HODGKIN’S LYMPHOMA

Prashant.P.Joshi
Thomas Hodgkin :
• 1798- 1866.
• Quaker religion, Victorian era..
• Guy’s hospital (1825-37), St.Thomas hospital..London,
now part of King’s college
• Astley Cooper  Edinburgh university (Scotland)
– “On the uses of Speen” first paper
– against popular Aristotelian and Hippocratic beliefs of the time
(seat of laughter..)
• Paris  Laennec (inventor of stethoscope)
• Von Humboldt (hero of my youth), Cuvier..
• Returned to Guy’s  “Inspector of the dead”
“ Curator of the museum”
• Close association with Joseph Jackson Lister
(developed achromatic microscope)
• Morbid anatomist : clinico-pathologic correlations
• Desired clinicians post but ran into difference with
Benjamin Harrison..resigned from all posts
• Journeyed, helping jews and christians in moslem
lands..
• Died of an unknown, lengthy illness
• “Nothing of Humanity was foreign to him”
 Medical accomplishments:
• Lecture at Guy’s hospital on uses of stethoscope lead to
its acceptance in England..
• Leading morbid anatomist of his day..by 1829 had 1600
pathologic specimens..pioneer of clinico-pathologic
correlations..
• Described
– Appendicitis with perforation peritonitis
– Spread of cancer to the lymph nodes
– Biconcave nature of erythrocyte
– Fibrillar nature of muscle
– Three layers of arterial wall
– Importance of fiber in diet
– Cautioned against tobacco, alcohol
“On some morbid appearances of the absorbent
glands and spleen”
• 1832, 6 cases, 3 of which turned out to be Hodgkin’s
on HPE.
• LN enlargement not assoc with
pain/heat/metastases..
• Microscopically described about 3 decades later..
• Described as Hodgkins lymphoma by Wilks in 1856 in
paper titled “ Historical notes on Bright’s disease,
Addison’s disease and Hodgkin’s disease”
 Clinical features

• Unusual presentations of hodgkins lymphoma:

– B-symptoms :
• unexplained fever >38 degrees
• Unexplained weight loss>10% in 6 months
• Night sweats
– Pruritus
– Cutaneous manifestations
• Primary cutaneous HL
• Lymphomatoid papulomatosis
• Paraneoplastic syndromes
• Infections
– Neurologic
– Alcohol induced pain
Microscopy:

Diagnostic RS cells/variants Appropriate cellular milieu

• Small lymphocytes predominantly • Histiocytes:

• Epitheliod/ foamy
– Tcells > Bcells
• granulomas, MNG’s
– CD4+ >>CD8+ • Foci of Langerhans cells
– LRCHL, esp nodular, Bcell rich infiltrate • D/d : lennerts lymphoma
Xanthogranulomaotus
• Eosinophils lipid storage disorder
– Usually > neutrophils
• Plasma cells:
– Abscesses
• Usually few, scatterd
• Neutrophils • if in large numbers reconsider
– Correlate with B symptoms Hodgkins as diagnosis
 Reed-Sternberg cells/ Hodgkin cells

Classic RS cell
Mononuclear variant
L&H cell/ popcorn cell Lacunar variant
Mummified/zombie cells
Classic RS cell:
• 20-50 microns
• Multi-nucleated (binucleated, mirror image, owl-eye)
• Thick nuclear membrane
• Nucleolus:
– ~10 microns
– Size of small lymphocyte nucleus
– Surrounded by clear zone
• Cytoplasm
– Abundant
– Acido/ampho/basophilic
– LACKS peri-nuclear hof ( seen in Immunoblastic cells)
• Mononuclear variant:
– Similar to classic RS cell
– Not multinucleated/lobated

• Lacunar variant:
– Mono/multinucleated
– Retracted cytoplasm in formalin fixed tissue
– In metal based fixatives :
amphophilic cytoplasm
– Nucleus:
• Smaller lobes
• More irregularities
• Eosinophilic nucleous may be
less prominent
• Mummified/ Zombie cells :
– Apoptotic RS cells
– Pyknotic chromatin
– Barely recognizable nucleolus
with fuzzy margins
– Deeply eosinophilc retracted cytoplasm

• L&H cell/ popcorn cell:

– In and around nodules in NLPHL
– ~centroblasts:
• Larger, lobulated nuclei
• Small-moderate sized nucleolus,
adjacent to nuclear membrane
• Cytoplasm slightly basophilic
– Do not form sheets usually
 Subtypes : necessary to differentiate?
• WHO present classification 1999
– Nodular lymphocyte predominant hodgkin lymphoma
– Classical hodgkins lymphoma
• Nodular sclerosis
• Mixed cellularity
• Lympocyte predominant
• Lymphocyte depleted
• NLPHL :
– different phenotype of L&H cell
– Early stages treated with RT only
• Classical:
– Different histomorphology
– Different cytokine expression
– Minor prognostic importance
 How to subtype..
• Grossly :

NLPHL:
Larger (2-8cms) Classical hodgkins
Vague/distinct lymphoma
nodules
Rim of uninvolved
lymphoid tissue

MC and LDCHL: NS:

Usu non-adherent Adherent
Soft-firm Firm
• Histomorphology Vague nodularity Distinct nodularity
Foci of necrosis
• Immunohistochemistry
 Nodular sclerosis (NS):
• Most common in western world; >2/3rd cases
• One or more collagenous bands + Lacunar cells
• Radiate from thickened capsule
Lacunar cells:
• Course of penetrating artery
Sheets
• Mature, laminated, acellular,
Surrounding a central area of
birefringent collagen
necrosis
• If absent ?
Eosinophils and neutrophils
• Cellular phase
predominate
• Follicular hodgkins
Few histoiocytes/plasma cells
•Follicular variant of LRCHL

GRADE 2 NODULAR SCLEROSIS:

(a) > 25% of the cellular nodules show reticular or pleomorphic lymphocyte depletion,
(b) > 80% of the cellular nodules show the fibrohistiocytic variant of lymphocyte
depletion
(c) > 25% of the nodules contain numerous bizarre and highly anaplastic
appearing Hodgkin cells without depletion of lymphocytes.
• NS pictures
Mixed cellularity:

• ~ 30% in western literature

• Most common in developing
countries
• Falls between LRCHL and LDCHL
• Intact capsule of normal thickness
• Vague nodularity, no sclerosis
• Classic RS cells, mononuclear variant + mixture of
background cells
• Small foci of necrosis
• MC pictures
 Lymphocyte depleted (LDCHL):

• Diffuse fibrosis:
– Reticulin fibrosis around individual cells
– Lymphocyte depletion
– No thick collagen bands
• Reticular:
– Sheets of hodgkins cells
– marked pleomorphism
• d/d large cell NHL
 Lymphocyte rich (LRCHL):

• Hodgkins cells relatively rare

• Background of small mature lymphocytes
– Predominantly B cells (other subtypes have T cells)
• Eosinophils, neutrophils restricted to blood vessels.
• Nodules:
– Vague
– Distinct : follicular variant of LRCHL
• Small reactive germinal centres
• RS cells in/near mantle zones
Other variants:
• Syncytial variant of NS:
– Cohesive aggregates of lacunar cells
• Interfollicular Hodgins :
– Reactive follicles
– Hodgkin cells in the interfollicular paracortical region
– ~ viral infections
• Fibroblastic variant:
– No collagen band deposition
– Associated with shorter relapse free survival period
• Follicular Hodgkins:
– Classic + b cell lineage antigens
– RS cells in mantle zone
– Atrophic follicle centre, eccentrically placed,
no RS cells.
Nodular lymphocyte predominant (NLPHL):
• Separate entity; L&H(popcorn) cells characteristic.
• Complete/subtotal effacement of LN architechture
• Rim of uneffaced LN tissue with PTGC
• Fibrosis uncommon, though band like fibrosis can be seen
• If no nodularity seen diagnosis should be reconsidered
• Lymphocytes and epithelioid histocytes predominate
• Eosinophils, neutrophils, plasma cells are rare
• Nodules:
– Large nos. of B cells in nodules CD21
– T cells predominate in interfollicular region
– L&H cells in nodules; surrounded by CD57 +ve T lymphocytes(rosetting)
– CD21 Follicular dendritic cells ++ in nodules, absent in diffuse areas
• 2-3% develop DLBCL
Large irregular nodules
Immunophenotype:
• Flow cytometry not useful; gating difficult
• IHC:
– CD45-RB:
• Leucocyte common antigen(LCA)
• Important NEGATIVE marker
• but ALCL : neg in 33%cases

– CD30 :
• Ki-1 antigen (cytokine receptor of TNF alpha family)
• Stains activated T and B lymphocytes, Immunoblasts CD30
• + in virtually all classical hodgkins lymphoma
• Strong membranous and/or paranuclear + weak diffuse cytoplamic positvity
• Also +ve : all cases of ALCL, lymphomatoid papulosis and 40% of PTCL.
• CD15:
– Carbohydrate X hapten (lacto-N-fucipentose, trisaccahride)
– Stains mature neutrophils, macrophages, activated T-cells,
– 2/3rd AML , 20% T cell lymphomas, Lungs Adenoca
– 87% of classical Hodgkin’s +ve
– NHL : cyt granular positivity
– HL: similar to CD30
– CD15-ve cases:
• Older patients, advanced stage
• Mixed cellularity
– Multivariate analysis shows CD15-vity as
an independent adverse prognostic indicator.
• CD20:
– Mature Bcell antigen
– Stains vast majority of B cell neoplasms except Bcell ALL, Plasma cell
neoplasms
– NHL: consistent strong staining
– HL: ~25% +ve, but only a subset of cells, that too in a heterogenous
pattern.
– Hodgkin cells:
• Do not have functional transcripts of immunoglobulin chains
• CRIPPLED B cells
• PAX-5 +ve,
• BOB1, Oct2 –ve
• May stain +ve for immunoglobulins due to passive adsorption from tissue fluid.
• CD3:
– Hodgkin cells rarely +ve

CD74
• Other markers: Restin
HLA-DR1
– EBV LMP:
Class 1 antigens
• +ve in MC, LDCHL
CD25(IL-2 receptor)
CD71(transferrin receptor)
– CD40: Ki-67
• 80-100% HL PCNA
P34
• 20% ALCL
cyclinD2
P53
– Fascin: Bcl-2
• Dendritic cell marker Mdm2
• Classical hodgkins +ve C-rel
• NHL +ve only in 15% cases
TRAP NF-kB pathway
•
C-FLIP
No staining of L&H cells of NLPHL.
• NLPHL IHC : (L&H cells)
– CD45 +ve
– Bcell markers +ve (CD20,45RA,79a, PAX-5)
– Tcell markers –ve (CD3, CD45RO)
– CD30-ve EBV LMP in mixed cellularity
– CD15 –ve almost always
– EBV LMP –ve.
Differentials:
• Interfollicular Hodgkinoid lymphadenitis:
– Reactive germinal centres + immunoblasts in paracortex
– Evenly dispersed immunoblasts
– Basophilic cytoplasm, perinuclear hof
– Plasmacytosis
– Transitional forms
– CD30+ve
– CD15-ve (though in CMV related : CD15+ve)

• Tcell rich Bcell lymphoma:

– CD15, 30 –ve
– 45,20+ve
– EMA +ve
– Close differential of NLPHL
 Nature of RS and L&H cells:
• Histology of Hodgkins lymphoma : Greenfield and Langhans
• Carl Sternberg and Dorothy Reed independently described
the giant cells..subsequently called RS cell.
 Classical RS cell L&H cell

IHC : ?activated B cells/ ?dendritic cells IHC : B cell origin

Ultrastructure : ~immunoblast Ig V region somatic mutations +

Microdissection & single cell PCR : But also show intraclonal diversification
i.e ongoing hypermutation activity
clonal Ig V region rearrangement
: B cell origin Bcl-6 : transcription factor specific to germinal
: Ag activated germinal/post germinal centre cells
centre cells
No intraclonal diversification Activation induced deaminase : +ve
25% carried non-sense mutations which
rendered V gene rearrangements non No crippling mutations found
functional
Crippling mutations  apoptosis
normally, but RS cells escape..(reasons largely
unknown)

Crippled B cell..but loss of phenotype due to Multinucleation :

epigenetic mechanisms ( DNA methylation) Endomitosis
Scheme for
development of
composite lymphoma
Transforming ability

• Comparative genomic hybridisation:

– Recurrent genomic imbalances in chr 2, 9, 12
– activated Jak2 kinases  STAT constiutive activation
– Mdm2 activation  p53 inactivation
– No mutations in caspases/FADD/CD95
– But increased FLIP
– Constitutive activation of NFkB pathway; essential for HRS
survival
• L&H :
– Not much known
Role of EBV:
• Serologically confirmed Infectious Mononucleosis increases
risk of EBV associated Hodgkins lymphoma
• 20-40% of hodgkins lymphoma were shown to harbor viral
DNA.
EBER EBER + CD15
• ~100% cases of Hodgins in HIV
infected patients
• Mixed cellularity predominant
• Correlation between crippling
Mutations and EBV +vity. LMP1 LMP2
• Main role thought to be in
prevention of apoptosis.
 • EBNA1: maintains genome, controlled
Episomal structure.. replication , inhibits antigen processing,
expressed in all known latently infected cells
irrespective of phenotype.
• EBNA2:activates viral LMP1,2A and cellular c-
fgr , CD23
• EBNA3,4,6 : latent EBV infection and
transformation.
• LMP1: viral oncogene, stimulates proliferation,
induces bcl-2 thereby preventing apoptosis.
• LMP2 : maintains latency
• Invitro lymphoblastoid cell lines express 13
genes including 6EBNAs,3LMPs,EBER1 and 2.
• EBER : EBV encoded poly (A) RNAs , EBER1
upregulates IGF1, GOLD standard for
detection of latent EBV infection.
EBER LMP1 LMP2
Staging and Evaluation
• Histologic subtyping minor role:
– Mixed cellularity & lymphocyte depleted : unfavourable prognosis
– Nodular sclerosis : importance of grading remains controversial.
 Treatment:
• Localised disease cured >90% of times.
• Advanced disease
– Long term disease free survival in >75% cases without B symptoms
– 60-70% cases with B symptoms
• Relapses also frequently cured
• CT:
– ABVD (doxorubicin,bleomycin,vinblastin,dacarbazine)
– MOPP (mechlorethamine, vincristine, procarbazine, prednisolone)
– BEACOPP
• RT:
– Usually in combination
– Only RT in early stage NLPHL and in cases with C/I to CT therapy.
Immunotherapy
 Long term complications
• Secondary malignancies
• Cardiovascular
• Endocrine
• Bone and soft tissue : esp in pediatric population
• Hematologic
• Neurologic
• GIT, skin, immune system..