Case year old male with abdominal lymphadenopathy Treated with 8 cycles of R-CHOP One year later B-symptoms and progressive disease

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1 Codirectors Tsieh Sun, M.D., FASCP Francisco Vega, M.D., Ph.D. Department of Hematopathology UT MD Anderson Cancer Center Houston Texas

2 There is no conflict of interest involved in the content and presentation of this workshop

3 Case 1 67 year old male with abdominal lymphadenopathy Treated with 8 cycles of R-CHOP One year later B-symptoms and progressive disease

4 Retroperitoneum 2006 Inguinal LN 2007 BCL2 IgH/BCL2 MYC

5 Double-Hit Lymphoma B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma (DLBCL) and Burkitt lymphoma (BL)

6 BCL-2 Ki-67

7 BCL-2 Ki-67

8 BCL-2 BCL-6

9 DLBCL/BL Definition Aggressive B-cell lymphoma with morphological and genetic features of both DLBCL and BL This is a heterogeneous category and not a distinct entity This category also includes "double-hit" or "triplehit" lymphomas (cases with translocations involving MYC and BCL2, and/or BCL6 genes)

10 DLBCL/BL Possible Scenarios for Diagnosis 1) Neoplasm resembles BL but too much variation in cell size and nuclear contours 2) Neoplasm resembles BL but atypical immunophenotype &/or genetic findings 3) Neoplasms with blastic chromatin with lymphoblastic lymphoma-like appearance

11 DLBCL/BL Immunophenotypic Features Frequent germinal center cell phenotype (CD10+ and BCL6+) Variable but usually high Ki-67 In double-hit lymphomas, BCL2 is usually strongly positive Lymphomas morphologically defined as BL with BCL2 positivity can also be placed in this category

12 DLBCL/BL Genetic Features Complex karyotype (> 3 abnormalities) MYC translocations in up to 50% of the cases: ~ 60% of cases involve Ig gene loci ~ 40% of cases other translocation partners ~ 15% have BCL2 translocations sometimes together with MYC rearrangements (double-hit lymphomas) BCL6 translocations are less frequent (along with BCL2 translocations define triple-hit lymphomas)

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14 Burkitt Lymphoma CD10 BCL2 Ki-67 TCL-1

15 32/M, skin lesion on his trunk with B symptoms for 6 months Hematology: no cytopenia or leukocytosis

16 IHC-skin: Positive for CD4, CD56, CD68, negative for CD3, CD5, CD8, CD20, MPO, lysozyme Flow-skin: Positive for CD2, CD4, CD7, CD45, CD56, HLA-DR, negative for CD3, CD8, CD10, CD13, CD19, CD33, CD34, CD117, TdT, MPO Flow-BM: Positive for CD2, CD4, CD7, CD13, CD33, CD56, negative for CD3, CD8, CD11c, CD14, CD19, CD20, CD57, κ, λ, TdT TCR rearrangement: germline

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21 Brody J et al. Acute agranular CD4-positive natural killer cell leukemia, Cancer 1995;75: WHO classification: Blastic NK-cell lymphoma WHO/EORTC classification for cutaneous lymphomas: CD4+/CD56+ hematodermic neoplasms WHO classification: Blastic plasmacytoid dendritic cell neoplasm

22 History: skin lesion, followed by bone marrow or lymph node involvement. Leukemic phase may or may not be present. Morphology: Immature blast-like cell with no cytoplasmic granules. Pearl necklace appearance, rare. Immunophenotype: diagnostic Molecular genetics: No specific karyotype or gene rearrangement

23 Basic immunophenotype: CD4+, CD56+, cell lineage marker negative Specific markers: CD123, blood dendritic cell antigen 2 (BDCA2), CD2-associated adaptor protein (CD2AP) Additional markers: T-cell leukemia/lymphoma 1 (TCL1), cutaneous lymphocyte-associated antigen (CLA), BDCA4

24 Cutaneous T-cell lymphoma: CD4+, CLA+, but CD56, CD123, BDCA2/CD2AP negative NK lymphoma: CD56+, but CD4 and PDC marker negative. EBV+ and cytotoxic proteins+ M4/M5/CMML: CD4, CD56, CD68, CD123 positive, but BDCA2 and CD2AP negative. Myelomonocytic panel positive.

25 Case 3 75 year old female with red/violaceous plaques and nodules in the distal aspect of her right leg

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27 CD10 MUM1 CD20 CD3 BCL-2

28 Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type

29 Primary Cutaneous DLBCL, Leg Type Definition Primary defined on the basis of morphologic features Confluent sheets of large cells with round nuclei, ie, centroblasts and immunoblasts (large cleaved cells are not allowed)

30 Primary Cutaneous DLBCL, Leg Type Clinical Findings Elderly (79 yrs) and females patients Rapidly growing tumors most commonly on the distal aspect of the leg 20% multiple skin lesions at presentation Ulceration is common Similar tumors can arise in other skin areas Aggressive behavior 5 yrs survival rate, ~50%

31 Primary Cutaneous DLBCL, Leg Type Important Features for the Diagnosis Monomorphism of the infiltrate Lack of background inflammatory cells Lack of stromal reaction Lack of networks of follicular dendritic cells

32 Primary Cutaneous DLBCL, Leg Type Immunohistochemistry CD20+ BCL-2+ (strong;100%) BCL6+ (30%) MUM-1+ (80%) HGAL+ (~30%) IgM+ (100%) CD10+ (weak; 25%) FOXP1+ (80%) CD10-

33 Primary Cutaneous Follicle Center Lymphoma

34 BCL-2

35 Primary Cutaneous Follicle Center Lymphoma BCL6+ (100%), LMO2+ (100%) CD10+ (37%) Negativity for CD10 correlates with a diffuse pattern BCL2- (60%) FOXP1- BCL-6 BCL-2

36 Primary Cutaneous Follicle Center Lymphoma Molecular Genetics t(14;18) by PCR: 60% of PCFCL* t(14;18) by FISH: 41% of cases & t(14;18)(q32;q21) frequently occurs in PCFCL The cases positive for t(14;18) are more frequently positive for BCL2 (54.5% vs 25%) *Weinberg et al. Am J Surg Pathol 2009; & Streubel et al. Am J Surg Pathol 2006;

37 71/Μ, admitted for splenectomy H/O polycythemia vera 5 yrs ago Lab findings: WBC 16,500/µl, Hb 11.8 g/dl, Hct 35%, platelets 325,000/µl, LDH 690 U/L

38 Spleen: Extramedullary hematopoiesis Bone marrow: myelofibrosis and megakaryocytic hyperplasia Normal karyotype and FISH for BCR-ABL 1 negative CT: Portal vein thrombosis (1 month later)

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43 Polycythemia vera: Hb 18.5 g/dl (16.5 g/dl); JAK2 V617F/JAK2 exon 12 (95%) Essential thrombocythemia: Platelets > 450K/µl; BM: proliferation of large, mature megakaryocytes; JAK2 or MPL mutations (50%) Primary myelofibrosis: Myelofibrosis with atypical megakaryocytic hyperplasia; JAK2 or MPL mutation (50%). Myelosis (prefibrotic)

44 Leukoerythroblastosis Increased serum LDH Anemia Splenomegaly One or more B-symptoms

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47 Case 5 31 year old female with L2 dorsal vertebral mass and left supraclavicular lymph node

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49 CD20 CD4 IgA EMA CD79a EBER CD30 CD45 ALK

50 ALK-Positive Diffuse Large B- Cell Lymphoma

51 ALK+ DLBCL Definition Diffuse large B-cell lymphoma expressing ALK protein and associated with ALK gene abnormalities t(2;17)(p23;q23) (70%) Clathrin (CTCL)-ALK t(2;5)(p23;q35) (10%) NPM-ALK t(2;3)(p23;q27) (?) SEC31A-ALK t(2;5)(p23.1;q35) (?) Sequestosome 1 (SQSTM1)-ALK

52 ALK+ DLBCL Epidemiology Rare tumor, less than 1% of all cases of DLBCL - ~ 80 cases reported to date Median age is 40 years (range 9-85) with 30% of cases occur in the pediatric population More frequent in male than female (ratio of 5 to 1) No apparent ethnic predisposition No association with immunosuppression

53 ALK+ DLBCL Immunophenotypic Features By definition ALK+ The pattern of ALK expression predicts ALK partner in fusion gene: -Clathrin (CLTC) and SEC31A: Granular/cytoplasmic -NPM: Nuclear, nucleolar, and cytoplasmic -Sequestosome 1 (SQSTM1): Diffuse/cytoplasmic Takeuchi K et al. Haematologica 2011;96:464-7.

54 ALK+ DLBCL Immunophenotypic Features Positive for: -CD138, VS38, EMA, -CD45/LCA (weak) -CD4 (50%) and CD43 (rare) -cyto Ig (90%) [IgA>95%; rare cases IgG] -CD57 & cytokeratin (~10%; dot like) Negative for: CD30, CD20, EBER

55 Pathologic Pearls Consider performing ALK on all tumors with plasmablastic features in particular in cases not associated to HIV Remember that these tumors are negative for CD20, CD30 and EBER Morphologic overlap with plasmablastic lymphoma

56 48/M, high fever and severe back pain for several days. Platelets dropped from 208,000 to 30,000/µl; WBC 10,500/µl with 13% blasts; Hct 33%, Hb 11.7 g/dl Epistaxis and oral mucosal bleeding. P.E. No organomegaly and lymphadenopathy

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63 T cell: CD3, except for CD3 zeta B cell: CD19, with coexpression of CD79a, CD10 or cytoplasmic CD22 Myeloid cell: Myeloperoxidase Monocyte: Nonspecific esterase, CD11c, CD14, CD64, lysozyme (2 markers)

64 FISH for MYC gene rearrangement: negative Rule out Burkitt lymphoma RT-PCR for Fms-like tyrosine kinase 3/internal tandem duplication (FLT3/ITD): negative High incidence in AML and poor prognostic indicator but potential target for therapy

65 t(9;22)(q34;q11.2); BCR-ABL 1 t(v;11q23); MLL rearranged B/myeloid NOS T/myeloid NOS Mixed phenotype acute leukemia, NOS - rare type (T/B; T/B/myeloid)

66 t(8;21)(q22;q22) t(15;17)(q22;q12) inv (16)(p13.1q22) or t(16;16)(p13.1;q22) Acute leukemia with FGFR1 mutation CML with lymphoid blast crisis MDS-related AML Therapy-related AML

67 Case 7 35 year old male with large mediastinal mass

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69 CD20 CD79a CD30 CD15 CD45 EBV-LMP1

70 B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and Classical Hodgkin Lymphoma

71 DLBCL/CHL Definition Lymphoma with clinical, morphologic, &/or immunophenotypic features between DLBCL and classical HL It does not include composite or sequential cases of both neoplasms

72 DLBCL/CHL Epidemiology and Prognosis Young patients, yrs (range:13-70 yrs) More frequent in males than females More common in western countries Less common in african americans Aggressive course and poorer outcome than CHL or primary mediastinal B-cell lymphoma

73 DLBCL/CHL Clinical Presentation Anterior mediastinal mass Direct extension into lungs Advanced clinical stage (III or IV) Supraclavicular LNs can be involved Other peripheral LNs are rarely involved

74 CD20

75 DLBCL/CHL Immunophenotypic Features Mixed phenotype Common markers of CHL Expression of markers usually absent in CHL: CD45 (LCA)+, CD20+ & uniformly strong, CD79a+ OCT2+ and BOB1+ Other markers: EBV+; EBER &/or LMP1

76 DLBCL/CHL Lack of uniform diagnostic criteria Minimal criteria required? Deviation of a single marker is enough? CD20 expression in otherwise typical CHL is not sufficient (?) CD15 expression in otherwise typical PMBL seems to be sufficient BOB.1 and OCT2

77 PMLBCL CD20 CD30 MUM1

78 70/M, chest pain, fever, night sweat for 2 wks. P.B.: WBC 14,500/µl, 77.5% poly, 12.2% lymph, 9.1% mono; Hb 15.7 g/dl, platelets 279,000/µl LDH 282 U/L CT: mass in post. mediastinal space with compression of subclavian vein

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88 Phenotype THRBCL NLPHL chl CD45 Positive Positive Negative CD20 Positive Positive Negative CD79a Positive Positive Negative BCL-6 Positive Positive Negative PAX5/BSAP Positive Positive Positive BOB1 Positive Positive Negative OCT2 Positive Positive Negative PU.1 Negative Positive Negative CD10 Variable Negative Negative BCL-2 Variable Negative Negative CD15 Negative Negative Positive CD30 Rare Negative Positive EBV Negative Negative Variable EMA Variable Positive Rare J-chain Positive Positive Negative sig Positive Positive Negative

89 BACKGROUND CELL Immunophenotype THRBCL NLPHL chl CD3 Positive Positive Positive CD57 Negative Positive Negative CD20 Negative Positive Negative CD21/CD23 Negative Positive Positive CD68 Positive Rare Variable PD1 Negative Positive Negative