The lymphomas: Hodgkin's disease and non-Hodgkin's lymphomas

This review presents an overview of a heterogeneous group of disorders that fall under the general heading of lymphomas. Many specific subtypes and presentations exist; their presentations, treatments, and prognoses vary greatly. Patients with lymphomas are generally treated with external beam radiation therapy, chemotherapy, or a combination of these two modalities. The community pharmacist may play an important role in management of patients by recognizing and alleviating the distressing side effects of treatment. Unfortunately, prevention and early detection play little role in the management of lymphomas. The improvement in survival rates of patients with all but indolent NHL is a direct result of advances in chemotherapy.

Changes over the course of time in histological subclassification of Hodgkin's disease in Denmark

Primary diagnostic lymph node biopsies from 317 patients with Hodgkin's disease pathologic stage (PS) I or II in the prospective randomised trial of the Danish National Hodgkin Study and from 174 patients with Hodgkin's disease stage III or IV examined and treated at the Finsen Institute, Copenhagen, Denmark, were reviewed. The original diagnosis of Hodgkin's disease was made during the period 1971-1983 and was a result of a consensus among three members of a panel of pathologists. In the current study, the histological material was re-examined in order to critically consider and exclude cases which are not histologically diagnostic but microscopically bear resemblance to Hodgkin's disease, to obtain a uniform subclassification in accordance with recent new points of the Rye classification, to examine possible changes in incidence over the course of time and to examine the NS subclassification according to the BNLI proposals. Two cases (0.4%) were reclassified as not being Hodgkin's disease, and 489 cases (99.6%) were reclassified as Hodgkin's disease in the subgroups: LP 7.5% (16.7%), NS 65.1% (54.7%), MC 21.9% (26.4%) and LD 1.2% (1.2%) (the numerals in brackets state the original subgroups). In 9.7% of the cases, the subclass could not be assessed, because the biopsies were too small for subclassification. The difference between the original and the present subclassification could be explained partly by a change in the criteria for the different subgroups and partly by interobserver disagreement. In the histologically reclassified material, the Rye classification lost its prognostic significance. It was not possible to demonstrate a gradual change over the course of time in the relative number of cases in each subgroup.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunophenotypic study of lymphocyte predominance Hodgkin's disease

An immunophenotypic study of 17 cases of diffuse lymphocyte predominance Hodgkin's disease and 20 cases of nodular lymphocyte predominance Hodgkin's disease, along with eight of mixed cellularity and five of nodular sclerosing Hodgkin's disease, is reported. The atypical cells in nodular lymphocyte predominance Hodgkin's disease showed only minor differences from the published consensus. However, the atypical cells in diffuse lymphocyte predominance Hodgkin's disease showed an immunophenotype which was commonly B-cell positive (59%), but in a minority of cases LeuM1 (24%) or epithelial membrane antigen (12%) positive; none of the cases was Ber-H2 positive. These results do not differ greatly from our findings in nodular lymphocyte predominance Hodgkin's disease, but do diverge from the published consensus for diffuse lymphocyte predominance Hodgkin's disease. The question as to whether morphology or immunophenotype should form the primary diagnostic criterion for the definition of lymphocyte predominance Hodgkin's disease is discussed.

[Hodgkin's disease in the Hospital General de México. Study of 309 cases]

In order to know the frequency and distribution of the histologic types of Hodgkin disease (HD) in the general Hospital of Mexico City and to compare the results with those of other countries; 96,909 surgical specimens were reviewed; 422 were of HD, from which only 309 (0.31%) could be reclassified according to the modified Rye classification, 214 (69%) were male and 95 (31%) female (M:F = 1:2.25). The mean age for the group was 26 years, for females was 30 and for males 24. The graphic for age and sex showed a unimodal curve in both sexes. The most frequent histologic type was mixed cellularity with 175 cases (56.6%), followed by the NE type with 83 (26.9%), the DL with 26 (8.4%) and finally the PL type with 25 (8.1%). In all the groups predominated the males as reported by other authors, but they reported a bimodal curve of age distribution and ours was unimodal as reported in Peru, Colombia, Uganda. The mean age is also one decade younger than in other countries, probably because almost 50% of the Mexican population are youngsters. The distribution of histologic types is similar to those of South Africa, Colombia, Uganda, Zambia and to the poor black population from USA, where the most frequent type is the mixed cellularity. The frequency of the other histologic types differs from the reports of Denmark Sweden, USA and England were the NE type predominates.(ABSTRACT TRUNCATED AT 250 WORDS)

Time trends in Hodgkin's disease incidence. The role of diagnostic accuracy

A prior study of Hodgkin's disease (HD) incidence using national cancer survey data (1969-1980) identified unprecedented rate declines among white persons older than 40 years, and rate increases among young adults aged 15 through 39. These trends could be due to improved diagnostic accuracy. To investigate this hypothesis, the authors updated incidence rates in whites by age, sex, and histologic subtype through 1984; quantified diagnostic accuracy in corresponding detail using Repository Center for Lymphoma Clinical Studies data, which include original and expert review diagnoses on lymphoma patients; and recalculated HD incidence rates (1969-1984) corrected for diagnostic error. Updated HD incidence rates through 1984 continued to decline in older adults and showed persistent increases for young adults with the nodular sclerosis (NS) histologic subtype. The percentage of original HD diagnoses confirmed on review (confirmation rate) decreased with age and increased over time; in older adults, these patterns opposed observed incidence trends. However, for young adults, confirmation rates of NS, the most common subtype at these ages, were high and changed little over time. After adjustment for diagnostic error, incidence rates for older adults were lower than previously observed and showed no secular changes. However, young adults with NS had slightly larger rate increases than in uncorrected data. Thus, contemporary changes in HD incidence for whites primarily involve growing risk to persons at the start of adult life. These patterns are compatible with trends in suspected sociodemographic risk factors that suggest an infectious etiology for HD.

Hodgkin's disease and CD30-positive anaplastic large cell lymphomas--a continuous spectrum of malignant disorders. A quantitative morphometric and immunohistologic study

The authors have examined cellular areas of lymphoma tissue in 28 cases of Hodgkin's disease (HD) or anaplastic large cell lymphoma (ALCL, 'Ki-1 cell lymphoma') to evaluate the boundaries between the two entities. Methods applied included conventional histology; test point analysis; semiautomated morphometry of nuclear profile features of Reed-Sternberg and other atypical large cells (RSALCs); and immunohistochemistry of these elements on all paraffin sections and, in 15 cases, on frozen sections. Mean nuclear profile morphotypes of RSALCs per case varied independently of immunophenotype and histologic diagnosis. Conversely, immunohistochemistry demonstrated significant, although not consistent, preferential positivities of these CD30+ elements for CD15 in HD, and for epithelial membrane antigen (EMA) and CD43 in ALCLs. In the latter, RSALCs also exhibited a tendency for CD45 and CD45RO positivity and for the expression of T-cell-associated antigens. However, there were considerable overlaps. This continuous spectrum of RSALC nuclear profile morphotypes and immunophenotypes, ranging from HD over questionable cases, intermediate between HD and ALCL, to ALCLs, was paralleled by differences in the reactive component of lymphomas. Lymphocytes and granulocytes were significantly deficient in ALCLs.

[Prognostic relevance of histopathologic subtyping of nodular-sclerotic types of Hodgkin's disease]

The paper analyzes the histopathologic pattern of 30 bioptically assessed cases of nodular-sclerotic (NS) type of Hodgkin's disease diagnosed before onset of therapy. The ratio of lymphocytes and tumor cells, as well signs of atypia, pleomorphism and blastic proliferation of tumor cells were evaluated in each case. On the basis of this analysis, the NS type was divided into the subtype NS 1 (14 cases) and subtype NS 2 (16 cases). In the subtype NS 1 lymphocytes were predominant in the tumor nodes and there were only few Sternberg-Reed cells, which were either isolated or in small clusters. Fibrosis in the tumor nodes was mild. In the subtype NS 2 the ratio of lymphocytes was lower, Sternberg-Reed cells were numerous and were found to be in groups and clusters. Pleomorphism and atypia of the tumor cells was remarkable. Pronounced fibrosis was seen in the nodes. The ratio of reactive cells and necroses exhibited individual variation in both subtypes. Statistical evaluation of survival time showed significant differences between the patients with subtype NS 1 and NS 2. Differentiation between NS 1 and NS 2 subtypes of the nodular-sclerotic type of Hodgkin's disease can thus ben considered to be prognostically relevant.

Fine needle aspiration cytodiagnosis of Hodgkin's disease and its subtypes. I. Scope and limitations

The fine needle aspiration (FNA) smears and paraffin-embedded sections from 89 cases with a cytologic and histologic diagnosis of Hodgkin's disease (HD) and 27 cases with minor or major cytohistologic discrepancies were reviewed. The accuracy of the initial cytologic study was found to be 91.8% for diagnosing HD and 58.1% for classifying its subtypes. Following review, 87 of the 89 agreement cases remained classified as HD. Of the 27 cases with initial cytohistologic discrepancies, 12 were classified as HD and 10 were categorized as lymphocytic or non-Hodgkin's lymphoma by both cytology and histology upon review. Following review, the accuracy of FNA cytology for the diagnosis of HD improved to 98.0%, with 71.4% correct subtyping. The greatest limitation of cytologic subtyping was in cases of nodular sclerotic HD: only 3 of 17 cases could be subtyped even after review. The cytomorphologic features of the HD subtypes are described, and the difficulties encountered in the cytodiagnosis of HD are discussed at length. The results of this study indicate that FNA cytology is a useful tool not only for the diagnosis of HD, but also for its subtyping.

Fine needle aspiration cytodiagnosis of Hodgkin's disease and its subtypes. II. Subtyping by differential cell counts

Differential cell counts were performed on fine needle aspiration (FNA) smears from 96 cytologically diagnosed and subsequently biopsy-proven cases of Hodgkin's disease (HD). Reed-Sternberg cells and Hodgkin cells showed a definitely increasing trend in three major HD subtypes (as diagnosed on the smears): lymphocytic predominance (LP), mixed cellularity (MC) and lymphocytic depletion (LD). Lymphocytes, on the other hand, showed a decreasing trend between these subtypes. The differences in the percentages of Hodgkin cells, Reed-Sternberg cells and lymphocytes were highly significant (P less than .001). No trends (increasing or decreasing) were observed in the smear content of other reactive components (non-neoplastic histiocytes, eosinophils, plasma cells and neutrophils). In 88.0% to 95.0% of the cytologically diagnosed cases of LP, MC and LD subtypes, the percentages of Hodgkin cells plus Reed-Sternberg cells fell within a distinct range: less than 1.5% for LP, greater than or equal to 1.5% to less than 7.5% for MC and greater than or equal to 7.5% for LD. Analysis of the data based on histopathologic subtyping of the cases showed similar significant trends in the proportions of Hodgkin cells, Reed-Sternberg cells and lymphocytes, with 70.0% to 80.0% of the LP, MC and LD subtype cases within these ranges. These results demonstrate the validity of the subjective subtyping of HD on FNA smears in most cases.

[Histopathology of malignant lymphomas]

Histopathological features of malignant lymphomas were described and discussed. For the standard classification of malignant lymphomas, the Rye classification for Hodgkin's disease and the International Working Formulation for the non-Hodgkin's lymphoma were recommended. Recent advances in immunology make immunophenotyping of lymphoma cells possible. The usefulness of immunophenotyping in routine paraffin sections was suggested. Some problems of the Working Formulation in classifying T-cell lymphomas were also discussed. A significant difference in the 5-year survival between the different histological grades of Working Formulation and between T and B phenotypes was found in a survey using 604 non-Hodgkin's lymphoma cases of our own. It is concluded that precise histological typing and immunophenotyping of lymphomas are mandatory in the diagnosis, treatment and prediction of the prognosis of patients with malignant lymphomas.

Hodgkin's disease with CD 20 (B1) positive Reed-Sternberg cells--an immunohistochemical and immunoelectron microscopic study

20 cases of Hodgkin's disease, [five nodular sclerosis (NS), 12 mixed cellularity (MC), and three lymphocytic depletion (LD)] were studied immunohistochemically and immunoelectron-microscopically to clarify the origin of Reed-Sternberg (RS) cells. The majority of RS cells expressed activated lymphoid cell-associated antigens (CD 30, CD 25, HLA-DR) and granulocyte-associated antigen (CD 15). RS cells in seven cases (one NS, five MC and one LD) reacted with CD 20 (B1). Three of these cases (all three MC) were also positive with CD 19 (B4). These findings suggest that some RS cells may be of B cell lineage.

[Hodgkin's disease--a histologic problem]

Since the Rye classification of Hodgkin's disease, many lesions which resemble Hodgkin's disease microscopically have been described. The histological features of Hodgkin's disease, including the BNLI subclassification of nodular sclerosis, and the lesions which resemble Hodgkin's disease microscopically such as reactive lymph node hyperplasias, some non-Hodgkin's B- and T-cell lymphomas are reviewed. Recent reclassifications of lymphomas originally diagnosed as Hodgkin's disease have indicated that the disease was overdiagnosed, before the description of these lesions and before the development of monoclonal antibodies.

Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin's disease: Cotswolds meeting

The Ann Arbor classification for describing the stage of Hodgkin's disease at initial presentation has formed the basis upon which treatment is selected and has allowed comparison of results achieved by different investigators for almost two decades. A meeting was convened to review the classification and modify it in the light of experience gained in its use and new techniques for evaluating disease. It was concluded that the structure of the classification be maintained. It was particularly recommended: (1) that computed tomography (CT) be included as a technique for evaluating intrathoracic and infradiaphragmatic lymph nodes; (2) that the criteria for clinical involvement of the spleen and liver be modified to include evidence of focal defects with two imaging techniques and that abnormalities of liver function be ignored; (3) that the suffix 'X' to designate bulky disease (greater than 10 cm maximum dimension) be introduced; and (4) that a new category of response to therapy, unconfirmed/uncertain complete remission (CR[u]), be introduced to accommodate the difficulty of persistent radiological abnormalities of uncertain significance.

Relationship of histopathologic features to survival and relapse in nodular sclerosing Hodgkin's disease. A study of 1659 patients

Nodular sclerosing (NS) Hodgkin's disease (HD) with extensive areas of lymphocyte depletion or with numerous anaplastic Hodgkin's cells, termed Grade II NS, is associated with a poor response to initial therapy, an increased relapse rate, and decreased survival when compared with other NS variants, termed Grade I NS. The histopathologic subdivision of NS HD into Grade I and Grade II is easy to perform and provides essential prognostic information that is independent of stage. Patients with Grade II NS HD may require more aggressive initial therapy if their survival is to be improved.

The nature of the lymphocytes surrounding Reed-Sternberg cells in nodular lymphocyte predominance and in other types of Hodgkin's disease

The lymphocytes surrounding Reed-Sternberg cells may play an important role in the pathogenesis of Hodgkin's disease. In this study, T cells in different subtypes of Hodgkin's disease were analyzed in situ by an immunoperoxidase method employing a panel of antibodies, including several paraffin tissue-reactive monoclonal antibodies. The T cells in Hodgkin's disease-involved tissues were found to be activated CD4-positive T cells that are UCHL1+ and CD45R-. This immunophenotype is compatible with an activated helper-inducer memory T cell population. The T cells in the nodular lymphocyte predominance subtype were found to have additional positivity for Leu 7, indicating a subpopulation of CD4+ T cells, normally confined to the light zone of germinal centers of secondary follicles.

The histopathologic diagnosis and subclassification of Hodgkin's disease

Although Hodgkin's disease is considered a distinct clinical entity, it exhibits a wide range of histologic and cytologic features. It is important to recognize histologic subtypes and their variants for diagnostic reasons, as well as for their clinical significance. An appreciation of the histologic diversity of Hodgkin's disease may also be critical for the interpretation of data regarding the origin of the RS cell.

Lymphoma phenotyping in formalin-fixed and paraffin wax-embedded tissues: II. Profiles of reactivity in the various tumour types

Recently, monoclonal antibodies capable of phenotyping malignant lymphomas in routinely fixed and processed tissue have become available. Some of these reagents identify lineage-restricted variants of the leucocyte common molecule, whereas others identify unique fixation-resistant epitopes on lymphoid cells, some of which are shared by non-lymphoid tissues. A new generation of antibodies recognizing 'classical' leucocyte antigens such as CD3 are also emerging. Refinements in antigen detection systems, especially for immunoglobulin recognition, combined with these new reagents promise to improve the accuracy of lymphoma diagnosis in routine histopathology. These new antibodies are reviewed, and their limitations, cross reactivities and profiles of staining in lymphoreticular disease are discussed. A strategy for their optimal use is proposed.

Nodular sclerosing, mixed cellularity and lymphocyte-depleted variants of Hodgkin's disease are probable dendritic cell malignancies

The normal counterpart of the Reed-Sternberg cell and its mononuclear variant, collectively referred to as Hodgkin's cells (HC), remains controversial. The possibility that HC are malignant dendritic cells was tested by using a panel of 38 monoclonal antibodies to phenotype the cells from 16 cases of Hodgkin's disease (HD), excluding lymphocyte-predominant HD, and the Hodgkin's cell line L428. The results were then compared with the known phenotype of human dendritic cells. HC stained strongly for HLA Class I and Class II antigens. The leucocyte common antigen was weakly expressed in most cases. Expression of T and B cell markers was unusual, with the exception of the CD40 antigen which was found on a majority of HC. HC commonly expressed the CD11a, CR4 (CD11c), CD15, CD18 and a number of activation antigens but did not stain with a variety of macrophage-specific antibodies. The antigenic phenotype of L428 and the HC of case material were similar. This immunocytological analysis failed to support a lymphocyte or macrophage origin for HC. Instead the antigenic phenotype of the Reed-Sternberg cell and its mononuclear variant more closely resembles that of dendritic cells than of any other haemopoietic cell normally resident in lymph nodes.

Chromosomal abnormalities in Hodgkin's disease

In the hematologic malignant diseases, specific cytogenetic abnormalities correlate with clinical, morphologic, and immunophenotypic features. Although relatively little is known regarding the karyotypic pattern of Hodgkin's disease, it is clear that the involvement of specific chromosomes in numerical and structural abnormalities is nonrandom. Hyperdiploidy is a characteristic feature of Hodgkin's disease and is observed in 70 per cent of tumors that have an abnormal karyotype. A gain of chromosomes 1, 2, 5, 12, and 21 is a recurring numerical abnormality; structural rearrangements involving chromosome 1 are frequently observed. Perhaps as a result of the relatively small number of cases that have been analyzed, recurring structural abnormalities have not yet been identified; it has also not been possible to determine whether the various histologic subtypes of Hodgkin's disease are characterized by unique abnormalities. The prognostic significance of cytogenetic abnormalities in Hodgkin's disease is unclear; however, preliminary results suggest that the karyotype may have prognostic importance in this disease. The correlation of the cytogenetic pattern with the clinical and morphologic features will be essential in evaluating the clinical and biologic significance of chromosomal abnormalities in Hodgkin's disease.

Plasmacytoid monocytes (so-called plasmacytoid T cells) in Hodgkin's disease

The occurrence and distribution of plasmacytoid monocytes (so-called plasmacytoid T cells) were investigated immunohistochemically in 40 cases of Hodgkin's disease. Large numbers of plasmacytoid monocytes were found in all cases of lymphocyte predominance, nodular sclerosing, and mixed cellularity Hodgkin's disease, characterized by a minor degree of architectural effacement. They occurred at the periphery of lymphoid aggregates which mimic the composite nodule of the reactive lymph node and which contained Reed-Sternberg cells and their variants. Despite some immunophenotypic similarities, no further arguments were found to support a relationship between plasmacytoid monocytes and Reed-Sternberg cells. We conclude that plasmacytoid monocytes represent one of the monocyte-derived cells that contribute to the cellular reaction in Hodgkin's disease.

[A review of childhood cases of malignant lymphoma in Osaka, Japan]

Fifty-one cases of malignant lymphomas in patients under 20 years of age have been reviewed in Osaka, Japan. The breakdown of these cases revealed 6 cases (11.8%) of Hodgkin's disease (HD) and 45 cases (88.2%) of a non-Hodgkin's lymphoma (NHL). Both the HD and NHL cases were determined by using the Rye classification, as well as the Rappaport, Kiel, and LSG classifications, respectively. The results have shown that (1) the incidence of HD in childhood is the same as that seen in the adult in Japan; (2) that a NHL of the nodular type is rare in Japan as it is in Western countries; (3) that any significant differences were not present in the distribution of each histologic subtype in the cases of a NHL among Japan and Western countries, and that the lymphoblastic type was the most common. From this study it is concluded that geographical differences were not a factor in comparing cases of childhood malignant lymphomas in Japan and Western countries.