Virchows Arch

DOI 10.1007/s00428-015-1864-y

REVIEW AND PERSPECTIVES

The heterogeneity of follicular lymphomas: from early

development to transformation
Luc Xerri 1 & Stephan Dirnhofer 2 & Leticia Quintanilla-Martinez 3 & Birgitta Sander 4 &
John K.C. Chan 5 & Elias Campo 6 & Steven H. Swerdlow 7 & German Ott 8

Received: 31 July 2015 / Revised: 10 September 2015 / Accepted: 1 October 2015

# Springer-Verlag Berlin Heidelberg 2015

Abstract Follicular lymphoma (FL) is a lymphoma com-
posed of germinal center B cells, i.e., centroblasts and
centrocytes, that almost always show at least a focal follicular
growth pattern. Most cases have a characteristic CD5-,
CD10+, BCL6+, and BCL2+ immunophenotype, and 85 %
of cases exhibit the hallmark translocation t(14;18)(q32;q21)
involving BCL2 and IGH. Although the typical clinicopatho-
logical findings of FL are well recognized, cases with unusual
clinical, morphologic, immunophenotypic, and genetic fea-
tures may pose problems in diagnosis and nomenclature. In
the slide workshop organized by the European Association for
Haematopathology (EAHP) and the Society for
Hematopathology (SH) held in Istanbul, Turkey, unusual var-
iants of FL were discussed based on the submitted cases,
including early lesions, localized extranodal presentation, un-
common immunophenotype, rare genetic alterations, diffuse
variant, and marginal zone differentiation. Interesting features
such as blastoid morphology and unusual progression forms
were presented, aiming to understand the genetic basis of
transformation. In this report, novel findings and diagnostic
challenges emerging from the submitted cases will be
highlighted, and new terminologies for some of these lesions
are proposed.
Keywords Follicular lymphoma . Classification .
Immunohistochemistry . Cytogenetics . BCL2
Introduction

* Luc Xerri Follicular lymphoma (FL), as defined in the current WHO

xerril@ipc.unicancer.fr
1
Department of Bio-Pathology, Institut Paoli-Calmettes,
Aix-Marseille University, Marseille, France
2
Institute of Pathology, University Hospital Basel, Basel, Switzerland
3
Institute of Pathology and Neuropathology, Eberhard Karls
University of Tübingen and Comprehensive Cancer Center,
University Hospital Tübingen, Tübingen, Germany
4
Department of Laboratory Medicine, Division of Pathology,
Karolinska Institutet and Karolinska University Hospital Huddinge,
Stockholm, Sweden
5
Queen Elizabeth Hospital, Hong Kong, SAR, China
6
Hospital Clinic, University of Barcelona, Barcelona, Spain
7
Division of Hematopathology, Department of Pathology, University
of Pittsburgh School of Medicine, Pittsburgh, PA, USA
8
Department of Clinical Pathology, Robert-Bosch-Hospital and Dr.
Margarete Fischer-Bosch Institute of Clinical Pharmacology,
Stuttgart, Germany
classification of hematolymphoid neoplasms [1], is a malig-
nant lymphoma composed of germinal center (GC) B cells,
namely centroblasts and centrocytes, usually with an at least
partially follicular growth pattern. Although most FL exhibit
the well-known typical morphological, immunophenotypic,
and genetic features, significant variations in each of these
features occur well exemplified by cases submitted to the
workshop. There are FLs that have a predominantly diffuse
growth pattern, or are composed exclusively of centroblasts or
uniform blastoid cells. Others have architectural and/or cyto-
logic features of marginal zone, monocytoid or plasmacytoid
differentiation, are CD10 negative, or lack the prototypic
t(14;18)(q32;q21)IGH/BCL2 chromosome translocation. In
addition, our knowledge of precursor lesions of FL such as
in situ follicular neoplasia (intrafollicular neoplasia/follicular
lymphoma in situ) has improved.
Cases presented during the workshop highlighted the
marked diversity of FL with respect to morphological,

phenotypical, and genetic features. This diversity was striking
enough to lead to a re-appraisal of the borders of the FL entity.
Among the 268 cases submitted to the workshop of the 17th
European Association for Haematopathology (EAHP) meet-
ing, 184 cases were reviewed by the lymphoma workshop
panel members, who identified 34 non-transformed FL cases
and 10 FL cases with progression/transformation.
These FL cases were initially categorized into the follow-
ing groups:
1) Follicular neoplasia/follicular lymphoma in situ and FL
precursors
2) FL with localized extranodal presentation
3) Predominantly diffuse variants of FL
4) FL with unusual immunophenotypes
5) FL with blastoid features
6) FL with monocytoid features and/or marginal zone differ-
entiation (MZD)
7) FL with unusual genetic features
8) Transformation of FL
Pediatric-type FL was covered in a separate session, and is
addressed in a separate publication (see Quintanilla-Martinez
et al. Virchows Arch 2015 in press). Primary cutaneous folli-
cle center lymphoma was excluded from the workshop since
they are considered a distinct entity in the current WHO
classification.
Follicular neoplasia/follicular lymphoma in situ
and FL precursors
Several workshop cases highlighted the diagnostic criteria for
follicular neoplasia in situ (intrafollicular neoplasia/follicular
lymphoma in situ) and its segregation from partial involve-
ment by FL (PFL). The term in situ follicular neoplasia (ISFN)
is expected to be adopted in the update of the 4th edition of the
WHO classification, and will be used in this manuscript.
Lymph nodes or other lymphoid tissues with ISFN demon-
strate architectural preservation but show one or more germi-
nal centers with variably prominent populations of CD10+,
BCL2+ B cells that are monoclonal and have the BCL2/
IGH/t(14;18) translocation. Strong BCL2 immunoreactivity
is a hallmark feature of the neoplastic cells, and should be
more intense than mantle cells and reactive T cells. There is
no infiltration outside the GCs, which have an intact mantle
zone, are not increased in size or number, but in some cases
lack polarization due to predominance of centrocytes and ex-
hibit decreased Ki-67 reactivity when compared to reactive
GCs [1–4]. The main differential diagnosis of ISFN is early/
partial involvement by follicular lymphoma (PFL). In most
cases, PFL corresponds to an early stage (stage I or II) of FL
evolution, but similar features can also be seen in
Virchows Arch
disseminated cases with early involvement of a given lymph
node. PFL follicles are larger than those in ISFN and cluster
together, resulting in a partially effaced lymph node architec-
ture. They display altered mantle zones, exhibit variable in-
tensity of BCL2 staining, and CD10+/BCL2+ cells may be
observed outside the PFL follicles [4–6].
As exemplified in case 52 submitted by S. Najendra
(Fig. 1), the diagnosis of ISFN is usually made as a fortuitous
discovery in 2–3 % of LN resected for a reason other than
lymphoma [2, 7]. Only a minority (6 %) of ISFN patients
eventually progress to overt FL, at least within the limited
follow-up times (median 26–41 months) in published studies
[4, 8]. The indolent behavior of ISFN was highlighted in this
case, in which ISFN was initially diagnosed in the spleen and
relapsed 2 years later in a cervical LN, again as ISFN. The
clinical features of this case, therefore, are well in line with the
current view that ISFN cells are not necessarily committed to
malignant transformation, albeit representing putative precur-
sors in follicular lymphomagenesis [6, 9, 10]. In fact, ISFNs
are not considered a mere GC accumulation of circulating
t(14;18)+FL-like B cells that may be detected in the periph-
eral blood in about 50 % of healthy individuals [6, 11] and
which only exceptionally carry additional genomic alter-
ations. ISFN cells harbor increased genomic instability as ev-
idenced by their acquired mutations in histone-modification
genes such as EZH2, CREBBP, and TNFSR14 [9, 10].
The diagnosis of ISFN requires careful staging procedures
since it can be associated with concomitant overt lymphoma
in a different site [4, 8]. In this respect, cases 258 and 127
(submitted by J. Morscio and L. Xerri, respectively) showed
simultaneous occurrence of overt follicular lymphoma (OFL)
and ISFN in the same lymph node (Fig. 1), with a t(14;18)
translocation documented in each lymphoma component. In
case 127, BCL2 sequencing provided evidence that both ISFN
and OFL originated from the same clone, since both compo-
nents shared the same BCL2/JH sequence at the t(14;18)+
breakpoint. In both cases, the ISFN component was BCL2
protein positive with the widely used DAKO-100 antibody
(directed against AA 41-54 of the human BCL2 protein),
whereas the OFL component was negative. In case 258, the
OFL proved to be BCL2 protein positive with the Epitomics
E17 antibody (directed against AA 61-76), explainable by the
presence of two mutations (at codons 52 and 59) in the area
encoding the epitope recognized by the DAKO antibody [12,
13]. Case 127, however, was more complex, since the OFL
component was negative with three anti-BCL2 clones, i.e.,
100, E17, and SP66. Upon sequencing, BCL2 mutations
resulting in amino acid substitutions were specifically found
in the OFL component, and located in the target epitopes of
clones 100, E17, and SP66, thereby preventing binding of the
antibodies. VH region sequencing, interestingly, showed that
the ISFN subclones were VH mutated to a greater extent than
the OFL subclones, pointing to strong somatic hypermutation
Virchows Arch

Fig. 1 FL precursors and related

composite lesions. Case 52
A C D
(courtesy of S. Nagendra) was an
ISFN lesion discovered by chance
in an otherwise normal, isolated
lymph node (a), with stronger
BCL2 staining of GC cells than in
surrounding T cells (a, insert).
Case 258 (courtesy of J. Morscio)
was a composite lymphoma
harboring an ISFN and an
established BCL2-negative FL
highlighting the ISFN by BCL2 B
immunostaining using the DAKO ISFN
clone 100 antibody (b).
Reactivity of FL follicles for
BCL2 could be observed using
other BCL2 antibodies like clone
E17. H&E staining illustrates the
minimally altered appearance of
follicles in the ISFN lesion (c). FL
Strong BCL2 positivity (d). Case
127 (courtesy of L. Xerri) was,
like case 258, a composite tumor E F
characterized by the presence of
both ISFN and overt FL in ISFN
adjacent areas of the same lymph
node (e). The ISFN component
appeared as small germinal
centers within an area of
preserved architecture (f). The
overt FL component displayed a
FL
typical pattern of a low-grade FL
on H&E staining (g). BCL2 ISFN
immunostaining using the clone
100 antibody (DAKO) showed
strong positivity of the ISFN G H ISFN
I
component, whereas the OFL
follicles were negative due to
mutations in the BCL2 gene (h, i).
In contrast to case 258, BCL2 ISFN
protein was not expressed in the
OFL follicles also using other
antibodies against BCL2
FL
FL FL

(SHM) activity in ISFN. This case suggests that OFL could
originate from a divergent or earlier clone than the synchro-
nous ISFN. In addition, it could be demonstrated that VH
somatic mutations resulted in N-glycosylation sites (Asn-X-
Ser/Thr), which could play a role in FL pathogenesis by bind-
ing lectins acting as surrogates for antigen stimulation
[14–16]. Both cases 127 and 258 further support the view that
ISFN represents a putative OFL precursor lesion with com-
mon genetic origin, but not necessarily progressive clinical
behavior. Both cases are similar to previously reported cases
of ISFL associated with OFL, in which the OFL was often
BCL2 protein negative [13, 17]. Although BCL2 mutations (in
a rearranged BCL2 gene) could play a role in the clonal evo-
lution of these cases, it is unclear at the moment if all OFL are
preceded by ISFN.
FL with localized extranodal presentation
FL usually presents as systemic disease, but there are well-
known exceptions.
Primary duodenal FL is characterized by a usually local-
ized lymphoid infiltrate with crowded CD10+, BCL2+
centrocyte-rich follicles with BCL2 rearrangements, frequent

IgA expression, and extrafollicular involvement including ex-
tension into the villi [1]. Similar to PFL, primary duodenal FL
harbors a low number of genetic alterations [9] Nodal exten-
sion is exceptional, and spontaneous regression may occur
[18].
This is well illustrated by case 244 (submitted by C.
Santonja), a primary duodenal FL with an indolent clinical
course watched for 6 years. Case 146 (submitted by A. D.
Attygalle), in contrast, featured a primary colonic FL with a
17-year history of multiple relapses, but without dissemina-
tion, suggesting that at least some primary colonic FL might
behave in an equally indolent manner.
Case 36 submitted by A. Dogan was an example of bilat-
eral FL grade 2 and 3A confined to the ovaries. In this partic-
ular site, FL cases have been reported to display heteroge-
neous clinicopathological characteristics with two main types:
a low-grade/high-stage/BCL2-positive group and a high-
grade/low-stage/BCL2-negative group. Patients in the latter
group tend to have favorable outcome, as has also been re-
ported for high-grade/low-stage FLs presenting in other
extranodal sites, such as the thyroid and spleen [19]. It is
tempting to speculate that these cases might be related to the
pediatric ones presenting in testis (see Quintanilla-Martinez
et al. Virchows Arch 2015 in press).
Predominantly diffuse variants of FL
FL with a predominantly diffuse growth pattern has been rec-
ognized in the WHO classification as a variant composed of
centrocytes and centroblasts with a growth pattern of less than
25 % follicularity [1]. Small biopsies are particularly problem-
atic, because an otherwise typical FL may lack a clearly fol-
licular growth pattern in the limited diagnostic material. In
such circumstance, a diagnosis of FL has to be supported by
immunoreactivity with two or more GC markers and/or pres-
ence of the t(14;18) chromosome translocation. These cases
must be distinguished from particular FL variants, as exem-
plified by case 24 submitted by R. King (Fig. 2), which cor-
responds to a distinctive variant of nodal FL with a predomi-
nantly diffuse growth pattern, absence of t(14;18), and dele-
tion in chromosomal band 1p36 [20]. This variant is usually
grade 1/2, with expression of most GC markers and frequent
co-expression of CD23. Clinical stage is usually low, and
large but localized inguinal tumors are characteristic [20]. It
should be noted, however, that 1p36 deletion is not specific
for this variant, but is also the second most frequent chromo-
somal alteration in classical t(14;18) positive FL [21, 22].
Other cases seen in the workshop featuring a predominant-
ly, or exclusively, diffuse growth pattern often showed unusu-
al cytological and/or genetic features, such as blastoid features
and absence of a BCL2 rearrangement but extra copies of
BCL2 in case 203 submitted by B. Christensson (Fig. 2).
Virchows Arch
FL with unusual immunophenotypes
BCL2 negative FL
Case 67 (submitted by C. Lome-Maldonado) illustrated the
phenomenon of BCL2 “pseudonegative” FL, in which the
lymphoma cells were negative with the classical BCL2
clone-100 DAKO antibody, but were positive with the Epi-
tomics BCL2 antibody E17. Similar to cases 127 and 258, this
profile suggests a conformational change in the BCL2 protein,
which was confirmed by the finding of mutations in the nu-
cleotides encoding the epitope recognized by the DAKO an-
tibody. These findings are well in line with previous studies on
BCL2 Clone-100 negative FL cases, in which approximately
half of the cases exhibited BCL2 expression upon staining
with the alternative antibodies E17 and SP66, attributable to
BCL2 missense mutations and BCL2 rearrangements [12, 23].
The other cases, which had an intact BCL2 gene locus, were
also negative for the E17 and SP66 antibodies and showed a
wild-type BCL2 sequence. The rarity of BCL2 gene mutations
in t(14;18) negative FL has recently been confirmed [24]. The
panel recommends application of additional BCL2 antibodies
in the work-up of suspected FL cases that are negative with
one BCL2 antibody.
CD10 and/or BCL6 negative FL: usefulness of additional
GC markers
CD10 and/or BCL6 negativity was observed in several
workshop cases, including FL with marginal zone differen-
tiation. Of note, an incomplete GC phenotype is quite often
seen in bone marrow infiltrates or in the leukemic phase of
FL that otherwise exhibits a regular GC phenotype in the
lymph node component. This condition was exemplified by
case 202 (submitted by M. Ehinger), in which an identical
BCL2 rearrangement was detected in different FL localiza-
tions that show discordant phenotypes. Although most GC
markers may be downregulated in bone marrow FL infil-
trates, more recently developed novel markers like GCET1,
human germinal center associated lymphoma (HGAL), and
LIM-only transcription factor 2 (LMO2) can be useful for
detecting FL in extranodal sites, especially cases that lack
CD10 [25, 26]. HGAL and LMO2 were positive in most
BCL6 and/or CD10 negative bona fide FL cases studied at
the workshop.
HGAL, also known as GCET2, is expressed in the cytoplasm
of normal GC B cells and in lymphomas of GC-cell derivation,
including subsets of diffuse large B cell lymphoma (DLBCL),
FL, Burkitt lymphoma and primary mediastinal large B cell lym-
phoma [27, 28]. HGAL expression is reported to be more sensi-
tive than LMO2, CD10, and BCL6 in detecting FL [27]. FL that
do not express CD10 and/or BCL6 are often positive for HGAL,
although some cases negative for HGAL can be BCL6+ [29].
Virchows Arch

Fig. 2 Diffuse and blastoid

variants of FL. Case 24 (courtesy
A B C
of R. King) was an inguinal
lymph node infiltrated by a
predominantly diffuse FL. The
subscapular architecture of the 1p36
LN, however, was partly
preserved (a). Note the lack of a
FDC network using CD21 (b).
FISH analysis showed 1p36
deletion (c) and lack of a BCL2/
IGH fusion (d). BCL2
immunostaining was negative in CD21 BCL2 D
vaguely nodular areas (e),
whereas a faint positivity was E F
observed in the diffuse areas (f).
Case 203 (courtesy of B.
Christensson) was a
predominantly diffuse, focally
vaguely nodular tumor (g)
consisting of small- to medium-
sized cells of blastoid appearance
(h) with minute areas of CD21+
FDC (i) and low mitotic activity.
GC markers including BCL6 (j),
CD10 (k), HGAL, and LMO2
were expressed. FISH analysis BCL2 BCL2
showed additional BCL2 signals
suggesting amplification, whereas G H
no BCL2 rearrangement was
found (l). This case was classified
as a diffuse FL, not gradable, with
blastoid features

I J K L

CD21 BCL6 CD10 BCL2

Notwithstanding this, recent reports have stressed that LMO2
and HGAL immunostaining must be interpreted with caution,
since the majority of B cell lymphomas can exhibit weak to
moderate staining for both markers, compared with the strong
staining in FL [27, 30]. LMO2, in particular, was reported to be
also expressed in 88 % of precursor B cell lymphoblastic
lymphoma/leukemia (B-ALL), 5 % of chronic lymphocytic
leukemia (CLL), and 14, 57, and 41 % of mantle cell, follicular,
and Burkitt lymphomas, respectively [27, 31]. The expression
of LMO2, in contrast to HGAL, is not B cell restricted since
acute and chronic myeloid leukemias are usually positive [27].
Less frequently used GC markers include Stathmin (STMN1),
which was shown to be helpful in distinguishing CD10-
negative FL from marginal zone B cell lymphoma (STMN1-
negative). However, STMN1 is not strictly GC- or FL-specific,
since it is strongly expressed also in mantle cell and Burkitt
lymphomas, and in rare T cell lymphomas [32]. GCET1 is
another promising GC marker which is positive in FL (60 %
of cases) and DLBCL (36 % of cases), but with little or no
expression in other B cell lymphomas [27, 30]. Similarly,
lectin-like transcript 1 (LLT1) was recently identified as a GC
B cell marker, which may have diagnostic utility, since it is
expressed in GC-derived B cell lymphomas, including FL,
DLBCL derived from GC cells, and Burkitt lymphoma [33].

FL with high proliferative index
A high proliferative index (PI) as demonstrated by Ki67 immu-
nostaining is a well-known feature of grade 3 FL, especially
grade 3B. The prognostic significance of a moderately high to
high PI in FL grade 1/2, however, remains controversial [34,
35]. Case 193 submitted by J. S. Sidhu (Fig. 3) and case 246
submitted by R. Kanagal-Shamana highlighted the striking dis-
crepancy that can occur in FL with typical grade 1/2
cytomorphology and high PI reaching virtually 100 % within
some follicles. For such cases, the workshop panel suggested to
retain the WHO grading, but to add a comment that FL1/2 with
high PI might pursue a more aggressive course [34]. Delinea-
tion of these cases from blastoid forms of FL is important.
Conversely, the FL tumor submitted by R. K. Pillai (case 149,
Fig. 3) had a very low Ki-67 proliferative index even though it
appeared histologically and clinically aggressive. The lympho-
ma was predominantly diffuse with medium-sized blastoid
cells, and the patient had a rapid onset of extensive adenopathy.
The panel performed additional staining using phospho-HH3
(pHH3) which was strongly positive. Since pHH3 is a marker
for cell cycle progression and is usually well correlated to Ki-
67, we cannot exclude that the Ki67 epitope has been altered in
this case due to the fixation process.
Other unusual FL phenotypes
Unusual phenotypes in FL may create diagnostic pitfalls, as
shown by the presence of CD30+ Hodgkin/Reed-Sternberg-
like cells in case 10 submitted by Y. Kim, mimicking Hodgkin
lymphoma. CD5 co-expression was demonstrated in case 44
(submitted by N. Özkaya), a grade 3B FL with tonsillar in-
volvement. In a recently published large series of CD5+ FL,
about two third of cases were grades 1 or 2, and the median
proliferation index (Ki-67) was 30 %. CD5 expression was
detected only by flow cytometry in the majority of cases, but
not by immunohistochemistry in paraffin-embedded tissues.
CD5 expression was reported to be associated with a higher
International Prognostic Index (IPI), a higher rate of transfor-
mation, and shorter progression-free survival [36].
Case 44 also showed strong IRF4/MUM1 expression, as
has been described for grade 3 FL [37, 38]. This case might
represent an example of IRF4/MUM1 positive FL pediatric-
type occurring in Waldeyer’s ring, that is dealt in detail in the
report on pediatric lymphomas (see Quintanilla-Martinez
et al.). Of note, low to moderate IRF4/MUM1 expression
was also found in several workshop cases considered as FL
grade 1/2 like case 63 submitted by M. R. Qiu, or as
ungradable FL like case 237 submitted by P. Gaulard
(Fig. 3). These IRF4/MUM1+ FL cases are clearly different
from case 44, expressed GC markers and had low Ki67 reac-
tivity. Of note, high IRF4/MUM1 reactivity in low-grade FL
was recently reported to be predictive of poor outcome [35].
Virchows Arch
FL with blastoid features
The descriptive term “blastoid” refers to cytological features
reminiscent of precursor cells, that is, medium-sized tumor
cells with finely distributed chromatin, and occasional pres-
ence of small nucleoli. This term was initially used for aggres-
sive, in part transformed, FL variants with a follicular or dif-
fuse growth pattern, with or without t(14;18), and trisomy 18
in some cases [39, 40].
In contrast to the cases described in the literature, cases 149
(submitted by R. K. Pillai) and 237 (submitted by P. Gaulard)
were FL with blastoid features that had a partly or minimally
follicular growth pattern, low mitotic count, and low PI and
GC marker expression (Fig. 3). Case 149 had a typical BCL2
rearrangement, whereas a gain of chromosome 18 was the
only cytogenetic abnormality identified in case 237, in line
with initially reported cases [39]. It appears from these work-
shop cases and those in the literature that a reproducible def-
inition of blastoid features is not easy to give, since cell sizes
can vary from small to medium, and the degree of chromatin
immaturity is also variable.
Thus, the panel considered it not possible to reproducibly
define a category of a “blastoid” FL variant. The term “FL not-
gradable, with blastoid features” was recommended. Of note,
blastoid features cannot be considered a reliable sign of clin-
ical aggressiveness per se, since clinical follow-up of larger
case cohorts is not available.
FL with monocytoid features and/or marginal zone
differentiation
FLs are tumors that grow maintaining the microenvironment
of the GC compartment. In some cases, downregulation of
GC markers is observed when tumor cells spread to the
interfollicular compartment indicating that these cells have
a preserved propensity to mature. More pronounced ongoing
lymphocyte development, however, can be seen in some
cases such as in FL with marginal zone differentiation
(MZD), in which post-follicular maturation of the neoplastic
cells seems to occur in a way at least reminiscent of normal
GC cells. In this context, the occurrence of sheets of
monocytoid or marginal zone cells outside of and/or around
the periphery of follicles points to memory cell (or marginal
zone) differentiation of the tumor cells [41]. Plasmacytoid
differentiation in FL (see Swerdlow et al. Virchows Arch
2015 in press) may be one end of the spectrum of post-
follicular maturation [42]. Several workshop cases displayed
these features, such as cases 123 (submitted by M. B.
Alikhan), 163 (submitted by A. Aline-Fardin), and 110 (sub-
mitted by Y. Kim). These tumors showed frequent downreg-
ulation of CD10 and/or BCL6, especially outside the follicles
whereas LMO2 and HGAL expression was mostly preserved
Virchows Arch

Fig. 3 FL with unusual

phenotypes Case 193 (courtesy of A B C D
J.S. Sidhu) featured follicles with
a starry-sky pattern (a).
Cytological analysis showed
small cleaved cells only (b)
contrasting with a high mitotic
activity and an exceptionally high
proliferative index (c). GC
markers including HGAL (d)
were positive. The diagnosis of
FL 1/2 with high proliferative
index was rendered. Case 149 Ki67 HGAL
(courtesy of R. K. Pillai) was a
predominantly diffuse tumor E F G
composed of medium-sized
blastoid cells (e). Although the PI
was lower than 10 % (f), the
strong positivity of phospho-HH3
(g) suggested cell cycle
dysregulation. Case 237 (courtesy
of P. Gaulard) displayed a vaguely
nodular architecture (h), blastoid
cytological features (i), and an
unusually strong reactivity for Ki67 pHH3
IRF4/MUM1 (j). The
proliferative index (PI) was low H I
(k). FISH analysis suggested a
BCL2/18q21 amplification due to
extra-signals without BCL2
rearrangement (l). This case was
classified as FL, t(14;18)
negative, not gradable with
blastoid features, but low PI

J K L

MUM1 Ki67 BCL2/18q21

in both follicular and monocytoid components, as observed in
case 110 (Fig. 4). In this latter case, the marginal zone differ-
entiation (MZD) resulted in perifollicular sheets of clear cells,
a striking accumulation of subcapsular monocytoid cells, and
decreased intrafollicular CD10 expression (Fig. 4). Of note, in
case 216 (submitted by X. Zhang), a CD10-/BCL6+/LMO2+/
HGAL+ typical FL component was associated with a CD10-/
BCL6-/LMO2-/HGAL- monocytoid component (Fig. 4). This
latter case probably represents an example of particularly
marked MZD leading to a complete loss of GC markers.
The diagnosis was based on the demonstration of a BCL2
breakpoint in both tumor components. A clonal relationship
within the same sample between typical FL cells and
those showing marginal zone differentiation has similarly
been documented in the literature, and provides the basis
to exclude composite lymphoma. Interestingly, there is an
increase of cytogenetic abnormalities usually associated
with marginal zone lymphomas, particularly +3 or +3q,
in FL cases with MZD [43]. This was demonstrated in
case 192 submitted by P. Kluin, which showed MZD
and a cytogenetic profile including BCL6 rearrangement,
trisomy 3, and lack of BCL2 translocation. The BCL6+/
HGAL+/CD10dim+phenotype of this case favored the di-
agnosis of FL.