Difference between revisions of "Hodgkin lymphoma"

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Hodgkin lymphoma (view source)

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'''Hodgkin [[lymphoma]]''', abbreviated '''HL''', is a malignancy that afflicts people in the prime of their life. Fortunately, it usually has a good prognosis.
{{ Infobox diagnosis
| Name      = Classical Hodgkin lymphoma
| Image      = Hodgkin_lymphoma_cytology_large.jpg
| Width      =
| Caption    = HL mixed cellularity - cytology.
| Micro      = Reed-Sternberg cell (large binucleated cell (>= 45 micrometres), +/-multinucleated, +/-horseshoe-like shape, [[macronucleolus]] - approximately the size of a RBC (~8 micrometers)), well-defined cell border, abundant cytoplasm.
| Subtypes  = nodular sclerosis CHL, mixed cellularity CHL, lymphocyte-rich CHL, lymphocyte-depleted CHL
| LMDDx      = [[diffuse large B cell lymphoma]] (esp. ''T-cell/histiocytic-rich LBCL''), [[anaplastic large cell lymphoma]],
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma, nodular lymphocyte-predominant Hodgkin lymphoma
| Stains    =
| IHC        = CD30 Reed-Sternberg cells (RSCs) +ve ~98%, CD15 Reed-Sternberg cells +ve ~80% (also stains neutrophils), CD45 ''often negative'' in RSCs, CD20 -ve/+ve, PAX5 +ve
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Site      = usu. [[lymph node]] - classically in the neck
| Assdx      =
| Syndromes  =
| Clinicalhx = young adults, older adults (bimodal distribution)
| Signs      = lymphadenopathy - usu. neck, +/-[[B symptoms]] (fever, night sweats, weight loss)
| Symptoms  =
| Prevalence = common
| Bloodwork  =
| Rads      =
| Endoscopy  =
| Prognosis  = usu. good, dependent on stage
| Other      =
| ClinDDx    =
}}
'''Hodgkin [[lymphoma]]''', abbreviated '''HL''', is a haematological [[malignancy]]. If not otherwise specified, Hodgkin lymphoma generally refers to classical Hodgkin lymphoma (CHL) rather than [[nodular lymphocyte-predominant Hodgkin lymphoma]] (NLPHL). The latter accounts for only about 5% of the loose label of Hodgkin lymphoma<ref name=Ref_WMSP567/> and shows a sufficiently different biology and immunophenotype that is essentially a different disease (see [[nodular lymphocyte-predominant Hodgkin lymphoma|main article on NLPHL]]). The common feature is large atypical cells: Hodgkin/Reed-Sternberg cells in the case of classical Hodgkin lymphoma and "popcorn"/lymphohistiocytic/L&H cells in NLPHL. However, at least in typical cases, there are morphological and immunophenotypic differences.


Pathologists say "... it is both the easiest and hardest diagnosis to make." The reason for this is: the diagnosis depends on finding Reed-Sternberg cells; if they are obvious the diagnosis is easy... if you can't find 'em and an alternative diagnosis is not apparent -- you wonder whether you're missing them.
Classical Hodgkin lymphoma has a bi-modal distribution, afflicting young adults and with a further peak in incidence in middle-age. Fortunately, it usually has a good prognosis.


==Clinical==
Pathologists say "... it is both the easiest and hardest diagnosis to make." The reason for this is: the diagnosis depends on finding Reed-Sternberg cells (or Popcorn cells); if they are obvious the diagnosis is easy... if you can't find 'em and an alternative diagnosis is not apparent -- you wonder whether you're missing them.
 
==General==
===Clinical===
Symptoms:<ref name=Ref_WMSP567>{{Ref WMSP|567}}</ref>
Symptoms:<ref name=Ref_WMSP567>{{Ref WMSP|567}}</ref>
*"B symptoms":<ref>URL: [http://lymphoma.about.com/od/symptoms/f/bsymptoms.htm http://lymphoma.about.com/od/symptoms/f/bsymptoms.htm]. Accessed on: 11 August 2010.</ref> fever, night sweats, weight loss.
*"[[B symptoms]]" - all required:<ref>URL: [http://lymphoma.about.com/od/symptoms/f/bsymptoms.htm http://lymphoma.about.com/od/symptoms/f/bsymptoms.htm]. Accessed on: 11 August 2010.</ref> weight loss, night sweats and fever.
*Infections (due to immune dysfunction).
*Infections due to immune dysfunction.


Diagnosis:
Diagnosis:
Line 12: Line 45:


Prognosis:
Prognosis:
*Usu. good.
*Usually good.
*Unlike non-Hodgkin lymphomas, it spreads in a predictable pattern; thus, staging plays an important role in determining the therapy.<ref>{{Ref PCPBoD8|315}}</ref>
*Unlike non-Hodgkin lymphomas, it spreads in a predictable pattern; thus, staging plays an important role in determining the therapy.<ref name=PCPBoD8_315>{{Ref PCPBoD8|315}}</ref>
 
*Clinically classified into early favourable, early unfavourable and late/advanced disease.
==Hodgkin lymphoma subtypes==
Types:<ref name=Ref_WMSP567/>
*Classical HL (CHL) - ~95% of HL.
*Nodular lymphocyte-predominant HL (NLPHL) - ~5% of HL.
 
===Classic HL===
*Four types of classic HL (see below).
 
===NLPHL===
*AKA ''lympho-histiocytic variant''.
*Abbreviated ''NLPHL''.
*Different IHC and morphologic appearance than classic HL.
*Significant risk for transformation into [[diffuse large B cell lymphoma]] (DLBCL); 10-year cumulative transformation rate (to DLBCL) in one study was 12%.<ref name=pmid20029973 >{{cite journal |author=Biasoli I, Stamatoullas A, Meignin V, ''et al.'' |title=Nodular, lymphocyte-predominant Hodgkin lymphoma: a long-term study and analysis of transformation to diffuse large B-cell lymphoma in a cohort of 164 patients from the Adult Lymphoma Study Group |journal=Cancer |volume=116 |issue=3 |pages=631–9 |year=2010 |month=February |pmid=20029973 |doi=10.1002/cncr.24819 |url=}}</ref>
 
==Microscopic==
By definition, HL has Reed-Sternberg cells (RSCs).
 
===Classical HL===
Features (classic HL):
*Reed-Sternberg cell.
**Large binucleated cell (>= 45 micrometres).<ref name=Ref_PCPBoD8_329>{{Ref PCPBoD8|329}}</ref>
***May be multinucleated.
***May have a horseshoe-like shape.
**Macronucleolus - approximately the size of a RBC (~8 micrometers).
**Well-defined cell border.
**Abundant cytoplasm.
 
Notes:
*Large mononuclear cells are common (so called "mononuclear RSCs") but not diagnostic.
 
Images (classic HL):
*[http://commons.wikimedia.org/wiki/File:Hodgkin_lymphoma_cytology_large.jpg HL mixed cellularity - cytology (WC)].
*[http://commons.wikimedia.org/wiki/File:Hodgkin_lymphoma_cytology_small.jpg HL mixed cellularity - cytology (WC)].
*[http://en.wikipedia.org/wiki/File:Hodgkin_lymphoma_%281%29_mixed_cellulary_type.jpg HL mixed cellularity (WC)].


===Classic HL sub-types===
====Subtypes of classic HL====
====Subtypes of classic HL====
There are four CHL subtypes:<ref name=Ref_WMSP567/>
There are four CHL subtypes:<ref name=Ref_WMSP567/>
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*The subtypes prevalence is in reverse alphabetical order.
*The subtypes prevalence is in reverse alphabetical order.


===Nodular lymphocyte-predominant HL===
==Gross==
Features (nodular lymphocyte-predominant Hodgkin's lymphoma):
Location:
*''Popcorn cell'' (previously known as ''Lymphocytic & histiocytic'' cell (L&H cell)<ref name=pmid9499174>{{cite journal |author=Küppers R, Rajewsky K, Braeuninger A, Hansmann ML |title=L&H cells in lymphocyte-predominant Hodgkin's disease |journal=N. Engl. J. Med. |volume=338 |issue=11 |pages=763–4; author reply 764–5 |year=1998 |month=March |pmid=9499174 |doi=10.1056/NEJM199803123381113 |url=}}</ref>) - variant of RSC:
*Almost always arises from a [[lymph node]] - classically in the neck, but may be in the axilla and mediastinum
**Cells (relatively) small (compared to classic RSCs).
*Spleen may be involved
**Lobulated nucleus - '''key feature'''.
*Bone marrow involvement is unusual (~5% of cases, higher in HIV-associated cases), so bone marrow assessment is usually not performed
**Small nucleoli.  
*''Extranodal Hodgkin lymphoma'' is (case report) rare.<ref name=pmid11100066>{{Cite journal | last1 = Vadmal | first1 = MS. | last2 = LaValle | first2 = GP. | last3 = DeYoung | first3 = BR. | last4 = Frankel | first4 = WL. | last5 = Marsh | first5 = WL. | title = Primary localized extranodal hodgkin disease of the transverse colon. | journal = Arch Pathol Lab Med | volume = 124 | issue = 12 | pages = 1824-7 | month = Dec | year = 2000 | doi = 10.1043/0003-9985(2000)1241824:PLEHDO2.0.CO;2 | PMID = 11100066 }}</ref>
*Subtle nodularity at low power (2.5x or 5x objective).
 
==Microscopic==
Defined by ''Reed-Sternberg cells'' (RSCs). Morphologically similar mononuclear cells are known as Hodgkin cells. RSCs are:
*Large binucleated cell (>= 45 micrometres).<ref name=Ref_PCPBoD8_329>{{Ref PCPBoD8|329}}</ref>
**May be multinucleated.
**May have a horseshoe-like shape.
*[[Macronucleolus]] - approximately the size of a RBC (~8 micrometers).
*Well-defined cell border.
*Abundant cytoplasm.
 
RSC may show peri-cellular clearing, making the cells appear within a space. These are called lacunar cells (as they are in a "lake"). Apoptotic RSC may show pyknotic nuclei and scant eosinophilic cytoplasm and are sometimes known as "mummified" cells.


Images (NLPHL):  
===Images (classic HL)===
*[http://webpathology.com/image.asp?case=388&n=16 Popcorn cell (webpathology.com)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Popcorn_cell_in_nodular_lymphocyte_predominant_Hodgkin_lymphoma_-_very_high_mag_cropped.jpg Popcorn cell (WC)].
Image:CHL mummified cell x40.jpg | "Mummified" RSC. (WC)
Image:CHL lacunar cell x40.jpg | "Lacunar cell". (WC)
Image:16S14098 cHL multinucleate HRS cell x40c.jpg | Multinucleate RSC. (WC)
Image:Hodgkin_lymphoma_cytology_large.jpg | HL mixed cellularity - cytology. (WC)
Image:Hodgkin_lymphoma_cytology_small.jpg | HL mixed cellularity - cytology. (WC)
Image:Hodgkin_lymphoma_%281%29_mixed_cellulary_type.jpg | HL mixed cellularity. (WC)
</gallery>


===DDx both CHL & NLPHL===
===DDx both CHL & NLPHL===
*CHL/NLPHL.
*CHL/NLPHL.
*[[Diffuse large B cell lymphoma]] (DLBCL).
*[[Diffuse large B cell lymphoma]] (DLBCL), esp. ''T-cell/histiocytic-rich LBCL''.
*[[Anaplastic large cell lymphoma]] (ALCL).
*[[Anaplastic large cell lymphoma]] (ALCL).
*B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma.<ref name=pmid22222636>{{Cite journal  | last1 = Gualco | first1 = G. | last2 = Natkunam | first2 = Y. | last3 = Bacchi | first3 = CE. | title = The spectrum of B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma: a description of 10 cases. | journal = Mod Pathol | volume =  | issue =  | pages =  | month = Jan | year = 2012 | doi = 10.1038/modpathol.2011.200 | PMID = 22222636 | URL = http://www.nature.com/modpathol/journal/vaop/ncurrent/full/modpathol2011200a.html }}</ref> (typically in cases of numerous large atypical cells where the morphology and immunophenotype do not neatly fit into either DLBCL or CHL).


==IHC==
==IHC==
Abbreviated panel:<ref name=Ref_WMSP568>{{Ref_WMSP|568}}</ref>
Abbreviated panel:<ref name=Ref_WMSP568>{{Ref_WMSP|568}}</ref>
*CD30 Reed-Sternberg cells (RSCs) +ve ~98%  
*CD30 Reed-Sternberg cells (RSCs) +ve ~98% (beware of mis-interpreting CD30+ activated lymphoid cells)
*CD15 Reed-Sternberg cells +ve ~80%, stains neutrophils.
*CD15 Reed-Sternberg cells +ve ~80%, stains neutrophils.
*Both CD30 and CD15 are classically positive in a membranous and Golgi pattern
*MUM1 +ve
*CD45 '''often negative''' in RSCs.
*CD45 '''often negative''' in RSCs.
*CD20 may stain RSCs.
*CD20 may stain RSCs (usually negative, but can be weak).
*PAX5 +ve.<ref name=Ref_APBR683>{{Ref APBR|683}}</ref>
*PAX5 +ve, though said to be weaker than background normal B-cells<ref name=Ref_APBR683>{{Ref APBR|683}}</ref>


Additional - for completeness:
Additional - for completeness:
*CD3 (T lymphocytes)
*CD3 (T lymphocytes) - negative in RSCs
*OCT2/BOB1 negative (co-transcription factors for immunoglobulin production, one or the other is usually negative)
*40% are EBV positive.


NLPHL IHC '''differs''' from the classical HL:<ref name=Ref_APBR683>{{Ref APBR|683}}</ref>
NLPHL IHC '''differs''' from the classical HL:<ref name=Ref_APBR683>{{Ref APBR|683}}</ref>
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*CD10 +ve.
*CD10 +ve.
*Bcl-6 +ve.
*Bcl-6 +ve.
*EMA +ve.
*[[EMA]] +ve (40-50%)
*CD30 -ve
*CD30 -ve
*CD15 -ve.
*CD15 -ve.


==="UHN panel"===
===A panel===
{| class="wikitable"
{| class="wikitable"
|Antibody || NLPHL || CHL
|Antibody || NLPHL || CHL
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|CD20 || +ve || -ve
|CD20 || +ve || -ve
|-
|-
|BCL6 || ||
|BCL6 || +ve || -ve
|-
|-
|MUM1<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/601900 http://www.ncbi.nlm.nih.gov/omim/601900]. Accessed on: 10 August 2010.</ref> || -ve ||
|MUM1<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/601900 http://www.ncbi.nlm.nih.gov/omim/601900]. Accessed on: 10 August 2010.</ref> || -ve || +ve
|-
|-
|CD30 || -ve || +ve (most sensitive).
|CD30 || -ve || +ve (most sensitive).
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|CD21 || networks present || no networks
|CD21 || networks present || no networks
|-
|-
|CD23 || networks present || no networks
|[[CD23]] || networks present || no networks
|-
|-
|OCT-2 || +ve || -ve
|OCT-2 || +ve || -ve
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|4 unstained || ||
|4 unstained || ||
|}
|}
==Sign out==
===Suggestive FNA===
<pre>
Lymph Node, Right Neck, FNA:
- Large binucleated and multinucleated cells with macronucleoli in
  a background of abundant lymphocytes, histiocytes, rare eosinophils.
Comment:
A cell block is not available for further work-up. The findings raise the possibility of Hodgkin's lymphoma.
A further biopsy is required for the diagnosis.
</pre>


==See also==
==See also==
Mark
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