PATHOLOGY: LECTURE

HEMATOPATHOLOGY SHIFT 2
Alejandro E. Arevalo, MD | Nov. 18, 2019 PATHOLOGY 5

OUTLINE ▪ Indolent tumors (chronic tumors) are usually not

I. INTRODUCTION TO NEOPLASTIC C. Immunophenotype cured despite chemotherapy
HEMATOPATHOLOGY D. Detection
A. Basis of Diagnosis E. Grading B. BASIS OF NOMENCLATURE
B. Basis of Nomeclature VII. Diffuse Large B-Cell Lymphoma
C. Brief Overview of Lymphocyte
Formation
A. Morphologic Variants
B. Cytogenetic Abnormalities of DLBCL
• Resemblance to the normal cell counterpart
1. Precursor B-Lymphocytes C. Immunophenotype → e.g., Follicular cell lymphoma from follicles, Marginal zone
(Hematogenes) in Bone D. Prognosis lymphoma arise from marginal zones of germinal center
Marrow E. Important Information From the Book
2. T-Cells VIII. Burkitt’s Lymphoma
D. WHO Classification A. Cytogenetic Abnormalities
C. BRIEF OVERVIEW OF LYMPHOCYTE FUNCTION
II. LYMPHOBLASTIC B. Methods of Detection: FISH • All lymphocytes come from bone marrow as immature lymphoid
LYMPHOMAS/LEUKEMIAS C. Morphology
A. 3-Stage Differentiation D. Staging and Treatment cells
III. LYMPHOMA OF MATURE E. Key Concepts → Nucleus is fine and open (fine chromatin, prominent
LYMPHOCYTES IX. Hodgkin’s Lymphoma
A. Types of Lymphoma A. Morphology
nucleoli)
B. Brief Overview of the Normal B. Pathogenesis → Shows that the cell is active and immature
Lymph Node C. Classification
C. Normal Secondary B-Follicle D. Clinical Features 1. Precursor B-Lymphoblasts (Hematogones in Bone Marrow)
D. Forming a Germinal Center E. Key Concepts
E. B-Cell Differentiation X. T-Cell Lymphoma Non-Hodgkin • Most immature
F. Origin of the Lymphomas
1. High Grade
Lymphoma
A. Nodal T-cell NHL • When you see “blast” → parent cell of mature lymphocytes
2. Low Grade B. Neoplasms of Uncertain • As they mature, they are released into peripheral blood as
IV. MARGINAL ZONE LYMPHOMA Lineage/Stage of Maturation
(MZBL) C. Leukemic/Disseminated T-cell NHL
naïve B lymphocyte (have not encountered an antigen)
A. Extranodal MZBCL D. Cutaneous T-cell NHL → Cytomorphology: appear darker, more condensed
B. Nodal MZBCL E. Other extranodal T-cell NHL
C. Splenic MZBCL XI. Myeloproliferative Neoplasms
chromatin, more inactive compared to blasts
D. Morphology A. Chronic Myelogenous Leukemia → “virgin lymphocytes”
E. Immunophenotype
F. Demographics
B. Polycythemia Vera
C. Essential Thrombocytosis
→ Find way into lymph nodes and occupy outer cortex as
G. Chromosomal Translocation D. Primary Myelofibrosis follicles
V. Mantle Zone Lymphoma XII. Acute Leukemia → Proliferate in germinal center, though many will die and a
A. Immunophenotype A. Acute Lymphoblastic Leukemia
B. Cytogenic Abnormalities B. Acute Myeloid Leukemia few will be selected to mature as plasma cells and return to
C. Morphology XIII. Chronic Lymphoproliferative Disorders the bone marrow.
D. Clinical Features A. Chronic Lymphoproliferative
E. Prognosis Leukemia 2. T-cells
VI. Follicular Lymphoma B. Multiple Myeloma
A. Morphology XIV. References • Originate from precursor T lymphoblasts in the bone marrow
B. Follicular Hyperplasia vs. XV. Appendices
Follicular Lymphoma • Migrate to the thymus before migrating to different organs
• Selection occurs in the thymus and differentiation into either
LEGEND CD4 helper T cell or CD8 cytotoxic T cells
MUST KNOW BOOK PREVIOUS NOTES • When they do differentiate, they eventually go to the different
   organs such as the skin, gastro intestinal mucosa, respiratory
I. INTRODUCTION TO NEOPLASTIC PATHOLOGY mucosa, spleen, and lymph node
• Particular area in the lymph node: paracortical area, usually in
• Lymphomas 
inner cortex
→ Proliferations that arise as discrete tissue masses (e.g.
within lymph nodes, spleen or extranodal tissues).
→ Two broad categories:
o Hodgkins lymphoma
o Non-Hodgkin’s lymphoma
• Leukemias
→ Neoplasms with widespread involvement of bone marrow
and often, but not always, the peripheral blood
• Myelomas
A. BASIS OF DIAGNOSIS
• No single feature can be a basis for diagnosis
• Multiple bases must be considered
1. Morphology
→ Slides and tissue specimens
→ The most basic approach
2. Immunophenotype Figure 1. Origin of lymphoid neoplasms
→ Use of immunohistochemistry staining
→ Determine cell lineage using markers
D. WHO CLASSIFICATION 
→ most of the time, these two will suffice for the diagnosis
3. Genetics ● Five broad categories in the WHO Classification scheme
→ For difficult cases, you will need to utilize based on clinical features, morphology,
genetics/karyotyping to diagnose immunophenotyped and genotype:
4. Clinical Behavior → Precursor B-cell neoplasms (immature B cells)
→ Correlate the disease process with the diagnosis → Peripheral B-cell neoplasms (mature B cells)
→ Distinct disease entities with particular prognosis → Precursor T-cell neoplasms (immature T cells)
→ Aggressive tumors usually have the potential to be cured
Trans 2.5 QUINTANA, QUINTIN, RABARA, RAGUDO. RAMOS M, RAMOS P, RAMOS R, VILLEGAS M, VILLEGAS S, WAHAB, YONZON, 1 of 24
ZACARIAS, ZENAROSA, TIAMZON, TOBIAS, TOH, TOREJA, TORNEA, TORRES C | RAPACON, XU, TARROSA, UY H,
 PATHO Lecture 2.5: Hematopathology 2 of 24

→ Peripheral T-cell and NK-cell neoplasms (mature T cells
and NK cells)
→ Hodgkin lymphoma (neoplasms of Reed-Sternberg cells)
● Categorized as T cell or B cell (adapted from Revised
European American Lymphoma [REAL] classification)
● Further divided whether they are derived from precursor
(immature [ex. Lymphoblastic lymphoma]) or from mature
(peripheral effector cells [ex. Follicular lymphoma, Mantle Cell
Lymphoma, Diffuse Large B cell lymphoma])
● Any tumor that will arise from lymphoblast are known
as Lymphoblastic Lymphomas
→ B-cell
→ Precursor B-cell
→ Precursor T-cell
● In terms of morphology, they appear blastic.
→ Meaning, the chromatin looks immature, fine, delicate,
or blast- like.
→ In the classification, we use phenotyping uses special
stains or basically, immunohistochemistry that utilizes
antigen-antibody reaction. So, if you have the
antigen/protein-antigen in the surface/cytoplasm of the
nucleus, they would mark positive for that marker and
that particular marker is specific for a certain lineage
● Those evolving from peripheral mature lymphocytes are called
mature B/T or NK cell lymphoma and are named mostly
according to its normal cell counterpart (particularly those with
B-cell origin)
II. LYMPHOBLASTIC LYMPHOMAS/LEUKEMIAS
● Immature cells give rise to Lymphoblastic Lymphoma
MORPHOLOGY
• Blastic (immature nuclei), sheets of cells with blastic nuclei
→ (+) vimentin: sarcoma
• Lymphoma/Leukemia connotes the site of involvement
Lymphoma - basically, involvement of extramedullary tissues or
outside the bone marrow (e.g. lymph nodes, cellular organs,
thymus)
→ Bone marrow involvement with extravasation in the
peripheral blood that makes it leukemic
→ If B- involvement of the extramedullary tissues like lymph
nodes, thymus, there are two major categories:
▪ LBL: involves extramedullary lymphoid tissues with <
25% bone marrow involvement
▪ ALL: > 25 % of bone marrow or without extramedullary
lesions (leukemic)
• Since LBL and ALL share considerable clinicopathological
features and present similar biological properties, they are
considered the same disease – but different manifestations.
• In terms of distribution, LBL or ALL represent about a third
(1/3) of lymphomas/leukemias involving children. But in the
adult, probably just one-tenth (1/10).
→ Common in the adult is mature B lymphoma: Diffuse Large
B-cell Lymphoma (DLBCL) followed by Follicular
Lymphoma
→ Children: Commonly Lymphoblastic Lymphoma/leukemia
(usually T cell), followed by mature lymphoma

Figure 3. NHL distribution Adult vs. Pediatric. Left: NHL distribution for children.
Right: NHL distribution for adults.

3-STAGE DIFFERENTIATION
• Lymphoblasts > Prolymphocytes > Mature Lymphocytes

Figure 2. Morphology of Lymphoblastic Lymphoma.

PHENOTYPE
• Tdt (Terminal dexynucleotidyl transferase; immature lymphoid
marker)
→ If (+), lymphoblastic but it does not tell you if T-cell or B-cell
• CD 34 (stem cell/blast cell marker)
→ If (+) → again, immature because it’s a BLAST cell marker
but it does not tell you whether you are dealing with an
immature myeloid cell or an immature lymphoid cell
• CD79a (B-cell, blast marker)
→ Immature B-cell marker
→ If (+), precursor B-cell lymphoblastic lymphoma
• CD3 (T-cell, blast marker) [if positive then it is a T-cell LBL)
→ Immature T-cell marker
→ If (+), precursor T-cell lymphoblastic lymphoma
• (+) reaction will always be a brown stain, (-) will be Figure 4. Three-Stage differentiation of Lymphocytic Leukemias
blue/the counterstain
• CD45
→ Common leukocyte antigen
→ Marks all hematolymphoid cells (panhematolymphoid
marker)
→ Marks a lymphoma, if (+) then you are dealing
with a panhematolymphoid neoplasm
→ (+) cytokeratin: carcinoma
 PATHO Lecture 2.5: Hematopathology 3 of 24

• If this involves soft tissues and lymph nodes, it is called

Lymphoblastic Lymphoma in nodal and extranodal organs (soft
tissue counterpart of AL Leukemia)
• Acute: blast percentage is 20% and above
• Chronic: blast percentage would be <20%
• Soft tissue counterpart of Chronic Lymphocytic Leukemia:
Small Lymphocytic Lymphoma in nodal and extranodal organs.
• CLL and SLL are one disease entity but different manifestations:
one is leukemic and the other is lymphomatous

Figure 5. Differentiation of Acute Lymphoblastic Leukemia from the most

immature lymphoblast (above); Differentiation of Chronic Lymphocytic
Leukemia from more mature lymphocytes (below).
Figure 9. Lymphoplasmacytic lymphoma. Bone marrow biopsy showing a
mixture of small lymphoid cells exhibiting various degrees of plasma cell
differentiation.

III. LYMPHOMA OF MATURE LYMPHOCYTES

• Lymphomas of mature lymphocyte can be T-cell or B-cell
→ For B-cell:
▪ Classical Hodgkin’s Lymphoma
▪ Non-hodgkin’s Lymphoma
→ For T-cell:
▪ Non-hodgkin’s Lymphoma
MORPHOLOGY
• Darker chromatin/ condensed/open chromatin
Figure 6. Histological features of Acute Lymphoblastic Leukemia (ALL) and • When chromatin is dark, the behavior tends to be indolent
Chronic Lymphopcytic Leukemia (CLL) in nodal and extranodal organs. • When chromatin is open, it means that it is active so it appears
• Chronic Lymphocytic Leukemia (CLL) more aggressive in terms of its clinical behavior
→ Proliferation involve the more mature lymphocytes PHENOTYPE
→ CLL is the most common leukemia of adults in the Western • Hodgkin’s Lymphoma
world → Reed Sternberg cell are positive for CD30
→ Markers will be associated with a certain disease but is not
specific
• Non- Hodgkin’s Lymphoma
→ CD 20 for B-cell
▪ Most common marker used
▪ Rituximab – drug that targets (+) CD 20 lymphomas;
added to the chemotherapeutic regimen of patients
diagnosed with B-cell Non-Hodgkin’s Lymphoma;
monoclonal antibody drug conjugate
→ CD 3 for T-cell
Figure 7. Chronic lymphocytic leukemia flooded with small lymphocytes with Table 1. Differences between Hodgkin and Non-Hodgkin Lymphomas
condensed chromatin and scant cytoplasm. Note disrupted tumor cells (smudge
cells).
• Acute Lymphoblastic Leukemia (ALL)
→ If the neoplasm will arise from the most immature
lymphoblast, and involves the bone marrow
→ ALL is the most common cancer of children. 

A. TYPES OF LYMPHOMA
• Lymphomas can be categorized into two main groups
→ Hodgkin Lymphoma or Hodgkin’s disease
▪ Characterized by the presence of specific abnormal
lymphocyte cells, most often B-cells (called Reed-
Sternberg cells)
▪ 10:90- ratio of Reed-Sternberg cells to inflammatory cells
Figure 8. Acute Lymphoblastic Leukemia/ Lymphoma with condensed nuclear ▪ 90% = lymphocytes, inflammatory cells, eosinophils, plasma
chromatin, small nucleoli, and scant granular cytoplasm
 PATHO Lecture 2.5: Hematopathology 4 of 24

Figure 12. Left: CD20 (B-cell marker). Right: CD3 (T-cell marker)
• First Order Architecture
Figure 10. Reed-Sternberg cells and Variants Upper left: Diagnostic Reed- → CD20: B-cell marker
Sternberg cells ; Upper right: Mononuclear variant; Lower left: Lacunar variant; ▪ Positive: Brown (follicles)
Lower right: Lymphohistiocytic variant
▪ Negative: blue (paracortex)
→ CD3: T-cell marker
→ Non- Hodgkin’s Lymphoma (NHL)
▪ Positive: brown (paracortex)
▪ Not a single disease, but rather a group of several
▪ Negative: blue (follicles)
closely related cancers. WHO has at least 61 types of
NHL • Second Order Architecture
▪ 90% will be lymphoma cells → Few B-cells in the paracortex
→ Few T-cells in the follicles
B. BRIEF OVERVIEW OF THE NORMAL LYMPH NODE → The cells are scattered and few, but not predominant
• Certain lymphomas can arise from the first order architecture or
• Cortex – very cellular which contains the lymphocytes
from the second order architecture
• Medulla – sinuses
→ First order: Clavicular Lymphoma B-cell lymphoma that will
• Three Layers of a Follicle arise in the paracortex: Classical Hodgkin Lymphoma
→ First layer: the one that is dark due to mostly small → T-cell that will arise in the paracortex first order
lymphocytes; the scanty cytoplasm. This layer is known as architecture: Peripheral T-cell lymphoma
the mantle zone. → B-cell that would arise within B-cell follicles:
→ The central portion is relatively pale in comparison with the Angioneoplastic B-cell lymphoma
mantle zone, this is known as the Germinal Center. It is
divided into two zones: C. NORMAL SECONDARY B-FOLLICLE
▪ Dark zone – dark-staining containing proliferating • Secondary follicle – with a germinal center and are active;
blastlike B cells (centroblasts) trilaminar structure
▪ Light zone - composed of B cells with irregular or • Primary follicle – without a germinal center
cleaved nuclear contours(centrocytes) • Composed of three layers
• In the lymph node, there is an indistinct, almost indistinguishable
mantle cell lymphocyte—little bit less dark, clearer than
mantle.

Figure 13. Normal secondary B-follicle

Mantle Zone
• A collar of small resting naïve B cells surrounding a pale
germinal center
Figure 11. Cellular components of lymph nodes. Central Layer (Germinal Center)
• Cellular Cortex • Dark zone
→ Subdivided into the follicles (upper cortex; mostly B- → Contains proliferating blast like B cells (centroblasts)
lymphocytes) and paracortex (deeper cortex; mostly T- • Light zone
cells) → B cells with irregular or cleaved nuclear contours
→ B-cell tend to organize into follicles they are driven to form (centrocytes)
follicles by a cytokine which is CxCL 13 (“13” looks like a ▪ Appears lighter than the dark zone
“B”) ▪ Compared to mantle, cells are larger with movement in
→ T-cells do not form follicles, they are scattered around the chromatin due to higher activity and proliferation
follicles and the cytokines that leads them to populate is ▪ Naive lymphocytes in mantle zone stimulated by antigens
CCR7 (“7” looks like a “T”) are driven to proliferate and increase in size resulting to
• Less cellular medulla change in chromatin pattern
▪ Some cells die, and phagocytic macrophages pick up
→ Region of the plasma cells
apoptotic debris
 PATHO Lecture 2.5: Hematopathology 5 of 24
▪ Surviving cells will become smaller centrocytes
• Benign reactive follicle:
→ Polarization of the germinal center into dark and light zones
→ Presence of starry sky pattern imparted by phagocytic
macrophages
→ Loss of these characteristics may indicate a lymphomatous
process
Marginal Zone
• Centrocytes mature and differentiate into memory B cells,
migrate into marginal zone lymphocytes, travel to medullary
sinus where they gain access to peripheral circulation and back
to lymph
Figure 16. Level of proliferation of different zones. Darker areas: more
proliferation. Lighter areas: more differentiated cells.

E. B-CELL DIFFERENTIATION
• First encounter
→ Precursor B cell → Naïve B cell makes contact with antigen
→ Travel to paracortex → B cell immunoblast →
Plasmacytoid lymphocyte

Figure 14. Trilaminar structure of a secondary lymphoid follicle

D. FORMING A GERMINAL CENTER

• Naive B cells
→ “Naïve” – have not encountered an antigen yet
→ Stimulated upon second encounter with antigen
→ Transformed from small cells and proliferate into larger cell
known as centroblasts and they will form the germinal
center
Figure 17. First encounter B-cell proliferation
• Second encounter
→ Form germinal center as centroblasts → Centrocytes →
Marginal zone/Monocytoid cell → Plasma cell

Figure 15. Germinal center cells

→ Not all centroblasts will mature → many will die
→ Somatic hypermutation – determines selection of B-cells
▪ Beneficial mutation that enables survival →
centroblasts mature into smaller centrocytes
▪ Detrimental mutations → apoptosis→ fragments
engulfed by phagocytic macrophages → starry sky
pattern in the germinal center
→ Populate dark zone
• Centrocytes
→ Populate light zone
→ Eventually mature as plasma cells and effector B cells
→ Migrate to marginal zone
• KI-67
→ Proliferation marker
→ Shows level of proliferation of different zones
→ Darker areas show more proliferation, lighter areas show
more differentiated cells
Figure 18. Second encounter B- cell proliferation
• During the first encounter with the antigen, the naïve B-cells
would be transformed into B-cell immunoblast in the paracortex
which will eventually mature into plasmacytoid lymphocytes
which secretes IgM.
• Upon second encounter with an antigen, mantle cell
lymphocytes which will be stimulated to form the germinal
center, where we have the centroblast which is selected will
transform into centrocyte then marginal cell lymphocytes and
eventually your plasma cells which secretes IgG.
• Highly proliferative lymphomas (very aggressive lymphomas)
from the centroblasts
→ Diffuse B-cell lymphoma
→ Burkitt’s lymphoma
 PATHO Lecture 2.5: Hematopathology 6 of 24

• Formation of lymphoid aggregates - usually when there is

chronic inflammation, and/or autoimmune disorders
→ Sites of chronic immune or inflammatory reactions: 
▪ Sjogren disease- salivary glands
▪ Hashimoto thyroiditis- thyroid
▪ H. pylori infection- stomach
→ Aggregates can undergo mutations
▪ Risk factor for development of MZBCL
B. NODAL MZBCL
• Rare - approximately 1.8% (~2%)
• Affects lymph nodes
C. SPLENIC MZBCL
• Rare - approximately 1%
Figure 19. Normal cell counterpart of each lymphomas. • Spleen is affected

F. ORIGIN OF LYMPHOMAS
1. High Grade
• Arise from very proliferative cells
• Diffuse Large B cell Lymphoma - Centroblast
• Burkitt’s lymphoma – Centroblast
• Hodgkin’s Lymphoma – Paracortical B cell immunoblast
• Lymphoblastic lymphoma – Precursor B cell
2. Low Grade
• Originate from small cells, patients may appear asymptomatic
• Small Lymphocytic Lymphoma – Naïve B cell Figure 22. Relative frequencies of B-cell lymphoma subtypes in adults.
• Mantle Cell Lymphoma – Mantle cell

Figure 20 . Mantle cell lymphoma. Left (LPO): Neoplastic lymphoid cells

surround a small, atrophic germinal center (mantle zone pattern of growth). Right Figure 23. Marginal zone pattern.
(HPO): Homogenous population of small lymphoid cells with somewhat irregular • Inverse follicular pattern due to the tendency of marginal zone
nuclear outlines, condensed chromatin and scant cytoplasm
to expand
• Follicular Lymphoma – Centrocytes → Lighter outer zone (proliferating zone) expands, and
extends to paracortex reaching up to sinuses
→ Dark center would display normal mantle zone, with or
without germinal center
D. MORPHOLOGY
• Marginal zone, and interfollicular cells infiltrated by marginal
zone B cells
→ Although cells have differentiated stages of B lymphoid
Figure 21. Left (LPO): Nodular aggregates of lymphoma cells throughout differentiation, the predominant population resembles a normal
lymph nodes. Right (HPO): Small lymphoid cells with condensed chromatin
marginal zone B cell 
and irregular cleaved nuclear outlines (centrocytes)
• Features/patterns seen at low magnification:
• Marginal zone lymphoma – Marginal zone lymphocytes → Benign follicles surrounded by confluent monocytoid B-
• Lymphoplasmacytic lymphoma – Plasmacytoid lymphocyte cells in:
▪ Marginal zones (marginal zone pattern)
IV. MARGINAL ZONE LYMPHOMA (MZBCL) ▪ Interfolicular areas (interfolicular, inverse interfollicular)
• Any tumor/malignancy that would arise from the marginal zone ▪ Sinuses (sinus pattern)
• Heterogenous group of B-cell lymph tumors arising in lymph nodes,
spleen or extranodal tissues. 
A. EXTRANODAL MZBCL
• Most common among marginal zone lymphomas
→ Approximately 9%
• Would originate from mucosal linings
→ Usually does not contain lymphoid aggregates
• Also known as Mucosa-associated lymphoid tissue (MALT)
type lymphoma (MALToma)
• Usually affects mucosal surfaces (e.g. Gastric, salivary,
conjunctival, thyroid, skin, nasopharyngeal mucosa, etc.)
 PATHO Lecture 2.5: Hematopathology 7 of 24

E. IMMUNOPHENOTYPE
• Diagnosis of Exclusion: rule out other low-grade lymphomas
→ Following markers must be ruled negative to consider
marginal zone (positive for the following conditions:
▪ CD5, CD23 - Small Lymphocytic Lymphoma
▪ CD10 (along with BCL2) - Follicular Lymphoma
▪ CD5, Cyclin D1 - Mantle Cell Lymphoma
• CD43 - Monoclonal light chains
→ Restricted B cells
▪ Normally, Polyclonal - mixture of Lambda, and Kappa
light chains
▪ Some would not express either (normal)
▪ Malignant - either Kappa, or Lambda light chain
predominant
Figure 24. Marginal zone B- cell lymphoma.
F. DEMOGRAPHICS
• Centrocyte-like B cells • Extranodal MZBCL
→ Homogeneous appearance → Occurs most of the time in stomach (Gastric MALT, 50%)
→ Cells are generally smaller → Usually associated with bacterial infection (i.e. H. pylori) In
→ Appear slightly irregular early detection, it can be countered with antibiotics.
→ Abundant pink cytoplasm • Also occurs in other sites with mucosal surfaces (e.g. Skin,
Thyroid, Salivary gland
→ Patients with history of chronic inflammation, or
autoimmune disorders (e.g. Hashimoto’s Thyroiditis,
Sjogren’s Syndrome)
▪ Polyclonal lymphocytes become monoclonal due to
mutation(s)
▪ Possibly, due to persistence of chronic inflammation
• Lymphoepithelial Lesions/Complexes
→ Infiltration of epithelial surfaces by lymphoma cells
→ Must be accompanied by Glandular destruction
▪ Glands destroyed and distorted by lymphocytic infiltrates
Figure 25. Marginal zone (centrocyte-like) B-cells. ▪ Benign: Sparse glandular dysfunction
▪ Malignant: Dense glandular dysfunction
• Monocytoid B cells ▪ Lymphoepithelial lesions alone are seen in normal
→ Homogeneous appearance tissues - form of antigen sampling from mucosa
→ Monocyte-like cells
→ Clear cytoplasm around the nucleus
▪ Clearly defined nucleus

Figure 28. Extranodal marginal zone lymphoma

Figure 26. Monocytoid B-cells • Polymorphic (Post-germinal GC differentiation)
• Polymorphous → Precursor lesion - Any lymphoid accumulation in extranodal
→ Small B cells sites (usually associated with chronic inflammation
→ Immunoblasts disorders)
→ Plasma cells ▪ Autoimmunity (e.g. Hashimoto’s Thyroiditis, Sjogren’s
→ Polymorphic Syndrome)
▪ Initially benign, may become lymphomatous
▪ Infections
o H. pylori - Stomach
o C. psittaci - Eyes
o C. jejuni - Small Intestines
o B. burgdorferi - Skin
→ Modified Ann Arbor Staging
▪ Stage I to II
o Localized in particular organ
o Excision can be performed
→ Bone marrow involvement rarely occurring in MALTomas
Figure 27. Polymorphic B-cells ▪ If ever, more prevalent in Gastric MALT than any other
extranodal site
 PATHO Lecture 2.5: Hematopathology 8 of 24
→ Neoplastic B cells will have some apparent expression of the
CD5 marker
→ CD5(+) and CD23(-) helps to distinguish it from CLL or SLL 

Figure 29. Polymorphic (post germinal GC differentiation)

G. CHROMOSOMAL TRANSLOCATION
• Movement/swapping of genetic elements between
chromosomes
Figure 31. Cells seen in CD5 immunophenotyping
• Common cause of neoplasms ● Cyclin D1
→ Proto-oncogene activation → Marker for MCL
→ Tumor suppressor inhibition → Not specific
→ Hybrid gene creation - neoplasm formation ▪ Can be positive for myelomas and hair cell leukemias
• Extranodal MZBCL
→ Trisomy 3
→ Translocation 11;18
▪ Shorter 11, Longer 18
▪ Fusion of API2 (11q21), and MALT1 (18q21)
- Found in 40% of MALToma cases
▪ Resistance to treatment of H. pylori infections
→ If associated with H. pylori:
▪ Early detection and eradication of infection can resolve
lymphoma
• Prognosis
→ Indolent clinical course due to origin (Small cells)
Figure 32. Cells seen in Cyclin D1 immunophenotyping
→ Slow dissemination
→ Recurrences possible after many years ● Most tumors also express CD19, CD20, and moderately high levels of
→ Patients may appear asymptomatic, long survival surface Ig (usually IgM and IgD) 
▪ Abdominal pain present
B. CYTOGENETIC ABNORMALITIES
→ Extranodal MZBCL is sensitive to radiation therapy
→ Transformation to Diffuse Large B Cell Lymphoma may ● Characterized by translocation involving chromosomes 11
occur and 14 or CCND1/BCL1 gene
▪ High-grade, aggressive lymphoma → Involves IgH locus on chromosome 14 and cyclin D1 locus in
chromosome 11 leading to overexpression of Cyclin D1. 
V. MANTLE CELL LYMPHOMA ▪ Upregulation promotes G1-to-S-phase progression
● Mantle zone - darker colored lymphocyte near your germinal
center C. MORPHOLOGY
● Present in about 7% of Non-Hodgkin’s Lymphoma ● Proliferation consists of a homogenous population of small
● Mantle zone pattern - small reactive follicle centers with very lymphocytes with irregular to occasionally deeply clefted nuclear
thick mantle zones contours. 
● Mantle Cell Lymphoma (MCL) - monomorphic small to medium ● Nuclear chromatin is condensed, nucleoli are inconspicuous, and
sized B-lymphoid cells with irregular contours  cytoplasm is scant. 
● Tumor cells closely resemble the normal mantle zone B cells that ● Tumors composed of intermediate-sized cells with more open
surround germinal centers.  chromatin and a brisk mitotic rate are observed.
● Population tends to be monotonous
→ Unlike the MCL in which some tend to be polymorphic
● Lymphocytes tend to be slightly irregular
→ not round like those of Small Cell Lymphoma
● Sometimes you will see lymphocytes in a monotonous sea in the
mantle zone

Figure 30. Mantle zone pattern. yellow arrows: expanding mantle. Green
circle: atrophic germinal center

A. IMMUNOPHENOTYPE
● CD5 and Cyclin D1 Positive
→ Marker for MCL
● CD5
→ T cell marker Figure 33. Monotonous population of slightly irregular lymphoid cells
→ Positive in normal T cells
 PATHO Lecture 2.5: Hematopathology 9 of 24

● Mantle zone pattern  ● More common in females

→ Mantle zone tends to expand and appear darker in color ● Sites: lymph nodes, spleen, bone marrow
→ Germinal center tends to be atrophic ● Usually diagnosed late (stage 4)
→ You will see a small germinal center surrounded by a very → patients can be asymptomatic
thick and dark mantle zone ● 25-35% may transform into DLBCL
● Bone marrow involvement in 40-70% with paratrabecullar
infiltrates

Figure 36. Events in Follicular Lymphoma.

A. MORPHOLOGY
Figure 34. Expanded mantle zone in Mantle Cell Lymphoma

D. CLINICAL FEATURES
● Usually affects middle-aged to older-aged male adults (5th to
6th decade of life)
● When diagnosed, usually already in Stage III or Stage IV
● Staging is known as the Ann Arbor Classification
→ Stage 1 – one contiguous region of the lymph node/mass
→ Stage 2 – two or more but on the same side
→ Stage 3 – lesions on both sides of the diaphragm including the
liver, spleen
→ Stage 4 – bone marrow involved
● Clinical Presentation: Figure 37. Germinal center with centrocytes (yellow arrow) and centroblasts
(red arrow)
→ Lymph node enlargement
● Originate in the light zone of the germinal center
▪ Most common presentation: painless lymphadenopathy
● Consists of centrocytes (predominant), and centroblasts (which
→ Splenic enlargement
increases in higher grades)
→ Liver enlargement
● Monomorphic follicular center with B cells
→ Bone marrow involvement
● Predominantly follicular with no zonation (mantle zone)
→ Hematologic involvement
● Features at low magnification:
▪ Can present as Marked Absolute Lymphocytosis
→ Back-to-back, poorly defined follicles throughout, usually
● A patient diagnosed with MCL warrants performing a
without mantle zones (follicular pattern)
colonoscopy
→ Sometimes patients can develop lymphoid nodules in the → Absent “starry-sky” pattern 
colon → polyp formation known as Multiple Lymphomatous ● Monomorphic follicular center with B-cells
Polyposis
→ If undiagnosed, patient can manifest with colonic obstruction B. FOLLICULAR HYPERPLASIA VS F. LYMPHOMA 
Table 2. Comparison of Follicular Hyperplasia and Follicular Lymphoma
Follicular Hyperplasia Follicular Lymphoma
• Follicles vary in size • Follicles are uniform in size,
• Well-defined dark mantle equidistant
• Presence of starry sky • Mantle cells are indistinct
pattern • No starry sky pattern

Figure 35. Multiple Lymphomatous Polyposis

E. PROGNOSIS
● Mean survival of 3-5 years despite treatment Figure 38. Follicular Hyperplasia vs Follicular Lymphoma
→ Not curable with conventional chemotherapy C. IMMUNOPHENOTYPE
● Certain subset of MCL which survived for more than 5 years are ● Germinal center markers: CD10 and BCL6
the more indolent behaving MCL.  ● Should also be positive for Bcl-2
● Blastoid variant and a “proliferative” expression profiling signature → Anti-apoptotic protein
are associated with even shorter survivals  → Overexpressed due to t(14;18)
VI. FOLLICULAR LYMPHOMA → Cells don’t die; follicles will expand
● Second most common lymphoma of adults in western
countries, not as common in Asia 
● Arises from the Light zone of centrocytes
● Age 60 years and older
 PATHO Lecture 2.5: Hematopathology 10 of 24

D. DETECTION • Clonal BCL-2 rearrangements are often seen, indicating a

● Fluorescence in-situ hybridization (FISH) potential germinal center origin in some cases 
→ Normal cell: 2 green signals (chromosome 14) and 2 red
signals (chromosome 18)
→ Positive translocation: 1 green, 1 red combined

Figure 39. Fluorescence in-situ hybridization (FISH). Left: Normal. Right: Abnomal
Figure 40. Large cell in contrast to other cells.
● Karyotyping
• To estimate size, compare a nucleus to a normal histiocyte, if it
E. GRADING is similar to the size, it is large
Table 3. Grading of Follicular Lymphoma • Or if it is twice the size of lymphocyte, then it is a large cell
GRADING MICROSCOPIC FINDINGS • If 2 lymphocytes fit in one nucleus of a lymphoma cell, then it is
Grade 1 0-5 centroblasts/10 HPF a large cell
(Low grade) Mono-chemotherapy • High proliferation-normally more than 40%
Grade 2 6-15 centroblasts/10 HPF
(Low grade) Mono-chemotherapy
Grade 3A >15 centroblasts/10 HPF
(High grade) Centrocytes still present
Multiple Chemotherapy
Grade 3B >15 centroblasts/10 HPF
(High grade) Centroblasts form solid sheets with no residue
centrocytes
Multiple Chemotherapy
Grade 3
● High chance of progression into DLBCL Figure 41. Aggressive lymphoma (ki-67 > 90%)
● Greater amount of centroblasts compared to low grade • ki-67  90% proliferation index: more aggressive type of
lymphoma
VII. DIFFUSE LARGE B-CELL LYMPHOMA (DLBCL) • Diffuse growth pattern; large cells (nuclei = macrophage nuclei
• Most common lymphoma of adults  or 2x a normal lymphocyte)
• Most common form of Non-Hodgkin’s Lymphoma 
• A germinal center lymphoma that arise from large centroblasts
• In contrast with the Follicular Lymphoma, they do not have the
follicular structure/nodules
• Pattern of involvement is diffused
• Cells are large
• ~40% of B-cell lymphomas are Diffuse Large B-cell Lymphoma
• Heterogenous group of aggressive, potentially curable B-cell
neoplasms
→ There is potential for cure if cytogenetics is good, like Bcl-6
→ Aggressive; Come into clinical attention almost immediately
→ You can target the cells, a drug known as anti-CD20 drug, any
B-lymphomas expressing CD-20 can be targeted by the drug
(Rituximab)
• Occurs in all age groups, but most prevalent between ages 60
and 70 years old (elderly) Figure 42. DLBCL: Tumor cells have large nuclei, open chromatin, and
• Cause: unknown, but may be seen in association with EBV and prominent nucleoli.

HIV infections 
→ Because of immunodeficiency you can have opportunistic
infections, EBV sets in, infects B-cells, immortalizes B cells, B
cells proliferate, become polyclonal, gets genetic hits and
become lymphoma
→ In patients who receive immunosuppressive agents and
patients who underwent transplants, one of the modalities to
prevent rejection is to have them on immunosuppressive
agents so those kinds of lymphoma can develop into post-
transplant lymphoproliferative disorders in the form of
lymphoma (immune deficiency causes it but other factors can
set in)
• Involve nodal and extranodal sites (up to 40% present initially
as extranodal lymphoma)
→ Like primary bone lymphoma or primary splenic DLBCL, when
Figure 43. Upper Left: Centroblastic. Upper Right: Multilobulated. Lower Left:
you talk about the spleen, usually it’s splenic marginal zone Immunoblastic. Lower Right: Anaplastic.
lymphoma, but you can have a primary splenic DLBCL
• Tumor cells resemble immunoblasts or centroblasts or appear as
bizarre cells with marked nuclear abnormalities
 PATHO Lecture 2.5: Hematopathology
A. MORPHOLOGIC VARIANTS
• Morphologic Variants 
→ Centroblastic
→ Multilobulated (extranodal; bone)
→ Immunoblastic (nucleolus is single, central, and large)
→ Anaplastic
• Molecular and immunophenotypical subgroups (subgroup as
germinal center B cell or nerve germinal center B cell in terms of
prognosis)
• 35% adult NHL; higher percentage in developing countries
• 7th decade; children and young adults; M > F
• Risk factor: Underlying immunodeficiency
• De novo (primary) or transformation of a less aggressive
lymphoma (secondary)
• Follicular lymphoma becomes DLBCL
• Mantle Cell Lymphoma usually DOES NOT progress to DLBCL
• Clinical Presentation: Nodal or extranodal sites (stomach and
ileocecal); rapidly enlarging mass; stage I-II 
• DLBCL occurring in a setting of immunodeficiency – (+) EBV
• Bone marrow involvement: 10-30%; Discordant > Concordant
→ Discordant: Metastasis in bone marrow involves small cells ;
Better prognosis (16% survival) compared to concordant
→ Concordant: Primary tumors involve large cells; connotes poor
prognosis (6% survival); both lymph node and bone marrow
are large cells
B. CYTOGENETIC ABNORMALITIES OF DLBCL
• Primary changes:
→ Up to 30% show abnormalities of 3q27 (BCL6)
▪ Dysregulation of BCL6, a DNA-binding zinc-finger
transcriptional repressor that is required for the formation
of normal germinal centers
▪ Acquired mutations in BCL6 promoter sequences that
abrogate BCL6 autoregulation (an important negative-
regulatory mechanism)- more frequent
▪ Various partners include: t(3;14)(q27;q32), t(2;3)(p12;q27),
t(3;22)(q27;q11), 4p11, 6p21, 11q32
▪ BCL6 translocation usually has good prognosis; responds
to chemotherapy
▪ Double Hit Lymphoma (does not respond to chemo): 
BCL2 + MYC
− t(14;18)(q32;q21): IgH; BCL2 → 20-30%
− t(8;14)(q24;q32): MYC; IgH → 7-10%
▪ Triple Hit Lymphoma: MYC + BCL2 + BCL6
• Secondary changes
→ Gain of 3, 5, 7, 11, 12, 18, X; loss of 13, 14, 15
→ Various structural including deletions of 1p, 6q
• Pediatric DLBCL rarely show rearrangements of BCL6 (3q27),
IgH (14q32), BCL2 (18q21), or MYC (8q24)
• Many DLBCL have IgH and/or BCL6 rearrangements 
C. IMMUNOPHENOTYPE
11 of 24
• These mature B-cell tumors express CD19 and CD20 and show
variable expression of germinal center B-cell markers such as
CD10 and BCL6
• Most have surface immunoglobulins
D. PROGNOSIS
• Aggressive but potentially curable 
• Poor prognosis associated with del(17p), del(19p), and
translocations of 8q24 (MYC)
• BCL2 (18q21) expression and p53 (17p13) overexpression has
been associated with poorer prognosis
• Some studies indicate a BCL6 translocation [t(3;14)] may be
associated with better prognosis
• Pediatric patients with DLBCL have an excellent prognosis
• Rearrangements or mutations of BCL6 gene are recognized
associations; 1/3 carry a (14;18) translocation involving BCL2
and may arise from follicular lymphomas 
NOT DISCUSSED IN LECTURE 
Pathogenesis
• BCL6 represses the expression of factors that normally
serve to promote germinal center B-cell differentiation,
growth arrest, and apoptosis, and each of these effects is
believed to contribute to the development of DLBCL
• Mutations similar to those found in BCL6 are also seen in
multiple other oncogenes, including MYC, suggesting that
somatic hypermutation in DLBCL cells is “mistargeted” to a
wide variety of loci
• Tumors with BCL2 rearrangements usually lack BCL6
rearrangements, suggesting that these rearrangements
define two distinct molecular classes of DLBCL
• Some tumors with BCL2 rearrangements may arise from
unrecognized underlying follicular lymphomas, which
frequently transform to DLBCL
• Deep sequencing of DLBCL genomes has identified frequent
mutations in genes encoding histones acetyltransferases
such as p300 and CREBP, proteins that regulate gene
expression by modifying histones and altering chromatin
structure
Special Subtypes
• Immunodeficiency-associated large B-cell lymphoma
→ Occurs in the setting of severe T-cell immunodeficiency
(e.g., advanced HIV infection and allogeneic bone
marrow transplantation)
→ Neoplastic B cells are usually infected with EBV, which
plays a critical pathogenic role
→ Restoration of T-cell immunity may lead to regression of
these proliferations
• Primary effusion lymphoma
→ Presents as a malignant pleural or ascitic effusion, mostly
in patients with advanced HIV infection or older adults
→ Tumor cells are often anaplastic in appearance and
typically fail to express surface B- or T-cell markers, but
have clonal IgH gene rearrangements
→ Tumor cells are infected with KSHV/HHV-8, which
appears to have a causal role
Clinical Features
• DLBCL typically presents as a rapidly enlarging mass at a
nodal or extranodal site
• It can arise virtually anywhere in the body
→ Waldeyer’s ring, the oropharyngeal lymphoid tissue that
includes the tonsils and adenoids, is commonly involved
→ Primary or secondary involvement of the liver and spleen
may take the form of large destructive masses
→ Extranodal sites include the GI tract, skin, bone, brain,
and other tissues
• DLBCLs are aggressive tumors that are rapidly fatal without
treatment
 PATHO Lecture 2.5: Hematopathology 12 of 24

VIII. BURKITT’S LYMPHOMA B. METHODS OF DETECTION: FLUORESCENCE IN-SITU

• Highly aggressive, responds well to aggressive chemotherapy
• Often presents at extranodal sites or as acute leukemia (L3-ALL)
→ Looks immature (leukemia), its behavior is still similar to a
lymphoma
→ Involves nodes, extranodal sites, and possibly the bone
marrow
→ Involvement of the bone marrow and peripheral blood is
uncommon
→ PHENOTYPE: mature despite looking immature
• Three clinical variants:
→ African/Endemic (equatorial Africa)- classic
→ Sporadic/Non-endemic
→ HIV-associated - aggressive
• Median age of adult patients > 30 years old
• MYC Translocation is constant genetic feature
→ MYC gene is the only cytogenic variation
• Epstein Barr virus (EBV)
→ found in a variable proportion of cases
→ Infection precedes transformation
→ Essentially all endemic BL are latently infected with EBV
→ 15-20% of sporadic BL
→ 25% of HIV-associated BL
Endemic Burkitt’s lymphoma
• often presents as a mandibular mass showing unusual
predilection for involving the abdominal viscera, especially the
kidneys, ovaries, and adrenal glands
Sporadic Burkitt’s Lymphoma
• often appears as a mass involving the ileocecum and peritoneum
• accounts for ~2% of all adult lymphomas, but ~40% of childhood
NHL
HYBRIDIZATION (FISH)
• Break apart probes (BAP)
→ Consist of two individually colored probes (ex. 1 red, 1 green)
→ Each probe binds to a specific sequence
→ In a normal cell, 2 sets of fused red/green signals visible
→ In an abnormal cell (BL), red/green signals are separated
since the allele has been split by a translocation.
Figure 45. Burkitt’s lymphoma t(8,14). Green arrow: Normal cell, red arrow:
Neoplastic cell (BL)
Primary and Secondary c-MYC Translocations
• MYC is not specific for BL
• BL is characterized by a primary MYC hit
→ Immediately brings the patient to clinical attention as a rapidly
enlarging mass
→ Take note of HIV status
• Secondary MYC hit → not BL
→ Low grade type that is transformed into a high grade
lymphoma after being hit by a secondary aberration (ex. c-
MYC translocation)
→ Transformed lymphoma, possibly Double Hit Lymphoma-
progression from follicular (low grade) to high-grade.
→ No such thing as Burkitt transformation
→ Presents with indolent symptoms

Figure 44. Burkitt’s lymphoma showing round nuclei and distinct nucleoli
Figure 46. Primary and secondary c-myc translocations
A. CYTOGENETIC ABNORMALITIES
• Primary chromosomal alteration: t(8;14) (q24;q32) C. MORPHOLOGY
MYC/IgH60-70% • Tumor cells are intermediate in size and have a round or oval nuclei and
→ Variants: two to five distinct nucleoli 
▪ t(2;8)(p12;q24) IgK/MYC • Very high rates of proliferation and apoptosis, the latter accounting
▪ t(8;22)(q24;q11) IgL/MYC for the presence of numerous tissue macrophages with ingested nuclear
→ The MYC coding sequence is positioned adjacent to a strong debris 
Ig promoter, which drive increased MYC expression (in all • Monomorphic, medium-sized B cells with basophilic cytoplasm
these variants). and numerous cytoplasmic vacuoles (L3 variant under FAB)
• Recurrent chromosomal aberrations associated with the 8q24 → Previously classified under Acute Lymphoblastic Leukemia
translocations include: (ALL)
→ dup(1q21<25) → Glass-like chromatin
→ del(13q) → Presence of Mature cells
→ del(6q) → Similar to a germinal center (neoplastic counterpart of the
→ del(17p) dark zone) but is diffuse (no follicles)
→ +7, 8, 12, 18
• Despite other variants, BL is still primarily MYC
• All variants involve translocations on chromosome 8 that lead
to increased MYC protein levels.
• MYC increases the expression of genes required for aerobic
glycolysis (Warburg effect)

Figure 47. Burkitt’s lymphoma showing round nuclei and distinct nucleoli
 PATHO Lecture 2.5: Hematopathology 13 of 24

• A starry sky pattern  is usually present, imparted by IX. HODGKIN’S LYMPHOMA

numerous benign macrophages that have ingested apoptotic ● First described by Thomas Hodgkin (1798-1866)
tumor cells and numerous mitotic figures ● Formerly known as Hodgkin disease/paragranuloma
→ Diffuse starry sky pattern present due to lack of BCL-2  ● Encompasses a distinctive group of lymphoid neoplasms that
▪ Starry sky pattern present signifies increased turnover rate arises in a single node or chain of nodes and spreads first
caused by increased apoptosis to the anatomically contiguous nodes
▪ Pattern only characterizes BL but is not pathognomonic → Predominantly nodal; rarely presents as extranodal
→ Primary MYC hit → high degree of apoptosis, starry sky → Has a very predictable spread
apoptosis → Nodal disease → splenic disease → hepatic disease →
▪ Phenotype is like that of a germinal center involvement of marrow and other tissues 🖉
● Present as multiple lymph nodes above the diaphragm
▪ (+) CD10, BCL-6; (-) BCL-2
(mediastinal, axillary, and cervical lymph nodes)
▪ (+) IgM, CD19, CD20, CD10, BCL-6 ● Typically good response to chemotherapy even in advanced
▪ Ongoing SHM stages 🖉
▪ t(8;14)(q24;q32) (90%)
Table 4. Clinical differences between HL and NHL
▪ t(2;8)(q11;q24) (5%) Hodgkin Lymphoma Non-Hodgkin Lymphoma
▪ t(8;22)(q24;q11) (5%) Localized to a single axial Involvement of multiple
▪ c-MYC overexpression group of nodes peripheral nodes
→ Primary MYC hit → proliferation marker is almost 100% Orderly spread by contiguity Noncontiguous spread
▪ Ki-67 > 95% Mesenteric nodes and Mesenteric nodes and Waldeyer
▪ Recall that MYC is the most powerful proliferation marker Waldeyer ring rarely involved ring commonly involved
• Tumor exhibits a high mitotic index and contains numerous Extranodal involvement Extranodal involvement common
apoptotic cells uncommon

A. MORPHOLOGY

Figure 49. Typical Reed-Sternberg (RS) cells with inflammatory cells (L) and
characteristic owl-eye appearance smiling at you (R).
● Histologically characterized by the presence of Reed-Sternberg
cells – secretes cytokines (10%)
● Tumor giant cell originating from the germinal center B cells
Figure 48. Burkitt’s lymphoma producing a Starry sky pattern ● Similar in appearance to B cell immunoblasts
→ Of primary immune response from the paracortex - HL may
D. STAGING AND TREATMENT appear similar to paracortical hyperplasia
• BL often presents with bulky disease and high tumor burden → Both positive for CD30 (non-specific for HL, also occurs in
due to short doubling time of the tumor (can have leukemic other lymphomas)
infiltration)
→ “Bulky disease” - 5 cm and above
→ Rapidly enlarging tumors
• Stages III-IV
→ Involvement of the bone marrow, bone, and CNS
• BL variant - seen in patients with bulky disease, rarely presents
as pure acute leukemia (L3-ALL) and tend to involve the CNS
• Chemosensitive, but watch out for Tumor Lysis Syndrome
→ Occurs due to rapid tumor cell death
→ Rapid increase in Uric acid
→ Give hypouricemic agents to lower blood uric acid (allopurinol,
febuxostat)
• Staging is related to tumor burden; identifies patients with
extensive intraabdominal or intrathoracic tumor.
• Poor prognosis factors:
→ Extensive disease Figure 50. (Top) Morphologic similarities of B-cell immunoblasts from
→ Bone marrow and CNS involvement paracortical hyperplasia and RS cells from Classical Hodgkin Lymphoma;
(Bottom) Both cells are positive for CD30.
→ Unresected tumor >10cm
→ High LDH ● Appear as very large and binucleated cells, with vesicular
chromatin & prominent inclusion-like nucleoli ("owl-eye
E. KEY CONCEPTS appearance") 
• BL is a very aggressive tumor of mature B cells that usually arise → Diagnostic RS cells have large cells (45 µm in diameter) with
at extranodal sites multiple nuclei OR a single nucleus with multiple nuclear lobes,
• Strongly assoc. with translocations involving MYC porto- each with a large inclusion-like nucleolus about the size of a small
oncogene lymphocyte (5 to 7 µm in diameter) surrounded by a clear zone 🕮
• Tumor cells are often latently infected by EBV → With abundant, usually slightly eosinophilic cytoplasm 🕮
 PATHO Lecture 2.5: Hematopathology 14 of 24
● Immunophenotype: (+) CD15, CD30 (-) CD45, B cell antigens, T
cell antigens
● Classic RS cells common in mixed-cellularity (MC) subtype 🕮
→ Uncommon in nodular sclerosis (NS) subtype, rare in
lymphocyte-predominance (LP) subtype - with other variants
of RS predominating
▪ Mononuclear variants - contain a single nucleus with
large inclusion like nucleolus
▪ Lacunar cells - with more delicate, folded, or multilobate
nuclei and abundant pale cytoplasm that is often disrupted
during the cutting of sections, leaving the nucleus sitting in
Figure 52. Simplified diagram of the activation of NF-κB.
an empty hole (lacunae); seen in NS subtype
▪ Lymphohistiocytic variants - with polypoid nuclei, ● Responding inflammatory cells produce additional factors that
inconspicuous nucleoli, and moderately abundant aid growth and survival of RS cells and contribute further to tissue
cytoplasm; seen in LP subtype reaction
→ Eosinophils & T cells express ligands that activate CD30,
CD40 receptors → upregulation of NF-κB
● RS cells also express PD ligands which antagonize T cell
responses, giving rise to a state of immunodeficiency (by
impairment of T helper and cytotoxic T cells and enhancing the
generation of regulatory T cells)
● EBV may be one of several steps contributing to the development of
the mixed-cellularity (MC) subtype 🕮
● EBV present in RS cells in 70% of cases, smaller in other
"classical" subtypes

C. CLASSIFICATION
Figure 51. RS cell variants. Upper Left: Diagnostic RS cell.
Upper Right: Mononuclear variant. Lower Left: Lacunar variant. ● The WHO classification recognizes five subtypes of HL: 🕮
Lower Right: Lymphohistiocytic variant. 1. Nodular sclerosis (NS)
2. Mixed cellularity (MC)
● Inflammatory cells (90%) 3. Lymphocyte-rich (LR)
→ Eosinophils 4. Lymphocyte depletion (LD)
→ Lymphocytes 5. Lymphocyte predominance (LP)
→ Histiocytes
→ Plasma cells Table 5. Classification of Hodgkin’s Lymphoma
→ Neutrophils
● Requirements for diagnosis of HL: presence of RS cells +
appropriate inflammatory cells (eosinophils, lymphocytes,
histiocytes, plasma cells, & neutrophils) 

B. PATHOGENESIS
● Mainly via the constitutive activation of NF-κB pathway in RS
cells [Horton et al.] 
→ Normally involved in innate inflammatory responses
→ Activation of NF-kB by EBV or other mechanisms rescues
● The first 4 subtypes (NS to LD) are termed as Classical
“crippled” germinal center B cells → acquisition of unknown
Hodgkin Lymphomas (CHL)
mutations that can produce the RS cell 🕮 ● CHL originates from the B cell immunoblasts in the
● Antigen binding to CD30 receptors induce pathway via IKK paracortex
complex phosphorylation (activation) → Mimics paracortical hyperplasia
→ CD30 upregulated in EBV-infected cells 🖉 → Lymph node specimen will exhibit paracortical expansion
→ EBV (+) tumor cells express latent membrane protein-1 (LMP-1), a ● In the fifth subtype (LP), Reed-Sternberg cells have a distinctive
receptor that can also activate the NF-κB pathway 🕮 B-cell immunophenotype that differs from the classical
● IKK phosphorylates IκB-α, inducing its degradation & subtypes
disassociation from NF-κB ● Modern classification: 🖉
→ loss-of-function mutation in IκB or A20 (negative regulators of → Classical Hodgkin Lymphoma (CHL; 95%)
NF-kB) in EBV (+) tumors → constitutive activation of NF-κB ▪ (+) CD30
pathway 🕮 ▪ Includes subtypes NS (most common), MC, LR, and LD
● Following dimerization, NF-κB enters nucleus via translocation, → Nodular Lymphocyte Predominant Hodgkin Lymphoma
driving: (NLPHL; 5%)
→ Proliferation and production of cytokines - responsible for ▪ (-) CD30
inflammatory cell background of RS cells  ▪ (+) B-cell markers
▪ IL-5 (attracts & activates eosinophils), IL-2, IL-4
▪ transforming growth factor-β - fibrogenic factor Nodular Sclerosis - CHL
▪ IL-13 - may stimulate RS cell growth through autocrine ● Most common form of HL (65-70%)
mechanism ● Nodular: with lymphocytic nodules; Sclerosis: with broad band
→ Inhibition of apoptosis → immortalization of RS cells  of fibrosis
→ Differentiation between NS 1 and NS 2: There is necrosis
inside the nodule of NS 2. 🖉
● Males = Females
 PATHO Lecture 2.5: Hematopathology 15 of 24
● Uncommonly associated with EBV (unlike MC, LR, LD Mixed Cellularity - CHL
subtypes)
● In adolescents or young adults, has a propensity to involve cervical,
supraclavicular, and mediastinal lymph nodes
→ Irregular tumor nodules may also appear in the spleen, liver, bone
marrow, and other organs in due time 🕮
● Characterized by:
→ Lacunar variant RS cells
▪ Found in a polymorphous background of T cells,
eosinophils, plasma cells, and macrophages
▪ Deposition of collagen in bands that divide involved
lymph nodes into circumscribed nodules Figure 55. Hodgkin lymphoma, mixed-cellularity type. A diagnostic, bi-nucleate
Reed-Sternberg cell is surrounded by reactive eosinophils, lymphocytes, and
▪ Fibrosis may be scant or abundant histiocytes.
● Constitutes 20-25% of HL cases
● Fine trabecular sclerosis, but no fibrous bands 🖉
● Involved lymph nodes are diffusely effaced with T cells, eosinophils,
plasma cells, benign macrophages, and abundant diagnostic and
mononuclear variants of RS cells. 🕮
● Immunophenotype of RS cells is identical to NS subtype
● RS cells are infected with EBV in 70% of cases
● Males > Females
● Bimodal age range (pediatric and older adults)🖉
Figure 53. Hodgkin lymphoma, nodular sclerosis type (LPO view). Well-
defined bands of pink, acellular collagen subdivide the tumor into nodules. ● More likely to be associated with: 🕮
→ Systemic symptoms (night sweats and weight loss)
● Immunophenotype of RS cells in NS CHL (applies to other classical
→ Advanced tumor stage (Stage III and IV) 🖉
HL subtypes): 🕮
→ (+) PAX5 (B-cell transcription factor) → May be HIV associated 🖉
→ (+) CD15, CD30 ● Nonetheless, overall prognosis is very good
→ (–) for other B-cell markers, T-cell markers, and CD45 Lymphocyte-Rich – CHL
(leukocyte common antigen)
● Diagnostic Reed-Sternberg cells (an RS cell variant) uncommon 🕮
● Excellent prognosis 🕮
Table 6. Comparison of Grade 1 and Grade 2 Nodular Sclerosis
GRADE 1 GRADE 2
• Low grade • High grade
• No necrosis • Localized disease
• (+) Necrosis in nodules
• BNLI series of 1659 patients (MacLennan et
al.) Figure 56. Hodgkin lymphoma, lymphocyte-rich type
→ Poorer response to initial therapy A. Mononuclear variant RS cell; B. Diagnostic RS cell; Cellular infiltrate is mainly
composed of lymphocytes.
(chemotherapeutic protocol of ABVD:
Adriamycin, Bleomycin, Vinblastine, ● Uncommon form of CHL
Dacarbazine) ● Reactive lymphocytes make up the majority of cellular infiltrate
→ Increased relapse rate ● Involved lymph nodes are diffusely effaced in most cases
→ Decreased survival rate ● Vague nodularity due to presence of residual B-cell follicles is
• Grade 2 correlates with other poor sometimes seen
prognostic features (DeVita et al.) ● Distinguished from lymphocyte predominance type by:
→ Advanced stage in 50% → Frequent mononuclear variants and diagnostic RS cells
→ B-symptoms in 61% (triad of fever, (sheets of RS cells) with a classical immunophenotypic
drenching night sweats, and weight loss profile
usually 10%) ● Associated with EBV (40%)
→ Independent prognostic significance with ● Very good to excellent prognosis
advanced stage disease, but not
localized disease Lymphocyte Depletion Type - CHL

Figure 57. Hodgkin lymphoma, lymphocyte-depletion type, diffuse fibrosis form.

Figure 54. Nodular sclerosis of Classical Hodgkin Lymphoma. Left: Nodular Few lymphocytes present; Nodal architecture with abundant connective tissue.
grade 1. Right: Nodular grade 2. NG2 shows characteristic nodular necrosis.
● Least common form of HL (<5%)
● Also called Mixed Cellularity CHL Type 2 🖉
● Characterized by:
→ Paucity of lymphocytes
 PATHO Lecture 2.5: Hematopathology
→ Relative abundance of RS cells or their pleomorphic variants
→ Immunophenotype identical to other classical types of HL
▪ Essential diagnostic since most tumors suspected of
being lymphocyte depletion HL prove to be large-cell
NHLs
● RS cells are infected with EBV in >90% of cases
● Occurs predominantly in:
→ Older adults
→ HIV+ individuals of any age
→ Non-industrialized countries
● Advanced stage and systemic symptoms are frequent
● Overall outcome somewhat less favorable than in other
subtypes
INCLUDED IN PREVIOUS TRANS 🖉
Lymphocyte Predominance Type - CHL
Figure 58. Hodgkin lymphoma, lymphocyte predominance type.
A. Mononuclear variant RS cell; B. Diagnostic RS cell; Numerous mature-
looking lymphocytes surround scattered, large, pale-staining
lymphohistiocytic variants (“popcorn” cells).
● Uncommon “non-classical” variant of HL
→ 5% of cases
● Nodes are effaced by a nodular infiltrate of small
lymphocytes and macrophages
● “Classical” Reed-Sternberg (RS) cells difficult to find
● Tumor contains L&H (lymphocytic and histiocytic)
variants of RS cells
→ Multilobed nucleus (“popcorn cell”)
→ Scant or absent eosinophils and plasma cells
→ Express B-cell markers typical of germinal-center such as
CD20 and BCL6; negative for CD15 and CD30
→ Can transform into a tumor resembling diffuse large B-cell
lymphoma (3%-5%)
● Typical nodular pattern of growth due to expanded B-cell
follicles
→ populated with L&H variants, reactive B cells, follicular
dendritic cells
● IgH genes show ongoing somatic hypermutation
● Majority of patients are males, < 35 years old with cervical
or axillary lymphadenopathy
● Mediastinal and bone marrow involvement is rare
● Not associated with EBV
● Prognosis is excellent 🕮
(See appendix for summary of subtypes of Hodgkin’s) 
INFORMATION FROM BOOK (not discussed in lecture)
Clinical Features
● Present as painless lymphadenopathy
● Those with nodular sclerosis or lymphocyte predominance
types (stage I-III disease) usually have no systemic
manifestations
● Those with disseminated disease (stages III-IV) or the
mixed-cellularity or lymphocyte depletion subtypes are more
likely to have constitutional symptoms
→ fever, night sweats, and weight loss
→ Anergy (cutaneous immune unresponsiveness)
→ TH1 immune response suppression contributes to
immune dysregulation
● SPREAD OF HL
→ first, nodal disease
16 of 24
→ then, splenic, hepatic disease
→ last, marrow and tissue involvement
● STAGING OF HL
→ physical examination
→ radiologic imaging of the abdomen, pelvis, and chest
→ biopsy of the bone marrow
● Most important prognostic variable: tumor stage
● With stages I and IIA, cure rate: almost 90%
● Disease-free survival at 5 years: 60-70%
● Treatment involving minimized use of radiotherapy and
less genotoxic chemotherapeutic agents results in
reduced incidences of secondary tumors
● Anti-CD30 antibodies treatments are used and produce
excellent responses
Table 7. Clinical Staging of Hodgkin and Non-Hodgkin Lymphomas (Ann
Arbor Classification).
E. KEY CONCEPTS
● Unusual tumor composed of reactive lymphocytes,
macrophages, eosinophils, plasma cells and stromal cells
mixed with Reed-Sternberg cells and variants
● Two broad types, classical (which has several subtypes) and
lymphocyte predominant
● Classical forms are frequently associated with acquired
mutations that activated NF-κB and with EBV infection
→ Reed-Sternberg cells of classical types make multiple
cytokines and chemokines that influence the host response
→ The host response makes factors that support the growth of
the tumor cells
● Lymphocyte predominance type expresses B cell markers and
is not associated with EBV 🕮
X. T-CELL LYMPHOMA NON-HODGKIN LYMPHOMA
● Proliferates in the thymus
● Would go to different organs like the spleen, lymph nodes, GI
tract, mucosa of nasopharynx
● T-cell lymphomas and their origin/location:
→ Bone marrow or thymus: T-cell Lymphoblastic Lymphoma
→ Leukemic: Adult T-cell Lymphoma Leukemia, Large Granular
Lymphocyte Leukemia, T-cell Prolymphocytic Leukemia
→ Lymph Nodes: Peripheral T-cell Lymphoma (most common
NHL), Angioimmunoblastic T-cell Lymphoma, Anaplastic
Large Cell Lymphoma
→ Skin: Mycosis fungoides
→ Nasopharynx: Extranodal NK/T-cell Lymphoma
→ GIT: Intestinal/Enteropathy T-cell Lymphoma
→ Spleen: Hepatosplenic T-cell Lymphoma
Mature/Peripheral/Adult T-cell Non-Hodgkin Lymphomas
(WHO Classification)
● Nodal (Lymph node in origin)
→ Peripheral T-cell Lymphoma, unspecified
→ Angioimmunoblastic T-cell Lymphoma
→ Anaplastic Large Cell Lymphoma
 PATHO Lecture 2.5: Hematopathology
● Neoplasms of uncertain lineage/stage of maturation
→ Blastic NK Cell Lymphoma
● Leukemic/Disseminated
→ T-cell Prolymphocytic Leukemia
→ T-cell Large Granular Lymphocytic Leukemia
→ Aggressive NK Cell Leukemia
→ Adult T-cell Leukemia/Lymphoma
● Cutaneous
→ Mycosis fungoides/Sezary Syndrome
→ Primary Cutaneous ALCL
→ Lymphomatous papulosis
● Other Extranodal (Origin outside LN)
→ Extranodal NK/T-cell, nasal type
→ Enteropathy-type T-cell Lymphoma
→ Hepatosplenic T-cell Lymphoma
→ Subcutaneous panniculitis-like T-cell Lymphoma
Figure 59. T-Cell Lymphomagenesis
T-Lymphoblastic Lymphomas
Major categories
Peripheral T-cell Lymphomas
Figure 60. Classification of T-Cell Non-Hodgkin Lymphomas
A. NODAL T-CELL NHL
Peripheral T-Cell Lymphoma
● Thymus expansion of the paracortex
● Lymphoma involving the first order architecture
● Mixed inflammatory cells in the infiltrate due to lymphokine
secretion which mimics Hodgkin’s Lymphoma
→ T-cell Lymphoma: T-cells are neoplastic, atypical, with
irregular nucleus
● Sometimes, these components can also be prominent that they
will form aggregates of epithelioid histiocytes interspersed
within the lymphoma cells - pattern known as “Lymphocytic
variant” of PTLC: Lennard Lymphoma special morphologic
architecture of PTLC
● Most patients present with generalized lymphadenopathy,
sometimes accompanied by eosinophilia, pruritus, fever, and
weight loss
● Worse prognosis than comparably aggressive mature B-cell
neoplasms (e.g. Diffuse Large B-cell Lymphoma)
Figure 61. Paracortex Expansion
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● Pattern of Proliferation
→ Paracortical or diffuse nodal involvement
→ Increased density of high endothelial venules (increased
vascular proliferation)
→ Variants: Lymphoepithelioid, T-zone, Follicular
Figure 62. Left: Interfollicular Homing of T-Cells (CCR7). Right: Proliferation
Pattern
● Cytologic Features
→ Pleomorphic or monomorphic infiltrate
→ Small to large cells
→ Clear cells and Reed-Sternberg-like cells (can be mistaken
for Hodgkin’s Lymphoma)
→ Reactive infiltrates of eosinophils, histiocytes, and
plasma cells
▪ that is why PTCL is very difficult to distinguish from
Hodgkin’s Lymphoma
▪ the only way to distinguish the two is by
immunohistochemistry/immunophenotyping
→ Occasional Large B-cells (EBV+/-)
● Immunophenotype
→ CD3+, often downregulation of CD5 and CD7 (commonly
CD7)
▪ Loss of CD2, CD5, and CD7 markers (T-cell markers)
→ CD4+/CD8-, double CD4+/8+, double CD4-/8-, CD8, CD56,
cytotoxic granule suppression, TCR (beta F1)
→ CD30+, with CD15+
▪ CD30+ usually seen in Hodgkin’s and used for
immunostaining but is not pathognomonic for HL because
it can also be positive for other lymphomas
→ CD20 and CD79a: occasionally
→ Ki67(>70%)
● EBV Positivity
→ Usually detected in B-cells; uncommonly in tumor cells
→ EBV can also be seen in PTCL → RS-like cells can be seen
→ Since T-cells are not functioning well, there will be a defect in
the immuno-surveillance so opportunistic infections can set in
→ EBV can infect other bystander B-cells and these B-cells can
be RS like because of the infection
● Mononuclear Genetics
→ Monoclonal TCR gene arrangements in 90-100%of cases
▪ Rearrangement of T cell receptor
→ Monoclonal or oligoclonal IgH gene rearrangements may be
present
→ Document clonality for B cells
Figure 63. Peripheral T-cell Lymphoma, unspecified
 PATHO Lecture 2.5: Hematopathology
Angioimmunoblastic T-Cell Lymphoma
● Monoclonal TCR gene arrangements in 90-100% of cases
● Lymphoma originates from T cells in the follicles
● Morphology
→ Partially to completely effaced and nodal architectures
→ Proliferation of arborizing high endothelial venules
→ Prominent proliferation of blood vessels surrounded by
immunoblasts (large cells) - “immunoblastic”
→ Diffuse lymphoproliferation with clusters of neoplastic T-cell
immunoblasts, often with a perivascular distribution
→ Disrupted and proliferated follicular dendritic networks
→ Polymorphic reactive cell background of eosinophils like in T-
cell lymphoma
→ Proliferation of the immunoblasts around the vessel
→ Similar to PTLC except for the prominent immunoblasts
around the vessels
→ Polymorphous infiltrates of the eosinophils, histiocytes and
plasma cells
Figure 64. Angioimmunoblastic T-cell Lymphoma
● Clinical Course and Prognosis
→ Rapid progression in AITL (median survival in 3 years due to
infectious complications rather than progressive lymphoma)
▪ Immune regulation in AITL is depressed
▪ Underlying immune T-cell dysfunction
▪ Difficult to treat with chemotherapy
▪ Opportunistic infection can set in
→ Can develop EBV + large B-cell lymphoma due to the
expanded EBV clones
Anaplastic Large Cell Lymphoma
● Activated mature cytotoxic T-cell
● CD30+; type of lymphoma other than Hodgkin’s wherein CD30 is
necessary for diagnosis
● ALK+ (anaplastic lymphoma kinase)
→ t(2;5) NPM1/ALK
● Defined by the presence of rearrangements in the ALK gene on
chromosome 2p23
● Clinical Course
→ Children and young adults but can also occur in elderly
individuals
→ Males > Females
→ Nodal or extranodal
→ Aggressive but curable
● Morphology
→ Sinusoidal, large cells, “hallmark cells”
▪ C-shaped type of cells
▪ Positive for CD30 and ALK
▪ Small cell, histiocyte rich variants
→ Commonly mistaken as metastatic carcinoma of the lymph
node because of the sinusoidal pattern
▪ Only way to distinguish is through immunostaining
▪ Positive for CD30: ALCL
▪ Positive for cytokeratin: metastatic carcinoma
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Figure 65. Anaplastic Large Cell Lymphoma
● Immunophenotype
→ T-cell antigens (+/-)
→ CD30+, ALK+, EMA+
Figure 66. Left: CD30 - see sheets of strongly staining CD30+ cells in ALCL
unlike in RS cells which are usually scattered with inflammatory background.
Right: FISH - dual color probe.
● Cytogenetics
→ 46XX, t(2;5)(p23;q35), del(10)(q24)[17]/46, idem,
del(10)(q26)[3]
→ chromosome 2 and chromosome 5 translocation
→ FISH can be done - dual color vision probe for t(2;5)
B. NEOPLASMS OF UNCERTAIN LINEAGE/STAGE OF
MATURATION
Blastic NK Cell Lymphoma
● Currently known as blastic plasmacytoid dendritic cell neoplasm
● (BPDCN)
● Clinically aggressive tumor derived from the precursors of
plasmacytoid dendritic cells (PCDs/Professional type 1
Interferon producing cells/Plasmacytoid monocytes)
● With a high frequency of cutaneous and bone marrow
involvement and leukemic dissemination
C. LEUKEMIC/DISSEMINATED T-CELL NHL
T-Cell Prolymphocytic Leukemia
● T-cell intermediate between cortical thymus and peripheral blood
● Translocations of TCRɑ/β and TCL1
Adult T-Cell Leukemia/Lymphoma
● Neoplasm of CD4+ T cells only observed in adults infected
by human T-cell leukemia retrovirus type 1 (HTLV-1)
→ Activated peripheral CD4+ T-cell
→ Caused by HTLV-1
● Often times seen in Japan
→ Must elicit travel to Japan
→ Documentation in the serum for (+) HTLV-1
● Usually manifests as leukemia, sometimes there is skin
manifestations
● Common findings: skin lesions, generalized
lymphadenopathy, hepatosplenomegaly, peripheral blood
lymphocytosis and hypercalcemia
● “Clover leaf” or “Flower” cells which have multilobulated
nuclei are frequently observed
● Very rare in the Philippines
T-Cell Large Granular Lymphocytic Leukemia
● Mainly occur in adults
● 30-40% have acquired mutations in STAT3
● CD3+
● Neutropenia and anemia dominate the clinical picture
 PATHO Lecture 2.5: Hematopathology
● Mild to moderate lymphocytosis and splenomegaly
● Large lymphocytes with abundant blue cytoplasm
Aggressive NK Cell Leukemia
● Occur mainly in adults
● Neutropenia and anemia dominate the clinical picture
● Little or no lymphocytosis or splenomegaly
● CD3-, CD56+
● 30-40% have acquired mutations in STAT3
D. CUTANEOUS T-CELL NHL
Mycosis Fungoides/Sezary Syndrome
● Lymphoma of skin-homing CD4+ T helper cells
→ Activated skin-homing T-lymphocyte
● In most individuals, disease remains localized to the skin but it
may eventually evolve into a systemic lymphoma
● May occur at any age (most common: older than 40 years)
● CD30+
● Most common cutaneous T-cell Non-Hodgkin Lymphoma
● Progress through 3 stages:
→ Premycotic Phase
→ Plaque Phase
→ Tumor Phase
● Mycosis fungoides histology
→ epidermis and upper dermis infiltrated by neoplastic T cells
which often have a cerebriform appearance due to marked
infolding of the nuclear membrane
● Sézary Syndrome is a variant in which skin involvement is
manifested as a generalized exfoliative erythroderma
● The tumor cells express the adhesion molecule cutaneous
leukocyte antigen (CLA) and chemokine receptors CCR4 and
CCR10 which contribute to the homing of normal CD4+ T cells to
the skin
Primary Cutaneous ALCL
● Activated skin-homing T-lymphocyte
● CD30+
Lymphomatous Papulosis
● Chronic papulonecrotic or papulonodular skin disease
E. OTHER EXTRANODAL T-CELL NHL
● Originate outside the lymph node
Extranodal NK/T-Cell, Nasal Type
● Activated NK cell or cytotoxic T-cell
● EBV-positive
→ You cannot make a diagnosis if EBV negative
● Aggressive neoplasms that respond to radiation therapy but
resistant to chemotherapy
● Poor prognosis in patients with advanced disease
Enteropathy Type T-Cell Lymphoma
● Rare gastrointestinal non-Hodgkin’s lymphoma
Hepatosplenic T-Cell Lymphoma
● Immature peripheral γδ T cell of cytotoxic type
● Primarily involved liver and spleen
● Isochromosome 7q
Subcutaneous Panniculitis-Like T-Cell Lymphoma
● Mature cytotoxic CD8+ T-cell
● Primarily involves the subcutaneous fat
→ Skin not involved
● Associated with hemophagocytic syndrome
→ Extensive activation of macrophages
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XI. MYELOPROLIFERATIVE NEOPLASMS
(CHRONIC MYELOPROLIFERATIVE DISORDERS)
● Mutated, constitutively activated tyrosine kinases or other
acquired aberrations in signaling pathways
● Hallmark is excessive, neoplastic proliferation of one or more
lineages of the myeloid series
→ Effective hematopoiesis: maturation is less affected, with no
maturation arrest or block
● Common features:
→ Increased proliferative drive
→ Extramedullary hematopoiesis
→ Variable transformation to a spent phase
→ Variable transformation to acute leukemia
Table 8. WHO Classification of myeloid neoplasma and acute leukemia
A. Chronic Myelogenous Leukemia (CML)
● Overproduction of granulocytes
● 15-20% of all leukemia cases
● Most common in 40 to 50 year old ae group
● The first neoplastic disease to be associated with a specific
recurrent chromosome abnormality
→ Philadelphia chromosome: Nowell & Hungerford, 1960
→ Translocation and subsequent fusion of the ABL oncogene on
chromosome 9 to the breakpoint cluster region (BCR) gene on
chromosome 22 [t:9;22) rearrangement]
→ Fusion gene chimeric protein: p210
● Natural history is of slow progression
→ Accelerated phase: increasing anemia and thrombo-
cytopenia, sometimes accompanied by a rise in the number of
basophils in the blood
→ Blast crisis: termination of accelerated phase or may occur
abruptly; may be lymphoid or myeloid blasts
● The first disorder in which therapy targets a specific molecular
target: imatinib mesylate (tyrosine kinase inhibitor; TKI)
B. Polycythemia Vera (PCV)
● Strongly associated with point mutations in JAK2
→ Most common: JAK V61F mutation
→ Low serum EPO levels (elevated in secondary polycythemia)
→ Less proliferative drive than CML
→ Hgb: 14-28 g/dL
→ Hct: ~60%
● Panmyelosis: increased marrow production of RBCs,
granulocytes, and platelets
→ Increase in red cells is responsible for most symptoms
→ Elevated hematocrit, thrombocytosis, and abnormal platelet
function make PCV patients prone to both thrombosis and
bleeding
● Clinical features
→ Patients are plethoric and cyanotic
→ Headache, dizziness, hypertension, and GI symptoms
→ Intense pruritus and peptic ulceration
→ Hyperuricemia and symptomatic gout
● Spent phase
→ Clinical and anatomic features of PMF develop
→ Appearance of obliterative fibrosis in the bone marrow and
extensive extramedullary hematopoiesis (i.e. spleen)
● May transform to AML (~2%)
 PATHO Lecture 2.5: Hematopathology
C. Essential Thrombocytosis (ET)
● Associated with JAK2 (50%), MPL (5-10%), or calreticulin
mutations
● Thrombopoietin-independent progenitors hyperproliferate due to
constitutive JAK2 or MPL signaling
● Clinical features
→ Elevated platelet counts and abnormally large platelets
→ Modest degrees of extramedullary hematopoiesis
→ Absence of polycythemia and marrow fibrosis
→ Uncommonly transforms to spent phase or AML
● Thrombosis and hemorrhage
→ Deep venous thrombosis, portal and hepatic vein thrombosis,
and myocardial infarction
→ Erythromelalgia: a throbbing and burning of hands and feet
due to occlusion of small arterioles by platelet aggregates
(may also be seen in PCV)
D. Primary Myelofibrosis (PMF)
● Associated with activating JAK2, MPL, or calreticulin mutations
● Hallmark is development of obliterative marrow fibrosis
→ Replacement of marrow by fibrous tissue (marrow failure)
→ Fibrotic marrow may be converted to bone (osteosclerosis)
→ May be due to inappropriate release of fibrogenic factors from
neoplastic megakaryocytes (e.g. PDGF and TGF-β)
→ Leads to cytopenias and extensive extramedullary
hematopoiesis
● May be distinct from PCV and ET, or reflect an unusually rapid
progression of the entities to the spent phase
● Characteristic findings in marrow infiltration
→ Leukoerythroblastosis: premature release of nucleated
erythroid and early granulocyte progenitors
→ Dacryocytes: teardrop-shaped cells
→ Bone marrow biopsy is essential for diagnosis
● Clinical features
→ Fatigue, weight loss, night sweats
→ Hyperuricemia and symptomatic gout
XII. ACUTE LEUKEMIA
● Clonal Proliferation of Blasts in Bone Marrow
● >20% Blasts in Peripheral Blood
● Bone marrow is totally effaced by proliferation of blasts
● 2 types of leukemia – lymphoid and myeloid
● Different protocol for ALL and AML
● If treatment was given to the wrong leukemia – No response
plus adverse effects
Criteria
● Classified by WHO and presently used: =/>20%
● FAB classification and outdated, =/>30% Blasts
Morphology
● Bone marrow infiltration by immature cells (Blastic chromatin)
→ Lymphoblast - small with convoluted nuclei
→ Myeloblast - large blasts, abundant cytoplasm, with
cytoplasmic inclusions (Auer Rods)
Cytology
● Used when morphology is difficult
→ Lymphoblasts: Periodic Acid Fast Stain (PAS) = fuchsia/pink
→ Myeloblasts: Myeloperoxidase (MPO) = black/brown color
Flow Cytometry
● Uses CD markers and Fluorescence
● Different protocol for ALL and AML
● Measuring properties of flow/motion of cells in single file,
interrogated with a laser beam of light
→ Lineage will depend on how the Fluorescence will scatter
→ Uses Fluorochrome for CD marker+ cell → hit by light →
fluoresce → picked up by detectors
▪ Antibody CD 45 - gated parameter, in the Blast region
20 of 24
Figure 67. Flow Cytometry
− Used to isolate a subpopulation from a heterogenous
distribution
− Allows the ability to look at parameters specific to only
that subset
▪ Parameters are used to identify CD markers
− Quadrant Dot Plot Analysis
o Quadrant 1: (+) for antibody one (Y)
o Quadrant 2: Double(+) for both antibodies (X and Y)
o Quadrant 3: Double (-)
o Quadrant 4: (+) only for CD4
▪ When using flow cytometry, ALWAYS note what markers
are positive
Figure 68. Quadrant Dot Plot Analysis
● Diagnosis - CD10, CD34, CD19, Cytoplasmic CD79a
→ 92.2% Blasts with low to intermediate FS and low SS
→ Expressing Dim CD45
▪ CD10 - Diagnostic flow pattern for ALL
− Common Acute Lymphoblastic Leukemia antigen
(CALLA)
− CML - Germinal Center marker
▪ CD34, CD19, Cytoplasmic CD79a
▪ Dim CD13, Dim CD56, HLA-DR, Cytoplasmic CD22
→ Lineage Identification: expression of cytoplasmic antigens
▪ B-Cell ALL - Cytoplasmic CD79a
▪ T-Cell ALL - Cytoplasmic CD3 and CD7
A. ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)
● Accumulation of blasts/immature lymphoid cells in bone
marrow and peripheral blood
● Children > Adults
→ Standard risks: 1-10 y.o.
→ High risks: <1 y.o. and >10 y.o.
→ 3-5 y.o. in children
→ Under 30 y.o. in adults
→ Incidence in childhood is 3/100,000
● Predominant in Males
● Clonal chromosome abnormalities are present in most ALL
patients (>85% adults, >90% children)
● Chromosome ploidy is predictive of clinical outcome and
informative as to risk-specific therapy
→ Hyperploidy: good prognosis
→ Hypoploidy: bad prognosis
● Translocation (9,22) - Minor BCR (chromosome 22)
● Subtypes based on ploidy/modal number of chromosomes
→ Massive Hyperdiploidy (>50 chromosomes)
→ Hyperdiploidy (47-50 chromosomes)
→ Normal diploid
→ Hypodiploidy (<46 chromosomes)
→ Diploid with structural arrangements
▪ Rearrangement involving chromosome 8 (MYC proto-
oncogene 8q24
 PATHO Lecture 2.5: Hematopathology 21 of 24
− t(8:14)(q24;q32), t(2;8)(p12;q24), t(8:22)(q24, q11) → FAB M3 - t(15;17)
− More common: ▪ Seen with bundle of Auer rods
o t(9;22) - High risk, prognostic cytogenetic risk, ▪ Assoc. with DIC
Minor Break Point ▪ Has dramatic response to ATRA (all trans retinoic acid)
o t11q23, t(1:19), t(12;21) ▪ Characteristic cell: Faggot cells
o More diagnostic for ALL with proper clinical history, ▪ Bilobed nucleus
manifestation, and morphology ▪ Kidney-shaped nucleus (reniform)
▪ Hypergranular cytoplasm
Translocation (9;22)(q34.1;q11.2) ▪ Characteristic classification: swapping between the
● Poor prognosis chromosome with PML and RARA
● Most common ALL-associated chromosomal abnormality (15- → Inversion 16 for M4
20% of all cases) → 11q23 for M5
→ Rare in childhood ALL (2-5%)
→ Often found with -7 Table 9. French-American-British (FAB) Classification of AML

Translocations Involved with 11q23

● Poor prognosis
● Most often exchanged with 4, 1, and 10
● Can also be seen in AML, not specific

Translocation on t(1;19)(q23;p13) and der(19)t(1;19)

● Bad prognosis before chemotherapy
→ favorable prognosis with chemotherapy
● Most common in Childhood ALL

Translocations on t(12;21)(p12;q22)
● Good prognosis
→ Undetectable cytogenetically XIII. CHRONIC LYMPHOPROLIFERATIVE DISORDERS
▪ FISH is used ● Characterized by clonal proliferation and accumulation in the
− shows fusion of the TEL-AML 1 genes bone marrow and peripheral blood of relatively mature cells of
● Common in pediatric ALL (22%) B- and T-cell lineage; <20% are Blast Cells
→ Most cases are B-cells (90%)
B. ACUTE MYELOID LEUKEMIA (AML) → Spontaneous Mitotic Activity of these cells is low because they
● Larger Blasts are already mature
● 79.52% Blasts with intermediate FS and SS ● DSP/IL2 are used as mitogenic stimulation to improve
cytogenetic analysis
Diagnosis
● Phenotyping: Expression of myeloid markers Types of Chronic Lymphoproliferative Disorders
→ Cytoplasmic Myeloperoxidase ● Peripheral B-Cell Neoplasms
→ Partial CD117 → Chronic lymphoproliferative leukemia (CLL)
→ Partial CD34 → Small Lymphocytic Lymphoma (SLL)
→ CD15 ● Hairy cell leukemia (HCL) - BRAF mutation
→ CD13 ● Waldenström’s Macroglobulinemia (WM)
→ CD45, HLA DR, Dim CD7, Dim CD33 → Associated with lymphoplasmacytic lymphoma - MYD88
mutation
Myelopoiesis
● Plasma Cell Leukemia (PCL)
● Common myeloid progenitor cells differentiate into 4 subtypes ● Multiple myeloma (MM)
of myeloid blasts ● CLL and MM are commonly seen in clinics
→ Megakaryoblast - platelets ● Most common genetic anomalies are deletions of 13q13.3, 11q,
→ Erythroblasts - RBCs 17, and Trisomy 12q
→ Myeloid blasts - granulocytes (neutrophils, basophils,
eosinophils)
A. CHRONIC LYMPHOPROLIFERATIVE LEUKEMIA (CLL)
→ Monoblasts – monocytes
● Originates from native B-cells
AML Subtypes ● Due to recirculating behavior of the B-cells
● Origin of AML subtypes ● Microscopic features
→ M0-M3: myeloblast → Resembles normal lymphocytes but smaller in size
→ M4-M5: monoblast → Scanty cytoplasm
→ M6: erythroblast → CBC: Absolute lymphocytosis (round hypercondensed
→ M7: megakaryoblast lymphocytes), anemia with or without thrombocytopenia
→ Nucleus: Ovoid/Round with hypercondensed chromatin
FAB Morphology → PE: Lymph node enlargement and/or splenomegaly
● 30% Blast cut off → Few circulating prolymphocytes (Blast-like cells)
● Relies only on morphology ▪ Blast Count (<10%)
● WHO - multi-disciplinary approach ▪ <20% in the lecture
● Not used anymore, uses genetic testing for mutations ● CLL is the most common leukemia of ADULTS in the western
→ FLT3 mutations - bad prognosis world © p. 593
→ to diagnose and prognosticate ● Median age of diagnosis is 60 y.o.
● Genetics > FAB ● There is a 2:1 male predominance
→ drugs available ● Bone marrow will show nodular aggregates of lymphocytes and
● Genetics: no leukemic infiltrates
→ t(8;21)-M2
 PATHO Lecture 2.5: Hematopathology 22 of 24
Common Chromosome Abnormalities → No germinal center seen
● Trisomy 12 (33%, Common) → Lacks the layering found in a normal follicle
→ Gain of 12CEP
● 14q32 rearrangements
→ Add 14(q32) (20%)
→ t(11;14)(q13;q32) - DC/DF
→ t(2;14)(q13;q32)
→ t(14;19)(q32;q13)
● t/del(13q)
→ Loss or nullisomy
● del(11q) (ATM)
→ Loss
● del(17p) (P53)
→ Loss Figure 71. Simple depiction of the pseudofollicular pattern of a lymph node in
→ Targeted therapy of lymphomatous leukemia: Anti-bcl2 drug SLL or CLL. Darker areas contain small, round lymphoid cells. Pale areas are
(VENETOCLAX) proliferation centers that contain prolymphocytes and paraimmunoblasts.
→ People with del(17p) respond well to Ibrutinib chemotherapy

Figure 72. Lymph node with SLL. Note the pale areas (encircled) and the dark
background. Features/patterns seen at low magnification: poorly defined, one-
layer ball-like structures that contain “prolymphocytes and paraimmunoblasts”
(pseudofollicular pattern)
Figure 69. Peripheral blood smear of CLL. Note the small lymphocytes with
condensed chromatin and scant cytoplasm. Two smudge cells can be seen on
the right side of the figure.

Figure 72. Left: Slide showing the different cells that can be seen in SLL. Small
round lymphoid cells are present. Slightly larger and paler compared to the
lymphoid cells are the prolymphocytes. Larger and even paler are the
paraimmunoblasts. Right: High power image of SLL/CLL. The arrow points at a
prolymphocyte. It is a large cell with a centrally placed nucleolus.
Figure 70. Left: Smear of CLL. Note the large blast cell on the lower right portion
of the image. Right: Bone Marrow with CLL. Note the presence of lymphoid High-Grade Transformations of SLL/CLL
aggregates.
● Prolymphocytic Transformation
Small Lymphocytic Lymphoma (SLL) → Increase prolymphocytes (>55%)
● Immunophenotype: CD5, 23 co-expression (HALLMARK of → Unresponsive to chemotherapy
SLL) → Pseudofollicular proliferative centers
● Other markers: CD19, 20, Monoclonal light chains (Surface
IgM+/IgD+)
● Naive B cells
● CD200 - New marker but is more specific for SLL
● CLL and SLL are both peripheral B-cell neoplasms and they
differ only in the degree of peripheral blood lymphocytosis
● Poorly defined, one-layer pseudofollicular pattern of lymph
nodes Figure 73. Prolymphocytic transformation.
→ Lymph node is effaced by CLL cells ● Richter Syndrome
→ Darker background: small round lymphoid cells → 3.5% of cases
→ Pale areas (pseudofollicular proliferative centers): → Transformation to large and diffuse B-cell lymphoma (3%)
prolymphocytes and paraimmunoblasts
→ More aggressive form of CLL and SLL
▪ Proliferation centers (when present) are pathognomonic
→ Heralded by rapidly enlarging mass within a lymph node
for CLL/SLL
of the spleen
→ Smudge cell - lymphocytes that are disrupted in the process
→ Patients only survive for less than a year
of making smears
 PATHO Lecture 2.5: Hematopathology
Figure 73. Richter Syndrome.
● Hodgkin transformation
→ 0.5% of cases
→ Classic RS cells
→ It cannot be called Hodgkin Transformation if there is
no inflammatory background
Figure 74. Hodgkin Transformation.
B. MULTIPLE MYELOMA (MM)
● Also known as Plasma Cell Myeloma or Kahler’s Disease
● Plasma cell myeloma
● Affects the bone marrow and vertebra
● Monoclonal proliferation of plasma cells (sheets of plasma
cells), also known as:
→ “Monoclonal gammopathies”
→ “Plasma cell dyscrasias”
→ “Paraproteinemias”
● Biopsy of BM will appear gelatinous
● Skeletal surface will have lytic lesions
● Characterized by a single class of immunoglobulin product;
referred to as M-component
→ Can be detected using electrophoresis
→ M-spike
→ Only producing monoclonal IgA Kappa
● Commonly associated with hypercalcemia, renal failure, acquired
immune abnormalities and lytic bone lesions ("CRAB")
● Multiple myeloma presents as destructive plasma tumors
(plasmacytomas) involving the axial skeleton (most common in
the vertebra)
● Bone lesions appear as punched-out defects, 1-4 cm in diameter
● Plasma cell variants may be seen
→ Flame cells - fiery red cytoplasm
→ Mott cells - multiple grape-like cytoplasmic droplets
→ Other inclusions - fibrils, crystalline rods
→ Globule inclusions - Russell bodies (cytoplasmic) and
Ditches bodies (nuclear)
● High levels of M protein cause red cells to stick to one another –
> Rouleaux formation
● Myeloma kidney
→ Bence Jones proteins are excreted in the kidney and
contribute to myeloma kidney
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Figure 75. Plasma Cell Myeloma.
Figure 76. Bone Marrow Aspirate showing Multiple Myeloma. Normal marrow
cells are replaced by plasma cells, including forms with multiple nuclei, prominent
nucleoli, and cytoplasmic droppings containing Ig.
Flow Cytometry
● (+) CD38, 138, 56
● (+) Kappa
● (-) Lambda
Diagnosis
● Criteria for the diagnosis of plasma cell myeloma set by
International Myeloma Working Group
● M-protein in serum and/or urine (by serum protein
electrophoresis or flow cytometry)
● Bone marrow clonal plasma cells of plasmacytoma
→ Bone marrow plasmacytosis of above 60% is diagnostic (cut-
off: 10-60%)
→ Related organ or tissue impairment (end-organ damage,
including bone lesions) → “CRAB” Acronym
▪ C - hyperCalcemia - myeloma plasma cells stimulate
osteoclasts → bone resorption → elevated Ca2+ → Bone
pains and fractures
− Can lead to neurologic manifestations (confusion,
weakness, lethargy), constipation, polyuria
− Contributes to renal
▪ R - Renal insufficiency - Plasma cells contain a
monoclonal protein that is very toxic to the renal tubules
and causes kidney destruction
− Single most important factor is Bence-Jones
proteinuria; the excreted light chains are toxic to the
renal tubular epithelial cells
▪ A - Anemia - Brought about by bone marrow infiltration
(decreased erythroid) and damage to the JGA of the
kidneys (decreased EPO production)
▪ B - Lytic Bone lesions- stimulation of osteoclasts by
plasma cells increases bone resorption
● Decreased production of normal immunoglobulins (Igs) sets the
stage for recurrent bacterial infection
● Cellular immunity is relatively unaffected
 PATHO Lecture 2.5: Hematopathology 24 of 24
Table 10. Myeloma-related organ or tissue impairment.
IMPAIRMENT DESCRIPTION
Elevated serum >0.25 mmol/L above the upper limit of
Calcium levels normal OR >2.75 mmol/L
Renal insufficiency Creatinine >173 mmol/L
Anemia Hemoglobin 2g/dL below the lower limit of
normal OR <10g/dL
Bone lesions Lytic lesions or osteoporosis with
compression fractures
Others Symptomatic hyperviscosity, amyloidosis,
recurrent bacterial infections

Cytogenetic or Chromosome Abnormalities

● Del(13)(q14q34)
→ Loss
→ Submicroscopic; seen utilizing FISH Figure 77. Trisomy 15.
● 14q+ (DC-BAP)
→ t(11;14)(q13;32) - cyclin D1 t(11;14), NSD t(4;14), MAF
t(14;16) mutations
→ Cyclin D1 encountered in mantle cell myeloma can also be REFERENCES
expressed in multiple myeloma because of t(11;14)
→ NSD t(4;14) and MAF t(14;16) - POOR PROGNOSIS; MAF Arevalo, A. (2019). Hematopathology [PowerPoint Presentation].
can progress to plasma cell leukemia Manila, Philippines: Faculty of Medicine and Surgery, University
● Structural abnormalities of Chromosome 1 (secondary) of Santo Tomas, PATHO.
● 17p-loss Cotran, R., Kumar, V., & Robbins, S. (2015). Pathologic basis of
● 6q21-loss disease (9th ed.). Philadelphia, PA: Saunders Elsevier.
● Numerical abnormalities involving Chromosomes 3, 5, 7, 9, 11, A2021 Trans
13, and 15 Outline uploaded by Dr. Arevalo

END OF TRANSCRIPT

Transcribed by: : Quintana P., Quintin N., Rabara E., Ragudo G., Ramos I.,
Ramos P., Ramos R., Villegas, M., Villegas, S., Vizcarra, L., Wahab, D.T.,
Yonzon, A.C., Zacarias, G., Zenarosa, A., Tiamson, C., Tobias, K., Toh, N.,
Toreja, J., Tornea, S., Torres, C.
Checked by: Rapacon, M., Xu, S., Tarrosa, N.
Edited by: Uy, H. and Trinidad, C.

APPENDICES
Appendix 1. Summary
Appendix 1. Summary of subtypes of
of Subtypes of Hodgkin’s
Hodgkin’s lymphoma.
Lymphoma