2. Case summary
Mr. Salim , 62 year old , history of right sided neck
swelling , , swelling in his left inguinal region , lost 7-
8 kg in past 3 months , physical examination
findings : right cervical + left inguinal LNs size 1.5-
2.5 cm , LDH was elevated , biopsy: NHL ,
CD19/CD20/CD45 +ve ; diagnosed with diffuse
large B cell NHL , treated with rituximab and CHOP.
3. Objectives
1 - lymphadenopathy ; generalized and
localized causes
2 - anatomy of lymphatic
system+histology -
3 - cat scratch and lymph node swelling
4 - criteria for significant weight loss
and relation between cancer and weight
loss
5 - physical examination of Lymph
nodes
6 - difference between lymphomas and
leukemias
7 - lymphoma
* difference between HL and NHL
* types
* signs and symptoms
* investigation
* grading and staging + pathogenesis
* risk factors / prognosis / follow up
* treatment
8 - EBV / toxoplasma / brucella
9 - B cell development
10 - BCL6/B2 microglobulin --
8. Cat scratch disease
Caused by: Bartonella henselae or Bartonella quintana
Usually in children 1-2 weeks following a scratch/bite from a cat
Presents as tender, swollen LN near site of bite/scratch and limited
to 1 side (regional lymphadenopathy). May have a erythematous
papule at the site, also have systemic symptoms (malaise, decreased
appetite, aches)
Course is benign and self-limiting, resolves spontaneously with or
without treatment after 1 month, but the lymphadenopathy may
persist for a few months even after the other symptoms disappear.
Best diagnosis by PCR, can also use Warthin-Starry stain.
9. What is the difference between
leukemia ad lymphoma ?
10.
11. Subtype Morphology & Immunophenotype
Nodular sclerosis (65-70%) Frequent lacunar cells and occasional diagnostic RS cells;
background infiltrate composed of T lymphocytes, eosinophils,
macrophages & plasma cells; fibrous bands dividing cellular
areas into nodules. RS cells CD15+, CD30+; EBV -
Mixed cellularity (20-25%)
Frequent mononuclear and diagnostic RS cells; background
infiltrate rich in T lymphocytes, eosinophils, macrophages,
plasma cells; RS cells CD15+, CD30+; 70% EBV+
Lymphocyte rich
Frequent mononuclear and diagnostic RS cells; background
infiltrate rich in T lymphocytes; RS cells CD15+, CD30+; 40%
EBV+
Lymphocyte depletion
<(5%)
Reticular variant: Frequent diagnostic RS cells and variants and a
paucity of background reactive cells; RS cells CD15+, CD30+;
most EBV+
Lymphocyte predominance
(5%)
Frequent L&H (popcorn cell) variants in a background of follicular
dendritic cells & reactive B cells; RS cells CD20+, CD15-, C30-;
EBV-
Hodgkin Lymphoma
13. 1. Indolent lymphomas(low grade)
– Follicular center lymphomas
– Small lymphocytic lymphomas
– Lymphoplasmacytoid lymphoma
– Mycosis fungoides
– Marginal zone lymphoma (MALT)
2. Aggressive lymphomas (high grade)
– Diffuse large B-cell lymphoma
– Anaplastic large cell lymphoma
– Follicular center cell lymphoma
– Mantle cell lymphoma
– Lymphoblastic lymphoma
– Burkitt’s lymphoma
13
14. Risk factors for non-hodgkin lymphoma
• Age: 60+
• Gender: male
• Race: whites > african/asian americans
• Exposure to chemicals: benzene, herbicides, insecticides,
treatment with chemotherapy for hodgkin disease
• Radiation exposure
• Immune deficiency (HIV, immunosuppressant after organ
transplant)
• Autoimmune disease (SLE, RA, celiac sprue)
• Infections: (HTLV-1, EBV, HHV8 act directly) and ( H. pylori,
Chlamydophila psittaci, C. jejuni, HCV, treat these with
antibiotics and the lymphoma is usually treated)
• Obesity and high fat diet
15. • Morphology
– Lymph nodes proliferation have a nodular appearance
– Predominantly small cleaved cells (centrocyte like cells) with
condensed chromatin and indistinct nucleoli admixed with variable
number of centroblast like cells (larger, vesicular chromatin, several
nucleoli, modest amount of cytoplasm)
• Immunophenotype & molecular features
– Pan-B- Cell markers : CD19, CD20, CD10
– BCL6 (transcription factor that’s required for follicular center formation)
– BCL2 (characteristic, absent in normal follicular B cells, functions to prevent
apoptosis, protects the tumor cells from the effects of chemo agents)
• Karyotype
– t(14;18) translocations
40% progresses to diffuse large B-cell lymphoma
15
16. • Morphology
Nuclei are 3-4x larger & can take a variety of forms, it can resemble
either:
– Centroblasts
• Round, irregular, cleared nuclear contours,
• dispersed chromatin,
• distinct nuclei
• > pale cytoplasm
– Immunoblasts
• Large, round multilobulated vesicular nucleus
• 1 or 2 central nucleoli
• Pale or intensely staining cytoplasm
16
17. • Immunophenotype & molecular features
These are mature B-cell tumors that express
– Pan-B-Cell antigen; CD19, CD20
– Variable expression of ;IgM, IgG, CD10
• Karyotype
– 30% t(14;18) translocation involving the BCL2 gene (represents
transformed follicular lymphomas)
– 1/3rd rearrangements of the BCL6 genes and mutations. (this leads to and
increase in BCL6 protein levels)
• Distinct subtypes
– AIDS, Immunosppression (iatrogenic -> transplants)EBV driven
polyclonal Bcell proliferation large B-cell lymphoma
– KSHV/HHV-8primary effusion lymphomas; pleura, pericardium,
peritoneum.
– Medistinal large Bcell lymphoma young females, abdominal
visera/CNS
17
18. • Morphology
– Involve LN in a diffuse /vaguely nodular pattern
– Tumor cells:
• Larger than normal lymphocytes
• Irregular nucleus
• Inconspicuous nucleoli
– Majority of cases Bone marrow spread
– 20% with peripheral blood involvement
– Characteristic: association of GIT (in the form of multifocal submucosal
nodules that resemble polyps-lymphatoid polyposis-)
• Immunophenotype & MF
– Tumor cells co-express surface IgM, IgD.
– Pan-B-cell Antigens CD19, CD20, CD5.
• Karyotype
– t(11;14) translocation.
18
19. Affects children /young adults.
o African variety (endemic): jaw tumor, strongly linked to EBV infection
o Sporadic type – worldwide- :(abdominal) bowel, retro-peritoneum
and Ovary
• Morphology
– Tumor cells; uniform intermediate in size
– Round/oval nuclei (2-5 prominent nucleoli)
– Characteristic:
• high mitotic rate & cell death.
• “Starry-sky” pattern macrophages surrounded by clear
space.
• Karyotype
– t(8;14), t(2;8), t(8;22)
19
21. EBV
• Epstein-Barr virus
• belongs to Herpesviridae
• transmission by close intimate contact
• infect B lymphocytes
• cause Infectious mononucleosis
• lymphocytes become 60-80% of TWBC –
30% are atypical lymphocytes – T cytotoxic
• establish latency
• immortalization of B cells
• first human virus related to malignancy
22. Virion Structure
• like all herpesvirus virions, it
has four structural elements
– envelope
– tegument
– capsid
– core
• single liner double-stranded
DNA
• replicate in the nucleus
23. Epidemiology
• the virus occurs worldwide
• most people become infected with EBV
sometime during their lives
• children become infected with EBV – usually
asymptomatic
• when adults get infected they present with IM –
increase severity of infection - 50% of the time
• transmission of EBV requires intimate contact
with the saliva
• kissing disease
24. EBV and malignancies
• Associated with Burkitt
lymphoma
• Unique malignancy of jaw, in
children in equatorial Africa
• BL cells contain one of the three
chromosome translocations
• C-myc proto-oncogene on
chromosome 8 is activated
• Malaria and HIV are known risk
factors for BL
NIHAR DASH/College of Medicine/UOS 24
25. EBV and malignancies
• Nasopharyngeal carcinoma
• in china, southeast Asia, North
Africa
• no chromosomal alteration
• cells involved are epithelial cells
28. NHL clinical presentation
Low-grade
• Painless, slowly progressive
peripheral
lymphadenopathy.
• Primary extranodal
involvement and systemic
symptoms in patients with
advanced or end-stage
disease.
• Bone marrow: cytopenia.
• Splenomegaly,
Hepatomegaly
Intermediate- and high-
grade
• rapidly growing and bulky
lymphadenopathy.
• Systemic symptoms and
extranodal involvement
• Hepatomegaly,
splenomegaly.
• Obstructive hydronephrosis
• Primary CNS lymphomas:
more commonly in patients
with immunodeficiency
• Testicular mass.
29. Skin lesions: associated with cutaneous T-cell lymphoma
& anaplastic large-cell lymphoma
Lymphoblastic lymphoma: mediastinal mass, superior
vena cava syndrome, and meningeal disease with cranial
nerve palsies.
Burkitt's lymphoma: large abdominal mass and symptoms
of bowel obstruction.
30. Physical Examination
This Is the link if you want to check it out
http://qap.sdsu.edu/resources/tools/pdf/lymphnode.pdf
31. Investigations
• CBC , peripheral smear and platelet count
• Metabolic assessment: ESR, LFT, U&E
• LDH, B2 Microglobin
• Serum protein electrophoresis : monoclonal gammopathy
• Serology for infections : HIV, EBV and Toxoplasma
• ANA
Laboratory tests
• CT scan
• PET scan
• MRI (localized )
Imaging
• Core needle biopsy for retroperitoneal area
• Excisional biopsy
Lymph node Biopsy
32. • T cells : CD 5, CD 3 (-)
• Mantle cell lymphoma : cyclin-D
• B cells: CD 19, CD 20 (+)
• Pan leukocyte ag : CD45 (+)
Flow cytometry
• Evaluation for Ig gene rearrangement , TCR
rearrangement or specific oncogenes (+)
Molecular studies (PCR/ FISH)
Culture
36. Staging tests
• Bone marrow biopsy
• CT scan
• MRI
• Ultrasound
• Spinal tap : 2 or more extranodal sites
involved with elevated LDH
• PET scan
• Bone scan
38. International prognostic index (IPI)
Tool to help predict prognosis of patients with aggressive non-Hodgkin’s lymphoma
One point is assigned for each of the following risk factors:
• Age greater than 60 years
• Stage III or IV disease
• Elevated serum LDH
• ECOG/Zubrod performance status of 2, 3, or 4
• More than 1 extranodal site
The sum of the points allotted correlates with the following risk groups:
• Low risk (0-1 points) - 5-year survival of 73%
• Low-intermediate risk (2 points) - 5-year survival of 51%
• High-intermediate risk (3 points) - 5-year survival of 43%
• High risk (4-5 points) - 5-year survival of 26%
This tool was developed before the use of Rituximab, which has greatly improved prognosis and therefore
they aren’t sure how it affects the validity of the tool.
39. Prognosis
5-year relative survival by stage at diagnosis
Stage at diagnosis
5-year relative
survival (%)
Percentage
of cases (%)
Localized (confined to
primary site)
82.1 27
Regional (spread to
regional lymph nodes)
77.5 19
Distant (cancer has
metastasized)
59.9 45
Unknown (unstaged) 67.5 9
This table was from the National Cancer Institute, USA, and was posted in 2010.
41. Lymphoid malignancies
• Hodgkin’s Lymphoma
– Pts with localized or good-prognostic factors brief course of
chemotherapy followed by radiotherapy
– Pts with more extensive dz or with B symptoms complete course of
chemotherapy
– Regimens:
1. ABVD: Doxorubicin, Bleomycin, Vinblastine, Dacarbazine
2. MOPP: Mechlorethamine, Vincristine, Procarbazine, Prednisone
3. Or combination of drugs from both regimens
4. Stanford V: weekly regimen for 12 weeks Mechlorethamine,
Vincristine, Vinblastine, Etoposide, Doxorubicin, Bleomycin,
Prednisone radiotherapy
5. Autologous BM transplant cure half pts who fail effective chemo
regimen.
42. Lymphoid malignancies
Low-grade disease, which may be asymptomatic and have no
significant effect on quality of life in some cases, often requires no
treatment or only intermittent treatment with oral chemotherapy. This
disease is not curable by chemotherapy alone.
Aggressive (high-grade) disease: R-CHOP (R =rituximab, an anti-CD20,
C=cyclophophamide, H= Hydroxydoxorubicin, O = oncovin = vincristine,
p=prednisone).
Treatment of Non- Hodgkin Lymphoma
43. . Diffuse Large B Cell Lymphoma
•CHOP plus rituximab.
•Patients with stage I or non bulky stage II can be effectively treated with
three to four cycles of combination chemotherapy followed by
radiotherapy.
•For patients with bulky stage II, stage III, or stage IV disease, six to eight
cycles of CHOP plus rituximab are usually administered.
45. Alkylating agents MOA USES SE
Cyclophosphamide
Forms DNA
cross-links,
inhibition
of DNA
synthesis &
function
NHL, breast & ovarian
carcinoma, CLL, Multiple
myeloma,
retinoblastoma, SCLC,
lupus nephritis, arthritis
Immunosuppression
Non-enzymatic cleavage
phosphoramide mustard (toxic to
tumor cells) and Acrolein (causes
hemorrhagic cystitis): Co-admin MESNA
Chlorambucil CLL, NHL Less severe BM suppression
Dacarbazine Malignant melanoma, HL Moderately myelosuppressive,
Hepatotoxicity + Hepatic vascular
occlusion
Mechlorethamine HL
Antimetabolites MOA USES SE
Fludarabine Purine antagonist
inhibit DNA synthesis &
induces cellular apoptosis
CLL, NHL Myelosuppression,
Fever, edema, severe
neurologic toxicity
Methotrexate Inhibits DHFR and
thymidine synthetase
Antimetabolites are S-phase specific and
Myelosuppression is the dose-limiting toxicity
6-Mercaptopurine
6-Thioguanine
Inhibits de novo purine
synthesis
46. Vinca alkaloids MOA USES SE
Vinblastine
Inhibits
mitosis
(disrupts
microtubule
assembly)
HL, in PVB regimen of metastatic
testicular tumor
BM suppression with
leucopenia is dose-
limiting toxicity
VinBLASTine BLASTs Bone
marrow (suppression)
Vincristine With Prednisone induce remissions in
childhood leukemia
MOPP, CHOP of HL & NHL,
rhabdomyosarcoma, nephroblastoma
Less toxic to BM
Peripheral neuropathies
dose-limiting toxicity
Severe constipation &
alopecia
Resistance: increase levels of MDR-1 gene product-glycoprotien transport drug out of the cells
Antibiotics MOA USES SE
Doxorubicin
Daunorubicin
Idarubicin
S-Phase specific
Oxygen free radicals binds to
DNA DNA breaks
Inhibits TopoisomeraseII
Intercalates into DNA
Reversible acute and
irreversible chronic
cardiomyopathies
Bleomycin Oxygen free radicals binds to
DNA DNA breaks
Inactivated by Bleomycin
hydrolase that is found in
many tissues except skin &
lungs
PVB (testicular
carcinoma), Squamous
cell carcinoma, ABVD
(HL) and NHL
Dose-related pulmonary
toxicity (fibrosis) and
serious cutaneous
toxicity
47. Procarbazine produces chromosomal breaks and inhibits DNA, RNA, and protein synthesis
(lipophilic found in the CSF)
USES: Hodgkin's disease (MOPP); it is also active against non-Hodgkin's lymphoma and brain
tumors.
Myelosuppression is dose dependent.
Procarbazine augments the effects of sedatives .
It also causes infertility.
Procarbazine is a weak monoamine oxidase inhibitor that may cause hypertension ,particularly
in the presence of sympathomimetic agents and food with high tyramine content..
10% risk of causing acute Leukemia.
Rituximab antibody to IgG that binds to CD20 antigen on B cells.
USES: relapsed non-Hodgkin's lymphoma (R-CHOP regimen), and mantle cell Lymphoma.
SE: Dermatologic and gastrointestinal side effects are most common; however, cardiovascular
(angina) and respiratory (obliterative bronchiolitis) toxicities have been reported.
Adrenocorticosteroids (e.g., prednisone, hydroxycortisone, dexamethasone)
Adrenocorticosteroids are antimitotic agents.
Can be administered orally.
They are useful in acute leukemia in children and lymphoma (CHOP and MOPP regimens).
Adrenocorticosteroids have significant systemic effects and long-term use is not recommended.
49. Follow up
• Depends on which type of lymphoma, which
treatment was received, and how well it
worked
• Usually regular appointments every few
months for the first year and then gradually
less, during the appointment you discuss any
complaints, physical examination is done with
more attention on the lymph nodes, can also
have imaging and blood tests done if needed.
50. Lymphomas and immunology
To understand lymphomas .. We have to
understand the diversity in the immune system .
Antibodies ( coming from B cells ) Diversity.
56. Somatic Hypermutation
Before hyper-mutation and class switch , what is
AID .. ?
AID : Activation –induced cytadine demainase ,
considered the master regulator of 2ndry Antibody
diversity because it is involved in Somatic hyper-
mutation and class switching also gene conversion.
57. Class switching
•Isotype switching occurs by
recombination between switch regions
•This is under the influence of
activation-induced cytadine
demainase (AID)
•AID promotes the cleavage of the
DNA at the switch regions
•Isotype switching does not affect the
antigen specificity of the antibody
58. Chromosomal tanslocations
Translocation: fusion of one part of the chromosome to
another
Proto-oncogenes: genes that can cause cancer when their
function or expression is perturbed
In B cell tumors the Ig gene is often joined to a gene involved
in control of cell growth
This leads to unregulated activation of the translocated gene
59.
BCL6
B-cell lymphoma 6 protein :
Is a protein that in humans is encoded by the BCL6 gene.
Function:
• This protein acts as a sequence-specific repressor of transcription, and has been
shown to modulate the STAT-dependent Interleukin 4 (IL-4) responses of B cells.
• This gene is found to be frequently translocated and hypermutated in diffuse
large B cell lymphoma (DLBCL),and contributes to the pathogenesis of DLBCL.
Diagnostic utility
The presence of BCL6 can be demonstrated in tissue sections using
immunohistochemistry. It is exclusively present in the B-cells of both healthy and
neoplastic germinal centres. It therefore demonstrates both reactive hyperplasia in
lymph nodes and a range of lymphomas derived from follicular B-cells, such as
Burkitt's lymphoma, follicular lymphoma.
60. Why do patients with cancer lose weight
Why do patients with cancer lose weight? In general, weight loss
develops because of a negative balance between intake and
expenditure of calories. Such a negative balance may occur with
decreased calorie intake and normal energy expenditure, with
normal calorie intake but increased energy spending, or with
decreased calorie intake and increased calorie expenditure.
At the clinical level, an imbalance can result from: (1) inadequate
food ingestion; (2) impaired digestion and absorption; (3)
external nutrient loss; (4) tumor-host competition for nutrients;
or
(5) increased energy expenditure of the host. In the cancer
patient, all these abnormalities may occur singly or in
combination, thereby contributing to weight loss and eventually
to the development of cachexia, the hallmark of cancer.3
61. A 64 year old man has inguinal, axillary, and cervical lymphadenopathy.
The nodes are firm and nontender. A biopsy specimen of a cervical
node shows a histologic pattern of nodular aggregates of small cleaved
lymphoid cells and larger cells with open nuclear chromatin, several
nucleoli, and moderate amounts of cytoplasm. A bone marrow biopsy
specimen shows lymphoid aggregates of similar cells with surface Ig
that are CD10+ and CD5-. Karyotyping of these lymphoid cells
indicates the presence of t(14;18). What is the most likely diagnosis?
1. Toxoplasmosis
2. Acute lymphadenitis
3. Follicular lymphoma
4. Mantle cell lymphoma
61
62. A 12 year old boy is taken to the physician because he has had increasing
abdominal distention and pain for the past 3 days. PE shows lower abdominal
tenderness. A CT scan was performed and the mass was removed. Histological
examination of the mass shows sheets of intermediate-sized lymphoid cells,
with nuclei having coarse chromatin, several nucleoli, and many mitosis. A
bone marrow bipsy sample is negative for this cell population. Cytogenic
analysis shows a t(8;14) karyotype. Tumor shrinks after aggressive course of
chemotherapy. Which of the following is the most likely diagnosis?
Burkitt lymphoma
Follicular lymphoma
Diffuse large b cell lymphoma
Plasmacytomas.
62
63. A 62 year old man visits his physician because of prolonged fever and a 4kg
weight loss over the past 6 months. On PE his temperature is 38.6. he has
generalized non tender lymphadenopathy, and palpable spleen. Lab studies
show Hb 10.1g/dL; hematocrit, 30.3%; platelet count, 140,000/mm3; WBC
count, 24,500/mm3 with 10% segmented neutrophils, 1%bands, 86%
lymphocytes, 3% monocytes. A cervical LN biopsy specimen shows a
nodular pattern of small lymphoid cells. A bone marrow specimen shows
infiltrates of similar small cells having surface Ig that are CD5+, but CD10-.
Cytogenic analysis indicates t(11:14) in these cells. What is the most likely
diagnosis?
1. Mantle cell lymphoma
2. Follicular lymphoma
3. Acute lymphoblastic leukemia
4. Burkitt’s lymphoma
63
