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Hodgkin Lymphomas Hodgkin Lymphomas L. Jeffrey Medeiros, MD MD Anderson Cancer Center James J. Butler, MD Robert J. Lukes, MD Cancer Research 26; 1063, 1966 Classification of Hodgkin Lymphoma Little Change Over Time Lukes & Butler Rye WHO - 2008 Lymphocytic Lymphocytic Nodular and/or histiocytic predominance lymphocyte Nodular predominant HL Diffuse Lymphocyte-rich classical HL Nodular sclerosis Nodular Nodular sclerosis sclerosis classical HL Mixed Mixed cellularity Mixed cellularity classical HL Diffuse fibrosis Lymphocytic Lymphocyte- Reticular depletion depleted classical HL Mercedes Benz Same name – different cars 2019 1934 Criteria for HL Diagnosis Criteria have shifted from purely histologic to histologic and immunophenotypic The shift has lead to: Reclassification of disease Change in disease frequencies Change in criteria for diagnosis of HL overall Impact of Immunophenotype Are RS Cells Needed for Dx of HL ? Old Formula RS cells + appropriate = Hodgkin lymphoma milieu Immunophenotype has changed this NLP LP cells NS Lacunar cells MC RS+ mononuclear variants LD RS+ anaplastic variants Impact of Immunophenotype Small Biopsy Specimens Reed-Sternberg cells not required for diagnosis Need mononuclear cells with appropriate immunophenotype Hodgkin Lymphomas Frequency HL ~ 12% lymphomas in USA (~9,000 cases) Nodular sclerosis 62% Mixed cellularity 27% Nodular lymphocyte predominant 5% Lymphocyte-rich classical 4% Lymphocyte depleted 1% J Clin Oncol 23: 5739, 2005 Nodular Lymphocyte Predominant HL Male predominance Peak incidence 30-50 years age group Localized peripheral LNs (cervical #1) B-symptoms unusual Mediastinum, spleen and bone marrow rarely involved Frequent relapses (late) Nodular LPHL Immunophenotype of Neoplastic Cells in HL Classical NLP HRS Cells LP Cells T-cell - - CD15 +/- - CD20 -/+ ++ CD30 + - CD45/LCA - + PAX-5 + dim + OCT-2 - + BCL-2 +/- - BCL-6 -/+ + EBV +/- - Nodular LPHL – CD20 LP cells are of B-cell lineage Many reactive cells are also B-cells Nodular LPHL Reactive cells also important for Dx A follicle-based tumor CD21 CD57 CD3 Patterns of NLPHL – CD20 A. B-cell rich nodular B. Serpiginous nodular CD3 CD20 C. Nodular with extranodular LP cells D. T-cell rich nodular E. Diffuse T-cell-rich (TCRBCL-like) F. Diffuse moth-eaten Am J Surg Pathol 27: 1350, 2003 Pattern is Prognostic in NLPHL Blood 122: 4246, 2013 NLPHL Pattern E Nodular areas are required to recognize pattern E in NLPHL Is pattern E = T-cell/histiocyte rich large B-cell lymphoma ? Patients tend to do better than patients with DLBCL No criteria to distinguish pattern E from true THRLBCL OK to use clinical criteria in this B symptoms Bone lesions, BM involvement Hepatosplenomegaly High serum LDH If treatment is R-CHOP (or CHOP) the distinction may not matter NLPHL Can Transform into Diffuse Large B-cell Lymphoma NLPHL DLBCL NLPHL pts have 3-5% increased risk of DLBCL Same or different anatomic sites Synchronous or metachronous Not true for classical HL Lymphocyte-rich Classical HL Median age, 43 yrs Male predominance (70%) Most commonly stage I or II disease Peripheral LNs typically involved Mediastinum (15%) Spleen (15%) B-symptoms (10%) Late relapses uncommon Lymphocyte-rich Classical HL Nodular variant Lymphocyte-rich Classical HL Nodular Variant CD20 CD20 CD30 CD3 Immunophenotype of Neoplastic Cells in HL Classical NLP HRS Cells LP Cells T-cell - - CD15 +/- - CD20 -/+ ++ CD30 + - CD45/LCA - + PAX-5 + dim + OCT-2 - + BCL-2 + - BCL-6 -/+ + EBV +/- - Lymphocyte Predominant HL vs. Lymphocyte-rich Classical HL Overall Survival Failure-free Survival German Hodgkin Study Group J Clin Oncol 17:776, 1999 Nodular Lymphocyte Predominant HL versus Lymphocyte-rich Classical HL Can look very similar Immunophenotyping is mandatory for differential diagnosis If you don’t do it you will be sorry about 30-40% of the time Is LRCHL a Real Type of Classical HL ? We have seen evidence of nodular sclerosis in cases that otherwise looks like LRCHL At relapse, a subset of cases of LRCHL resemble nodular sclerosis CHL My opinion About 25% of LRCHL cases are “early” NS Other cases are likely “true” LRCHL Nodular Sclerosis HL Median age 28 years No male predominance Stage II disease in most patients Peripheral lymphadenopathy (cervical #1) Mediastinal involvement in 80% Spleen and/or lung 10% Bone marrow uncommon (3%) B-symptoms 40% Nodular Sclerosis Classical HL Any degree of fibrosis supports NS Diagnostic triad Nodules Sclerosis Lacunar cells Nodular Sclerosis HL Lacunar cells Nodular Sclerosis HL Syncytial Variant Nodular Sclerosis HL Syncytial Variant CD15 LCA CD20 PAX5 Differential Diagnosis of NSHL Other HL Fibrosis is not dense and does not polarize types with LN fibrosis DLBCL, nos Nodularity and sclerosis can mimic HL Sheets of large cells CD20+ CD45+ CD15- Primary Sheets of large cells without inflammatory mediastinal background; sclerosis common LBL CD20+ CD45+ CD15- CD30 +/- Gray zone Can look like HL or DLBCL or mixture lymphoma HL-like: CD45+ B-cell+ (strong) EBV- DLBCL-like: CD15+ CD30+ CD45- DLBCL with Sclerosis CD20 Mediastinal Large B-cell Lymphoma CD20 CD30 A B-lineage lymphoma that demonstrates overlapping clinical, morphological and/or immunophenotypic features between classical Hodgkin lymphoma and DLBCL. 2017 WHO book p.342 Gray Zone Lymphoma Two Variants Resembles HL but has immunophenotype more like DLBCL Resembles DLBCL but has immunophenotype more like HL In other words, there is discordance between morphology and immunophenotype 2017 WHO book, p.342 Gray Zone Lymphoma Clinical Features Young, 20-40 years Male > Female Anterior mediastinal mass is common Most reported cases from Western countries 2017 WHO book, p.342 Gray Zone Lymphoma Intermediate between Classical HL and DLBCL HL-like Gray Zone Lymphoma Intermediate between Classical HL and DLBCL CD15 CD30 LCA CD20 PAX5 Gray Zone Lymphoma Intermediate between Classical HL and DLBCL CD15 CD20 DLBCL-like CD30 CD45LCA What is Best Therapy for Gray Zone Lymphoma ? 24 pats treated with DA-EPOCH-R PMBL MGZL Median age = 33y (14-59) 63% male 46% mass >10 cm 50% high LDH Blood 124: 1563, 2014 Diagnosis of Gray Zone Lymphoma What Are Stakes For Patient? Recommended Therapy Classical HL ABVD +/- IF XRT (standard) DLBCL R-CHOP + XRT (standard) DA-EPOCH-R (emerging) Gray Zone DA-EPOCH-R Lymphoma Mixed Cellularity HL Median age 37 Male predominance Stage III or IV and B-symptoms more frequent than in nodular sclerosis Peripheral LNs common Mediastinal LNs uncommon Spleen (30%), bone marrow (10%) and liver (3%) EBV+ (75%) Increased in HIV+ patients and developing countries Mixed Cellularity HL EBV-LMP Mixed Cellularity HL Granulomatous Variant CD30 Mixed Cellularity HL Interfollicular Pattern CD15 Lymphocyte-depleted HL Advanced age B-symptoms (80%) Stage III or IV disease (IV) Extensive disease below diaphragm Abdominal LNs Spleen, liver and BM Most aggressive form of HL Lymphocyte-depleted HL CD30 EBER1 Criteria for Dx of CHL Are Evolving RS-H cells can occur in many settings Infectious mononucleosis Transformed B-cell lymphomas T-cell lymphomas (AITL) Post-transplant LPDs Histiocytic tumors The essential question (for me): Is standard HL therapy likely to work? If the answer is no, I try to avoid calling a case HL Single Cell PCR in NLPHL All cases are of B-cell lineage IgH gene rearrangements High level of somatic mutations Ongoing somatic mutations are present These results support origin from “functional” germinal center B-cells Single Cell PCR in Classical HL >98% of cases have IGH rearrangements High level of somatic mutations ~25% have “crippling” mutations Rare ongoing mutations These results support origin from “non- functional” germinal center B-cells Rare cases are reported to be T-cell Really HL ? Nodular Sclerosis HL T-cell Antigen + Nodular Sclerosis HL T-cell Antigen + CD15 CD30 PAX5 CD2 CD3 T-cell antigens expressed by RS-H cells classical HL T-cell antigens expressed in 10-15% of classical HL cases Most are PAX5+ and IgH rearranged Blood 95: 3020, 2000 Does T-cell HL even exist? (I think not) I call PTCL with HL-like features Most common in NSHL At MDACC, T-cell antigen expression does not influence treatment plan Blood 121: 1795, 2013 RS+H Cells in HL are “Sick” Evidence of “sickness” in RS-H cells Many Ig gene mutations Crippling mutations in ~25% B-cell program is highly defective Promoter hypermethylation Inhibitors RS+H cells should undergo apoptosis in GC Why don’t they ? Frequency of EBV Infection in HL Latency Type II Pattern Nodular LP 0% Nodular sclerosis 10-20% Lymphocyte-rich classical 50-60% Mixed cellularity 60-70% Lymphocyte depletion 60-70% Classical Hodgkin lymphoma Cross talk between RS+H and reactive cells Promotes survival of RS+H cells Allows RS+H cells to escape cytotoxic T/NK- cells J Clin Invest 122: 3439, 2012 Classical HL Pathogenesis Major Pathways NF-κB JAK-STAT Escape from immune surveillance PD1-PD-L1/L2 axis NF-κB Pathway Activation is Common in Classical HL EBV provides signals bypassing RS+H apoptosis LMP2a mimics B-cell receptor LMP1 mimics CD40 activating NF-κB TNFAIP3 is mutated in ~40% of classical HL Encodes A20 protein = suppressor of NF-κB EBV infection and TNFAIP3 mutations are mutually exclusive JAK-STAT Pathway Activation is Common in Classical HL Amplification of JAK2 Located at chromosome 9p24.1 Mutations of SOCS1 and PTPN1 Inhibitors of JAK-STAT pathway Mutated in 20-30% of cases Chromosome 9p24.1 is also site of PD-L1 / PD-L2 108 cases of classical HL assessed by FISH Abnormalities of chromosome 9 Polysomy = 5 cases (5%) Copy gain = 61 cases (56%) Amplification = 39 cases (36%) Amplification of PD-L1 or PD-L2 associated with advanced stage and shorter progression-free survival PD-L1 / PD-L2 by IHC correlates with genetics J Clin Oncol 34: 2690, 2016 Progression-Free Survival by Decade Hodgkin Lymphoma n = 3216 1.0 2000s 0.8 1990s, BM transplant 0.6 1980s, ABVD 1970s, wide 0.4 field XRT and MOPP 0.2 Cummalative survival 1960s 10 20 30 40 Years Courtesy of J.
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