Intra- and extrathymic B cells in physiologic and pathologic conditions. Immunohistochemical study on normal thymus and lymphofollicular hyperplasia of the thymus

Primary Mediastinal Nodal and Extranodal Non-Hodgkin Lymphomas: Current Concepts, Historical Evolution, and Useful Diagnostic Approach: Part 1

Primary mediastinal non-Hodgkin lymphomas (PM-NHLs) represent ~5% of all NHLs and comprise lymphomas of B-cell and T-cell origin. PM-NHLs are defined as involvement of mediastinal lymph nodes, thymus, and/or mediastinal organs (heart, lung, pleura, pericardium) by NHL without evidence of systemic disease at presentation. The clinical scenario is variable and depends on the lymphoma subtype. The radiologic presentation is also variable ranging from a mediastinal mass with or without superior vena cava syndrome, a pleural or a cardiac mass associated with an effusion, or as an effusion only. The diagnosis of PM-NHLs can only be established by microscopic evaluation, and therefore, general pathologists should be aware of these tumors and familiar with their diagnostic approach. The most common anterior mediastinal NHLs (90% to 95%) are primary mediastinal large B-cell lymphoma and T lymphoblastic lymphoma. Thymic marginal zone lymphoma and mediastinal gray zone lymphoma are very rare. The remainder PM-NHLs involving middle or posterior mediastinum include diffuse large B-cell lymphoma (DLBCL) and rare cases of T-cell lymphoma, including anaplastic large cell lymphoma and breast implant-associated anaplastic large cell lymphoma extending to the anterior mediastinum. Primary pleural and cardiac NHLs are mostly DLBCLs. Other rare subtypes of PM-NHLs include DLBCL associated with chronic inflammation/pyothorax-associated lymphoma, fibrin-associated DLBCL (both EBV), and pleural and/or pericardial primary effusion lymphoma (HHV-8/EBV). We review the historical aspects, epidemiology, clinico-radiologic features, histopathology, immunohistochemistry, differential diagnosis, and relevant cytogenetic and molecular features of PM (thymic) LBCL, PM "nonthymic" DLBCL, BCL, unclassifiable, with features intermediate between DLBCL and classic Hodgkin lymphoma (mediastinal gray zone lymphoma), DLBCL associated with chronic inflammation (pyothorax-associated lymphoma), fibrin-associated DLBCL, and primary effusion lymphoma. This review represents the first part of 2 manuscripts covering PM-NHLs.

Primary Mediastinal Large B-Cell Lymphoma: A Review for Radiologists

OBJECTIVE. The purpose of this article is to provide a primer for radiologists focused on integrating the radiologic, pathologic, and clinical features of primary mediastinal large B-cell lymphoma (PMLBCL). CONCLUSION. PMLBCL is a unique subtype of lymphoma that poses diagnostic and therapeutic challenges to the fields of radiology and oncology. Knowledge of this distinctive clinical-pathologic entity and its associated imaging and clinical features is critical for radiologists.

Primary mediastinal lymphoma: diagnosis and treatment options

Primary mediastinal large B-cell lymphoma (PMBCL) is a unique B-cell lymphoma variant that arises from a putative thymic medulla B cell. It constitutes 2-4% of non-Hodgkin lymphomas and occurs most frequently in young females. PMBCL is characterized by a diffuse proliferation of medium-to-large B cells associated with sclerosis. Molecular analysis shows that PMBCL is a distinct entity compared to other types of diffuse large B-cell lymphomas. PMBCL is characterized by a locally invasive anterior mediastinal bulky mass. The combination of rituximab with CHOP/CHOP-like regimens followed by mediastinal radiation therapy (RT) is associated with a 5-year progression-free survival of 75-85%. However, the role of consolidation RT still remains uncertain. More intensive regimens, such as DA-EPOCH-R without mediastinal RT, have shown very promising results. The conclusive role of PET-CT scan requires prospective studies and there is hope that this may allow to de-escalate RT and accordingly yield reliable prognostic information.

Radiological thymus alterations in systemic sclerosis: our experience and a review of the literature

OBJECTIVE

Thymus alterations have been related to several autoimmune disorders. In particular, previous studies identified a significant frequency of gland abnormalities by chest high-resolution CT (HRCT) in SSc patients. In this study we aimed to investigate the prevalence of radiological thymic alterations and their correlation with clinical and serological features in a large SSc series.

METHODS

We retrospectively evaluated thymic shape on CT scans of 200 consecutive, unselected SSc patients aged over 30 years The presence of radiological abnormalities, i.e. enlarged gland >13 mm or nodular lesions >7 mm, was correlated with SSc clinico-serological features. Moreover, the patients were also classified using a second thickness cut-off of 7 mm in order to identify incomplete thymic involution.

RESULTS

Twenty-four of 200 (12%) SSc patients presented an abnormal thymus at HRCT, including hyperplasic (19/24) and nodular (5/24) glands. Otherwise, using the cut-off of 7 mm for gland thickness and excluding subjects with nodular thymus, 50/195 (25.6%) patients presented an incomplete thymic involution. Thymic radiological alterations are significantly correlated with younger age and diffuse cutaneous SSc. Moreover, an abnormally enlarged thymus tended to be more common in patients with shorter disease duration.

CONCLUSION

The present report on a large series of SSc patients further reinforces previous data present in the literature that includes other cohort studies and a number of anecdotal observations. Even though the actual role of thymus radiological abnormalities remains unclear, possible involvement of the gland in the early phase of immune-mediated SSc pathogenesis might be supposed.

B-cell activity of polyclonal antithymocyte globulins

Polyclonal antithymocyte globulins (AThG) are a subset of antilymphocyte antibody preparations derived from the sera of rabbits or horses immunized with unfractionated cells isolated from pediatric human thymi. In vivo, AThG preparations have been used to successfully treat antibody mediated rejection in kidney transplant recipients. In vitro, AThG can induce apoptosis of naïve and memory B cells and terminally differentiated plasma cells. The presence of B-cell reactive antibodies in AThG results from a thymic inoculum containing a significant percentage of CD20(+) B cells and CD138(+) plasma cells. In this paper, the experimental and clinical evidence supporting the B-cell activity of AThG preparations, and their mechanisms of action, are reviewed.

Synchronous deletion of Mtv-superantigen-reactive thymocytes in the CD3(medium/high) CD4(+)CD8(+) subset

Multiple model systems have demonstrated that negatively selected thymocytes can be deleted during the immature CD4(+)CD8(+) CD3(low) stage after high affinity interaction of T-cell receptors (TCRs) with antigen:major histocompatibility complex (MHC) complexes. Superantigens (SAGs) derived from endogenous mammary tumour viruses (Mtv) induce negative selection of Mtv-SAG-reactive thymocytes regardless of which peptide antigen is presented by MHC molecules. In this study, the timing of deletion of multiple subsets of Mtv-SAG-reactive CD4(+)CD8(+) thymocytes was investigated by a 4 colour flow cytometry in SJL x CBA/J cross-bred mice. Deletion of V beta 3(+), V beta 5(+), V beta 11(+), and V beta 17(+) Mtv-SAG-reactive thymocytes was found to occur synchronously in the most mature CD3(medium) and early CD3(high) subsets of CD4(+)CD8(+) thymocytes, in contrast with reports showing that the deletion of Mtv-SAG-reactive thymocytes can occur at different stages in particular model systems.

Thymic Hodgkin's disease--a histological and immunohistochemical study of three cases

Thymic Hodgkin's disease (HD) shows some peculiar histological features different from nodal disease which are a result of the interaction with the specific thymic microenvironment. We describe the histological and immunohistochemical findings in three cases presenting as a primary thymic neoplasm both clinically and radiologically. Histological hallmarks were the prominent formation of epithelium-lined cysts, inflammatory changes, a marked proliferation of thymic epithelium in association with Hodgkin- and Reed-Sternberg (RS) cells and the occurrence of the nodular sclerosing subtype in all cases. The immunophenotype of the neoplastic cells was that of classical HD. They expressed CD30, CD15 and lacked CD45. In two cases CD20 expression was observed. All cases were negative for the latent membrane protein (LMP) of the Epstein-Barr virus (EBV). The accompanying inflammatory infiltrate was rich in mature T-cells, but also showed a significant number of B-cells with frequent formation of follicles and proliferation of follicular dendritic cells. Thymic HD develops in a microenvironment with features of thymic medulla as defined by the morphology and pattern of the proliferating epithelial cells and the mature immunophenotype of the admixed thymocytes. These findings, especially the CD20 positivity in Hodgkin and RS-cells, may point to the possible origin of thymic HD from medullary B-cells.

Use of the international prognostic index and the tumor score to detect poor-risk patients with primary mediastinal large B-cell lymphoma: a study of 37 previously untreated patients

We tested two prognostic models devised for intermediate-grade lymphomas, the age-adjusted international prognostic index and the tumor score, in 37 consecutive untreated patients treated for a diagnosis of primary mediastinal large B-cell lymphoma (PMLCL). Neither model selected for a group of patients with statistically significant differences in rates of complete response, failure-free survival (FFS) and overall survival (OS). Because the level of beta microglobulin (beta2m) is consistently low in the serum of patients with PMLCL despite bulky disease, we tested the median value of this continuous variable in the 37 patients and found it to be statistically significant for predicting FFS. A hypothetical tumor score model using the adjusted value for beta2m improved the prognostic accuracy for achievement of complete response (93% vs. 60%; P = 0.02), FFS (73% vs. 35%; P = 0.02), and OS (80% vs. 55%; P = 0.05). This hypothetical model merits further testing in a larger population of patients with PMLCL.

Thymic B-cell non-Hodgkin's lymphoma in a child

A 13-year-old male developed thymic non-Hodgkin's lymphoma. Microscopically, the tumor was composed of large cells, resembling centroblasts. Immunohistochemically, the tumor demonstrated leukocyte common antigen+, L26 (B-cell)+, UCHL1 (T-cell)-, suggesting the B-cell phenotype. In contrast to the terminally differentiated phenotype (CD10-, surface immunoglobulin-) observed in adult cases, flow cytometric analysis showed that they were relatively immature: CD10+, CD19+, HLA-DR-, IgM+/-, kappa+. He was successfully treated with intensive chemotherapy. Since childhood thymic lymphomas are exclusively small non-cleaved cell lymphoma with T-cell phenotype, this case represents a unique entity in children.

Production of a monoclonal antibody (59.4) against canine lymphocyte surface antigen and its immunohistochemical application

A monoclonal antibody was produced by immunizing BALB/c mice with freshly prepared canine thymocytes and peripheral blood leukocytes. The antibody, designated 59.4, was of the IgG1 subclass type and mainly reacted with lymphocytes. In single-color flow cytometric analysis, lymphocytes from the peripheral blood, thymus and spleen were graded into three categories according to their fluorescence intensity labeling by antibody 59.4: weakly, moderately and intensely positive cells. Two-color analysis revealed that a major population of CD8-positive cells were intensely labeled by antibody 59.4, but less than 50% of CD4-positive cells were moderately reacted with antibody 59.4. Immunohistochemically, thymocytes in the medulla showed moderately intense immunoreactivity to 59.4, but most lymphocytes in the cortex were negative in reaction. Immunostaining using antibody 59.4 demonstrated characteristic aggregations of 59.4-positive lymphocytes in the reticulum cell-free region of the thymic medulla. In the spleen, scattered lymphocytes in the outer layer of the marginal zone and in the red pulp were intensely labeled by antibody 59.4, while lymphocytes gathering in the mantle zone and periarterial lymphatic sheath (PALS) were moderately stained. Antibody 59.4 appears to recognize an antigen which is expressed by a more-differentiated T cell-lineage but not by immature T cells in the thymic cortex.

Endocrine characterization of primary mediastinal lymphoma

Because of the characteristic presentation of primary mediastinal large cell lymphoma (PMLCL) in young females its known origin from thymic B-cells, there might be a role in lymphomagenesis for estrogen receptors as well as for known neuroendocrine thymic mediators. A retrospective review of all patients with diffuse large cell lymphoma seen at our institution from January 1985 to January 1994 revealed 75 consecutive cases with a diagnosis of PMLCL. Through retrieval from our pathologic archives and requests to outside pathologists, we recovered and analyzed 17 biopsy specimens for the presence of the following hormone receptors: estrogen, beta endorphin, prolactin, T3, growth hormone, and leutinizing hormone. None of the specimens stained for any of the reagents. The most plausible explanation is that PMLCL tissues are devoid of these hormonal receptors and thus these receptors do not seem to play a role in the pathogenesis of PMLCL.

Primary mediastinal large B-cell lymphoma. A clinicopathologic study of 141 cases compared with 916 nonmediastinal large B-cell lymphomas, a GELA ("Groupe d'Etude des Lymphomes de l'Adulte") study

Among non-Hodgkin's lymphomas, primary mediastinal large B-cell lymphoma (PMLCL) has been considered a separate entity that has specific clinical and histological aspects and a poor prognosis. In this study, we reexamined the clinicopathologic features and the response to current treatment of 141 PMLCL and compare them with 916 nonmediastinal large B-cell lymphomas (NMLCL) recorded in the same period and treated with similar combined chemotherapy. The clinical features of PMLCL at diagnosis were largely homogeneous and distinct from NMLCL, with a predilection for young women (59% with a mean age of 37 years versus 42% with a mean age of 54 years), bulky tumor (77% versus 7%, p < 10(4)), high serum lactic dehydrogenase (LDH) level 76% versus 51%, p < 10(4)), and frequent intrathoracic extension to adjacent organs such as pleura, pericardium, and lung. By contrast, extrathoracic or hematologic dissemination was uncommon (2% of bone marrow involvement versus 17%). All patients had diffuse large B-cell nonimmunoblastic, nonanaplastic lymphomas. Histological analysis of the 141 PMLCL evaluated two common patterns: the presence of large cells with clear cytoplasm (found in 38% of cases) and the presence of fibrosis (marked in 25% of cases). The presence of clear cells or intense fibrosis did not constitute prognostic indicators. Immunologic and molecular analysis assessed the profile of bcl-2 expression and the presence of Epstein-Barr virus (EBV) in PMLCL: 30% expressed a high level of bcl-2 protein; EBER RNAs were detected by in situ hybridization in only two of the 41 cases tested. Monotypic light chain restriction could be demonstrated in seven of the 41 PMLCL tested on fixed-section. Treated with polychemotherapy regimens without radiotherapy, 79% of PMLCL patients achieved a complete remission compared with 68% in the NMLCL patient group (p = 0.01). Overall, 3-year survival rates were estimated at 66 and 61%, respectively (p = 0.05), and disease-free survival rates were not significantly different (61 versus 64%). Stratified analysis on the International Prognostic Index (based on age, tumor stage, serum LDH level, and performance status) showed no difference in the overall and disease-free survivals between the two lymphoma groups. In conclusion, PMLCL can be combined with other diffuse large B-cell lymphomas on morphologic grounds; it is not associated with EBV. It responds favorably to treatment and should be managed like other high-grade lymphomas of equivalent histology. However, the uncommon clinical presentation makes it a distinct entity.

Location and sequence of rearranged immunoglobulin genes in human thymus

Thymic B cells are a proliferating B cell population concentrated in normal thymic medulla. They are large cells, some with dendritic morphology, and are not associated with any organized follicular structure. Previous work in this laboratory has shown that most of these B cells are surrounded by tightly adherent thymocytes. The literature on human thymic B cells contains many inconsistencies. There is no consensus on whether they express CD5. Even the existence of thymic B cells has been questioned. In this study we have undertaken the first analysis of rearranged immunoglobulin (Ig) genes, looking in particular for evidence of affinity maturation. The Ig VH genes of human thymic B cells in this study are those of the fetal repertoire, though the resemblence to fetal Ig genes is limited in other respects. They are mostly unmutated, but the presence of mutated sequences suggests that this is not a uniform population, as has been previously indicated by phenotypic studies.

A comparative histological and immunohistochemical study of thymomas with and without myasthenia gravis

Because myasthenia gravis (MG) is frequently associated with thymoma, in this study the histological patterns of thymomas from 11 patients with MG (group A) were compared with those from 8 patients without MG (group B). An immunohistochemical examination was also conducted to determine whether the thymoma associated with MG is the site where autoantibodies are produced or secreted. Lymphoid follicles (LFs) and medullary differentiation (MD) were histologically evident only in group A in 4 and 5 patients, respectively, but were completely absent in group B. Moreover, an elevated serum antiacetylcholine receptor antibody titer was found in group A. Typical LFs were histologically and phenotypically similar to the lymph follicles seen in reactive lymph nodes. The number of cells expressing the B-cell antigen differed between groups A and B in terms of IgM- or IgD-bearing cells in the mantle zones and LN1-positive cells in the germinal centers of LFs. Thus, it is thought that LFs consist of B cells under stimulatory conditions and that these B cells may have the potential to produce autoantibodies in MG; however, since the differentiation of these Ig-bearing cells to plasma cells was hardly evident, the thymoma itself is possibly not the site of autoantibody production or secretion in patients with MG.

Immunohistochemical study of thymic B cells in myasthenia gravis and ulcerative colitis

The phenotypes of B cells and dendritic cells in human thymus were examined immunohistochemically using various monoclonal antibodies. Normal thymus contained a few B lymphocytes recognized by CD19, CD20, CD22, L26 and LN-2, which were localized in the medulla. These B cells were negative for LN-1, L30 and CD11c (Leu M5). Activated B cells recognized by CD23 (B6) and L29 antibodies were not present in normal thymus. Dendritic cells stained by CD11c were weakly positive for L26 and CD20. There was no difference in the distribution of dendritic cells between normal thymus and thymus from the patients. In the thymus from patients with myasthenia gravis, numerous B cells were demonstrated in the medullary area and lymphoid follicles. Activated B cells were seen mainly in the germinal center of lymphoid follicles and were scarce in the medulla. Many B cells were also found in the medulla and lymphoid follicles of the thymus from patients with ulcerative colitis. However most of those B cells were not activated, even in the lymphoid follicles. These results suggest that thymic B cells may contribute to the induction of immune abnormalities in patients with myasthenia gravis and those with ulcerative colitis, however, the mechanisms by which thymic B cells participate in the pathogenesis of these two diseases would be different.

Phenotype and topography of human thymic B cells. An immunohistologic study

Using single and double labeling immunohistochemical techniques and a large panel of monoclonal antibodies against B-cell differentiation antigens, including those newly defined at the Fourth International Leucocyte Typing Workshop, we have examined the immunophenotype and tissue distribution of human thymic B-cells. The existence of a distinct B-cell population as a constant constituent of the thymic microenvironment has been noted only recently. We found a significant population of B-lymphocytes in the thymic medulla expressing the B-cell restricted antigens CD19, CD20, CD22, CD37, CD72, CD76 and IgM and IgD. As with other extrafollicular B-lymphocytes, they differ significantly from both follicle mantle and germinal center cells in morphology and immunophenotype, which points to alternative modes of B-cell differentiation. Thymic B-cells themselves show considerable heterogeneity and a subpopulation with dendritic features and the expression of CD23 has been referred to as "asteroid" cells. Their close association with T-cells and medullary epithelial cells points to a functional role for B-cells in the thymus. A second population of B-lymphocytes together with frequent lymph follicles is found within the extrathymic perviascular space. Though separated from the medulla by a layer of epithelial cells, a clear distinction between the B-cells of these two compartments is not always possible. The intramedullary B-cell compartment shows a parallel numeric increase with the occurrence of germinal centers in the perivascular space, mostly due to an accumulation of B-cells in the medulla adjacent to these lymph follicles. Thus a close relationship between the intra- and extramedullary B-cell population of the thymus seems likely.

Towards an integrated view of thymopoiesis

One prediction from the complex series of steps in intrathymic T-cell differentiation is that to regulate it the stroma controlling the process must be equally complex: the attraction of precursors, commitment to the T-cell lineage, induction of T-cell receptor (TCR) gene rearrangement, accessory molecule expression, repertoire expansion, major histocompatibility complex (MHC) molecule-based selection (positive and negative), acquisition of functional maturity and migratory capacity must all be controlled. In this review, Richard Boyd and Patrice Hugo combine knowledge of T-cell differentiation with thymic stromal cell heterogeneity to offer an integrated view of thymopoiesis within the thymic microenvironment.

Alteration of idiotypic connectivity in prenatally tolerized neonatal mice

Prenatal tolerization with trinitrobenzenesulphonic acid (TNBS) leads to expansion of trinitrophenyl (TNP)-specific B cells, the majority of which become refractory to stimulation during postnatal development. One possible explanation could be that they belong to the repertoire of naturally activated B cells which are limited in expansion after antigenic stimulation due to a high degree of idiotypic connectivity. To evaluate this hypothesis, 59 thymus- and 490 spleen-derived B-cell hybridomas from 6-day-old prenatally untreated and prenatally TNBS-treated mice were tested for reactivity against 33 arbitrarily chosen clones derived from the same fusions, 17 being derived from control and 16 from tolerized litters. Two major points could be deduced: (1) Idiotypic connectivity, including connectivity of TNP- and anti-TNP-reactive monoclonal antibodies (MoAb), was maintained after prenatal tolerization. This accounted for thymus- and spleen-derived MoAb. (2) Only TNP- and anti-TNP-reactive MoAb derived from prenatally untreated and prenatally tolerized mice displayed significantly distinct idiotypic profiles. Differences were pronounced, especially with thymus-derived MoAb. Thus, TNP-specific B cells in prenatally tolerized newborns do not behave like B cells of adult mice stimulated by external antigen, but rather like a part of the naturally activated, idiotypically connected B-cell repertoire of the newborn. This could explain B-cell unresponsiveness at older age as a consequence--at least partly--of their high idiotypic connectivity.

Comparison between thymus- and spleen-derived B-cell hybridomas

When fusing thymocytes and spleen cells (SC) of 7- and 28-day-old BALB/c mice with Sp2/0, comparable numbers of clones were obtained. Immunoglobulin secretion was observed in 53-79% of splenic, but only 10-18% of thymic hybridomas. This was irrespective of tolerization through prenatal treatment with trinitrobenzenesulphonic acid (TNBS). Differences between control and tolerant mice were observed with respect to the frequency of anti-trinitrophenol (TNP)-producing hybridomas: in 7-day-old tolerant litters their frequency was increased in thymus and spleen as compared with controls, but it was decreased in 28-day-old tolerant mice. It is concluded that the majority of thymic B cells are in an activated, but non-producing state and that the repertoire of thymic B cells is influenced by prenatal contact with nominal antigen.

Recognition of idiotypic structures in the thymus

During the passage through the thymus, T cells are selected which recognize self major histocompatibility complex (MHC) antigens with low avidity. Whether the T-cell repertoire for recognition of altered self is also built up intrathymically or in the periphery, and whether it is determined exclusively by external antigens or is shaped by the internal environment is still a matter of debate. This question was addressed by analysing the responsiveness of thymocytes during post-natal development towards a nominal antigen [trinitrophenyl (TNP)] and an anti-TNP monoclonal antibody (Sp6), which carries a recurrent idiotype. During the first weeks of life, in vitro cultures of thymocytes proliferated strongly in the absence of nominal antigen. Proliferation rates were not increased by the addition of nominal antigen [TNP-ovalbumin (OA)], but a significant increase was noted in the presence of Sp6, thymocytes recognizing the processed immunoglobulin. After in vivo stimulation with TNP conjugates, 'antigen-specific' clones could also be detected in the thymus, the frequency of clones proliferating in response to Sp6 being further augmented. With increasing age, the proliferative capacity of thymocytes from unstimulated and antigenically stimulated mice decreased significantly. Responsiveness of spleen cells (SC) differed in some respects. The response towards Sp6 decreased with age, while antigen-specific clones were detected at increasing frequencies during post-natal development. Furthermore, after antigenic stimulation, the frequency solely of antigen-specific, but not of Sp6-specific clones was increased. Thus, it appears that the T-cell repertoire is shaped already during the intrathymic passage, being influenced primarily by the B-cell repertoire and modulated further by external antigen.

Expression of cortical and medullary thymic epithelial antigens in thymomas. An immunohistological study of 14 cases including a characterization of the lymphocytic compartment

Four monoclonal antibodies against antigens expressed differentially by the normal thymus epithelium, which define the cortical, medullary and subcapsular compartments, were used for immunohistological characterization of the epithelial cells in 14 thymomas. Furthermore, thymoma-associated lymphocytes were studied with monoclonal antibodies directed against T-lymphocyte differentiation antigens (CD1a, CD3, T-cell antigen receptor). Only four of the 14 thymomas could be classified into either medullary or cortical type thymoma based on the immunophenotype of epithelial cells. Ten cases escaped immunophenotypical classification due to co-expression of medullary and cortical antigens by the tumour cells. This aberration from the normal phenotype might indicate the failure of differentiation of such tumours. The immunophenotype of the associated lymphocytes, on the other hand, made it possible to classify the tumours as cortical (5 cases), mixed (2) and medullary (3) thymomas. Four thymomas escaped this classification scheme due to the absence of lymphocytes (2) or to a hybrid immunophenotype (2). Nevertheless, thymocytes of cortical type clearly predominated and were seen in all thymomas with associated lymphocytes. This feature may constitute a good diagnostic tool in differential diagnosis since, in 28 mediastinal or extramediastinal metastasis of tumours not derived from thymic epithelium and associated with various numbers of lymphocytes, none of them were found to contain CD1a positive lymphocytes.