CHAPTER 13

DISEASES OF WHITE BLOOD CELLS, LYMPH NODES, SPLEEN, AND

THYMUS

!
DISORDERS OF WHITE CELLS
!
LEUKOPENIA:
• Reduction in circulating granulocytes occurs:
• Inadequate or Ineffective granulopoiesis
• Suppression of stem cells – aplastic anemia and infiltrative disorders
• Suppression of committed precursors – drugs
• Ineffective hematopoiesis – megaloblastic anemias and myelodysplasia (defective
precursors die in the marrow)
• Congenital conditions – Kostmann syndrome (defects in genes required for
granulocytic differentiation
• Accelerated removal or destruction
• Immune mediated injury to neuts (SLE, drugs)
• Splenomegaly
• Increased utilization in overwhelming infection
• The most common cause of agranulocytosis is drug toxicity. Infections are the most
common and serious consequence of agranulocytosis.
!
LEUKOCYTOSIS:
• Peripheral leukocyte count increases with:
• Increased production
• Increased release from stores
• Decreased margination
• Decreased extravasation
!
BENIGN DISEASES OF LYMPH NODES
!
ARCHITECTURAL PATTERNS OF HYPERPLASIA
• Follicular hyperplasia – seen in LN draining sites of chronic inflammation, infections (syphilis,
toxo – part of toxo triad), inflammatory conditions (rheumatoid lymphadenopathy), and HIV
• Paracortical hyperplasia – common in viral infections (EBV, CMV), often get follicular
hyperplasia as well, also seen secondary to medications (phenytoin)
• also Dermatopathic Lymphadenitis (with melanin pigment deposition)
• Sinus hyperplasia – sinus histiocytosis is a nonspecific response to chronic inflammation and also
seen in LN draining cancers, RDD, ingestion of mineral oil, lymphangiography, infections
(Whipple’s disease), vascular transformation of the sinuses, dermatopathic lymphadenopathy
• Granulomatous lymphadenopathy
• Caseating – TB, leprosy, histoplasmosis
• Suppurative – cat scratch, viral infection, yersinia, tularemia, lymphogranuloma venereum,
SLE
• Necrotizing without neuts – kikuchi (histoiocytic)
• Non-necrotizing, non-caseating – sarcoid, Crohn’s
• Other: met’c NPC and Seminoma can be assoc with prominent “sarcoid like”
granulomatous lymphadenitis
 • Also lymphomas such as Hodgkin Lymphoma, NLP-HL, LPlL, PTCL NOS
• Other patterns: Extensive necrosis; Deposition of Interstitial substances; Lymph Node
Framework

PRECURSOR B AND T NEOPLASMS

ALL
• Immature B or T cell neoplasms
• 85% of B-ALL present as childhood acute leukemia
• T-ALL is less common and presents in adolescents as thymic lymphoma
• ALL is the most common cancer of children
• Poor prognostic factors:
• Age < 2 yo
• Presentation in adolescence or adulthood
• High blast count
• Certain cytogenetics t(9;22) – this Philadelphia chromosome is different than the one
in CML and results in a genetically unstable leukemia and is prone to develop
resistance to Gleevec
• Residual disease following treatment
• Favorable prognostic factors:
• Age 2 – 10 yo
• Low white count
• Certain cytogenetics
• No residual disease following treatment

PERIPHERAL B-CELL NEOPLASMS

B-CELL LYMPHOMAS
• Account for 90% of lymphomas, DLBCL and FL are the most common in adults
• Risk factors include immunosuppression of any cause
!
CLL/SLL:
• monomorphic small, round to slightly irregular B-lymphocytes forming proliferation centres
in tissue in filtrates, usually express CD5 and CD23
• Cytogenic abnormalities: del 13q - good px
!
Burkitt lymphoma
• Endemic (African)
• Nonendemic
• HIV associated
• All associated with translocations of the c-myc gene
• Most tumors manifest at extranodal sites – mandible and abdominal viscera
• Ki-67 >95-100%, Bcl2 negative
• EBV +/-
• t(8;14), t(8;22), t(2;8)
• have good outcome but superior survival requires intense chemo regimens with CNS
prophylaxis

DLBCL
• Can subclassify as:
• germinal centre phenotype (Bcl6+,CD10+, Mum1-)
• 5 year survival 60%, median 10 years
 • activated B-cell phenotype (Bcl6-/+, CD10+, Mum1+, Cyclin D2+)
• 5 year survival 35%, median 2 years
• Myc amplification is more important than the GCT/aGCT typing
!
• B-cell markers: CD20, CD79a, PAX-5, MUM-1 OCT2/BOB1 (but some B-cell lymphomas
may co-express CD5, CD30, CD15, ALK-1, EMA, CD56 and CD43)
• when to test for c-myc, Bcl-6, t(14;18)/Bcl-2 by FISH in DLBCL??
• DLBCL with high Ki-67 (>80%)
• DLBCL with BL like features
• Transformed DLBCL from low grade NHL

Gray-zone between Burkitt and DLBCL/double hit/atypical Burkitt

• Proliferation index > 90% and starry sky but too pleomorphic for Burkitt
• Morphology of Burkitt but discordant IHC (Bcl2+, Ki67 < 90%)
• Transformation of previous low grade lymphoma with myc translocation

Lymphoplasmacytic lymphoma
• Resembles CLL/SLL but some of the cells undergo terminal differentiation to plasma cells
• Secrete monoclonal IgM causing Waldenstrom macroglobulinemia
• Heavy and light chain secretion is balanced so you don’t get the complications of excess
light chains like MM
• May also have autoimmune hemolysis due to cold agglutinins
• Features of hyperviscosity syndrome:
• Visual impairment
• Neurologic symptoms
• Bleeding
• Cryoglobulinemia – Raynaud’s and cold urticaria
!
B-cell neoplasms that can be CD20 Negative:
• plasmacytoma
• plasmablastic lymphoma
• ALK positive DLBCL
• B-ALL
• Primary effusion/body cavity based lymphoma
• Lymphomas post rituximab therapy
!
B-cell neoplasms that LACK surface light chains by flow cytometry:
• Plasmacytoma (often cytoplasmic)
• PL (cytopalsmic or neative)
• mediastinal LBCL
• ALL
• DLBCL (neg in 30%)
• CLL/SLL (weka in many cases, can be neg)
!
Classification of plasma cell neoplasms (monoclonal gammopathies)
• Multiple myeloma
• Waldenstrom macroglobulinemia
• Heavy-chain disease
• Primary or Immunocyte associated amyloidosis
• MGUS

Classification of amyloidosis:
• Primary – due to a plasma cell neoplasm, always AL and systemic
 vs
• Secondary
!
• Systemic
• Non-hereditary
• Reactive systemic (CTD associated) – AA
• Hemodialysis associated (CRF) – beta 2 microglobulin
• Systemic senile amyloidosis – ATTR
• Hereditary
• Familial Mediterranean fever – AA
• Familial amyloidotic neuropathies – several types
vs
• Localized
• Senile cerebral – APP
• Endocrine
• Neoplastic – accumulation secondary to NE tumors (calcitonin in MTC)
• Non-neoplastic – accumulation in islets in DM2 (islet amyloid peptide)
• Isolated amyloidosis – can occur in the atrium, larynx, skin, bladder, and many other
organs as an isolated event – can be AL type

Classification of marginal zone lymphomas

• Nodal
• Splenic
• Extra-nodal/MALTomas
• Often arise in tissues involved by chronic inflammation
• Salivary gland – Sjogren’s
• Thyroid – Hashimoto’s
• Stomach – HP infection
• Remain localized for long periods
• May regress if the inciting agent is eradicated

Classification of T-cell lymphomas

• Cutaneous
• MF
• Lymphomatoid papulosis – not yet a lymphoma but cannot distinguish from ALCL on histo
• ALCL – are ALK neg in skin
• Panniculitis-like T-cell lymphoma
• Nodal
• T-cell NOS
• ALCL ALK pos versus neg
• Angioimmunoblastic T cell lymphoma
• Extra-nodal
• Most commonly presents as nasopharyngeal NK lymphoma
• Leukemic
• Adult T-cell leukemia – only associated with HTLV-1 infection
• HTLV-1 infection also gives rise to a progressive demyelinating condition of the brain
and spinal cord

Hodgkin lymphoma
Classical: CD15+. CD30+, CD45-
• NS
• Most common subtype, EBV-
• MC
• 70% are EBV associated
 • LR
• Uncommon, tends to be older adults, 40% EBV+
• LD
• HIV associated and older age
• Outcome less favourable than the other subtypes, most are EBV+
!
NLPHL: CD15- CD30-, CD45+
• More common in young males
• Tend to be localized and prognosis is excellent, EBV-
!
Differential Dx of Large Cells in Polymorphous Infalmmatory Background
• Hodgkin’s Lymphoma
• Anaplastic Large Cell Lymphoma
• Peripheral T-cell lymphoma

MYELOID NEOPLASMS

Classification
Acute myeloid leukemia
• AML occurs at all ages but peaks after 60 yo
!
Myelodysplastic syndromes
• Clonal stem cell disorders with maturation defects with a high rate of transformation to
AML
• Mostly a disease of the elderly
!
Myeloproliferative disorders
• CML – t(9;22) in 100%, may transform to ALL or AML
• PCV – JAK2 point mutations, may transform to AML or myelofibrosis
• ET – JAK2 point mutations, MPL point mutations; may transform to AML or myelofibrosis
• Primary myelofibrosis – JAK2 point mutations, MPL point mutations
• Represents the spent phase of PCV and ET
• Systemic mastocytosis – KIT point mutations
• Chronic eosinophilic leukemia – PDGFR fusions
• Stem cell leukemia – FGFR1 fusions

Classification of LCH:
• Multifocal multisystem:
• “Letterer-Siwe Disease”
• Mostly children < 2 yo
• Seborrheic eruption over the abdomen and scalp
• May appear anaplastic – Langerhans cell sarcoma
• Poor prognosis
• Unifocal:
• Eosinophilic granuloma
• Multifocal, Unisystem:
• Hand-Schuller-Christian Triad – calvarial bone defects, diabetes insipidus (due to posterior
pituitary stalk involvement), exophthalmos
• Good prognosis
• Pulmonary
• Seen in smokers, likely a reactive hyperplasia
!!
Splenomegaly - Ddx:
1. Infection: huge list
2. Congestive states (secondary to portal hypertension): cirrhosis, cardiac congestion
3. Lymphohematogenous diseases
4. Immunological-Inflammatory Disorders - RA, SLE
5. Storage Disorders: Gaucher, Nieman-Pick
6. Miscellaneous: amyloid, primary and secondary neoplasms
!!
THYMUS:
• arises from the 3rd and sometimes 4th pair of pharyngeal pouches
• DiGeorge syndrome: 22q11
• thymic hyperplasia: see an increase in numbers of B-cell germinal centres
• primary seen in myasthenia gravis
• also in SLE, Scleroderma, RA, others
!
Thymomas:
• tumors of thymic epithelial cells (which are both in the medullary and cortical spaces)
• most commonly seen in anteroposterior mediastinum
• Broad classifications:
1. Non-invasive thymoma
2. Invasive thymoma
3. Thymic carcinoma (mainly SqCC, followed by LE-like ca)
• WHO classification: A, AB, B1, B2, B3, C
!
!
IHC in Hodgkin Lymphoma
CD20 CD79a PAX5 CD45 Bcl6 Oct2/ Mum1 EMA CD15 CD30 CD43 EBER
BOB1
NLP + + + + + + + +/- - - - -
NS -/+ -/+ +/- - -/+ ++(nuc) - +/- + -/+
MC -/+ -/+ +/- - -/+ ++(nuc) - +/- + +/-
LR -/+ -/+ +/- - -/+ ++(nuc) - +/- + -/+
LD -/+ -/+ +/- - -/+ ++(nuc) - +/- + +/-
NLPHL: t-cells rosette around Land H cells, express CD3 and CD57 (helps to diff from T cell rich DLBCL and CHL)

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Cotswold Revision of the Ann Arbor Staging Classification
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Stage I: involvement of a single LN region (I), or lymphoid structure (eg. spleen, thymus,
Waldeyers ring)
Stage II: involve of 2 or more LN regions at same side of diaphragm (II) (the mediastinum is
considered a single site)
Stage III: Involvement of LN regions on both sides of the diaphragm (III) which may be
accompanied by extralymphatic extension in association with LN involvement (IIIE)
or splenic involvement (IIIS)
Stage IV: Involvement of extra nodal site(s) beyond those designated E
!!
Clinical Px’c Factors and Indices:
• International Prognostic Score (IPS): to predict outcome based on following adverse factors:
• serum albumin <4g/dL
• [Hb} < 10.5 g/dL
 • male sex
• age ≥45
• stage IV disease
• wbc count ≥15,000/mm3
• lymphopenia <600/mm3 or <8%
!
• The rate of freedom from progression by risk category is:
• 0 factors 84%
• 1 factor 77%
• 2 factors 67%
• 3 factors 60%
• 4 factors 51%
• 5+ factors 42%
!
• Also, presence of B symptoms (fever >38C, unexplained weight loss (>10% body weight), and
drenching night sweats in 6 months prior to dx
• correlates with extent of disease (stage and tumor bulk) but Sx have also been shown to
have px’c significance for cause-specific survival that is independent of stage
!
• Apart from IPS, other px’c factors, incl HIV status, Bcl-2 expression and pretx IL-10 serum
levels may be important
!
• Special Handling Procedures for Lymphoma Protocol:
• tissue received fresh
• touch imprints from freshly cut surface - air dried or fixed in EtOH
• for cytogenetics or cultures: submit fresh specimen in appropriate transport medium
(eg RPMI)
• snap-frozen tissue is optial for DNA and RNA extraction
!
AJCC/UICC Staging for Non-Hodgkin Lymphomas
Stage I: Involvement of a single lymph node region (I), or localized involvement of a single
extralymphatic organ or site in the absence of any lymph node involvement (IE)#, ##
Stage II: Involvement of 2 or more lymph node regions on the same side of the diaphragm (II), or
localized involvement of a single extralymphatic organ or site in association with regional
lymph node involvement with or without involvement of other lymph node regions
on the same side of the diaphragm (IIE) ##,###
Stage III: Involvement of lymph node regions on both sides of the diaphragm (III), which also
may be accompanied by extralymphatic extension in association with adjacent lymph
node involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE+S) ##,###,^
Stage IV: Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or
without associated lymph node involvement; or isolated extralymphatic organ
involvement in the absence of adjacent regional lymph node involvement, but in
conjunction with disease in distant site(s). Stage IV includes any involvement of the liver, bone
marrow or nodular involvement of the lung(s) or CSF
!
# Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV.
## For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.
!
### The number of lymph node regions involved may be indicated by a subscript: eg, II3. For stages
II to IV, involvement of more than 2 sites is an unfavorable prognostic factor.
^ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.
Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence classification
of stage.
!
!
AJCC/UICC Staging for Plasma Cell Myeloma
Stage I Hemoglobin greater than 10.0 g/dL
Serum calcium 12 mg/dL or less
Normal bone x-rays or a solitary bone lesion
IgG less than 5 g/dL
IgA less than 3 g/dL
Urine M-protein less than 4 g/24 hours
Stage III One or more of the following are included:
Hemoglobin less than 8.5 g/dL
Serum calcium greater than 12 mg/dL
Advanced lytic bone lesions
IgG greater than 7 g/dL
IgA greater than 5 g/dL
Urine M-protein greater than 12 g/24 hours
Stage II Disease fitting neither stage I nor stage III
!
Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL or (B) serum
creatinine 2.0 mg/dL or greater. The median survival for stage IA disease is about 5 years, and that
for stage IIIB disease is 15 months
!
Mature B-Cell Neoplasms
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Faint sIGM+, sIGD+/-,
cIG-/+, panB+ (CD19+, CD20+), CD5+, CD10-, CD23+, CD43+, CD11c-/+; IGH and IGL gene
rearrangements; trisomy 12; del 13q, del(17p), or del(11q) can be seen
!
Hairy Cell Leukemia: sIG+ (IGM, IGD, IGG, or IGA), PanB+, CD79a+, CD79b-, DBA.44+, CD123+,
CD5-, CD10-, CD23-, CD11c+, CD25+, FMC7+, CD103+ (mucosal lymphocyte antigen as
detected by B-ly7), tartrate resistant acid phosphatase (TRAP)+; IGH and IGL gene rearrangements,
no specific cytogenetic findings
!
Lymphoplasmacytic Lymphoma: sIGM+, sIGD-/+, cIG+, PanB+, CD19+, CD20+, CD138+ (in
plasma cells), CD79a+, CD5-, CD10-, CD43+/-, CD25-/+; IGH and IGL gene rearrangements, no
specific cytogenetic findings
!
Plasma Cell Myeloma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,
CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-,
cyclin D1+; IGH and IGL gene rearrangements; numerical and structural chromosomal
abnormalities are common, including trisomies (often involving odd numbered chromosomes),
deletions (most commonly involving 13q14), and translocations (often involving 14q32)
!
Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue
(MALT Lymphoma): sIG+ (IGM or IGA or IGG), sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-,
CD43-/+; IGH and IGL gene rearrangements, BCL1 and BCL2 germline, trisomy 3 or t(11;18)
(q21;q21) may be seen
!
Nodal Marginal Zone Lymphoma: sIGM+, sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+;
IGH and IGL gene rearrangements, BCL1 and BCL2 germline
!
Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-/+, CD23-/+,
CD43-, CD11c-, CD25-; overexpression of BCL2+ (useful to distinguish from reactive follicles),
BCL6+; IGH and IGL gene rearrangements, t(14;18)(q32;q21) with rearranged BCL2 gene (70-95%
in adults)
!
Mantle Cell Lymphoma: sIGM+, sIGD+, lambda>kappa, PanB+, CD5+, CD10-/+, CD23-, CD43+,
CD11c-, CD25-, cyclin D1+; IGH and IGL gene rearrangements, t(11;14)(q13;q32); BCL1 gene
rearrangements (CCND1/cyclinD1) common
!
Diffuse Large B-Cell Lymphoma (DLBCL), NOS: PanB+, surface or cytoplasmic IGM>IGG>IGA,
CD45+/-, CD5-/+, CD10+/-, BCL6 +/-, 3q27 region abnormalities involving BCL6 seen in 30% of
cases, t(14;18) involving BCL2 seen in 20-30% of cases, MYC rearrangement seen in 10% of cases
!
Burkitt Lymphoma: sIGM+, PanB+, CD5-, CD10+, BCL6+, CD38+, CD77+, CD43+, CD23-; Ki-67
(95-100%), BCL2-; TdT-, IGH and IGL gene rearrangements, t(8;14)(q24;q32) and variants t(2;8)
(p12;q24) and t(8;22)(q24;q11); rearranged MYC gene; EBV common (95%) in endemic cases and
infrequent (15-20%) in sporadic cases, intermediate incidence (30-40%) in HIV-positive cases
!
B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell
Lymphoma and Burkitt Lymphoma: PanB+, CD10+, BCL6+, BCL2-/+, IRF4/MUM1-, Ki-67
(50-100%), 8q24/MYC translocation (35-50%), BCL2 translocation (15%), and occasionally both
translocations (so called double hit lymphoma)
!
B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell
Lymphoma and Classical Hodgkin Lymphoma: CD45+/-, CD20+/-, CD79a+/-, CD30+/-, CD15+/-,
PAX-5+/-, OCT-2+/-, BOB.1+/-, CD10-, ALK-
!
!
Criteria to differentiate FL from Follicular Hyperplasia
Feature Follicular Lymphoma Follicular Hyperplasia

↑ in follicle density Yes, with follicles throughout and Yes, with follicles in subcortical region
beyond capsule mainly

lack of tangible body Mϕ Yes No

Mantle zone Poorly formed or absent Present

Follicle polarization Not present Often present
Bcl2, light chain restriction, t(14;18) Present Absent
Ki-67 proliferation rate Low High

!
IHC Profile for “Small Lymphoid Neoplasms”
LCA CD20/ Cyclin D1 CD5 CD43 CD23 CD10 Bcl2 Bcl6
CD79a/
PAX-5
FL + + - - - -/+ + + +
MZL + + - - +/- -/+ - + -
MCL + + + + - -/+ - + -
LPL + + - - - - - + -
B-CLL + + (weak to - + + + - + -
-CD20)
*Cyclin D1 can also be positive in Myeloma and Hairy cell leukemia
** Splenic MZL (white pulp spleen -ve for CD43)

!
Molecular Dx in B cell Lymphoid Neoplasms
Diagnosis Translocation Genes Incidence
 FL t(14;18) IgH/Bcl2 80-90%
t(3:V) Bcl6 and many partners 5-15%
MCL t(11;14) IgH/CCND1 nearly 100%
MZL t(11;18) API2/MALT1 variable
t(14;18) IgH/MALT1 variable
t(1;14) Bcl10/IgH uncommon
t(3;14) FOXP1/IgH variable
DLBCL t(14;18) IgH/Bcl2 20-30%
t(3;V) Bcl6 and many partners up to 30%
BL t(8;14) c-myc/IgH nearly 100%
CLL/SLL del (13q) 30-50% (good px)
+12 15-20% (int’d)
Normal 20% (int’d)
del (11q23) 15-20% (poor)
del (17p) 5-10% (poor)