Cytopathology presentation

Dr. Jiwan Kshetry 2070/2/30

 One Giemsa stained slide Left supraclavicular lymph node of a 40 years old male

Slide description
Low power
Predominantly dispersed cells with some areas of clustering Background shows blood

 High power:
Predominantly composed of lymphoid cells, nearly uniformly dispersed in a background of blood, slightly increased in size (~1.5 times normal lymphocyte)
These cells have scant amount of cytoplasm in one side of the nucleus Nuclei of some of these are cleaved while most cells have round, non-cleaved nuclei Chromatin is condensed with inconspicuous nucleoli

 Larger cells are present in small number

These cells have finer chromatin but nucleoli are inconspicuous

Mitosis are frequent among the larger cells Necrosis and apoptosis are absent Tingible body macrophages are absent but some dendritic reticulum cells are seen.

 The cell clusters are composed of poorly preserved cells whose morphology is not clear (pseudo-clustering) Background also shows plenty of bare nuclei and lymphoglandular bodies Small lymphocytes and neutrophils are also seen. Some of the neutrophils show finely vacuolated bluish cytoplasm

 Impression: Lymphoid lesion.

D/d:
1) Non-Hodgkin lymphoma (Follicular lymphoma, Tlymphoblastic lymphoma/leukemia, Mantle cell lymphoma) 2) Reactive lymphoid hyperplasia

Approach to diagnosis
Cytomorphology ( pap stain missing) Flow cytochemistry Immunocytochemistry Molecular cytogenetics

A complete blood count can also be useful. Presence of enlarged lymph nodes in other areas has to be checked for.

Cytomorphology For and against RLH

+ Frequent mitoses _ Monotonous population of cells

Absence of apoptosis and tingible-body macrophages

Site

Cytomorphology For and against FL

+ Monotonous population of slightly enlarged, often cleaved lymphoid cells Absence of apoptosis and tingible-body macrophages Condensed chromatin with inconspicuous nucleoli in the centrocytes Relatively low no. of small lymphocytes

_ Frequent mitoses

Cytomorphology For and against T-LBL

+ Age (any/adolescent) Frequent mitoses _ No tingible body macrophages

Cytomorphology For and against MCL

+ _ Monotonous population of centrocyte like No tingible body macrophages cells Age (middle aged to older)

Immunocytochemistry
FL:
Monoclonality shown by staining for Ig chains +ve for CD19, cD20, CD10, BCL-2, BCL-6 Aberrant CD5 expression in floral variant

RLH:
Presence of cells of both B and T cell lineage in logical proportions Polyclonality of the cells

MCL:
+ve for CD19, Cd20, Sig, CD5, FMC7, cyclin-D1 -ve for CD10 and CD23

 T-Lymphoblastic lymphoma/leukemia
TdT , most often CD3 and CD7 positive, often CD4 and CD8 double positive or double negative

Cytogenetics
FL:
t(14;18) in over 90% of cases

MCL:
t(11;14) in almost all cases

T-lymphoblastic lymphoma/leukemia
50-70% have abnormal karyotype.

Confirmatory diagnosis
Histology with immunohistochemistry

Discussion

Reactive Lymphoid Hyperplasia

Non-specific hyperplasia yields a cytological pattern on FNA which depends on the proportions of follicular and interfollicular tissue in the aspirate, and this in turn usually correlates with the histological findings. Thus, smears from a node composed predominantly of large follicles with active germinal centres contain many centroblasts and centrocytes, while the interfollicular tissue is comparatively sparse and represented by mature lymphocytes, plasma cells and immunoblasts

 In extreme cases, the pattern may mimic a mixed lymphoma of centroblastic/centrocytic type. The presence or absence of tingible body macrophages is of little diagnostic value. Immunocytochemical evaluation of the lymphoid population may be the only way to resolve this diagnostic problem.

 In contrast, when interfollicular tissue predominates, the smears are rich in lymphocytes, plasma cells, lymphoplasmacytoid cells and some immunoblasts. Such smears are difficult to differentiate from those of a low-grade lymphoma. Analysis of light chain immunoglobulin restriction is usually required to arrive at a conclusive diagnosis. Some conditions lead to a cytological pattern which clearly deviates from the general types described above. A description of the best recognised of these will be done here It is important to remember that definitive diagnosis is dependent on good clinical correlation.

HIV infection
Generalised lymphadenopathy is common in patients with acquired immunodeficiency syndrome (AIDS). There is a florid follicular hyperplasia with immature follicle centre cells in a background of mature lymphocytes, plasma cells and macrophages . Immunoblasts are always present. The pattern is non-specific and thus not diagnostic for AIDS. The lymphoid cells are mostly polyclonal B cells but some mature T cells are also present.

Infectious mononucleosis
Infectious mononucleosis can also cause lymphadenitis, which is mainly confined to the interfollicular tissue Cytologically, it is characterised by numerous immunoblasts, some of which are atypical with large irregular nuclei. In rare cases the pattern may even be suggestive of Hodgkins disease. Serological tests can be helpful, but phenotyping of the atypical cell population may be the only way to rule out a lymphoma.

Rheumatoid arthritis, systemic lupus erythematosus and secondary syphilis

All of these conditions can cause massive lymphadenopathy. Cytologically, there is a reactive pattern with numerous plasma cells, some containing Russell bodies, which may lead to a suspicion of a lowgrade lymphoma with plasmacytic differentiation. In such cases, it may be impossible to arrive at a conclusive diagnosis without resorting to immunocytochemistry.

Dermatopathic lymphadenopathy
This is a special variant of reactive lymphadenitis which is observed in patients with chronic skin disorders such as psoriasis or dermatitis. The germinal centres are hyperplastic and the interfollicular tissue is expanded by cells of histiocytic appearance. Smears from such lymph nodes show numerous small lymphocytes, plasma cells, eosinophils and occasional blast cells. There are numerous histiocyte-like cells, also known as interdigitating reticulum cells, with pale indistinct cytoplasm. Macrophages containing brown melanin pigment from the damaged skin are always present.

WHO classification of B-cell neoplasms and

Precursor B-cell neoplasm Precursor B lymphoblastic leukaemia/lymphoma Mature B-cell neoplasms Chronic lymphocytic leukaemia/small lymphocytic lymphoma[ B-cell prolymphocytic leukaemia Lymphoplasmacytic lymphoma] Splenic marginal zone lymphoma Hairy cell leukaemia Plasma cell myeloma Monoclonal gammopathy of undetermined significance (MGUS) Solitary plasmacytoma of bone Extraosseous plasmacytoma Primary amyloidosis Heavy chain diseases

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) Nodal marginal zone B-cell lymphoma Follicular lymphoma Mantle cell lymphoma Diffuse large B-cell lymphoma Mediastinal (thymic) large B-cell lymphoma Intravascular large B-cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukaemia

B-cell proliferations of uncertain malignant potential Lymphomatoid granulomatosis Post-transplant lymphoproliferative disorder

Follicular lymphoma
The predominating cell is the medium-sized centrocyte which has little cytoplasm and an irregular cleaved or angulated nucleus. These cells have a scant cytoplasm and may seem to form aggregates. Centroblasts are present but the proportion varies. Follicular lymphomas are subdivided into Grade I, Grade II and Grade III based on the proportion of large cells present histologically. (Grade I has 05, Grade II 6 15 and Grade III >15 centroblast/high power field, respectively).

 Other cell types present in follicular lymphomas are small mature non-neoplastic lymphoid cells, macrophages and epithelioid cells. A smear with a high number of non-neoplastic cells may be impossible to differentiate from reactive lymphadenopathy unless cytomorphology is complemented by immunocytochemical evaluation.

Immunocytochemistry
The B-cell lineage of these tumour cells is readily identified by expression of CD19, CD20 and CD79a. Light chain restriction can usually be demonstrated as well as positive staining for CD10. Expression of BCL-2 is seen in a majority of cases. Mature reactive T cells are present, and may constitute up to 50% of the lymphoid population. The proliferation fraction in the neoplastic B-cells varies considerably from case to case. Figures below 5% are seldom seen but in occasional cases up to 75% of the neoplastic population may react positively to proliferation markers. Such cases show aggressive behaviour and should be treated as high-grade lymphomas irrespective of their cytological grading.

Cytological findings: mantle cell lymphoma

The smears are monotonous composed of small- to medium-sized lymphoid cells, slightly larger than lymphocytes. The nuclei are cleaved and have a dispersed chromatin, inconspicuous nucleoli and a thin pale cytoplasm thus resembling centrocytes. In rare cases the cells are immature with larger nuclei and a high proliferation rate. Two main variants are described.
One shows a resemblance to lymphoblastic lymphoma and the term lymphoblastoid has been proposed. The second type shows a more heterogeneous population of cells with oval to cleaved nuclei and is referred to as the pleomorphic variant.

Immunocytochemistry
The cells are of B phenotype (CD20) with light chain restriction. In addition the cells are consistently CD5 and CD43 positive and most often CD10 negative. All cases express Cyklin D1 and bcl-2. The fraction of proliferating cells is usually low, around 10% as measured by Ki-67 (Mib-1). The blastoid variant has a high proliferation rate.

Cytogenetics
Translocation t(11;14) is observed in a majority of cases

T-lymphoblastic leukaemia/lymphoblastic lymphoma

Both the leukaemia and lymphoma are most frequent among adolescent males. The leukaemia often presents with a mediastinal mass, which is also the site of predilection for the lymphoma. A majority of the patients have long survival and many are cured.

 Cytology:
The blasts are medium-sized with irregular nuclei and basophilic sparse cytoplasm often with vacuoles. Macrophages with tingible bodies are frequent.

 Immunocytochemistry
Most cells are CD3 and CD7 positive while other Tcell markers are variably expressed. TdT is expressed in all cases. CD10 may be expressed. The proportion of proliferating cells is high.

Case study
Metastatic seminoma and grade 1 follicular lymphoma presenting concurrently in a supraclavicular lymph node: a case report.
Cases J. 2009 Aug 19;2:7273.

H&E

CD20 and CD10

CD20 and c-kit

 Thank U