Linfomas de Células B iniciales e

indolentes

Elías Campo

Hospital Clinic, University of Barcelona

Malignant Transformation of Cells a Multistep Process

Environment

Hereditary

Challenges to recognize early neoplastic steps in lymphoid neoplasias

– Physiologically circulating cells

– Colonization of multiple sites

– Clonal expansions, regulated and self limited

– Morphological and phenotypic overlap between benign and

malignant cells

• Highly sensitive methods

– Clonal cell expansions

– Aberrant phenotypes

– Oncogenic alterations

• Aberrant cells in blood, and tissues

without morphological or clinical

evidences of malignancy

Recognition of Early Steps in Lymphoid

Neoplasms

BCL2

CyclinD1

• Diagnostic criteria and terminology

– Lesions seems a continuum, where are the limits?

• Clinical and Biological Significance still not fully

understood

– Do all these lesions really progress to overt lymphomas?

– Proportion? Rate?

– Can we predict which lesions will progress?

– How should we manage these individuals?

Challenges in Early Lymphoid Lesions

“Early” lymphoid lesions

• Atypical Lymphoid Hyperplasias

– Follicular hyperplasias with IG light chain restriction

– Atypical marginal zone hyperplasia

– Florid reactive lymphoid hyperplasias of the lower female genital tract

• Lymphoid proliferations with features of lymphoid neoplasias

without morphological or clinical evidences of overt neoplasias

– Monoclonal B-cell lymphocytosis

– “In situ” FL/intrafollicular neoplasia

– “In situ” MCL

Follicular Hyperplasias with IG Light-Chain Restriction

• Incidence ~ 1%

• Clinical Presentation – Localized or multiple (LN, tonsil)

– Autoimmune disorders

• Pathology

– Follicular Hyperplasia with monotypic cells (

– Plasma cell differentiation

• Molecular – Clonal IGH (not all)

– t(14;18) negative, BCL2 expression usually negative

– EBV negative

• Follow-up – No evidence of lymphoma 1-6 years (Most cases)

Kussick SJ et al Am J Clin Pathol 2004 Nam-Cha SH Histopathology 2008

λ

κ

Atypical Marginal Zone Hyperplasia

• Clinical Presentation

– Children

– Extranodal lymphoid sites (Appendix/ Tonsil)

• Pathology

– Expansion of large cells in MZ & Intraepithelial B-cells

– Lambda chain restriction; CD43 +; CD27 -

– Polyclonal IG gene pattern; Unmutated IGHV

• Follow-up: No lymphoma after median follow-up 35 months

Attygalle AD et al Blood 2004

λ κ

λ κ

Florid Reactive Lymphoid Hyperplasias of the Lower

Female Genital Tract

• Clinical Presentation

– Young women

– Superficial lesions in cervical and

endometrial mucosas without

forming tumor masses

• Pathology

– Dense lymphoid infiltrate with large

cells

– Polyclonla plasma cells

– Clonal IG gene rearrangement in 45%

of cases

• Follow-up: No lymphoma after

median follow-up 3.5 years

Geyer et al Am J Surg Pathol 2010

Courtesy of Dr J Ferry

CLL Diagnostic Criteria

1996 NIH Guidelines • Lymphocytes> 5x109/L

2008 iWCLL, WHO • B-Cell >5x109/L

0

5

10

15

20

B clonal (x109/L) Lymphocytes (x109/L)

Monoclonal B-cell Lymphocytosis Definitions and Subtypes

• CLL-like

CD5+, CD20(dim), Ig(dim)

• Atypical CLL

CD5+, CD20(bright) or CD23-

• Non-CLL

CD5-, CD20+

CLL-like

Atypical CLL

Non-CLL

• B-cells ≤ 5000 x 109/L

• Monoclonal

– Κ:λ < 0.3:1 or > 3:1

– 25% lacking surface IG

• Absence of other lymphoproliferative disorders or autoimmune disease

Monoclonal B-cell Lymphocytosis

• CLL-like MBL – More frequent in family members of CLL patients (4-8-fold increase in risk)

– Virtually all cases of CLL are preceded by MBL, often for years (Landgren

2009)

– Same genetic risk variants (SNP) in MBL and CLL (Crowther-Swanepoel 2010)

– 70-90% Mutated genes, Del(13q) 48%, Tri12 (20%)

• CD5- Monoclonal B-cell lymphocytosis (Non-CLL MBL) – Hypermutated Ig with different family gene use

– Associated genetic alterations i(17q); del (7q)

Marti GE et al Br J Haematol 2005, Rawstron A et al N Engl J Med 2008;

Shanafelt et al Leukemia 2010; Amato D et al Am J Clin Pathol 2007

CLL-like Monoclonal B-cell Lymphocytosis Prevalence and Subtypes

• Low lymphocyte and B cell counts (<50/μl)

• Detection only with sensitive methods

• No high risk cytogenetic alterations

• Very low risk of progression

• No indication to monitor even if detected

incidentally

• High lymphocyte and B cell counts (>2000/μl)

• Lymphocytosis

• High risk cytogenetic alterations (5-9%)

• Annual Progression requiring treatment 1-

2%

• Clinical monitoring

Low count MBL Clinical MBL

Karube K et al Sem Cancer Biol 2013c

Clinical course (at least one year follow-up) of high-count and low-count MBL

Diagnosis Case

number

Sex

(M:F)

Age

(median)*

Observation period

(median, years)*

Case number with

development of CLL requiring

treatment

Time to first treatment

(median, years)* Reference

High-count

MBL 185 9.3:10 71 (39-99) 6.7 (0.2-11.8) 13/185 (7%) 4.0 (1.1-10.1) 18

302 13.8:10 69 (34-93) 1.5 (0.0-8.1) 7/302 (2.3%) Not reached 19

123 9.5:10

68

(59-75)** 3.5 (n.r.-n.r.) 19/123 (15.4%) Not reached 53

124 9.3:10 65

(32-100) 3.9 (0.2-10.0) 19/124 (15.3%) Not reached 54

184 11.9:10

64

(56-70)** 3.8 (0.0-25.5) 24/182 (13.2%) Not reached 23

Low-count

MBL 54*** 18.4:10 66 (40-92) 2.8 (0.9-4.2) 0/54 (0%) n.a. 11

MBL, monoclonal B cell lymphocytosis; CLL, chronic lymphocytic leukemia; M, male; F, female;*range; **25th-75th percentiles; n.r. not reported;

n.a. not applicable; ***CLL-like MBL

Karube et al Sem Cancer Biol 2013 (In press)

“In situ” Follicular Lymphoma/Intrafollicular Neoplasia

CD10 Bcl-2

FL “in situ”

• Prior or synchronous FL (6/34)

• Overt lymphoma (1/21) follow-up: median: 41m range,

10-118m

• Differential diagnosis: partial Involvement by FL

Cong P, et al. Blood 2002

Montes-Moreno S et al Histopathology 2010

Jegalian AG et al Blood 2011

Adam P et al AJSP 2005 Cong P et al. Blood 2002

“In situ” vs Partial Involvement in FL

“In situ” FL/ Intrafollicular

Neoplasia

Partial involvement by FL

Preserved general architecture Partial effacement of the architecture

Centrocytes + for BCL2 and CD10

within GC stronger than in mantle cells

or reactive T-cells

Affected follicles usually restricted to

a limited region of the lymph node

Involved follicles usually scattered,

not confluent

Tumor cells may be present in

interfollicular areas

Germinal centers normal in size and

often not completely replaced by BCL-

2+ cells

Germinal centers expanded in size

and completely replaced by tumor

cells

t(14;18) Translocation in Healthy Individuals

• 79% of healthy individuals had the t(14;18)

– Increase with age

– Multiple clones but usually one predominant

– Persistent in time (> 3yr)

– Progression in some cases but also regression in minor clones

– Increased prevalence in HVC-infected patients and pesticide exposure

• B-cells carrying the t(14;18) are germinal center derived with genotypic and phenotypic features of FL cells

Roullard S et al InJ Cancer 2003, J Exp Med 2006, Agopian et al J Exp Med 2009

in situ FL in reactive lymph nodes

3/132 (2.3%) Henopp et al Histopathology 2012

2/100 (2%) Carvajal-Cuenca et al Haematologica 2012

MCL with Minimal LN Involvement

• “Waxing Wannig Nodes

• Peripheral Blood involvement

• CD5 - and CD5 +

• IGHV < 96% homology

• del(3)(p12); inv(8)(p21;q22)

• No treated

• AWD 12 years

• Incidental nodal finding

• Peripheral Blood involvement

• CD5 -

• IGHV <94% homology

• No secondary genetic aberrations

• No treated

• AWD 5 years

Nobit et al Hum Pathol-03 Espinet et al Hum Pathol-06

Cyclin D1

Cyclin D1

Cyclin D1 Cyclin D1 Cyclin D1

In situ vs Mantle Zone Pattern in MCL

“In situ” MCL Mantle zone pattern in MCL

Preserved general architecture Architecture preserved or focally effaced

Mantle zones usually not expanded Mantle zones usually expanded

Cyclin D1+ cells restricted to the mantle

zones of reactive follicles with only

scattered positive cells in interfollicular

areas

Cyclin D1 + cells replace virtually all the

mantle zone of reactive follicles

Cyclin D1 + cells tend to accumulate in the

inner layers of the mantle zone. Not all

mantle cells are positive

Focal extension of clusters of tumor cells

into interfollicular areas may be seen.

Mantle zones of different follicles may

merge

“In situ” MCL 17 cases ( 7 previously published)

• Male/Female 9/8

• Age median 64 y (range 41-84)

• Location at diagnosis

– Solitary LN 10

– LN several sites 2

– Extranodal 5

• Bone Marrow, Peripheral blood 3/7

• Follow-up

– 6 W&W

• 1 Progression to overt MCL (4 years)

• 4 Alive with stable (3) or no disease (1) (med 8 yr; range 5-19)

• 1 Dead, unrelated cause (1.4 y, 84 year-old)

– 2 Chemotherapy Alive No Disease 4 yr

– 1 Rx Alive no Disease > 2 yr

• “In situ” MCL found incidentally 3 yrs after a classical MCL in complete remission

Carvajal et al Haematologica 2012

Associated Lymphoid Proliferations in “in situ” MCL

Roullet Am J Clin Pathol 2009

CD10 t(11;14 CD10 t(14;18)

SOX11 Cyclin D1

• Associate lesions 7/17 (41%) – “In situ” FL 2

– MZL 2

– CLL 2

– Castleman Disease 1

t(11;14) Translocation in Healthy Individuals

• 6/71 healthy individuals had the t(11;14) (8%)

– Median age 41 yr (Range 27-53)

– Number of clones 4 -1.7 x 10-7

– Clones persisted 7-9 years

– The clone expanded in 2 patients (3-10x), no new clones

• The t(14;18) translocation found in 35/71 (49%) healthy individuals (1 x 10-5 Clones)

• Five of the 6 (83%) patients with the t(11;14) also had clones with t(14;18)

Lecluse et al Leukemia 2009

in situ MCL in reactive lymph nodes

0/132 Henopp et al Mod Pathol 2012

0/100 Carvajal-Cuenca et al Haematologica 2012

Circulating

lymphocyte

t(11;14)

Cyclin D1

Long Latency Periods in the Progression of MCL

≥ 12 yrs

Classical

MCL

Christian B et al JCO 2010

Circulating

lymphocyte

“In situ”

MCL

Classical

MCL

t(11;14)

Cyclin D1

Long Latency Periods in the Progression of MCL

Christian B et al JCO 2010, ASH 2010, Carvajal et al Haematologica 2012

≥ 12 yrs

2-15 yrs

Residual

“In situ”

MCL

Chemotherapy

2 yrs

Clinical course (at least one year follow-up) of in situ

FL or MCL without overt lymphomas at diagnosis

Diagnosis Cases Sex

(M:F)

Age

(median)

Observation

period

(median, mths)

Case number with

development of

overt FL/MCL

Time to progression

to overt FL/MCL

(median, mths)

In situ

FL 33 13:20 53 (23-85) 40 (12-132) 2/33 (6%) 22 (15-29)

In situ

MCL 15 7:8 70 (29-84) 36 (12-234) 1/15 (7%) 48 (48-48)

Karube et al Sem Cancer Biol 2013 (In press)

Fend F et al J Haematopatol 2012

in situ involvement by FL/MCL-like cells (of uncertain significance)

“Early” Neoplastic Lymphoid Lesions

• Morphology Reactive /Atypical

• Monotypic, No clonal

• Some lesions clonal

• Clinically self-limited

• Almost never progress

Overt Lymphoid

Neoplasia

Atypical Lymphoid Hyperplasias

Clinically Detected

Lesion

Research Detected

Clonal Population

Gen Pop MBL

Clonal B-cells

t(14;18) / t(11;14)

Clinical MBL

“In situ” FL/ MCL

?

• Increased recognition of lesions with pathological features shared by lymphoid neoplasias

• Atypical lymphoid hyperplasias (Virtually no malignant progression )

• Clonal lymphoid proliferations with features of malignant cells (CLL, FL, MCL)

– Detected in research studies (highly sensitive methods)

– Detected in clinical practice (incidental or mild clinical findings)

• Potential to progress to malignancy low or very low but not absent

• Terminology

– “Clinical “Monoclonal B-cell lymphocytosis

– FL or MCL-like B-cells of undetermined significance (Uppsala Workshop)

• Clinical monitoring

Conclusions

Acknowledgments

Hospital Clínic, Barcelona

Alejandra Carvajal, Luz Sua, Nhora Silva,

Cristina Royo, Silvia Bea, Luis Colomo

Hospital de Bellvitge, Barcelona

Fina Climent

Hospital del Mar Barcelona

Blanca Espinet, Francisco Solé, Sergi Serrano

NCI, Bethesda, MD

Elaine S Jaffe, Stefania Pittaluga, Mark Raffeld

University of Pittsburg

Rachel L Sargent, Samuel Jacobs, Steven Swerdlow

Oslo University Hospital

Jan Delabie

Hammersmith Hospital, London

Naresh Kikkeri

Stanford University

Roger Warkne

University of Pennsylvania, Philadelphia Adam Bagg

Brigham & Women’s Hospital, Boston MA

Jeffery L Kutok MGH, Boston

Nancy L Harris, Judith Ferry Purpan Hospital, Toulousse

Pierre Brousset

SOX11 Expression Identifies Two Subtypes of MCL

SOX11

SOX11 Cyclin D1

Conventional

MCL

Indolent

MCL

0 2 4 6 8 10 12 14 16

YEARS

0

.2

.4

.6

.8

1

PR

OB

AB

ILIT

Y

SOX11 -

SOX11 +

Fernandez V et al Cancer Res 2010

Indolent MCL

> 2 yr no tratment

Conventional

MCL

Cyclin D1 SOX11

Cyclin D1 SOX11

SOX11 in “in situ” MCL

SOX11 +

n=7 (44%)

SOX11 –

n=9 (56%)

Male 5/7 (71%) 3/9 (33%)

Age 65 (42-82) 60 (41-84)

Peripheral Blood + 0/2 2/5

CD5 - 2/5 5/9

t(11;14) 2/2 6/6

Overt MCL 2

1, 4yr after isMCL

1, 3 yr post cMCL

0

Follow-up > 1 yr 3 5

Alive > 4 yr 2 (Chemo) 4 (untreated)

5-19 years

Carvajal et al USCAP 2011

CLL-like Monoclonal B-cell Lymphocytosis Prevalence and Subtypes

• Low lymphocyte and B cell counts (<50/μl)

• Detection only with sensitive methods

• No high risk cytogenetic alterations

• Very low risk of progression

• No indication to monitor even if detected incidentally

• High lymphocyte and B cell counts (>2000/μl)

• Lymphocytosis

• High risk cytogenetic alterations (5-9%)

• Annual Progression requiring treatment 1%

• Clinical monitoring

General Population MBL Clinical MBL

“in-situ” FL/ Intrafollicular Neoplasia BCL2+ t(14/18)+ follicles in reactive LN

• Synchronous FL 8/36 (22%) (Related to the extension of the lesion)

• Subsequent FL 4/26 (15%) (3-72 months)

• No development of overt lymphoma (26) 3-72 months (Median follow-up 12-

15 months)

Cong P et al. Blood 2002; Montes-Moreno S et al Histopathology 2010

Courtesy of P Ghia, Dagklis A et al Blood 2009

CLL-like General Population MBL may

not be a CLL Precursor

• Different IGHV gene family usage (Mutated 71% )

• Only 2/51(4%) stereotyped IGVH genes (CLL 30%)

• Detection of biclonal or oligoclonal populations

• Absolute B-cell count at diagnosis predicts evolution of MBL as a

continuous variable and also different cut-offs

• 1% of individuals per year will require treatment for progressive CLL

• Progression to need for treatment is slower in MBL than in Rai 0 CLL

• Not clear influence on overall survival

Progression in MBL