Week 6 presentation

Swelling In Neck Presentation by Group E

Case summary Mr. Salim , 62 year old , history of right sided neck

swelling , , swelling in his left inguinal region , lost 7-8 kg in past 3 months , physical examination findings : right cervical + left inguinal LNs size 1.5-2.5 cm , LDH was elevated , biopsy: NHL , CD19/CD20/CD45 +ve ; diagnosed with diffuse large B cell NHL , treated with rituximab and CHOP.

Objectives 1 - lymphadenopathy ; generalized and

localized causes

2 - anatomy of lymphatic system+histology -

3 - cat scratch and lymph node swelling

4 - criteria for significant weight loss and relation between cancer and weight loss

5 - physical examination of Lymph nodes

6 - difference between lymphomas and leukemias

7 - lymphoma 

* difference between HL and NHL  

* types

* signs and symptoms

* investigation

* grading and staging + pathogenesis

* risk factors / prognosis / follow up

* treatment

8 - EBV / toxoplasma / brucella

9 - B cell development

10 - BCL6/B2 microglobulin --

Anatomy Of Lymphatic system

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Lymphadenopathy• Literally "disease of the lymph nodes“• Synonymously used with "swollen/enlarged

lymph nodes" • Causes:

– Infection– Auto-immune– Malignancy

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Lymphadenopathy - Types Localized lymphadenopathy

Generalized lymphadenopathy Persistent generalized lymphadenopathy (PGL)

Dermatopathic lymphadenopathy

Tangier disease

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Lymphadenopathy - Causes Reactive

Tumoral

Autoimmune

Immunocompromised

Bites

Unknown etiology

Cat scratch disease Caused by: Bartonella henselae or Bartonella quintana

Usually in children 1-2 weeks following a scratch/bite from a cat

Presents as tender, swollen LN near site of bite/scratch and limited to 1 side (regional lymphadenopathy). May have a erythematous papule at the site, also have systemic symptoms (malaise, decreased appetite, aches)

Course is benign and self-limiting, resolves spontaneously with or without treatment after 1 month, but the lymphadenopathy may persist for a few months even after the other symptoms disappear.

Best diagnosis by PCR, can also use Warthin-Starry stain.

What is the difference between leukemia ad lymphoma ?

Subtype Morphology & Immunophenotype

Nodular sclerosis (65-70%) Frequent lacunar cells and occasional diagnostic RS cells; background infiltrate composed of T lymphocytes, eosinophils, macrophages & plasma cells; fibrous bands dividing cellular areas into nodules. RS cells CD15+, CD30+; EBV -

Mixed cellularity (20-25%) Frequent mononuclear and diagnostic RS cells; background infiltrate rich in T lymphocytes, eosinophils, macrophages, plasma cells; RS cells CD15+, CD30+; 70% EBV+

Lymphocyte rich Frequent mononuclear and diagnostic RS cells; background infiltrate rich in T lymphocytes; RS cells CD15+, CD30+; 40% EBV+

Lymphocyte depletion <(5%)

Reticular variant: Frequent diagnostic RS cells and variants and a paucity of background reactive cells; RS cells CD15+, CD30+; most EBV+

Lymphocyte predominance (5%)

Frequent L&H (popcorn cell) variants in a background of follicular dendritic cells & reactive B cells; RS cells CD20+, CD15-, C30-; EBV-

Hodgkin Lymphoma

Germinal centerMantle

zoneNaïve B cells

Follicular

Marginal zone memory B cell

Plasma cells

Marginal zone lymphoma(MALToma)

MyelomaSmall lymphocytic lymphoma

Mantle cell lymphoma

Histogenesis of B cell Non-Hodgkin Lymphoma

Lymphoma

NHL1. Indolent lymphomas(low grade)

– Follicular center lymphomas– Small lymphocytic lymphomas– Lymphoplasmacytoid lymphoma– Mycosis fungoides– Marginal zone lymphoma (MALT)

2. Aggressive lymphomas (high grade)– Diffuse large B-cell lymphoma– Anaplastic large cell lymphoma– Follicular center cell lymphoma– Mantle cell lymphoma– Lymphoblastic lymphoma– Burkitt’s lymphoma

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Risk factors for non-hodgkin lymphoma• Age: 60+• Gender: male• Race: whites > african/asian americans• Exposure to chemicals: benzene, herbicides, insecticides,

treatment with chemotherapy for hodgkin disease• Radiation exposure• Immune deficiency (HIV, immunosuppressant after organ

transplant)• Autoimmune disease (SLE, RA, celiac sprue)• Infections: (HTLV-1, EBV, HHV8 act directly) and ( H. pylori,

Chlamydophila psittaci, C. jejuni, HCV, treat these with antibiotics and the lymphoma is usually treated)

• Obesity and high fat diet

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Follicular lymphoma• Morphology

– Lymph nodes proliferation have a nodular appearance– Predominantly small cleaved cells (centrocyte like cells) with

condensed chromatin and indistinct nucleoli admixed with variable number of centroblast like cells (larger, vesicular chromatin, several nucleoli, modest amount of cytoplasm)

• Immunophenotype & molecular features– Pan-B- Cell markers : CD19, CD20, CD10– BCL6 (transcription factor that’s required for follicular center formation)– BCL2 (characteristic, absent in normal follicular B cells, functions to prevent

apoptosis, protects the tumor cells from the effects of chemo agents)

• Karyotype– t(14;18) translocations

40% progresses to diffuse large B-cell lymphoma

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Diffuse Large B-Cell Lymphoma

• MorphologyNuclei are 3-4x larger & can take a variety of forms, it can resemble

either:– Centroblasts

• Round, irregular, cleared nuclear contours, • dispersed chromatin, • distinct nuclei • > pale cytoplasm

– Immunoblasts• Large, round multilobulated vesicular nucleus• 1 or 2 central nucleoli• Pale or intensely staining cytoplasm

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• Immunophenotype & molecular featuresThese are mature B-cell tumors that express

– Pan-B-Cell antigen; CD19, CD20– Variable expression of ;IgM, IgG, CD10

• Karyotype– 30% t(14;18) translocation involving the BCL2 gene

(represents transformed follicular lymphomas)– 1/3rd rearrangements of the BCL6 genes and mutations.

(this leads to and increase in BCL6 protein levels)• Distinct subtypes

– AIDS, Immunosppression (iatrogenic -> transplants)EBV driven polyclonal Bcell proliferation large B-cell lymphoma

– KSHV/HHV-8primary effusion lymphomas; pleura, pericardium, peritoneum.

– Medistinal large Bcell lymphoma young females, abdominal visera/CNS

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Mantle Cell lymphoma• Morphology

– Involve LN in a diffuse /vaguely nodular pattern– Tumor cells:

• Larger than normal lymphocytes• Irregular nucleus• Inconspicuous nucleoli

– Majority of cases Bone marrow spread– 20% with peripheral blood involvement– Characteristic: association of GIT (in the form of multifocal

submucosal nodules that resemble polyps-lymphatoid polyposis-)• Immunophenotype & MF

– Tumor cells co-express surface IgM, IgD.– Pan-B-cell Antigens CD19, CD20, CD5.

• Karyotype– t(11;14) translocation.

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Burkitt’s lymphomaAffects children /young adults.o African variety (endemic): jaw tumor, strongly linked to

EBV infectiono Sporadic type – worldwide- :(abdominal) bowel, retro-

peritoneum and Ovary • Morphology

– Tumor cells; uniform intermediate in size– Round/oval nuclei (2-5 prominent nucleoli)– Characteristic:

• high mitotic rate & cell death. • “Starry-sky” pattern macrophages surrounded

by clear space.• Karyotype

– t(8;14), t(2;8), t(8;22)

EBV

EBV

• Epstein-Barr virus • belongs to Herpesviridae• transmission by close intimate contact• infect B lymphocytes• cause Infectious mononucleosis• lymphocytes become 60-80% of TWBC –

30% are atypical lymphocytes – T cytotoxic• establish latency• immortalization of B cells• first human virus related to malignancy

Virion Structure

• like all herpesvirus virions, it has four structural elements– envelope– tegument– capsid– core

• single liner double-stranded DNA

• replicate in the nucleus

Epidemiology• the virus occurs worldwide• most people become infected with EBV sometime

during their lives• children become infected with EBV – usually

asymptomatic• when adults get infected they present with IM –

increase severity of infection - 50% of the time• transmission of EBV requires intimate contact with

the saliva• kissing disease

EBV and malignancies

• Associated with Burkitt lymphoma

• Unique malignancy of jaw, in children in equatorial Africa

• BL cells contain one of the three chromosome translocations

• C-myc proto-oncogene on chromosome 8 is activated

• Malaria and HIV are known risk factors for BL

NIHAR DASH/College of Medicine/UOS 24

EBV and malignancies

• Nasopharyngeal carcinoma• in china, southeast Asia, North

Africa• no chromosomal alteration• cells involved are epithelial cells

Epstein-Barr virus and cancer

NHL clinical presentation

Low-grade

• Painless, slowly progressive peripheral lymphadenopathy.

• Primary extranodal involvement and systemic symptoms in patients with advanced or end-stage disease.

• Bone marrow: cytopenia.• Splenomegaly,

Hepatomegaly

Intermediate- and high-grade

• rapidly growing and bulky lymphadenopathy.

• Systemic symptoms and extranodal involvement

• Hepatomegaly, splenomegaly.

• Obstructive hydronephrosis• Primary CNS lymphomas:

more commonly in patients with immunodeficiency

• Testicular mass.

Skin lesions: associated with cutaneous T-cell lymphoma & anaplastic large-cell lymphoma

Lymphoblastic lymphoma: mediastinal mass, superior vena cava syndrome, and meningeal disease with cranial nerve palsies.

Burkitt's lymphoma: large abdominal mass and symptoms of bowel obstruction.

Physical Examination This Is the link if you want to check it outhttp://qap.sdsu.edu/resources/tools/pdf/lymphnode.pdf

Investigations

• CBC , peripheral smear and platelet count• Metabolic assessment: ESR, LFT, U&E• LDH, B2 Microglobin• Serum protein electrophoresis : monoclonal gammopathy• Serology for infections : HIV, EBV and Toxoplasma• ANA

Laboratory tests

• CT scan • PET scan• MRI (localized )

Imaging

• Core needle biopsy for retroperitoneal area• Excisional biopsy

Lymph node Biopsy

• T cells : CD 5, CD 3 (-)• Mantle cell lymphoma : cyclin-D• B cells: CD 19, CD 20 (+)• Pan leukocyte ag : CD45 (+)

Flow cytometry

• Evaluation for Ig gene rearrangement , TCR rearrangement or specific oncogenes (+)

Molecular studies (PCR/ FISH)

Culture

Histopathology

Diffuse Large B-Cell Lymphoma

Burkitt’s Lymphoma Follicular Lymphoma

Hodgkin Lymphoma Nodular-Sclerosing HL

SLL

Mantle cell lymphoma

Staging tests

• Bone marrow biopsy• CT scan• MRI• Ultrasound• Spinal tap : 2 or more extranodal sites

involved with elevated LDH• PET scan• Bone scan

NHL stagingClinical stages

International prognostic index (IPI)Tool to help predict prognosis of patients with aggressive non-Hodgkin’s lymphoma

One point is assigned for each of the following risk factors:• Age greater than 60 years• Stage III or IV disease• Elevated serum LDH• ECOG/Zubrod performance status of 2, 3, or 4• More than 1 extranodal site

The sum of the points allotted correlates with the following risk groups:• Low risk (0-1 points) - 5-year survival of 73%• Low-intermediate risk (2 points) - 5-year survival of 51%• High-intermediate risk (3 points) - 5-year survival of 43%• High risk (4-5 points) - 5-year survival of 26%

This tool was developed before the use of Rituximab, which has greatly improved prognosis and therefore they aren’t sure how it affects the validity of the tool.

Prognosis5-year relative survival by stage at diagnosis

Stage at diagnosis 5-year relativesurvival (%)

Percentageof cases (%)

Localized (confined to primary site) 82.1 27

Regional (spread to regional lymph nodes) 77.5 19

Distant (cancer has metastasized) 59.9 45

Unknown (unstaged) 67.5 9

This table was from the National Cancer Institute, USA, and was posted in 2010.

Management

Lymphoid malignancies• Hodgkin’s Lymphoma

– Pts with localized or good-prognostic factors brief course of chemotherapy followed by radiotherapy

– Pts with more extensive dz or with B symptoms complete course of chemotherapy

– Regimens:1. ABVD: Doxorubicin, Bleomycin, Vinblastine, Dacarbazine2. MOPP: Mechlorethamine, Vincristine, Procarbazine, Prednisone3. Or combination of drugs from both regimens4. Stanford V: weekly regimen for 12 weeks Mechlorethamine,

Vincristine, Vinblastine, Etoposide, Doxorubicin, Bleomycin, Prednisone radiotherapy

5. Autologous BM transplant cure half pts who fail effective chemo regimen.

Lymphoid malignancies

Low-grade disease, which may be asymptomatic and have no

significant effect on quality of life in some cases, often requires no

treatment or only intermittent treatment with oral chemotherapy. This

disease is not curable by chemotherapy alone.

Aggressive (high-grade) disease: R-CHOP (R =rituximab, an anti-CD20,

C=cyclophophamide, H= Hydroxydoxorubicin, O = oncovin = vincristine,

p=prednisone).

Treatment of Non- Hodgkin Lymphoma

. Diffuse Large B Cell Lymphoma

•CHOP plus rituximab.

•Patients with stage I or non bulky stage II can be effectively treated with

three to four cycles of combination chemotherapy followed by

radiotherapy.

•For patients with bulky stage II, stage III, or stage IV disease, six to eight

cycles of CHOP plus rituximab are usually administered.

Cancer Drug Cell Cycle

Alkylating agents MOA USES SE

Cyclophosphamide

Forms DNA cross-links, inhibition of DNA synthesis & function

NHL, breast & ovarian carcinoma, CLL, Multiple myeloma, retinoblastoma, SCLC, lupus nephritis, arthritis

ImmunosuppressionNon-enzymatic cleavage phosphoramide mustard (toxic to tumor cells) and Acrolein (causes hemorrhagic cystitis): Co-admin MESNA

Chlorambucil CLL, NHL Less severe BM suppression

Dacarbazine Malignant melanoma, HL Moderately myelosuppressive, Hepatotoxicity + Hepatic vascular occlusion

Mechlorethamine HL

Antimetabolites MOA USES SE

Fludarabine Purine antagonist inhibit DNA synthesis & induces cellular apoptosis

CLL, NHL Myelosuppression, Fever, edema, severe neurologic toxicity

Methotrexate Inhibits DHFR and thymidine synthetase

Antimetabolites are S-phase specific and Myelosuppression is the dose-limiting toxicity

6-Mercaptopurine

6-Thioguanine Inhibits de novo purine synthesis

Vinca alkaloids MOA USES SE

Vinblastine

Inhibits mitosis (disrupts microtubule assembly)

HL, in PVB regimen of metastatic testicular tumor

BM suppression with leucopenia is dose-limiting toxicity

VinBLASTine BLASTs Bonemarrow (suppression)

Vincristine With Prednisone induce remissions in childhood leukemiaMOPP, CHOP of HL & NHL, rhabdomyosarcoma, nephroblastoma

Less toxic to BMPeripheral neuropathies dose-limiting toxicitySevere constipation & alopecia

Resistance: increase levels of MDR-1 gene product-glycoprotien transport drug out of the cells

Antibiotics MOA USES SE

DoxorubicinDaunorubicinIdarubicinS-Phase specific

Oxygen free radicals binds to DNA DNA breaksInhibits TopoisomeraseIIIntercalates into DNA

Reversible acute and irreversible chronic cardiomyopathies

Bleomycin Oxygen free radicals binds to DNA DNA breaksInactivated by Bleomycin hydrolase that is found in many tissues except skin & lungs

PVB (testicular carcinoma), Squamous cell carcinoma, ABVD (HL) and NHL

Dose-related pulmonary toxicity (fibrosis) and serious cutaneous toxicity

Procarbazine produces chromosomal breaks and inhibits DNA, RNA, and protein synthesis(lipophilic found in the CSF)USES: Hodgkin's disease (MOPP); it is also active against non-Hodgkin's lymphoma and brain

tumors.Myelosuppression is dose dependent.Procarbazine augments the effects of sedatives. It also causes infertility.Procarbazine is a weak monoamine oxidase inhibitor that may cause hypertension, particularly

in the presence of sympathomimetic agents and food with high tyramine content..10% risk of causing acute Leukemia.

Rituximab antibody to IgG that binds to CD20 antigen on B cells.USES: relapsed non-Hodgkin's lymphoma (R-CHOP regimen), and mantle cell Lymphoma.SE: Dermatologic and gastrointestinal side effects are most common; however, cardiovascular

(angina) and respiratory (obliterative bronchiolitis) toxicities have been reported.

Adrenocorticosteroids (e.g., prednisone, hydroxycortisone, dexamethasone) Adrenocorticosteroids are antimitotic agents. Can be administered orally. They are useful in acute leukemia in children and lymphoma (CHOP and MOPP regimens). Adrenocorticosteroids have significant systemic effects and long-term use is not recommended.

Common Chemotoxicities• Cisplatin/Carboplatin nephrotoxic and acoustic nerve damage• Vincristine peripheral neuropathy• Bleomycin pulmonary fibrosis• Doxorubicin cardiotoxicity• Cisplatin/Carboplatin nephrotoxic and acoustic nerve damage• CYclophosphamide hemorrhagic cystitis• 5-FU myelosuppression• 6-MP myelosuppression• Methotrexate myelosuppression

Follow up

• Depends on which type of lymphoma, which treatment was received, and how well it worked

• Usually regular appointments every few months for the first year and then gradually less, during the appointment you discuss any complaints, physical examination is done with more attention on the lymph nodes, can also have imaging and blood tests done if needed.

Lymphomas and immunology To understand lymphomas .. We have to

understand the diversity in the immune system .

Antibodies ( coming from B cells ) Diversity.

Antibody structure

Antibody diversity Somatic recombination

Junctional diversity

Somatic hyper-mutation

Class switching

Somatic Recombination

RAG Action

Junctional diversity

Somatic Hypermutation Before hyper-mutation and class switch , what is

AID .. ?

AID : Activation –induced cytadine demainase , considered the master regulator of 2ndry Antibody diversity because it is involved in Somatic hyper-mutation and class switching also gene conversion.

Class switching •Isotype switching occurs by recombination between switch regions

•This is under the influence of activation-induced cytadine demainase (AID)

•AID promotes the cleavage of the DNA at the switch regions

•Isotype switching does not affect the antigen specificity of the antibody

Chromosomal tanslocations

Translocation: fusion of one part of the chromosome to another

Proto-oncogenes: genes that can cause cancer when their function or expression is perturbed

In B cell tumors the Ig gene is often joined to a gene involved in control of cell growth This leads to unregulated activation of the translocated gene

BCL6

B-cell lymphoma 6 protein :Is a protein that in humans is encoded by the BCL6 gene.

Function:• This protein acts as a sequence-specific repressor of transcription, and has been

shown to modulate the STAT-dependent Interleukin 4 (IL-4) responses of B cells.

• This gene is found to be frequently translocated and hypermutated in diffuse large B cell lymphoma (DLBCL),and contributes to the pathogenesis of DLBCL.

Diagnostic utility

The presence of BCL6 can be demonstrated in tissue sections using immunohistochemistry. It is exclusively present in the B-cells of both healthy and neoplastic germinal centres. It therefore demonstrates both reactive hyperplasia in lymph nodes and a range of lymphomas derived from follicular B-cells, such as Burkitt's lymphoma, follicular lymphoma.

Why do patients with cancer lose weight

Why do patients with cancer lose weight? In general, weight loss develops because of a negative balance between intake and expenditure of calories. Such a negative balance may occur with decreased calorie intake and normal energy expenditure, with normal calorie intake but increased energy spending, or with decreased calorie intake and increased calorie expenditure.

At the clinical level, an imbalance can result from: (1) inadequate food ingestion; (2) impaired digestion and absorption; (3) external nutrient loss; (4) tumor-host competition for nutrients; or

(5) increased energy expenditure of the host. In the cancer patient, all these abnormalities may occur singly or in combination, thereby contributing to weight loss and eventually to the development of cachexia, the hallmark of cancer.3

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A 64 year old man has inguinal, axillary, and cervical lymphadenopathy. The nodes are firm and nontender. A biopsy specimen of a cervical node shows a histologic pattern of nodular aggregates of small cleaved lymphoid cells and larger cells with open nuclear chromatin, several nucleoli, and moderate amounts of cytoplasm. A bone marrow biopsy specimen shows lymphoid aggregates of similar cells with surface Ig that are CD10+ and CD5-. Karyotyping of these lymphoid cells indicates the presence of t(14;18). What is the most likely diagnosis?

1. Toxoplasmosis2. Acute lymphadenitis3. Follicular lymphoma4. Mantle cell lymphoma

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A 12 year old boy is taken to the physician because he has had increasing abdominal distention and pain for the past 3 days. PE shows lower abdominal tenderness. A CT scan was performed and the mass was removed. Histological examination of the mass shows sheets of intermediate-sized lymphoid cells, with nuclei having coarse chromatin, several nucleoli, and many mitosis. A bone marrow bipsy sample is negative for this cell population. Cytogenic analysis shows a t(8;14) karyotype. Tumor shrinks after aggressive course of chemotherapy. Which of the following is the most likely diagnosis?

Burkitt lymphoma

Follicular lymphoma

Diffuse large b cell lymphoma

Plasmacytomas.

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A 62 year old man visits his physician because of prolonged fever and a 4kg weight loss over the past 6 months. On PE his temperature is 38.6. he has generalized non tender lymphadenopathy, and palpable spleen. Lab studies show Hb 10.1g/dL; hematocrit, 30.3%; platelet count, 140,000/mm3; WBC count, 24,500/mm3 with 10% segmented neutrophils, 1%bands, 86% lymphocytes, 3% monocytes. A cervical LN biopsy specimen shows a nodular pattern of small lymphoid cells. A bone marrow specimen shows infiltrates of similar small cells having surface Ig that are CD5+, but CD10-. Cytogenic analysis indicates t(11:14) in these cells. What is the most likely diagnosis?

1. Mantle cell lymphoma

2. Follicular lymphoma

3. Acute lymphoblastic leukemia

4. Burkitt’s lymphoma