淋巴组织肿瘤

1、.,淋巴瘤 Lymphoma 基础医学院病理学系 同济医院病理研究所 敖启林,.,Dr John K.C.CHAN 陈国璋,.,4th Edition Published 20/9/2008,.,第一节 概述 一、定义 “来源于”成熟淋巴细胞及其前体细胞（淋巴母细胞）的恶性肿瘤，分为非霍奇金/白血病和霍奇金淋巴瘤两大类。 二、分类 （一）非霍奇金淋巴瘤(NHL)：包括B，T和NK细胞（70%） 1、前体细胞： B/T/NK前体细胞（淋巴母细胞）淋巴瘤（2%） 2、成熟细胞：成熟细胞淋巴瘤（68%） B细胞（54%） T细胞（12%） NK/T或NK细胞（2%）,.,(二)霍奇金淋巴瘤(HL):

2、特殊类型成熟B细胞淋巴瘤(30%) 结节性淋巴细胞为主型（1.5%） 经典型(28.5%) (缺陷性B细胞) 结节硬化型 淋巴细胞丰富型 混合细胞型 淋巴细胞消减型,.,第二节 淋巴结的免疫结构 （immunoarchitecture） 一、概念：通过免疫组织化学染色显示淋巴结的结构特征。包括肿瘤性或非肿瘤性细胞的成分（淋巴细胞,辅助性非淋巴细胞,淋巴窦,血管,网状纤维等）、数量、分布方式等特征。通过对比，掌握正常和异常免疫结构，对淋巴结病变进行诊断和鉴别诊断。高质量的组织学切片和合理的免疫标记物的选择是识别免疫结构的关键。,.,二、淋巴结的正常免疫结构 （一）淋巴结结构:皮质,髓质,窦,被膜

3、和纤维小梁,.,（二）B淋巴细胞分布： 1.主要在浅皮质区的初级和次级滤泡，髓索和副 皮质区也含一定量B细胞; 2.B细胞分化过程中的形态和免疫学特征成为非霍 奇金B细胞淋巴瘤分类的基础。,.,.,.,Pre pre B cell,Pre B cell,Immature B cell,Mature B cell,Activated B cell,Plasma cell,Precursor cells; antigen non-responsive,Virgin B cells; antigen responsive,Germinal center antigen encountered,TdT

4、,CD20, CD22,CD19, PAX5,CD79a,CD10,Bcl-6,CD138,Cytoplasmic CD22,.,Immunoarchitecture of normal lymph node,B cells (CD20+,CD10+,BCL-6+),T cells (CD3+); only small numbers of CD20+ cells,.,.,1、初级滤泡：处女型B细胞和成熟小淋巴细胞；,.,CD20,2、次级滤泡：由生发中心、套区和边缘区构成。,.,Organization of secondary lymphoid follicle,Marginal zone

5、 cells (IgM),Mantle zone cells (IgM+D),Follicle center cells (IgM, IgG, IgA or IgE, not IgD),:约2:1，当:8-10:1或:3:1提示轻链限制表达,.,次级滤泡生发中心、套区和边缘区免疫标记： （1）生发中心(Germinal Center, GC)： 1）中心细胞和中心母细胞：CD10+,BCL-6+,Bcl-2-, 2）滤泡树突细胞(Follicular dendritic cells, FDC) : CD21+,CD23+, CD35+ 3）T细胞：CD4+, CD10+, CXCL13/PD-

6、1+,少量CD57+ 4）可染体巨噬细胞：CD68+,lysozyme+,CD11c+ （2）套区:处女型B细胞和记忆细胞,表达IgM, IgD （3）边缘区：无特殊标记，绝大多数次级滤泡难以鉴别，腹腔 淋巴结易识别。,.,CD20,.,CD79a,.,.,.,.,CD21,.,CD10,Bcl-6,.,反应性滤泡增生的特点 对T细胞依赖性抗原的反应 滤泡增多，大小、形态不等，可弥漫分布，主要位于皮质区，无背靠背现象。 典型生发中心具有极性(Polarity):明区和暗区，套区明显，扁桃体组织更易识别； 星天现象，中心细胞和中心母细胞混杂， 免疫染色：生发中心细胞BCL-2-，ki-67指数较

7、高。 滤泡间区一般无B细胞弥漫阳性，B细胞CD43和CD5阴性。,.,.,.,Dark zone,Light zone,.,BCL-2,Ki67,.,Marginal zone cells,.,CD20,.,（三）T淋巴细胞分布：副皮质区(paracortex),T淋巴细胞为主 (CD4CD8): 主为小淋巴细胞，偶尔出现大细胞 (可以是活化的B细胞); 含有高内皮静脉 (High endothelial venules,HEV): 血液淋巴细胞入淋巴结的通道; 含有指状树突细胞(interdigitating dendritic cells,IDC): S100+ 的专职抗原递呈细胞；,.,

8、.,.,Prothymocyte,Subcapsular thymocyte,Cortical thymocyte,Medullary thymocyte,Peripheral T cell,Precursor cells,Mature T cells,Cytoplasmic,Surface,CD4,CD8,CD1,CD4, CD8,CD3,CD2,CD7,TdT,.,.,IDC,.,CD3,.,副皮质区增生,常见病因: 病毒感染, 接种疫苗，药物，自身免疫疾病, 皮病性淋巴结炎，肿瘤转移等 形态特征：副皮质扩大，可形成结节； HEV增生； 混合小淋巴细胞和转化淋巴细胞，浆细胞，树突细胞，嗜酸

9、性粒细胞等； 免疫染色：主为T细胞，或T/B细胞混合,一般无B细胞为主弥漫分布。,.,.,.,Immunoblast,Infectious mononucleosis,.,CD20,CD3,Large cells comprise mixture of B and T cells-Reactive process,.,CD30+ cells are scattered and staining is weak or moderate, which indicates the heterogeneity of the large cell population.,CD30 staining is

10、 diffusely strong positive, which indicates the monoclone entity.,.,Kappa,Lambda,Large B cells are polytypic,.,T细胞为主时支持良性的依据（谨慎！）： （1）结构不同程度保留：淋巴窦和皮质淋巴滤泡； （2）大细胞群体分布不规则或呈地图样，不形成膨胀性团块； （3）无浸润现象：上皮,脂肪,血管,神经,纤维间质中单行排列； （4）细胞无明显异型： B Leukemia (ALL): B T Untreated: rapidly fatal Aggressive therapy: good

11、survival Cannot predict lineage from morphology Defining marker: TdT+，CD99,.,.,.,CD20,CD79a,B-LBL,.,T-LBL,.,滤泡性淋巴瘤 FOLLICULAR LYMPHOMA,Usually involving lymph nodes High-stage disease at presentation Pathology: Recapitulates the organization and cytology of the normal germinal centers Key immunophen

12、otype: B marker+, CD10+, Bcl6+, Bcl2+ Follicular lymphoma involving some extranodal sites (such as skin, duodenum, testis) show distinctive clinical and biologic features Genetics:Ig gene rearrangement; t(14;18)(q32;q21) bcl-2 gene rearrangement (due to BCL2/IGH translocation),.,Follicular lymphoma

13、vs reactive follicular hyperplasia,Major criterion Closely packed follicles throughout, with scanty interfollicular tissues,1 major criterion or 3 minor criteria. But confirm by ancillary tests if uncertain,.,滤泡性淋巴瘤主要诊断标准示意图,Major criterion fulfilled in 80% of cases of follicular lymphoma,Just go on

14、 to high magnification to confirm follicle center cell morphology,.,.,.,Centrocytes often have triangular shaped nuclei,.,滤泡性淋巴瘤的次要诊断标准,In the remaining 20% of cases (non-crowded follicles), a combination of minor criteria (3) have to be considered, and supplemented by ancillary studies as required,

15、.,Minor criteria No tingible-body macrophages Cellular monotony: centrocyte predominance No cellular polarisation Absent or incomplete mantles Follicles in perinodal tissues Dysplastic follicular center cells, e.g. signet ring cells, frequent cytoplasmic globules Atypical cells in interfollicular ti

16、ssues Invasion of walls of blood vessels,.,.,.,.,.,Follicular lymphoma vs RFH: ancillary techniques,Immunostaining for bcl-2 Most useful immunostain Normal: Both T and B cells positive except follicle center cells Look for positive staining of cells in follicle centers: positive staining supports di

17、agnosis of lymphoma,.,Reactive follicles,.,Follicular lymphoma (Bcl-2 immunostaining),.,Common misconceptions in hematopathology,Negative bcl-2 stain rules out follicular lymphoma The truth: It does not. 20-25% of follicular lymphoma cases are negative. Pursue with other tests to confirm or refute a

18、 diagnosis of follicular lymphoma,.,Bcl-2 staining in follicular lymphoma,.,.,Bcl-2,.,Look for evidence interfollicular invasion Densely packed CD20+ or CD79+ B-cells between follicles is indicative of interfollicular invasion Presence of a significant number of CD10+ lymphoid cells (not neutrophils

19、, which are also CD10+) between follicles also indicates interfollicular invasion Look for vascular invasion Many CD10+ cells in the walls of perinodal blood vessels,.,CD20,.,CD10,.,.,Look for monoclonality or low proliferation index Immunostain for Ig to look for light chain restriction Demonstrate

20、d by Ki67, a low Ki67 index favors diagnosis of follicular lymphoma over RFH (mean index 15.6% vs 64.9%); a high Ki67 index is inconclusive Molecular analysis Ig gene rearrangement by Southern blot or PCR (Note that PCR may have false negative results) Detection of BCL2 gene rearrangement by Souther

21、n blot, PCR or FISH,.,Kappa,Lambda,.,FL1: Ki67,RFH: Ki67,.,FL3: Ki67,.,套细胞淋巴瘤 Mantle cell lymphoma: morphology,Diffuse, vaguely nodular, or mantle zone pattern Broad cytologic spectrum Classic type: small lymphoid cells with irregular to round nuclei Blastoid variant ( lymphoblasts, but TdT-) Pleomo

22、rphic variant Often with solitary epithelioid histiocytes Interspersed naked nuclei (follicular dendritic cells) Genetics: Ig gene rearrangement t(11,14) (q13;q32),.,Growth pattern of MCL,.,.,.,.,Round nuclei,.,Mantle cell lymphoma: biologic markers,B marker+, CD5+, CD10-, CD23-, IgM+, IgD+ Key defi

23、ning feature: Cyclin D1+ due to t(11;14) (q13;q32) or cryptic translocation,.,Cyclin D1,.,粘膜相关淋巴组织 Mucosa-Associated Lymphoid Tissue(MALT),Specialized secondary lymphoid compartments of mucosal tissues Natural, e.g., Waldeyers ring, small intestine, lung Acquired in autoimmune disease/inflammation e

24、.g., thyroid, salivary gland, lacrimal gland, stomach Similar organization as lymph node: B-cell follicles, T-cell zones Lymphoid cells acquire homing properties,.,.,LOW GRADE B CELL MALT LYMPHOMA (extranodal marginal zone B-cell lymphoma),Usually localized at presentation (66-79%) Recurrence at oth

25、er MALT sites (“homing”) Many can be treated by locoregional therapy or eradication of antigen-stimulation source Complete remission rate = 72% 5-year overall survival = 74% (Gastric: 90%),.,Histologic features of low grade MALT lymphoma,Small/medium-sized cells (lymphocytes, centrocyte-like, monocy

26、toid B cells) Patterns: diffuse, interfollicular, marginal zone Lymphoepithelial lesions Plasma cells are common Reactive lymphoid follicles +/- colonization,.,.,.,.,Low grade MALT lymphoma: Immunophenotype,A neoplasm of post-germinal center B cells Pan B+, CD10-, CD5-, Cyclin D1-, CD23 - Key featur

27、es: site of involvement lymphoepithelial lesion exclusion of other low grade B-cell lymphomas,.,After Helicobacter eradication therapy,.,弥漫性大B细胞淋巴瘤 DIFFUSE LARGE B CELL LYMPHOMA（DLBCL）,Commonest nodal B-cell lymphoma A heterogeneous entity Final common pathway for high grade transformation of low gr

28、ade B-cell lymphomas,.,Centroblastic/Immunoblastic,.,.,Multilobated,Pleomorphic,.,BURKITT LYMPHOMA,Three different forms: Endemic (Equatorial Africa; strong association with EBV 90%; commonly affecting jaws, gonads, kidneys) Sporadic (EBV association only 15%; commonly involving terminal ileum and W

29、aldeyers ring) AIDS-related (EBV association 30%; commonly involving lymphonode and bone marrow) African cases can also be AIDS-related!,.,Burkitt lymphoma,t(8;14) (q24;q32) or variants, with translocation between c-myc and Ig gene Mostly a disease of young patients Highly aggressive, but potentiall

30、y curable by chemotherapy,.,.,.,Burkitt lymphoma: Immunogenetics,Probably corresponds to IgM+ blasts in germinal center Pan-B+, CD10+, Bcl-6+, Bcl-2- Key features: C-MYC translocation medium-sized cells high Ki67 index：100% germinal center cell phenotype,.,CD20,CD10,.,Ki67,.,外周T和NK细胞淋巴瘤 PERIPHERAL T

31、 AND NK CELL LYMPHOMAS,Uncommon; 80%),.,Extranodal NK/T cell lymphoma: Pathology,Necrosis (apoptosis) common Angioinvasion common (not invariably seen) Broad cytologic spectrum: small, medium-sized or large cells, or mixed May have many admixed inflammatory cells,.,.,.,Small,Medium-sized,Large,Broad

32、 cytologic spectrum,.,Extranodal NK/T cell lymphoma: immunophenotype,CD2+. sCD3-, cCD3e+, CD56+ Cytotoxic granules perforin, granzyme B, TIA-1 positive CD4, CD5, CD7, CD8: usually negative Key features: CD56+, EBER+ If CD56-, requires EBER+ and cytotoxic granules+ for diagnosis,.,Surface CD3,Cytopla

33、smic CD3,CD56,Frozen tissue,Paraffin section,.,PERIPHERAL T CELL LYMPHOMA UNSPECIFIED 外周T细胞淋巴瘤，非特殊型,A wastebasket category Variable clinical manifestations Usually high stage disease (nodal/extranodal) May have eosinophilia Aggressive; relapse common The extranodal cases often express a cytotoxic ce

34、ll phenotype,.,Peripheral T-cell lymphoma: Morphologic clues for recognition,Predominant paracortical involvement Prominent high endothelial venules Spectrum of cells sizes and shapes Irregular nuclear contours Clear cells Many admixed epithelioid histiocytes and eosinophils,But immunostaining essen

35、tial for confirming T lineage,.,.,.,ANAPLASTIC LARGE CELL LYMPHOMA, primary systemic form 间变性大细胞淋巴瘤，原发系统性,Tends to occur in children and young adults Nodal or extranodal presentation (which may include skin, soft tissue, bone, G.I. tract) Immunophenotype: CD30+; EMA usually + T-lineage markers +/- (

36、T or null cell) A proportion of cases express ALK due to translocation involving ALK gene,.,Hallmark cells,.,ALK translocation (or expression) has helped to define a homogeneous subgroup of ALCL This can be easily detected by immunostaining for ALK - permitting re-definition of the morphologic spect

37、rum of ALCL: Classical type Monomorphic Small cell Lymphohistiocytic Hypocellular,.,.,CD30,.,Overall survival Primary systemic form of ALCL,0,5,10,Years,ALCL, ALK+*,100%,50%,ALCL, ALK-,.,霍奇金淋巴瘤 HODGKIN LYMPHOMA,.,Lymphocyte predominance,Mixed cellularity,Nodular sclerosis,Lymphocyte depletion,Nodula

38、r lymphocyte predominant Hodgkin lymphoma (N-LPHL),RYE CLASSIFICATION,WHO CLASSIFICATION,.,5,10,Years,Overall survival,N-LPHL defined by immunohistochemistry,cHL defined by immunohistochemistry,p = 0.0071,.,A lymphoma characterized by: presence of Reed-Sternberg cells and their variants confirmed by

39、 mmunohistochemistry in an appropriate reactive cellular environment,.,Reed-Sternberg cells and variants,Diagnostic Reed-Sternberg cells Mononuclear Hodgkin cell Lacunar cell L&H cell Pleomorphic Reed-Sternberg cell Ki67+100%,No need to find diagnostic Reed-Sternberg cells in rendering a diagnosis of Hodgkin lymphoma. Its okay if cells are large enough, with prominent nucleoli and compatible immunophenotype.,.,Reed-Sternberg cells and variants,Small lymphocytes,Nuclear size of most neoplastic cells usually exceeds 3 times tha