Mantle cell lymphoma: an update

Malignant hematopoietic cell lines: in vitro models for the study of mantle cell lymphoma

Mantle cell lymphoma (MCL) is a distinct type of B cell malignancy and accounts for approximately 5-10% of non-Hodgkin's lymphomas (NHL). The characteristic cytogenetic aberration in MCL is the translocation (11;14)(q13;q32) present in virtually all cases. This rearrangement at the BCL1 locus at 11q13 dysregulates the gene CCND1 following juxtaposition with immunoglobulin heavy chain (IGH) transcriptional enhancers at 14q32 and leading to overexpression of its protein product, cyclin D1, which plays a key role in the control of the cell cycle. Eight continuous cell lines (plus several sister cell lines) have been hitherto established from lymph nodes or peripheral blood of patients with MCL (n=5) or with a lymphoma which would nowadays be classified as MCL (n=3). Six of these cell lines carry the specific t(11;14) translocation and a seventh cell line while being negative for t(11;14) shows a rearranged BCL1 locus and cyclin D1 overexpression. Each of these MCL cell lines is unique with regard to its immunophenotypical, additional cytogenetic and functional features. In light of the relatively low frequency of this lymphoma and the poor results of current treatment strategies, the availability of various types of MCL-derived cell lines for immunologic, cytogenetic, molecular and functional studies is expected to illuminate the biology of this disease, which in turn will be hopefully translated into new and better therapies.

Mantle cell lymphoma

OBJECTIVE

This article summarizes the most useful ancillary immunohistochemical and molecular assays for use in the diagnosis of mantle cell lymphoma.

DATA SOURCES

The English language literature was surveyed, with an emphasis on recent publications, for articles presenting key advances in the molecular characterization of mantle cell lymphomas and for series of cases testing the utility of molecular diagnostic tests. The authors' series of 26 small B-cell lymphomas, analyzed for the cyclin D1 protein by paraffin immunohistochemistry and for t(11;14) by polymerase chain reaction, is included.

CONCLUSIONS

Mantle cell lymphoma, a B-cell lymphoma now recognized in the 1994 Revised European-American Classification of Lymphoid Neoplasms (REAL) classification, is a relatively aggressive lymphoma with a poor prognosis. Its characteristic t(11;14)(q13;q32) translocation has a role in oncogenesis and has been exploited for molecular diagnostic tests, but these tests vary in sensitivity, specificity, and ease of use. Improved immunohistochemical tests are sufficient to confirm the diagnosis in most cases. Conventional cytogenetics and molecular diagnostic tests for t(11;14)-Southern blot and polymerase chain reaction analysis-may be helpful in selected cases, but are laborious or of limited sensitivity. Other methods, such as fluorescence in situ hybridization, need further development to provide faster, more sensitive diagnosis.

Mantle cell lymphoma in leukemic phase: characterization of its broad cytologic spectrum with emphasis on the importance of distinction from other chronic lymphoproliferative disorders

BACKGROUND

Mantle cell lymphoma is a mature, virgin B-cell neoplasm characterized immunologically by a panB+, CD5+, CD23-, cyclin D1+ phenotype and genetically by t(11;14)(q13;q32) with overexpression of the cyclin D1 (bcl-1) gene. It usually presents as advanced stage disease, involving lymph nodes, spleen, bone marrow, and extranodal sites, particularly the gastrointestinal tract. However, frank leukemic presentation with high white cell counts is uncommon and can be difficult to distinguish from other chronic lymphoproliferative disorders. The aim of this study was to characterize the morphologic spectrum of leukemic mantle cell lymphoma.

METHODS

During the period July 1994 through October 1998, 14 patients with mantle cell lymphoma in leukemic phase were diagnosed at the Department of Pathology, Queen Elizabeth Hospital, Hong Kong. The diagnosis of mantle cell lymphoma was based on histologic and immunocytochemical findings and was confirmed by cyclin D1 immunoreactivity in all cases. The clinical records and laboratory results were reviewed. Peripheral blood smears, bone marrow, and other tissue biopsies were examined, with particular attention to the cytologic features of the leukemic mantle cells.

RESULTS

Mantle cell lymphoma in leukemic phase showed a very aggressive clinical course. Eight patients died at a mean of 13 months, and only 1 patient was disease free. Morphologically, the leukemic mantle cells exhibited a broad morphologic spectrum, with several cytologic patterns identified: 1) mixed small and medium-sized cells, 2) predominantly medium-sized cells, 3) predominantly large cells, and 4) giant cells. Despite variations in the size and nuclear shape, the leukemic mantle cells could usually be recognized by the nuclear irregularity and clefting, moderately dense but evenly distributed chromatin, small nucleoli, and scant cytoplasm.

CONCLUSIONS

Recognition of the characteristic cytologic features of leukemic mantle cells can help to distinguish them from other chronic lymphoproliferative disorders. In contrast to the latter, the clinical course is aggressive and response to conventional chemotherapy is poor.

Morphologic spectrum of cutaneous B-cell lymphomas

Cutaneous B-cell lymphomas represent a heterogeneous group of entities which show variation in histology, immunophenotype, and in prognosis. In the current review the morphologic spectrum of cutaneous B-cell lymphomas comprising primary and secondary cutaneous B-cell lymphomas is discussed according to the REAL classification scheme.

The Revised European-American Classification of Lymphoid Neoplasms (REAL): a new perspective for the classification of cutaneous lymphomas

Differing classification schemes for malignant lymphomas have been used in Europe and the United States. Attempts to translate between the principle classifications have been unsuccessful and historically it has been difficult to arrive at an unified approach. In addition, many new lymphoma entities have been recognized in recent years that are not delineated in any of the existing classification schemes. To provide a unified international basis for clinical and investigative work in this field, in 1994 the International Lymphoma Study Group (ILSG) proposed a new classification termed Revised European-American Classification of Lymphoid Neoplasms (REAL). This review discusses the REAL classification, especially as it pertains to cutaneous lymphomas, and provides insight into the clinicopathologic features of lymphoproliferative disease involving the skin. The premise of the REAL classification is that a classification scheme should be based on the delineation of disease entities, utilizing pathologic, immunophenotypic, genetic, and clinical features. Therefore, if cutaneous involvement is an integral aspect of any lymphoma subtype, this clinical information is included in the definition of that neoplasm. We conclude that the principles of the REAL classification are applicable to cutaneous lymphomas, as well as lymphomas involving other anatomic sites.

Practical role of molecular diagnostics in non-Hodgkin's lymphomas

Molecular techniques are becoming increasingly important in the analysis of NHL, both for diagnostic purposes and in order to evaluate prognosis accurately. The increasing number of techniques available renders evaluation of their relative roles important and a review of their informativity in NHL at diagnosis timely. Molecular equivalents of chromosomal translocations generate either a qualitative change due to the expression of a chimaeric, relatively tumour specific, protein, such as the NPM-ALK associated with the t(2;5) in ALCL or a quantitative change in the extent, stage or site of expression of a full length protein, due to its juxtapositioning to and deregulation by an Ig or TCR gene. The latter represents errors of the somatic recombination process which lymphoid precursors undergo. In NHL, this category includes BCL1/CCND1, BCL2, BCL6 and MYC. The molecular characteristics, the functional consequences and the main clinical correlations of each of these abnormalities is reviewed. At diagnosis, immunological detection of the deregulated 'protooncogene' may well provide the simplest, most appropriate screening technique for CCND1 and NPM-ALK induced ALK expression. BCL6 abnormalities demonstrate similarities to BCL2 and MYC and a combination of immunophenotypic, FISH, Southern blot and PCR techniques are useful in their characterization. For the approximately 50% of NHL without one of the above markers, identification of a clonal Ig or TCR rearrangement can provide a useful 'pan' B or T molecular equivalent, provided that the limitations of the detection techniques are appreciated. Appropriate use of these techniques will transform our ability to classify, stratify and eventually treat in a risk adapted manner, patients with NHL.

Clinicopathologic study of PRAD1/cyclin D1 overexpressing lymphoma with special reference to mantle cell lymphoma. A distinct molecular pathologic entity

Mantle cell lymphomas (MCLs) are frequently associated with the overexpression of PRAD1/cyclin D1, activated by 11q13 translocation and its molecular counterpart BCL-1 gene rearrangement. We recently described the correlation of positive nuclear staining using monoclonal antibody against a PRAD1/cyclin D1 product with mRNA overexpression in MCLs. In the present study, we immunohistochemically investigated the PRAD1/cyclin D1 protein in a large series of 334 lymphoproliferative disorders, including 39 cases of MCLs on paraffin sections. Based on the cyclin D1 positivity, CD5 expression, and the morphologic features of the tumor tissue, four groups of MCL-related lesions were identified among the B-cell lymphomas examined: 36 cases with cyclin D1 overexpression, 35 (95%) of which exhibited CD5-positivity and MCL-morphology (Group 1); four cases of lymphomas with MCL morphology and CD5 expression but lacking cyclin D1 overexpression (Group II); four cases of lymphomas without cyclin D1 overexpression and surface CD5 but that fall within the morphologic boundaries of MCLs (Group III); and 11 cases of CD5-positive diffuse large cell lymphomas without cyclin D1 overexpression (Group IV). The Group I cases demonstrated quite homogeneous clinicopathologic features identical to those of MCLs. This group showed a poor prognosis (11% had 5-year survival), which is highly contrasted with that of Group II (100%). Although the four groups of MCL-related lesions sometimes overlapped in their histologic or phenotypic spectrums, each appeared to show distinct clinicopathologic and prognostic profiles. Our study provides a basis for further clarification of the nature of the neoplasms of Groups II, III, and IV. Moreover, this comprehensive study may indicate that the overexpression of PRAD1/cyclin D1 is biologically essential to defining MCLs.

Mantle cell lymphoma. A morphological, immunohistochemical and molecular genetic study

In order to identify helpful markers in the classification of mantle cell lymphoma, a morphological, immunohistochemical and molecular genetic analysis of 41 cases of NHL, originally referred to us as CC, ILL or IDL, was performed. We revised these lymphomas using the strict morphological criteria described in the updated Kiel classification and the more recently described criteria for MCL. The term MCL was used to designate the small lymphocytic B-cell NHL, previously referred to as CC or ILL/ IDL. This revision yielded 20 MCL, 8 CLL, 3 Cb/Cc, 1 CB, 6 IC and 3 MALT lymphomas. The presence of scattered histiocytes was seen in 90% of MCL and 5% of the other cases. No other morphological parameter, besides the used criteria, differentiated between MCL and similar small lymphocytic B cell lymphomas. Helpful immunohistochemical markers to distinguish MCL from similar small lymphocytic lymphomas were CD5+, CD10-, CD23- and Alkaline Phosphatase+. Large fields of dendritic reticulum cells, often in a loose and disrupted arrangement were seen in 82% of MCL and in 19% of the other lymphomas. Analysis with Southern blotting showed a rearrangement in the BCL-1 locus in 12/20 cases of MCL but not in the other 21 lymphomas. Although very specific for MCL, Southern blotting to detect BCL-1 rearrangements is, due to the large number of probes necessary, not of great help in daily practice for routine diagnostic purposes. We conclude that using strict morphological criteria, the diagnosis MCL can be made reliably and that immunophenotyping is helpful in supporting the diagnosis.

The involvement of the chromosome 11q13 region in human malignancies: cyclin D1 and EMS1 are two new candidate oncogenes--a review

Amplification of oncogenes has been observed frequently in various human malignancies and might be of clinical relevance. In the last decade, the exploration of oncogene activation due to DNA amplification in cancer research has mainly focussed on three aspects: (i) the assessment of oncogene amplification as a prognostic marker for survival of cancer patients, (ii) the development of reliable methods for detection of tumors which harbor DNA amplification of oncogenes and (iii) the identification of the gene or genes responsible for the biological (prognostic) significance in tumors with DNA amplification and the characterization of these candidate proto-oncogenes that might help to elucidate their normal function and the role in tumor development. In this review, these three aspects will be highlighted with regard to DNA amplification of the chromosome 11q13 region. Chromosome 11q13 amplification has been found frequently in certain human malignancies; in cancer of the breast and of the head and neck region, amplification of this region is observed in 13 and 29% of tumors, respectively. The 11q13 amplification has been reported to be of clinical relevance in these cancers, since patients with this amplification show a poor clinical course of disease. The amplified 11q13 region is estimated to be 3-5 Mb in size and to harbor many (putative) genes. Recently, two candidate genes, CCND1 and EMS1, were identified which were both over-expressed in all carcinomas with an 11q13 amplification. Therefore, the activation of these genes might confer the selective advantage to these tumors. In addition, the characterization of these two novel genes sustained their potential role in carcinomas with 11q13 amplification.

Mantle-cell lymphoma

Histological subtyping of non-Hodgkin's lymphomas is of prognostic significance. Current classification systems subdivide them into low-, intermediate-, and high-grade malignancies. These subgroups are largely supported by clinical findings, but immunophenotyping and genotyping have shown that several of these histologically defined subcategories are heterogeneous. This is exemplified by the 'diffuse small cleaved-cell lymphoma' which comprises B-cell and T-cell lymphomas. Moreover, within the B-cell lymphomas, several entities have been included, which recapitulate the different compartments present in the reactive B follicle, e.g., the follicle centre, the mantle, and the marginal zone. Mantle-cell lymphomas have been identified in the United States as mantle-zone lymphomas and as intermediate differentiated lymphomas and in Europe as centrocytic lymphomas. Morphology, immunophenotyping, and cytogenetics of these three lymphomas support their similarity and underline their distinction from follicle centre-cell lymphomas as well as from small lymphocytic lymphomas. All three are composed of a mixture of small round and small cleaved cells, expressing several B-cell markers, surface immunoglobulins, and CD5, but lacking CD10 expression. They often carry the translocation t(11;14) with rearrangement of bcl-1/PRAD1 gene. The behaviour and responsiveness to therapy of mantle-cell lymphomas has not been fully documented yet. In order to obtain these data, precise subtyping of non-Hodgkin's lymphomas--not only based on morphology, but supported by immunophenotyping and cytogenetic analysis--is now mandatory.