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7/28/2019 jiwan_lymphoma_cyto.pptx

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Cytopathology presentation

Dr. Jiwan Kshetry

2070/2/30


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One Giemsa stained slide

Left supraclavicular lymph node of a 40 years

old male


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Slide description

Low power

Predominantly dispersed cells with some areas of

clustering

Background shows blood


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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


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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.


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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


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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.


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Cytomorphology

For and against RLH

+ _

Frequent mitoses Monotonous population of cells

Absence of apoptosis and tingible-bodymacrophages

Site


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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


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Cytomorphology

For and against T-LBL+ _

Age (any/adolescent) No tingible body macrophages

Frequent mitoses


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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


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T-Lymphoblastic lymphoma/leukemia

TdT , most often CD3 and CD7 positive, often CD4

and CD8 double positive or double negative


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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.


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Confirmatory diagnosis

Histology with immunohistochemistry


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Discussion


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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


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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.


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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.


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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.


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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.


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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.


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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


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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


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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).


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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.


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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.


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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.


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T-lymphoblastic


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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.


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Cytology:

The blasts are medium-sized with irregular nuclei

and basophilic sparse cytoplasm often with

vacuoles. Macrophages with tingible bodies are frequent.


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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.


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H&E


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CD20 and CD10


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CD20 and c-kit


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Thank U