Lymphomas, B-Cell - B-Cell Lymphomas

Diagnosis

Indications for Testing

• Most common presentation for lymphoma is adenopathy with or without fever, also night sweats and fatigue

Laboratory Testing

• See the Lymphoma Phenotyping algorithm for specific test ordering recommendations
• Initial testing involves the following
  • CBC with peripheral smear
  • Liver chemistries
  • Lactate dehydrogenase (LD)
  • Serum uric acid, potassium, calcium, phosphorus
  • HIV for at-risk patients
• Immunophenotyping to identify the lymphoid proliferation malignancy and to categorize lymphoma type
  • May also be performed on bone marrow
• Testing prior to treatment with immunosuppressive therapies
  • HBV – surface antigen and core antibodies for all patients considering rituximab
    • Also include HBV e antigen testing for patients with relevant risk factors
  • HCV – for high-risk patients considering rituximab
  • CMV – PCR quantitative

Histology

• Follow-up testing with bone marrow biopsy
  • ≥2 cm specimen length
  • Classified as involved or not
  • Flow cytometry testing and immunoperoxidase staining of tissue for specific B-cell antigens or clonality with kappa and lambda light-chain staining
• B-cell clonality studies
  • Locate clonal rearrangements of the immunoglobulin gene in B-cell malignancies
  • Provide information regarding prognosis and treatment recommendations
  • Identify specific molecular translocations that characterize specific NHL subtypes
  • Translocation characterizations
    • Follicular lymphoma – BCL2 t(14;18)(q32;q21)
    • Burkitt lymphoma – MYC  t(8;14), t(2;8), t(8;22)
    • Mantle cell lymphoma – BCL1 (CCND1)  t(11;14)(q13;q32)
    • Diffuse large B-cell lymphoma (DLBCL) – BCL6 and BCL2 rearrangement
    • Lymphomas with intermediate features between BL and DLBCL – testing for BCL2, BCL6 and MYC
      • Dual-hit lymphomas – BCL2 and MYC
      • Triple-hit lymphomas – BCL2, MYC and BCL6
    • ALL translocations – refer to acute lymphoblastic leukemia
  • NHL – fluorescence in situ hybridization (FISH) testing for t(11;14), t(14;18) and MYC translocations, ALK rearrangement and BCL6 translocations
  • Mucosa-associated lymphoid tissue (MALT) – molecular testing for t(11;14), t(14;18)
  • EBV genome presence in immune suppression (eg, post transplantation) – in situ hybridization testing
  • Kappa and lambda light-chain clonality in situ hybridization
• Other testing may be necessary to differentiate B-cell from T-cell NHL (eg, ALK by FISH)
• Immunohistochemistry – useful in conjunction with phenotyping for NHL cell type
  • Most commonly used stains include cyclin D1, Pax-5, Ki-67, MUM1-IRF4, HHV8, EBV, ALK-1, CD3, CD5, CD10 (CALLA), CD19, CD20, CD21 (dendritic cell), CD22, CD23, CD25, CD30 (Ki-1), CD79A, CD138 (Syndecan-1), BCL-2, kappa and lambda light chains, TRAP and TdT
  • Other available stains – BOB-1, Bax, caspase-3, CD15, CD43, CD45, CD45RA-MT2, CD45RO, CD74, c-Myc, DBA.44 and Oct 2

Prognosis

• International Prognostic Index scoring system
  • Based on pretreatment clinical factors of age (≤60 years); Ann Arbor tumor stage (I or II); number of extranodal sites (≤1); Eastern Cooperative Oncology Group (ECOG) performance status (0 or 1); and serum LD (≤1 times normal) – all scored as 0
  • Patients placed in 4 risk groups
  • Limited usefulness in follicular lymphoma, mantle cell lymphoma, NK lymphoma, nasatype, hepatosplenic lymphoma and enteropathy-type lymphoma
• Follicular Lymphoma International Prognostic Index scoring system
  • 5 risk factors (scored as 1)
    • IgG <12 g/dL
    • LD >normal
    • Ann Arbor tumor stage (III or IV)
    • >4 nodal sites
    • Age >60 years
  • 0-1 risk factors – low risk (5-year survival 90%)
  • 2 risk factors – intermediate risk (5-year survival 78%)
  • 3 risk factors – high risk (5-year survival 53%)
• All prognostic indices may change in the future as the IPI and FLIPI indices were developed before immunotherapy
• Genetic mutations (cytogenetics)
  • Follicular lymphoma
    • Adverse prognosis associated with del 17p, trisomy 12 and abnormalities of 6p
  • Diffuse large B-cell lymphoma (DLBCL)
    • Better prognosis associated with t(14;18)
    • Adverse prognosis with MYC oncogene; BCL2 gene, p53(+)
  • Follicular and DLBCL
    • Dismal outcomes for 8q24/MYC in association with 18q21/BCL2 or 3q27/BCL6
  • Dual-hit and triple-hit lymphomas
    • MYC, BCL2, BCL6 to identify double- or triple-hit lymphomas
    • Very poor prognosis
  • CLL
    • CD38 and ZAP-70 – mutation status correlates inversely with prognosis

Differential Diagnosis

• Lymphomas
  • T/NK-cell lymphoma
  • Hodgkin lymphoma
• Reactive lymphocytosis
• Sarcoidosis
• Other malignancy
  • Head and neck cancer
  • Metastatic
• Infections
  • EBV
  • M. tuberculosis
  • Bartonella spp
  • Human herpesvirus 8
  • CMV
  • HIV
  • Toxoplasma gondii
  • Treponema pallidum
  • Babesia microti
  • Fungal disease

Monitoring

Clinical Background

B-cell non-Hodgkin lymphomas (NHL) represent a heterogenous group of malignancies of the lymphoid system.

Epidemiology

• Incidence – represents 80-85% of the cases of NHL diagnosed annually
  • >66,000 new cases of NHL diagnosed in 2008
• Age – peaks in 60s
• Sex – M<F (minimal)

WHO Classification of Mature B-Cell Neoplasms (2008)

• Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL)
• B-cell prolymphocytic leukemia
• Splenic marginal zone lymphoma (MZL)
• Hairy cell leukemia
• Splenic lymphoma/leukemia, unclassifiable
• Lymphoplasmacytic lymphoma
• Heavy chain diseases
• Plasma cell neoplasms
• Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT)
• Nodal MZL
• Follicular lymphoma
• Primary cutaneous follicle center lymphoma
• Mantle cell lymphoma
• Diffuse large B-cell lymphoma (DLBCL), NOS (not otherwise specified)
• T-cell/histiocyte rich large B-cell lymphoma
• Primary DLBCL of the central nervous system
• Primary cutaneous DLBCL, leg type
• Epstein-Barr virus (EBV)-positive DLBCL of the elderly
• DLBCL associated with chronic inflammation
• Lymphomatoid granulomatosis
• Primary mediastinal (thymic) large B-cell lymphoma
• Intravascular large B-cell lymphoma
• ALK-positive large B-cell lymphoma
• Plasmablastic lymphoma
• Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease
• Primary effusion lymphoma
• Burkitt lymphoma
• B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma
• B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma

Risk Factors

• Presence of autoimmune diseases, iatrogenic or acquired immune deficiency
  • Sjögren syndrome
  • Celiac disease
  • Rheumatoid arthritis
  • Post-transplant immunosuppression
  • Immunosuppressive drugs
  • HIV infection
• Inherited disorders
  • Chédiak-Higashi syndrome
  • Common variable immune deficiency
  • Wiskott-Aldrich syndrome
• Chronic infection
  • EBV – diffuse large B-cell lymphoma (DLBCL) of the CNS
  • Helicobacter pylori – gastric extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma
  • Hepatitis C (HCV) – lymphoplasmacytic lymphoma, marginal zone lymphoma (MZL), follicular lymphoma
  • Human herpes virus 8 (HHV8) – primary effusion lymphoma
  • Hepatitis B (HBV) – risk of reactivation with immunosuppressive treatment regimens (eg, rituximab)
  • Cytomegalovirus (CMV) – high risk of reactivation with immunosuppressive treatment regimens (eg, alemtuzumab)

Clinical Presentation of Selected Lymphoma Subtypes (based on WHO classification)

• CLL/SLL
  • Incidence – 2-6/100,000; 6-7% of NHL
  • Age – median >60 years
  • Sex – M>F, 1.5-2:1
  • Symptoms – adenopathy hepatosplenomegaly; some patients present with autoimmune hemolytic anemia, fatigue, infections
  • Prognosis – good; indolent tumor
• Splenic marginal zone lymphoma (MZL)
  • Incidence – rare
  • Age – >50 years
  • Sex – M:F, equal
  • Symptoms – splenomegaly, often with autoimmune thrombocytopenia
  • Prognosis – good; indolent adenopathy
• Hairy cell leukemia
  • Incidence – rare; ≤2% of NHL
  • Age – median 50 years
  • Sex – M>F, 5:1
  • Symptoms – peripheral adenopathy rare; splenomegaly, fatigue, weakness, fever, bleeding, infections
  • Prognosis – good; with treatment, disease may remain silent for years
• Lymphoplasmacytic lymphoma
  • Incidence – rare; 3/1,000,000
  • Age – median 65 years
  • Sex – M>F (minimal)
    • Higher risk if patient has monoclonal gammopathy of unknown significance
  • Symptoms – fatigue, malaise, hepatosplenomegaly, adenopathy, hyperviscosity syndrome (~30%)
  • Prognosis – usually moderately good; indolent tumor
• Plasma cell neoplasms – plasmacytoma (plasma cell dyscrasias)
  • For incidence, age, sex, symptoms and prognosis, see plasma cell dyscrasias
• Extranodal marginal zone lymphoma (MLZ) of mucosa-associated lymphoid tissue (MALT)
  • Incidence – 8-10% of NHL; increased risk with chronic Helicobacter infection
  • Age – median 60 years
  • Sex – M<F (minimal)
  • Ethnicity – increased prevalence in northeast Italy and Middle East
  • Symptoms – related to organ location
  • Prognosis – favorable; indolent tumor
• Nodal MZL (+/- monocytoid B-cells)
  • Incidence – rare
  • Age – median 60 years
  • Sex – M:F, equal
  • Symptoms – lymphadenopathy
  • Prognosis – good; can be predicted from Follicular Lymphoma International Prognostic Index
• Follicular lymphoma
  • Incidence – 20-25% of NHL
  • Age – 50s-60s; rare in children
  • Sex – M<F, 1:1.7
  • Ethnicity – higher incidence in U.S. and western Europe
  • Symptoms – lymphadenopathy extranodal disease, bone marrow involvement (other sites uncommon)
  • Prognosis – reasonably good but disease tends to relapse; can be predicted from International Prognostic Index
• Mantle cell lymphoma
  • Incidence – 6-10% of NHL
  • Age – median is 60 years
  • Sex – M>F, 2:1
  • Symptoms – adenopathy, splenomegaly, bone marrow involvement
  • Prognosis – poor; aggressive tumor
• Diffuse large B-cell lymphoma (DLBCL)
  • Incidence – 25-31% of NHL
  • Age – median is 60 years
  • Sex – M>F (minimal)
  • Symptoms – rapidly enlarging tumor at nodal or extranodal site
  • Prognosis – poor, aggressive tumor
• Primary effusion lymphoma
  • Incidence – rare; occurs in HIV patients and universally associated with HHV8
  • Age – 30s-40s
  • Sex – M>F
  • Symptoms – dyspnea, abdominal distention
  • Prognosis – poor; aggressive tumor
• Burkitt lymphoma
  • Incidence – rare in U.S., endemic in Africa; significant risk with EBV
  • Age
    • Children – endemic form
    • Individuals in 30s – nonendemic form
  • Symptoms – lesions commonly found in jaw and face
  • Prognosis – poor; highly aggressive tumor

Indications for Laboratory Testing

• Tests generally appear in the order most useful for common clinical situations
• Click on number for test-specific information in the ARUP Laboratory Test Directory

Click the plus sign to expand the table of additional tests.

Test Name and Number	Comments
B-Cell CD20 Expression 0092099 Method: Flow Cytometry
B-Cell Clonality Screening (IgH and IgK) by PCR with Reflex to B-Cell Clonality Assessment by Restriction Fragment Southern Blot Hybridization 2006283 Method:
B-Cell Clonality Screening (IgH and IgK) by PCR 2006193 Method: Polymerase Chain Reaction/Capillary Electrophoresis
Leukemia/Lymphoma Phenotyping (Comprehensive - Miscellaneous) 0095243 Method: Flow Cytometry
B-Cell Clonality Assessment by Restriction Fragment Southern Blot Hybridization 0055592 Method: Restriction Fragment Southern Blot Hybridization
Chromosome Analysis, Bone Marrow 2002292 Method: Giemsa Band	Identify neoplastic populations in marrow
B Cell Specific Octamer Binding Protein-1 (BOB-1) by Immunohistochemistry 2003442 Method: Immunohistochemistry
Caspase-3 by Immunohistochemistry 2003496 Method: Immunohistochemistry
CD15, Leu M1 by Immunohistochemistry 2003529 Method: Immunohistochemistry
CD43, L60 (Leu 22) by Immunohistochemistry 2003568 Method: Immunohistochemistry
CD45 by Immunohistochemistry 2003574 Method: Immunohistochemistry
Hairy Cell Leukemia, DBA.44 by Immunohistochemistry 2003860 Method: Immunohistochemistry
Octamer Transcription Factor-2 (Oct 2) by Immunohistochemistry 2004061 Method: Immunohistochemistry
Hepatitis B Virus Core Antibodies (Total) 0020091 Method: Qualitative Chemiluminescent Immunoassay	Identify HBV status if considering rituximab therapy
Hepatitis B Virus Surface Antigen, Confirmation 0020128 Method: Chemiluminescent Immunoassay	Identify HBV status if considering rituximab therapy
Hepatitis C Virus Antibody by CIA 2002483 Method: Qualitative Chemiluminescent Immunoassay	Identify HCV status of at-risk patients if considering rituximab therapy
Cytomegalovirus, Quantitative PCR 0051813 Method: Quantitative Polymerase Chain Reaction	Follow patients with history of CMV for reactivation during alemtuzumab therapy
Human Immunodeficiency Virus Types 1 and 2 (HIV-1, HIV-2) Antibodies with Reflex to Human Immunodeficiency Virus Type 1 (HIV-1) Antibody Confirmation by Western Blot 2005377 Method: Qualitative Chemiluminescent Immunoassay/Qualitative Western Blot	Use for at-risk patients

Diagnostic Algorithm

  Lymphoma Leukemia Phenotyping Testing Algorithm