Lymphadenopathy: Follicular Lymphoma and Lymphoid Hyperplasia – White Blood Cell Pathology

by Carlo Raj, MD

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    00:02 Our first major non-Hodgkin lymphoma that we’ll take a look at will be follicular lymphoma.

    00:07 Let’s go straight to the point.

    00:09 Where is the translocation taking place in? 14;18.

    00:12 This 14;18 is then going to over express BCL-2.

    00:16 If we move on, BCL-2 is going to do what with cytochrome C from the mitochondria? Our discussion, apoptosis, remember this is a cancer.

    00:26 It will do everything in its power to upregulate anti-apoptotic factors.

    00:31 So therefore, BCL-2 if upregulated prevents the release of cytochrome C from the mitochondria.

    00:37 You are not going to activate caspase and you’ve inhibited apoptosis.

    00:44 Causing increased survival of your germinal center.

    00:47 I’ll show you a picture in which follicular lymphoma in your lymph node in non-Hodgkin’s lymphoma, a common one by the way, is involvement of your follicular, follicular, portion of the lymph node.

    01:02 And you’ll find this to be extremely, extremely expanded and active.

    01:07 And at some point in time, I wish to mention here as well that 30 to 40% of time, follicular lymphoma may actually then go on to diffuse large B-cell lymphoma.

    01:17 We’ll talk about different ways that you will be responsible for developing diffuse large B-cell lymphoma for your boards.

    01:24 One method might be from follicular lymphoma.

    01:27 If you find a diffuse large B-cell lymphoma, having translocation 14;18, you know for a fact that it came from follicular lymphoma.

    01:38 The description of morphology in follicular lymphoma in the lymph node, which is where the problem began, you would find enlarged lymph node consisting of small cleaved lymphocytes.

    01:52 If you would take a look at a lymph node and here, it’s a lower amplification, you’ll find in the middle there huge areas of the follicle that are just about engrossing this entire follicle.

    02:06 Quite a bit of increase in size of the follicle.

    02:11 Upon closer examination, here once again, you’ll find in the middle quite a bit of small cleaved lymphocytes in which you’ll find follicular activity to be extremely prevalent.

    02:25 This is follicular lymphoma translocation 14;18.

    02:28 Upregulation in BCL-2.

    02:30 These cancer cells, these B cells are going to remain alive forever.

    02:36 Our topic here, an important differential is the fact that you might have reactive lymphoid hyperplasia versus follicular lymphoma.

    02:46 The immunohistochemistry stain, at least be able to identify what’s known as spectrin staining.

    02:52 And your focus here, I’d like for you to take a look at would be reactive type of your lymphoid hyperplasia.

    02:59 Reactive.

    03:00 Not a cancer per se.

    03:02 So you would still have increased activity of your follicle based on the reaction that’s taking place, maybe perhaps your infection.

    03:10 Ands so therefore, how would you be able to differentiate this from follicular lymphoma? Spectrin staining would then help you.

    03:19 And what you’re seeing here would be the germinal center, which is quite active.

    03:24 And you have an area, that’s the mantle.

    03:26 And then outside of this, you then have your paracortex.

    03:30 What you also would find is that, well, stronger expression of spectrin and numerous tingible body macrophages.

    03:38 However, in the middle, do not, do not appear to be take up your spectrin.

    03:44 However, the T zone, paracortex however will.

    03:48 And this is quite important for you to differentiate reactive lymphoid hyperplasia versus what we’ll take a look at with follicular lymphoma.

    03:57 And follicular lymphoma, what you end up finding is going to be positive spectrin staining in what kind of cells? B-cells.

    04:07 And B-cells are located where? In the follicle.

    04:11 Let’s stop here and make sure that you truly understand how to differentiate reactive lymphoid hyperplasia in which it’s responding to an invader versus follicular lymphoma, which is going to be a cancer.

    04:26 If you remember correctly, if it’s an acute type of reaction, the paracortex is going to come and play and it’s going to start activating, well, T-cells.

    04:36 And you need CD4 and you need CD8.

    04:38 And because of this, the spectrin will be taken up by the T-cells and therefore, the anatomy of the lymph node now comes in handy.

    04:46 Your T-cells reside where in your lymph node? Paracortex.

    04:51 Next, if you’re thinking about follicular lymphoma, what kind of lymphoma is this? A non-Hodgkin’s lymphoma of the follicle and what kind of cells are involved? B cells.

    05:03 So now the B-cells are going to start taking up your spectrin.

    05:07 You’d expect this to occur in your follicle as you’ll see in the picture.

    05:15 A few more words about follicular lymphoma.

    05:18 It is a common non-Hodgkin’s lymphoma, it usually presents in middle age and fairly indolent and average survival age of eight years.

    05:29 Chemotherapy works quite well and as I mentioned earlier, about 30 to 50% of your patients who have a translocation 14;18 may then go onto diffuse aggressive large B-cell lymphoma.

    05:45 Therefore, if you find diffuse large B cell lymphoma as being your morphologic picture and they’re giving you translocation 14;18.

    05:54 It came from follicular lymphoma.

    05:58 A possible cause.

    05:59 We’ll talk about two more when the time is right.

    06:03 This is not equivalent to Richter syndrome.

    06:06 When we talk about chronic lymphocytic leukemia, the oldest of all the leukemias in terms of your age group.

    06:15 With CLL, there’s a fixed population or small population in which that CLL goes on to become diffuse large B-cell lymphoma.

    06:29 That is going to be your Richter syndrome.

    06:34 So right off the bat, I’m giving you two major possibilities of developing diffuse large B-cell lymphoma.

    06:43 Number one here, you’d focus upon follicular lymphoma and when we discuss together CLL, at that point, I will mention Richter syndrome.

    06:53 And finally, I will refer to de novo type of development of your diffuse large B-cell lymphoma.

    About the Lecture

    The lecture Lymphadenopathy: Follicular Lymphoma and Lymphoid Hyperplasia – White Blood Cell Pathology by Carlo Raj, MD is from the course Lymphadenopathy – White Blood Cell Pathology (WBC).

    Included Quiz Questions

    1. t(14;18)
    2. t(8;14)
    3. t(8;21)
    4. t(11;14)
    5. t(11;18)
    1. Inhibition of apoptosis
    2. Autophagy
    3. Ferroptosis
    4. Promotes apoptosis
    5. Inhibition of necroptosis
    1. Diffuse large B-cell lymphoma
    2. Mantle cell lymphoma
    3. Burkitt lymphoma
    4. Small lymphocytic lymphoma
    5. Primary mediastinal large B-cell lymphoma
    1. Positive II spectrin staining in neoplastic B-cell nodule and in surrounding reactive lymphocytes.
    2. Hyperchromatic and pleomorphic spindled endothelial cells.
    3. Germinal hyperplasia and large, abnormal, nonneoplastic T lymphocytes.
    4. B-cell follicle has a germinal centre and a mantle zone and surrounding paracortical T zone expressing II spectrin.
    5. Atypical neoplastic lymphoid cells.

    Author of lecture Lymphadenopathy: Follicular Lymphoma and Lymphoid Hyperplasia – White Blood Cell Pathology

     Carlo Raj, MD

    Carlo Raj, MD

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