Hodgkin lymphoma

Hodgkin disease was first described more than 175 years ago. Clinically and histomorphologically, the features of Hodgkin lymphoma are unusual for a lymphoma or for other malignancies. The incidence of Hodgkin lymphoma is estimated to be 7400 new cases per year in the United States, resulting in an age-adjusted yearly rate of 2.7 per 100,000 per year. There have been numerous classifications of non-Hodgkin lymphoma over the years, but the organizational schemes of Hodgkin lymphoma have been stable. This article reviews the diagnosis of the various types of Hodgkin lymphoma classification, diagnosis and differential.

Pitfalls in diagnostic hematopathology -- Part II

The overlapping features of malignant lymphomas create a diagnostic "grey zone" , and lead to the invention of "grey zone lymphomas". There are several major grey zone lymphomas: 1) Lymphomas with overlapping features of Hodgkin lymphoma and large B-cell lymphoma; 2) Lymphomas with overlapping features of Burkitt lymphoma and diffuse large B-cell lymphoma; 3) Lymphomas with overlapping features of nodular lymphocyte predominant Hodgkin lymphoma and T-cell/histiocyte rich large B-cell lymphoma; 4) Lymphomas with overlapping features of Hodgkin lymphoma, anaplastic large cell lymphoma (ALCL) and peripheral T-cell lymphoma (PTCL); 5) T-cell classical Hodgkin lymphoma and ALCL-HL. The second review of this series will be dedicated to discussion of the "grey zone" features of the lymphomas and how to narrow down the "grey zone" between those lymphomas.

Childhood lymphomas in Yemen. Clinicopathological study

OBJECTIVE

To find out the frequency of childhood lymphomas in all ages, and to describe patterns of lymphomas in relation to gender and site in Yemen.

METHODS

This is a descriptive record-based study of 1167 cases of lymphomas diagnosed by 3 pathologists in the Department of Pathology, Sana'a University, Sana'a, Yemen from 1st January 2004 to 30th December 2007. The diagnoses were made on hematoxylin and eosin stained, and categorized non-Hodgkin's lymphoma (NHL) according to the National Cancer Institute Working Formulation classification, and Hodgkin's disease (HD) according to Rye classification.

RESULTS

Out of 1167 lymphomas, 801 (68.6%) were NHL, and 366 (31.4%) were HD, amongst these 347 (29.7%) were patients aged < or = 18 years, and 221 (63.7%) had NHL, and 126 (36.3%) had HD. The NHL found was Burkitt (64.8%), diffuse large cell lymphoma (23%), lymphoblastic lymphoma (6.3%), and other miscellaneous types account for 5.9%. The histological types of HD were mixed cellularity (72.3%), lymphocyte predominance (16.6%), nodular sclerosis (7.9%), lymphocyte depletion (0.8%), and nonclassified cases (2.4%). The female to male ratio was 1:1.7. The nodal site accounts for 205 (59%) cases, and 142 (41%) were extranodal. The HD was totally nodal, whereas NHL showed 37.4% nodal, and 62.6% extranodal.

CONCLUSION

Childhood lymphomas in this study is of high grade NHL, and of less favorable prognostic type in HD. This indicates that childhood lymphomas in Yemen have similar patterns as that found in other international studies.

Multicentre phase II study of the baseline BEACOPP regimen for patients with advanced-stage Hodgkin's lymphoma

A German Hodgkin's lymphoma (HL) study group designed the BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone) regimen. In the BEACOPP regimen, treatment intervals were shortened and the dose-intensity was increased compared with those in the ABVD regimen (doxorubicin, bleomycin, vinblastine and darcarbacine), resulting in a long-term disease-free survival rate of approximately 75-80%. In the present study, we evaluated the safety and efficacy of the BEACOPP regimen. Between April 2001 and February 2004, 20 patients with HL of stage IIB or higher who had received no previous treatment were enrolled. The patients were aged 17-69 years (median 22 years). The histologic types were mixed cellularity in four cases and nodular sclerosis in 16 cases. The stages were stage IIB in four cases, stage III in 12 cases, and stage IV in four cases. Nineteen (95%) of the 20 patients achieved complete remission. The 3-year survival rate was 100% and the 3-year progression-free survival rate was 89.7%. Adverse drug reactions were grade 4 neutropenia in 12 patients, grade 3-4 thrombocytopenia in seven patients, and grade 3 or higher non-hematologic toxicities in two patients (stomatitis in one patient and ALT/AST elevation in one patient). The BEACOPP regimen for advanced-stage HL showed an excellent complete remission rate and high efficacy even in stage III/IV patients. However, a long-term risk of the BEACOPP regimen is the development of secondary leukemia or myelodysplastic syndrome. Therefore, long-term follow-up of these patients, including monitoring for toxicities, is necessary.

Classical Hodgkin's lymphoma in adults: guidelines of the Italian Society of Hematology, the Italian Society of Experimental Hematology, and the Italian Group for Bone Marrow Transplantation on initial work-up, management, and follow-up

The Italian Society of Hematology (SIE), the Italian Society of Experimental Haematology (SIES) and the Italian Group for Bone Marrow Transplantation (GITMO) commissioned a project to develop practice guidelines for the initial work-up, therapy and follow-up of classical Hodgkin's lymphoma. Key questions to the clinical evaluation and treatment of this disease were formulated by an Advisory Committee, discussed and approved by an Expert Panel (EP) composed of senior hematologists and one radiotherapist. After a comprehensive and systematic literature review, the EP recommendations were graded according to their supporting evidence. An explicit approach to consensus methodologies was used for evidence interpretation and for producing recommendations in the absence of a strong evidence. The EP decided that the target domain of the guidelines should include only classical Hodgkin's lymphoma, as defined by the WHO classification, and exclude lymphocyte predominant histology. Distinct recommendations were produced for initial work-up, first-line therapy of early and advanced stage disease, monitoring procedures and salvage therapy, including hemopoietic stem cell transplant. Separate recommendations were formulated for elderly patients. Pre-treatment volumetric CT scan of the neck, thorax, abdomen, and pelvis is mandatory, while FDG-PET is recommended. As to the therapy of early stage disease, a combined modality approach is still recommended with ABVD followed by involved-field radiotherapy; the number of courses of ABVD will depend on the patient risk category (favorable or unfavorable). Full-term chemotherapy with ABVD is recommended in advanced stage disease; adjuvant radiotherapy in patients without initial bulk who achieved a complete remission is not recommended. In the elderly, chemotherapy regimens more intensive than ABVD are not recommended. Early evaluation of response with FDG-PET scan is suggested. Relapsed or refractory patients should receive high-dose chemotherapy and autologous hemopoietic stem cells transplant. Allogeneic transplant is recommended in patients relapsing after autologous transplant. All fertile patients should be informed of the possible effects of therapy on gonadal function and fertility preservation measures should be taken before the initiation of therapy.

[Clonality analysis and mutational status of IgVH gene in Hodgkin variant of Richter syndrome]

OBJECTIVE

To detect the clonal relationship, the rearrangement, and the mutational status of IgVH gene; the influence of these molecular characteristics on the clinical outcome in Hodgkin variant of Richter syndrome; and the possible molecular pathogenesis in this transformation.

METHODS

The clonal rearrangements and mutational status of IgVH genes were analyzed in Hodgkin variant of Richter syndrome and B-CLL with Reed-Stemberg (R-S)-like cells by GeneScan analysis and sequencing. Semi-nest PCR based on laser capture microdissection was utilized to compare the clonal relationship between B-CLL and R-S/R-Slike cells. Immunohistochemical staining was used to detect the different expressions of ZAP70, p53, IRF-4 and LMP1 in the two components.

RESULTS

(1) 5/6 B-CLL cases transformed to Hodgkin lymphoma (HL)/R-S-like cells carried the mutated IgVH genes; (2) 2 cases of R-S cells and 1 case of R-S-like cells were clonally distinct from B-CLL clone and express LMP1, whereas 1 case of R-S-like cells was relating to the surrounding B-CLL cells and did not express LMP1; (3) 2/6 B-CLL cases transformed to HL convey VH4-34 and VH3-48 respectively.

CONCLUSIONS

(1) Richter transformation to HL/R-S-like cells evolves from the B-CLL which originates from the germinal center or post germinal center B cells, indicating that different lymphoma cells of different subtypes in Richter syndrome come from different B cell lineage and possibly involve a different pathogenesis and pathway; (2) HL and R-S-like cells evolve from either the B-CLL clone or may develop as a clonally unrelated lymphoma, the independent secondary malignancies are appear to be EBV-positive, possibly as a consequence of the underlying immunodeficiency; (3) The biased usage of IgVH genes suggested a role of antigens involved in the HL variant of Richter syndrome.

Smoking and lymphoma risk in the European prospective investigation into cancer and nutrition

Lymphomas are one of the few cancers that have been increasing in incidence over the past decades. So far, only a few established risk factors have been identified, including immunosuppression and viral infections. Recent evidence suggests etiologic heterogeneity of different lymphoma subtypes. Smoking may affect risk differently, depending on the lymphoma entity. The European Prospective Investigation into Cancer and Nutrition was used to study the role of smoking in the etiology of lymphomas and individual subtypes within a prospective study. Information on baseline and lifetime tobacco smoking by 478,590 participants was collected between 1992 and 2000. Cox proportional hazards regression was used to calculate multivariate-adjusted hazard ratios and 95% confidence intervals. During 3,567,410 person-years of follow-up, 1,371 lymphoma cases (1,304 non-Hodgkin's lymphomas and 67 Hodgkin's lymphomas) were identified. Relative risk for smokers at recruitment was more than twofold higher for Hodgkin's lymphoma (hazard ratio = 2.14, 95% confidence interval: 1.18, 3.87) but was not elevated for non-Hodgkin's lymphoma (hazard ratio = 1.06, 95% confidence interval: 0.94, 1.19) and individual B-cell non-Hodgkin's lymphoma subtypes. In this prospective study, smoking appeared to increase Hodgkin's lymphoma risk consistently in both genders, whereas B-cell non-Hodgkin's lymphoma risk was not associated. Future analysis should involve viral biomarkers and genetic susceptibility markers to elucidate potential mechanisms of smoking-induced carcinogenesis, particularly for Hodgkin's lymphoma.

Malignant lymphomas in Pakistan according to the WHO classification of lymphoid neoplasms

OBJECTIVE

To determine the spectrum of malignant lymphomas in our set up, according to the WHO classification.

METHODS

All the cases diagnosed as malignant lymphoma, during the year 2005, were retrieved from the institution based tumour registry record and classified according to WHO criteria depending on the immunohistochemical results of a panel of lymphoma markers.

RESULTS

The male to female ratio was 2.5:1 for almost all types of malignant lymphomas. The age range was 3 to 80 years. The frequency of Hodgkin's lymphoma, Burkitt's lymphoma and lymphoblastic lymphoma were higher amongst the children, whereas follicular lymphomas, mantle cell lymphoma and CLL/SLL were more frequently reported in 5th, 6th and 7th decades. Of the total cases 62% were nodal and 38% extranodal (majority in the GI tract). Non Hodgkin's lymphoma was more (73%) frequent than Hodgkin's disease. Mixed cellularity and nodular sclerosis were the main histological variants of Hodgkin's disease.

CONCLUSIONS

Immunohistochemistry is not very frequently used in our set up and also at very few other centres. Therefore, its application should be encouraged to raise the quality of data on lymphoid neoplasms and contribute to their control.

Allogeneic transplantation with reduced-intensity conditioning for Hodgkin and non-Hodgkin lymphoma: importance of histology for outcome

Allogeneic stem cell transplantation (SCT) with reduced-intensity conditioning (RIC) has the potential to lead to long-term remissions for patients with lymphoma. However, the role of RIC SCT in the treatment of lymphoma is still unclear. Specifically, the relative benefit of RIC SCT across lymphoma histologies and the prognostic factors in this population are incompletely defined. We retrospectively analyzed the outcomes of 87 patients with advanced lymphoma who underwent RIC SCT at the Dana-Farber Cancer Institute over a 6-year period with a homogeneous conditioning regimen consisting of fludarabine and low-dose busulfan. Thirty-six patients had Hodgkin disease (HD) and 51 had non-Hodgkin lymphoma (NHL). Sixty-eight percent had undergone prior autologous transplantation. The 1-year cumulative incidence of nonrelapse mortality was 13%, and the 3-year cumulative incidence of progression was 49%. The incidence of grade 3-4 acute GVHD was 11%. The 2-year cumulative incidence of chronic GVHD was 68%, and its development was associated with a decreased risk of progression and an improved progression-free survival (PFS). Three-year overall survival (OS) was 56% for patients with HD, 81% for indolent NHL, 42% for aggressive NHL, and 40% for mantle cell lymphoma. The corresponding figures for 3-year PFS were 22%, 59%, 22%, and 30%, respectively. Multivariate analysis identified elevated pretransplantation lactate dehydrogenase (LDH) as an adverse factor for PFS, while indolent NHL histology was favorable. For OS, advanced age and elevated pretransplantation LDH were adverse factors, whereas indolent NHL histology was favorable. Low early donor chimerism was not predictive of poor outcome in univariate or multivariate analyses. Moreover, progression was not associated with loss of chimerism. These results emphasize the importance of lymphoma histology for patients undergoing RIC SCT, as well as the lack of relevance of donor chimerism for outcome in this patient population.

Nodular lymphocyte predominant Hodgkin lymphoma at atypical locations may be associated with increased numbers of large cells and a diffuse histologic component

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) typically affects predictable lymph node groups with excellent treatment outcomes, but cases with a diffuse histologic pattern are associated with recurrence and rarely, cases will transform to diffuse large B-cell lymphoma. Although increased numbers of large cells has not been associated with poor prognosis, transformation is thought to histologically progress through a stage distinguished by increasing numbers of large atypical B-cells. From 55 cases of NLPHL, we describe a possible subset of NLPHL occurring in older individuals at atypical sites, associated with increased numbers of large cells, a diffuse histologic component, and expression of Bcl-2.

Changing patterns in the frequency of Hodgkin lymphoma subtypes and Epstein-Barr virus association in Taiwan

Epstein-Barr virus (EBV) infection is a risk factor for Hodgkin lymphoma (HL). To test whether the frequency of HL subtypes and their association with EBV has shifted with rising socioeconomic status in Taiwan, we compared the pathological features and EBV status, detected by in situ hybridization, of HL diagnosed between 1996 and 2007 (99 cases) and 1982 and 1995 (74 cases). The male-to-female ratio was 121:52 (2.3:1) and the mean age at presentation was 41.5 years. The overall EBV positivity rate was 50% (86/173 cases). Comparing the distribution of HL cases diagnosed at two different time periods, we found an increased frequency of the nodular sclerosis (NS) subtype (53 vs 68%, P = 0.045), a decreased frequency of the mixed cellularity subtype (35 vs 13%, P < 0.001), a reduced male-to-female ratio (2.9:1 compared to 1.4:1) and mean age (42.4 vs 36.6 years) in the NS subtype, and a significant decrease in EBV positivity rates among the NS and lymphocyte-depletion subtypes (61 vs 39%, P = 0.03). These data indicate shifts in the frequency of histological subtype and EBV association for HL in Taiwan over the last decade, with a trend closer to that seen in Western countries and Japan.

Lymphomas in Iran

BACKGROUND

The present study aimed at examining the lymphomas in Iran.

METHODS

This study was conducted in 1994 on patients' specimens who were referred to our centers during 1981-1994. Using the histochemical methods, the immunohistochemical markers were used to examine the biopsied specimens of 434 patients with non-Hodgkin's and Hodgkin's lymphomas. The patients were classified according to the updated Kiel and Rye classifications, respectively.

RESULTS

Out of the 385 cases that were diagnosed as lymphoma, 277 had non-Hodgkin's and 108 had Hodgkin's lymphomas. Sixty-four point five percent of those with non-Hodgkin's lymphoma had the B type disease; 7.5% had the T-type; and the remaining 28% had Hodgkin's lymphoma. In the present study, most (48%) patients with Hodgkin's lymphoma had mixed cellularity whereas in western countries the most common type is reported to be nodular sclerosis (69.4%).

CONCLUSION

The comparison made between the findings of this study and those of western countries indicates that high-grade non-Hodgkin's lymphomas are more prevalent in Iran.

Cigarette smoking and risk of Hodgkin lymphoma: a population-based case-control study

BACKGROUND

Studies have inconsistently reported an association between tobacco smoking and Hodgkin lymphoma (HL) risk. The conflicting finding may reflect etiologic heterogeneity between HL subtypes, warranting further characterization of the relationship.

METHODS

We collected information on tobacco-smoking habits in 586 classic HL cases and 3,187 population controls in a Danish-Swedish case-control study. HL EBV status was established for 499 cases by standard techniques. Odds ratios (OR) for an association with cigarette smoking were calculated by logistic regression for HL overall and stratified by age, sex, major histology subtypes, and tumor EBV status, adjusting for known confounders.

RESULTS

Compared with never smokers, current cigarette smokers were at an increased overall HL risk [adjusted OR, 1.57; 95% confidence interval (95% CI), 1.22-2.03]. The association was strongest for EBV-positive HL (adjusted OR, 2.36; 95% CI, 1.51-3.71), but also applied to EBV-negative HL (adjusted OR, 1.43; 95% CI, 1.05-1.97; P(homogeneity EBV-pos) versus P(homogeneity EBV-neg) = 0.04). The association did not vary appreciably by age, sex, or histologic subtype, the apparent EBV-related difference present in all strata. There was no evidence of a dose-response pattern, whether by age at smoking initiation, daily cigarette consumption, number of years smoking, or cumulative number of cigarettes smoked. Similar results were obtained in analyses using non-HL patients (n = 3,055) participating in the founding study as comparison group.

CONCLUSION

The observed association between cigarette smoking and HL risk is consistent with previous findings and biologically credible. Although not easily dismissed as an artifact, the limited evidence of a dose-response pattern renders the overall evidence of causality weak.

World Health Organization and beyond: new aspects in the pathology of an old disease

Hodgkin's lymphoma is a highly enigmatic lymphoma disease that still covers most of its secrets up to now. Much effort has been made to successfully wrest at least some of the pathogenetic particularities. The current diagnostic criteria are well established allowing hemato-pathologists to make a clear-cut distinction from other lymphomas in almost all cases. Although classic Hodgkin's lymphoma is curable in the vast majority of cases by treatment with highly aggressive drugs with or without radiotherapy, further molecular studies may lead to the identification of therapeutic targets that enable a more tailored treatment with fewer side effects.

High expression of several tyrosine kinases and activation of the PI3K/AKT pathway in mediastinal large B cell lymphoma reveals further similarities to Hodgkin lymphoma

Mediastinal large B-cell (MBL) and classical Hodgkin lymphoma (HL) have several pathogenic mechanisms in common. As we recently observed aberrant tyrosine kinase (TK) activities in HL, we now analysed also MBL for such activities. Indeed, MBL and HL were the only B-cell lymphomas where elevated cellular phospho-tyrosine contents were typical features. Three TKs, JAK2, RON and TIE1, not expressed in normal B cells, were each expressed in about 30% of MBL cases, and 75% of cases expressed at least one of the TKs. Among the intracellular pathways frequently triggered by TKs, the PI3K/AKT pathway was activated in about 40% of MBLs and essential for survival of MBL cell lines, whereas the RAF/mitogen-activated protein kinase pathway seemed to be inhibited. No activating mutations were detected in the three TKs in MBL cell lines and primary cases. RON and TIE1 were each also expressed in about 35% and JAK2 in about 53% of HL cases. JAK2 genomic gains are frequent in MBL and HL but we observed no strict correlation of JAK2 genomic status with JAK2 protein expression. In conclusion, aberrant TK activities are a further shared pathogenic mechanism of MBL and HL and may be interesting targets for therapeutic intervention.

Nodular lymphocyte-predominant hodgkin lymphoma

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL), a distinct subtype of Hodgkin lymphoma, is a rare disease with a generally favorable prognosis. The hallmark of NLPHL is the presence of the lymphocytic and histiocytic cell, which, in contrast to the classic Reed-Sternberg cell, is CD20+, CD15-, and CD30-. NLPHL tends to have an indolent natural history, a long time to disease progression, a delayed time to relapse, and a high likelihood of presenting as early-stage disease. The evidence to guide the management of patients with NLPHL is limited by the rarity of this disease, but the available data support the use of involved-field radiation therapy alone for localized disease. Treatment-related late effects contribute significantly to the causes of death in patients treated for NLPHL.

Clinical perspectives in lymphoma

The classification of both Hodgkin's and non-Hodgkin's lymphomas continues to evolve. The current World Health Organization classification incorporates data derived from advances in our understanding of the pathogenesis of these disorders together with their distinguishing immunophenotypic, genotypic, clinical and histopathological characteristics. As outcomes have improved, the main emphasis of treatment has been to incorporate a risk-adapted approach to reduce long-term toxicity without sacrificing efficacy through the use of varying combinations of chemotherapy, radiotherapy and immunotherapy.

Haematopathology practice: the commonest problems encountered in a consultation practice

Although not specifically recognized as a subspecialty of histopathology, haematopathology has a long history of specialist practice in the UK, with a few centres attracting large numbers of referred cases. The specialist nature of haematopathology has been enhanced by the advent of immunohistochemistry and, more recently, molecular genetics, which now play a major role in the diagnosis of haematopoietic and lymphoid neoplasms. Problems encountered by non-specialist pathologists, and reflected in those cases submitted for consultation, include difficulties in the differential diagnosis of certain benign lymphoproliferative disorders from lymphoma and the precise classification of lymphomas which may have an impact on therapeutic decisions. Lymphomas that frequently pose problems include common lesions such as follicular lymphoma and more esoteric disorders such as T-cell/histiocyte-rich large B-cell lymphoma. This review is an attempt to clarify a logical approach to the differential diagnosis of these lesions.

MMA monoclonal antibody is a superior anti-CD15 reagent for the diagnosis of classical Hodgkin's lymphoma

CD15 is a useful immunohistochemical marker to identify Reed-Sternberg cells in classical Hodgkin's lymphoma (HL) and to distinguish it from HD-like neoplasms, but data from the literature concerning its expression in HL are quite variable. Using immunohistochemistry we compared the reactivity of three different anti-CD15 clones (MMA, C3D1 and BY87) and found that anti-CD15 MMA clone is a superior reagent in identifying atypical cells, detecting more numerous cells in 28.2%, and being the only positive marker in 12.8% of cases. We conclude that it is advisable to include this reagent in diagnostic immunohistochemical panels.