Hematopathology LECTURE OUTLINE
This document contains the text shown on the lecture slides. The purpose is the aid students taking notes during lectures. The following is not what you have to learn for the exam, many things are mentioned only to present complexity or to spark interest.
2014/15
Hematopathology SLIDES 1. 2. 3. 4. 5. 6.
PREPARATIONS 1. 2. 3. 4.
Toxoplasma lymphadenitis Follicular lymphoma CLL/SLL in lymph node Diffuse large B-cell lymphoma Hodgkin’s lymphoma CML, CP, smear
Burkitt’s lymphoma Lymphomatous polyposis Multiple myeloma CML - splenomegalia
EXAM TOPICS 1. 2. 3. 4. 5. 6. 7. 8.
Reactive lymph node changes Indolent B cell lymphomas (FL, CLL, MCL, MZL) High grade B cell lymphomas (BL, DLBCL). Plasma cell neoplasms Hodgkin’s lymphoma T/NK cell lymphomas. Non-neoplastic bone marrow diseases AML and MDS Myeloproliferative neoplasms
Hematopathology
Hematopoiesis Lymphoid cell populations Reactive lymph node alterations
Hematopoiesis
Normal ranges in blood Neutrophil 1.8 – 5.4 ×109 Eosinophil 0.0 – 0.5 × 109
Production
Basophil
0.0 – 0.08 × 109
Leukocyte
60 ×109 /day
Monocyte
0.3 – 0.8 × 109
Rbc
210×109 /day
Lymphocyte
1.3 – 3.6 × 109 Thrombocyte
140×106 /day
Red blood cell Thrombocyte
×1012
4.5 – 6 140 – 440 ×109
Hematopoiesis thrombocyte
>16 weeks
erythrocyte
LT-HSC 6-8 weeks
mast cell
ST-HSC MEP Stem cell
BMCP
CMP
eosinophil
MPP self renewal supporting 2-6 weeks hematopoiesis active LT-HSC quiescent LT-HSC
basophil
GMP
neutrophil
CLP
monocyte/ macrophage
BCP „myeloid” LT-HSC „lymphoid” LT-HSC
TNKP B-cell T-cell
NK-cell
dendritic cell
Hematopoiesis thrombocyte
MYELOID
erythrocyte
LT-HSC
mast cell
ST-HSC MEP
basophil
BMCP
CMP
eosinophil
MMP GMP
neutrophil
CLP
monocyte/ macrophage
BCP TNKP B-cell
LYMPHOID T-cell
NK-cell
dendritic cell
HISTIOCYTIC
B-lymphoid cell populations CLP
5’
V genes
D genes
C genes
J genes
3’
µ δ γ DHJH
3’
5’
pro-B (BCP)
µ δ γ CDR3
VHDHJH V
pre-B
D N1
TdT VHDHJH VLJL
(terminal dezoxyribonucleotidil transferase)
immature B-cell
5’
IgM+ mature IgD+
Bone marrow
(naive) B-cell
µ δ γ
IgM
VDJ
J N2
C genes
3’
µ δ γ δ γ
IgD
B-lymphoid cell populations CLP
SOMATIC HYPERMUTATION
DHJH V
pro-B (BCP)
D
J
VHDHJH
Centrocyte
pre-B VHDHJH VLJL
FDC
SHM
immature B-cell
T-cell
IgM+ mature IgD+
Bone marrow
(naive) B-cell
activated B-cell
Centroblast
B-lymphoid cell populations CLP
ISOTYPE SWITCH (CLASS SWITCH RECOMBINATION) VDJ
DHJH
5’
µ δ γ εγ α
IgM
pro-B (BCP)
C gének
5’
VHDHJH
CSR Centro-
pre-B VHDHJH VLJL
cyte FDC
SHM
immature B-cell
T-cell
IgM+ mature IgD+
Bone marrow
3’
εγ α
IgE
3’
(naive) B-cell
activated B-cell
Centroblast
B-lymphoid cell populations plasma cell CLP DHJH
pro-B (BCP)
B1 B-cell?
plasma cell memory B-cell marginal zone B-cell?
VHDHJH
pre-B VHDHJH VLJL
plasmablast
extrafollicular B-cell
Centrocyte CSR
FDC
SHM
immature B-cell
T-cell
IgM+ mature IgD+
Bone marrow
(naive) B-cell
activated B-cell
Centroblast marginal zone
T-lymphoid cell populations 90% DβJβ
pro-T
γ/δ T-cell TCRβ V
VβD β J β pre-T VβD β J β VαJ α
CD4+/CD8T-cell
TCR αβ TCR γδ IgHL
NKT-cell (CD4-, CD8+/-)
J
TCRα V
CD4-/CD8+ T-cell
medulla
D
TCRγ
CD4+/CD8+ T-cell
Thymus-cortex
TCRδ
J
diversity 1016 1018 1011
T-lymphoid cell populations 90% DβJβ
pro-T
γ/δ T-cell
VβD β J β pre-T VβD β J β VαJ α
TH1-cell TH2-cell
CD4+/CD8T-cell
CD4+/CD8+ T-cell
TH17-cell CD4-/CD8+ T-cell
Treg-cell
CD8+ memory T-cell
TFH-cell cytotoxic T-cell
Thymus-cortex
medulla
NKT-cell (CD4-, CD8+/-)
CD4+ memory T-cell
Lymphocyte differentiation and maturation TCR/BCR rearrangement IgH/IgL TCRαβ TCRγδ
no costimulation: apoptosis anergy
costimulation: immune response
TCR/BCR signal
activation
Positive selection eliminating useless cells
Negative selection eliminating autoreactive cells
apoptosis
other survival signal
Lymphoid cell populations – B cells B1 B-cell in mice: lymphocyte in body cavities, innate immune cells debatable in humans, present in blood? spontaneous IgM production, T-cell independent activation
Marginal zone B-cell T-cell independent activation low affinity, IgM antibodies, isotype switching possible heterogenous population in humans: B1? + memory B-cells? + MZ B-cells?
Follicular B-cell T-cell dependent activation high affinity antibodies, isotype switching (IgG)
Lymphoid cell populations – T- and NK-cells CD4+ T-cell modulating limmune/inflammatory reactions „helper” and „regulatory” cells
CD8+ T-cell cytotoxic T-cells granzyme B, perforin, etc. enzymes inducing membrane damage
NKT-cell similar to NK-cells, rare T-cell population, usually suppressing function
γδ T-cell has a role in mucosal immunity, analogue of B1 B-cells
NK-cell innate immunity, not a T-cell cell lysis/induction of apoptosis without antibody recognition
Lymphatic tissue abnormalities General definitions lymphadenopathy
lymph node enlargement
lymphadenomegaly
lymph node enlargement
lymphadenitis
lymph node inflammation
Clinical characteristics localized vs. generalized painful vs. painless soft vs. firm/hard rapid growth vs. persitant, stable
General differential diagnosis reactive changes/inflammation hematological malignancy metastasis
Reactive lymph node abnormalities Non-specific lymph node changes follicular hyperplasia paracortical hyperplasia sinus histiocytosis
Specific lymphadenitis Toxoplasma lymphadenitis cat scratch disease
Infectious mononucleosis
Non-specific lymph node abnormalities Follicular hyperplasia germinal centrum reaction B-cell expansion due to humoral immune response Examples: characteristic in children lymph node/tonsil enlargement may be due to autoimmune disease may be due to HIV+
>1 cm usually is abnormal soft, painful– inflammation firm, painless – chr. inflammation or neoplasm
Non-specific lymph node abnormalities Paracortical hyperplasia hyperplasia of T-cell compartment
Examples: lymph node near tumors dermatopathic lymph node (eg. dermatitis) viral infection (herpes, mononucleosis, etc.)
Non-specific lymph node abnormalities Sinus histiocytosis expansion of sinuses due to macrophages
Examples: anthracosis Rosai-Dorfmann disease (sinus histiocytosis with hemophagocytosis)
Specific lymph node abnormalities Toxoplasma lymphadenitis Toxoplasma gondii – protozoon, human is not a definite host toxoplasma lymphadenitis diffuse toxoplasmosis with immunosuppression – encephalitis, myocarditis, etc. intrauterine toxoplasma infection – CNS, eye, liver changes, growth retardation
Piringer-Kuchinka lymphadenitis follicular hyperplasia epithelioid cell microgranulomas monocytoid B-cell hyperplasia
Specific lymph node abnormalities Cat scratch disease Bartonella henselae (G-negative) asbcedating reticulohistiocytic lymphadenitis suppurating granulomas
Others Kikuchi-Fujimoto lymphadenitis (necrotizing reticulohistiocytic lymphadenitis) granulomatous lymphadenitis – Myocbacterium, Yersinia, Pastorella, Chlamydia, etc. drug induced lymphadenopathy sarcoidosis Castleman disease others
Infectious mononucleosis Microbiology Epstein-Barr virus gamma-herpesvirus, DNA virus
Pathogenesis lytic infection of epithelium latent infection of B-cells T-cell immune response - atypical mononuclear cells humaral immune response
Clinicopathology general signs of inflammation lymph node and spleen enlargement leukocytosis atypical mononuclear cells
B-lymphoid populations plasma cell CLP
EBV
DHJH
pro-B (BCP)
VHDHJH
pre-B VHDHJH VLJL
plasma cell
lytic infection
latency I (survival) memory B-cell
plasmablast
extrafollicular B-cell
Centrocyte CSR
FDC
SHM
immature B-cell
activated B-cell IgM+ mature latency III IgD+ (naive) (proliferation) B-cell Bone marrow
T-sejt latency II Centro(differentiation) blast marginal zone
Infectious mononucleosis
EBER: EBV encoded small RNAs intranuclear RNA
Lytic infection: EBNA1 Latency III: EBER, EBNA1, EBNA2, LMP1 Latency II: EBER, EBNA1, LMP1 Latency I: EBER, EBNA1, LMP2
EBNA1: EB nuclear antigen1 EBV genome replication LMP1: Latent membrane protein 1 EBV associated diseases: infectious mononucleosis Burkitt lymphoma Hodgkin lymphoma immunosuppression related DLBCL extranodal NK/T-cell lymphoma primary effusional lymphoma nasopharyngeal carcinoma lymphoepithelial carcinoma
Hematopathology
foundations of the WHO classification morphology and immunophenotype genetic alterations clinical characteristics
Hematopoietic and lymphoid neoplasms lymphoid neoplasms myeloid neoplasms histiocytic and dendritic cell neoplasms
Lymphoid neoplasms – basic concepts
Hodgkin lymphoma vs non-Hodgkin lymphoma leukemia vs lymphoma nodal vs extranodal lymphoma aggressive vs indolent lymphoma epidemiology clinical signs staging
Lymphoid neoplasms – basic concepts Hodgkin lymphoma
non-Hodgkin lymphoma
described by Thomas Hodgkin
every other lymphoma
mature B-cell lymphoma characteristic morphology characteristic clinical picture excellent prognosis
Lymphoid neoplasms – basic concepts Leukamia
Lymphoma
neoplastic cells in blood
neoplasm of lymphatic tissue
manifestation, not disease
lymph node enlargement
many lymphomas may be leukemic
may be extranodal
leukemias may be aleukemic
may appear as leukemia
Lymphoid neoplasms – basic concepts Nodal lymphoma
Extranodal lymphoma
lymphatic tissue involvement:
often with disseminated lymphoma
lymph node, spleen, thymus,
primary extranodal lymphoma:
(Waldeyer’s ring )
GI tract, skin, CNS, head and neck, testis, etc.
Lymphoid neoplasms – basic concepts Aggressive lymphoma
Indolent lymphoma
rapid proliferation/progression
slow progression, little proliferation
higher chance of being treatable
usually uncurable
„blastic”:
„cytic”
lymphoblast, centroblast, immunoblast pediatric lymphomas
older age
due to immunosuppresion:
chronic lymphcytic activation
EBV, HHV8
alterations of the memory B cells H.pylori, B.burgdorferi, C.psitacci HCV
Lymphoid neoplasms – basic concepts Epidemiology
Prognosis
4-5% of all adult cancer (7-10th)
very heterogeneous
incidence: 19.7/100,000 (USA, 2013.)
summary: 5 year survival - approx. 69%
most frequent cancer in children (ALL) 1.5× more frequent in males approx. 85% B-cell NHL approx. 5% T-cell NHL approx. 10% HL
Lymphoid neoplasms – basic concepts Clinical picture Lymph node enlargement painless, firm Rapid tumor growth – extranodal lymphoma Splenomegaly Hepatomegaly Bone marrow failure anemia, thrombocytopenia, neutropenia Systemic signs autoimmune hemolytic anemia, infections B signs weight loss, fever, nigh sweats
Lymphoid neoplasms – basic concepts Staging Ann-Arbor staging I
one lymph node region
II
more lymph node regions on one side of diaphragm
III
lymph nodes on both sides of diaphragm
IV
bone marrow, liver, lung, pleura, etc.
E:
extranodal involvement, or spread from lymph node
B:
B signs
X:
>10 cm „bulky” involvement
Lymphoid neoplasms – morphology CD (cluster of differentiation) markers (cell surface epitopes) B-cell markers
T-cell markers
CD19: general B-cell
CD2, CD3, CD5, CD7: general T-cell
CD20: mature B-cell
CD1a ,CD34, TdT: precursor T-cell
CD21: C3d receptor (EBV), mature B-cell
CD4, CD8: T-cell subpopulations
CD23: FCεRII (IgE receptor), mature B-cell
CD56: NK-cell
CD34, TdT, CD10: precursor cells
granzyme B: cytotoxic T-cell
CD10, Bcl6: germinal center B-cell CD138, Mum1: plasma cell CD5: small fraction of mature B-cells
Other markers CD34: precursor cells CD45: general leukocyte marker
Lymphoid neoplasms – genetics IgH/TCRγ gene rearrangement – clonality test monoclonal
single PCR product is dominant
polyclonal
many PCR products in the sample
oligoclonal
few PCR products in the sample
Alternative testing of clonality detecting light chain restriction in case of B cells
Lymphoid neoplasms – genetics Translocations
IgH/IgL translocations
Gene rearrangement (VDJ/VJ) V
D
IgH/Partner
IgH region
C
J
5’
3’
µ δ γ
E
E
3’
5’
µ δ γ CDR3 D
V TdT
N1
J N2
Class switch recombination Centrocyte FDC T-cell Centroblast
Somatic hypermutation (SHM)
Partner gene region
Examples t(8;14) IgH/C-Myc
BL
t(11;14) IgH/CyclinD1
MCL
t(14;18) IgH/Bcl2
FL
Point mutations eg. Bcl6, Myc, Bcl2, p53 Translocations eg. C-Myc, Bcl6
Lymphoid neoplasms – WHO classification Precursor B-cell lymphomas B-lymphoblastic leukemia/lymphoma, with recurrent genetic aberrations BCR-ABL1 translocation MLL translocation ETV6-RUNX1 translocation Hyperdiploidity Hypodiploidity IL3-IGH translocation E2A-PBX1 translocation B-lymphoblastic leukemia/lymphoma, NOS Mature B-cell lymphomas Chronic lymphocytic leukemia/Small lymphocytic lymphoma B-cell prolymphocytic leukemia Splenic marginal zone lyphoma Hairy cell leukemia Splenic B-cell lymphoma/leukemia, NOS Splenic diffuse red pulp small B-cell lymphoma Hairy cell leukemia variant Lymphoplasmacytic lymphoma Heavy chain diseases Gamma heavy chain disease Mu heavy cahin disease Alpha heavy chain disease Plasma cell neoplasms Monoclonal gammopathy of unknown significance Plasma cell myeloma Solitary bone plasmacytoma Extraosseal plasmacytoma Extranodal marginal zone lymphoma in MALT (MALT lymphoma) Nodal marginal zone lymphoma Follicular lymphoma Primary cutaneous follicular lymphoma Mantle cell lymphoma
Precursor T-and NK-cell lymphomas T-lymphoblastic leukemia/lymphoma Hodgkin lymphomas Nodular lymphocyta predominant Hodgkin lymphoma Classic Hodgkin lymphoma Nodular sclerosis Lymphocyte rich Mixed cellularity Lymphocyte depletion
Diffuse large B-cell lymphoma, (DLBCL) NOS T-cell/histiocyte rich large B-cell lymphoma Primary CNS DLBCL Primary cutaneous DLBCL, leg type EBV-positive DLBCL of the elderly Chronic inflammation associated DLBCL Lymphomatoid granulomatosis Primary mediastinal (thymicus) large B-cell lymphoma Intravascular large B-cell lymphoma ALK-positive large B-cell lymphoma Plasmablastic lymphoma Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease Primary effusional lymphoma Burkitt lymphoma B-cell lymphoma, unclassifiable, intermediate between DLBCL Burkitt lymphoma B-cell lymphoma, unclassifiable, intermediate between DLBCL and Hodgkin lymphoma
Mature T- and NK-cell lymphomas T-cell prolymphocytic leukemia T-cell large granular cell leukemia Chronic NK-cell lymphoproliferative disorders Aggressive NK-cell leukemia Pediatric EBV-positive T-cell lymphoproliferative disease Pediatric systemic EBV-positive T-cell lymphoproliferative disease Hydroa vacciniforme-like lymphoma Adult T-cell leukemia/lymphoma Extranodal NK/T-cell lymphoma, nasal type Enteropathy associated T-cell lymphoma Hepatosplenic T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Mycosis fungoides Sézary syndrome Primary cutaneous CD30+ T-cell lymphoproliferative diseases Primary cutaneous anaplastic large-cell lymphoma Lymphomatoid papulosis Primary cutaneous peripheral T-cell lymphoma, rare variants Primary cutaneous gamma-delta T-cell lymphoma Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma Primary cutaneous CD4+ small/medium sized T-cell lymphoma Peripheral T-cell lymphoma, NOS Angioimmunoblastic T-cell lymphoma Anaplastic large-cell lymphoma, ALK positive Anaplastic large-cell lymphoma, ALK negative
B-cell lymphomas (that will be discussed) Precursor B-cell lymphomas Acute lymphoblastic leukemia/lymphoma (ALL/LBL)
Aggressive, mature B-cell lymphomas Burkitt lymphoma (BL) Diffuse large B-cell lymphoma (DLBCL)
Indolent, mature B-cell lymphomas Chronic lymphocytic leukemia/Small lymphocytic lymphoma (CLL/SLL) Follicular lymphoma (FL) Marginal zone lymphomas (MZL)
Other, mature B-cell lymphomas Mantle cell lymphoma (MCL) Plasma cell neoplasms (PCN)
B-cell lymphomas ALL
plasma cell CLP PCN
pro-B (BCP)
memory B-cell extrafollicular B-cell
VHDHJH
pre-B VHDHJH VLJL
DLBCL
plasma cell
DHJH
plasmablast
CLL/SLL MZL
Centrocyte CSR
DLBCL
FDC
SHM
immature B-cell
T-cell MCL IgM+ mature IgD+
Bone marrow
(naive) B-cell
activated B-cell
BL CentroDLBCL blast marginal zone
FL
Precursor B-cell lymphoma/leukemia Acute lymphoblastic leukemia (lymphoblastic lymphoma) Epidemiology 80-85% of precursor cell leukemias, 10% of such lymphomas are B-cell 75% of patients are under 6 years
Symptoms anemia, thrombocytopenia usually lymph node, spleen and liver enlargement bone pains
Morphology lymphoblastic infiltration in bone marrow usually leukocytosis in peripheral blood CD34+, CD19+, CD10+
Genetics hyperdiploidity – favorable prognosis translocation producing gene fusion eg. t(9;22) – BCR-ABL1 – unfavorable eg. t(12;21) – ETV6-RUNX1 – favorable
Mature B-cell lymphoma - aggressive Burkitt lymphoma (BL) History 1958: Denis Parsons Burkitt: recognized BL in Uganda tried chemotherapy with success 1964: Michael Anthony Epstein/Yvonne Barr: recognition of virus 1967: Werner és Getrude Henle: EBV in mononucleosis
Epidemiology third of pediatric NHL more frequent in males endemic: Africa (near Equator): malaria and EBV sporadic: anywhere, 30% EBV+ with immunsuppression: HIV+, 25-40% EBV+
Symptoms endemic: tumor of head and neck area sporadic: abdominal and retroperitoneal rarely leukemic manifestation
Mature B-cell lymphoma - aggressive Burkitt lymphoma (BL) Morphology diffuse, medium sized blastic infiltrate high mitotic and apoptotic activity („starry sky pattern”) CD20+, CD10+, Mib1 > 95%
Genetics MYC-translocation: t(8;14) – IGH/C-MYC t(2;8) – IGL/C-MYC t(8;22) – IGK/C-MYC
Mature B-cell lymphoma - aggressive Diffuse large B-cell lymphoma (DLBCL) Epidemiology 20-30% of adult NHL (most frequent) 60-70 year is average primary (de novo) secondary (transformation): CLL, FL, MZL, NLPHL immunsuppression increases risk, mostly EBV+
Symptoms rapidly growing tumor, approx. 60% extranodal 5 year survival approx. 60%
Classification DLBCL, NOS – GC-type, non-GC-type T-cell/histiocyte rich large B-cell lymphoma (TCRBCL), Primary CNS DLBCL, Primary cutaneous DLBCL, leg type, Elderly EBV+ DLBCL Other large cell lymphomas: Primary mediastinal large B-cell lymphoma (PMBCL), Lymphomatoid granulomatosis, Intravascular large B-cell lymphoma, Primary effusional lymphoma, etc.
Mature B-cell lymphoma - aggressive Diffuse large B-cell lymphoma (DLBCL) Morphology diffuse, „blastic” infiltrate centroblastic/immunoblastic/anaplastic CD20+, everything else is variable
Genetics Bcl6 translocation (30-40%) Bcl6 mutation (70%) IGH/BCL2 (15%) IGH/C-MYC (10%)
Mature B-cell lymphoma - indolent Chronic lymphocytic leukemia (CLL) Epidemiology most frequent adult leukemia most frequent lymphoma in Hungary incidence: 3-5/100,000, 90% > 50 years rarely familial
Symptoms often symptomless lymphocytosis splenic and lymph node enlargement B-signs anemia, thrombocytopenia autoimmune manifestations: AIHA, ITP different staging system, since it is often disseminated
Mature B-cell lymphoma - indolent Chronic lymphocytic leukemia (CLL) Morphology Blood: monoclonal B-cell lymphocytosis in blood CD5+, CD19+, CD20+, CD23+
Bone marrow: nodular or diffuse infiltrate
Lymph node: diffuse, small lymphocytic infiltrate, sometimes pseudofollicles if restricted to lymph node: small lymphocytic lymphoma (SLL)
Mature B-cell lymphoma - indolent Chronic lymphocytic leukemia (CLL) Pathogenesis Mutated IgH gene
Non-mutated IgH gen
(„postfollicular”)
(„prefollicular”)
approx. 40%
approx. 60%
rarely IgG/IgA
characteristic VDJ gene usage
poly/autoreactive BCR
poly/autoreactive BCR
slow progression
faster progression
usually no treatment is needed
usually requires treatment
long survival similar to an autoimmune disease
Mature B-cell lymphoma - indolent Chronic lymphocytic leukemia (CLL) Pathogenesis - theory Mutated IgH gene
Non-mutated IgH gen
(„postfollicular”)
(„prefollicular”)
polyreactive, anergic IgM+ memory cells
IgM+ memory cells
(marginal zone B-cells)
(marginal zone B-cells)
clonal expansion due to restriction
ongoing aberrant SHM
of the memory B cell compartment
(AID expression)
Mature B-cell lymphoma - indolent Chronic lymphocytic leukemia (CLL) Treatment only observation cytostatic drugs chemotherapy anti-CD20 (Mabthera), anti-CD52 (MabCampath) treatment
Progression advanced stage (anemia, thrombocytopenia develops) prolymphocytic transformation Richter-transformation: DLBCL develops
Mature B-cell lymphoma - indolent Follicular lymphoma (FL) Epidemiology 2nd most frequent NHL in Western world (approx. 20-30% of lymphomas) rare in Asia mean age: 60 years
Symptoms slow, painless lymph node enlargement 50-60% bone marrow involvement may be extranodal
Morphology follicles without mantle zones no apoptotic activity centrocytoid/centroblastoid cells CD19+, CD20+, CD10+, Bcl6+, Mib1 low
Mature B-cell lymphoma - indolent Follicular lymphoma (FL) Genetics 50-90% IgH/BCL2 translocation occurs in bone marrow at DJ rearrangement, detectable in some memory cells in adults may develop due to SHM in germinal centers increased Bcl2 expression – apoptosis resistance clone „gets stuck” in germinal center accumulating genetic damage
Prognosis usually treatment is not needed approx. 30-50% transforms to DLBCL in 10 years
Mature B-cell lymphoma - indolent Marginal zone lymphoma (MZL)
Extranodal marginal zone lymphoma (MALToma)
Nodal marginal zone lymphoma
Splenic marginal zone lymphoma
Mature B-cell lymphoma - indolent Extranodal marginal zone lymphoma (MALToma)
H.pylori gastritis
Epidemiology 7-8% of lymphomas, more frequent in women, around 60 years stomach – 30% eye, salivary gland, skin, lung, etc. acquired MALT
Symptoms depends on localization often chronic inflammation: stomach – H.pylori, salivary gland – Sjögren thyroid gland – Hashimoto, conjunctiva – C. trachomatis may be large, bulky, often disseminated (extranodal!)
high grade transformation
clonal B-cells
MALT lymphoma
Mature B-cell lymphoma - indolent Extranodal marginal zone lymphoma (MALToma) Morphology centrocytoid cells with wide cytoplasm infiltrate originating in lymphoid follicles lymphoepithelial lesion
Genetics stomach: approx. 25% t(11;18)(q21;q21) – AIP2/MALT1 not stomach: apporx. 20-25% (14;18)(q32;q21) – IGH/MALT1
Mature B-cell lymphoma - indolent Splenic marginal zone lymphoma (SMZL) Epidemiology rare (3 g/l 55 years mild male dominance first curable lymphoma; now 80-90% is cured
Symptoms cervical, axillary, mediastinal lymph node enlargement rarely B signs
Mature B-cell lymphoma – Hodgkin lymphoma Classic Hodgkin lymphoma Morphology rare neoplastic cells – large, bizarre cells Reed-Sternberg cells: binucleated/multinucleated Hodgkin cells: mononuclear „mummy” cells: apoptotic, shrunken cells lacunar cells: clear halo many inflammatory/reactive cells T-cells, eosinophils, macrophages, plasma cells
Mature B-cell lymphoma – Hodgkin lymphoma Classic Hodgkin lymphoma Immunophenotype CD45-, CD20-/+ CD30+, CD15+, fascin+ Bcl6+, Mum1+ EBV+ (LMP1, EBER; latency type II) – 30-70%
Mature B-cell lymphoma – Hodgkin lymphoma Classic Hodgkin lymphoma Nodular sclerosis cHL 50-70% of cHL mean age: 15-35 years most frequently mediastinal EBV+/-
Mixed cellularity cHL 25-30% of cHL mean age: 40 years rarely mediastinal, often EBV+
Lymphocyte rich cHL rare, more frequent in males mean age: 30-50 years usually localized
Lymphocyte depletion cHL very rare, more frequent in males mean age: 30-40 years aggressive, disseminated
Mature B-cell lymphoma – Hodgkin lymphoma Nodular lymphocyte predominant Hodgkin lymphoma Epidemiology approx. 5% Hodgkin lymphomas mean age: pediatric and between 30-40 years tends to recur, but good prognosis
Symptoms cervical and axillary lymph node enlargement
Morphology L&H cells/popcorn cells
Phenotype CD45+, CD20+, CD30-, CD15-, EBVBcl6+, Mum1+
Genetics 50% 3q27 (Bcl6) translocation
Mature B-cell lymphoma – Hodgkin lymphoma L&H-cell
Pathogenesis HRS-cells are monoclonal SHM+ approx. 25% destroyed IgH mutation
PB CC
abnormal transcription autocrine programs function LMP1 apoptosis (EBV) resistance increased proliferation
FDC T-cell CB
EBV? preapoptotic CG-cell destroyed IgH gene lacking transcription factors
NFκB activation
HRS-cell cytokine production
T-cell lymphomas
Precursor T-cell lymphomas
Extranodal T-cell lymphomas
Acute lymphoblastic leukemia/ lymphoma (ALL/LBL)
NK/T-cell lymphoma, nasal type
Cutaneous T-cell lymphomas
Enteropathy associated T-cell lymphoma Hepatosplenic T-cell lymphoma
mycosis fungoides (MF) Sézary syndrome (SS)
Nodal T-cell lymphomas Peripheral T-cell lymphoma, NOS Anaplastic large-cell lymphoma Angioimmunoblastic T-cell lymphoma
Leukaemic T-cell lymphomas Adult T-cell leukemia Large granular lymphocyte (LGL) leukemia
Precursor T-cell lymphoma/leukemia Acute lymphoblastic leukemia (lymphoblastic lymphoma) Epidemiology 80-85% of precursor cell leukemias, 10% of such lymphomas are B-cell 75% of patients are under 6 years
Symptoms leukemia – like B cell lymphoma – usually mediastinal tumor
Morphology diffuse lymphoblastic infiltration CD3+, TdT+, CD34+
Genetics TCRα (14q11), TCRβ (7q35) translocation usually with homeobox genes
Cutaneous T-cell lymphomas Mycosis fungoides Definition epidermotropic cutaneous mature T-cell lymphoma
Epidemiology 50% of cutaneous lymphomas mean age: 55-60 years, may appear anytime 2× more frequent in males
Symptoms indolent, long course, localized to the skin for a long time rarely, late: lymph node, liver, spleen, bone marrow
Cutaneous T-cell lymphomas Mycosis fungoides Macroscopy
patch (premycotic) stage
Microscopy Pautrier microabscesses Sézary cells
plaque stage
tumor stage
Cutaneous T-cell lymphomas Mycosis fungoides Immunophenotype cutaneous CD4+ memory T-cell phenotype: TCRβ+, CD3+, CD2+, CD5+, CD4+ often CD7 loss rarely CD8+
Genotype monoclonal TCR gene rearrangmenet
Pathogenesis - theories chronic antigen-stimulation? – no evidence chronic exposition (eg. like contact dermatitis), bacterium? chr. inflammation? viral infection? – HTLV, CMV?
Cutaneous T-cell lymphomas Sézary syndrome Definition erythroderma, generalized lymph node enlargement neoplastic cells in peripheral blood (leukemia)
Epidemiology 5% of cutaneous lymphomas mean age: 60 years 2× more frequent in males
Morphology similar to mycosis fungoides
Nodal T-cell lymphomas Peripheral T-cell lymphoma, NOS (not otherwise specified) Definition heterogenous group
Epidemiology 30% of T-cell lymphomas adult, 2× frequent in males
Symptoms disseminated lymph node enlargement, often B signs often bone marrow and spleen involvement often dermal and GI tract involvement eosinophilia frequent 5 year survival: approx. 25%
Nodal T-cell lymphomas Peripheral T-cell lymphoma, NOS (not otherwise specified) Morphology heterogeneous usually diffuse infiltrate in lymph nodes medium sized, clear cells
Immunophenotype CD3+, CD2+, CD5+/-, CD7+/CD4 more frequently, than CD8 may be CD30+
Nodal T-cell lymphomas Anaplastic large-cell lymphoma Definition CD30+ T-cell lymphoma ALK+ systemic ALCL ALK- systemic ALCL cutaneous ALCL
Epidemiology ALK+ ALCL: 10-20% of lymphomas in children 3% in adults
Symptoms B-signs, disseminated lymph node enlargement frequent extranodal involvement
Nodal T-cell lymphomas Anaplastic large-cell lymphoma Morphology/immunophenotype anaplastic lymphoid cells CD30+ frequently CD3-, but T-cells! cytotoxic markers
Genetics t(2;5)(p23;q35): NPM-ALK1 variants
Prognosis ALK+ ALCL: 5 year survival: 75-90% ALK- ALCL: 5 year survival: 20-30%
Nodal T-cell lymphomas Angioimmunoblastic T-cell lymphoma Definition CD4+ follicular helper T-cell neoplasm (CD4+, PD1+)
Epidemiology 15-20% of T-cell lymphomas adulthood, male = female frequency
Symptoms disseminated lymph node enlargement, often B signs spleen, liver, bone marrow involvement, hypergammaglobulinemia skin rashes, pruritus, arthritis frequently EBV+ B-cell expansion
Extranodal T-cell lymphomas NK/T-cell lymphoma, nasal type Asia, Middle/South America nasal cavity, nasopharynx, oral cavity EBV+, NK, or NKT-cell phenotype angiocentric growth, aggressive (lethal midline granuloma)
Enteropathy associated T-cell lymphoma rare, intraepithelial T-cell neoplasm often associated with coeliac diseas; poor prognosis ulcerative jejunitis, intestinal perforation CD4-, CD8+/-, cytotoxic phenotype, TCRβ+
Hepatosplenic T-cell lymphoma γδ-T-cell neoplasm, cytotoxic phenotype mean age is 35 years, hepatosplenomegaly, bone marrow involvement poor prognosis: 20% of blood volume is lost exsanguination: bleeding out (hypovolemic shock)
Chronic blood loss compensation – increased iron utilization iron deficiency anemia tissue hypoxia – increased ventillation, reduced cardiac output weekness, fatigue, pallor
Anemia – reduced production Reduced proliferation aplastic anemia reduced proliferation/survival of stem cells and progenitor cells unknown cause in 50% of cases drugs, viral hepatitis, thymoma, irradiation, etc. reduced proliferation due to genetic damage of progenitors T-cell activation induced myelosuppression
anemia due to bone marrow infiltration (myelophthisis) metastasis, fibrosis, granulomatous inflammation, storage disease, etc. teardrop red blood cells + leukoerythroblastosis
anemia due to chronic disease chr. renal disease, RA, IBD, carcinomas chr. inflammation – hepcidin↑, erythropoietin↓, thrombopoietin↓
Anemia – reduced maturation Iron deficiency anemia (cytoplasmic maturation is inhibited) metabolism: 3.5/2.5 g iron, 15-20% in iron storage pools; 1-2 mg/day excretion 10% of adults are iron deficient (in developed countries) causes:
chronic bleeding – GI, female genital tract insufficient diet malabsorption syndromes
microcytic/ hypochromic anemia anisocytosis
Anemia – reduced maturation Megaloblastic anemia (nucelar maturation is inhibited) folate (B9): casues of def.: cobalamin (B12): causes of def.:
DNS synthesis, repair, methylation pregnency, obesity, malabsorption, inadequate diet DNS synthesis, fat metablosm, etc. intrinsic factor def. (autoimmune gastritis) – anaemia perniciosa malabsorption
megaloblasts in bone marrow macrocytosis, anisocytosis
Anemia – hemolytic Intrinsic abnormalities spherocytosis sickle cell anemia thalassemia
Extrinsic abnormalities autoimmune hemolytic anemia microangiopathy hemolytic anemia
Anemia – hemolytic Spherocytosis usually AD cytoskeleton-cell membrane interaction failure (spectrin, ankyrin, etc. mutation) spherocytes –sequestered in spleen splenomegaly, cholelithiasis aplastic crisis – parvovirus B19 infection
Anemia – hemolytic Structure of hemoglobin
Haemoglobin A (α2β2)
Haemoglobin A2 (α2δ2) 1-3% normally Haemoglobin F (α2γ2) 51/48%, vvt > 6.1 / 5.4 × 1012 /l polyglobulia: > 185/165 g/l hemoglobin concentration polycythemia: increased red blood cell mass
polycythemia vera neoplastic disease
secondary polycythemia
Secondary polycythemia Secondary polycythemia
Hypoxia heart/lung disease smoking sleep apnoe renal artery stenosis
Congenital Acquired EPO not↓
No hypoxia
EPO↓
Hgb-O2 affinity
P50 ↓
Hemoglobinopathy 2,3BPG-deficiency
drugs paraneoplastic (liver/kidney cc, hemangioblastoma) EPOR mutation
P50 normal
VHL mutation HIF2A mutation based on Tefferi A. et al. Nat Rev Clin Oncol 2009
Granulocytic disorders
Leukopenia
Leukocytosis
Neutropenia Basic concepts leukopenia: < 4000 / µl WBC neutropenia: < 1500 / µl absolute neutrophil count agranulocytosis: < 100 / µl absolute neutrophil count
Casues Reduced production
Increased destruction
suppression of granulopoesis
immunological damage
damage of precursors
splenomegaly
ineffective hematopoesis
peripheral consumption
congenital disease
Neutropenia Consequences bacterial/fungal infection frequent oral, necrotizing, gangrenous inflammation frequent airway infections
Morphology hypocellular or hypercellular bone marrow
Leukocytosis Basic concepts leukocytosis: > 10000 / µl EBC leukemoid reaction: severe leukocytosis, with immature precursors
Causes bacterial infection – granulocytosis viral infection – lymphocytosis allergic reactions – eosinophilia paraneoplastic: Hodgkin lymphoma, plasma cell myeloma
Thrombocytosis Basic concepts normal thrombocyte count: 150 - 400,000 / mm3
Causes inflammation (IL6)
IBD, RA, tuberculosis
paraneoplasia
carcinoma
iron deficiency
Thrombocytopenia Basic concepts normal thrombocyte count: 150 – 400.000 / mm3 bleeding: 10-20.000 / mm3
Casues: A. Reduced production: bone marrow insufficiency, infiltration B. Reduced survival: ITP, TTP, HUS, DIC C. Sequestration: hypersplenism
Hematopoiesis thrombocyte
MYELOID
erythrocyte
LT-HSC
mast cell
ST-HSC MEP
basophil
BMCP
CMP
eosinophil
MMP GMP
neutrophil
CLP
monocyte/ macrophage
BCP TNKP B-cell
LYMPHOID T-cell
NK-cell
dendritic cell
HISTIOCYTIC
Histiocyte neoplasms Langerhans cell neoplasms (histiocytosis X) Epidemiology 0.5-0.9/100,000 children, rarely adults high mortality before age of 2 (30-50%)
Clinical characteristics eosinophil granuloma: 5-15 years, solitary lesion: bone, lung, soft tissue Hand-Schüller-Christian disease: 2-10 years, multiple bone lesions, diabetes insipidus Letterer-Siwe disease: < 2 years, disseminated; bone and soft tissue involvement
Histiocyte neoplasms Langerhans cell neoplasms (histiocytosis X) Morphology Langerhans cell: dendritic cell in skin/mucosa morphologo: oval nucleaus, nuclear groove immunohistochemistry: CD1a, langerin, CD68 elektronmicroscopí: Birbeck-granulum frequent BRAF mutation
Histiocyte neoplasms Dendritic cell sarcomas Epidemiology very rare
Clinical characteristics lymph node involvement soft tissue/organ manifestation lung/liver metastasis may occur
Types interdigitating dendritic cell sarcoma follicular dendritic cell sarcoma others
Myeloid neoplasms myeloproliferative neoplasm increased 6-10/100,000 incidence proliferation 50-70 years most frequent (some exceptions)
myelodysplastic syndromes patients 80% are above 60 years 60-69 years:
7.1/100,000 incidence
over 80 years:
35.5/100,000 incidence
acute myeloid leukemia mean age: 60 years approx. 3/100,000 incidence
maturation defect
maturation defect and increased proliferation
Myeloproliferative neoplasms
Epidemiology 6-10/100,000 incidence 50-70 years most frequent (some exceptions)
Classification chronic myeloid leukemia polycythemia vera essential thrombocythemia primary myelofibrosis chronic neutrophilic leukemia mastocytosis MPN with eosinophilia
Chronic myeloid leukemia
1845 – first clinicopathological description of CML 1960 – description of Ph-chromosome (first cytogenetic change in malignancy) 1973 – description of Ph-translocation 1984 – BCR-ABL1 fusion protein altered adhesion in bone marrow increased proliferation increased survival more frequent commitment 1996 – first tyrosine kinase inhibitor (imatinib)
Chronic myeloid leukemia Epidemiology 1-2/100,000 incidence 50-60 years most frequent PTE Path: mean age: 52.9 years (7-84 years)
Clinical characteristics 20-45% symptomless loww of weight, fatigue, night sweats, abdominal dyscomfort leukocytosis (usually >100,000 /µl) thrombocytosis (usually >450,000 / µl) splenomegaly
Ph-negative MPNs Polycythemia vera
Essential thrombocythemia
Primary myelofibrosis
1-3
1-2
0.5-1.5
60 years
60 years
70-80 years
symptoms
hyperviscosity, thrombosis, spleen↑
thrombosis, bleeding, erythromelalgia
B-signs, anemia, liver/spleen↑
peripheral blood
erythrocytosis (Hgb>185, Htc>51%), mild neutrophilia, basophilia
thrombocytosis (>450), tct anisocytosis
thrombocytosis/CMLlike, leukoerythroblastosis, anisopoikilocytosis
bone marrow
trilinear proliferation mature, heterogenous megakaryocytes
normocellular hyperlobulated megakaryocytes
myeloid proliferation atypical megakaryocytes
cytogenetics
20%, not specific
< 5% , not specific
35-40%, not specific
mol. biology
JAK2
JAK2, MPL, other
JAK, MPL, other
transformation
2-3%
15 years
>15 years
3-10 years
incidence age
survival
Mastocytosis Epidemiology heterogenous diseases cutaneous mastocytosis: pediatric, usually < 6 months systemic mastocytosis: 50-80 years Classification cutaneous mastocytosis urticaria pigmentosa diffuse cutaneous mastocytosis solitary mastocytoma systemic mastocytosis bone marrow, skin, GI tract
MPNs are tyrosine kinase diseases
JAK2exon12 ≈4%
BCR-ABL1 100%
CML
JAK2V617F ≈95%
PRV
MPLW515 ≈5%
MPLW515 ≈10%
JAK2V617F ≈50%
JAK2V617F ≈50%
KITD816V ≈85%
PMF
Mastocytosis
ET
PDGFRα PDGFRβ FGFR1 abnorm. 100%
PDGFR/ FGFR1 neoplasms
Myeloproliferative neoplasms Summary • diseases of old age • increased proliferation – tyrosine kinases are often involved • complications due to high blood counts • risk of acute leukemia (blastic crisis) • risk of bone marrow fibrosis/insufficiency
Myelodysplastic syndromes
heterogenous diseases clonal HSC disease ineffective hematopoiesis
risk of acute leukemia diseases of old age
Myelodysplastic syndromes
Epidemiology 80% of patients are over 60 years 60-69 years:
7.1/100,000 incidence
over 80 years:
35.5/100,000 incidence
below 14 years: 0.1/100,000 incidence males are involved more frequently (2×) Etiology congenital bone marrow insufficiency, previous chemotherapy ionising radiation, chemical exposure (agriculture, chemical industry) Clinical characteristics neutropenia, anemia, thrombocytopenia
Myelodysplastic syndromes Morphology blood and bone marrow cytology/histology morphological signs of dysplasia dyserythropoesis dysgranulopoesis dysmegakaryopoesis blast ratio ring sideroblasts monocytes Genetics clonal cytogenetic/molecular genetic abnormalities Clinical picture exluding potential causes (eg. alcoholism, chronic liver disease, vitamin deficiency, etc.)
MDS – ineffective hematopoiesis
proaptotic bone marrow microenvironment inflammatory cytokines? (eg. TNFα, IFNγ) increased proliferation
T-cell mediated myelosuppression chronic, autoimmune-like activity?
restricted stem cell repertoir restricted differentiation potential myeloid as default pathway
Acute myeloid leukemia
Epidemiology 60 years mean age approx. 3/100,000 incidence
Etiology ionizing radiation chemotherapy: alkilating agents, topoisomerase inhibitors chemicals: pesticides, benzene, etc. genetic diseases: Down, Fanconi anemia, Bloom, Wiscott-Aldrich, etc.
Clinical picture complications of cytopenias: weakness, infections, bleeding extramedullary manifestation
Acute myeloid leukemia
Definition >20% blast in blood/bone marrow presence of characteristic genetic change + increased blasts „blast” may be: myeloblast promyelocyte monoblast promonocyte megakaryoblast erythroblast
Acute myeloid leukemia
Peripheral blood
Bone marrow
anemia, thrombocytopenia
hyper/hypocellular
may be aleukemic
may be fibrotic
Flow cytometry blast ratio determining lineage leukemia-associated immunophenotype (LAIP)
Molecular genetics RT-PCR based detection of translocations demonstrating mutations
Cytogenetics karyotyping and FISH
Acute myeloid leukemia Molecular pathogenesis type I mutation signal transduction pathway – increased proliferation eg.: NRAS/KRAS, FLT3, KIT, JAK2, PTPN11 type II mutation transcription factors – abnormal differentiation eg.: CBF, MLL, NPM1, CEPBA, RUNX1, RARA type III mutation? epigenetic regulation – abnormal differentiation eg.: TET2, IDH1/2, DNMT3A, ASXL2, EZH2
Pedersen-Bjergaard J et al. Leukemia. 2006;20(11): 1943–1949.
AML – WHO classification t(8;21)(q22;q22) – RUNX1-RUNX1T1
AML with recurrent genetic change
inv(16)(p13q22) – CBFB-MYH11 t(15;17)(q24;q21) – PML-RARA
AML with myelodysplasia associated changes
t(9;11)(p22;q23) – MLLT3-MLL
AML, therapy related
inv(3)(q21q26) – RPN1-EVI1
t(6;9)(p23;q34) – DEK-NUP214
t(1;22)(p13;q13) – RBM15-MKL1
AML, not otherwise specified
NPM1 mutation CEBPA mutation
Myeloid sarcoma
AML – t(15;17)
Characteristics 5-10% AML young adults DIC frequent favorable prognosis ATRA treatment induced differentiation myeloblasts around 10% variant translocations eg. t(11;17)(q23;q11) are not favorable hypergranular (classical) hypogranular (microgranular): bilobed, folded nucleus – monocyte-like strong CD33, CD177, however CD34-, HLADRPML-RARA fusion, abnormal PML localisation