The classification of malignant lymphomas has undergone significant

changes over the past 50 years. The current approach is based on the
integration of morphologic, phenotypic, genetic, and clinical features
that allows the identification of distinct disease entities. This practical
approach to lymphoma categorization was initially proposed by the
International Lymphoma Study Group in 1994 and formed the basis of
the Revised European-American Classification of Lymphoid Neoplasm
(REAL). It was then adopted by the World Health Organization (WHO)
classification of neoplasms of the hematopoietic and lymphoid tissues,
published in 2001 and updated in 2008.The WHO classification
represents a significant achievement in terms of cooperation,
communication, and consensus among pathologists, hematologists, and
oncologists.
WHO
B-Cell Neoplasms
Precursor B-cell neoplasm
Precursor B-lymphoblastic leukemia/lymphoma
(precursor B-acute lymphoblastic leukemia)
Mature (peripheral) B-neoplasms
B-cell chronic lymphocytic leukemia / small lymphocytic lymphoma
B-cell prolymphocytic leukemia
Lymphoplasmacytic lymphoma
Splenic marginal zone B-cell lymphoma
(+ villous lymphocytes)
Hairy cell leukemia
Plasma cell myeloma/plasmacytoma
Extranodal marginal zone B-cell lymphoma of MALT type
Nodal marginal zone B-cell lymphoma
(+ monocytoid B cells)
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma
Mediastinal large B-cell lymphoma
Primary effusion lymphoma
Burkitt’s lymphoma/Burkitt cell leukemia
T and NK-Cell Neoplasms
Precursor T-cell neoplasm
Precursor T-lymphoblastic leukemia/lymphoma
(precursor T-acute lymphoblastic leukemia
Mature (peripheral) T neoplasms
T-cell chronic lymphocytic leukemia / small
lymphocytic lymphoma
T-cell prolymphocytic leukemia
T-cell granular lymphocytic leukemia
Aggressive NK leukemia
Adult T-cell lymphoma/leukemia (HTLV-1+)
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-like T-cell lymphoma
Hepatosplenic γδ T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
Mycosis fungoides/Sézary syndrome
Anaplastic large cell lymphoma, T/null cell,
primary cutaneous type
Peripheral T-cell lymphoma, not otherwise characterized
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma, T/null cell,
primary systemic type
Hodgkin’s Lymphoma (Hodgkin’s Disease)
Nodular lymphocyte predominance Hodgkin’s lymphoma – 5%
Classic Hodgkin’s lymphoma – 95%
Nodular sclerosis Hodgkin’s lymphoma
Lymphocyte-rich classic Hodgkin’s lymphoma
Mixed cellularity Hodgkin’s lymphoma
Lymphocyte depletion Hodgkin’s lymphoma

More than 150 years ago, Thomas Hodgkin described several cases of a
lymphoproliferative disease, which was later named Hodgkin disease. This
malignancy, which is now called Hodgkin lymphoma (HL), has been one of
the most enigmatic forms of lymphomas for a long time. This is due to
several key features of the disease: First, the pathognomonic and
suspected tumor cells of HL, the mononuclear Hodgkin and the bi- or
multinucleated large Reed-Sternberg cells, are very rare in the tumor
tissue, often accounting for only about 1% of the cells. Thus the
molecular analysis of these cells was very much hampered until methods
became available to isolate these cells by microdissection from tissue
sections. Second, the Hodgkin and Reed-Sternberg (HRS) cells have a very
unusual immunophenotype, which does not resemble any normal cell in
the hematopoietic system. Therefore immunophenotyping, which was
very informative in revealing the cellular derivation of most other
lymphoid malignancies, did not help to uncover the cellular origin of
HRS cells. Third, only a few cell lines could be established from HL
patients, these lines were rather heterogeneous, and for hardly any of
these lines was the derivation from the HRS cells in the patient
unequivocally shown. Hence it was initially difficult to draw firm
conclusions from the study of such lines. Although HL still harbors many
secrets, exciting novel insights into the cellular origin of the HRS cells
and the pathogenetic processes in their generation have been obtained in
the last years, which will be discussed in this chapter.

Classification of Hodgkin Lymphoma

HL is subdivided into classical HL, which accounts for about 95% of
cases, and nodular lymphocyte predominant HL (NLPHL). The tumor
cells are called HRS cells in classical HL and lymphocyte predominant (LP)
cells in NLPHL (until recently, the tumor cells in NLPHL were called
lymphocytic and histiocytic [L&H] cells). Classical HL and NLPHL differ
in the histologic picture, the morphology and immunophenotype of the
tumor cells, and multiple clinical features. Classical HL is further
subdivided into four subforms: nodular sclerosis, mixed cellularity,
lymphocyte-rich classical, and lymphocyte depletion HL. Again,
differences in the histologic picture and HRS cell morphology are the
basis for this subtyping.
B-cell Development and Differentiation
Because we now know that HRS and LP cells are derived from B cells
(see later), a brief outline of B-cell development and differentiation is
given first. B cells are generated in the bone marrow from hematopoietic
stem cells in a multistep developmental process. The key determinant for
B-cell development is the generation of a functional B-cell receptor
(BCR), which is composed of two identical immunoglobulin (Ig) heavy
chains and two identical light chains, the latter of which can be of
the κ or λ type. B-cell development is initiated when common lymphoid
progenitors undergo gene rearrangements at the Ig gene heavy chain
locus. The variable part of the antibody heavy chain is composed of three
gene segments: variable (V), diversity (D) and joining (J). First, a
randomly selected DH gene segment is rearranged to one JH gene
segment. In the next step, a VH gene segment is rearranged to a DH-
JH joint. If the rearrangement is in-frame and productive, a heavy chain
can be expressed and the developmental stage of a pre-B cell is reached.
In the next step, Vκ to Jκ rearrangements occur to generate a κlight chain.
If this is not successful, V gene rearrangement processes take place at
the λlight chain locus. B cells expressing a functional (and
nonautoreactive) BCR are released into the periphery and express their
BCR as IgM and IgD receptors—that is, two different classes of the heavy
chain constant region. The first DH-JH rearrangements are not completely
specific for B-lineage cells, but VHDHJH rearrangements and light chain
gene rearrangements are highly specific for B cells. Thus their detection
in a cell unequivocally defines that cell as a B cell. Moreover, because of
the availability of multiple V, D, and J gene segments and additional
diversity generated at the joining sites of the rearranging gene segments,
a V(D)J rearrangement (in particular for the heavy chain locus) is unique
for each B cell and thus can be used as a clonal marker for B cells
deriving from the same mature B cell.
If B cells are activated through binding of antigen to their BCR and
through cognate help from T-helper cells, the cells undergo a T-
dependent immune response in specific histologic structures, the
germinal centers (GC), in lymph nodes or other secondary lymphoid
organs. In these follicles, activated B cells undergo massive clonal
expansion and further diversify their BCR through two processes:
somatic hypermutation and class switching. The process of somatic
hypermutation introduces point mutations and some deletions and
duplications at a very high rate into the Ig heavy and light chain V region
genes. This randomly modifies amino acids in the V regions, and in a
selection process involving follicular dendritic cells and follicular T-
helper cells, B cells expressing mutated BCR with increased affinity to
the stimulating antigen are positively selected, whereas B cells acquiring
unfavorable mutations undergo apoptosis within the GC
microenvironment. Unfavorable mutations include clearly destructive
mutations, such as nonsense mutations and deletions or duplications
causing reading frame–shifts that prevent expression of a BCR as such.
Other disadvantageous replacement mutations still allow BCR
expression but reduce the affinity to the antigen. After multiple rounds of
proliferation, mutation, and selection, positively selected B cells
expressing a high-affinity BCR differentiate into long-lived memory B
cells or plasma cells and exit the GC. Many GC B cells also undergo class
switching before they are selected into the memory or plasma cell pool.
In class switching, the originally expressed Cµ and Cδ heavy chain
constant region genes (encoding IgM and IgD, respectively) are replaced
by downstream-located Cγ, Cα, or Cε genes, encoding IgG, IgA, and IgE
heavy chains, respectively, so that antibodies with altered effector
functions are generated. At all stages of their development, B lineage
cells are selected for expression of the appropriate BCR, and cells failing
this selection are eliminated.
Cellular Origin of Lymphocyte Predominant Cells in Nodular Lymphocyte
Predominant HodgkinLymphoma
LP cells in NLPHL express multiple typical B cell markers, such as the
surface molecules CD20 and CD79. LP cells mostly lack expression of
markers of other hematopoietic cell lineages. Thus their
immunophenotype suggests a B-cell origin. Moreover, LP cells are
located in follicular structures in close association with follicular
dendritic cells and GC-type T-helper cells, suggesting a close relationship
with GC B cells. All of these phenotypic features point to a GC B cell
origin of LP cells. This was further corroborated at the genetic level when
clonally rearranged and productive Ig V region genes were amplified
from isolated LP cells. These rearrangements were always somatically
mutated. In some cases, intraclonal diversity of V region genes was
observed, indicating ongoing somatic hypermutation during clonal
expansion. Therefore the Ig V gene analysis further strongly supported a
GC B cell origin of LP cells.

Cellular Origin of Hodgkin and Reed-Sternberg Cells in

Classical Hodgkin Lymphoma
HRS cells show a very peculiar immunophenotype that does not
resemble any normal hematopoietic cell type. HRS cells express markers
of different cell lineages in a fraction or even most cases, including B cell
genes , T cell genes , natural killer cell genes , myeloid genes dendritic
cell markersTherefore immunohistochemical studies could not resolve
the cellular origin of HRS cells. In addition, the first cell lines established
from HL patients and presumed to be derived from HRS cells were either
of B-cell origin, of T-cell origin, or of nonlymphoid origin (discussed in
further detail later). The origin of HRS cells was finally clarified when
HRS cells microdissected from tissue sections were analyzed for
rearranged Ig V region genes. These studies revealed that HRS cells in
nearly all cases carry clonal Ig heavy and light chain gene
rearrangements.5 This established their B-cell nature, because such
rearrangements are highly specific for B cells. Moreover, with rare
exceptions, the rearranged V region genes were highly mutated, pointing
to a derivation from GC or post-GC B cells.5
In about a quarter of the cases of classical HL, the Ig V gene
rearrangements carried clearly destructive mutations that rendered
originally functional V region genes nonfunctional. Such “crippling”
mutations included deletions and insertions causing loss of the correct
reading frame, as well as nonsense mutations. Most disadvantageous
mutations that cause apoptosis of normal GC B cells are likely
replacement mutations that reduce affinity to the antigen. Decisive steps
in HL pathogenesi become effective or take place in GC B cells. Thus
although some final transforming events may well occur when HRS
precursor cells have already left the GC microenvironment, classical HL
is considered as a GC B cell–derived malignancy.

The Role of Epstein-Barr Virus in Classical HodgkinLymphoma

In about 40% of cases of classical HL in the Western world, and in about
90% of childhood HL cases in Central and Southern America, HRS cells
are infected by EBV. Molecular analyses of EBV+ cases showed that EBV
infection of HRS cells is a clonal event (i.e., EBV infected or was already
present in the founder cell of the HRS cell clone. EBV determine NF-κB
activation.
Summary of Mechanisms Underlying Malignant Transformation

Although much has been learned about the derivation of the HRS cells, little is
known about the basic mechanisms underlying malignant
transformation of HL. The HRS cells in HL are derived from pre-
apoptotic germinal center B cells in most cases, but in some cases, they
are of T-cell origin. The expression of EBV-latent genes in EBV-positive
cases (50%) may play a role in cellular transformation by upregulating
the transcription factor NF-κB. The events underlying the
transformation process in the EBV-negative cases, however, are still not
understood. Several studies have focused on the apoptosis-resistant
phenotype of HRS cells, and some data suggest that constitutively
expressed FLICE-inhibitory protein (FLIP), a protein that inhibits FAS-
mediated apoptosis, contributes to apoptosis resistance in HL. Genetic
instability is a typical feature of HRS cells, and studies point to distinct
genetic imbalances rather than subtile genetic alterations such as point
mutations or microsatellite instability. Besides NF-κB, other
transcription factors are deregulated in HRS cells, contributing to the
lost B-cell identity of malignant cells in HL. The discovery that the HRS
cells themselves contribute to the ineffective immune response by
expressing immunosuppressive cytokines or by expressing chemokines
that predominantly attract Th2 lymphocytes that are incapable of cell
killing has widened our understanding of the environmental cross talk of
these peculiar cells.

Clinical Features

Patients with NSHL or MCHL have a central pattern of lymph node

involvement (e.g., cervical, mediastinal, paraaortic). In most patients
with cHL, primary lymphadenopathy occurs in the left cervical or
supraclavicular region or in the mediastinum. NSHL patients more often
have a supradiaphragmatic onset of disease. MCHL patients present with
smaller disseminated nodes and predominantly subdiaphragmatic nodes
or organ involvement. In contrast, certain nodal chains (e.g., mesenteric,
hypogastric, presacral, popliteal) are seldom involved. Patients with
NLPHL typically present with involved peripheral nodes in the cervical,
submandibular, axillary, or inguinal region. NLPHL is mostly diagnosed
in early stages. B symptoms and involvement of the spleen or other
organs rarely occur. The spleen is involved more frequently in patients
with adenopathy below the diaphragm, systemic symptoms and MCHL
histology. Involvement of the liver is rare and mainly occurs with
concomitant splenic involvement. Infiltration of the bone marrow at
diagnosis is uncommon, usually focal, and almost always associated with
extensive disease, systemic symptoms, and unfavorable histology.
Bulky lymph node involvement or a contiguous collection of smaller
lymph nodes (>10 cm in diameter) may result in regional complications
such as vascular, tracheal, bronchial, or gastrointestinal compression or
obstruction. Invasion of adjacent anatomic regions such as the lung,
pericardium, pleura, chest wall, or bone can occur in patients with HL.
Effusions of the pericardium, pleural cavity or peritoneal cavity are often
associated with extranodal involvement and invasive growth into
neighboring structures. Despite a large mediastinal mass, superior vena
cava syndrome is seldom observed; if it occurs, it is often associated with
venous thrombosis.
Compared with NHL, bulky infradiaphragmatic lesions with obstructive
symptoms are rare in HL. Spleen involvement is often subclinical and
sometimes hard to diagnose with modern imaging techniques. Tumor
involvement is not necessarily associated with splenic enlargement; a
small spleen can have diffuse HL involvement.
Hematopoietic spread to organs is mainly seen in the lung, liver, bone
marrow, and bone, and it must be distinguished from disease invasion
into adjacent organs by an extranodal tumor that penetrates the capsule
of a lymph node. Skin involvement is seen very rarely and can appear as
small, opaque, or red papules or as ulcerating lesions. Involvement of the
central nervous system can occur by extension from nodes within the
paraaortic region through the intervertebral foramina, manifesting as
neurologic symptoms and pain.
A considerable number of undiagnosed patients with HL present with
systemic symptoms before the discovery of enlarged lymph nodes.
Typical symptoms include fever, drenching night sweats, and weight loss
(i.e., B symptoms). The characteristic HL-associated fever (i.e., Pel-
Ebstein type) occurs intermittently and recurs at variable intervals over
several days or weeks. Fever and drenching night sweats are identified in
25% of all patients at the time of initial presentation, increasing to 50%
of patients with more advanced disease. Other nonspecific symptoms
include pruritus, fatigue, and the development of pain shortly after
drinking alcohol. This pain is usually transient at the site of nodal
involvement and may be severe. Pruritus, although not a defined B
symptom, may be an important systemic symptom of disease, although it
affects less than 20% of patients. It often occurs months or even a year
before the diagnosis of HL. The underlying pathophysiologic
mechanisms leading to pruritus are unknown, but possible causes
include an intrinsic production of cytokines such as growth factors by the
HRS cells and an autoimmune reaction in which a number of cytokines
are activated by tumor lysis.
 Malignant cell in HL
• Sternberg – Reed cell
• Variants
– Hodgkin cell
– Lacunar cell
– L&H cell (popcorn)

Investigation
Essential
– physical examination
– documentation of B symptoms
– laboratory evaluation
• complete blood count, ESR, Fbg
• liver function tests
• renal function tests
• lactate dehydrogenase
 – chest X ray
– ultrasonography
– CT scan of chest, abdomen and pelvis
Essential under certain circumstances
– liver biopsy
– bone X rays
– MRI
– staging laparotomy
– bone marrow biopsy
Useful but not essential tests
– cell-surface marker phenotypic analysis

Positive diagnosis

• Clinic
• Lab tests
Mandatory : lymph node biopsy with hystopathological exam: Reed
Sternberg cells (typical and variants) admixed within a reactive cell
infiltrate composed of variable proportions of lymphocytes, histiocytes,
eosinophils and plasma cells.
Prognosis
Bad:
• stages III si IV
• age ≥ 50 years
• Extranodal site by contiguity
• ESR > 50mm/h
• B symptoms (except stage I)
• >3 lymph node regions
• “bulky” tumor
Good:

• stage I si II
 • age < 50 years
• Without mediastinal tumor
• ESR < 30 mm/1h with B symptomes or ESR < 50 mm/1h without B
symptomes
Treatment – the goal = cure
• Stage I/II
– Favorable (2-)3 x ABVD + 30 Gy IN-RT
– Unfavorable 4 x ABVD + 30 Gy IN-RT
5 years survival rate 98%
• Stage III/IV 6 - 8 x ABVD/BEACOOP
5 years survival rate < 40%
15-30% relapse – high dose CT + autoSCT

Suspicion of HL

• identify B symptoms
• clinical exam – all lymph nodes
• ESR, Fbg, CBC, renal function, liver function…
• X ray, ultrasonography, CT
• Lymph node biopsy – Hp exam +/- IHC
• Stage
• Treat according to stage and prognosis factors

ABVD
Doxorubicin 25 mg/2, IV, day 1, 15
Bleomycin 10 mg/, IV, day 1, 15
Dacarbazin 375 mg/m2, IV, day 1, 15
Vinblastin 6 mg/m2, IV, day 1, 15
Every cycle at 30 days
BEACOPP basic
Doxorubicin 25 mg/2, IV, day 1
Ciclofosfamida 650/mp, IV, day 1
Etoposide 100mg/m2, IV, days 1-3
Vincristin 1,4mg/m2 (max. 2mg), IV, day 8
Bleomycin 10 mg/m2, IV, day 8
Procarbazina 100mg/m2, PO, days 1-7
Prednison 40mg/m2, PO, days 1-14
Every cycle at 21 days