de differentiaal diagnose tussen diffuus grootcellig b-cel ... · centroblastic / immunoblastic...
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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
diffuse large-B-cell
lymphomas:
21 % with
chromosomal
breakpoint at the myc locus
associated with
complex chromosomal
changes
and an
unfavorable
clinical
course.
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
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)
Clinical significance
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)
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
et al. Molecular diagnosis of Burkitt’s
lymphoma. New England J of Med 354 (23): 2431-42 (2006)
Results
Sandeep
et al. Molecular diagnosis of Burkitt’s
lymphoma. New England J of Med 354 (23): 2431-42 (2006)
PA: DLBCL vs Molecular: BL
Sandeep
et al. Molecular diagnosis of Burkitt’s
lymphoma. New England J of Med 354 (23): 2431-42 (2006)
DLBCL with MYC+ > Molecular DLBCL
Sandeep
et al. Molecular diagnosis of Burkitt’s
lymphoma. New England J of Med 354 (23): 2431-42 (2006)
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
diffuse large-B-cell
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
et al. Molecular diagnosis of Burkitt’s
lymphoma. New England J of Med 354 (23): 2431-42 (2006)
N=28 molecular BL with complete clinical FU
Sandeep
et al. Molecular diagnosis of Burkitt’s
lymphoma. New England J of Med 354 (23): 2431-42 (2006)
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
WHO 2008: gray zone DLBCL / BL
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
Adapted from Dr. Ph.M. Kluin, Dept. of Pathology, University Medical Center Groningen
WHO 2008: gray zone DLBCL / 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!!
Adapted from Dr. Ph.M. Kluin, Dept. of Pathology, University Medical Center Groningen
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