De differentiaal diagnose tussen diffuus grootcellig B-cel ... · Centroblastic / immunoblastic...

De differentiaal diagnose tussen diffuus grootcellig B-cel lymfoom en Burkitt lymfoom

Dr. King H. Lam

Afd. Pathologie

Overzicht

Inleiding

in Burkitt

lymfoom

(BL) en diffuus

grootcellig

B-cel

lymfoom

(DLBCL)

Het verschil

tussen

BL en DLBCL in de dagelijkse

praktijk

Het verschil

tussen

BL en DLBCL op moleculair

niveau

Het leven

in een

imperfecte

wereld

(veel

dia’s

in het Engels)

Origine BL en DLBCL aan de hand van lymfklier microanatomie

Cortex (B-cel gebied)

Mantel zone and kiemcentrum: Follikels

Memory

B-cells: Marginale zone

Macrofagen and folliculair dendritische

cellen: antigeen presenterende cellen

Paracortex (T-cel gebied)

T-cel

immunoblastaire

reactie

met

T-helper/cytotoxische

T-cellen

Interdigiterende

dendrische

cellen/macrofagen: antigeen presenterende cellen

Medulla

Plasmacellen

in mergstrengen

Warnke

RA et. al. Tumors of the Lymph

Nodes

and Spleen. Vol. 14

American Registry

of Pathology, Washington, 1995

Relatieve frequentie B-cel NHL

Swerdlow

SH et al. WHO classification

of tumours

of haematopoietic

and lymphoid

tissues. IARC. Lyon 2008

Endemic in Africa (EBV related)

Children and Young adults (Western hemisphere)

ENT area and abdominal

Diffuse pattern with tingible

body macrophages (starry sky pattern)

Medium sized cells often with vacuolated cytoplasm, uniform nuclear aspect, variants described. Germinal

centre

characteristics.

CD 79a+, CD 20+, CD 10+, BCL6+, IgM

Lambda, TdT-, MIB-1 almost 100%+

20% BCL2-/+, almost none BCL6-

(acceptable only if morphology fits), BCL2-

and MYC+

t(8;14) MYC oncogene

is over-expressed by the IgH

promotor, others t(2;8) and t(8;22)

Burkitt’s Lymphoma (BL)

Diffuse Large Cell Lymphoma (DLBCL)

Older patients and HIV infected patients

Disseminated in many lymph nodes or extra-nodal

Diffuse pattern in HE

Large cells (centroblasts, immunoblasts)

CD 79a+, CD 20+, Some times CD 5+

t(14;18) / Bcl-2 in 30% of the cases

t(3;14) / Bcl-6 in 30% of the cases

10% MYC+

DLBCL / Sub-types

Centroblastic

/ immunoblastic

Anaplastic

/ plasmacytoid

(CD 30+, ALK-1+)

WHO 2008: Plasmablastic

often immunoblasts, EBV+, IH of plasma cells, oral cavity, HIV, elderly

T-cell rich large B cell Lymphoma (WHO 2008: greyzone

with NLPHL)

Primary mediastinal

(thymic) with sclerosis (WHO 2008: greyzone

with CHL)

Primary effusion lymphoma

Intravascular large B-cell lymphoma

Lymphomatoid

granulomatosis

WHO 2008: EBV related DLBCL of the elderly

8-10% of DLBCL

Median

age

71

70% extranodal

Large, polymorhic

cell

type (RS-like)

EBER+, EBV-LMP+, EBNA-1+, CD30+, CD15-

De theorie: morfologie Burkitt lymfoom vs DLBCL

Compact 2-dimensionaal groeipatroon, meestal weinig fibrose

Middelgrote cellen (1,5-2x diameter lymfocyt)

Kernen met vrij egaal chromatinepatroon, 1-4 kleine nucleoli

Hoog aantal delingsfiguren

Veel sterrenhemel macrofagen

Compact 3-dimensionaal groeipatroon, soms veel fibrose

Grote cellen (2-2,5x diameter lymfocyt)

Kernen met blazig

aspect, grof

chromatine, 1-2 grote nucleoli, centro-

/immunoblasten

Meestal een wat lager aantal delingsfiguren

Meestal weinig sterrenhemel macrofagen

De praktijk: histologie BL vs DLBCL

De praktijk: cytologie BL vs DLBCL

Courtesy of Dr. Kirsten van Lom, Dept. of Hematology

Burkitt immunohistochemie: CD20+, CD10+, BCL6+, MUM1-/+, BCL2- Ki-67+ (+/- 100%)

HE Mib-1

CD10 TdT / BCL2

Onderscheid niet altijd duidelijk te maken..

Er zijn ook DLBCL met

CD20+, CD10+, BCL6+, MUM1-/+, BCL2-

en Ki-67+ (+/-

100%) !

BL DLBCL

BL?/DLBCL?

Common translocations in malignant lymphoma

van Dijk et al. Translocation

detection

in lymphoma

diagnosis by

split-signal

FISH: a standardised

approach. J Hematopathol

1:119-126 (2008)

Translocations Burkitt’s lymphoma

Complicating the story (1)

Methods

220 mature

aggressive

B-cell

lymphomas, including

a core group

of 8 Burkitt’s

lymphomas

that

met all World Health Organization

(WHO) criteria

Gene-expression

profiling

using

Affymetrix

U133A GeneChips

with RNA extracted

from

frozen

samples

A molecular

signature for

Burkitt’s

lymphoma

was generated

Chromosomal

abnormalities

were

detected

with

interphase fluorescence

in situ

hybridization

and array-based

comparative

genomic

hybridization.

Hummel et al. A biologic definition of Burkitt’s

lymphoma from transcriptional and genomic profiling. New England J of Med 354 (23): 2419-30 (2006)

Results

44 cases with

molecular

signature for

Burkitt’s

lymphoma:

11 with

diffuse large-B-cell

lymphoma

morphology,

4 are unclassifiable

mature

aggressive

B-cell

lymphoma

29 had a classic or

atypical

Burkitt’s

morphologic

appearance.

5 did

not

have a detectable

IG-myc Burkitt’s

translocation,

39 contained

an

IG-myc fusion, mostly

in simple

karyotypes.

176 lymphomas

without the molecular

signature for

Burkitt’s

lymphoma:

155 were


lymphomas:

21 % with

chromosomal

breakpoint at the myc locus

associated with

complex chromosomal

changes

and an

unfavorable

clinical

course.



Results



Clinical significance



Complicating the story (2)

Methods

Tumor-biopsy

specimens from

303 patients

with

aggressive

lymphomas

Profiled

for

gene expression

Classified

according

to

morphology

immunohistochemistry

detection

of the t(8;14) c-myc translocation

Sandeep

et al. Molecular diagnosis of Burkitt’s

lymphoma. New England J of Med 354 (23): 2431-42 (2006)

Results

Sandeep



PA: DLBCL vs Molecular: BL

Sandeep



DLBCL with MYC+ > Molecular DLBCL

Sandeep



Results

A classifier

based

on

gene expression

correctly

identified

all 25 pathologically

verified

cases of classic Burkitt’s

lymphoma.

Burkitt’s

lymphoma

was readily

distinguished

from


lymphoma

by

the high level of expression

of c-myc target genes, the expression of a subgroup

of germinal-center

B-cell

genes, and the low level of expression

of major-histocompatibility-complex

class

I genes

and nuclear

factor-κB

target genes.

Eight

specimens with

a pathological

diagnosis of diffuse large-B-cell

lymphoma

had the typical

gene-expression

profile

of Burkitt’s

lymphoma, suggesting

they represent

cases of Burkitt’s

lymphoma

that

are difficult

to diagnose by

current

methods.

Among

28 of the patients

with

a molecular

diagnosis of Burkitt’s

lymphoma, the

overall survival was superior among

those

who

had received

intensive chemotherapy

regimens

instead

of lower-dose

regimens.

Sandeep



N=28 molecular BL with complete clinical FU

Sandeep



WHO 2008: BL vs DLBCL

IgM+, Lambda+, TdT-

GC characteristics: CD10+, BCL6+, CD38+, CD77+

Ki-67: 100%

Ig

hypermutated, no

class

switch

85% t(8;14); other

t(2;8) and t(8:22)

Genetically

simple

malignancy, no

complex karyotype

Characteristics BL:

WHO 2008: gray zone DLBCL / BL

Intermediate

chapter

WHO 2008:

Keep DLBCL and BL categories

clean

Prevent patients

needing

more only

get

R-CHOP

Classification

problems

in practice:

2-5% DLBCL have features consistent with

BL

There

are lymphoma’s

with

BL morphology, MYC translocation

and aberrant

phenotype, such

als BCL2+

Typical

BL morphology

and phenotype

but

no

MYC translocation

BL / atypical

BL with

MYC+ and BCL2+ and/or

BCL6+ and/or

CCND+

Adapted from Dr. Ph.M. Kluin, Dept. of Pathology, University Medical Center Groningen


2-5% DLBCL have features consistent with

BL:

Morphology

classical

or

monomorphic

Ki-67: 100%, CD10+, BCL2+, MUM-1+/-, 30-40% MYC+

Check IgH+, IgL+ of IgK+ partner: BL, clinical

correlation, other

FISH studies (exclude

complex karyotype)

There

are lymphoma’s

with

BL morphology, MYC translocation

and aberrant

phenotype, such

als BCL2+:

20% of BL have some

BCL2 expression

Double hit / other

mechanisms

that

give

aberrant

BCL2 expression

Exclude

double hits (BCL2, BCL6, CCND)

If

all other

data are typical

(only

BCL2+ in IH): call

it

BL



Typical

BL morphology

and phenotype

but

no

MYC translocation:

10% have no

breakpoint

Technical

reason: breakpoint to far

away

for

probe

set

Biological

reason: some

cases have a little

more complex karyotype

Incorrect diagnosis: use

multiple probe

tests, karyotype

for

complexity, accept

as BL only

if

this

is the only

aberrant

finding

BL / atypical

BL with

MYC+ and BCL2+ and/or

BCL6+ and/or

CCND+:

Origen

probably

VDJ recombination

by

RAG 1/2. If

BCL2 strongly

+: look for

BCL2 and BCL6 rearrangements. DLBCL with

MYC+; look for

other breakpoints

Usually

BCL2+ and MYC+

Higher

age

groups

Each

BL with

BCL2+ in IH: FISH and karyotyping

BCL2-

is not

specific

for

BL!!


WHO 2008: B-cell lymphoma unclassifiable with features between DLBCL and BL

Not

an

entity

BL-like

morphology

with

more or

less

large

cells

Variabel proliferation

rate

BCL2 expression

variable, often

+

MYC often

+

Complex karytype

common

Including

double hit lymphoma’s: MYC+ and BCL2+ /BCL6+

Conclusies

Het verschil tussen een Burkitt

lymfoom en diffuus grootcellig

B-cel lymfoom is meestal, maar niet altijd te maken met de klinische

presentatie, morfologie (cytologie en histologie), immunofenotypering (immunohistochemie

en flowcytometrie).

Uitbreiding met cytogenetica

helpt men in de meeste gevallen wel verder.

Genexpressie arrays

lijken in principe de gouden standaard, maar in de dagelijkse klinische praktijk nog moeilijk te realiseren

Overwogen moet worden om betrokkenheid van het MYC gen bij elke diffuus grootcellig

B-cel

NHL na te gaan met FISH en dan de

therapie hierop aan te passen

De differentiaal diagnose tussen diffuus grootcellig B-cel ... · Centroblastic / immunoblastic...

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Transcript of De differentiaal diagnose tussen diffuus grootcellig B-cel ... · Centroblastic / immunoblastic...