Difference between revisions of "Follicular lymphoma"

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Follicular lymphoma (view source)

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#redirect [[Small_cell_lymphomas#Follicular_lymphoma]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Follicular lymphoma -- low mag.jpg
| Width      =
| Caption    = Follicular lymphoma. [[H&E stain]].
| Synonyms  =
| Micro      = Lymph node: abundant abnormally-shaped lymphoid follicles with some of the following: non-polarized mantle zone, non-polarized germinal center, loss of tingible body macrophages, sinuses effaced (lost)
| Subtypes  =
| LMDDx      = [[diffuse large B-cell lymphoma]], other [[small cell lymphomas]], reactive follicular hyperplasia
| Stains    =
| IHC        = CD20 +ve, CD10 +ve, BCL-6 +ve, BCL-2 +ve
| EM        =
| Molecular  = t(14;18)(q32;q21) / IGH-BCL2
| IF        =
| Gross      = white lesions +/-subtle fine nodularity (fish flesh-like appearance)
| Grossing  =
| Site      = [[lymph node]], [[spleen]], [[bone marrow]], others
| Assdx      =
| Syndromes  =
| Clinicalhx =
| Signs      =
| Symptoms  =
| Prevalence = common
| Bloodwork  =
| Rads      =
| Endoscopy  =
| Prognosis  = moderate to good
| Other      =
| ClinDDx    = other causes of lymphadenopathy - other [[lymphoma]]s, metastatic carcinoma
| Tx        =
}}
'''Follicular lymphoma''', abbreviated '''FL''', is a very common [[non-Hodgkin lymphoma]].  It is a [[small cell lymphoma]].
 
==General==
*A very common type of lymphoma.
*Moderate prognosis - overall five year survival ~ 66% in one cohort without transformation.<ref name=pmid23897955>{{Cite journal  | last1 = Link | first1 = BK. | last2 = Maurer | first2 = MJ. | last3 = Nowakowski | first3 = GS. | last4 = Ansell | first4 = SM. | last5 = Macon | first5 = WR. | last6 = Syrbu | first6 = SI. | last7 = Slager | first7 = SL. | last8 = Thompson | first8 = CA. | last9 = Inwards | first9 = DJ. | title = Rates and outcomes of follicular lymphoma transformation in the immunochemotherapy era: a report from the University of Iowa/MayoClinic Specialized Program of Research Excellence Molecular Epidemiology Resource. | journal = J Clin Oncol | volume = 31 | issue = 26 | pages = 3272-8 | month = Sep | year = 2013 | doi = 10.1200/JCO.2012.48.3990 | PMID = 23897955 }}
</ref>
*May transform to a more aggressive lymphoma, e.g. [[diffuse large B-cell lymphoma]].
**Prognosis after transformation significantly worse - five year survival ~ 22%.<ref name=pmid23897955/>
**Approximately 2% transform per year, or 10.7% in five years.<ref name=pmid23897955/>
 
==Gross==
*Lymph node enlargement.
*Classically white and uniform - usually described as ''fish flesh-like''.
**May have a vague nodularity.
 
===Images===
<gallery>
Image:Lymphoma_macro.jpg | FL in a lymph node. (WC)
Image:Follicular_lymphoma,_spleen.jpg | FL in the [[spleen]]. (WC)
</gallery>
 
==Microscopic==
Features (lymph node):
*Abundant abnormally-shaped lymphoid follicles - '''key feature''' - including some of the following:
**Non-polarized mantle zone (normal mantle zone is usu. thicker at capsular aspect).
**Non-polarized germinal center (normal germinal center has dark & light area).
**Loss of tingible body macrophages.
**Sinuses effaced (lost).
 
Note:
*The intrafollicular component of the lymph node is compressed - follicles are often described as "kissing", as they nearly touch.
*In [[bone marrow]] specimens the neoplastic cells classically have a paratrabecular arrangement,<ref name=pmid17284114>{{Cite journal  | last1 = Iancu | first1 = D. | last2 = Hao | first2 = S. | last3 = Lin | first3 = P. | last4 = Anderson | first4 = SK. | last5 = Jorgensen | first5 = JL. | last6 = McLaughlin | first6 = P. | last7 = Medeiros | first7 = LJ. | title = Follicular lymphoma in staging bone marrow specimens: correlation of histologic findings with the results of flow cytometry immunophenotypic analysis. | journal = Arch Pathol Lab Med | volume = 131 | issue = 2 | pages = 282-7 | month = Feb | year = 2007 | doi = 10.1043/1543-2165(2007)131[282:FLISBM]2.0.CO;2 | PMID = 17284114 }}</ref> i.e. the lymphoma cells are found adjacent to the bone spicules.
 
DDx:
*Reactive follicular hyperplasia.
*[[Diffuse large B-cell lymphoma]] - esp. for the grade 3B.
 
===Images===
<gallery>
Image: Follicular lymphoma -- very low mag.jpg | FL - very low mag.
Image: Follicular lymphoma -- low mag.jpg | FL - low mag.
Image: Follicular lymphoma -- intermed mag.jpg | FL - intermed. mag.
Image: Follicular lymphoma -- high mag.jpg | FL - high mag.
Image: Follicular lymphoma -- very high mag.jpg | FL - very high mag.
</gallery>
<gallery>
Image:Follicular_Lymphoma,_Paratrabecular_Involvement_of_Bone_Marrow_(5691578596).jpg | FL - bone marrow. (WC/euthman)
</gallery>
www:
*[http://www.flickr.com/photos/euthman/3311641845/ Follicular lymphoma - bone marrow (flickr.com)].
*[http://library.med.utah.edu/WebPath/HEMEHTML/HEME034.html Follicular lymphoma (utah.edu)].
 
===Grading===
*Grade 1-2: <= 22 centroblasts / HPF; where 1 HPF ~= 0.2376 mm^2 (22 mm eye piece @ 40X objective).
*Grade 3A: >22 centroblasts / HPF; where 1 HPF ~= 0.2376 mm^2 (22 mm eye piece @ 40X objective).
*Grade 3B: only centroblasts (within a nodular architecture).
 
Notes:
*Significant interobserver variability.<ref>Good, D. 17 August 2010.</ref>
*Grade 1 & Grade 2 lumped together.
*One should evaluate 10 HPFs.
*''Only'' centroblasts ''without'' a nodular architecture is ''[[Diffuse large B cell lymphoma]]'' ([[DLBCL]]).
 
The usual cut points mentioned by people with [[HPFitis]] are:<ref name=Ref_Sternberg4_813>{{Ref Sternberg4|813}}</ref>
*Grade 1: 0-5 centroblasts / HPF.
*Grade 2: 5-15 centroblasts / HPF.
*Grade 3: >15 centroblasts / HPF.
 
==IHC==
Features:<ref name=pmid18359244/>
*[[CD10]] +ve.
*BCL6 +ve.
 
Others:
*CD5 -ve.
**+ve in mantle cell lymphoma.
*CD23 -ve/+ve.
**+ve in CLL.
*CD43 -ve.
**+ve in mantle cell lymphoma, marginal zone lymphoma.
*CD11c -ve -- flow cytometry only.
*CD21 -ve in tumour cells; highlights follicular dendritic cells.
*BCL2 +ve<ref name=pmid18359244>{{cite journal |author=Vitolo U, Ferreri AJ, Montoto S |title=Follicular lymphomas |journal=Crit. Rev. Oncol. Hematol. |volume=66 |issue=3 |pages=248–61 |year=2008 |month=June |pmid=18359244 |doi=10.1016/j.critrevonc.2008.01.014 |url=}}</ref> - like many other small cell lymphomas.
**Usually negative in benign germinal centres.
 
A panel to work-up:
*BCL2, BCL6, CD3, CD5, CD10, CD20, CD23, cyclin D1.
===Images===
<gallery>
Image: Follicluar lymphoma - bcl2 -- low mag.jpg | FL - BCL2 - low mag.
Image: Follicular lymphoma - control bcl2 -- low mag.jpg | FL - BCL2 control - low mag.
</gallery>
www:
*[http://www.pathpedia.com/education/eatlas/histopathology/lymph_node/follicular_lymphoma/follicular-lymphoma-%5B16-ln021_cd21%5D.jpeg Follicular lymphoma - CD21 (pathpedia.com)].
 
==Molecular==
*t(14;18)(q32;q21)/IGH-BCL2 in 70-95% of cases.<ref name=pmid18359244/>
**Should not be confused with t(14;18)(q32;q21)/IGH-MALT1 seen in MALT lymphomas.<ref name=pmid16950858>{{cite journal |author=Bacon CM, Du MQ, Dogan A |title=Mucosa-associated lymphoid tissue (MALT) lymphoma: a practical guide for pathologists |journal=J. Clin. Pathol. |volume=60 |issue=4 |pages=361–72 |year=2007 |month=April |pmid=16950858 |pmc=2001121 |doi=10.1136/jcp.2005.031146 |url=}}</ref>
 
==Sign out==
<pre>
RETROPERITONEAL MASS, RIGHT, CORE BIOPSIES:
- NON-HODGKIN B-CELL LYMPHOMA, FAVOUR FOLLICULAR LYMPHOMA.
 
COMMENT:
Morphology:
-Small cells: size ~ mature lymphocytes, quantity - many, angular and round.
-Large cells (intermixed with small cells): size ~1.5-2x mature lymphocyte,
small nucleoli, moderate quantity of grey/basophilic cytoplasm, moderate
nuclear pleomorphism.
-Architecture: no gland formation, discohesive, no follicles apparent, no sheets
of large cells.
-Mitoses are uncommon.
 
Immunohistochemical stains (tumour cells):
Positive: CD45 (strong, membranous/cytoplasmic), CD20 (strong, membranous/cytoplasmic),
BCL-2 (strong, membranous/cytoplasmic), CD10 (strong, membranous), BCL-6 (moderate,
patchy, nuclear).
 
Negative: pankeratin, CD3, CD5, CD30, CD21 (follicular dendritic cells not apparent),
CD23 (scattered, rare).
 
Ki-67: highlights the large cells, primarily -- 5-35% of cells within the core.
 
The findings favour a follicular lymphoma, based on the cellular morphology and
immunostains; however, they are limited by the type of tissue sampling (core biopsy).
Clinical correlation is suggested.
</pre>
 
==See also==
*[[Small cell lymphomas]].
*[[Lymphoma]].
*[[Lymph node pathology]].
 
==References==
{{Reflist|2}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Small cell lymphomas]]
Michael
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