Malignant large cell lymphoma of B-cell type with multilobated nuclei. Report of a case and review of the literature

The multilobated morphology is still a better prognosis factor of diffuse large B-cell lymphoma in the R-CHOP era

Diffuse large B-cell lymphoma (DLBCL) is the most common type of B-cell lymphoma. Although the multilobated subtype of DLBCL has been observed since the 1970s, little is known about the clinical significance of this unique variant in the era of rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone/prednisolone (R-CHOP) therapy. In this study, the retrospective clinicopathological analysis of 312 patients diagnosed with DLBCL showed that the multilobated DLBCL group comprised 11% of the cases and was predominantly male (p = 0.027), achieved complete remission in the first therapy (p = 0.023), and exhibited germinal center B-cell phenotypes in the Hans algorithm (p = 0.025). The multilobated DLBCL groups had a better prognosis in overall survival (OS) and progression-free survival (PFS) than the non-multilobated DLBCL group (OS, p = 0.006; PFS, p = 0.010). In the multivariate Cox regression analyses for OS, independent prognosis factors were high soluble IL-2 receptor (p = 0.025), high risk of International Prognostic Index, and multilobated morphology (p = 0.031). The most characteristic copy number gains found in more than 50% of the cases were located at 1q, 3p, 10q, 12q, and 14q. Overall, the multilobated morphology in DLBCL exhibits a good outcome in the R-CHOP era.

Characteristics and Results of the Management of Diffuse Large B-Cell Lymphomas: The Experience of Côte d'Ivoire

Diffuse large B-cell lymphomas have been little studied in black Africans. The purpose of our study was to determine the characteristics and results of the management of these lymphomas. Patients and Methods. In a descriptive and analytic retrospective study we studied the medical records of 63 patients with diffuse large B-cell lymphoma hospitalized during the period from 1991 to 2007. The diagnosis was made after lymph node or organ biopsy. Response to treatment, OS, PFS, and toxicity were studied. The complete response has been analyzed univariate and multivariate analysis. Results. The median age was 42 years. The sex ratio was 2. The HIV serology was positive in 11 cases, and 8 patients had antiretroviral therapy. In 71% the lymphoma was at stages III and IV of Ann Arbor. IPI was ≥3 in 65%. Complete remission was achieved in 43%. Only 43% of patients had had a good compliance. Progression-free survival at 3 years was 32%, and overall survival at 3 years was 50%. 13% of patients were lost to follow up, and 51% of them died. In terms of analysis the complete remission rate was influenced by the stage of Ann Arbor (P < 0.0001), biological b symptoms (P < 0.01), the IPI (P < 0.0001), and the socioeconomic standing (P = 0.001). In multivariate analysis, only IPI and stage of Ann Arbor influence the complete remission.

Primary mediastinal B-cell lymphoma: a review of pathology and management

PURPOSE

Primary mediastinal B-cell lymphoma (PMBL) is recognized as a separate disease entity in the REAL classification. There is uncertainty about the relevance and especially the optimal management of this disorder. In this review, we discuss clinical presentation, pathology, pathobiology, and management of PMBL in order to provide a platform for initiation of further clinical and biologic studies.

MATERIALS AND METHODS

Studies were identified through a MEDLINE search and from the bibliographies of relevant articles.

RESULTS

PMBL is a tumor of young adults who present with a rapidly proliferating tumor. At diagnosis, the tumor is usually limited to intrathoracic organs. Spread to parenchymal organs such as liver, kidneys, and CNS is common at recurrence. Fibrosis and the presence of so-called clear cells are distinctive morphologic features of PMBL, although they are not pathognomonic or even necessary for diagnosis. On the other hand, biologic features relating to oncogene rearrangement and overexpression as well as cytogenetic features clearly differentiate PMBL from other types of diffuse large B-cell lymphoma. Phase II studies and retrospective series indicate cure rates that range from 38% to 88%. The role of chemotherapy, radiation, and high-dose chemotherapy with stem cell rescue in the management of PMBL is reviewed.

CONCLUSION

PMBL has unique clinical and biologic characteristics that are radically different from those of other types of diffuse large B-cell lymphoma. Although relatively rare, its aggressive growth and its occurrence in young patients increase the clinical relevance of this entity. The consistent recognition and study of PMBL will allow the development of new approaches to its management.

Primary mediastinal large cell lymphoma

PURPOSE

Primary mediastinal large cell lymphoma PMLCL is a recently described entity which has provoked considerable interest lately. The unique immunophenotype of the malignant cell, as well as conflicting reports regarding its response to therapy, prompted us to review the current literature focusing on the pathological and clinical aspects of this disease.

DESIGN

We reviewed the current literature that contained details on the clinical presentation, pathological profile and clinical outcome.

RESULTS

Most reports agree that PMLCL typically affects a young female population and presents with symptoms related to compression of mediastinal structures. Pathologically, the malignant cells may arise from a distinctive thymic medullary B cell subpopulation which is characterized by the following phenotype: CD19+, CD21-, CD20+, CD22+. Alterations of c-myc and lack of expression of HLA class 1 antigens on the tumour cell surface have been described. Response to treatment and clinical outcome have varied from one series to another and is possibly explained by the small number of patients in most series and by the heterogeneity of therapy. In general, the outcome does not appear to be worse than that of other large cell lymphomas although, given the young age of these patients, it might be expected to be more favourable.

CONCLUSIONS

Primary mediastinal large cell lymphoma is a distinct clinico-pathological entity characterized by: (1) a predominance of young adults; (2) female predominance (female/male ratio of 2:1) in contrast to the other large cell lymphomas; (3) CD19+/CD21- immunophenotype; (4) absence of HLA-class 1 antigen expression; (5) possible involvement of c-myc; (6) frequent dissemination at relapse to unusual anatomic sites in a pattern reminiscent of Burkitt's lymphoma. The role of radiotherapy and the optimal treatment for this disorder are issues that remain unresolved.

B-cell lymphoma of large multilobated type: an immunohistochemical study of 8 cases and review of the literature

Large multilobated cell lymphomas represent an heterogenous group comprising both B-cell and T-cell subtypes. The correct lineage identification of each subtype cannot be based on morphologic grounds, as it has already been stressed by other authors, and demands the use of immunophenotyping methods. In this study we review the literature and present eight new cases of large multilobated B-cell lymphoma which have been immunophenotyped in paraffin sections with a panel of monoclonal [L26 (CD20), 4KB5 (CD45R), UCHL1 (CD45RO), MT1 (CD43)] and polyclonal (anti-CD3, anti-kappa, anti-lambda) antibodies. We further investigated the expression of c-myc p62 oncoprotein and of proliferating cell nuclear antigen (PCNA) using the monoclonal antibodies c-myc 1-9E10 and PC-10 respectively. In all cases the neoplastic cells were positive for L26 (CD20) and negative for anti-CD3. Five cases were positive for 4KB5 (CD45R) while six cases stained positively for UCHL1 (CD45RO) or MT1 (CD43). Four cases were monoclonal in respect to light chain restriction. Immunoreactivity with c-myc 1-9E10 and PC-10 was observed in all cases. As far as c-myc 1-9E10 is concerned, positive cells constituted more than 45% of the neoplastic population in six cases, whereas in all cases the percentage of PC-10 positive cells was greater than 45%. The staining pattern was nuclear and/or cytoplasmic for c-myc 1-9E10 but solely nuclear for PC-10. The elevated c-myc and PCNA expression are indices of high proliferation rate in this type of lymphoma and may suggest a high malignancy grade.

A cutaneous multilobated B-cell lymphoma

A patient with multilobated B-cell malignant lymphoma with lesions limited to the skin is described. The light, electron microscopic, and immunohistochemical features of this unusual morphologic variant of non-Hodgkin's lymphoma are described. The nosologic position of this histologic subtype is discussed. The clinical course, with lesions confined to the skin, and the response to treatment suggest a favorable prognosis.

Primary anterior mediastinal B-cell lymphoma. A clinicopathologic and immunohistochemical study of 16 cases

Sixteen cases of primary anterior mediastinal B-cell lymphoma were characterized by morphologic, immunophenotypic, and clinical profiles. Twelve were men and four were women. The median age was 42 years. Virtually all tumors were of large cell type. Three main morphologic categories were identified, with one rare exception. In some tumors, the cells were compatible with centrocytes and centroblasts (four). Others had cells readily identifiable as centroblasts (six). Both these groups had a variable proportion of cells with multilobed nuclei. A third group was composed mainly of unclassifiable cells with multilobed nuclei (five). All had discernible sclerosis of varying intensity. A wider range of morphologic features and different sex distribution was noticed in comparison with previously reported clear cell features and younger women. The dominant phenotype of these B-cell lymphomas was CD19+, CD22+, CD37+, CD21-, CD30-, CD10-, CD5-, and Ig-negative. The finding of CD21-, Ig-negative phenotype, as observed by the authors and others, overlaps with some high-grade lymphomas of follicular center cell origin but is thought to bear similarity to a noncirculating population of thymic medullary B-cells. The tumors attained large size without peripheral dissemination and responded to chemotherapy as well as radiotherapy.

Multilobated lymphoma of B cell type: a multiparameter investigation

Multilobated lymphomas were originally described as T-cell neoplasms, but many of B-cell type have subsequently been reported. A case of B-cell origin is reported in which both immunophenotypic and genotypic studies performed on a cell suspension of the lymphoma gave inconclusive and potentially misleading information, while paraffin and frozen section immunohistologic studies, as well as genotypic studies performed on DNA obtained from snap-frozen tissue, were definitive. Thus, this case illustrates some of the problems that may be encountered using cell suspensions as a source for immunophenotypic, and even the much more sensitive genotypic, studies.

Imprint cytology of non-Hodgkin's lymphomas based on a study of 212 immunologically characterized cases: correlation of touch imprints with tissue sections

The classification of non-Hodgkin's lymphomas (NHLs) has been traditionally based on analysis of histologic sections and has been supplemented more recently by immunologic marker studies. It was the purpose of the present study to illustrate, side-by-side, sections and Romanowsky-stained imprints from the same surgical specimen from practically all categories of immunophenotyped NHLs, including rare and atypical variants that were difficult to classify from the histologic sections alone. Our results indicate that imprint cytology may reveal nuclear and cytoplasmic details not discernible in even the best tissue sections and that it may be selectively helpful in contributing to the classification of NHLs. Our results also show that the relative value of imprint cytology in the classification of malignant lymphomas varies greatly among categories. Specifically, we have found that imprints assist in three ways: the recognition of plasmacytoid features in small cell lymphocytic lymphomas, the recognition of plasmacytoid immunoblastic lymphoma, and the differentiation between NHLs which may be difficult to distinguish histologically. These include (1) small lymphocytic lymphoma versus lymphocytic lymphoma of intermediate differentiation, (2) true histiocytic malignancies versus large cell malignant lymphomas with abundant cytoplasm and/or phagocytosis, (3) anaplastic myeloma versus plasmacytoid immunoblastic lymphoma, (4) large noncleaved versus plasmacytoid immunoblastic lymphoma, (5) lymphoblastic lymphoma versus diffuse small cleaved cell lymphoma, and (6) lymphoblastic lymphoma versus small noncleaved cell lymphoma. Lymph node imprints are easy to prepare and readily interpretable by those experienced in the study of abnormal blood and bone marrow films. Their value as an ancillary methodology aimed at optimal accuracy in the classification of NHLs should be recognized.

Multiple myeloma associated with multilobated plasma cell nuclei

Ten cases of multiple myeloma are reported in which there were a large number of plasma cells with excessively convoluted or lobulated nuclei. These cases represent 3% of the 297 evaluable multiple myeloma patients treated at our institution over a 22-year period. All 10 had intermediate or advanced stage disease at the time of diagnosis, and all have died after a mean survival of 19.5 months. Ultrastructural features of 2 cases are described. When found in abundance, such cells can cause difficulty in establishing a morphologic diagnosis of multiple myeloma because of their resemblance to other cell types. Therefore, it may be necessary to perform immunoperoxidase staining and/or electron microscopy to confirm the plasmacytic identity of these cells. The findings add further support to the contention that the presence of excessive nuclear convolutions is not a completely reliable indication of T-cell, as opposed to B-cell, lineage.

T-cell-rich lymphoproliferative disorders. Morphologic and immunologic differential diagnoses

To differentiate peripheral T-cell lymphomas (PTCL), the authors evaluated the results of T11 monoclonal antibody studies on consecutive cell suspensions prepared from 509 lymph nodes from various lymphoproliferative disorders (LPD). They used T11 (CD2) positivity to identify those LPD in which the content of T cells was high. There were 266 (52%) cell suspensions which contained more than 50% T11-positive cells. More than 75% of the following non-Hodgkin's lymphomas had over 50% T11-positive cells: diffuse mixed cell (DM), diffuse atypical poorly differentiated lymphocytic and lymphoblastic lymphomas; mycosis fungoides; and true histiocytic lymphoma. Eleven cell suspensions had more than 90% T11-positive cells; four were involved by B-cell lymphomas. The cell suspensions prepared from nine of 14 diffuse large cell lymphomas of the T-cell type had more than 50% T11-positive cells. Of these, three of five cases of the polymorphous subtype had fewer than 50% T11 cells, but six of seven lymph nodes of the clear-cell type had more than 50% T11-positive cells. Each of seven DM samples of the T-cell type contained over 50% T11 cells; none had a polymorphous appearance. In the 112 cases of reactive LPD studied, more than 75% of cases of necrotizing lymphadenitis, dermatopathic lymphadenitis, angioimmunoblastic lymphadenopathy, and those with lymph nodes with no specific reactive pattern had more than 50% T11-positive cells. The authors' findings indicate that T11 positivity is a reliable T-cell marker in reactive and neoplastic LPD except for those cases of PTCL with a polymorphous appearance; these tend to lose T11-expression. A multi-parameter diagnostic approach is required in the following LPD: (1) PTCL which are T11-negative; (2) PTCL of small lymphocytic type having an unremarkable T-cell phenotype; (3) SIg-negative B-cell lymphomas which are rich in nonneoplastic T cells; (4) non-Hodgkin's lymphomas with minimal disease which are rich in reactive T cells; and (5) polymorphous large cell proliferations.

Circulating cerebriform lymphoid cells (Sezary-type cells) in a B-cell malignant lymphoma

Circulating cerebriform lymphoid cells (Sezary cells) are considered to be highly predictive of cutaneous T-cell Lymphoma (CTCL). A leukemic peripheral blood (leukocyte count 24.5 x 10(9)/l) composed predominantly of cerebriform cells was found in a 75-year-old man presenting with weight loss and generalized lymphadenopathy but without skin lesions. Cell suspensions studies and immunohistochemistry of peripheral blood revealed that the cerebriform cells were B-cells (IgM+ Kappa+, HLA DR+, Leu 1+, CALLA-, B1+, and OKT 10+). A variety of T-cell markers (other than Leu1) was negative. Computer-assisted morphometry confirmed a nuclear profile typical of CTCL (mean nuclear contour index, 7.47). A lymph node that underwent subsequent biopsy revealed a follicular malignant lymphoma of small to intermediate cells with similar morphologic and immunologic characteristics to the circulating cerebriform cells. The findings of a leukemic presentation of a cerebriform B-cell lymphoma extends the recent observation of nodal B-cell lymphomas composed of cerebriform cells and indicates that circulating cerebriform cells should not be considered to be exclusively of T-cell origin.

Multilobated non-Hodgkin's lymphoma. A clinicopathologic entity

Multilobated non-Hodgkin's lymphomas (NHL) have recently been recognized as an NHL variant. During a period of 10 years we observed 30 individuals with NHL in which more than 30% of the malignant cells had a characteristic multilobation. The immunologic phenotype was determined in 14 of these cases. One was of T-cell lineage, and the others exhibited B-lymphoid markers. Sixty-eight percent of the patients presented with extranodal localizations. In the clinical follow-up a complete remission was observed in 78% of patients with a mean duration of 37 months (range, 5 to 120 months). The actuarial survival after 5 years was 45%. From these data we conclude that multilobated NHL are comparable to diffuse, large cleaved-cell NHL of an intermediate grade malignancy according to the Working Formulation or are comparable to the diffuse centrocytic-centroblastic NHL according to the Kiel classification. The neoplastic cells are to be considered as variants of follicle center cells, but the clinicopathologic correlation indicates that multilobated NHL represent a distinct nosologic entity.

Primary T-cell lymphoma of the thyroid

A rare case of non-Hodgkin's malignant T-cell lymphoma of the thyroid in a 79-year-old woman is reported. Light microscopically, the tumor showed diffuse proliferation of lymphoid cells, revealing prominent nuclear irregularity and occasional multilobulated nuclei, and was diagnosed as a diffuse lymphoma of medium-sized cell type. Electron microscopically, the tumor cells were seen to possess irregularly indented nuclei. Immunologic surface marker studies showed that the lymphoma cells were positive for T-lymphocyte-lineage antigens, OKT4 and OKT11, and did not react with B-lymphocyte-associated antigens. These findings indicated that the lymphoma had a T-cell phenotype.

Non-Hodgkin's lymphoma in bone. Pathologic and radiologic features with clinical correlates

Thirty-seven lymphomas of bone were studied, including 33 diffuse large cell lymphomas, three undifferentiated (small noncleaved cell) lymphomas, and one well-differentiated (small) lymphocytic lymphoma. The large cell lymphomas were subclassified as large cleaved, large noncleaved, multilobated cell, and immunoblastic sarcoma (large cell lymphoma, immunoblastic type). Eleven of 26 large cell lymphoma patients with adequate follow-up were long-term survivors (free of disease for more than 5 years). Nineteen of the 33 large cell lymphomas were localized to one bone. The stage and histologic pattern significantly correlated with long-term survival among large cell lymphomas. Seventy-three percent of patients with localized lymphoma were long-term survivors, in contrast to 9% of those with disseminated disease. Sixty-seven percent of patients with large cleaved and multilobated cell lymphoma were long-term survivors, but only 21% of those with large noncleaved cell and immunoblastic sarcoma were. The tumors had a blastic, lytic, or mixed radiographic appearance and had either sclerotic, lytic, or permeative borders; none of the radiologic findings were diagnostically useful.

B- and T-cell non-Hodgkin's lymphomas with large multilobated cells: morphological, phenotypic and clinical heterogeneity

Ten cases of non-Hodgkin's lymphomas, mainly composed of large multilobated cells, have been studied. Our results are consistent with the view that they represent a somewhat heterogeneous group of lymphoid tumours displaying different morphological, clinical and immunophenotypic features. In B-cell type the large multilobated cells were histologically characterized by prominent nucleoli and distinctly basophilic cytoplasm whereas in the T-cell type they had indistinct or small nucleoli and ill-defined weakly eosinophilic cytoplasm. These differential features between B- and T-cell type were confirmed by electron microscopy. From a clinical standpoint B-cell type was characterized by a constant involvement of lymphoid tissues (lymph nodes and/or Waldeyer's ring); T-cell type showed, on the contrary, a more frequent involvement of extra-lymphoid sites (mainly bone and subcutaneous tissues). Our study provides some morphological features that may be helpful for a correct differential diagnosis in this heterogeneous group of non-Hodgkin's lymphomas.

Nonlymphoblastic T-cell lymphoma in children

Three children with nonlymphoblastic, non-Hodgkin's lymphomas, showed morphologic features that suggested nonlymphoblastic T-cell origin. Tissue for immunologic study was available from two of the three patients; both showed immunophenotypes of T-cells. Although nearly all T-cell lymphomas in children are lymphoblastic based on morphology, nonlymphoblastic T-cell lymphomas do occur in pediatric patients.

Richter's syndrome with two different B-cell clones

The diagnoses of chronic lymphocytic leukemia (CLL) in prolymphocytic transformation, and diffuse large cell lymphoma (DLC), were made simultaneously in a 71-year-old man. The DLC showed mu lambda surface immunoglobulin. The CLL in a lymph node and in the peripheral blood showed mu kappa. Immunoglobulin gene DNA analysis confirmed the presence of different rearrangements in the heavy and light chain genes of the CLL and DLC. Other cases reported of Richter's syndrome are discussed, and it is concluded that there may be two types of Richter's syndrome, those arising from transformation of a single clone, and those occurring from expansion of two morphologically and immunologically distinct clones, as, it is believed, is the case in this patient.

Non-Hodgkin's lymphoma, multilobated B-cell type: report of nine cases with immunohistochemical and immunoultrastructural evidence for a follicular center cell derivation

The clinical, pathologic, and immunologic features in nine cases of non-Hodgkin's lymphoma of the multilobated B-cell type are described. Clinical and phenotypic heterogeneity was observed in these B-cell neoplasms. A probable follicular center cell derivation for these cytologically unusual B-cell lymphomas is supported by antecedent histories of follicular center cell neoplasms in three cases; a focal nodular pattern in one case; the demonstration of peanut lectin (PNA) receptors, a marker for follicular center cells, on neoplastic multilobated B cells; and immunoultrastructural studies of nonneoplastic tonsillar cells that identified and characterized rare multilobated cells, immunoreactive for B1, B2, and Ia membrane antigens, a phenotype consistent with follicular center-type cells. Comparison of B- and T-cell multilobated lymphomas revealed that only immunologic studies accurately discriminated between these neoplasms.

Multilobated B-cell lymphoma, a variant of centroblastic lymphoma. Report of four cases

Four cases of multilobated B-cell lymphoma, one follicular and three diffuse, are described. Many of the lymphoma cells show marked lobulation of the nuclei, and possess multiple prominent nucleoli. There are admixed classical centrocytes, classical centroblasts, and cells with morphology intermediate between classical centroblasts and multilobated cells. Multilobated cells are also observed in small numbers in germinal centres of lymph nodes showing reactive follicular hyperplasia. We believe that the multilobated B-cell may represent one form of centroblast during transition between the centroblastic and centrocytic stages. Multilobated B-cell lymphoma may be its neoplastic counterpart in which the nuclear lobulation is further exaggerated.

Primary mediastinal clear cell lymphoma of B-cell type

This is a report on 8 mediastinal tumours that occurred in young adults (19-43 years, mean: 29.4); predominantly in females (6/8). Initial symptoms consisted of thoracic pain and venectasia and in only one case in B symptoms. After surgical tumour reduction, radiation and/or chemotherapy, local recurrence was observed in each case under clinical care; abdominal spread is presently suspected in 3 patients; 3 died 11, 13 and 22 months after diagnosis. None developed leukaemia. The tumours are B-cell neoplasms with a characteristic immunophenotype: leucocyte common antigen+, common acute lymphoblastic leukaemia antigen-, B 1-antigen+, surface and cytoplasmic immunoglobulin-. Flow cytometry revealed DNA-diploidy in 7 cases and a moderately (3.2-3.8%) to extremely high (8.0-20.6%) S-phase component. The proliferation associated antigen Ki67 was detectable in 10-60% of the tumour cell nuclei, thus stressing the considerable or rapid growth. Histopathology is characterized by a diffuse growth pattern and a clearness and abundance of cytoplasm of the pleomorphic tumour cells, which vary in size and nuclear morphology from patient to patient. Apoptoses are more numerous than mitoses. Fibrosis and focal necrosis are common, sclerosis is present in 3 cases. We suggest that primary mediastinal lymphoma of B cell type is a novel B-lymphoma variant.