Aggressive B-Cell Lymphomas

Aggressive B-cell Lymphomas Aggressive B-Cell Lymphomas Stephen Hamilton Dutoit Institute of Pathology Aarhus Kommunehospital B-lymphoblastic lymphoma Diffuse large cell lymphoma, NOS T-cell / histiocyte-rich; primary CNS ; primary leg skin; EBV+ elderly Diffuse large B-cell lymphoma with chronic inflammation Lymphomatoid granulomatosis Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma ALK+ large B-cell lymphoma Plasmablastic lymphoma Large BCL, HHV8+ ex.castleman disease Primary effusion lymphoma Burkitt lymphoma B cell lymphoma, unclassifiable, Burkitt-like B cell lymphoma, unclassifiable, Hodgkin-like Mantle Cell Prolymphocytic Immunodeficiency associated lymphoma Post transplantation AIDS-associated Aggressive B-cell Lymphomas B-lymphoblastic lymphoma Diffuse large cell lymphoma, NOS T-cell / histiocyte-rich; primary CNS ; primary leg skin; EBV+ elderly Diffuse large B-cell lymphoma with chronic inflammation Lymphomatoid granulomatosis Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma ALK+ large B-cell lymphoma Plasmablastic lymphoma Large BCL, HHV8+ ex.castleman disease Primary effusion lymphoma Burkitt lymphoma B cell lymphoma, unclassifiable, Burkitt-like B cell lymphoma, unclassifiable, Hodgkin-like Mantle Cell Prolymphocytic Immunodeficiency associated lymphoma Post transplantation AIDS-associated Survival 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Large Cell Lymphomas: Overall Survival Log Rank Test: p<0.001 Anaplastic Large T-Cell Diffuse Large B-Cell Burkitt-like Peripheral T-Cell 0 1 2 3 4 5 6 7 8 9 Years Armitage et al, 1997 Danish Aggressive Lymphomas LYFO 2000 ca. 2100 patients DSB CB 78% IB 10% Burkitt 4% ALC 8% Precursor B-Cell B Lymphoblastic Lymphoma/Leukaemia Morphology lymphoblasts diffuse Immunology TdT + cytoplasmic mu -/+ CD19, 22, 79a + CD10 +/- CD34 +/- Genetics various Clinical leukaemic children > adults aggressive; curable CD45 CD10 1

Case 18 65-årig kvinde Hurtigt voksende lymfeknude på hals. Hun har haft feber nattesved. utilsigtet vægttab (ca. 9 kg. på 3 mdr.) Plasma LDH er forhøjet (840 U/L) Excision af 4 cm. stor lymfeknude (snit herfra). Case 18 - diagnoseforslag DLBCL 6 Mantlecelle lymfom - 5 Burkitts lymfom 1 Storcellet; obs ALC DDx: MCL, blastoid DLBL (B-cellNHL unclassified betweendlbcl & BL) Rule out PTL chl DSB Case 18 - diagnosis Diffuse Large B-cell Lymphoma Difuse large B-cell lymphoma Nodal 50% Extranodal 40% Both 10% BM involved 20% Most stage 1 or 2 DLBCL Presenting Features Enlarging mass in nodal or extranodal site Frequently symptomatic Occurs at all ages, more common after age 60 Extranodal sites: head & neck, GI, liver, skin, bone, bone marrow, others Presents both in limited and advanced stage Curative potential based on prognostic features DLBCL Presenting Features Enlarging mass in nodal or extranodal site Frequently symptomatic Occurs at all ages, more common after age 60 Extranodal sites: head & neck, GI, liver, skin, bone, bone marrow, others Presents in limited and advanced stage Curative potential based on prognostic features 2

CB IB B-ana Diffuse Large B-cell B Lymphoma Morphology large cells TCRBCL nucleoli diffuse Immunology surface Ig +/- cytoplasmic Ig -/+ CD19, 20, 22, 79a + CD30 -/+ CD20 CD38, CD138 pc CD5 10% CD10 40% bcl6 79% mum1 50% Genetics t(14;18) CD79 BCL-6 rearranged/mutated Clinical adult > children aggressive curable Large B-cell Lymphomas Morphologic Variants Centroblast-like Immunoblast-like > 90% IBs Centrocytoid Multilobated Anaplastic DLBCL: Centroblastic DLBCL: IB DLBCL: Centrocytoid DLBCL: Multilobated Diffuse large B-cell lymphoma: anaplastic 3

DLBCL: multilobated Basic IHC panel for lymphoma diagnosis CD45 CD20 CD79α (PAX-5) kappa/lambda CD3 CD5 CD30 CD43 CD163 (CD68) Bcl-2 Bcl-6 CD23 (CD21) Cyclin-D1 Ki-67 Immunophenotyping in DLBCL IHC panel for DLBCL diagnosis Add to basic panel: CD10 CD138 MUM1 DLBCL - Cell of Origin Large B-cell Lymphomas Molecular Variants 15 years ago! Germinal Centre B-cell Activated B-cell Nature. 2000 Feb 3;403(6769):503-11 4

DLBCL: cell of origin subtypes Molecular Profiling in B-Diffuse Large Cell Lymphoma Rosenwald et al. NEJM 346:1937, 2002 Overall Survival Nature. 2000 Feb 3;403(6769):503-11 DLBCL: Cell-of-Origin DLBCL - the HANS Classifier: Germinal centre (GC) & Activated B cell (ABC) types Can IHC be used as a surrogate for molecular profiling? Hans et al Blood. 2004;103(1):275-82 WHO Update 2016: Large B-cell lymphomas DLBCL: Cell-of-origin IHC classifiers Distinguishing GCB from non-gcb types will be now mandatory Any IHC algorithm accepted (state in report) many proposed no clear winner 5

Cell-of origin assay mrna molecular profiling (Nanostring) paraffin blocks Nanostring assay, paraffin Microarray assay, frozen Novel therapies in DLBCL based on of Cell of origin Several ongoing studies: Bortezomib in DLBCL (ABC) Ibrutinib in DLBCL (ABC) Etc. Large B-cell Lymphomas Subtypes T-cell-rich Primary CNS Mediastinal B-cell lymphoma Primary leg type EBV+ of elderly T-cell Rich Large B-cell Lymphoma T-cell Rich Large B-cell Lymphoma CD20 6

Diffuse Large B-cell Lymphoma Primary Mediastinal (Thymic) Large B-cell Lymphoma Rare variants: Mediastinal Intravascular Effusion younger patients + + sclerosis Hodgkin-like Primary Mediastinal (Thymic) Large B-cell Lymphoma Primary Mediastinal (Thymic) Large B-cell Lymphoma CD20 CD30 Ki-67 MUM-1 Cutaneous DLBCL, leg type Cutaneous DLBCL, leg type Elderly Often lower leg not always! Monomorphous large cell infiltrate CD20+ bcl2+ bcl6+ CD10- Better prognosis than DLBCL,nos 7

EBV-positive DLBCLs of the elderly Cutaneous Intravascular Large BCL CD20 EBER typical DLBCL > 50 yrs. EBVpos Asia?? ca. 5 % DLBCL weakened immune system? Intravascular Large B-cell Lymphoma Intravascular Large B-cell Lymphoma CD79 Plasmablastic B-celI Lymphoma Plasmablastic Lymphoma especially HIV+ especially oral CD138+ CD38+ MUM1+ Weak/neg for CD45 / CD20 / PAX5 8

Aggressive B-celI Lymphomas BL: Classical (30%) Burkitt lymphoma classical monomorphous, cohesive medium-sized blasts starry sky macrophages Burkitt Lymphoma Paraffin-FISH myc split probe Phenotype surface IgM + CD19, 20, 79a + CD10 +/- CD5, 23 - Ki-67 > 90% EBV positive 30% CD20 (B-cell) Genetics t(2;8), t(8;14), t(8;22) monoclonal c-myc rearranged TP53 inactivated (60%) Normal control lymph node t(8;14) positive Burkitt lymphoma Gray zone (bordeline) B-cell lymphomas Overlap between BL and DLBCL BL = Burkitt lymphoma BCLU = B-cell lymphoma unclassified, between DLBCL-BL DLBCL = diffuse large B-cell lymphoma DH = double hit lymphoma. These are seen in each group 9

Gray zone lymphomas new provisional WHO entities, 2008 Gray zone lymphomas new provisional WHO entities, 2008 B-cell lymphoma, unclassifiable intermediate between DLBCL and BL B-cell lymphoma, unclassifiable intermediate between DLBCL and BL B-cell lymphoma, unclassifiable intermediate between DLBCL and chl Less common lymphomas! B-cell lymphoma, intermediate between DLBCL and BL (BCLU, DLBCL/BL) BCLU DLBCL / BL Definition: B lineage lymphoma aggressive not common widespread disease, often extranodal some previously called BL-like overlapping features of DLBCL and BL: morphological immunophenotypic genetic mix of cells too big for BL, too small for DLBCL high proliferation rate with starry sky background morphology not typical for either DLBCL or BL Double-hit lymphomas Translocations - e.g. myc+ plus bcl-2+ or bcl-6+ DO NOT include Typical DLBCL with MYC rearrangement Typical BL without MYC rearrangement BCLU DLBCL / BL B-cell lymphoma, intermediate between DLBCL and BL (BCLU, DLBCL/BL) Starry sky background BL-like morphology BUT nuclei too big and irregular Immunophenotype: B-cell positive CD19 pos CD20 pos CD79 pos sig pos Often BL-like immunophenotype CD10 pos BCL6 pos BCL2 neg MUM1 neg/weak Includes BL-like morphology with strong BCL2 pos Test BCL2 pos cases for double-hit lymphoma with FISH Ki-67 index often very high e.g. >95% May also be lower than typical BL 10

BCLU DLBCL / BL BCLU, DLBCL-BL CD20 CD3 CD10 TdT Ki-67 BL-like immunophenotype (BCL2 neg ) Bcl-2 Male 30 years testis lymphoma starry sky background medium-sized blasts some nuclear irregularity BCLU, DLBCL-BL B-cell lymphoma, intermediate between DLBCL and BL (BCLU, DLBCL/BL) Genetics: IG genes rearranged 35+% - typical 8q24/MYC translocations BUT unlike BL, often not involving IG gene loci 15% have BCL2 translocation Often with BCL6 see double-hit lymphoma 100% proliferation (Ki-67) Bcl-2 expression Double-hit lymphoma BCL2 MYC Rearrangements of both BCL-2 & MYC Break apart probes show: 1 fusion signal 1 red arrow 1green arrow 11