Lymphomes Diffus à Grandes Cellules B Classification Des .

Lymphomes diffus à grandes cellules BClassification des différentes entitésT. J. Molina

Diffuse large B cell lymphomasDefinitionLymphomas defined by a neoplasm of large lymphoidB-cells with nuclear size equal to or exceeding normalmacrophage nuclei or more than twice the size of anormal lymphocyteThat has a diffuse growth pattern

Immunophénotype Les cellules tumorales expriment :– CD20, CD79a, mais peuvent perdre certainsmarqueurs– immunoglobuline intracytoplasmique quand il y a unedifférenciation plasmocytaire– CD30 dans les variantes anaplasiques et dans quelquesformes non anaplasiques– CD10 (25-50%), CD5 (10%)– Ki67; habituellement plus de 40%

WHO 2008 Classification of DLBCLMorphological, biological and clinical studieshave subdivided DLBCL into Morphological variants Molecular and immunophenotypicalsubgroups Subtypes Distinct disease entities

Diffuse large B-cell lymphoma subtypesT-cell rich large B-cell lymphomaPrimary DLBCL of the CNSPrimary cutaneous DLBCL, leg typeEBV positive DLBCL of the elderlyOther lymphomas of large B-cellsPrimary mediastinal (thymic) large B-cell lymphomaIntravascular large B-cell lymphomaDLBCL associated with chronic inflammation (EBV)Lymphomatoid granulomatosis (EBV)ALK positive DLBCL (ALK)Plasmablastic lymphoma (EBV)Large B-cell lymphoma arising in HHV-8 associatedmulticentric Castleman disease (HHV8)Primary Effusion lymphoma (HHV8, EBV)

Diffuse Large B-cell lymphomas, not otherwise specified (NOS)Common morphological variantsCentroblasticImmunoblasticAnaplasticRare morphological variantsMolecular subgroupsGerminal centre B-cell like (GC-B)Activated B-cell like (ABC)Immunohistochemical subgroupsCD5 DLBCLGerminal Centre B-cell like (GCB)Non Germinal centre B-cell like (non-GCB)

Importance of assessing if this lymphoma arises denovo or is developing fromB-CLL (Richter Syndrome )Follicular lymphomaMarginal zone lymphomaNLPHL (Nodular LymphocytePredominance Hodgkin lymphoma)Crucial role of the size of the sample

OTHER DIFFICULT DIFFERENTIAL DIAGNOSESMantle cell lymphoma , aggressive , pleomorphic subtypeCyclin D1 DLBCL do existCD5 DLBCL is a phenotypical subtypeIs this a transformed small B-cell lymphoma?Follicular LymphomaMarginal zone lymphoma

Centroblastic

Centroblastic multilobated

Immunoblastic

Anaplastic

Plasmablastic

DLBCL NOS , Molecular subgroups GC like DLBCL Activated like DLBCL Other (According to Wright/type III).

Cell of OriginsignatureAlizadeh et al, 2000

Lenz , NEJM, 2008Molecular subgroups defined by GEP or QRTPCR impacts on survivalIndepedently from IPI among R-CHOP treated DLBCL patients

Classification OMS des DLBCL NOS Immunohistochemical subgroups– Germinal center B-cell (GC-B)– Non germinal center B-cell (n-GCB)– CD5 positive DLBCLLymphome à grandes cellules B dumédiastin à part (entité)

C Hans et al, Blood 2004

PN Meyer, 2011

GC/nGC according to Hans’algorithmis not reproducibly prognostic inDLBCL treated by R-CHOP Nyman 2007,Saito 2007,Copie-Bergman 2009,Ott G 2010,Gutierrez Garcia 2011,Salles G, 2011

Prognostic forMeyer N, JCO, 2011Not prognostic forGuttierez Garcia,Blood 2011

Autres algorithmes Combiner FISH IHC : Immunofish, Copie-Bergman, 2009– Mum-1 (30%), foxp1 (0 vs P), FISH bcl6 : 2 parmi trois marqueurspositifs

ImmunoFISH négatifImmunoFISH positifCopie-Bergman et al, JCO, 2009Multivariate analysisIPI :p 0.04nGC score : p 0.04

Ces biomarqueurs peuvent ils êtreprédictifs? Identifier la population cible, la plus susceptiblede répondre Guide parmi les options thérapeutiques– C Thieblemont : BioCoral– O3-2B: RACVBP vs RCHOP

Primary Mediastinal Large B-celllymphoma (PMLBCL) Variant of DLBCL derived from a putativethymic B-cell (asteroid variant of thymicmedullary B cell)

LM A GRANDES CELLULES B PRIMITIF DU MEDIASTIN ( THYMIQUE )- Clinique Adulte jeune, F H Tumeur médiastinale antérieure- Histopathologie LM diffus Grandes cellules /- cytoplasme clair Cbl, Ibl, parfois de type RS Sclérose Lymphocytes réactionnels ,histiocytes,plasmocytes, éosinophiles-Cellule d’origineCellule B intrathymique

Thymus IFCD79a / MALCopie Bergman, 2002 No expression of immunoglobulins but expressionof pu-1, bob2, oct 1 Activation of NF-κB with nuclear expression ofc-rel Functional rearrangement of IgH withoutintraclonal variation. No rearrangement of bcl-2 and rare bcl-6rearrangement

The gene expression signature of PrimaryMediastinal B Cell LymphomaA Rosenwald et al. J Exp Med, 2003

RosenwaldJEM, 2003

Mutations of SOCS1 in classicalHodgkin lymphoma are frequent(Wenger et al, Oncogene, 2006)8/19 HL patients and 3/5 cell linesA20 is a tumor suppressor gene in CHLAnd PMBL.(Schmitz R, J Exp Med, 2009)A20 which negatively regulates NF-KB ismutated in 40% of PMBL and CHL;in CHL, mostly in EBV negative cases.Georg Lenz, M.D., and Louis M. Staudt,.N Engl J Med 2010; 362:1417-1429

MHC Cl II transactivator CIITA is rearranged in38% PMBL and 15%CHLSTEIDL C , Nature, 2011 Translocation partner : in PMBL, half of the casesPDL1, PDL2 with overexpression anddownregulation of MHC cl II. CIITA rearrangement in 4%DLBCL (11% testis)and in 15% NLPHL.

T-cell Histiocyte Rich large B-cell lymphoma- Histopathology difuse infiltration large B-cellsLimited numbers ( 10% cells)Scattered cellsNo sheetsCb, Ibl, anaplastic,rare RS-like cells Numerous reactive cellsT lymphocyteshistiocytes

T-cell/ histiocyte rich large B-cell lymphomas- Immunophenotype tumor cellsCD20 , EMA /CD15-, CD30-, LMP1 Reactive cellsCD3 Low number of PD1 No FDC network- diagnostic différentiel CHL NLPHL T cell lymphomaCD20

Immunohistochemical study CD20 CD30 :2/46EMA: 34/38CD15 : 0/38few CD57 cells

Specific Clinical Characteristics of Patients With T-Cell/HistiocyteRich Large B-Cell LymphomaTCRBCL(n 50)DLBCL(n 150)pSex, male/female, n44/682/68 21.20Pelvis3816.002Spleen6017 .0001Bone marrow3126.50Liver3311.001Gastrointestinal tract010.005Bone412.01

Bouabdallah et al, J Clin Oncol 2006; Anthracyclin based therapyWithout rituximab

Microenvironment and DLBCL HU 133A et U 133 B, 33 000 gènes 176 patients (série de validation : 221) Unsupervised clustering (three profiles highlyreproducible)– oxydative Phosphorylation– BCR proliferation cluster– Host immune response No prognostic vaueMonti, Blood, 2004

Gamma interferonInduced lysosomalthiolreductaseFewCD1a orCD123;

LM B PRIMITIF DES SEREUSES- Définition Lymphome se développantessentiellement dans lescavités des séreuses: pleuralepéricardiqueabdominale En l’absence habituelle de massetumorale extension 2d d’un LM à grandescellules B- Clinique Epanchement pleural sans tumeursolideHIV , EBV , HHV8

Immunophénotype Absence d ’expression de CD19, CD20, CD79a,cIg expression de CD45 expression aberrante de CD3 protéine latente HHV8, EBER1 , LMP1-

LM A GRANDES CELLULES B INTRAVASCULAIRE- CliniqueAdulteLésions cutanéesSymptomes neurologiquesHépatosplénomégaliePancytopénie, CIVD- Histopathologie Grandes cellules (Cb, Ib, anaplasiques) Dans les petits vaisseauxsinus (moelle osseuse, rate)sinusoïdes (foie)capillaires (peau, cerveau, poumon) Histiocytes avec Erythrophagocytose- ImmunophénotypePan B CD20

Lymphome B de type granulomatoselymphomatoïde– Lésion lymphoproliférative angiocentrique etangiodestructrice, extranodale, comportant descellules lymphoïdes B de grande tailleassociées à l ’EBV et des lymphocytes T le plussouvent nombreux» grade histologique (I, II, III) selon laproportion de grandes cellulesB.» Le Grade III est considéré comme unevariante de lymphome diffus à grandescellules B– Evolution en 2 à 5 ans du grade I au grade III.L ’Alpha-interferon pourrait contrôler lesgrades I et II.

– Masses pulmonaires nécrotiques Nombreux lymphocytes T réactionnels ,histiocytes et polynucléaires neutrophiles Vasculite lymphocytaire et nécrose fibrinoïde grandes cellules lymphoïdes B EBV demorphologie centroblastique ou immunoblastique– dispersées ou de topographie périvasculaires, infiltrantla paroi des vaisseaux, réalisant un aspectangiocentrique– Autres localisations : cerveau (26%), rein(32%), foie (29%),peau (25-50%)

LMP1CD20MIB1EBER

Other subtypes/entities Primary DLBCL of the CNS– Intracerebral and/or intraocular,mum-1 Primary cutaneous DLBCL, leg type– N-GC phenotype, female 7th decade EBV positive DLBCL of the elderly– More than 50 year-old, noimmunodeficiency, mum1 , polymorphicsubtype DLBCL associated with chronic inflammation (EBV)– Pyothorax associated lymphoma, osteomyelite chronic– More than 10 years inflammation– CD20, CD79a often positive, CD138 /-, T- cell markers

Other subtypes/entities ALK Positive DLBCL– Lymph nodes, Immunoblast with plasma celldifferentiation, CD138, EMA, IgA, CD20 neg, CD79aneg, CD45 neg,mum1 . Plasmablatic lymphoma– Oral cavity ,other extranodal sites, HIVpositive, CD138,CD30, EMA, EBER, IgG Large B-cell lymphoma arising in HHV-8 associatedmulticentric Castleman disease (HHV8)– IgM plasmablast EBER neg IgM lambda present in mantle zone areasat the beginning

Borderline casesB-cell lymphoma, unclassifiable, with featuresintermediate between DLBCL and Burkitt lymphomaB-cell lymphoma, unclassifiable, with featuresintermediate between DLBCL (PMBL) and classicalHodgkin lymphoma

LYMPHOME DE BURKITTsous-types, cliniques et génétiques- EndémiqueAfrique et autres régions tropicalesEnfant , Mâchoire Association à EBV: 90%Rôle de la malaria- SporadiqueLocalisation intraabdominale Ganglion, plus fréquent chez l’adulteAssociation à EBV: 20%- Associé à une immunodéficienceLa plupart HIV Souvent ganglionnaireAssociation à EBV: 40%EBER

LYMPHOME DE BURKITT- Histopathologie Infiltration diffuse Aspect de ciel étoilé Cellules cohésives Cellules de taille moyenne Fine couronne cytoplasmiquebasophile avec des vacuoleslipidiques Noyau rond, /- irrégulier Chromatine en mottes Multiples (2-5) nucléolescentraux, de taille moyenne Nombreuses mitoses

LYMPHOME DE BURKITT- ImmunophénotypePan B , sIgM ,bcl-6 CD10CD10 , bcl2- , Ki67 90%CD5-, CD23-, TdT-- Biologie moléculaire t(8;14)(q24;32) et variantes réarrangement de c-mycMib-1

BURKITT LYMPHOMACD10Mib-1

CD10MIB1BCL2Sporadic Burkitt, Child, EBV -

BCL2MIB1Diffuse Large B-cell Lymphoma or Intermediate BL/DLBCL?

Recommandation WHO Look for myc rearrangement Look for double hit lymphoma ((bcl2/myc,bcl6/myc, bcl2/bcl6/myc). Double hit particularly myc/bcl2 have a worseprognosis compared to paired DLBCL– May qualify for intermediate features between BL andDLBCL

Controversy Intermediate Molecular Burkitt have been definedby GEP and correlated with genome complexity.(Hummel, NEJM, 2006) Not by atypical morphology and /or phenotype asin WHO– might increase according to the WHO numbers ofintermediate features– Therefore, lack of consensus criteria to define thosecases that might benefit from alternative therapy thanclassical DLBCL.

Hummel, NEJM, 2006

Borderline casesB-cell lymphoma, unclassifiable, with featuresintermediate between DLBCL and Burkitt lymphomaB-cell lymphoma, unclassifiable, with featuresintermediate between DLBCL (PMBL) and classicalHodgkin lymphoma

B-cell lymphoma, unclassifiable, withfeatures intermediate between ClassicalHodgkin Lymphoma (CHL) and Diffuselarge B- cell Lymphoma (DLBCL). Composite or Sequential– Both entities within the same patient at the same time (C)– To differentiate from metachronously occurrence of NSHL andPMBCL (S) Intermediate features– between CHL and PMBL

Intermediate Features areExceptional !!Most often PMBL or CHLOr other diagnosis .In big centers specialised inHematopathology includingLocal cases and consult casesMax : 1-2 cases per year.

CD20CD3

CD30

EMACD7ALK 1TiA1

TTake Home Message Except PMLBL, entities of DLBCL are rare A CD5 agressive B cell lymphoma :exclude MMantle cell lymphoma aggressive variantbefore assessing CD5 DLBCL DLBCL are not rarely transformed FISH is important in addition toimmunohistochemistry, specially Myctranslocation– Burkitt/ Double hit lymphoma

Department of Pathology

Lymphome B de type granulomatose lymphomatoïde – Lésion lymphoproliférative angiocentrique et angiodestructrice , extranodale, comportant des cellules lymphoïdes B de grande taille associées à l ’EBV et des lymphocytes T le plus souvent nombreux »grade histologique (I, II, III) selon la proportion de grandes cellulesB.