Protocol for the Examination of Specimens From Patients With Non-Hodgkin Lymphoma/Lymphoid Neoplasms

Abstract

The College of American Pathologists offers these protocols to assist pathologists in providing clinically useful and relevant information when reporting results of surgical specimen examinations. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary (Checklist)” portion of the protocols as essential elements of the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice.The College developed these protocols as an educational tool to assist pathologists in the useful reporting of relevant information. It did not issue the protocols for use in litigation, reimbursement, or other contexts. Nevertheless, the College recognizes that the protocols might be used by hospitals, attorneys, payers, and others. Indeed, effective January 1, 2004, the Commission on Cancer of the American College of Surgeons mandated the use of the checklist elements of the protocols as part of its Cancer Program Standards for Approved Cancer Programs. Therefore, it becomes even more important for pathologists to familiarize themselves with these documents. At the same time, the College cautions that use of the protocols other than for their intended educational purpose may involve additional considerations that are beyond the scope of these documents.This protocol applies to non-Hodgkin lymphoma/lymphoid neoplasms involving any site except the ocular adnexa or bone marrow or the primary cutaneous lymphomas mycosis fungoides and Sezary syndrome. The staging systems for non-Hodgkin lymphoma and plasma cell myeloma adopted by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC), and the 2008 histologic classification for hematopoietic and lymphoid neoplasms of the World Health Organization (WHO) are recommended.Non-Hodgkin Lymphoma/Lymphoid Neoplasms: Biopsy, ResectionSelect a Single Response Unless Otherwise Indicated* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.Specimen (select all that apply) (note A)ProcedureTumor Site (select all that apply) (note B)Histologic Type (note C)Precursor Lymphoid NeoplasmsMature B-Cell NeoplasmsMature T- and NK-Cell NeoplasmsHistiocytic and Dendritic Cell NeoplasmsPosttransplant Lymphoproliferative Disorders (PTLDs)bEarly lesionsNote: Italicized histologic types denote provisional entities in the 2008 WHO classification.a An initial diagnosis of “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic results are available.b These disorders are listed for completeness, but not all of them represent frank lymphomas.c Classic Hodgkin lymphoma type PTLD can be reported by using either this protocol or the separate College of American Pathologists protocol for Hodgkin lymphoma.1*Pathologic Extent of Tumor (select all that apply) (note D)*Additional Pathologic FindingsImmunophenotyping (Flow Cytometry and/or Immunohistochemistry) (note E)*Molecular Genetic Studies (note E)*Clinical Prognostic Factors and Indices (select all that apply) (note F)Any number of specimen types may be submitted in the evaluation of lymphoid neoplasms. Lymph nodes, skin, gastrointestinal (GI) tract, bone marrow, spleen, thymus, and tonsils are among the most common. Specimens submitted with a suspected diagnosis of lymphoma require special handling to optimize the histologic diagnosis and to prepare the tissue for molecular and other ancillary special studies.2,3 The guidelines detailed below are suggested for specimen handling in cases of suspected lymphoma.The anatomic sites that constitute the major structures of the lymphatic system include groups and chains of lymph nodes, the spleen, the thymus, Waldeyer ring (a circular band of lymphoid tissue that surrounds the oropharynx, consisting of the palatine, lingual, and pharyngeal tonsils), the vermiform appendix, and the Peyer patches of the ileum.2,3 Minor sites of lymphoid tissue include the bone marrow, mediastinum, liver, skin, lung, pleura, and gonads. Involvement of extranodal sites is more common in non-Hodgkin lymphomas (NHLs) than in Hodgkin lymphoma. In addition, some NHLs, such as mycosis fungoides and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT), occur predominantly or entirely in extranodal sites.This protocol recommends assigning histologic type on the basis of WHO classification of lymphoid neoplasms.4 It was originally published in 2001 and recently was revised and updated in 2008.5 This classification encompasses both nodal and extranodal lymphomas and provides distinction of individual lymphoid neoplasms based upon morphologic, immunophenotypic, cytogenetic, and clinical features. While histologic examination typically is the gold standard, most lymphoid neoplasms will require the utilization of 1 or more other ancillary techniques, such as immunophenotyping, molecular studies, and/or cytogenetics to arrive at the correct diagnosis.4–10 If the specimen is inadequate or suboptimal for a definitive diagnosis and subtyping, this information should also be relayed to the clinician with an explanation of what makes the specimen inadequate or suboptimal.In general, the TNM classification has not been used for staging of lymphomas because the site of origin of the tumor is often unclear and there is no way to differentiate among T, N, and M. Thus, a special staging system (Ann Arbor system) is used for both Hodgkin lymphoma and NHL.11,12 It was originally published more than 30 years ago for staging Hodgkin lymphoma. The Ann Arbor classification for lymphomas has been applied to NHL by the AJCC13 and the UICC except for mycosis fungoides and Sezary syndrome.14For multiple myeloma, the Durie-Salmon staging system is recommended by the AJCC.13–15 The international staging system for multiple myeloma is useful for determining survival.13 The Ann Arbor classification and Durie-Salmon staging systems are shown below. It should also be realized that the St Jude staging system is commonly used for pediatric patients.16Pathologic staging depends on the biopsy of multiple lymph nodes on both sides of the diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of disease. Currently, staging of NHL is more commonly clinical than pathologic. Clinical staging generally involves a combination of clinical, radiologic, and surgical data. Physical examination, laboratory tests (eg, complete blood examination and blood chemistry studies including lactate dehydrogenase [LDH] and liver function tests), imaging studies (eg, computed tomography scans, magnetic resonance imaging studies, and positron emission tomography), biopsy (to determine diagnosis, histologic type, and extent of disease), and bone marrow examination are often required. In patients at high risk for occult CNS involvement, cerebrospinal fluid cytology should be performed.There is almost universal agreement that the stage of the NHL is prognostically significant.17–20 Correct diagnosis and staging are the key factors in National Comprehensive Cancer Network treatment schema that most clinicians use.21Stage I: Involvement of a single lymph node region (I), or localized involvement of a single extralymphatic organ or site in the absence of any lymph node involvement (IE).*,†Stage II: Involvement of 2 or more lymph node regions on the same side of the diaphragm (II), or localized involvement of a single extralymphatic organ or site in association with regional lymph node involvement, with or without involvement of other lymph node regions on the same side of the diaphragm (IIE).†,‡Stage III: Involvement of lymph node regions on both sides of the diaphragm (III), which also may be accompanied by extralymphatic extension in association with adjacent lymph node involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE + S).†,‡,§Stage IV: Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or without associated lymph node involvement; or isolated extralymphatic organ involvement in the absence of adjacent regional lymph node involvement, but in conjunction with disease in distant site(s). Stage IV includes any involvement of the liver, bone marrow, or nodular involvement of the lung(s) or cerebral spinal fluid.†,‡,§* Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV.† For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.‡ The number of lymph node regions involved may be indicated by a subscript: for example, II3. For stages II to IV, involvement of more than 2 sites is an unfavorable prognostic factor.§ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence classification of stage.Note: Patients are further classified as having (1) serum creatinine levels lower than 2.0 mg/dL or (2) serum creatinine levels 2.0 mg/dL or greater. The median survival for stage IA disease is about 5 years and that for stage IIIB disease is 15 months.13,14Immunophenotyping can be performed by flow cytometry8 or immunohistochemistry. Each has its advantages and disadvantages. Flow cytometry is rapid (hours), quantitative, and allows multiple antigens to be evaluated on the same cell simultaneously. Antigen positivity, however, cannot be correlated with architecture or cytologic features. Immunohistochemistry requires hours/days to perform, quantitation is subjective, but importantly it allows correlation of antigen expression with architecture and cytology. Not all antibodies are available for immunohistochemistry, particularly in fixed tissues, but one of its advantages is that it can be performed on archival tissue. Both techniques can provide diagnostic as well as clinically relevant information (eg, identification of therapeutic targets such as CD20). Molecular studies now play an increasingly important role in the diagnosis of hematopoietic neoplasms. They aid not only in helping establish clonality but also in determining lineage, establishing the diagnosis of specific disease entities, and monitoring minimal residual disease.10,22–24The following is to be used as a guideline for the more common immunophenotyping and cytogenetic findings for each entity.3,4,8,22–27 It is, however, not entirely comprehensive and individual cases may vary somewhat in their immunophenotypic and cytogenetic profile.Precursor Lymphoid NeoplasmsB Lymphoblastic Leukemia/Lymphoma, NOS: sIG−, cytoplasmic μ chain (30%), CD19+, CD20−/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/−, CD34+/−, CD13−/+, CD33−/+, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, variable cytogenetic abnormalities.B Lymphoblastic Leukemia/Lymphoma With t(9;22)(q34;q11.2); BCR-ABL1: sIG−, cytoplasmic μ chain (30%), CD19+, CD20−/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/−, CD34+/−, CD13−/+, CD33−/+, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, t(9;22)(q34;q11.2), may have either p190 kDa or p210 kDa BCR-ABL1 fusion protein.B Lymphoblastic Leukemia/Lymphoma With t(v;11q23); MLL Rearranged: sIG−, cytoplasmic μ chain (30%), CD19+, CD20−/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10−, CD34+/−, CD13−/+, CD33−/+, CD15+/−, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, t(v;11q23).B Lymphoblastic Leukemia/Lymphoma With t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1): sIG−, cytoplasmic μ chain (30%), CD19+, CD20−, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/−, CD13+/−, CD33−/+, CD15+/−, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, t(12;21)(p13;q22).B Lymphoblastic Leukemia/Lymphoma With Hyperdiploidy: sIG−, cytoplasmic μ chain (30%), CD19+, CD20−/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/−, CD34+/−, CD13−/+, CD33−/+, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, hyperdiploid (>50 chromosomes, often with extra copies of chromosomes 21, X, 4, and 14) without structural abnormalities.B Lymphoblastic Leukemia/Lymphoma With Hypodiploidy: sIG−, cytoplasmic μ chain (30%), CD19+, CD20−/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/−, CD34+/−, CD13−/+, CD33−/+, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, hypodiploid with 45 chromosomes to near haploid.B Lymphoblastic Leukemia/Lymphoma With t(5;14)(q31;q32); IL3-IGH: sIG−, cytoplasmic μ chain (30%), CD19+, CD20−, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/−, CD13+/−, CD33−/+, CD15+/−, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, t(5:14)(q31;q32).B Lymphoblastic Leukemia/Lymphoma With t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1): sIG−, cytoplasmic μ chain (30%), CD19+, CD20−, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/−, CD13+/−, CD33−/+, CD15+/−, IGH gene rearrangement +/−, IGL gene rearrangement −/+, TCR gene rearrangement −/+, t(1;19)(q23;p13.3).T Lymphoblastic Leukemia/Lymphoma: TdT+, CD7+, CD3+/− (usually surface CD3−), variable expression of other panT antigens, CD1a+/−, often CD4 and CD8 double positive or double negative, IG−, panB−; variable TCR gene rearrangements; IGH gene rearrangement −/+, chromosomal abnormalities are common and often involve 14q11–14, 7q35, or 7p14–15.Mature B-Cell NeoplasmsChronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Faint sIGM+, sIGD+/−, cIG−/+, panB+ (CD19+, CD20+), CD5+, CD10−, CD23+, CD43+, CD11c−/+; IGH and IGL gene rearrangements; trisomy 12; del(13q), del(17p), or del(11q) can be seen.B-Cell Prolymphocytic Leukemia: sIgM, sIgD+/−, pan B+ (CD19, CD20, CD22, CD79a, CD79b, and FMC-7), CD5 −/+, CD23−/+, del(17p), t(11;14)(q13;q32), breakpoints involving 13q14.Splenic B-Cell Marginal Zone Lymphoma: sIGM+, sIGD+/−, CD20+, CD79a+, CD5−, CD10−, CD23−, CD43−, nuclear cyclin D1−, CD103−, allelic loss at 7q31–32 (40%).Hairy Cell Leukemia: sIG+ (IGM, IGD, IGG, or IGA), panB+, CD79a+, CD79b−, DBA.44+, CD123+, CD5−, CD10−, CD23−, CD11c+, CD25+, FMC7+, CD103+ (mucosal lymphocyte antigen as detected by B-ly7), tartrate resistant acid phosphatase (TRAP)+; IGH and IGL gene rearrangements, no specific cytogenetic findings.Splenic Diffuse Red Pulp Small B-Cell Lymphoma: sIGG+, sIGD−/+, sIGM+/−, CD20+, DBA.44+, CD5−, CD103−/+, CD123−, CD25−, CD11c−/+, CD10−, CD23−, t(9;14)(p13;q32) occasionally seen, rarely abnormalities in TP53 or del(7q).Hairy Cell Leukemia Variant: sIGG+, panB+, DBA.44+, CD11c+, CD103+, FMC7+, CD25−, CD123−, Annexin A1−, TRAP-IHC−, no specific cytogenetic findings.Lymphoplasmacytic Lymphoma: sIGM+, sIGD−/+, cIG+, panB+, CD19+, CD20+, CD138+ (in plasma cells), CD79a+, CD5−, CD10−, CD43+/−, CD25−/+; IGH and IGL gene rearrangements, no specific cytogenetic findings.α Heavy-Chain Disease (Immunoproliferative Small Intestinal Disease): cytoplasmic α heavy chain +, CD20+ (lymphocytes), CD138+ (plasma cells), light chain −.γ Heavy-Chain Disease: IgG heavy chain +, CD79a+, CD20+ (on lymphocytes), CD138+ (in plasma cells), CD5−, CD10−, light chain −, abnormal karyotype in 50% without recurring abnormalities.μ Heavy-Chain Disease: monoclonal cytoplasmic μ heavy chain +, B-cell antigen +, CD5−, CD10−, surface light chain −.Plasma Cell Myeloma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), panB− (CD19−, CD20−, CD22−), CD79a+/−, CD45−/+, HLA-DR−/+, CD38+, CD56+/−, CD138+, EMA−/+, CD43+/−, cyclin D1+; IGH and IGL gene rearrangements; numerical and structural chromosomal abnormalities are common, including trisomies (often involving odd-numbered chromosomes), deletions (most commonly involving 13q14), and translocations (often involving 14q32).Solitary Plasmacytoma of Bone: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), panB− (CD19−, CD20−, CD22−), CD79a+/−, CD45−/+, HLA-DR−/+, CD38+, CD56+/−, CD138+, EMA−/+, CD43+/−, cyclin D1+; IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in particular t(11;14)(q13;q32).Extraosseous Plasmacytoma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), panB− (CD19−, CD20−, CD22−), CD79a+/−, CD45−/+, HLA-DR−/+, CD38+, CD56+/−, CD138+, EMA−/+, CD43+/−, cyclin D1+; IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in particular t(11;14)(q13;q32).Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue (MALT Lymphoma): sIG+ (IGM or IGA or IGG), sIGD−, cIG−/+, panB+, CD5−, CD10−, CD23−, CD43−/+; IGH and IGL gene rearrangements, BCL1 and BCL2 germline, trisomy 3 or t(11;18)(q21;q21) may be seen.Nodal Marginal Zone Lymphoma: sIGM+, sIGD−, cIG−/+, panB+, CD5−, CD10−, CD23−, CD43−/+; IGH and IGL gene rearrangements, BCL1 and BCL2 germline.Follicular Lymphoma: sIG+ (usually IGM+/− IGD, IGG, IGA), panB+, CD10+/−, CD5−/+, CD23−/+, CD43−, CD11c−, CD25−; overexpression of BCL2+ (useful to distinguish from reactive follicles), BCL6+; IGH and IGL gene rearrangements, t(14;18)(q32;q21) with rearranged BCL2 gene (70%–95% in adults).Pediatric Follicular Lymphoma: sIG+ (usually IGM+/− IGD, IGG, IGA), panB+, CD10+/−, CD5−, CD23−/+, CD43−, CD11c−, CD25−; overexpression of BCL2−, BCL6+, t(14;18) with rearranged BCL2 gene −.Primary Cutaneous Follicle Center Lymphoma: CD20+, CD79a+, CD10+/−, BCL2−/+, BCL6+, CD5−, CD43−, BCL2 gene rearrangement −/+.Mantle Cell Lymphoma: sIGM+, sIGD+, λ > κ, panB+, CD5+, CD10−/+, CD23−, CD43+, CD11c−, CD25−, cyclin D1+; IGH and IGL gene rearrangements, t(11;14)(q13;q32); BCL1 gene rearrangements (CCND1/cyclinD1) common.Diffuse Large B-Cell Lymphoma (DLBCL), NOS: panB+, surface or cytoplasmic IGM > IGG > IGA, CD45+/−, CD5−/+, CD10+/−, BCL6+/−, 3q27 region abnormalities involving BCL6 seen in 30% of cases, t(14;18) involving BCL2 seen in 20% to 30% of cases, MYC rearrangement seen in 10% of cases.T Cell/Histiocytic-Rich Large B-Cell Lymphoma: panB+, BCL6+, BCL2−/+, EMA−/+, background composed of CD3+ and CD5+ T cells and CD68+ histiocytes.Primary DLBCL of the CNS: CD20+, CD22, CD79a, CD10−/+, BCL6+/−, IRF4/MUM1+/−, BCL2+/−, BCL6 translocations +/−, del(6q) and gains of 12q, 22q, and 18q21 common.Primary Cutaneous DLBCL, Leg Type: sIG+, CD20+, CD79a+, CD10−, BCL2+, BCL6+, IRF4/MUM1+, FOX-P1+; translocations involving MYC, and IGH are Diffuse Large B-Cell Lymphoma of the CD79a+/−, CD10−, IRF4/MUM1+/−, With CD79a+/−, −/+, CD20+, Large B-Cell Lymphoma: panB+, CD20, CD45+/−, IRF4/MUM1+/−, BCL2+/−, BCL6+/−, CD23+, IGH and IGL gene Large B-Cell Lymphoma: pan B+ (CD19, CD20, CD22, CD5−/+, CD10−/+, Large B-Cell Lymphoma: CD138+, CD45−/+, CD20−, +/−, Lymphoma: CD38+, CD138+, IRF4/MUM1+, CD79a+/−, +/−, CD45−/+, CD20−/+, B-Cell Lymphoma in Disease: λ Lymphoma: CD45+/−, CD20−, IGH and IGL gene Lymphoma: sIGM+, panB+, CD5−, CD10+, BCL6+, CD38+, CD43+, IGH and IGL gene rearrangements, and and rearranged MYC common in cases and in cases, in With Diffuse Large B-Cell Lymphoma and Lymphoma: panB+, CD10+, BCL6+, BCL2−/+, BCL2 and occasionally both translocations double With Diffuse Large B-Cell Lymphoma and Classic Hodgkin Lymphoma: CD45+/−, CD79a+/−, CD15+/−, CD10−, and NK-Cell Prolymphocytic Leukemia: CD25−, > > TCR gene rearrangements, with breakpoints at and 10% have a Large Lymphocytic Leukemia: CD25−, most cases TCR gene Lymphoproliferative of karyotype is typically NK-Cell Leukemia: +, and del(11q) can be Lymphoproliferative Disease of associated with TCR gene rearrangements Lymphoma: or often TCR gene rearrangement Leukemia/Lymphoma CD10+, CD25+, TCR gene rearrangements, Lymphoma: CD5−/+, CD56+/−, no TCR or gene rearrangements; Lymphoma: CD7+, CD103+, Lymphoma: TCR TCR rarely +, CD5−, CD7+, CD56+/−, CD25−; gene rearrangements +/−, variable gene rearrangements and trisomy Lymphoma: TCR CD5−/+, TCR gene rearrangements Cutaneous Lymphoma: CD5−/+, TCR gene rearrangements Cutaneous Lymphoma: TCR CD5−, Cutaneous Lymphoma: CD5−, TCR gene rearrangements Cutaneous Lymphoma: TCR gene rearrangements NOS: panT variable CD5−/+, most cases some cases a cases are or TCR gene rearrangements Lymphoma: (often with variable loss of some panT TCR gene rearrangements in IGH gene rearrangements in to often positive in Large Cell CD43+/−, CD25+, CD45+/−, TCR gene rearrangements +/−, in of cases, in 10% to of translocations can also be Large Cell CD5−/+, CD43+, TCR gene rearrangements and Dendritic Cell NeoplasmsHistiocytic IGH and TCR gene Cell HLA-DR+, most and are negative, there are no cytogenetic Cell HLA-DR+, most and are negative, there are no cytogenetic Dendritic Cell CD45+/−, CD23−, most and are negative, IGH and TCR gene Dendritic Cell CD23+, HLA-DR+, IGH and TCR gene IGH and TCR gene specific histologic type of the lymphoid stage of as well as the International Prognostic are the factors used to determine treatment in The 5 that have been shown to be in years tumor stage or II III or IV number of extranodal sites of involvement or 1 or 1 2 to and serum the basis of the number of risk patients can be to 1 of or high or high or Patients by the number of risk factors to have with to complete survival and survival Studies that patients an and an of at 5 years as to patients a and a survival revised has been for patients with large B-cell lymphoma are with In pediatric cases, there is no of the and is based on stage and type of separate prognostic has for lymphoma. The Follicular Lymphoma International Prognostic to provide greater and among patients with It 5 prognostic risk factors including years Ann Arbor stage to IV to number of nodal and serum or Patients are into 3 risk risk and risk are also in other lymphoid neoplasms such as cell lymphoma and not to the by the the specific clinical findings are to be of prognostic in all stages of In of than loss than 10% in the before diagnosis, and are used to 2 for each stage of and The of is to with extent of disease and tumor but also have been shown to have prognostic for survival that is of