Category Archives: Lymph Node

Mantle cell lymphoma

Mantle cell lymphoma (MCL) is a mature B-cell neoplasm, which represents 2-3% of cases of non-Hodgkin lymphoma in the US.  The IgH/Cyclin D1 translocation is characteristic of this lymphoma, and can be confirmed by FISH testing in almost all cases.  Clincially, patients often present with widespread disease.  In addition to adenopathy, patient often have involvement of blood (20-40%) and other organ sites (gastrointestinal tract, liver spleen,  bone marrow).
Morphology
MCL is typically characterized by a small to intermediate sized lymphocytes with an irregular nuclear membrane (CLL/SLL tends to have a smoother nuclear membrane and follicular lymphoma has cleaved cells).  A subset of cases have a larger size and increased mitotic rate and can be confused with acute lymphoblastic lymphoma, and are referred to as the “blastoid” variant of MCL.
 
2008 WHO Classification identifies multiple morphologic variant including: blastoid variant (resembles ALL with increased mitoses), pleomorphic (also aggressive), small cell variant (resembles CLL/SLL), and marginal zone-like morphology.  Architectural pattern can have a diffuse pattern (often with scattered histiocytes within the infiltrate) or nodular (resembling follicular lymphoma).  Minimal lymph node involvement can show expansion of the mantle zones with relative intact lymph node architecture.  Bone marrow involvement can have a varied appearance, but can mimic follicular lymphoma with paratrabecular aggregates.
2016 WHO Classification Revision
Two subtypes of mantle cell lymphoma are now recognized, which center around the mutation status of IgHV.
  • IgHV unmutated/minimally mutated (mostly SOX11+) – classical disease that is aggressive, typically involves lymph nodes and other extra nodal sites.
  • IgHV mutated (SOX11 negative) – associated with indolent non-nodal disease with peripheral blood and bone marrow involvement.  Some of these cases may have been difficult to separate from CLL/SLL in the past.
Half of cyclin D1 negative cases show a CCND2 rearrangement.
Molecular Characteristics
  • FISH + for t(11;14)
  • Cytogenetics + t(11;14) ~70% of cases
  • 50% of Cyclin D1 negative cases have CCND2 rearrangements
Immunophenotypic Expression Pattern

 

 

Marker
Comment
Negative
Positive (93-95%).  Some data indicates up to 12% of MCL cases may be negative for CD5.
Negative.  Up to 8% of cases may express CD10 (expression will usually be <30%).
Positive
Positive
Negative.  21% may express CD23.
Positive.  Nuclear expression.  The rabbit monoclonal antibody clone SP4 appears to have the highest sensitivity and stain intensity.  Sensitivity ~95%.
Positive
Negative (~12% of cases may have expression)
Usually negative (35% may be positive, of these 2/3rds will also be bcl-6+)
Highlights the residual FDC meshwork.
Inverse relationship between quantitative Ki-67 index and prognosis.  Ki-67 >40% is an adverse prognostic factor.
 Expressed in classic form and lack of expression is associated with more indolent variant of MCL.
Important caveats
Cyclin D1 expression is not entirely specific for mantle cell lymphoma.  Some expression can be seen in a zonal pattern in CLL/SLL in proliferation centers.   Other entities such as plasma cell myeloma (up to 50%) and hairy cell leukemia can also express cyclin D1.  CD10 (8%), Bcl-6, and CD23 (21%) has been reported to be expressed in a small number of cases.  Loss of CD5 (12%) has been noted in some cases.  Most of these studies were by flow cytometry.
 
CD5 expression on a B-cell lymphoma should practically result in testing for exclusion of a t(11;14) IgH/Cyclin D1 gene fusion.  There are other B-cell lymphomas, which may also have CD5 expression (e.g. DLBCL, CLL/SLL, etc.) that are not MCL and have separate prognostic characteristics because of/or separate from CD5 expression.
 
Rarely, plasmacytic differentiation may be identified.  Classic MCL is derived form naive B-cells, which tends to not to progress to plasmacytic differentiation, compared to post germinal center derived B-cell lesions, which more commonly have plasmacytic differentiation.
 
Ki-67 staining index has been shown to be directly proportional the aggressiveness of the clinical course (higher staining index, more aggressive).

References
WHO Classification of Tumors of Haematopoietic and Lymphoid Tissues.  SH Swerdlow,et al.International Agency for Research on Cancer. Lyon, 2008. p. 229-231.
 
Robbins and Cotran Pathologic Basis of Disease.  V Kumar, et al. 9th Edition. Elsevier Saunders. 2015. pp. 602-603.
 
Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016;127: 2375–2390. doi:10.1182/blood-2016-01-643569
 
Katzenberger T, Petzoldt C, Höller S, Mäder U, Kalla J, Adam P, et al. The Ki67 proliferation index is a quantitative indicator of clinical risk in mantle cell lymphoma. Blood. 2006;107: 3407. doi:10.1182/blood-2005-10-4079
 
Gao J, Peterson L, Nelson B, Goolsby C, Chen Y-H. Immunophenotypic variations in mantle cell lymphoma. Am J Clin Pathol. 2009;132: 699–706. doi:10.1309/AJCPV8LN5ENMZOVY
 
Boyd SD, Natkunam Y, Allen JR, Warnke RA. Selective immunophenotyping for diagnosis of B-cell neoplasms: immunohistochemistry and flow cytometry strategies and results. Appl Immunohistochem Mol Morphol. 2013;21: 116–131. doi:10.1097/PAI.0b013e31825d550a
 
Young KH, Chan WC, Fu K, Iqbal J, Sanger WG, Ratashak A, et al. Mantle cell lymphoma with plasma cell differentiation. Am J Surg Pathol. 2006;30: 954–961.
 
Gualco G, Weiss LM, Harrington WJ, Bacchi CE. BCL6, MUM1, and CD10 expression in mantle cell lymphoma. Appl Immunohistochem Mol Morphol. 2010;18: 103–108. doi:10.1097/PAI.0b013e3181bb9edf
 
Wang H-Y, Zu Y. Diagnostic Algorithm of Common Mature B-Cell Lymphomas by Immunohistochemistry. Arch Pathol Lab Med. 2017;141: 1236–1246. doi:10.5858/arpa.2016-0521-RA

Lymphoplasmacytic Lymphoma (LPL)

Lymphoplasmacytic Lymphoma (LPL)
  • Neoplastic proliferation of B-cells ranging in spectrum from lymphocytes to plasma cells (typically involves the bone marrow, but can also involve the spleen and lymph nodes).  
  • Bone marrow involvement
    • Nodular, diffuse, and/or interstitial
    • Small lymphocytes admixed with plasma cells and plasmacytoid lymphocytes
  • IgM paraprotein
    • Sometimes result in a hyperviscosity syndrome(30%)
    • IgM and IgG paraprotein (minority)
    •  Some cases may be IgG or IgA. 
  • Cryoglobulinemia (20% of WM)
  • Coagulopathy (IgM binds to clotting factors)
  • MYD88 (L265P) point mutation (>90%)
    • Results in up-regulation of NF-κB (promotes tumor cell survival). 
    • Not specific for LPL.
  • LPL is a diagnosis of exclusion after other B cell lymphoid neoplasms with plasmacytic differentiation have been excluded.  
  • IgM MGUS is now thought to be more closely related to LPL than plasma cell myeloma.

Most patients present with non-specific B-symptoms.  However, ~10% have hemolysis secondary to cold agglutinins (IgM binds to RBCs at temperature <37C).

Waldenstrom macroglobulinemia
Waldenstrom macroglobulinemia (defined as bone marrow involvement by LPL and IgM monoclonal gammopathy) may manifest as a hyperviscosity syndrome due to the circulating IgM in the blood (IgM tends to stay in the vascular system, compared to IgG which can penetrate into soft tissue).  Because IgM molecules tend to be well-segregated to the vascular compartment, plasmapheresis can be very effective to treat hyerpviscosity symptoms.  Clinical signs/symptoms include:
  • Cryoglobulinemia – precipitation of macroglobulins as temperatures <37C
  • Bleeding – macroglobulins interfere with clotting factors
  • Neurologic disturbances – secondary to increased blood viscosity
  • Visual impairment – secondary to increased viscosity and hemorrhage
Immunophenotype
Marker
Comment
Negative
Negative (~10% +)
Negative
Positive
Negative (rare atypical cases +)
Positive (best marker).  Marks from Mature B-Cells through Plasma Cell differentiation.
Often Positive
Positive
Negative
Positive
Morphology
The bone marrow can have a varying degree of involvement (usually interstitial to nodular) by tumor cells showing a range from small lymphocytes to plasmacytoid lymphocytes to plasma cells.  Mast cell hyperplasia is commonly present.
 
Lymphoplasmacytic Lymphoma (LPL) - Aspirate Smear
Lymphoplasmacytic Lymphoma (LPL) – Aspirate Smear
Lymphoplasmacytic Lymphoma (LPL) - CD138
Lymphoplasmacytic Lymphoma (LPL) – CD138
Lymphoplasmacytic Lymphoma (LPL) - BM Core Biopsy
Lymphoplasmacytic Lymphoma (LPL) – BM Core Biopsy.  Plasma cells (not obvious) admixed with small lymphoid infiltrate.

References
Robbins and Cotran Pathologic Basis of Disease.  V Kumar, et al. 9th Edition. Elsevier Saunders. 2015. pp. 601-602.
 
Harmon CM, Smith LB. B-cell Non-Hodgkin Lymphomas with Plasmacytic Differentiation. Surg Pathol Clin. 2016;9: 11–28. doi:10.1016/j.path.2015.09.007
 
WHO Classification of Tumors of Haematopoietic and Lymphoid Tissues.  SH Swerdlow, et al. International Agency for Research on Cancer. Lyon, 2008. p. 194-195
 
Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016;127: 2375–2390. doi:10.1182/blood-2016-01-643569
 
Martinez-Lopez A, Curiel-Olmo S, Mollejo M, Cereceda L, Martinez N, Montes-Moreno S, et al. MYD88 (L265P) somatic mutation in marginal zone B-cell lymphoma. Am J Surg Pathol. 2015;39: 644–651. doi:10.1097/PAS.0000000000000411
 
Treon SP, Xu L, Yang G, Zhou Y, Liu X, Cao Y, et al. MYD88 L265P somatic mutation in Waldenström’s macroglobulinemia. N Engl J Med. 2012;367: 826–833. doi:10.1056/NEJMoa1200710
 
Bone Marrow IHC.  Torlakovic, EE, et. al. American Society for Clinical Pathology Pathology Press © 2009.  pp. 27.
 
Hematopathology. [edited by] Jaffe, ES. 1st. ed. Elsevier, Inc. © 2011. pp.194-195.

MYD88 (L265P) Mutation

MYD88 (L265P) mutation has garnered a lot of excitement because of its usefulness in diagnosing lymphoplasmacytic lymphoma (LPL).  Traditionally, LPL has been difficult to diagnose because exclusion of other B-cell neoplasms with plasmacytic differentiation is required. MYD88 mutations are present in approximately 90% of cases of LPL, and in a much lower percentage of cases of B cell lymphomas, which are typically in the differential diagnosis of LPL.
 MYD88 mutation frequency

References
Harmon CM, Smith LB. B-cell Non-Hodgkin Lymphomas with Plasmacytic Differentiation. Surg Pathol Clin. 2016;9: 11–28. doi:10.1016/j.path.2015.09.007
 
WHO Classification of Tumors of Haematopoietic and Lymphoid Tissues.  SH Swerdlow, et al. International Agency for Research on Cancer. Lyon, 2008. p. 194-195
 
Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016;127: 2375–2390. doi:10.1182/blood-2016-01-643569
 
Martinez-Lopez A, Curiel-Olmo S, Mollejo M, Cereceda L, Martinez N, Montes-Moreno S, et al. MYD88 (L265P) somatic mutation in marginal zone B-cell lymphoma. Am J Surg Pathol. 2015;39: 644–651. doi:10.1097/PAS.0000000000000411
 
Treon SP, Xu L, Yang G, Zhou Y, Liu X, Cao Y, et al. MYD88 L265P somatic mutation in Waldenström’s macroglobulinemia. N Engl J Med. 2012;367: 826–833. doi:10.1056/NEJMoa1200710