A Practical Approach to the

Diagnosis of B-Cell Lymphomas

Robert (Bob) Ohgami, MD, PhD
Professor of Pathology
Chief Medical Director for Research and Development, IOG
University of Utah and ARUP Laboratories

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 Outline
• Introduction
• Body
• Didactic and case review of B-cell lymphomas
• Key features and important studies
• Nuances
• Conclusion
• Summary
• Future for B-cell lymphomas

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 A brief history of lymphoma classification
• 1860s: Virchow and Cohnheim: lymphosarcoma
Clinical
Morphology • 1920s: Oberling1950s:
and BrillDNA
anddiscovered;
Symmers: Humans
“reticulum
havecell
46 sarcoma” and giant follicular lymphoma.
chromosomes
• 1950s and 1960s: 1960s: 1 colorWinter,
Rappaport, flow cytometry; simpleon
Hicks,: based IHCarchitectural organization and cell size.
• 1974: Lukes and Collins’ classifications: B or T, site of origin, cell size, and nuclear shape
1970s: Sanger sequencing; Q&C and G banding
Clinical • 1974: Kiel classification: Improved
tumour grade; centrocytic, centroblastic and immunoblastic
IHC; Immuno-EM
Morphology
Immunophenotype • 1974: British National Lymphoma Investigation (BNLI) classification
• 1978: NCI working formulation: low- and high-grade groups, an intermediate grade.
• 1994: Stein and1980s:
Isaacson:4 Revised
color flowEuropean-American
cytometry; PCR; interphase FISH (REAL) classification
Lymphoma
1990s: 8 color flow cytometry; CGH
Clinical
Morphology
• 2001: World Health Organization classifications of haematopoietic and lymphoid tissue tumours
Immunophenotype
Genetics
• 2008: World Health Organization
2000s: classifications
Mass cytometry; of haematopoietic
Human genome and lymphoid
sequenced; Roche 454 tissue tumours
• 2010s:
2017: World Health Imaging mass
Organization cytometry; 30+
classifications color flow cytometry,
of haematopoietic Nanopore, tissue
and lymphoid Pacbio tumours
“single
Clinical
• molecularclassifications
2022: World Health Organization real-time” sequencer
of haematopoietic and lymphoid tissue tumours
Morphology
Immunophenotype
Genetics • 2022: ICC 2020s: Artificial Intelligence and machine learning

Greater importance of Genetics

and molecular phenotyping
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Norton AJ. Classification of non-Hodgkin’s lymphomas. Ballieres Clin Haematol. 1996;9:641–52. doi: 10.1016/s0950-3536(96)80046-1. [PubMed] [CrossRef] [Google Scholar] 5. van Besien K, Schouten H. Follicular lymphoma: A historical review. Leuk Lymphoma. 2007;48:232–43. doi: 10.1080/10428190601059746. [PubMed] [CrossRef] [Google Scholar]
Lukes RJ, Collins RD. A functional approach to the classification of malignant lymphoma. Recent Results Cancer Res. 1974;46:18–30. doi: 10.1007/978-3-642-80829-6_4. [CrossRef] [Google Scholar] 8. Lukes RJ, Collins RD. Immunologic characterization of human malignant lymphomas. Cancer. 1974;34:1488–503. doi: 10.1002/1097-0142(197410)34:8+<1488::AID-CNCR2820340822>3.0.CO;2-
Updated Kiel classification for lymphomas.Stansfeld AG, Diebold J, Noel H, Kapanci Y, Rilke F, Kelényi G, Sundstrom C, Lennert K, van Unnik JA, Mioduszewska O Lancet. 1988 Feb 6; 1(8580):292-3.
Bennett MH, Farrer-Brown G, Henry K, Jaliffe AM, Gerard-Marchant R, Hamlin I, et al. Classification of non-Hodgkin’s lymphomas. Lancet. 1974:405–6. doi: 10.1016/S0140-6736(74)91786-3.
National Cancer Institute sponsored study of classifications of non-Hodgkin’s lymphomas: Summary and description of a working formulation for clinical usage - The Non-Hodgkin’s Lymphoma Pathologic Classification Project. Cancer. 1982;49:2112–35.
 What information is necessary to diagnose a B-
cell lymphoma?

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 Information
• Clinical: Age, Gender, Sequelae
• Anatomic: Sites of involvement
• Laboratory data: CBC, LDH, Chem
• Radiology: PET, CT, MRI
• Histomorphology: Architecture of tissue, Neoplastic cell features, Inflammatory
response
• Immunophenotype: Flow cytometry, IPOX
• Cytogenetics: Karyotype
• FISH: MYC, BCL2
• Molecular: Next generation sequencing, Single gene PCR testing

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 Broad Pathology Classification of Mature B-cell lymphomas
• Nodal • Extranodal
• Diffuse large B-cell lymphoma, NOS • Extranodal MZL of MALT

• Nodal marginal zone lymphoma • Lymphomatoid granulomatosis

• Mantle cell lymphoma • Plasmablastic lymphoma

• Follicular lymphoma • Burkitt lymphoma

• High grade B-cell lymphomas • Duodenal type FL

• Nodular lymphocyte predominant HL/BCL • EBV+ MCU

• T-cell histiocyte rich LBCL

• Splenic
• SLL
• Hairy cell leukemia
• ALK+ LBCL
• Splenic MZL
• KSHV/HHV8 Multicentric CD
• Splenic diffuse red pulp small B-cell lymphoma
• EBV+ LBCL
• HCL-V/ Splenic B-cell lymphoma/leukemia with prominent nucleoli
• Primary Mediastinal LBCL
• Mediastinal Grey Zone Lymphoma • Leukemic
• HHV8+ germinotropic LPD • Mononclonal B-cell lymphocytosis

• PTLD/ Lymphoid proliferations/lymphomas associated with immune deficiency and dysregulation • CLL

• Large B-cell lymphoma with IRF4 rearrangement • Leukemic non-nodal MCL

• DLBCL/HGBCL with MYC and BCL2 gene rearrangements • Lymphoplasmacytic lymphoma

• HGBCL, NOS • Other

• HHV8+ DLBCL • Fibrin associated LBCL
• Intravascular LBCL
• Cutaneous • DLBCL associated with chronic inflammation
• Cutaneous MZL • Primary effusion lymphoma
• Primary cutaneous LBCL, leg type • Fluid overload-associated large B-cell lymphoma/HHV8andEBV negative PEL
• Primary cutaneous FL

LBCL = large B-cell lymphoma; CLL = chronic lymphocytic leukemia; SLL = small lymphocytic lymphoma; MZL = marginal zone lymphoma; HGBCL = high grade B-cell lymphoma
MALT = mucosa associated lymphoid tissue; HL = Hodgkin lymphoma; LPD = lymphoproliferative disorder; CD = Castleman disease; MCU = mucocutaneous ulcer
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 We cannot cover all

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 Broad Pathology Classification of Mature B-cell lymphomas
• Nodal • Extranodal
• Diffuse large B-cell lymphoma, NOS • Extranodal MZL of MALT

• Nodal marginal zone lymphoma • Lymphomatoid granulomatosis

• Mantle cell lymphoma • Plasmablastic lymphoma

• Follicular lymphoma • Burkitt lymphoma

• High grade B-cell lymphomas • Duodenal type FL

• Nodular lymphocyte predominant HL/BCL • EBV+ MCU

• T-cell histiocyte rich LBCL

• Splenic
• SLL
• Hairy cell leukemia
• ALK+ LBCL
• Splenic MZL
• KSHV/HHV8 Multicentric CD
• Splenic diffuse red pulp small B-cell lymphoma
• EBV+ LBCL
• HCL-V/ Splenic B-cell lymphoma/leukemia with prominent nucleoli
• Primary Mediastinal LBCL
• Mediastinal Grey Zone Lymphoma • Leukemic
• HHV8+ germinotropic LPD • Mononclonal B-cell lymphocytosis

• PTLD/ Lymphoid proliferations/lymphomas associated with immune deficiency and dysregulation • CLL

• Large B-cell lymphoma with IRF4 rearrangement • Leukemic non-nodal MCL

• DLBCL/HGBCL with MYC and BCL2 gene rearrangements • Lymphoplasmacytic lymphoma

• HGBCL, NOS • Other

• HHV8+ DLBCL • Fibrin associated LBCL
• Intravascular LBCL
• Cutaneous • DLBCL associated with chronic inflammation
• Cutaneous MZL • Primary effusion lymphoma
• Primary cutaneous LBCL, leg type • Fluid overload-associated large B-cell lymphoma/HHV8andEBV negative PEL
• Primary cutaneous FL

LBCL = large B-cell lymphoma; CLL = chronic lymphocytic leukemia; SLL = small lymphocytic lymphoma; MZL = marginal zone lymphoma; HGBCL = high grade B-cell lymphoma
MALT = mucosa associated lymphoid tissue; HL = Hodgkin lymphoma; LPD = lymphoproliferative disorder; CD = Castleman disease; MCU = mucocutaneous ulcer
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 We will create a foundational framework for diagnoses

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 So let’s get started!

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 Broad Pathology Classification of Mature B-cell lymphomas
• Nodal • Extranodal
• Diffuse large B-cell lymphoma, NOS • Extranodal MZL of MALT

• Nodal marginal zone lymphoma • Lymphomatoid granulomatosis

• Mantle cell lymphoma • Plasmablastic lymphoma

• Follicular lymphoma • Burkitt lymphoma

• High grade B-cell lymphomas • Duodenal type FL

• Nodular lymphocyte predominant HL/BCL • EBV+ MCU

• T-cell histiocyte rich LBCL

• Splenic
• SLL
• Hairy cell leukemia
• ALK+ LBCL
• Splenic MZL
• KSHV/HHV8 Multicentric CD
• Splenic diffuse red pulp small B-cell lymphoma
• EBV+ LBCL
• HCL-V/ Splenic B-cell lymphoma/leukemia with prominent nucleoli
• Primary Mediastinal LBCL
• Mediastinal Grey Zone Lymphoma • Leukemic
• HHV8+ germinotropic LPD • Mononclonal B-cell lymphocytosis

• PTLD/ Lymphoid proliferations/lymphomas associated with immune deficiency and dysregulation • CLL

• Large B-cell lymphoma with IRF4 rearrangement • Leukemic non-nodal MCL

• DLBCL/HGBCL with MYC and BCL2 gene rearrangements • Lymphoplasmacytic lymphoma

• HGBCL, NOS • Other

• HHV8+ DLBCL • Fibrin associated LBCL
• Intravascular LBCL
• Cutaneous • DLBCL associated with chronic inflammation
• Cutaneous MZL • Primary effusion lymphoma
• Primary cutaneous LBCL, leg type • Fluid overload-associated large B-cell lymphoma/HHV8andEBV negative PEL
• Primary cutaneous FL

LBCL = large B-cell lymphoma; CLL = chronic lymphocytic leukemia; SLL = small lymphocytic lymphoma; MZL = marginal zone lymphoma; HGBCL = high grade B-cell lymphoma
MALT = mucosa associated lymphoid tissue; HL = Hodgkin lymphoma; LPD = lymphoproliferative disorder; CD = Castleman disease; MCU = mucocutaneous ulcer
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 How can we handle this?
• We need a starting point
• Anatomic
• Clinical features
• Immunophenotype
• Cell size

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 Cell size
• Small-medium sized B-cell lymphomas
• Large in cell size B-cell lymphomas

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 Small-medium sized B-cell lymphomas
• Follicular lymphomas (FL)
• Marginal zone lymphomas (MZL)
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Mantle cell lymphoma (MCL)

There are subtypes and nuances to these groups

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 Follicular Lymphoma
• In situ follicular neoplasm/neoplasia
• Duodenal type follicular lymphoma
• Primary cutaneous follicle center lymphoma
• Pediatric-type follicular lymphoma
• Testicular follicular lymphoma

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 Marginal zone lymphoma
• Extranodal marginal zone lymphoma of mucosa-associated lymphoid
tissue (MALT lymphoma)
• Primary cutaneous marginal zone lymphoma/LPD
• Nodal marginal zone lymphoma
• Pediatric marginal zone lymphoma
• Splenic marginal zone lymphoma

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 Mantle cell lymphoma
• In situ mantle cell neoplasm/neoplasia
• Mantle cell lymphoma
• Leukemic non-nodal mantle cell lymphoma

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 Covering each of these
• Not too difficult
• We can use decision trees to help us

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 Small-medium cell size B-cell lymphoma

CD5+ CD5-

CyclinD1+/SOX11+ CyclinD1-/SOX11-; LEF1+ CD10+/BCL6+ CD10-/BCL6-

Mantle cell lymphoma Chronic lymphocytic leukemia/ Follicular lymphoma Marginal zone lymphoma
Small cell lymphoma
In situ mantle cell neoplasm/neoplasia In situ follicular neoplasm/neoplasia MALT lymphoma
Mantle cell lymphoma Duodenal type follicular lymphoma Primary cutaneous marginal zone lymphoma
(Monclonal B-cell lymphocytosis)
Leukemic non-nodal mantle cell lymphoma Primary cutaneous follicle center lymphoma Nodal marginal zone lymphoma
Pediatric-type follicular lymphoma Pediatric marginal zone lymphoma
Testicular follicular lymphoma Splenic marginal zone lymphoma

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 Let’s look at clinical cases to shape this talk

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 Case 1
• 70 year old
• Some bloating and intestinal discomfort
• GI biopsies performed

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 In particular a.. .duodenal biopsy

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 H&E H&E CD20

BCL2 BCL6 CD5

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 What is this?

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 Small-medium cell size B-cell lymphoma

X
CD5+ CD5-

CyclinD1+/SOX11+

Mantle cell lymphoma

CyclinD1-/SOX11-; LEF1+
Chronic lymphocytic leukemia/
Small cell lymphoma
CD10+/BCL6+

Follicular lymphoma
X
CD10-/BCL6-

Extranodal
Marginal zone lymphoma

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 But there is more to this…
• The lesion is in the duodenum…
• No other lymphadenopathy
• This is a “special” follicular lymphoma…
• In the duodenum…

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 Diagnosis?

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 Duodenal-type follicular lymphoma

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 Duodenal-type follicular lymphoma
• Typically adults
• Classically localized to the small intestine (multiple localized polyps
may be seen)
• Excellent prognosis (indolent)
• Aggressive features (i.e. extensive infiltration into the muscularis
propria or grade 3) are not those of d-FL
• CD20+/CD10+/BCL6+ and BCL2+
• Most cases show BCL2 and/or BCL6 translocation

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 “Types” of follicular lymphoma
• Classic/”Adult-type”/”Usual-type” follicular lymphoma
• Pediatric-type follicular lymphoma
• Duodenal-type follicular lymphoma
• Primary cutaneous follicle center lymphoma
• Large B-cell lymphoma with IRF4 rearrangement

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 “Classic” follicular lymphoma
• In adults
• CD20+/CD10+/BCL6+ and BCL2+
• This is a systemic lymphoma
• WHO-HAEM5 does not require grading
• ICC
• Grade 1, 2, 3A, 3B
• Depends on numbers of centroblasts

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Follicular large B-cell lymphoma/ Follicular lymphoma grade 3B
WHO-HAEM5 ICC

• Sheets of large B-cells in a follicular pattern

• Usually no BCL2 translocation
• Molecularly and immunophenotypically distinct from follicular
lymphoma
• Sometimes MYC translocation seen
• Often CD10 negative and MUM1 protein positive

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 Pediatric-type follicular lymphoma
• In children and young adults
• Localized lymphoma (one site/lymph node involved) usually neck
region
• CD20+/CD10+/BCL6+ and BCL2 protein negative or very dim
• NO BCL2 or BCL6 gene translocation
• Somatic mutations in IRF8 and MAPK pathway

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 Primary cutaneous follicle center lymphoma
• Usually adults
• In the skin
• CD10+/CD20+/BCL6+ usually BCL2 protein negative or dim
• More indolent

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 Large B-cell lymphoma with IRF4
rearrangement
• Kids and younger adults
• Presents at low stage
• Often head and neck region (Waldeyer ring)
• CD20+, CD10+/-, MUM1/IRF4+, BCL6+ protein
• Looks like large B-cell lymphoma or high grade follicular lymphoma
• 100% of cases with IRF4 translocation

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 Case 2:
• 67 year old with a history of some lymphoma
• Increasing lymphadenopathy resistant to ibrutinib

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 CD20 CD5 Ki67

LEF1

SOX11 and CyclinD1 negative

CD20 CD5 Ki67

LEF1

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 Small-medium size B-cell lymphoma

CD5+
X
CD5-

CyclinD1+/SOX11+ CyclinD1-/SOX11-; LEF1+ CD10+/BCL6+ CD10-/BCL6-

Mantle cell lymphoma Chronic lymphocytic leukemia/ Follicular lymphoma Extranodal

Small cell lymphoma Marginal zone lymphoma

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 What is the diagnosis?
• CLL/SLL
• With enlarged proliferation centers
• And DLBCL

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 What is the significance of enlarged
proliferation centers?
• Accelerated form of CLL/SLL

Giné E, et al., Expanded and highly active proliferation centers identify a histological subtype of chronic lymphocytic leukemia
("accelerated" chronic lymphocytic leukemia) with aggressive clinical behavior. Haematologica. 2010 Sep;95(9):1526-33.
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 Why isn’t this B-prolymphocytic leukemia?

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 What about B-cell prolymphocytic leukemia (B-PLL)?
• ICC still has B-PLL as entity
• No history of CLL/SLL
• No hairy cell projections
• No sinusoidal infiltration
• Complex karyotype (affecting TP53 and MYC)
• WHO-HAEM5 deletes B-PLL as most cases in the past were actually:
• Leukemic mantle cell lymphoma
• Prolymphocytic progression of CLL/SLL (>15% prolymphocytes)
• Splenic B-cell lymphoma with prominent nucleoli
• Hairy cell leukemia variant
• (would include cases of ”B-PLL” by ICC)

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 Chronic lymphocytic leukemia/small
lymphocytic lymphoma
• Immunophenotype: CD19, CD20, CD5, CD23
• Molecular: IGHV and TP53; NOTCH1, SF3B1, BIRC3
• Cytogenetics: Complex karyotype
• WHO-HAEM5 has Prolymphocytic progression of CLL/SLL (>15%
prolymphocytes in BM or PB)
• Accelerated CLL
• Richter’s transformation
• Richter-like transformation (after Ibrutinub interruption)
• Just re-start Ibrutinib and large cells go away

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 Case 3
• 63 year old male
• Complains of some mild indigestion
• Stomach biopsy performed

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H&E H&E CD20

CD3 CD5 CD10

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 What is this?

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 One way to approach the diagnosis…

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 Use algorithms

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 Low grade or small-medium size B-cell lymphoma

X
CD5+ CD5-

CyclinD1+/SOX11+

Mantle cell lymphoma

CyclinD1-/SOX11-; LEF1+
Chronic lymphocytic leukemia/
Small cell lymphoma
X
CD10+/BCL6+

Follicular lymphoma
CD10-/BCL6-

Marginal zone lymphoma

Extranodal MZL
Primary cutaneous marginal zone lymphoma
Anatomic site: Stomach Nodal marginal zone lymphoma
Pediatric marginal zone lymphoma
Splenic marginal zone lymphoma

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 Extranodal marginal zone lymphoma

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 Extranodal marginal zone lymphoma (ENMZL)
• In stomach Helicobacter Pylori infections (30-90% of cases)
• ENMZL show monocytoid appearance, with cleared cytoplasm, and
lymphoepithelial lesions (destructive invasion of B-cells into glands)
• Some cases have amyloid deposition; this is not primary amyloidosis
• The immunophenotype is CD20 positive; no CD5 and CD10.
• CD43+ can help determe that the infiltrate is neoplastic.
• A subset of cases may be positive for t(11;18)(q21;q21) (may be more
resistant to antibiotic therapy)
• Trisomies of chromosome 3 or 18 can be seen

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 Differential diagnosis and pointers
• Mantle cell lymphoma, follicular lymphoma, reactive infiltrate
• Cyclin D1 and SOX11 are always negative (rules out mantle cell lymphoma)
• MNDA and CD43 may be positive in a subset of cases (argues against
follicular lymphoma)
• BCL2 is often positive and kappa and lambda IHC may show monotypia
(rules out reactive infiltrate)
• You don’t get atypical reactive marginal zone hyperplasia in the stomach
• You can get atypical reactive marginal zone hyperplasia in other areas of
the gut

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 Extranodal marginal zone lymphoma (ENMZL) vs reactive marginal zone hyperplasia (rMZH)

ENMZL rMZH

Morphology Small-medium size lymphocytes with cleared Small-medium size lymphocytes

cytoplasm/monocytoid in a diffuse or marginal with cleared cytoplasm/monocytoid

zone pattern. Lymphoepithelial lesions and/or in a marginal zone pattern.

follicular colonization may be present. Lymphoepithelial lesions and/or

follicular colonization are rare.

Immunophenotype CD20+, CD43+/-, MNDA+/-, Bcl-2+/- CD20+, CD43+/-, MNDA+/-, Bcl-2+

B-cell light chain Restricted light chain expression expected. May show restricted light chain

restriction (by expression

immunostains)

B-cell clonality (by DNA Clonal Non-clonal

sequencing)

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 But as I said…
• You can get atypical reactive marginal zone hyperplasia in some areas
of the gut
• You don’t get atypical reactive marginal zone hyperplasia in the
stomach

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 Then you look in another area of the biopsy…

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 A B C

Larger cells are seen…

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 What do you do when you have increased
large cells?
• If you see “sheets” then it is diffuse large B-cell lymphoma
• However, cases with fewer than 20% large cells are NOT LBCL
• When you see sheets of large B-cells outside follicles = LBCL
• With >20% large cells, literature supports these cases behave
clinically more aggressively than typical ENMZL
• Ki67, p53, c-myc immunostains may be useful to diagnose large cell
transformation in ENMZL.

May reflect underlying genetic abnormalities

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 Transformations of indolent B-cell lymphomas
WHO-HAEM5

• New entity in WHO-HAEM5

• What is this?
• When you see DLBCL in the setting of low-grade lymphoma (i.e. CLL/SLL, FL, MZL)

• DLBCL MUST be clonally related to the low-grade lymphoma

• Signout: Large B-cell lymphoma transformed from ENMZL

In CLL/SLL 22% of cases with DLBCL; the DLBCL is NOT related to the CLL/SLL
Subset of MZL with DLCBL; the DLBCL may not always be related to MZL though typically it is
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 Case 4
• 51 year old with polyps discovered along the small intestine during
routine GI biopsy

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H&E H&E CD20

CD5 BCL1 Ki67

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 What is this?

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 Low grade or small-medium size B-cell lymphoma

CD5+ CD5-

CyclinD1+/SOX11+ CyclinD1-/SOX11-; LEF1+ CD10+/BCL6+ CD10-/BCL6-

Mantle cell lymphoma Chronic lymphocytic leukemia/ Follicular lymphoma Marginal zone lymphoma
Small cell lymphoma

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 Mantle cell lymphoma

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 Mantle cell lymphoma
• Mantle cell lymphoma may present anywhere in the gastrointestinal
tract.
• In the colon, mantle cell lymphoma may present as an intestinal
polyposis (so can follicular lymphoma or marginal zone lymphoma)
• Cyclin D1 protein expression and the identification of
t(11;14)(q13;q32) are diagnostic of this entity
• A Ki67 index must be evaluated to assess for prognosis
• TP53 mutations are important for appropriate treatment
• Mantle cell lymphoma is not a low grade lymphoma, it typically
proliferates more aggressively.

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 Mantle cell lymphoma
• In situ mantle cell neoplasm/neoplasia
• Incidental finding
• Slightly expanded mantle zone with cyclinD1 positive B-cells
• Shows t(11;14)(q13;q32)
• Indolent
• Leukemia non-nodal mantle cell lymphoma
• In blood and bone marrow and spleen
• Shows t(11;14)(q13;q32)
• Often SOX11 negative but cyclinD1 positive; low Ki67, CD5 may be dimmer
• May have some CD200 and CD23 expression
• Clinically more indolent

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 Some like tables

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 Small-medium size B-cell lymphomas

Entity Morphology Immunophenotype Genetics

Monotonous infiltrate of small cells with cleared CD20+, CD5-, CD10-, BCL6-, Cyclin D1- May show t(11;18)(q21;q21);BIRC3/MALT1, trisomy 3 or 18
ENMZL
cytoplasm or monocytoid appearance, may show ,CD43+/-, MNDA+/-
plasmacytic differentiation.

Monotonous infiltrate of small cells with blocky CD20+, CD5+, CD10-, BCL6-, Cyclin D1-, May show deletions of 11q, 13q, 17p, and trisomy 12
CLL/SLL
chromatin. Proliferation centers may be seen. CD43+/-, MNDA+/-, LEF1+

Back to back follicles without polarization and no CD20+, CD5-, CD10+, BCL6+, Cyclin D1-, t(14;18)(q32;q21); IGH/BCL2 or less frequently t(3;14)(q27;q32);
FL
tingible body macrophages. Centrocytic cells and CD43-, MNDA- IGH/BCL6. The presence of either of these translocations in the setting
centroblastic cells in varying proportions of small B-cells is diagnostic for FL.
depending on grading (1-3A/B)

Vague nodules or diffuse effacement by CD20+, CD5+, Cyclin D1+, SOX11+, CD10-, t(11;14)(q13;q32); IGH/CCND1. The presence of this translocation is
MCL
monotonous small-medium size cells with BCL6- diagnostic for MCL.
irregular indented nuclei.

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 Case 5
• 64 year old with lesions of the conjunctiva suspicious for lymphoma

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 CD20

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 CD3

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 CD21

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 BCL2

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 CD10

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 Other negative markers
• CD5 and BCL1/CyclinD1 and SOX11 negative

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 Low grade or small-medium size B-cell lymphoma

CD5+ CD5-

CyclinD1+/SOX11+ CyclinD1-/SOX11-; LEF1+ CD10+/BCL6+ CD10-/BCL6-

Mantle cell lymphoma Chronic lymphocytic leukemia/ Follicular lymphoma Extranodal

Small cell lymphoma Marginal zone lymphoma

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 Diagnosis?

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 Marginal zone lymphoma

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 Salama ME, Lossos IS, Warnke RA, Natkunam Y. Immunoarchitectural patterns in nodal marginal zone B-cell lymphoma: a study
Private Information of 51 cases. Am J Clin Pathol. 2009 Jul;132(1):39-49.
 However… molecular was done on this case

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 Next generation sequencing
• MYD88 and TBL1XR1 mutations seen!
• What does this mean? Is this lymphoplasmacytic lymphoma?
• We often think of MYD88 in lymphoplasmacytic lymphoma or diffuse
large B-cell lymphoma
• But these mutations are all consistent with MZL of the ocular adnexa
(conjunctiva)
• Combinations of these mutations = MZL in this location

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 Case 6
• 24 year old with diffuse lymphadenopathy
• Given dose of steroids
• Elevated LDH, PET shows SUV of 16 in lymph nodes

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 Why focus on SUV?

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 PET, SUV and aggressive lymphomas
• SUV >10 typically is an aggressive lymphoma

SUV = 6 SUV = 16
Low grade follicular lymphoma Diffuse large B-cell lymphoma

1. Yuasa et al., Clinical Significance of Uptake Value on F18-FDG PET/CT and Histological Grade in 164 Patients with Follicular Lymphoma Including Transformation - a Single Center Retrospective Study. Blood (2019) 134 (Supplement_1): 1529.
2. Gallamini A, Borra A. FDG-PET Scan: a new Paradigm for Follicular Lymphoma Management. Mediterr J Hematol Infect Dis. 2017;9(1):e2017029. Published 2017 Apr 15. doi:10.4084/MJHID.2017.029
3. Schöder et al., Intensity of 18Fluorodeoxyglucose Uptake in Positron Emission Tomography Distinguishes Between Indolent and Aggressive Non-Hodgkin’s Lymphoma. Journal of Clinical Oncology 2005 23:21, 4643-4651
4. Ngeow JYY, Quek RHH, Ng DCE, et al. High SUV uptake on FDG-PET/CT predicts for an aggressive B-cell lymphoma in a prospective study of primary FDG-PET/CT staging in lymphoma. Ann Oncol. 2009;20(9):1543-1547.

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 Case 6
• 24 year old with diffuse lymphadenopathy
• Given dose of steroids
• Elevated LDH, PET shows SUV of 16 in lymph nodes
• Clinical suspicion for an aggressive lymphoma

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 What do we know about aggressive lymphomas?

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 Large B-cell lymphoma features
• ~150,000 new cases/year.
• Risk factors: genetic features, immune dysregulation, viral, environmental,
occupational exposure
• De novo or transformation
• 50% of patients are low stage (I/II).
• Present with rapidly enlarging lymph nodes or mass(es)
• 30-40% extranodal sites involved: GI tract, head and neck, bone, liver, kidney
and adrenal gland.
• 20% have bone marrow involvement.

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 Patient gets an FNA

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 What is role of FNA in diagnosis of large B-cell
lymphoma?
• WHO-HAEM5 recommends tissue biopsy for definitive diagnosis.

Private Information Balassanian R, Wool GD, Ono JC, et al. A superior method for cell block preparation for fine-needle aspiration biopsies. Cancer Cytopathol. 2016
 FNA diagnosis
• Suspicious for lymphoma

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 Lymph node biopsy

• Large cells
• Sheets
• Centroblastic
• Mitotic figures

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 Morphology of large B-cell lymphomas
• Centroblastic: ~ 80% of cases. Large cells, round to oval nuclei, typically
several small nucleoli.
• Immunoblastic: ~10% of cases. Large cells, single prominent, centrally
located nucleolus. Poor prognosis, often associated with IGH-MYC
gene rearrangements.
• Anaplastic: 5% of cases. Very large cells, bizarre nuclei, often cohesive
tumor-like growth, may have sinusoidal involvement. Often TP53
mutations and CD30 expression.

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 Immunohistochemistry

CD20 BCL6

Negative for CD10 and MUM1

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 Is this important?

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 Diffuse large B-cell lymphoma, cell of origin

Non-GCB
ABC
GCB-DLBCL
DLBCL

Quintanilla-Martinez, Hematological Oncology 2015

Alizadeh AA, Eisen MB, Davis RE, et al. Distinct types of diffuse large B-cell lymphoma identified by gene expression
Private Information profiling. Nature. 2000;403(6769):503-511. doi:10.1038/35000501
 Cell of origin (COO), Hans classifier

Christine P. Hans,Dennis D. Weisenburger,Timothy C. Greiner,Randy D. Gascoyne,Jan Delabie,German Ott,H. Konrad Müller-Hermelink,Elias Campo,Rita M. Braziel,Elaine S. Jaffe,Zenggang Pan,Pedro Farinha,Lynette M. Smith,Brunangelo Falini,Alison H. Banham,Andreas Rosenwald,Louis M.
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Staudt,Joseph M. Connors,James O. Armitage,Wing C. Chan, Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray, Blood, 2004,
 Germinal center B-cell (GCB) vs non-GCB

Christine P. Hans,Dennis D. Weisenburger,Timothy C. Greiner,Randy D. Gascoyne,Jan Delabie,German Ott,H. Konrad Müller-Hermelink,Elias Campo,Rita M. Braziel,Elaine S. Jaffe,Zenggang Pan,Pedro Farinha,Lynette M. Smith,Brunangelo Falini,Alison H. Banham,Andreas Rosenwald,Louis M.
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Staudt,Joseph M. Connors,James O. Armitage,Wing C. Chan, Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray, Blood, 2004,
 But in recent years… WHO-HAEM5 and ICC
• Cell of origin classification may not be useful anymore

• Though cell of origin classification is still recommended

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 Negative for
• CD10
• MUM1

• BCL2
• C-MYC

• CD5

• CD30

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 GCB Non-GCB
Non-DE Non-DE

Double-Expressor (DE) DE
DE

C-MYC+ BCL2-
(IHC) (IHC)
Non-DE
Non-DE
DE DE

C-MYC+ BCL2+
(IHC) (IHC) IPI score
Non-DE
Non-DE
DE
DE

1.Green TM, Young KH, Visco C, et al. Immunohistochemical double-hit score is a strong predictor of outcome in patients with diffuse large B-cell lymphoma treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone. J Clin Oncol. 2012;30(28):3460-3467.
2.Johnson NA, Slack GW, Savage KJ, et al. Concurrent expression of MYC and BCL2 in diffuse large B-cell lymphoma treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone. J Clin Oncol. 2012;30(28):3452-3459. doi:10.1200/JCO.2011.41.0985
3.Staiger AM, Ziepert M, Horn H, et al. Clinical Impact of the Cell-of-Origin Classification and the MYC/ BCL2 Dual Expresser Status in Diffuse Large B-Cell Lymphoma Treated Within Prospective Clinical Trials of the German High-Grade Non-Hodgkin's Lymphoma Study Group. J Clin Oncol. 2017;35(22):2515-2526.
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4.Horn Information
H, Ziepert M, Becher C, et al. MYC status in concert with BCL2 and BCL6 expression predicts outcome in diffuse large B-cell lymphoma. Blood. 2013;121(12):2253-2263. doi:10.1182/blood-2012-06-435842
 Double-Expressor (DE)
C-MYC+
(IHC)
BCL2-
(IHC)
In 2022
Is this prognostically
Important?
C-MYC+ BCL2+
(IHC) (IHC) …maybe not…

1.Green TM, Young KH, Visco C, et al. Immunohistochemical double-hit score is a strong predictor of outcome in patients with diffuse large B-cell lymphoma treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone. J Clin Oncol. 2012;30(28):3460-3467.
2.Johnson NA, Slack GW, Savage KJ, et al. Concurrent expression of MYC and BCL2 in diffuse large B-cell lymphoma treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone. J Clin Oncol. 2012;30(28):3452-3459. doi:10.1200/JCO.2011.41.0985
3.Staiger AM, Ziepert M, Horn H, et al. Clinical Impact of the Cell-of-Origin Classification and the MYC/ BCL2 Dual Expresser Status in Diffuse Large B-Cell Lymphoma Treated Within Prospective Clinical Trials of the German High-Grade Non-Hodgkin's Lymphoma Study Group. J Clin Oncol. 2017;35(22):2515-2526.
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4.Horn Information
H, Ziepert M, Becher C, et al. MYC status in concert with BCL2 and BCL6 expression predicts outcome in diffuse large B-cell lymphoma. Blood. 2013;121(12):2253-2263. doi:10.1182/blood-2012-06-435842
 Double-Hit Signature positive (DHTsig+)/Molecular high grade (MHG)

• (DHTsig+)/ molecular high grade (MHG)

signature, (dark zone expression)
• Poor prognosis to standard treatment

van den Brand, M. (2020). Lymph Node. In: Molina, T.J. (eds) Hematopathology. Encyclopedia of Pathology. Springer, Cham.
Ennishi D, Jiang A, Boyle M, et al. Double-Hit Gene Expression Signature Defines a Distinct Subgroup of Germinal Center B-Cell-Like Diffuse Large B-Cell Lymphoma. J
Private Information Clin Oncol. 2019;37(3):190-201.
 Other stains Low Ki67

High Ki67

• Ki67: low (30%)

• Low is Better survival
Low Ki67

High Ki67

• p53: was low and considered negative (<10%)

• Low is better survival

1.Yoon DH, Choi DR, Ahn HJ, et al. Ki-67 expression as a prognostic factor in diffuse large B-cell lymphoma patients treated with rituximab plus CHOP. Eur J Haematol. 2010;85(2):149-157. doi:10.1111/j.1600-0609.2010.01467.x
2.Private Information
Wang, X., et al. P53 expression correlates with poorer survival and augments the negative prognostic effect of MYC rearrangement, expression or concurrent MYC/BCL2 expression in diffuse large B-cell lymphoma. Mod Pathol 30, 194–203 (2017).
 Other stains
• Negative for CD3
• Rare cases may show aberrant CD3 expression. Typically
expression is cytoplasmic and dim.
• Negative for TdT
• Almost all cases lack TdT. Expression of partial TdT can be seen in
mature LBCL with MYC and BCL2 gene rearrangements.
• Negative for CD30
• Relevant in the context of targeted therapies (Brentuximab)

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 FISH
• No MYC, BCL2 or BCL6 translocation

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 Why do we care about MYC, BCL2 and BCL6?

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 MYC, BCL2 and BCL6 rearrangements

Immunoglobulin partner for

prognostic impact

MYC with BCL2 and/or BCL6 gene rearrangement

(IG partner)

1. Lauren C. Chong, Susana Ben-Neriah, Graham W. Slack, Ciara Freeman, Daisuke Ennishi, Anja Mottok, Brett Collinge, Pau Abrisqueta, Pedro Farinha, Merrill Boyle, Barbara Meissner, Robert Kridel, Alina S. Gerrie, Diego Villa, Kerry J. Savage, Laurie H. Sehn, Reiner Siebert, Ryan D. Morin,
Randy D. Gascoyne, Marco A. Marra, Joseph M. Connors, Andrew J. Mungall, Christian Steidl, David W. Scott; High-resolution architecture and partner genes of MYC rearrangements in lymphoma with DLBCL morphology. Blood Adv 2018; 2 (20): 2755–2765.
2. Clipson A, Barrans S, Zeng N, et al. The prognosis of MYC translocation positive diffuse large B-cell lymphoma depends on the second hit. J Pathol Clin Res. 2015;1(3):125-133. Published 2015 Mar 30. doi:10.1002/cjp2.10
3. Ye Q, Xu-Monette ZY, Tzankov A, et al. Prognostic impact of concurrent MYC and BCL6 rearrangements and expression in de novo diffuse large B-cell lymphoma. Oncotarget. 2016;7(3):2401-2416. doi:10.18632/oncotarget.6262
4.Private Information
Rosenwald A, Bens S, Advani R, et al. Prognostic Significance of MYCRearrangement and Translocation Partner in Diffuse Large B-Cell Lymphoma: A Study by the Lunenburg Lymphoma Biomarker Consortium. J Clin Oncol. 2019;37(35):3359-3368.
 Are all double-hit lymphomas equal?

1. Lauren C. Chong, Susana Ben-Neriah, Graham W. Slack, Ciara Freeman, Daisuke Ennishi, Anja Mottok, Brett Collinge, Pau Abrisqueta, Pedro Farinha, Merrill Boyle, Barbara Meissner, Robert Kridel, Alina S. Gerrie, Diego Villa, Kerry J. Savage, Laurie H. Sehn, Reiner Siebert, Ryan D. Morin,
Randy D. Gascoyne, Marco A. Marra, Joseph M. Connors, Andrew J. Mungall, Christian Steidl, David W. Scott; High-resolution architecture and partner genes of MYC rearrangements in lymphoma with DLBCL morphology. Blood Adv 2018; 2 (20): 2755–2765.
2. Clipson A, Barrans S, Zeng N, et al. The prognosis of MYC translocation positive diffuse large B-cell lymphoma depends on the second hit. J Pathol Clin Res. 2015;1(3):125-133. Published 2015 Mar 30. doi:10.1002/cjp2.10
3. Ye Q, Xu-Monette ZY, Tzankov A, et al. Prognostic impact of concurrent MYC and BCL6 rearrangements and expression in de novo diffuse large B-cell lymphoma. Oncotarget. 2016;7(3):2401-2416. doi:10.18632/oncotarget.6262
4.Private
Rosenwald A, Bens S, Advani R, et al. Prognostic Significance of MYCRearrangement and Translocation Partner in Diffuse Large B-Cell Lymphoma: A Study by the Lunenburg Lymphoma Biomarker Consortium. J Clin Oncol. 2019;37(35):3359-3368.
Information
 Are all double-hit lymphomas equal?
Is MYC and BCL6 the same as MYC and BCL2?

MYC with BCL2:

Double hit lymphoma

NO prognostic value of MYC with BCL6:

Double hit lymphoma

1. Lauren C. Chong, Susana Ben-Neriah, Graham W. Slack, Ciara Freeman, Daisuke Ennishi, Anja Mottok, Brett Collinge, Pau Abrisqueta, Pedro Farinha, Merrill Boyle, Barbara Meissner, Robert Kridel, Alina S. Gerrie, Diego Villa, Kerry J. Savage, Laurie H. Sehn, Reiner Siebert, Ryan D. Morin,
Randy D. Gascoyne, Marco A. Marra, Joseph M. Connors, Andrew J. Mungall, Christian Steidl, David W. Scott; High-resolution architecture and partner genes of MYC rearrangements in lymphoma with DLBCL morphology. Blood Adv 2018; 2 (20): 2755–2765.
2. Clipson A, Barrans S, Zeng N, et al. The prognosis of MYC translocation positive diffuse large B-cell lymphoma depends on the second hit. J Pathol Clin Res. 2015;1(3):125-133. Published 2015 Mar 30. doi:10.1002/cjp2.10
3. Ye Q, Xu-Monette ZY, Tzankov A, et al. Prognostic impact of concurrent MYC and BCL6 rearrangements and expression in de novo diffuse large B-cell lymphoma. Oncotarget. 2016;7(3):2401-2416. doi:10.18632/oncotarget.6262
4.Private
Rosenwald A, Bens S, Advani R, et al. Prognostic Significance of MYCRearrangement and Translocation Partner in Diffuse Large B-Cell Lymphoma: A Study by the Lunenburg Lymphoma Biomarker Consortium. J Clin Oncol. 2019;37(35):3359-3368.
Information
 Are all double-hit lymphomas equal?
Is MYC and BCL6 the same as MYC and BCL2?
MYC+BCL2 MYC+BCL6

1. Lauren C. Chong, Susana Ben-Neriah, Graham W. Slack, Ciara Freeman, Daisuke Ennishi, Anja Mottok, Brett Collinge, Pau Abrisqueta, Pedro Farinha, Merrill Boyle, Barbara Meissner, Robert Kridel, Alina S. Gerrie, Diego Villa, Kerry J. Savage, Laurie H. Sehn, Reiner Siebert, Ryan D. Morin,
Randy D. Gascoyne, Marco A. Marra, Joseph M. Connors, Andrew J. Mungall, Christian Steidl, David W. Scott; High-resolution architecture and partner genes of MYC rearrangements in lymphoma with DLBCL morphology. Blood Adv 2018; 2 (20): 2755–2765.
2. Clipson A, Barrans S, Zeng N, et al. The prognosis of MYC translocation positive diffuse large B-cell lymphoma depends on the second hit. J Pathol Clin Res. 2015;1(3):125-133. Published 2015 Mar 30. doi:10.1002/cjp2.10
3. Ye Q, Xu-Monette ZY, Tzankov A, et al. Prognostic impact of concurrent MYC and BCL6 rearrangements and expression in de novo diffuse large B-cell lymphoma. Oncotarget. 2016;7(3):2401-2416. doi:10.18632/oncotarget.6262
4.Private
Rosenwald A, Bens S, Advani R, et al. Prognostic Significance of MYCRearrangement and Translocation Partner in Diffuse Large B-Cell Lymphoma: A Study by the Lunenburg Lymphoma Biomarker Consortium. J Clin Oncol. 2019;37(35):3359-3368.
Information
 Diffuse large/High-grade B-cell lymphoma with
MYC and BCL2 gene rearrangements
• Aggressive lymphoma in elderly (7th decade of life)
• Stage by IPI
• Mutations in BCL2, KMT2D, CREBBP, EZH2, TNFRSF14 (FL type genes)
and MYC

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 Back to our case…

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 Next generation sequencing identifies
• Mutations in:
• SOCS1 p.C178*, SOCS1 p.L84fs
• GNA13 p.Q27*
• BTG1 p.Q45*, BTG1 p.S65P
• STAT6 p.N421S, STAT6 p.N417Y

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 What do we do with these results?

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 How do we interpret these results?
• There have been multiple DLBCL molecular subtyping studies in the
last <5 years
• Lacy et al., Wright et al., Chapuy et al., Schmitz et al., others

1. Chapuy B, Stewart C, Dunford AJ, et al. Molecular subtypes of diffuse large B cell lymphoma are associated with distinct pathogenic mechanisms and outcomes [published correction appears in Nat Med. 2018
Aug;24(8):1292] [published correction appears in Nat Med. 2018 Aug;24(8):1290-1291]. Nat Med. 2018;24(5):679-690.
2. Wright, George W et al. “A Probabilistic Classification Tool for Genetic Subtypes of Diffuse Large B Cell Lymphoma with Therapeutic Implications.” Cancer cell vol. 37,4 (2020): 551-568.e14.
3. Pedrosa L, Fernández-Miranda I, Pérez-Callejo D, et al. Proposal and validation of a method to classify genetic subtypes of diffuse large B cell lymphoma. Sci Rep. 2021;11(1):1886. Published 2021 Jan 21.
4.Private
Lacy SE, Barrans SL, Beer PA, et al. Targeted sequencing in DLBCL, molecular subtypes, and outcomes: a Haematological Malignancy Research Network report. Blood. 2020;135(20):1759-1771.
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 All these studies converge

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 From Schmitz et al.,

Schmitz R, Wright GW, Huang DW, et al. Genetics and Pathogenesis of Diffuse Large B-
Private Information Cell Lymphoma. N Engl J Med. 2018;378(15):1396-1407. doi:10.1056/NEJMoa1801445
 To Chapuy et al.,

Chapuy B, Stewart C, Dunford AJ, et al. Molecular subtypes of diffuse large B cell lymphoma are associated with distinct
Private Information pathogenic mechanisms and outcomes.Nat Med. 2018 Aug;24(8):1290-1291]. Nat Med. 2018;24(5):679-690.
 To Lacey et al.,

Lacy SE, Barrans SL, Beer PA, et al. Targeted sequencing in DLBCL, molecular subtypes, and outcomes:
Private Information a Haematological Malignancy Research Network report. Blood. 2020;135(20):1759-1771.
 There is good molecular concordance between
studies

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 As summarized by:
Pileri et al.,

Pileri SA, Tripodo C, Melle F, Motta G, Tabanelli V, Fiori S, Vegliante MC,

Mazzara S, Ciavarella S, Derenzini E. Predictive and Prognostic Molecular
Factors in Diffuse Large B-Cell Lymphomas. Cells. 2021; 10(3):675.
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 Different name, same thing
• You say soda, she says pop, he says coke

It’s all the same

• You say crawfish, she says crayfish, he says crawdads

It’s all the same

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 That said… let’s focus on one of the more
commonly cited and used
• Wright et al.,
• Studied hundreds of DLBCL

Wright, George W et al. “A Probabilistic Classification Tool for Genetic Subtypes of Diffuse Large B Cell Lymphoma with Therapeutic Implications.” Cancer cell vol. 37,4 (2020): 551-568.e14.
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 MCD, BN2, N1, EZB, ST2, A53 subtypes of DLBCL
MCD BN2 N1 EZB ST2 A53

NOTCH1 TET2
MYD88 and CD79a SGK1
BCL6 transl TP53
EZH2 SOCS
NOTCH2
BCL2 transl

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 Molecular subtype and outcome

Years
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 Molecular subtype and therapy
OS Tx

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 Returning to our case…

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 We can predict the following just based on
mutations
• Diffuse large B-cell lymphoma, NOS, GCB, non-double expressor
• Molecularly classify it as: ST2 or TET2/SGK1
• Prediction:
• Non-GCB
• Good prognosis for patient
• Indeed other markers: p53, ki67, c-myc and bcl2 all point to good prognosis
• Patient is doing well 1 year after chemotherapy
• Therapy:
• ?Potential targeted therapeutics- ?JAK/STAT?

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 There are other large B-cell lymphomas

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 Primary mediastinal large B-cell lymphoma

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 Primary mediastinal large B-cell lymphoma
• “PRIMARILY” in Mediastinum

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 Primary mediastinal large B-cell lymphoma
• “PRIMARILY” in Mediastinum
• Fibrotic/Sclerotic background
• CD20+/ CD30+/ CD23+

•
Often sIg negative
• Can be sIg+(Weinberg et al., 2016) Kappa

Lambda
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 Mediastinal grey zone lymphoma

• Also known as: MGZL

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 MGZL

• Essentially some features of DLBCL… some features of CHL…

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 MGZL
• More confluent sheets of large cells
• CD30+
• CD15-
• CD20+
• EBV-/+

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 MGZL
H&E CD20

CD30 CD15

PAX5 OCT2

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 Case 7
• 57 year old who complains of dizziness
• No lymphadenopathy, no organomegaly
• Imaging identifies a mass in the brain only

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 H&E

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 H&E

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 H&E

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 CD20

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 CD3

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 Other stains and information
• EBV negative
• No other lymphadenopathy or PB or marrow involvement

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 Diagnosis?
• Primary CNS lymphoma

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 Primary CNS lymphoma
• Primarily arises in the brain, spinal cord, leptomeninges, and
vitreoretinal compartment of the eye
• No significant systemic involvement.
• 4–7% of all brain tumors
• Male predominance (ratio of 1.25); median age 66
• Two important risk factors of PCNSL are increasing age and human
immunodeficiency
• Median age at diagnosis is 66 years
• Diffuse large B-cell lymphoma (DLBCL) accounts for 90–95% of all
PCNSL

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 Primary CNS lymphoma
• Diffuse proliferation of medium-to-large-sized lymphoid cells with
pleomorphic, round to oval, irregular, and vesicular nuclei with
prominent nucleoli, morphologically consistent with centroblasts or
immunoblasts
• Tumor cells usually exhibit perivascular arrangement (angiocentricity)
by forming layers around blood vessels
• However, microvascular proliferation (frequently encountered in high-
grade gliomas) is rare
• PCNS DLBCL is a mature B-cell neoplasm, and the tumor cells express
B-cell markers, particularly CD19, CD20, CD22, CD79a, and PAX5

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 Primary CNS lymphoma: Prognostication
• A majority (67–96%) of cases are of an activated B-cell (ABC)/non-
germinal center B-cell (non-GCB) subtype

• Co-expression of c-Myc and Bcl-2 (double-expressor) and/or co-

rearrangement of MYC and BCL2 and/or BCL6 (double or triple hit
lymphoma) may be seen

• Uncertain yet how any of the above impacts prognosis

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 Now in WHO-HAEM5 grouped in a new category
• Primary large B-cell lymphoma of immune privileged sites
• Testis, CNS, vitreoretinal
• Common genetic alterations for immune escape
• Frequent MYD88 and CD79B mutations; C5/MCD/MYD88 genetic signature
• Frequent CDKN2A/9p21 inactivation

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 Future for B-cell lymphomas
• Integrated diagnoses
• Clinical, Anatomic, Laboratory data, Radiology
• Histomorphology, Immunophenotype, Cytogenetics
• More molecular NGS testing
• Utilization and incorporation of novel technologies

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 Future…
• Digital pathology/Digital Imaging
Oncotopix® AI deep learning

• High resolution immunophenotyping

• Advanced NGS molecular analysis

• Artificial intelligence, Machine learning

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 Thank you

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