Lymphoma

Dr. Mahmoud Elprawy

‫اى صورة او ساليد زيادة فهى للفهم فقط وال تمت •‬
‫لالمتحانات بأى صلة‬
 Content of lecture
Types of lymphoma
1. Hodgkin’s lymphoma
2. Non Hodgkins lymphoma
Types of Hodgkin’s lymphoma
A- nodular lymphocytic predominent
B- Nodular sclerosis HL
C- Mixed cellularity HL
D- Lymphocyte Depletion HL
E- Lymphocyte rich HL
Types of non Hodgkin’s lymphoma
A- Follicular Lymphoma.
B- Small Lymphocytic Lymphoma / Chronic Lymphocytic Leukemia
C- Diffuse Large B-Cell Lymphoma.
D- Burkitt Lymphoma.
E- Peripheral T-cell lymphoma
 Case Senario
Male ptn aged 54 years come to out patient clinic suffering from multiple
masses in axillary area Localized to single axial group of L.N (cervical,
mediastinal, para- aortic L.N) then spread in a stepwise fashion to the contiguous
nodes. The patient has no other lymph nodes involved.
Histopathologically there was identification of Reed-Sternberg cells in a
background of reactive inflammatory cells.
Reed-Sternberg (RS) is a large cell (15-45 μm in diameter) with large
multilobated nucleus, prominent nucleoli and abundant usually slightly
eosinophilic, cytoplasm. The Immunophenotyping of the RS cells is positive
expression of CD15 & CD30.
The reactive inflammatory cells include small lymphocytes, eosinophils,
plasma cells and benign histiocytes.
1- what is the probable diagnosis?
 Tumors of LN

2ndry ( Metastasis ) Primary ( Lymphoma )

General Features :
N/E :
-Enlarged
-Firm
-Greyish pink in C/S
--start discrete >>> invasion of capsule >>> Mated
M/E :
-loss of nodal architecture
-replacement of tissue by a neoplastic one

Normal ( Normal lymphocyte + Malignant cell R.S ) >>>

Hodgkin

Turned and replaced by Malignant cells

>>>Non-Hodgkin
Hodgkin Lymphoma

Normal cell >>> ( Normal cell LYMPHOCYTE + Malignant cell R.S. )

Reed Strenberg Cell : Hodgkin

Age Young age
-Large cell > 50 yrs
-Large multi lobulated nucleus
-prominent nucleoli Lymphocyte B-lymphocyte
-large cytoplasm R.S.
-CD 15 & CD 30 Spread Contagious
-Two mirror image nuclei LN Localized to single
-owl-eye appearance LN ( Cervical )
Extra-nodal Rare
- Rare in
mesenteric and
waldeyer ring
Story Timeline

Thomas Hodgkin
Group of clinical manifestation with Enlarged LN ( Hodgkin dse ).

Reed & Sternberg

Studied pathology of enlarged LN and found characteristic cell

Others
Studied Variants of R.S cell

Mono-nuclear H cell Lacunar cells ( cavity ) Pop Corn(lymp-histocyte)

Hodgkin Lymphoma Pathology

Reed Sternberg cell + Normal reactive cell ( lymphocyte, plasma cell ,etc )
Reed Sternberg cell + Normal reactive cell ( lymphocyte, plasma cell ,etc )

Lymphocytic Rich ( predominant ) Nodular Lymphocytic predominant

Lymphocytic Depletion

Mixed cellularity Nodular Sclerosis

 Lymphocyti Lymphocyti Mixed Nodular Nodular
c Rich ( c Depletion cellularity Sclerosis Lymphocyti
predomina c
nt ) predomina
nt

Age & -Any age -Older - >50 Yrs -Young -4th decade
gender MCQ -Male -M=F -Male
M/E General features General features General features General features General features

Structure
RS vs Lymphocyte R.S . Lymphocyte
Lymphocyte

prognosis Good Bad Intermediate Good Good

R.S cell Typical Typical Typical Lacunar Pop corn

MCQ

Note MCQ uncommon Common >50 Most

common
Definition: Malignant neoplasms derived from native cells of lymphoid tissues
(lymphocytes and rarely histiocytes).
According to the presence or absence of of characteristic Reed-Sternberg (RS) cells;
Two broad categories are recognized:
- Hodgkin’s lymphoma
Non Hodgkin’s lymphoma
Hodgkin’s lymphoma (HL)
A group of neoplasms the diagnosis of which rests on the identification of Reed-
Sternberg cell or their variants in a background of mixture of reactive inflammatory cells.
It arises in a single lymph node or chain of lymph nodes.
N/B: Carl Sternberg (1898) and Dorothy Reed (1902) are credited with the first
definitive and thorough descriptions of Hodgkin lymphoma, so the diagnostic Reed
Sternberg cells is named after them
Clinical characters:
The disease has two peaks; first in young adults; second peak over the age of 50.
Localized to single axial group of L.N (cervical, mediastinal, para- aortic L.N) then
spread in a stepwise fashion to the contiguous nodes.
Mesentric nodes & Waldeyer ring rarely involved.
Extra- nodal involvement is uncommon.
Histopathology:
The histologic diagnosis depends on identification of Reed-Sternberg cells in a background of
reactive inflammatory cells.
Reed-Sternberg (RS) is a large cell (15-45 μm in diameter) with large multilobated nucleus,
prominent nucleoli and abundant usually slightly eosinophilic, cytoplasm. The immunophenotype
of the RS cells is positive expression of CD15 & CD30.
The reactive inflammatory cells include small
lymphocytes, eosinophils, plasma cells and benign histiocytes
Types of Hodgkin's lymphoma:

- Nodular lymphocyte predominant HL

- Nodular sclerosis HL

- Mixed cellularity HL

- Lymphocyte depletion HL
 Classic or typical (RS) cells: Characteristic
cells have two mirror-image nuclei, each
containing a large (inclusion-like)
acidophilic nucleolus giving owl-eye
appearance.
Reed-Sternberg cells and variants:
 Classic or typical Reed-Sternberg cell Classic or typical (RS)
 Reed-Sternberg cell, mononuclear variant
 Reed-Sternberg cell, lacunar variant
 Reed-Sternberg cell, lymphohistiocytic
(L&H) popcorn variant

mononuclear variant
1- Nodular lymphocyte predominant
HL:
-Common in male gender in the 4th decade of
life.
-Microscopically: Loss of nodal architecture
Diffuse infiltrate (with mature lymphocytes
admixed with histiocytes). lacunar variant
-Classic RS cells are extremely difficult to find
but instead there is lympho-histiocytic (L&H)
variant that have multilobed, puffy nucleus
similar in appearance to popcorn ("popcorn
cell").
-Excellent prognosis

Popcorn cell
2- Nodular sclerosis HL:
-The most common subtype of Hodgkin lymphoma
-Adolescent or young
-Equally in men and women
-Dense collageneous bands subdivide the lymphoid tissue in to circumscribed nodules.
-Varying proportions of lacunar cells and lymphocytes.
-Excellent porgnosis
3- Mixed cellularity HL:
-This is the most common form in patients older than the age of 50 year
-Typical RS are plentiful
-Mixed celluar infiltrate (eosinophils, plasma cells, and histiocytes).
-The prognosis is intermediate
4- Lymphocyte Depletion HL:
Uncommon pattern, affects older patients.
Paucity of lymphocytes and relative abundance of RS (anaplastic).
Mixed cellular infiltrate. Very poor prognosis

5-Lymphocyte rich HL
It can occur at any age , and is more common in men than in women
Lymphocyte rich type
Excellent prognosis
Non Hodgkin Lymphoma (NHL):
Characters of NHL
- NHL may be indolent or aggressive in behavior.
- They interfere with the immune system by dysregulating the function of normal B and T
cells.
- They often contain chromosomal translocations or mutations involving genes that regulate
development and survival
- More frequent involvement of multiple peripheral node
- Non contiguous spread
- Mesenteric nodes and Waldeyer ring commonly involved
- Extra-nodal involvement is common
Follicular Lymphoma
40% of adult lymphomas of B cell phenotyping.
It usually involves lymph nodes, marrow, and spleen.
The growth pattern is mainly nodular & formed of small "cleaved" cells& large cell.
It is associated with t(14;18) with BcL-2 over expression by mature B cells
 Tumors of LN

2ndry ( Metastasis ) Primary ( Lymphoma )

General Features :
N/E :
-Enlarged
-Firm
-Greyish pink in C/S
--start discrete >>> invasion of capsule >>> Mated
M/E :
-loss of nodal architecture
-replacement of tissue by a neoplastic one

Normal ( Normal lymphocyte + Malignant cell R.S ) >>>

Hodgkin

Turned and replaced by Malignant cells

>>>Non-Hodgkin
NON-Hodgkin Lymphoma

Normal cell >>> (Abnormal Malignant LYMPHOCYTE )

Non-Hodgkin
Age Any age
Lymphocyte B-lymphocyte
T-lymphocyte
No R.S.
Spread Non-Contagious
LN Multiple
Extra-nodal Common
-common in
mesenteric and
waldyer ring
 Hodgkin Non-Hodgkin

Age Young age Any age

> 50 yrs

Lymphocyte B-lymphocyte B-lymphocyte

R.S. T-lymphocyte
No R.S.

Spread Contagious Non-Contagious

LN Localized to single Multiple

LN

Extra-nodal Rare Common

- Rare in mesenteric -common in
and waldeyer ring mesenteric and
waldyer ring
Follicular ( Nodular ) Lymphoma

40 % of adult B-cell lymphoma -

Large cells >>> nodular
Nodal & extra nodal
T(14;18) with BCL 2 gene over expression

Small Lymphocytic Lymphoma /CLL

3 % of adult lymphoma
30% Of leukaemia ( blood , bone marrow )
Small cells
Nodal & extra nodal
CD5+B-cell expression surface Ig
Diffuse Large B-cell Lymphoma

50 % of lymphoma >>> Aggressive

Any age
large cells
extra nodal mainly
Associated with BCL 6 gene
CD10

Burkitt’s B-cell Lymphoma

Children
Endemic and Sporadic
EBV
Starry Sky appearance ( macrophages )
CD10

A>Africa B>Burkitt B-cell C>Children

D>CD10, Dead bodies SS E>EBV
Small Lymphocytic Lymphoma / Chronic
Lymphocytic Leukemia
- 3% of adult lymphomas, 30% of all
leukemias, indolent course
- Occurs in older adults usually involves nodes,
marrow, and spleen.
- Most patients have peripheral blood
involvement
- Diffuse effacement by small rounded
lymphocytes
- CD5+ B-cell expressing surface Ig.
Diffuse Large B-Cell Lymphoma
- 50% of lymphomas; aggressive course
- Occurs in all ages; often arise at extra-nodal
sites
- Highly associated with rearrangements or
mutations of BCL6 gene.
- Transformed lymphoid cells with vesicular
nuclei and mitotic figures
- B cells with variable expression of CD10 and
surface Ig
Burkitt’s Lymphoma

- High grade lymphoma predominantly affects children it divides into two types

1. Endemic in Africa, usually presents as mass in the jaw in young boys

2. sporadic elsewhere, often presents at extra-nodal sites with visceral involvement.

- It is often associated with infection by Epstein-Barr virus.

- Highly aggressive tumor of B cells formed of diffuse involvement by intermediate-sized

cells, excess mitoses & a "starry-sky" appearance.

- Immunophenotyping expression of CD10+ B cells & surface Ig.

Peripheral T-cell lymphoma
- Most common adult T-cell lymphoma.
- Often disseminated, generally aggressive.
- Spectrum of small to large lymphoid cells with
irregular nuclear contours.
- CD3+ mature T-cell phenotype.
Mycosis fungoides
• Most common cutaneous lymphoid
malignancy, generally indolent.
• Presents with localized or more generalized
skin involvement.
• Small lymphoid cells often infiltrate the
epidermis (Pautrier micro abscesses).
• The lymphoid cells are CD4+mature T cells.
• Sézary syndrome: a more aggressive
variant characterized by diffuse skin
involvement presented clinically as erythema
with peripheral blood involvement.
Follicular Small Large Burkitt T-cell
lymphom
a

T(14;18) CD5 CD10 CD10 CD3

 Question 1
- Regarding classic RS (reed sternburg) is diagnostic and specific of which one of the

followings?

Nodular lymphocyte predominant HL

- Nodular sclerosis HL

- Mixed cellularity HL

- Lymphocyte depletion HL

- Lymphocyte rich HL
 Question 2
- Regarding pop corn or lacunar cells is diagnostic and specific of which one of the

followings?

Nodular lymphocyte predominant HL

- Nodular sclerosis HL

- Mixed cellularity HL

- Lymphocyte depletion HL

- Lymphocyte rich HL
 Question 3
Regarding Pautrier micro abscesses is diagnostic and
specific of which one of the followings?
A- Follicular Lymphoma.
B- Small Lymphocytic Lymphoma / Chronic Lymphocytic Leukemia
C- Diffuse Large B-Cell Lymphoma.
D- Burkitt Lymphoma.
E- Peripheral T-cell lymphoma
 References or further
readings
• Robbins pathological bases of diseases