LGCB LGCB riccoricco in in linfocitilinfociti T/T/istiocitiistiociti

•• 10% 10% deidei LGCBDLGCBD•• LinfonodiLinfonodi, , midollomidollo osseoosseo, , fegatofegato e e milzamilza•• BclBcl--6+, Bcl6+, Bcl--2+/2+/--, EMA+/, EMA+/--•• D.D. con LHPL (D.D. con LHPL (fondamentalefondamentale!)!)•• DecorsoDecorso clinico clinico estremamenteestremamente

aggressivoaggressivo, non , non responsivoresponsivo allealle terapieterapiecorrenticorrenti

LGCB ricco in linfociti T e/o istiocitiLGCB ricco in linfociti T e/o istiociti

CD20CD20 CD68CD68

““Diffuse largeDiffuse large--BB--cell lymphoma is the most cell lymphoma is the most common type of lymphoma worldwide, common type of lymphoma worldwide, making up to 30% of all nonmaking up to 30% of all non--HodgkinHodgkin’’s s lymphomas, and approximately 90% of lymphomas, and approximately 90% of primary CNS lymphomasprimary CNS lymphomas””

Batchelor TT, Batchelor TT, BuchbinderBuchbinder BR and Harris NL.BR and Harris NL.New Engl J Med 2005, 352:185New Engl J Med 2005, 352:185--194.194.

CNS CNS lymphomalymphoma

CD79aCD79a

CamilleriCamilleri--BroetBroet S et al.S et al. A uniform activated BA uniform activated B--cellcell--like immunophenotype might explain the like immunophenotype might explain the poor prognosis of primary central nervous poor prognosis of primary central nervous system lymphomas: analysis of 83 cases.system lymphomas: analysis of 83 cases.Blood. 107(1). 190Blood. 107(1). 190--196. 2006. 196. 2006.

PonzoniPonzoni M et al.M et al. Reactive perivascular TReactive perivascular T--cell cell infiltrate predicts survival in primary central infiltrate predicts survival in primary central nervous system Bnervous system B--cell lymphomas. Br J cell lymphomas. Br J HaematolHaematol. 138(3). 316. 138(3). 316--323. 2007.323. 2007.

CD3CD3

CD20CD20

Loss of 6p21.32Loss of 6p21.32--p25.3: p25.3: comunecomune aiai linfomilinfomi del del SNC e del SNC e del testicolotesticolo --> > alterataalterata regolazioneregolazione deideigenigeni didi HLA e HLA e didi genigeni coinvolticoinvolti nellnell’’apoptosiapoptosi, , compresacompresa la via la via didi p53.p53.

Gain Gain didi 12q1512q15--21.1 e 21.1 e didi 12q24.3212q24.32--p25.3 = CNSp25.3 = CNS

Gain Gain didi 19q13.1219q13.12--q13.34 = q13.34 = testicolotesticolo

The formerly poor prognosis has been The formerly poor prognosis has been remarkably amelioratedremarkably ameliorated by novel by novel chemotherapeutic protocols that include chemotherapeutic protocols that include methotrexate. methotrexate.

LINFOMA B A GRANDI LINFOMA B A GRANDI CELLULE DELLA GAMBACELLULE DELLA GAMBA

•• Pazienti anziani (>70aa); Pazienti anziani (>70aa); F>M; malattia confinata F>M; malattia confinata alla gamba.alla gamba.

•• Lesioni tumorali rossoLesioni tumorali rosso--bluastre, talvolta ulcerate.bluastre, talvolta ulcerate.

•• OutcomeOutcome: peggiore dei : peggiore dei linfomi con istologia linfomi con istologia simile ma interessanti simile ma interessanti altri siti (es. testa e altri siti (es. testa e tronco).tronco).

B CELL LYMPHOMA OF B CELL LYMPHOMA OF THE LEGTHE LEG

•• ““PatternPattern”” usualmente diffusousualmente diffuso

•• Grandi cellule Grandi cellule (prevalentemente (prevalentemente centroblasticentroblastied ed immunoblastiimmunoblasti).).

BclBcl--66

•• Profilo fenotipico: CD20Profilo fenotipico: CD20++; ; CD10CD10--; Bcl; Bcl--66++; IRF4; IRF4++; CD138; CD138--; ; BclBcl--22++..

•• Dal punto di vista Dal punto di vista molecolare, molecolare, PLBCLPLBCL--legleg porta porta con scon séé ipermutazioniipermutazioni dei geni dei geni IgG e, nella maggior parte dei IgG e, nella maggior parte dei casi, mutazioni di Bcl6.casi, mutazioni di Bcl6.

•• La ricerca di EBV e HHVLa ricerca di EBV e HHV--8 8 èènegativa.negativa.

La La ““hierarchicalhierarchicalanalysisanalysis”” dei PCFCCL dei PCFCCL e PCLBCL e PCLBCL ““legleg typetype””ha dimostrato profili di ha dimostrato profili di espressione simili, espressione simili, rispettivamente, a rispettivamente, a quelli tipo quelli tipo ““germinalgerminalcenter center likelike”” e tipo e tipo ““activatedactivated B cell B cell likelikediffuse diffuse largelarge B cell B cell lymphomalymphoma””. .

Linfomi B cutanei e Linfomi B cutanei e ““gene gene profilingprofiling””

LL’’analisi di analisi di ““gene gene profilingprofiling”” ha ha evidenziato levidenziato l’’ ””upup--regulationregulation”” di di geni con diversa prevalenza geni con diversa prevalenza rispettivamente espressi nel rispettivamente espressi nel PCLBCL PCLBCL ““legleg typetype”” e nei PCFCCL.e nei PCFCCL.Ad esempio:Ad esempio:

-- ““legleg typetype””: ciclo cellulare/ : ciclo cellulare/ proliferazione; sintesi/ proliferazione; sintesi/ replicazione/ riparazione DNA; replicazione/ riparazione DNA; regolazione trascrizione, ecc..;regolazione trascrizione, ecc..;

-- PCFCCL: adesione; antigene HLA; PCFCCL: adesione; antigene HLA; processing RNA,ecc..processing RNA,ecc..

Linfomi B cutanei e Linfomi B cutanei e ““gene gene profilingprofiling””

OyamaOyama T et al. Clin Cancer Res 2007; T et al. Clin Cancer Res 2007; 13:512413:5124--32.32.

•• Processo Processo linfoproliferativolinfoproliferativo clonale clonale EBV+EBV+ che occorre in che occorre in un Paziente di oltre 50 anni senza pregressa storia un Paziente di oltre 50 anni senza pregressa storia clinica di immunosoppressione o tumore.clinica di immunosoppressione o tumore.

•• 88--10% dei LGCBD in Asia.10% dei LGCBD in Asia.•• Correlato alla senescenza del sistema immunitario.Correlato alla senescenza del sistema immunitario.•• 70% extranodale.70% extranodale.•• Citologia polimorfa od a grandi cellule, con elementi Citologia polimorfa od a grandi cellule, con elementi

similsimil--RSRS..•• CD10CD10--, Bcl, Bcl--66--, IRF4+, , IRF4+, EBER+EBER+, EBNA2+, LMP1+, CD30v., EBNA2+, LMP1+, CD30v.•• Mediana di sopravvivenza: 2 anni.Mediana di sopravvivenza: 2 anni.

Geographic necrosisGeographic necrosis

Polymorphic typePolymorphic type

Large cell typeLarge cell type

EBNA2EBNA2 LMP1LMP1 EBEREBER

CD10CD10 IRF4IRF4 CD30CD30

Morphologic and phenotypic characteristicsMorphologic and phenotypic characteristics

Original contributionOriginal contribution

EpsteinEpstein--Barr virusBarr virus––positive diffuse large Bpositive diffuse large B--cell cell lymphoma in elderly patients is rare in Western lymphoma in elderly patients is rare in Western populationspopulationsS. S. HoellerHoeller, A. , A. TzankovTzankov, S. A. Pileri, P. Went and S. , S. A. Pileri, P. Went and S. DirnhoferDirnhofer

Institute of Pathology, University Hospital, University of BaselInstitute of Pathology, University Hospital, University of Basel, 4031 Basel, Switzerland, 4031 Basel, SwitzerlandDepartment of Department of HematologyHematology and Oncological Sciences and Oncological Sciences ““L. and A. SerL. and A. Serààgnolignoli””, Hematopathology , Hematopathology Section, Bologna University School of Medicine, St. Orsola HospiSection, Bologna University School of Medicine, St. Orsola Hospital, 40138 Bologna, Italytal, 40138 Bologna, ItalyInstitute of Pathology, Institute of Pathology, TriemliTriemli Hospital, Hospital, BirmensdorferstrasseBirmensdorferstrasse 497, 8063 Z497, 8063 Züürich, Switzerlandrich, Switzerland

Human Pathology 2009, EHuman Pathology 2009, E--pub ahead of print.pub ahead of print.

•• Median age: 70 yrs.Median age: 70 yrs.•• M/F = 12.3/1M/F = 12.3/1•• 55--yryr--OS: 20OS: 20--35%35%

ACTACT

EBVEBV--ISHISH

HHV8HHV8--ISIS--PCRPCR

VDJVDJCD79aCD79a

PyothoraxPyothorax--associatedassociated

Ann Ann OncolOncol, 8:1133, 1997, 8:1133, 1997

DLBCL associated with chronic inflammationDLBCL associated with chronic inflammation

•• Liu A et al.: Alterations of Liu A et al.: Alterations of DNA damageDNA damage--response response genes ATM and ATR in genes ATM and ATR in pyothoraxpyothorax--associated associated lymphoma. Lab Invest lymphoma. Lab Invest 2005; 85(3): 4362005; 85(3): 436--46.46.

•• NishiuNishiu M et al.: Distinct M et al.: Distinct pattern of gene expression pattern of gene expression in pyothoraxin pyothorax--associated associated lymphoma (PAL), a lymphoma (PAL), a lymphoma developing in lymphoma developing in longlong--standing standing inflammation. Cancer inflammation. Cancer SciSci2004; 95(10): 8282004; 95(10): 828--34.34.

IFI27IFI27HLA class IHLA class I

•• Nakatsuka S et al: PyothoraxNakatsuka S et al: Pyothorax--associated lymphoma: a review of 106 associated lymphoma: a review of 106 cases. J Clin cases. J Clin OncolOncol 2002; 20(20): 42552002; 20(20): 4255--60.60.

•• Liu A et al.: Alterations of DNA damageLiu A et al.: Alterations of DNA damage--response genes ATM and response genes ATM and ATR in pyothoraxATR in pyothorax--associated lymphoma. Lab Invest 2005; 85(3): associated lymphoma. Lab Invest 2005; 85(3): 436436--46.46.

•• NishiuNishiu M et al.: Distinct pattern of gene expression in pyothoraxM et al.: Distinct pattern of gene expression in pyothorax--associated lymphoma (PAL), a lymphoma developing in longassociated lymphoma (PAL), a lymphoma developing in long--standing inflammation. Cancer standing inflammation. Cancer SciSci 2004; 95(10): 8282004; 95(10): 828--34.34.

•• CheukCheuk W et al: Metallic implantW et al: Metallic implant--associated lymphoma: a distinct associated lymphoma: a distinct subgroup of large Bsubgroup of large B--cell lymphoma related to pyothoraxcell lymphoma related to pyothorax--associated associated lymphoma? Am J lymphoma? Am J SurgSurg PatholPathol 2005; 29(6): 8322005; 29(6): 832--6.6.

•• HojoHojo N et al.: NonN et al.: Non--Hodgkin's lymphoma developing in a pacemaker Hodgkin's lymphoma developing in a pacemaker pocket. pocket. IntInt J J HematolHematol 2003; 77(4): 3872003; 77(4): 387--90.90.

•• MolinieMolinie V et al: Primary EpsteinV et al: Primary Epstein--Barr virusBarr virus--related nonrelated non--Hodgkin's Hodgkin's lymphoma of the pleural cavity following longlymphoma of the pleural cavity following long--standing standing tuberculoustuberculousempyemaempyema. Arch . Arch PatholPathol Lab Med 1996; 120(3): 288Lab Med 1996; 120(3): 288--91.91.

•• Processo EBVProcesso EBV--correlato ad insorgenza extranodale.correlato ad insorgenza extranodale.•• Polmone, encefalo, rene, fegato, cute. Polmone, encefalo, rene, fegato, cute. •• Condizioni di immunodeficienza: Condizioni di immunodeficienza:

trapianto dtrapianto d’’organo allogenico,organo allogenico,sindrome di sindrome di WiskottWiskott--AldrichAldrich, , infezione da HIV, infezione da HIV, sindrome linfoproliferativa sindrome linfoproliferativa ““XX--linkedlinked””, ,

oppure pazienti con alterata funzione immune. oppure pazienti con alterata funzione immune. •• Differenzia da: linfoma nasale/tipo nasale (T/NK; EBVDifferenzia da: linfoma nasale/tipo nasale (T/NK; EBV++; ;

extranodale).extranodale).•• Altamente aggressivo.Altamente aggressivo.

Granulomatosi Granulomatosi linfomatoidelinfomatoide (LYG)(LYG)

LYGLYG

Grado I: Grado I: infiltrato linfoide polimorfo, infiltrato linfoide polimorfo, necrosi non prominente,necrosi non prominente,blasti EBV+/B rari (EBER <5/HPF), blasti EBV+/B rari (EBER <5/HPF), clonalitclonalitàà Ig Ig --. .

Grado II:Grado II: infiltrato linfoide polimorfo,infiltrato linfoide polimorfo,necrosi prominente,necrosi prominente,blasti B (RS simili) EBV+ molto abbondanti,blasti B (RS simili) EBV+ molto abbondanti,clonalitclonalitàà Ig +/Ig +/-- (anche diverse in sedi diverse).(anche diverse in sedi diverse).

Grado III:Grado III: quadro da linfoma a grandi cellule B, quadro da linfoma a grandi cellule B, (approccio clinico(approccio clinico--terapeutico da LGCBD), terapeutico da LGCBD), clonalitclonalitàà Ig +.Ig +.

CuteCute SNCSNC PolmonePolmone

Lymphomatoid granulomatosis Lymphomatoid granulomatosis

EBEREBER EBNA2EBNA2

LMP1LMP1 ZEBRAZEBRA

ExtrathymicExtrathymic perivascular perivascular spacespace

Thymic folliclesThymic follicles

CD23CD23+ + asteroid Basteroid B--cellscellsMedullary B lymphocytesMedullary B lymphocytes

Fend F et al, Fend F et al, VirchowsVirchows Arch B 60:381, 1991.Arch B 60:381, 1991.TCL1TCL1--, CD27, CD27++: : RemottiRemotti D et al. J Clin D et al. J Clin PatholPathol ((SupplSuppl), 2002.), 2002.CD23CD23++: : CalaminiciCalaminici MR et al, Histopathology 45:619, 2004.MR et al, Histopathology 45:619, 2004.

Thymus: normal B lymphocytesThymus: normal B lymphocytes

CLINICACLINICA

Predilezione per donne nellaPredilezione per donne nellaIV decade di vita.IV decade di vita.

Malattia in I/II stadio allMalattia in I/II stadio all’’esordio, con frequente esordio, con frequente massa massa bulkybulky ((∅∅≥≥10 cm) e sindrome della vena 10 cm) e sindrome della vena cava superiore.cava superiore.

Possibile diffusione al polmone, fegato, rene, Possibile diffusione al polmone, fegato, rene, gonadi, intestino e SNC.gonadi, intestino e SNC.

Molto sensibile al MACOPMolto sensibile al MACOP--B (in associazione con B (in associazione con la radioterapia, pila radioterapia, piùù recentemente al Rituximab).recentemente al Rituximab).

Sclerosi con compartimentalizzazioneSclerosi con compartimentalizzazione

Cellule Cellule chiarechiare Cellule Cellule acidofileacidofile

FENOTIPOFENOTIPO

CD30CD30 86%86%CD45 e CD45 e marcatorimarcatori BB 100%100%CD15CD15 --EBVEBV --BclBcl--66 80%80%IRF4IRF4 75%75%BclBcl--22 80%80%Ig (Ig (ancheanche ISH) (BOB.1ISH) (BOB.1++/Oct/Oct--22++/PU.1/PU.1++)) --ProteinaProteina MAL MAL 70%70%FIG1FIG1 75%75%CC--relrel 100%100%

} } CGCG

CD30CD30 BclBcl--66 IRF4IRF4

IgIgOct.2Oct.2 BOBBOB--11

GENOTIPOGENOTIPO

Mutazioni di BCLMutazioni di BCL--66

Mutazioni somatiche dei geni delle IgMutazioni somatiche dei geni delle Ig

Amplificazione in 9p24Amplificazione in 9p24

Break Break pointpoint in 16p13.13 in 16p13.13

CGCG

9p

NFNF--kB kB –– CC--RELREL

Large neoplastic cells within the Large neoplastic cells within the luminaluminaof vessels, particularly capillaries, with of vessels, particularly capillaries, with exception of larger arteries and veins.exception of larger arteries and veins.

IVLIVL

CD5CD5+ + DLBCLDLBCL

Phenotype, GenotypePhenotype, GenotypeClinical featuresClinical features

Histology, Clinical featuresHistology, Clinical features

Neurological signs Neurological signs Cutaneous lesionsCutaneous lesionsRespiratory disturbanceRespiratory disturbance

•• When characteristic neurological and dermatologic When characteristic neurological and dermatologic abnormalities are absent, the diagnosis of IVLBCL is abnormalities are absent, the diagnosis of IVLBCL is usually difficult, and often not made until autopsy.usually difficult, and often not made until autopsy.

•• IVLBCL is usually associated withIVLBCL is usually associated with nonspecific nonspecific symptoms, such as fever, malaise and anemia, symptoms, such as fever, malaise and anemia, probably due to probably due to dysregulationdysregulation of inflammatory of inflammatory cytokines.cytokines.

•• Many of the IVLBCL patients among Japanese are Many of the IVLBCL patients among Japanese are associated with associated with hemophagocytichemophagocytic syndrome (syndrome (MuraseMuraseet al.1997et al.1997).).

KiKi--6767

IVLBCLIVLBCLAsian Asian variantvariant

AnthracyclineAnthracycline--based chemotherapies are based chemotherapies are effective for IVLBCLeffective for IVLBCL

Survival (Days)

3000200010000

Prob

abilit

y1.0

.8

.6

.4

.2

0.0

Anthracycline

Yes(N=62)

censored

No (N=17)

censored

LogLog--lanklankP<P<0.00010.0001

(N=61)(N=61)

(N=14)(N=14)

, 2008

ALK+ DLBCLALK+ DLBCL: : IgAIgA/ALK/ALK++, CD30, CD30--, CD45, CD45+w+w, EMA, EMA++, , CD4CD4++, CD57, CD57++

t(2;17)/CLTR/ALK, fullt(2;17)/CLTR/ALK, full--length ALK or t(2;5)/NPM/ALKlength ALK or t(2;5)/NPM/ALK

Median survival: Median survival: 11 months11 months

LinfomaLinfoma PlasmoblasticoPlasmoblastico•• MaschiMaschi HIV+ HIV+ didi etetàà compresacompresa frafra 11 11 eded 86 86 annianni ((medianamediana: :

50).50).•• AltreAltre cause: cause: immunosoppressioneimmunosoppressione iatrogenaiatrogena..•• CostanteCostante presenzapresenza delldell’’EBVEBV nelnel genoma genoma delledelle cellule.cellule.•• Markers Markers ““plasmacellulariplasmacellulari”” (CD38, CD138, VS38c, (CD38, CD138, VS38c,

hTPD52, IRF4); hTPD52, IRF4); negativitnegativitàà per CD20, PAX5 e CD45; per CD20, PAX5 e CD45; CD79a+; CD79a+; CIgCIg+/+/--..

•• EstremaEstrema aggressivitaggressivitàà ((decessodecesso entroentro 12 12 mesimesi).).

linfoplasmociticolinfoplasmocitico plasmoblastoplasmoblasto plasmacellulaplasmacellula

IRTA1IRTA1--, CD45 , CD20 ,, CD45 , CD20 ,

markersmarkers plasmacellulariplasmacellulari

CD45CD45--, CD20, CD20--,,

markersmarkers plasmacellulariplasmacellulari++

EBEREBER

Linfoma plasmoblastico (CD20Linfoma plasmoblastico (CD20--, CD45, CD45--, CD138, CD138++))ChettyChetty R et al. Histopathol 42:605R et al. Histopathol 42:605--9, 20039, 2003

LGCBD in malattia di Castleman HHV8+LGCBD in malattia di Castleman HHV8+

•• Pazienti Pazienti HIV+HIV+ con malattia di Castleman con malattia di Castleman multicentrica HHV8+ (Africa e Mediterraneo).multicentrica HHV8+ (Africa e Mediterraneo).

•• Possibile associazione con il sarcoma di Possibile associazione con il sarcoma di KaposiKaposi..

•• Linfonodi, milza ed eventualmente sangue Linfonodi, milza ed eventualmente sangue periferico.periferico.

•• Linfoma Linfoma plasmoblasticoplasmoblastico..•• Sopravvivenza di pochi mesi.Sopravvivenza di pochi mesi.

HHV8HHV8 IgMIgM

κκ λλ

Primary effusion lymphomaPrimary effusion lymphoma::

Immunodeficiency (HIV).Immunodeficiency (HIV).

HHV8HHV8--associated (+EBV).associated (+EBV).

Pleural, pericardial or peritoneal cavity + GIT or softPleural, pericardial or peritoneal cavity + GIT or soft

tissues; no lymph node involvement.tissues; no lymph node involvement.

--Morphology: very pleomorphic cells with someMorphology: very pleomorphic cells with some

plasmacellular differentiation.plasmacellular differentiation.

Phenotype:Phenotype: CD45CD45++, CD30, CD30++, CD38, CD38++, CD138, CD138+or +or --, LMP, LMP--11--,,

BB--cell markerscell markers-- or + (IRF4)or + (IRF4). ISH: EBER. ISH: EBER++..

Prognosis:Prognosis: rapidly fatal.rapidly fatal.

Primary effusion lymphoma Primary effusion lymphoma

Rectum Rectum –– HIVHIV++ patientpatient

LANA > IL10 & IL6LANA > IL10 & IL6

HHV8HHV8++ DLBCLDLBCL

HIVHIV++ patientpatient

IRTAIRTA--11 LambdaLambdaCMVCMV

CD20CD20

LANALANA

κκ

VV--IL6IL6

λλ

•• Most cases have morphologic features intermediate Most cases have morphologic features intermediate between BL and DLBCL.between BL and DLBCL.

•• Some of them have been previously classified as Some of them have been previously classified as BurkittBurkitt--like lymphoma.like lymphoma.

•• They more often have high proliferation rate, starryThey more often have high proliferation rate, starry--sky sky pattern and immunophenotype consistent with BL.pattern and immunophenotype consistent with BL.

•• Some cases may be morphologically more typical of BL Some cases may be morphologically more typical of BL but have an atypical immunophenotype or genetic but have an atypical immunophenotype or genetic features that preclude a diagnosis of BL.features that preclude a diagnosis of BL.

•• These relatively rare lymphomas are more often widely These relatively rare lymphomas are more often widely disseminated and observed in old individuals.disseminated and observed in old individuals.

TrainingsetmBL index >.95 mBL index <.05

Typical Burkitt morphologyTypical Burkitt morphology

Age Age distributiondistribution

kein MYC Bruchkein MYC Bruch

MYC BruchMYC Bruch

Impact of MYC Impact of MYC breaksbreaks on on survivalsurvival of of molecularmolecular subgroupsubgroup

Genetic featuresGenetic features mBLmBL IntermediateIntermediateNonNon--mBLmBL

Genetic ComplexityGenetic Complexity 3,53,5 8,88,8 9,39,3

MYC break (total)MYC break (total) 91%91% 54%54% 7%7%IGIG--MYCMYC--breakbreak 91%91% 33%33% 4%4%

NONNON--IGIG--MYCMYC--breakbreak 0%0% 21%21% 3%3%

mBLmBL

NonNon--mBL/IntermediatemBL/Intermediate MYCMYC--

NonNon--mBL/IntermedimBL/Intermediäärr MYC+MYC+

MYC MYC breakbreak = = favorablefavorable prognosisprognosis

MYC MYC breakbreak = = ununfavorablefavorableprognosisprognosisDefinition of a Definition of a novelnovel prognosticprognosticsubgroupsubgroup in aggressive Bin aggressive B--NHL NHL ororDLBCLDLBCL