RESEARCH ARTICLE
CD56-Positive Large B-cell Lymphoma
James Weisberger, MD,* Wojciech Gorczyca, MD, PhD,w and Marsha C. Kinney, MDz
Abstract: CD56 (NCAM), a neural adhesion molecule, is
normally expressed on natural killer cells and subsets of T cells
and is commonly seen on hematolymphoid neoplasms such as
plasma cell myeloma and acute myelogenous leukemia. It is
uncommon in B-cell lymphoma. From 2001 to 2003 a cohort of
20 cases of CD56+ B-cell lymphomas was identified by flow
cytometry (<0.5% of all B-cell lymphomas studied) during a
2-year period. Most (90%) expressed CD10 and 5/5 tested cases
were BCL6+, suggesting a follicular origin. An extranodal
disease presentation was seen in 45% and may be related to
CD56 expression. These CD56+ B-cell lymphomas may
represent a new subset of large B-cell lymphoma. The relation-
ship of cells with this antigenic profile to normal B-cell
differentiation is explored.
Key Words: CD56, B cell, flow cytometry, immunophoeno-
typing, immunohistochemistry
(Appl Immunohistochem Mol Morphol 2006;14:369–374)
C D56 identifies an isoform of the neural adhesion
molecule, or NCAM, which is a 140 kd membrane
glycoprotein normally expressed on natural killer (NK)
cells and a subset of T cells and monocytes1–3 as well as
neuroendocrine tissues and a variety of other epithelial
cells. It can also be commonly present in a variety of
hematolymphoid neoplasms, including those not asso-
ciated with NK origin, such as plasma cell myeloma
and acute myelogenous leukemia.4–12 CD56 expression is
rare in B-cell neoplasms. In the entity described as
microvillous B-cell lymphoma (MVML), a subset of large
cell lymphoma, 50% of cases were CD56+.13 There have
been other rare case reports of CD56+ B-cell neo-
plasms.14,15 We present data on 20 cases of CD56+ large
B-cell lymphoma (LBCL), 18 of which (90%) were
CD10+. Histology was available in 10 cases; all showed
diffuse large B-cell lymphoma (DLBCL) without a
sinusoidal growth pattern; one had immunoblastic/plas-
macytoid features. Extranodal presentation occurred in
Received for publication September 6, 2005; accepted October 27, 2005.
From the *Bio-Reference Laboratories, Inc, Elmwood Park, NJ;
wGenzyme Genetics, NY; and zDepartment of Pathology, Division
of Hematopathology, University of Texas Health Center, San
Antonio, TX.
Reprints: James Weisberger, MD, Bio-Reference Laboratories, Inc, 481
Edward H. Ross Drive, Elmwood Park, NJ 07407 (e-mail:
jweisberger@bioreference.com).
Copyright r 2006 by Lippincott Williams & Wilkins
Appl Immunohistochem Mol Morphol  Volume 14, Number 4, December 2006
45% of patients. CD56 expression in LBCL is uncom-
mon, and further study is required to determine whether
this represents a new and unusual subset of DLBCL.
MATERIALS AND METHODS
Specimens
The specimens were obtained from cases submitted
to IMPATH, Inc. (NY) over a 2-year period, from June
2001 to June 2003. Nineteen of the specimens were
analyzed by flow cytometry (FC), and 5 of these also had
immunohistochemical (IHC) evaluation. One additional
specimen had only IHC analysis, for a total of 6 IHC
analyses.
Cytomorphologic Correlation
Cytocentrifuge preparations and/or touch imprints
were prepared from the flow cytometric specimens for
cytologic correlation. In 10 cases there was sufficient
lymphoid or extranodal tissue so that a portion of the
sample was fixed in formalin, embedded in paraffin, and
H&E sections prepared. The one IHC only case also had
an accompanying H&E section.
FC
Multiparameter FC analysis was performed with
fresh cell suspensions of solid tissues, obtained by using a
manual dispersion method, in accordance with the
guidelines outlined in the US-Canadian Consensus
Conference on flow cytometric analysis.16,17 Immunophe-
notypic analysis was performed on FACSCalibur system
instruments equipped with a 15-mW, 488-nm, air-cooled
argon-ion laser supplemented with a 635-nm red diode
laser [Becton Dickinson Immunocytometry Systems
(BDIS), San Jose, CA]. Four-color directly labeled
antibody combinations consisting of fluorescein isothio-
cyanate, phycoerythrin, peridinin chlorophyll protein,
and allophycocyanin were used for surface staining of the
cell suspensions. Internal negative controls within each
tube and isotype controls for IgG1, IgG2a, and IgG2b
were used as negative controls. FC data were collected in
list mode and analyzed using CellQuest and CellQuest
Pro software (BDIS).
The daily instrument setup for intensity and color
compensation using CaliBRITE beads and FACSComp
software (version 4.0, BDIS) placed the lymphocyte
population between 200 and 400 on a linear channel on
forward scatter. Fluorescent beads were used to monitor
the consistency of the optical alignment of the instrument
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Weisberger et al Appl Immunohistochem Mol Morphol  Volume 14, Number 4, December 2006

TABLE 1. Four Color Flow Cytometry Tissue Panel

FITC PE PercP APC
Tube CD Clone Isotype CD Clone Isotype CD CD Clone Isotype
1 lgG2b lgG2b 7AAD lgG2b
2 lgG2a lgG2a 7AAD lgG2a
3 CD71 YDJ1.2.2 IgG1 CD56 NKH-1 IgG1 7AAD CD45 J.33 IgG1
4 CD8 T8 IgG1 CD2 T11 IgG1 7AAD CD4 13B8.2 IgG1
5 CD7 3A1E-12H7 lgG2b CD13-33 MY7-MY9 IgG1-2b 7AAD CD3 UCHT-1 IgG1
6 CD23 HD50 lgG2b CD5 BL1a IgG2a 7AAD CD38 HB7 IgG1
7 CD22 HD239(B3) lgG2b CD11c BU15 IgG1 7AAD CD19 J4.119 IgG1
8 CD20 B9E9 lgG2a Kappa F(ab)2 7AAD CD19 J4.119 IgG1
9 CD20 B9E9 lgG2a Lambda F(ab)2 7AAD CD19 J4.119 IgG1
10 CD5 BL1a lgG2a CD10 ALB1 IgG1 7AAD CD19 J4.119 IgG1

as part of daily instrument control, which assured the contained appropriate positive controls on the same slide,
reproducibility of the data generated. and a negative control.
Table 1 describes the 4-color antibody cocktails used
in analysis. All antibodies were obtained from Immunotech, RESULTS
a division of Beckman Coulter (Marseille, France) with the
exception of k and l, which were from DAKO Corporation Clinical Features
(Carpinteria, CA). In selected cases, tube combinations with Of the 20 cases identified during the study period,
CD19/CD56/CD45 were also run. there were 13 men and 7 women (M/F ratio, 1.9), ranging
in age from 23 to 84 years (median, 60 y). The anatomic
locations of the cases showed a tropism for extranodal
Immunohistochemistry sites (45%): 11 were in lymph nodes, 2 were in the parotid
Formalin-fixed paraffin-embedded tissue sections gland, 2 in brain or CSF, and 1 each in breast, lung,
were used for IHC studies in 6 cases. The antibody panel ileum, extranodal abdominal mass, and paraspinal soft
consisted of CD3, CD5, CD10, CD20, CD30, CD43, tissue. The lesions were de novo in 19 cases; 1 case
CD56, BCL2, and BCL6. EMA and ALK (CD246) were (number 13, Table 3) had a history of stage IV small
also analyzed in 5 cases. The primary antibodies and their lymphocytic lymphoma (SLL) 10 years prior to the
staining conditions are listed in Table 2. The staining was present diagnosis. Follow-up data were available in only
performed using a labeled streptavidin-biotin procedure in 2 cases: one patient relapsed after 1 year and is still alive
TechMate 500 automatic immunostainers (Ventana Med- with disease, and the other died of disease approximately
ical Systems, Tucson, AZ). Briefly, 4-mm-thick sections 1 year after diagnosis.
were incubated with unconjugated primary antibodies after
antigen retrieval, followed by incubation with biotinylated Immunophenotypic Features
secondary antibodies and streptavidin-conjugated perox- The FC (and the 1 IHC only case) immunopheno-
idase (BioGenix, San Ramon, CA). The colorimetric typic analyses are summarized in Table 3. All cases
reaction was completed with the chromogenic substrate displayed a forward scatter of >500 on a linear channel
diaminobenzidine (Sigma, St Louis, MO). Antigen retrie- and were positive for CD45RB, CD20 and CD56. Surface
val was performed with the heat-induced epitope retrieval immunoglobulin (sIg) light chain restriction was detected
method using a Tuttnauer 2340E autoclave at 1051C for 3 in 17/19 cases; k in 13 cases, l in 4 cases (k:l
minutes in target retrieval solution (DAKO). Each case ratio = 3.25:1) and 2 cases were sIg negative. CD10 was
positive in 18/20 cases (90%); the 2 negative cases were
TABLE 2. Primary Antibodies and Staining Conditions for both extranodal. CD11c was positive in 6/19 cases (32%);
Immunohistochemical Analysis these cases were all CD10 positive. CD5 was positive in 1
pH of Antigen
case (5%) which also expressed CD1018 and BCL6 and
Antibody Vendor Clone Dilution Retrieval lacked BCL1. All cases were negative for all other T-
cell–associated antigens, including CD2, CD3, CD4,
CD3 Novo-Castra F7.2.38 1:2000 9.50 ± 0.5
CD5 Novo-Castra 4C7 1:250 9.50 ± 0.5 CD7, and CD8. CD71, an activation antigen associated
CD10 Novo-Castra 56C6 1:25 5.95 ± 0.5 with higher grade lymphomas, was positive in 16/19 cases
CD20 Dako L26 1:2000 5.95 ± 0.5 (84%). See Table 3 for complete data and Figure 1 for
CD30 Dako BerH2 1:800 5.95 ± 0.5 representative flow cytograms.
CD43 BD Pharmingen L60 1:1,200,000 5.95 ± 0.5
CD56 Neomarkers NCAM 1:400 5.95 ± 0.5
IHC was done on 6 cases (30%), of which 5 also had
BCL2 Dako 124 1:800 5.95 ± 0.5 FC correlation. The 1 IHC only case was positive for
BCL6 Dako PG-B6p 1:160 9.50 ± 0.5 CD20, CD56, CD10, CD43, BCL2, and BCL6, and
CD246/ Dako ALK-1 1:20 5.95 ± 0.5 negative for CD30, EMA, and ALK. There was complete
ALK concordance between the 2 methodologies for CD5,
EMA Dako E29 1:2000 5.95 ± 0.5
CD10, CD20, and CD56. BCL2 was positive in all 6

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Appl Immunohistochem Mol Morphol

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TABLE 3. Immunophenotypic Data

Immunophenotypic Findings: FC & IHC


Volume 14, Number 4, December 2006
Cell Size
Age Sex Location (FS)* Histology CD5 CD10 CD11c CD19 CD20 CD22 CD23 CD30 CD43 CD45 CD56 CD71 Kappa Lambda BCL2 BCL6 EMA ALK
1. 74 M Peritoneal fluid Large Large cellsz    ++ + +++  ND ND ++ ++ +   ND ND ND ND
2. 41 M Ileocecal valve Large DLBCL  ++  ++ ++ +  ND ND ++ ++ ++  +++ ND ND ND ND
3.w 52 M LN Large DLBCL  + ND ND ++ ND   ++ ND ++ ND ND ND  ++  
4. 54 M LN Medium DLBCL ++ ++  ++ ++ ++  ND ++ ++ S  +++  ND ++ ND ND
5. 83 M spine Large DLBCL  + + ++ ++ ND    ++ ++ ++ ++  ++ ND ND ND
6. 56 M CSF Large Large cellsz  ++  ++ +++ ND  ND ND ++ ++ ++ ++  ND ND ND ND
7. 49 M LN Large DLBCL  ++ + ++ ++ ++  ND ND ++ ++ ++ ++  ND ND ND ND
8. 57 F Abdomen Large DLBCL  ++ + ++ ++ ++ ++ ND ND ++ +++ ++ +++  ND ++ ND ND
9. 69 F LN Large DLBCL  ++  ++ ++    ND ++ S +  ++ S ND  ND
10. 56 M Abdomen Med./Large Large cellsz  +++  ++ +++ + + ND ND ++ +++ ++ +++  ND ND ND ND
11. 80 F LN Large Large cellsz  ++ ++ ++ ++ ++ + ND ND ++ ++  +  ND ND ND ND
12. 60 F Breast Med./Large Large cellsz  ++ ++ ++ ++ +  ND ND ++ ++ +  + ND ND ND ND
13. 77 M LN Large DLBCL  ++  ++ +++ +    ++ +++ ++ +++  ++ ++  
14. 35 F Parotid Large Large cellsz  ++  + ++   ND ND ++ +++  ++  ND ND ND ND
15. 50 F Lung Medium Large cellsz  +  ++ ++ +   ++ ++ ++ S ++  ++ ++  
16. 41 M Parotid Large NA (QNS)  ++  ++ ++ ++  ND ND ++ ++ ++ ++  ND ND ND ND
17. 23 M LN Medium NA (QNS)  ++  ++ ++ +  ND ND ++ +++ ++ ++  ND ND ND ND
18. 81 F LN Large Large cellsz  ++  ++ ++ ++  ND ND ++ +++ ++  ++ ND ND ND ND
19. 84 M LN Large DLBCL  ++ + + ++ +  ND ND ++ +++ ++   ND ND ND 
20. 77 M Brain Large DLBCL    + ++ ++  S  ++ ++ ++ +  ++ ND  

CD56-Positive Large B-cell Lymphoma

*By forward scatter, except case 3, which was by cytomorphology.
wOnly IHC performed; all other results by FC analysis. See text for details.
zBy touch imprint cytology.
ND indicates not done; S, subset (<50% of cells immunoreactive); +, dim; ++, moderate; +++, bright.
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Weisberger et al Appl Immunohistochem Mol Morphol  Volume 14, Number 4, December 2006

FIGURE 1. Representative flow cytometric analysis depicts a k-restricted B-cell population expressing CD10 and CD56 (top
cytograms), and a surface immunoglobulin-negative and CD56-positive B-cell population (bottom cytograms).

cases (2 were only focally positive) and BCL6 was positive
in 5/5 tested cases. CD43 was positive in 3/6 tested cases
(50%); all of these cases were CD10 and BCL6 positive.
Both ALK and EMA were negative in 5 tested cases (0/5).
CD30 was focally positive in 1 of 6 tested cases (17%; this
case was also negative for ALK and EMA). See Figure 2
for a representative IHC case.
Cytomorphology
Histology was available in 10 cases, all of which
showed DLBCL with complete nodal architectural
effacement and without any apparent sinusoidal distribu-
tion or nodularity. The cytology ranged from centrocytic/
centroblastic (5 cases), pure centroblastic (4 cases) to
immunoblastic/plasmacytoid (1 case, see Table 3, no.13).

FIGURE 2. A representative com-

posite IHC analysis (from patient
#3, Table 3) showing, from left to
right: top: H&E, CD20 (moderately
positive), CD10 (dimly positive);
middle: CD3 (negative), CD5 (ne-
gative), CD43 (moderately posi-
tive); bottom: BCL2 (negative),
BCL6 (moderately positive), CD56
(moderately positive). All images
are 400  .

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Appl Immunohistochem Mol Morphol  Volume 14, Number 4, December 2006
The remaining FC cases had touch imprints and/or
cytospins, all of which showed large lymphoid cells (more
than twice the size of a small lymphocyte) with mostly
inconspicuous nucleoli and scanty pale blue to basophilic
cytoplasm without vacuoles.
DISCUSSION
Herein we report a cohort of CD56+ LBCL, the
majority of which also express CD10 and/or BCL6,
antigens associated with germinal center cell origin. This
unique antigenic profile is rare and represents <0.5% of
B-cell lymphomas analyzed over the data collection
period. Previous studies of 83 cases of DLBCL showed
weak expression of CD56 in one case (1.2%).11,19
CD56 (NCAM) is a member of the immunoglobulin
superfamily and is instrumental in cell adhesion and
recognition. It mediates cell to cell adhesion by CD56
molecules from adjacent cells binding together (eg,
homotypic adhesion interactions).20,21 Its expression on
NK cells and subsets of T cells, acute myelogenous
leukemia, and plasma cell neoplasms is well known. It is
useful in distinguishing plasma cell myeloma from
monoclonal gammopathy of undetermined significance
and non-Hodgkin lymphoma (NHL) with plasmacytoid
differentiation.22 CD56 is expressed on a majority of
plasma cell myelomas and may connote a better prog-
nosis than CD56-negative myeloma.23 Bone marrow
stromal cells express CD56 and clonotypic up-regulation
and amplification of CD56 might confer a selective
advantage with respect to plasma cell proliferation in
the bone marrow matrix. Of note, primary plasma cell
leukemia is often CD56-negative,24 which also implies
that up-regulation of CD56 in plasma cells plays an
important role in confinement of tumor cells to the
marrow.
Current lymphoma classification is principally
based on the normal lymphocyte counterpart of the
neoplastic proliferation. The function of CD56 with
respect to B-cell ontogeny is unclear. Although non-
neoplastic plasma cells and peripheral B-cells do not
express CD56, the expression of NCAM has been
detected in a precursor B-cell lineage NALM-16 cell
line.25 It has also been noted that human pluripotent stem
cells coexpress CD10 and CD56.26 Reynauld et al27 have
demonstrated that early pro-B-cells (PAX 5 negative)
have the capacity to differentiate into CD56+ NK cells as
well as macrophages and T cells. On the basis of these
studies, it seems that a subset of very early precursor B-
cells have the innate capacity for CD56 expression that is
down-regulated and extinguished later in differentiation.
In addition to CD56 and CD10, the lymphomas
described herein express BCL6. In contrast to CD56,
BCL6 was studied in B-cell lines from pre-B to plasma cell
stage, and is only activated (fused to heterologous
promoter regions) in B-cells within the germinal center.28
However, somatic BCL6 mutation has been detected in
1/21 (4.8%) of pregerminal center cells.29
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CD56-Positive Large B-cell Lymphoma
CD43, expressed in 50% of IHC-tested cases in this
series, is a major cell surface sialoglycoprotein on most
hematopoietic cells and has been implicated in lympho-
cyte activation, intercellular adhesion, and locomotion.
CD43 is present in up to 90% to 100% of small
lymphocytic lymphoma, mantle cell lymphoma, and
Burkitt lymphoma, and in approximately 20% to 30%
of diffuse LBCL, lymphoplasmacytoid lymphoma,
and marginal zone lymphoma (other than splenic
marginal zone lymphoma, which is lower).30 CD43
expression is uncommon in follicular lymphoma (1% to
2% of grade I or II) but has been noted to be more
frequent in grade II follicular lymphoma with diffuse
areas (6%).30
This rare CD56+, CD10+, BCL2+, BCL6+,
CD43+/  subset of LBCL seems unique. Expression of
CD45RB, CD20, and surface immunoglobulin argues
against the diagnosis of dysplastic myeloma. The absence
of ALK, EMA, and CD4 expression excludes ALK+ B-
cell lymphoma described by Delsol et al.31 CD30
expression was tested to investigate the relationship of
these CD56+ lymphomas to CD30+ LBCL. CD30 was
only weakly expressed in 1 of 6 cases tested. In addition,
Hamilton et al32 examined 25 cases of CD30+ B-cell
lymphoma (with and without anaplastic features) for
CD56 expression and all were negative. The presence of
CD56 and lack of EMA suggests a relationship to
microvillous malignant lymphoma (MVML). Hammer
et al13 studied 8 cases of MVML and found 50% of the
cases were CD56+ and 88% were BCL2+; BCL2 gene
rearrangement was found in 1 of 3 cases tested (33%). All
cases were negative for EMA and CD43. IHC staining for
BCL6 has not been performed in MVML. Ultrastructural
studies were performed on paraffin-embedded tissue in
2 cases in the present study (case numbers 8 and 13, data
not shown; microvilli were not detected, but the cellular
detail was not optimal). Most MLVL have a component
of sinus growth33 that was not seen in our cases, but tissue
correlation was only available in 6 cases.
It is well known that CD56+ NHL of T or NK
derivation has an aggressive clinical course, but the
clinical relevance of CD56+ expression in B-NHL is
unknown. One case report of CD56+ B-cell NHL14
describes complete remission for 10 months after CHOP
chemotherapy. This case also expressed CD5. The limited
follow-up data in our cohort is inconclusive (1 patient
relapsed after 1 y and is alive with disease and the other
died of disease after 1 y); however, follow-up data
collection is limited in a reference laboratory setting.
In summary, we report a group of CD56+ B-cell
LBCL, most of which are of germinal center cell origin
and have a propensity for extranodal involvement. It is
tempting to speculate that the predominance of extra-
nodal involvement in our series may be related to the
adhesive properties of CD56. There is some immuno-
phenotypic overlap of these cases with MVMLs that are
frequently CD56+. Further studies are required to
determine whether this is a distinct clinicopathologic
entity.
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Weisberger et al Appl Immunohistochem Mol Morphol
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