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Lymph Node

- Introductory Lecture
This lecture is designed to provide general
histopathology of lymph node. By the end of the learning,
you should:
Know the normal histology of lymph node
Know how to assess the lymph node under microscope
Be able to distinguish malignancy from reactive or benign
Be able to make diagnosis or narrow down the diagnoses based
on morphology
Know what other tests needed to make a definite diagnosis
Know the markers for common pediatric lymphomas
Normal lymph node architectures
Normal lymph node histology

Subcapsular sinus
Follicles of cortex
Medullary sinus

Medullary cords
Lymphocyte homing
The site of T cell homing is the
After initial maturation in the primary
immune organs, "virgin" B and T
The separation of B and T lymphocytes
lymphocytes --> peripheral blood -->
not absolute,
home to specific sites within the lymph
Both cell types present throughout
node (and the other secondary organs),
lymph node, necessary for coordinated
The sites of B cell homing include: lymphoid immune response.
The primary and secondary follicles
of cortex-the sites of
Antigen presentation
Consequent lymphocyte
proliferation and differentiation
The medullary cords -->plasma
cells aggregate--> release their
immunoglobulins into the efferent
Lymph node variation
Lymph node histology
is dynamic: follicles
In the absence of
immune stimulation,
primary follicles (no
germinal centers)

In the presence of
immune stimulation,
secondary follicles and
germinal centers
( GC)

Normal IHC pattern


B- CD20: B cells,
concentrated in folicles

C- IgD: Mantle cells

D- CD23: Folicular
dendritic cells and B

E- CD10: germinal
center cells

F- Bcl6 (nuclear stain):

germinal center cells
Normal IHC pattern

G-Bcl2: absent in
germinal center (GC)
B cells
H-CD3: T cells,
concentrated in
paracortical area,
I-CD57: Scattered
follicular regulatory T
J-PD1: GC regulatory
T cells
K-Ki67: GC
proliferating cells
L-CD21: Follicular
dendritic cells
Where to begin?

Architecture (low power, preserved or

Recognizing lymph node patterns (low
Overall growth pattern: Nodular(Follicular)/
Capsule (intact/thickened, invasion)
Granuloma (necrotic?)
Benign LN pathology

Architecture preserved or mostly preserved

Four growth patterns
Follicular Pattern Sinus Pattern Diffuse Pattern Mixed Pattern
Nonspecific Sinus histiocytosis Postvaccinial Toxoplamosis
lymphadenitis lymphadenitis
Rheumatoid Lymphangiographic Infectious Dermatopathic
arthritis changes mononucleosis lymphadenitis

Syphilis Rosai-Dorfman Herpes zoster SLE

disease lymphoadenitis
AIDS -realated Whipples disease Diphenylhydantoin Granulomatous
hypersensitivity histiocytic
PTGC Monocytoid B-cell Angioimmunoblastic Granulomatous
hyperplasia lymphadenopathy lymphadenitis
Castlemans Infection-associated CMV lymphadenitis Kawasakis disease
disease hemophagocytic
Kaposis sarcoma
Transformation of
Non-specific Reactive Follicular
Children and adolescents
Often seen in nodes draining infected sites
Commonly fail to identify a specific
etiologic agent
Increased in both of size and number of
follicles in the cortex


Feature Reactive Neoplastic(FL)
Shape of follicles Variable, fused, dumbbell regular, similar sized
Location of follicles Predominantly cortex Throughout
Interfollicular areas Gen. preserved Scant, back-to-back fol.
GC cells heterogeneous monotonous
Tingible Body Macroph present absent
Mitoses frequent Very rare
Mantle zones Present, sharply Often obliterated
polarity present absent
Fol. in perinodal tis. absent May present
BCL-2 in GC negative Positive (90%)
IG gene rearrangement poly mono
CD10/BCL-6 GC only Outside GC
Syphilitic lymphadenoapthy
Generalized lymphadenopathy----- feature of 2
Follicular hyperplasia
Plasma cell expands medullary cords
Epithelial cell clusters in paracortex
Naked giant cells
Capsular fibrosis
Arteritis and phlebitis of capsular vessels
Perivascular lymphoplasmacytic cuffing
Silver stains ----Spirochetes
Vascular proliferation and plasmacytosis in the interfollicular

pericapsular inflammation and fibrosis vasculitis

HIV-related lymphadenopathy

Generalized lymphadenopathy
Florid Follicular HyperplasiaFollicular.
Involution (PRGC) Lymcyte Depletion
HIV Lymphadenitis (acute stage)
Florid FH, large, irregular
May coalesce to form giant, geographic
Thin mantle zones---naked GC
Follicle lysis (MZ invagination)
Paracortex monocytoid B-cell
Warthin-Finkeldey giant cells
Follicular lysis

Monocytoid B cell hyperplasia polykaryocytes

HIV-related lymphadenopathy
Follicular involution Lymphocyte depletion
(subacute/chronic stage) (Burnout)

Follicular effacement Atrophic or absent

GC with hyaline material follicles
Lymph. depl. In Hyalinized GC with
paracortex prominent thick vessels
and PAS-postive deposits
Plasma cell accumulation
and vascular proliferation Lymph. depl. In
in paracortex paracortex
Paracortex: extensive
vascular proliferation and
Effacement of lymph node architecture and excessive
proliferation of blood vessels in the paracortex.

Lymphoid follicle depopulated of lymphocytes and largely fibrosed

Young males
May recurrent
Single, asymptomatic, enlarged node
Expanded follicles (3 x) with thick mantle cells
which may infiltrate GC (inwards and
In a background of FH
NLPHL: relationship, differential?
High power of PTGC: many
mantle B cells with residual GC
Castleman disease
Hyaline vascular type

Young adults
Common location: mediastinum or neck
Concentric layering of lymphocytes
Atrophic germinal center (GC), multiple GCs
Small hyaline vessels radially penetrating the
GC (lollipop)
Vascular interfollicular tissue
Reactive process, curable by surgical resection
Monoclonality shown in a recent study
Chang KC, et al. Modern Path (2014) 27, 823-
Castlemans disease of plasma cell type
Wide age range
Systemic symptoms
Anemia, hyperglobulinemia,
Increased plasma cells in
Abdominal nodes
FH with narrow mantle
zones; dense interfollicular
plasma cells obscuring
sinus; 1/3 light chain
Multicentric CD
Old age
Primary or associated with HIV/AIDS, KS
Histopathology similar to PCD
Assosiated with HHV-8, IL-6-----
systemic symptoms
60% POEMS syndrome
Poor prognosis
Sinus histocytosis
Common in nodes draining the limbs,
Nodes draining carcinoma (breast ca, etc.)
Histocytes originate from the sinus lining
cells, which are derived from blood
Rosai-Dorfman disease
Childhood and young adult
Fever, night sweats, weight loss, elevated ESR
Bilateral non-tender cervical lymphadenopathy
1/3 extranodal (skin, upper airways, bone)
Marked dilated sinus with histiocytes
Striking emperiopolesis
: S100+, CD1a-, CD207-
Whipples disease
Foamy macrophages
contain bacilli,
Tropheryma whippelli,
and characteristically
stain with PASD.

cystic spaces, sheets of macrophages replace

most of lymphoid tissue
Macrophages filled with PAS-positive bacilli PAS stain.
Vascular transformation of sinuses
Also called nodal
Usually found incidentally
after resection of a nearby
Benign; all ages
Due to vascular obstruction
Sinus transformed into
vascular channels
Infectious mononucleosis
Teenagers and young adults
FH, Paracortical expansion
Numerous B- and T-immunoblasts in
paracotex with mottled appearance
Atypical Hodgkin/RS-like cells, more
common in tonsils
Autoimmune lymphoproliferative syndrome (ALPS)

Due to mutations of genes in the Fas apoptosis pathway. Relatives may

carry mutations without overt evidence of disease

Disease usually presents in childhood and may ameliorate with age

Patients present with lymphadenopathy often accompanied by


Patients usually have autoimmune disease at presentation. Autoimmune

cytopenias are the most common

Increased levels of double negative T-cells (CD4 CD8) are found in the
blood and tissues

Lymph nodes show marked paracortical expansion with T-cells/blasts and

polytypic plasma cells

Germinal centres usually prominent, may show progressive transformation

Increased incidence of T- and B-cell lymphomas and Hodgkin lymphoma in

CD3:T cells

CD20: B cells CD79a: B cells and plasma cells

Drug hypersensitivity
Most commonly seen in hypersensitivity
to anticonvulsant drugs (dilantin,
phenytoin, carbamazepine)
Fever, skin rashes, and
PB eosinophilia
Paracortical expansion with mixed
immunoblast cells and eos.
Necrosis may present
Regress after drug withdrwal
Eosi abscess Immunoblasts and eosi
Toxoplasmosis lymphadenitis
Posterior cervical lymph node unilaterally
a.Follicular Hyperplasia
b.small aggregates of epithelioid
histiocytes at the periphery of FC, often
encroach FC
c. monocytoid B-cell hyperplasia
subcapsular and trabecular sinuses
Typical Triad
Dermatopathic lymphadenitis
Superficial lymph nodes draining chronic
Cut surface of node may show subcapsular
rim of pigment
Paracortical expansion with aggregates of
interdigitating reticulum cells and
Langerhans cells
Scattered macrophages containing lipid
and melanin
Kikuchi Disease (histiocytic necrotizing
Young female, asia
Fever and
painful cervical
Widespread apoptosis and necrosis,
no neutrophils
Paracortical small lymphocytes,
immunoblasts, plasmacytoid
monocytes, histocytes, and plasma
Phagocytic histiocyte---cresentic
Non specific change
Follicular hyperplasia
Increased vasculartiy
Immunoblasts and plasma cells
DNA containing basophillic material
deposit in the stroma and wall of blood
vessel (hematoxylin body, DDx with
Kikuchis )
Cat scratch disease
Suppurative granulomas with stellate
microabscesses surround by pallisading
Background of FH---- early stage
Bartonella henselae----G+, Warthin-starry
silver stain (seen in early stage)
Lymphogranuloma venereum: similar
histology, by CT
area of stellate necrosis in a proven High power view: palisaded epithelioid
case of cat-scratch disease. histiocytes around an area of necrosis
Non necrotizing granuloma
Asteroid body
Kimura Disease
Common in Asians, male
Neck and periauricular LN, may be matted
Blood eosinophlia
Florid follicular and GC hyperplasia with
proteinaceous precipitate (amorphous eosino.
FDC IgE deposition
Paracortical: plasma cells, SL, and mast cells
Marked Eos. Infil. of GC, paracortex, and
medulla with microabscess
Warthin-Finkeldy type giant cells
There is follicular hyperplasia and massive perinodal infiltration, which is
predominantly composed of eosinophils.
Malignant LN pathology

Effacement of normal nodal architecture

Atypical cytology
B cell lymphoma
Large (> histiocyte nucleus): high grade
Small (< histiocyte nucleus): low grade
T cell lymphoma
Size not useful for grading
Commonly variable size
Increased eosinophils, vasculatures
Clonality detected by molecular study (PCR or Southern Blot)

B cell Ig heavy chain and light chain gene rearrangement:

SLL ~ 100 %, MCL ~ 100 %, DLBCL ~ 60 %, FL ~ 50 %
False negative?
o Chromosomal translocations into the IgH locus (in FLor DLBCL)
o Somatic hypermutation (in FL and DLBCL)
o Others

False positive? Limited amount of DNA, etc

Reactive clonal proliferation
T cell TCR gene rearrangement:
False positive or negative
Lineage infidelity of Ig and TCR gene rearrangements
Always interpreted in the context of other clinicopathologic information
Clonality detected by flow cytometry
For mature B lymphoma: surface light chain

Lymphoma: lambda restricted - Reactive, K/L: 0.9 ~ 3.7(?)

For mature T-cell lymphoma: TCR Vb subtypes ( 24 subtypes?

Not an easy test)
Loss of pan-T markers indicating malignancy
Nodular Pattern Sinus Pattern Diffuse Pattern Paracortical
Follicular lymphoma LCH DLBCL (large cells) granulocytic
CHL, NS type Anaplastic Lymphoblastic lymphoma Anaplastic large
(Nodular pattern with large cell (medium size, starry sky) cell lymphoma,
fibrous bands, scattered lymphoma
large multilobated cells)
NLP HL (Vague nodular Metastatic Burkitts(medium size, NK-cell leukemia/
pattern with rare large cells lymphoma
with popcorn cells/LP cells)
tumors starry sky)
Small lymphocytic Kaposis CHL, MC (Diffuse infiltrate by CHL
lymphoma sarcoma a mixed inflammatory
(psedofollicular pattern) background)

Lymphoblastic rare DLBCL Anaplastic large cell peripheral T-cell

lymphoma lymphoma, lymphoma, NOS
(hallmark cells)
Marginal zone peripheral T- peripheral T-cell DLBCL
lymphoma cell lymphoma lymphoma (large cells or
variable size)
Some MC lymphoma non-hematopoietic metastatic tumors
How many faces, living creatures can you see?
A: diffuse infiltrate of large cells, seen in DLBCL, PTCL; B: diffuse lymphoid infiltrate
with numerous histiocytes, starrysky, Burkitt lymphoma, lymphoblastic lymphoma;
C: pseudofollicular pattern with small cells background, CLL/SLL; D: nodular pattern,
follicular lymphoma; E: nodular pattern with fibrous bands and scattered large
multilobated cells, NS classical Hodgkin lymphoma (HL); F: vague nodular pattern with
rare large cells with vesicular nuclei (popcorn cells, LP cells), NLPHL; G: paracortical
(interfollicular) infiltrate, PTCL, NOS, granulocytic sarcoma, CHL, anaplastic large cell
lymphoma, occasional DLBCL, metastatic tumors; H: expansion of the marginal zone with
prominent monocytoid B-cells, in marginal zone B-cell lymphoma; I: mantle zone pattern
mantle cell lymphoma (MCL), MCL can present also diffuse and nodular patterns;
J: onionskin mantle cells with more than one germinal center, Castlemans disease
(hyaline-vascular type); K: large expanded follicles composed of small lymphocytes with
disruption of the follicular dendritic meshwork, progressively transformed germinal
centers (PTGC); L: intrasinusoidal pattern, LCH, anaplastic large cell lymphoma,
metastatic non-hematopoietic tumors, rare DLBCL and variants PTCL; M: eosinophils,
increased vascularity, angioimmunoblastic T cell lymphoma; N: diffuse pleomorphic
infiltrate composed of a mixed population of lymphocytes, eosinophils, plasma cells and
histiocytes (inflammatory background) and large multilobated cells, CHL;
O: large mononuclear highly atypical cells predominate, anaplastic large cell lymphoma
should be considered;
Langerhans Cell Histiocytosis

Common in children
Birbeck granules on
Electron microscopy
Single site or single system
Langerhans histiocytosis
Solitary or multiple lesions (papules, nodules, plaques) containining
Langerhans cells
Grooved histiocytes in the sinus
Multinucleated giant cells
Increased eosinophils
+: S100, CD1a, langerin / CD207
Common lymphomas in pediatric population
Lymphoblastic lymphoma
Hodgkin lymphoma
Burkitt lymphoma
Diffuse large B cell lymphoma
Anaplastic large cell lymphoma
Lymphoblastic lymphoma
One of the most common lymphomas in children
lymphoblastic lymphoma and Acute Lymphoblastic Leukemia (ALL)
represent the same disease entity based on morphologic, genetic,
and immunophenotypic features, the WHO classification has unified
these entities as B or T lymphoblastic leukemia/lymphoma.
Most institutes use >=25% blasts in PB or BM as the diagnostic
criterion for ALL though the distinction is not clearcut
Immature T in 85-90% of cases and immature B in the remainder.
No difference on morphologies of T or B origin.
Immunophenotyping and cytogenetics studies for classification and
Typical flow cytometric findings for B-lymphoblastic lymphoma:
CD19+ CD10 bright, CD20+/, CD22+/, TdT+, HLA-DR+, CD34+/, slg;
T-lymphoblastic lymphoma: sCD3, but cCD3+, CD4+ CD8+ or CD4-
CD8, CD1a+/-, CD2+/, CD5+/, CD7+/, TdT+, CD34+/, CD10+/.
Lymphoblastic lymphoma

Infiltrates lymph node

leaving reticulin architecture
partially intact
Residual reactive
germinal centres may be
Infiltration of capsule and
around blood vessels
often shows Indian file
Smooth or dust-like
nuclear chromatin
Inconspicuous nucleoli or
one nucleolus
Cytoplasm inconspicuous
Nuclei may be convoluted

Mitotic figures frequent, numerous macrophages, starry- sky pattern

Burkitt Lymphoma


Children 4-7 y/o
Jaw/facial bones
95% EBV

Sporadic Burkitt lymphoma

adult median 30 y.o.
30-50% of childhood lymphomas
EBV positive cells in 30% of cases
Touch imprint. A Classical BL. The deeply basophilic cytoplasm can be appreciated as well
as abundant lipid vacuoles in the cytoplasm. B Atypical BL. The cells are relatively similar to

classical BL but have more irregular nuclei .

Immunophenotype and Molecular

-Positive for CD20, CD10 & bcl-6
-Ki-67 100% of cells
-Neg for bcl-2, or weakly+ in 20%
-T(8;14) IgH/myc
-T(2;8) myc/kappa
-T(8;22) myc/lambda
Diffuse Large B cell lymphoma
Common morphologic variant Other lymphomas of large B cells
-Centroblastic -Primary mediastinal (thymic)
large B cell lymphoma
-Intravascular large B cell
Molecular subgroups lymphoma
-Germinal centre B cell like -DLBCL associated w chronic
-Activated B cell like inflammation
-Lymphomatoid granulomatosis
IHC subgroups -ALK-positive LBCL
-Plasmablastic lymphoma
-Germinal centre B cell like
-LBCL arising in HHV8+
-Non germinal centre B cell
like multicentric Castlemans
-Primary effusion lymphoma
-T cell/histiocyte-rich large B
cell lymphoma Borderline cases
-Primary DLBCL of the CNS
-Primary cutaneous DLBCL, leg type
-EBV + DLBCL of the elderly
Score 10 if the arrow hits center Germinal center type: CD10+
Score 5 if it hits Para-center zone Burkitt
No scores if it hits marginal zone Follicular lymphoma
AITL (GC T cells)

B Lymphoblastic Lymphoma

Mantle cell lymphoma
10 Rare DLBCL

CD10- CD5-:
0 Marginal zone lymphoma
Immunoblastic variant

Centrablast variant

Anaplastic variant
Lung, brain, liver, kidney skin
Grading based on # of EBV+ cells
Grade 1 <5 EBER+ per hpf
Grade 2 5-20 EBER+ per hpf
Grade 3 >50 EBER+ per hp

Immunodeficient Children or Adult

M:F>= 2:1
Hodgkin lymphoma

WHO classification:
- Nodular lymphocyte predominant
- Classical
Nodular sclerosis
Mixed cellularity
Nodular Lymphocyte Predominant Hodgkin

Nodular, LP cells (popcorn cells)

CD45+, CD20+, J-chain and EMA+

CD3+ and CD57+ T-cells in background

ring malignant cells

Nearly all cases are CD15 & CD30 neg

Oct2 and BOB.1 consistently present

whereas in classic HL one or both will be

5% HL
Common in young middle age male (30-50yo)
Classic Hodgkin lymphoma
-- 95% of HL with bimodal age with
15-35 year peak and 2nd peak late life
-- Mediastinal
Nodular Sclerosis Hodgkin lymphoma
Nodular pattern with fibrous bands and scattered large multilobated cells: nodular
sclerosis type of classical Hodgkin lymphoma (HL).

CD30+, CD15+ (75-85%); CD45 neg, LMP-1 and EBER variable, BSAP(PAX5)+
Mixed cellularity Hodgkin lymphoma (MCHL)

Interfollicular growth pattern may be seen

May have interstitial fibrosis but no capsular thickening or
broad bands of collagen fibrosis
EBV-LMP- highest frequently-75%
Mediastinal involvement uncommon
Lymphocyte rich Hodgkin lymphoma

5% of all HL
nodular growth pattern
Regressed germinal centers
RS cells in mantle zone
No eos + PMNs in background
Lymphocyte depleted Hodgkin lymphoma (LDHL)

Variable appearance with RS cells predominating over background cells

May resemble mixed cellularity with increased RS cells
May have a sarcomatoid appearance similar to anaplastic large cell lymphoma
May have diffuse fibrosis with few RS cells
Definition: T-cell lymphoma consists of lymphoid cells with large
abundant cytoplasm and polymorphic, often horse-shoe-shaped nuclei.
These cells are CD30+ and most cases express cytotoxic granule-
associated proteins. ALK+

-First three decades of life, M:F =1.5:1
-maybe nodal or extranodal
-B symptom
-aggressive, but excellent response to
- broad morphologic spectrum
- typically sinusoidal/subcapsular
-hallmark cells: eccentric, embryo-like,
reniform, wreath-like nuclei, eosinophilic
Golgi zone in cytoplasm, multiple nucleoli
-numerous variants:
common; small cell; monomorphic;
lymphohistiocytic; giant; sarcomatoid
ALCL, ALK+ common type

A: nodal architecture is obliterated by malignant cells and intrasinusoidal cells. B.

predominant large cells, hallmark cells; C. CD30, D. EMA, F. Granzyme B
Lymphohistiocytic variant
Tumor cells
admixed with a
large number of
The histiocytes may
mask the malignant
cells which are
often smaller than
in the common type.
The neoplastic cell
clusters around
blood vessels and
can be highlighted
by CD30, ALK,
and/or cytotoxic

Left: The neoplastic cells are difficult to identify: they are medium-sized to large, and possess distinct
nucleoli. The background is rich in small lymphocytes, histiocytes and plasma cells. Right:
Immunostaining for CD30 reveals a surprising number of neoplastic cells not appreciated on routine
ALCL, ALK+ Small cell type

Small to
cells with
Hallmark cells
are present
and often
around blood

-variable T-cell marker: CD3- (75%),
CD4+, CD2+, CD5+, CD8-, CD43+,
-Cytotoxic associated antigens: TIA1,
granzyme B, perforin
- null-cell type: negative T- and B-
- CD30+, EMA+

- t(2;5)(p23;q35) by karyotype
-NPM (nucleophosmin):ALK fusion
- ALK on 2p23
- ~ 15% have partners other than
- Better than ALCLALK-
NPM: cytoplasmic and/or nuclear
Definition: CD30+ T-cell neoplasm, indistinguishable from
ALCL, ALK+ based on morphology. ALK-
Adults (40-65 yo), M:F =1.5:1
LN and extranodal involvement
Advanced stage, Lymphadenopathy, B symptoms
Morphology: similar to ALCL, ALK+
CD30 strong positive, ALK-
Null T-cell type
CD43+; CD2+, CD3+; CD5+; CD4+
Cytotoxic associated markers: TIA1, granzyme B and/or perforin
Postulated normal counterpart:
Activated mature cytotoxic T-cell
Genetics: TCR rearrangement, chromosome abnormalities deffer from