Hematopathology Service Memorial Sloan Kettering Cancer Center, New York
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1 SH t(14;18) Negative Follicular Lymphoma with 1p36 abnormality associated with In Situ Follicular Neoplasia with t(14;18) translocation Pallavi Khattar MD, Jennifer Maerki MD, Alexander Chan MD, Janine Pichardo, Robert Cimera, Caleb Ho MD, Yanming Zhang MD PhD, Lu Wang MD PhD, Ahmet Dogan MD PhD Hematopathology Service Memorial Sloan Kettering Cancer Center, New York
2 Clinical History May y/o female presented with a painless mass in her right groin. No c/o fever, night sweats or unexplained weight loss Laboratory Findings : CBC (WBC: 6.6 K/ul; HgB: 13.3 g/dl; Hct: 37.3%; MCV:93 fl; Platelet: 359 K/ul) LDH: 188 U/L
3 CT and PET Scan Images: May 2013 Localized mass: Right Groin: 3.5 x 2.4 cm; SUV: 4
4 Clinical History Lymph node excision and bone marrow biopsy were performed Diagnosis : At outside institute Lymph node: Marginal zone lymphoma Bone marrow: No morphologic or immunophenotypic evidence of Lymphoma Clinical Stage 1A We received slides for consultation at MSKCC
5 H&E: Area with Follicular Lymphoma, In Situ Follicular Neoplasia and Reactive Follicles Follicular Lymphoma In Situ Follicular Neoplasia Reactive follicles H&E 20x
6 Morphologic and immunohistochemical features of Follicular Lymphoma and In Situ Follicular Neoplasia H&E 20x ISFN FL- Diffuse areas Reactive follicles CD20 BCL2 CD10 CD23 H&E section shows FL with diffuse areas on right, ISFN (center) and reactive follicles on left (20x)
7 Follicular Lymphoma: Diffuse Growth Pattern H&E 400x
8 Morphologic and immunohistochemical features of Follicular Lymphoma (FL) H&E CD20 BCL2 CD10 BCL6 CD23 FISH studies using BCL2 Break apart probe: Negative for BCL2 gene rearrangement Ki67
9 Morphologic and immunohistochemical features of In Situ Follicular Neoplasia (ISFN) H&E H&E CD20 BCL2 CD10 BCL6 CD23 Ki67 FISH studies using BCL2 Breakapart probe: Positive for BCL2 gene rearrangement
10 Click to edit Master title style Chromosome 1 TNFRSF14 Gene Genetic Studies SNP (Single Nucleotide Polymorphism) array analysis Chromosome 16 CREBBP Gene 1. Copy Neutral Loss of Heterozygosity (CN-LOH) in 1p35.1p36.33 that harbors TNFRSF14 gene 2. Coexistence of Copy Neutral Loss of Heterozygosity (CN-LOH) in 16p involving CREBBP gene
11 Comprehensive Genomic Analysis: Two mutations were detected in this patient: 1. TNFRSF14 p.q158* (A change in nucleotide resulting in a premature stop codon), variant frequency 27.9% 2. CREBBP p.s1436r (Missense mutation), variant frequency 29.5% Patient s normal control (blood) is also sequenced to filter germline variant.
12 Summary of Findings Follicular Lymphoma Diffuse Growth Pattern In situ Follicular Neoplasia (ISFN) Immunostains CD20 Positive Positive BCL2 Weak to negative Strong CD10 Dim Strong BCL6 Variable Variable CD23 Strong Negative Cytogenetic Studies BCL2 gene rearrangement SNP array analysis Comprehensive Genomic Analysis Not detected Detected (CN- LOH in chromosome 1p35.1p36.33 and 16p) Detected (57% of the cells)?? TNFRSF14 p.q158*?? CREBBP p.s1436r??
13 Diagnosis t(14;18) Negative Follicular Lymphoma with 1p36 abnormality associated with In Situ Follicular Neoplasia with t(14;18) Translocation Follow Up Patient was treated with 24 Gy of involved field radiation therapy (IFRT), completed in August CT scan after treatment- August 2013 Follow up examination showed no clinical or radiological evidence of disease- Complete remission after 45months
14 In Situ Follicular Neoplasia (ISFN) (1) How should in situ follicular neoplasia be defined and diagnosed? (2) Is in situ neoplasia an early step of lymphomagenesis? (3) How should patients with in situ neoplasia be managed in situ follicular neoplasia without overt lymphoma: No evidence for starting therapy: wait-and-watch policy is strongly suggested. For patients with concomitant overt lymphoma: Staging and treatment: based on malignant counterpart. Emerging issues after the recognition of In Situ Follicular Neoplasia (ISFN). Leuk Lymphoma Carbone A, Gloghini A How I treat: diagnosing and managing in situ lymphoma. Blood, Carbone A and Santoro A
15 t(14;18) Negative Follicular lymphoma with Diffuse Growth Pattern Presents as large, localized tumors in inguinal region Diffuse growth pattern CD20, BCL2 (dim to negative), CD10 (dim), BCL6 with CD23 co-expression Lacks BCL2 gene rearrangement Deletion in the terminal parts of the short arm of chromosome 1 (1p36). Low clinical stage, indolent disease A distinctive subtype of t(14;18)-negative nodal follicular non-hodgkin lymphoma characterized by a predominantly diffuse growth pattern and deletions in the chromosomal region 1p36. Tiemo Katzenberger, German Ott. Blood 2009
16 MSKCC t(14;18) Negative Inguinal/ Groin Follicular Lymphoma Inguinal/ groin FL cases were retrieved from archives of Department of Hematopathology at MSKCC Morphologic and immunohistochemical stains were reviewed. FFPE inguinal/ groin follicular lymphoma tissue samples were analyzed by BCL2-rearrangement FISH assay (Abbott molecular). Genomic DNAs extracted from FFPE tumor material were used for copy number and allelic imbalance analysis by SNP-array (OncoScan, Affymetrix).
17 Case No. MSKCC t(14;18) Negative Inguinal/ Groin Follicular Lymphoma Cases FISH studies: BCL2 gene rearrangement SNP array analysis: Chromosome 1p SNP array analysis: Chromosome 16p 1 Negative CN-LOH of 1p CN-LOH of 16p12.1-ter 2 Negative CN-LOH of 1p36.23-ter - 3 Negative CN-LOH of 1p36.31-ter CN-LOH of 16p13.13-ter 4 Negative CN-LOH of 1p35.2-ter - 5 Negative CN-LOH of 1p36.11-ter CN-LOH of 16p11.3-ter 6 Negative CN-LOH of 1p36.11-ter - 7 Negative del of 1p (2.7 Mb) CN-LOH of 16p11.2-ter 8 Negative CN-LOH of 1p35.2-ter CN-LOH of 16p11.2-ter 9 Negative CN-LOH of 1p36 CN-LOH of 16p13.3-p Negative CN-LOH 1p36.32-ter (2.7 Mb) - 11 Negative deletion of 1p36.23-ter - 12 Negative deletion of 1p36.23-ter CN-LOH of 16p11.2-ter 13 Negative - CN-LOH of 16p13.13-ter 14 Negative CN-LOH of 1p34.2-ter CN-LOH of 16p11.2-ter 15 Negative CN-LOH 1p36.32-ter (2.9 Mb) - 16 Negative CN-LOH 1p33-ter - 17 Negative deletion of 1p35.1-ter Focal homozygous deletion of TNFRSF14-18 Negative - CN-LOH of 16p13.13-ter
18 Cell Biology of TNFRSF14/HVEM: 1p36 Follicular Lymphoma Diagram representing the concept of CAR-T cells that produce solhvem locally and continuously at the lymphoma site in vivo. Loss of the HVEM Tumor Suppressor in Lymphoma and Restoration by Modified CAR-T Cells.M. Boice. Cell 2016
19 Take home message: Inguinal/Groin Follicular Lymphoma with 1p36 abnormality 1. Clinical features Isolated large inguinal/groin mass 2. Phenotype CD20, BCL2 (dim to negative), CD10 (dim), BCL6 with CD23 coexpression 3. Molecular work up FISH Studies: BCL2 gene rearrangement SNP Array: Deletion or CN-LOH in chromosome 1p36 SNP array, not FISH would be the test of choice for this aberration. Comprehensive Genomic Analysis: TNFRSF14 gene mutation
20 Final Panel Diagnosis t(14;18) Negative Follicular Lymphoma with 1p36 deletion
21 Thank You
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