in other
areas has to be checked for.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
9/51
Cytomorphology
For and against RLH
+ _
Frequent mitoses Monotonous population of cells
Absence of apoptosis and tingible-bodymacrophages
Site
-
7/28/2019 jiwan_lymphoma_cyto.pptx
10/51
Cytomorphology
For and against FL
+ _
Monotonous population of slightly
enlarged, often cleaved lymphoid cells
Frequent mitoses
Absence ofapoptosis and tingible-body
macrophages
Condensed chromatin with inconspicuous
nucleoli in the centrocytes
Relatively low no. of small lymphocytes
-
7/28/2019 jiwan_lymphoma_cyto.pptx
11/51
Cytomorphology
For and against T-LBL+ _
Age (any/adolescent) No tingible body macrophages
Frequent mitoses
-
7/28/2019 jiwan_lymphoma_cyto.pptx
12/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
13/51
Immunocytochemistry
FL: Monoclonality shown by staining for Ig chains
+ve for CD19, cD20, CD10, BCL-2, BCL-6
Aberrant CD5 expression in floral variant
RLH: Presence of cells of both B and T cell lineage in
logical proportions
Polyclonality of the cells
MCL: +ve for CD19, Cd20, Sig, CD5, FMC7, cyclin-D1
-ve for CD10 and CD23
-
7/28/2019 jiwan_lymphoma_cyto.pptx
14/51
T-Lymphoblastic lymphoma/leukemia
TdT , most often CD3 and CD7 positive, often CD4
and CD8 double positive or double negative
-
7/28/2019 jiwan_lymphoma_cyto.pptx
15/51
Cytogenetics
FL:
t(14;18) in over 90% of cases
MCL:
t(11;14) in almost all cases
T-lymphoblastic lymphoma/leukemia
50-70% have abnormal karyotype.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
16/51
Confirmatory diagnosis
Histology with immunohistochemistry
-
7/28/2019 jiwan_lymphoma_cyto.pptx
17/51
Discussion
-
7/28/2019 jiwan_lymphoma_cyto.pptx
18/51
Reactive Lymphoid Hyperplasia
Non-specific hyperplasia yields a cytological pattern onFNA which depends on the proportions of follicular andinterfollicular tissue in the aspirate, and this in turnusually correlates with the histological findings.
Thus, smears from a node composed predominantly oflarge follicles with active germinal centres containmany centroblasts and centrocytes, while theinterfollicular tissue is comparatively sparse and
represented by mature lymphocytes, plasma cells andimmunoblasts
-
7/28/2019 jiwan_lymphoma_cyto.pptx
19/51
In extreme cases, the pattern may mimic a
mixed lymphoma of centroblastic/centrocytic
type.
The presence or absence of tingible body
macrophages is of little diagnostic value.
Immunocytochemical evaluation of the
lymphoid population may be the only way to
resolve this diagnostic problem.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
20/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
21/51
In contrast, when interfollicular tissue predominates, thesmears are rich in lymphocytes, plasma cells,lymphoplasmacytoid cells and some immunoblasts.
Such smears are difficult to differentiate from those of alow-grade lymphoma.
Analysis of light chain immunoglobulin restriction is usuallyrequired to arrive at a conclusive diagnosis.
Some conditions lead to a cytological pattern which clearlydeviates from the general types described above.
A description of the best recognised of these will be donehere
It is important to remember that definitive diagnosis isdependent on good clinical correlation.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
22/51
HIV infection
Generalised lymphadenopathy is common in patientswith acquired immunodeficiency syndrome (AIDS).
There is a florid follicular hyperplasia with immaturefollicle centre cells in a background of maturelymphocytes, plasma cells and macrophages .
Immunoblasts are always present.
The pattern is non-specific and thus not diagnostic forAIDS.
The lymphoid cells are mostly polyclonal B cells butsome mature T cells are also present.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
23/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
24/51
Infectious mononucleosis
Infectious mononucleosis can also causelymphadenitis, which is mainly confined to theinterfollicular tissue
Cytologically, it is characterised by numerousimmunoblasts, some of which are atypical withlarge irregular nuclei.
In rare cases the pattern may even be suggestiveof Hodgkins disease.
Serological tests can be helpful, but phenotypingof the atypical cell population may be the onlyway to rule out a lymphoma.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
25/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
26/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
27/51
Dermatopathic lymphadenopathy
This is a special variant of reactive lymphadenitis whichis observed in patients with chronic skin disorders suchas psoriasis or dermatitis.
The germinal centres are hyperplastic and the
interfollicular tissue is expanded by cells of histiocyticappearance.
Smears from such lymph nodes show numerous smalllymphocytes, plasma cells, eosinophils and occasionalblast cells.
There are numerous histiocyte-like cells, also known asinterdigitating reticulum cells, with pale indistinctcytoplasm.
Macrophages containing brown melanin pigment from
the damaged skin are always present.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
28/51
WHO classification of B-cell neoplasms and
Precursor B-cell neoplasm
Precursor B lymphoblastic leukaemia/lymphoma
Mature B-cell neoplasms
Chronic lymphocytic leukaemia/small lymphocytic lymphoma[
B-cell prolymphocytic leukaemia Lymphoplasmacytic lymphoma] Splenic marginal zone lymphoma Hairy cell leukaemia Plasma cell myeloma
Monoclonal gammopathy of undetermined significance (MGUS) Solitary plasmacytoma of bone Extraosseous plasmacytoma Primary amyloidosis Heavy chain diseases
http://www.expertconsultbook.com/expertconsult/b/linkTo?type=bookPage&isbn=9780702031540&eid=4-u1.0-B978-0-7020-3154-0..00013-2--fn1&appID=NGEhttp://www.expertconsultbook.com/expertconsult/b/linkTo?type=bookPage&isbn=9780702031540&eid=4-u1.0-B978-0-7020-3154-0..00013-2--fn1&appID=NGEhttp://www.expertconsultbook.com/expertconsult/b/linkTo?type=bookPage&isbn=9780702031540&eid=4-u1.0-B978-0-7020-3154-0..00013-2--fn1&appID=NGE -
7/28/2019 jiwan_lymphoma_cyto.pptx
29/51
Extranodal marginal zone B-cell lymphoma ofmucosa-associated lymphoid tissue (MALT-lymphoma) Nodal marginal zone B-cell lymphoma Follicular lymphoma
Mantle cell lymphoma Diffuse large B-cell lymphoma Mediastinal (thymic) large B-cell lymphoma Intravascular large B-cell lymphoma Primary effusion lymphoma
Burkitt lymphoma/leukaemia
B-cell proliferations of uncertain malignant potential
Lymphomatoid granulomatosis Post-transplant lymphoproliferative disorder
-
7/28/2019 jiwan_lymphoma_cyto.pptx
30/51
Follicular lymphoma
The predominating cell is the medium-sized centrocytewhich has little cytoplasm and an irregular cleaved orangulated nucleus.
These cells have a scant cytoplasm and may seem to
form aggregates.
Centroblasts are present but the proportion varies.
Follicular lymphomas are subdivided into Grade I,Grade II and Grade III based on the proportion of largecells present histologically. (Grade I has 05, Grade II 615 and Grade III >15 centroblast/high power field,respectively).
-
7/28/2019 jiwan_lymphoma_cyto.pptx
31/51
Other cell types present in follicular lymphomasare small mature non-neoplastic lymphoid cells,macrophages and epithelioid cells.
A smear with a high number of non-neoplastic
cells may be impossible to differentiate fromreactive lymphadenopathy unlesscytomorphology is complemented byimmunocytochemical evaluation.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
32/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
33/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
34/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
35/51
Immunocytochemistry
The B-cell lineage of these tumour cells is readily identifiedby expression of CD19, CD20 and CD79a.
Light chain restriction can usually be demonstrated as wellas positive staining for CD10.
Expression of BCL-2 is seen in a majority of cases. Mature reactive T cells are present, and may constitute up
to 50% of the lymphoid population.
The proliferation fraction in the neoplastic B-cells variesconsiderably from case to case. Figures below 5% are
seldom seen but in occasional cases up to 75% of theneoplastic population may react positively to proliferationmarkers.
Such cases show aggressive behaviour and should betreated as high-grade lymphomas irrespective of their
cytological grading.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
36/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
37/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
38/51
Immunocytochemistry
The cells are of B phenotype (CD20) with lightchain restriction.
In addition the cells are consistently CD5 and
CD43 positive and most often CD10 negative. All cases express Cyklin D1 and bcl-2.
The fraction of proliferating cells is usually low,around 10% as measured by Ki-67 (Mib-1).
The blastoid variant has a high proliferation rate.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
39/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
40/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
41/51
T-lymphoblastic
-
7/28/2019 jiwan_lymphoma_cyto.pptx
42/51
T-lymphoblasticleukaemia/lymphoblastic lymphoma
Both the leukaemia and lymphoma are most
frequent among adolescent males.
The leukaemia often presents with a
mediastinal mass, which is also the site of
predilection for the lymphoma.
A majority of the patients have long survival
and many are cured.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
43/51
Cytology:
The blasts are medium-sized with irregular nuclei
and basophilic sparse cytoplasm often with
vacuoles. Macrophages with tingible bodies are frequent.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
44/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
45/51
Immunocytochemistry
Most cells are CD3 and CD7 positive while other T-
cell markers are variably expressed.
TdT is expressed in all cases.
CD10 may be expressed.
The proportion of proliferating cells is high.
-
7/28/2019 jiwan_lymphoma_cyto.pptx
46/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
47/51
-
7/28/2019 jiwan_lymphoma_cyto.pptx
48/51
H&E
-
7/28/2019 jiwan_lymphoma_cyto.pptx
49/51
CD20 and CD10
-
7/28/2019 jiwan_lymphoma_cyto.pptx
50/51
CD20 and c-kit
-
7/28/2019 jiwan_lymphoma_cyto.pptx
51/51
Thank U