B-Cell Lymphomas

B-cell non-Hodgkin lymphomas (NHL) represent a heterogenous group of hematologic malignancies of lymphoid cells. Following biopsy, flow cytometry, immunohistochemical stains, and cytogenetic studies can confirm the diagnosis.

Tabs Content

Clinical Overview

Key Points

Double- and Triple-Hit Lymphomas

B-cell lymphomas with 2 or 3 recurrent chromosomal breakpoint aberrations (rare) are referred to as double- or triple-hit lymphomas. These usually involve the MYC oncogene in association with the BCL2 and/or BCL6 gene rearrangements. These are classified by WHO as a “high-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements” (Swerdlow, WHO, 2016).

It is important to identify these high-grade lymphomas as they tend to manifest aggressive behavior and respond poorly to traditional chemotherapy.

Follicular lymphoma
DLBCL
High-grade lymphomas (rare)

Breakpoints Used to Identify Double- or Triple-Hit Lymphomas
Oncogene	Break-apart MYC	BCL2	BCL6
Locus	8q24	18q21	3q27
Biology	Accelerator of cell proliferation	Apoptosis inhibitor	Transcription modifier
Cytogenetics (translocations)	Any MYC translocation	BCL2/IGH t(14;18)(q32;21)	BCL6 almost always has a non-Ig translocation partner – BCL6 (3q27) Uncommon partner – BCL6/IGH [t(3;14)(q27;q32)]
Specific lymphomas associated with translocation	Burkitt lymphoma Diffuse large B-cell lymphoma (DLBCL) High-grade B-cell lymphomas (HGBL)	Follicular lymphoma DLBCL HGBL	Follicular lymphoma DLBCL High-grade lymphomas (rare)
Other malignancies associated with translocation	B-cell ALL (rare)	B-cell ALL (rare)	n/a
DIAGNOSTIC TESTING ARUP Tests Individual probes Chromosome FISH, Interphase 2002298 – order probes separately Panels Aggressive B-Cell Lymphoma Reflex Panel by FISH, Tissue 3001495 – if MYC (8q24) gene rearrangement by FISH is positive, then IGH-BCL2 fusion t(14;18) by FISH is added; if IGH-BCL2 fusion, t(14;18) by FISH is negative, then BCL6 (3q27) gene rearrangement by FISH will be added Lymphoma (Aggressive) Panel by FISH 2002650 – probes include IGH/BCL2, BCL6, and MYC For histologically aggressive B-cell lymphomas with either Burkitt-like or diffuse large cell morphologies in adults demonstrating a CD20+, CD10+ phenotype with high proliferative index OR CD20+ neoplasms with morphologic features indeterminate between DLBCL and Burkitt lymphoma, it is reasonable to test for MYC, BCL2, and BCL6 rearrangements using FISH IGH-BCL2 Fusion, t(14;18) by FISH 3001298 IGH-MYC t(8;14) by FISH 3001299 MYC (8q24) Gene Rearrangement by FISH 3001300 BCL6 (3q27) Gene Rearrangement by FISH 3001311
References: Aukema SM, 2011; Johnson NA et al, 2009; Salaverria I et al, 2011; Savage et al, 2009; WHO, 2008. ALL, acute lymphoblastic lymphoma; n/a, not available

Diagnosis

Indications for Testing

Adenopathy
Fevers/night sweats
Recurrent infections
Unexplained lymphocytosis or abnormal manual differential

Laboratory Testing

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
- See the Lymphoma Phenotyping algorithm for specific test-ordering recommendations
- May be performed on peripheral blood, bone marrow

Histology

Fine-needle aspiration (FNA) not considered adequate – use incisional biopsy specimen (NCCN, 2015)
Follow-up testing with bone marrow biopsy
- ≥2 cm specimen length
- Classified as involved or not
Immunophenotyping (flow cytometry testing) and immunoperoxidase staining of tissue for specific B-cell antigens or clonality with kappa and lambda light-chain staining
Immunohistochemistry – useful in conjunction with phenotyping
- Most commonly used stains – 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, and TdT
- Other available stains – BOB-1, Bax, caspase-3, CD15, CD43, CD45, CD45RA-MT2, CD45RO, CD74, c-Myc, DBA.44, and Oct-2
B-cell clonality studies
- Locate clonal rearrangements of the immunoglobulin gene in B-cell malignancies
- Provide information regarding prognosis and treatment recommendations
T-cell clonality studies

Genetic Testing

Disease	Genetics	Comments
High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements, and Burkitt lymphoma	MYC, BCL2, BCL6	Refer to Key Points
Burkitt lymphoma	MYC t(8;14), t(2;8), t(8;22)
Diffuse large B-cell lymphoma (DLBCL)	BCL6, BCL2, IRF4/MUM1
Follicular lymphoma	BCL2 t(14;18)(q32;q21), IRF4/MUM1	Recommended methodology – FISH or cytogenetics
Hairy cell leukemia	BRAF V600E
Mantle cell lymphoma	BCL1(CCND1) t(11;14)(q13;q32)
Marginal zone lymphoma (nodal, MALT, splenic)	MYD88	Use to differentiate from lymphoplasmacytic lymphoma
Mucosa-associated lymphoid tissue (MALT) (gastric)	t(11;14), t(14;18), t(1;14), t(3;14), t(11:18)	FISH or cytogenetics PCR useful for t(14;18)

Other Testing

Virus testing
- EBV – posttransplant lymphomas, endemic nasopharyngeal lymphomas
- HHV8 – AIDS-related lymphomas
Bacteria testing
- Helicobacter – mucosa-associated lymphoid tissue (MALT) lymphoma
Kappa and lambda light-chain clonality in situ hybridization
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

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 four risk groups
- Limited usefulness in follicular lymphoma, mantle cell lymphoma, NK lymphoma, nasal-type lymphoma, hepatosplenic lymphoma, and enteropathy-type lymphoma
Follicular Lymphoma International Prognostic Index scoring system
- Five risk factors (each scored as one point)
  - Blood hemoglobin <12 g/dL
  - Serum LD >normal
  - Ann Arbor tumor stage (III or IV)
  - >4 nodal sites
  - Age >60 years
- 0-1 risk factor – 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
- Double-hit and triple-hit lymphomas
  - Refer to Key Points for double- and triple-hit lymphomas
- CLL
  - CD38 – mutation status correlates inversely with prognosis

Differential Diagnosis

Infections
- Babesia microti
- Bartonella spp
- CMV
- EBV
- Fungal disease
- HIV
- M. tuberculosis
- Toxoplasma gondii
- Treponema pallidum
- Human herpesvirus 8
Reactive lymphocytosis
Malignancy
- Head and neck cancer
- Metastatic cancer
- Other lymphomas – T-cell, Hodgkin
Sarcoidosis

Monitoring

Alemtuzumab (Campath) therapy – risk of CMV reactivation
- PCR quantitative two to three weeks after start of therapy
Rituximab (Rituxan) therapy – high risk of hepatitis reactivation
- HBV surface antigen and core antibody testing for all patients
  - Add HBV e antigen testing for patients with relevant risk factors
- HCV testing for at-risk patients

Background

Epidemiology

Incidence – represents 80-85% of the cases of non-Hodgkin lymphomas (NHL) diagnosed annually
- >70,000 new cases of NHL (NCCN, 2014)
Age – peaks in 60s
Sex – M<F (minimal)

Classification

Mature B-cell Neoplasms (WHO, 2016)

Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL)
Monoclonal B-cell lymphocytosis
B-cell prolymphocytic leukemia
Splenic marginal zone lymphoma (MZL)
Hairy cell leukemia
Splenic lymphoma/leukemia, unclassifiable (provisional entities)
- Splenic diffuse red pulp small B-cell lymphoma
- Hairy cell leukemia variant
Lymphoplasmacytic lymphoma
- Waldenström macroglobulinemia
Monoclonal gammopathy of undetermined significance (MGUS), IgM
Heavy chain diseases
- Alpha heavy chain disease
- Gamma heavy chain disease
- Mu heavy chain disease
MGUS, IgG/A
Plasma cell neoplasms
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Monoclonal immunoglobulin deposition diseases
Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT)
Nodal MZL
- Pediatric nodal marginal zone lymphoma (provisional entity)
Follicular lymphoma
- In situ follicular neoplasia
- Duodenal-type follicular lymphoma
Pediatric-type follicular lymphoma
Large B-cell lymphoma with IRF4 rearrangement (provisional entity)
Primary cutaneous follicle center lymphoma
Mantle cell lymphoma
- In situ mantle cell neoplasia
Diffuse large B-cell lymphoma (DLBCL), not otherwise specified (NOS)
- Germinal center B-cell type
- Activated B-cell type
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
EBV-positive mucocutaneous ulcer (provisional entity)
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
Primary effusion lymphoma
Human herpes virus 8 (HHV8)-positive DLBCL, NOS
Burkitt lymphoma
Burkittlike lymphoma with 11q aberration (provisional entity)
High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements
High-grade B-cell lymphoma, NOS
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma

Risk Factors

Presence of autoimmune diseases immune deficiency (iatrogenic or acquired)
- Celiac disease
- HIV infection
- Immunosuppressive drugs
- Posttransplant immunosuppression
- Rheumatoid arthritis
- Sjögren syndrome
Inherited disorders
Chronic infection
- Cytomegalovirus (CMV) – high risk of reactivation with immunosuppressive treatment regimens (eg, alemtuzumab)
- 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 B (HBV) – risk of reactivation with immunosuppressive treatment regimens (eg, rituximab)
- Hepatitis C (HCV) – lymphoplasmacytic lymphoma, marginal zone lymphoma (MZL), follicular lymphoma
- Human herpes virus 8 (HHV8) – primary effusion lymphoma

Clinical Presentation

Selected Lymphoma Subtypes (Based on WHO, 2016)

Diffuse large B-cell lymphoma (DLBCL)

Incidence – 25-30% of NHL
Age – median is 60 yrs
Sex – M>F (minimal)
Symptoms – rapidly enlarging tumor at nodal or extranodal site
Prognosis – poor, aggressive tumor

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
Genetics – BCL2 mutation
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

CLL/SLL

Incidence – 2-6/100,000; ~7% of NHL
Age – median >60 yrs
Sex – M>F, 1.5-2:1
Symptoms – fatigue, adenopathy, hepatosplenomegaly, autoimmune hemolytic anemia, recurrent infections
Prognosis – good; indolent tumor

Mantle cell lymphoma

Incidence – 6-10% of NHL
Age – median is 60 yrs
Sex – M>F, 2:1
Genetics – CCND1 mutation
Symptoms – adenopathy, splenomegaly, bone marrow involvement
Prognosis – poor; aggressive tumor

Extranodal marginal zone lymphoma (MZL) of mucosa-associated lymphoid tissue (MALT)

Gastric subtype associated with chronic Helicobacter infection
Incidence – 8-10% of NHL
Age – median 60 yrs
Sex – M<F (minimal)
Ethnicity – increased prevalence in northeast Italy and Middle East
Symptoms – related to organ location
- Gastric subtype associated with chronic Helicobacter infection
Prognosis – favorable; indolent tumor

Splenic marginal zone lymphoma (MZL)

Incidence – rare
Age – >50 yrs
Sex – M:F, equal
Symptoms – splenomegaly, often with autoimmune thrombocytopenia
Prognosis – good; indolent tumor

Nodal MZL (+/- monocytoid B-cells)

Incidence – rare
Age – median 60 yrs
Sex – M:F, equal
Symptoms – peripheral lymphadenopathy
Prognosis – good; can be predicted by Follicular Lymphoma International Prognostic Index

Burkitt lymphoma

Incidence – rare in U.S., endemic in Africa
Age – depends on subtype; endemic in young
Three clinical forms
- HIV/transplant patients – immunocompromised form
- EBV-associated endemic form
- Sporadic form
Symptoms – lesions commonly found in jaw and face in endemic form

Hairy cell leukemia

Incidence – rare
Age – median 50 yrs
Sex – M>F, 5:1
Symptoms – hepatosplenomegaly, fatigue, fever, pancytopenia, recurrent infections, peripheral adenopathy rare
Prognosis – good; with treatment, disease may remain silent for years

Primary effusion lymphoma

Associated with HIV infection and HHV8
Incidence – rare
Age – 30s-40s
Sex – M>F
Symptoms – dyspnea, abdominal distention
Prognosis – poor; aggressive tumor

Lymphoplasmacytic lymphoma

Incidence – rare
Age – median 65 yrs
Increased risk for patients with monoclonal gammopathy of undetermined significance
Genetics – MYD88 L265P, CXCR4 mutations
Symptoms – fatigue, malaise, hepatosplenomegaly, adenopathy, hyperviscosity syndrome, and Waldenstrom macroglobulinemia
Prognosis – moderately good; indolent tumor

Posttransplant lymphoproliferative disorder

Incidence – more common following solid organ transplantation or allogeneic hematopoietic stem cell transplant
- 1-3% of transplant patients
- Majority occur 6-12 months posttransplant
Symptoms – depend on site of tumor
Associated with EBV and CMV (in EBV-negative patients)
- Usually B cell, uncommonly T cell or NK cell

Cutaneous B-Cell Lymphomas

Incidence – 20-25% of all cutaneous lymphomas
3 types
- Primary cutaneous MZL
- Primary cutaneous follicular cell lymphoma
- Primary cutaneous DLBCL
Symptoms – lesions that grow in size
Prognosis – good; indolent course except for DLBCL (tends to be aggressive in the legs)

Plasma cell neoplasms – plasmacytoma (plasma cell dyscrasias)
- See plasma cell dyscrasias

ARUP Lab Tests

Primary Tests

Aid in evaluation of hematopoietic neoplasms (ie, leukemia, lymphoma)

Specimens include bone marrow, whole blood, tissue, or fluid

Monitor therapy in patients with established diagnosis of hematopoietic neoplasms

Markers selected based on provided clinical history and/or previous test results

Antigens included

T cell: CD1a, CD2, CD3, CD4, CD5, CD7, CD8, TCR γ-δ, cytoplasmic CD3

B cell: CD10, CD19, CD20, CD22, CD23, CD103, CD200, kappa, lambda, cytoplasmic kappa, cytoplasmic lambda

Myeloid/monocyte: CD11b, CD13, CD14 (Mo2), CD14 (MY4), CD15, CD33, CD64, CD117, myeloperoxidase

Miscellaneous: CD11c, CD16, CD25, CD30, CD34, CD38, CD41, CD42b, CD45, CD56, CD57, CD61, HLA-DR, glycophorin, TdT, bcl-2, ALK-1, CD123, CD138, CD26, CD45, CRLF-2

Leukemia/Lymphoma Phenotyping Evaluation by Flow Cytometry 3001780

Method: Flow Cytometry

Use to order individual or multiple oncology FISH probes if standard FISH panels are not desired

Fresh tissue sample required

Indicate names of probes needed for testing

ARUP Oncology FISH Probes menu

Chromosome FISH, Interphase 2002298

Method: Fluorescence in situ Hybridization

Aid in the diagnosis of lymphoproliferative disorders

Aid in differentiating malignant from reactive lymphoid proliferations

Equally sensitive for both kappa and lambda restricted populations

False-negative results may result from specimen inadequacy and mutations affecting primer sites

Detection of clonally rearranged IgH is seen in a subset of T-cell neoplasms (ie, a positive result in the test should not be used to differentiate between T- and B-cell neoplasms)

B-Cell Clonality Screening (IgH and IgK) by PCR 2006193

Method: Polymerase Chain Reaction/Capillary Electrophoresis

Diagnose mantle cell lymphoma in conjunction with morphology and immunohistochemical studies

Formalin-fixed, paraffin-embedded (FFPE) tissue specimens only

Stained and returned to client pathologist for interpretation; consultation available if needed

Cyclin D1, SP4 by Immunohistochemistry 2003842

Method: Immunohistochemistry

Diagnose follicular lymphoma in conjunction with clinical, morphologic, and flow cytometric data

Most sensitive method to detect IGH-BCL2 fusion in FFPE tissue specimens

Not validated for tissue fixed in alcohol-based or nonformalin fixatives

Negative result does not exclude possibility of translocations involving other partners or rule out follicular lymphoma

IGH-BCL2 Fusion, t(14;18) by FISH 3001298

Method: Fluorescence in situ Hybridization

Diagnose Burkitt lymphoma (BL) or diffuse large B-cell lymphoma (DLBCL) with features intermediate between BL and DLBCL in conjunction with clinical, morphologic, and flow cytometric data

Requires FFPE tissue

Negative result does not rule out BL or B-cell lymphomas with features intermediate between BL and DLBCL involving MYC with other translocation partners, such as t(2;8) or t(8;22)

IGH-MYC t(8;14) by FISH has not been validated for tissue fixed in alcohol-based or nonformalin fixatives

MYC is not specific for BL or B-cell lymphomas with features intermediate between BL and DLBCL

IGH-MYC Fusion t(8;14) by FISH 3001299

Method: Fluorescence in situ Hybridization

Diagnose BL or DLBCL with features intermediate between BL and DLBCL in conjunction with clinical, morphologic, and flow cytometric data

Detects all MYC rearrangements including t(8;14), t(2;8), and t(8;22) rearrangements; does not identify translocation partner

Requires FFPE tissue

Negative result does not rule out BL or B-cell lymphomas with features intermediate between BL and DLBCL

MYC (8q24) gene rearrangement by FISH has not been validated for tissue fixed in alcohol-based or nonformalin fixatives

MYC is not specific for BL or B-cell lymphomas with features intermediate between BL and DLBCL

MYC (8q24) Gene Rearrangement by FISH 3001300

Method: Fluorescence in situ Hybridization

Diagnose BL or DLBCL with features intermediate between BL and DLBCL in conjunction with clinical, morphologic, and flow cytometric data

Sensitive method for detecting BCL6 rearrangements in FFPE, which can contribute to diagnosis and prognostication in B-cell lymphomas

BCL6 (3q27) Gene Rearrangement by FISH 3001311

Method: Fluorescence in situ Hybridization

Aid in diagnosis of aggressive large B-cell lymphoma with intermediate features between Burkitt lymphoma and diffuse large B-cell lymphoma (DLBCL) and confirmation of suspected double-hit lymphoma

Specimens – formalin-fixed, paraffin-embedded (FFPE) tissue specimens

Interpretation of results requires correlation with morphology and immunophenotype

MYC and/or BCL2 overexpression can be due to other mechanisms not detected by this test

Chromosome alterations outside probe region are not detected

Aggressive B-Cell Lymphoma Reflex Panel by FISH, Tissue 3001495

Method: Fluorescence in situ Hybridization

Aid in diagnosis of aggressive large B-cell lymphoma with intermediate features between Burkitt lymphoma and diffuse large B-cell lymphoma (DLBCL) and confirmation of suspected double hit lymphoma

For reflex test, refer to Aggressive B-Cell Lymphoma FISH Reflex, Tissue

Specimens – bone marrow or whole blood specimens; other specimens may be acceptable

Probes in this panel include MYC, BCL2, IGH, BCL6

Interpretation of results requires correlation with morphology and immunophenotype

MYC and/or BCL2 overexpression can be due to other mechanisms not detected by this test

Chromosome alterations outside probe region are not detected

FFPE and frozen specimens unacceptable

Lymphoma (Aggressive) Panel by FISH 2002650

Method: Fluorescence in situ Hybridization

Confirm diagnosis of hairy cell leukemia (HCL)

Monitor tumor burden in patients with HCL

Limit of detection – 0.2% mutant allele

BRAF V600E Mutation Detection in Hairy Cell Leukemia by Real-Time PCR, Quantitative 2007132

Method: Polymerase Chain Reaction

Determine risk group in newly diagnosed CLL

Results should always be correlated with morphologic and clinical information

Samples that do not yield amplification product may contain too few CLL cells (<50% B cells) or express VH genes with high numbers of mutations that may compromise clonal B-cell amplification

Not intended to detect minimal residual disease

IGHV Mutation Analysis by Sequencing 0040227

Method: Polymerase Chain Reaction/Sequencing

Preferred test at time of diagnosis for detecting prognostically important genomic abnormalities in leukemias/lymphomas and solid tumors involving loss/gain of DNA; loss of heterozygosity

Monitor disease progression and response to therapy

Panel only detects prognostically important imbalances (gain or loss of DNA) in the chromosomes of interest

Chromosome alterations outside the regions complementary to these FISH probes will not be detected

Ideal testing is when significant disease is present

Cytogenomic SNP Microarray - Oncology 2006325

Method: Genomic Microarray (Oligo-SNP Array)

Alternate test to detect prognostically important genomic abnormalities in CLL

Probes include ATM (11q22.3), chromosome 12 centromere (trisomy 12), D13S319 (13q14.3), and p53 (17p13.1)

Panel only detects prognostically important imbalances (gain or loss of DNA) in the chromosomes of interest

Chromosome alterations outside the regions complementary to these FISH probes will not be detected

Ideal testing is when significant disease is present

Chromosome FISH, CLL Panel 2002295

Method: Fluorescence in situ Hybridization

Aid in diagnosis of mantle cell lymphoma (MCL) if cyclin testing is noninformative

FFPE specimen require

Not validated for tissue fixed in alcohol-based or nonformalin fixatives or decalcified tissue

Negative result does not exclude the possibility of translocations involving other partners

This mutation is not specific for MCL; results should be analyzed in conjunction with morphology, immunohistochemistry, and immunophenotyping results

IGH-CCND1 Fusion, t(11;14) by FISH 3001306

Method: Fluorescence in situ Hybridization

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

Anaplastic Lymphoma Kinase 1 (ALK-1) by Immunohistochemistry 2003439

Method: Immunohistochemistry

Aid in identifying colorectal adenomas, carcinomas; distinguishes follicular lymphoma from reactive follicles

Stained and returned to client pathologist for interpretation; consultation available if needed

BCL-2 by Immunohistochemistry 2004513

Method: Immunohistochemistry

Aid in identifying large cell lymphomas, BL, and Hodgkin lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

BCL-6 by Immunohistochemistry 2003457

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD3 by Immunohistochemistry 2003508

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD5 by Immunohistochemistry 2003514

Method: Immunohistochemistry

Aid histologic diagnosis of lymphoblastic lymphoma, BL, follicular lymphoma, and CML

Aid differential diagnosis of small B-cell lymphomas and subtyping of lymphoblastic leukemias

Stained and returned to client pathologist for interpretation; consultation available if needed

CD10 (CALLA) by Immunohistochemistry 2003523

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell leukemia/lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD19 by Immunohistochemistry 2005114

Method: Immunohistochemistry

Aid in identifying common acute lymphoblastic leukemia, pre-B ALL, CLL, prolymphocytic leukemia, hairy cell leukemia, lymphoma cell leukemia, B-cell lymphomas, including BL, Waldenstrom, macroglobulinemia, and immunoblastic B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD20, L26 by Immunohistochemistry 2003532

Method: Immunohistochemistry

Aid in identifying B-cell CLL, follicular lymphoma, low-grade MALT-type B-cell lymphoma, primary salivary gland and gastric lymphoma, T-cell and histiocyte-rich B-cell lymphoma, angioimmunoblastic T-cell lymphoma, nodular lymphocyte-predominant Hodgkin lymphoma, follicular dendritic sarcoma and some Reed-Sternberg cells not expressing other B- or T-cell-associated markers

Stained and returned to client pathologist for interpretation; consultation available if needed

CD21 (Dendritic Cell) by Immunohistochemistry 2003535

Method: Immunohistochemistry

Aid in differentiating small lymphocytic lymphoma (+) and mantle cell lymphoma (-)

Stained and returned to client pathologist for interpretation; consultation available if needed

CD23 by Immunohistochemistry 2003541

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD25 by Immunohistochemistry 2003544

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD30 (Ki-1) by Immunohistochemistry 2003547

Method: Immunohistochemistry

Aid in identifying acute leukemia of precursor B-cell type, B-cell lymphomas and some myelomas

Stained and returned to client pathologist for interpretation; consultation available if needed

CD79A by Immunohistochemistry 2003800

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

CD138 (Syndecan-1) by Immunohistochemistry 2003812

Method: Immunohistochemistry

Primarily aids the distinction between CLL/SLL and mantle cell lymphoma where CD200 is usually positive in CLL/SLL and negative in mantle cell lymphoma; CD200 is also positive in other B-cell lymphoproliferative disorders

Stained and returned to client pathologist for interpretation; consultation available if needed

CD200 by Immunohistochemistry 2012844

Method: Immunohistochemistry

Aid histologic diagnosis of multicentric Castleman disease, angioimmunoblastic lymphadenopathies, and Kaposi sarcoma

Stained and returned to client pathologist for interpretation; consultation available if needed

Herpes Virus 8 by Immunohistochemistry 2003932

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

Kappa Light Chains by Immunohistochemistry 2003981

Method: Immunohistochemistry

Aids in the prognostic determination of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

Ki-67 with Interpretation by Immunohistochemistry 2007182

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

Lambda Light Chains by Immunohistochemistry 2003984

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

MUM1/IRF4 by Immunohistochemistry 2003975

Method: Immunohistochemistry

Detect IRF4/DUSP22 rearrangements which can contribute to diagnosis and prognosis in B-cell and T-cell lymphomas

IRF4/DUSP22 (6p25) Gene Rearrangement by FISH 3001568

Method: Fluorescence in situ Hybridization

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

Pax-5 by Immunohistochemistry 2004082

Method: Immunohistochemistry

Useful for cyclin D1-negative MCL that is difficult to distinguish from other small B-cell lymphomas

Highly specific marker for both cyclin D1-positive and negative MCL

Stained and returned to client pathologist for interpretation; consultation available if needed

SOX11 by Immunohistochemistry 2012561

Method: Immunohistochemistry

Aid histologic diagnosis of B-cell lymphoma

Stained and returned to client pathologist for interpretation; consultation available if needed

TdT by Immunohistochemistry 2004142

Method: Immunohistochemistry

Related Tests

Initial test to evaluate lymphoma

May provide prognostic information

CBC with Platelet Count and Automated Differential 0040003

Method: Automated Cell Count/Differential

Initial test to evaluate lymphoma

May provide prognostic information

Hepatic Function Panel 0020416

Method: Quantitative Enzymatic/Quantitative Spectrophotometry

Initial test to evaluate lymphoma

May provide prognostic information

Lactate Dehydrogenase, Serum or Plasma 0020006

Method: Quantitative Enzymatic

Initial test to evaluate lymphoma

May provide prognostic information

Assay interference (negative) may be observed when high concentrations of N-acetylcysteine (NAC) are present

Negative interference has also been reported with NAPQI (an acetaminophen metabolite) but only when concentrations are at or above those expected during acetaminophen overdose

Uric Acid, Serum or Plasma 0020026

Method: Quantitative Spectrophotometry

Order for rituximab monitoring

B-Cell CD20 Expression 0092099

Method: Flow Cytometry

Diagnose, prognose, and monitor hematopoietic neoplasms

Chromosome Analysis, Bone Marrow 2002292

Method: Giemsa Band

B Cell Specific Octamer Binding Protein-1 (BOB-1) by Immunohistochemistry 2003442

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

Identify HBV status if considering rituximab therapy

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

Screen for hepatitis C virus (HCV) infection in at-risk individuals

Screen for IgG antibodies to HCV

Hepatitis C Virus Antibody by CIA 2002483

Method: Qualitative Chemiluminescent Immunoassay

Detect and quantify cytomegalovirus (CMV)

Cytomegalovirus by Quantitative PCR 0051813

Method: Quantitative Polymerase Chain Reaction

Use for at-risk patients

Human Immunodeficiency Virus (HIV) Combo Antigen/Antibody (HIV-1/O/2) by CIA, with Reflex to HIV-1 Antibody Confirmation by Western Blot 2006526

Method: Qualitative Chemiluminescent Immunoassay /Qualitative Western Blot

Medical Experts

Lamb, Allen N., PhD, FACMG, Laboratory Section Chief, Cytogenetics and Genomic Microarray, ARUP Laboratories; Professor of Clinical Pathology, University of Utah

Miles, Rodney R., MD, PhD, Laboratory Section Chief, Hematopathology, at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

Perkins, Sherrie L., MD, PhD, Chief Executive Officer at ARUP Laboratories ; Professor of Pathology, University of Utah

References

Guidelines

Protocol for the Examination of Specimens From Patients With Non-Hodgkin Lymphoma/Lymphoid Neoplasms. Based on AJCC/UICC TNM, 7th ed. Protocol web posting date: Oct 2013. College of American Pathologists (CAP). Northfield, IL [Revised: Oct 2013; Accessed: May 2017]
Protocol for the Examination of Specimens from Patients with Hematopoietic Neoplasms of the Ocular Adnexa. Based on AJCC/UICC TNM, 7th ed. Protocol web posting date: Mar 2010. College of American Pathologists (CAP). Northfield, IL [Revised : Mar 2010; Accessed: Dec 2016]
NCCN Clinical Practice Guidelines in Oncology, Non-Hodgkin's Lymphomas. National Comprehensive Cancer Network. Fort Washington, PA [Accessed: Jun 2015]
Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, Advani R, Ghielmini M, Salles GA, Zelenetz AD, Jaffe ES. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016; 127(20): 2375-90. PubMed

General References

Aukema SM, Siebert R, Schuuring E, van Imhoff GW, Kluin-Nelemans HC, Boerma E, Kluin PM. Double-hit B-cell lymphomas. Blood. 2011; 117(8): 2319-31. PubMed

Behdad A, Bailey NG. Diagnosis of splenic B-cell lymphomas in the bone marrow: a review of histopathologic, immunophenotypic, and genetic findings. Arch Pathol Lab Med. 2014; 138(10): 1295-301. PubMed

Carbone A, Gloghini A, Aiello A, Testi A, Cabras A. B-cell lymphomas with features intermediate between distinct pathologic entities. From pathogenesis to pathology. Hum Pathol. 2010; 41(5): 621-31. PubMed

de Tute RM. Flow cytometry and its use in the diagnosis and management of mature lymphoid malignancies. Histopathology. 2011; 58(1): 90-105. PubMed

Elenitoba-Johnson K, Lim M, Kjeldsberg C. Mature B-cell Neoplasms with Primary Tissue Manifestations. In Kjeldsberg C and Perkins SL. Practical Diagnosis of Hematologic Disorders, 5th ed. Chicago: ASCP Press, 2010.

Gascoyne RD, Rosenwald A, Poppema S, Lenz G. Prognostic biomarkers in malignant lymphomas. Leuk Lymphoma. 2010; 51 Suppl 1: 11-9. PubMed

Good DJ, Gascoyne RD. Classification of non-Hodgkin's lymphoma. Hematol Oncol Clin North Am. 2008; 22(5): 781-805, vii. PubMed

Johnson NA, Savage KJ, Ludkovski O, Ben-Neriah S, Woods R, Steidl C, Dyer MJ, Siebert R, Kuruvilla J, Klasa R, Connors JM, Gascoyne RD, Horsman DE. Lymphomas with concurrent BCL2 and MYC translocations: the critical factors associated with survival. Blood. 2009; 114(11): 2273-9. PubMed

Ondrejka SL, Hsi ED. Pathology of B-cell lymphomas: diagnosis and biomarker discovery. Cancer Treat Res. 2015; 165: 27-50. PubMed

Peterson L. Mature B-cell Neoplasms with Leukemic Manifestations. In Kjeldsberg C and Perkins SL. Practical Diagnosis of Hematologic Disorders, 5th ed. Chicago: ASCP Press, 2010.

Peterson L. Mature B-cell Neoplasms with Plasma Cell or Plasmacytoid Differentiation. In Kjeldsberg C and Perkins SL. Practical Diagnosis of Hematologic Disorders, 5th ed. Chicago: ASCP Press, 2010.

Pizzi M, Gazzola A, Mannu C, Pileri SA, Sabattini E, Pileri SA. The role of molecular biology in the diagnosis of lymphoid neoplasms. Front Biosci (Landmark Ed). 2014; 19: 1088-104. PubMed

Salaverria I, Siebert R. The gray zone between Burkitt's lymphoma and diffuse large B-cell lymphoma from a genetics perspective. J Clin Oncol. 2011; 29(14): 1835-43. PubMed

Savage KJ, Johnson NA, Ben-Neriah S, Connors JM, Sehn LH, Farinha P, Horsman DE, Gascoyne RD. MYC gene rearrangements are associated with a poor prognosis in diffuse large B-cell lymphoma patients treated with R-CHOP chemotherapy. Blood. 2009; 114(17): 3533-7. PubMed

Shi M, Xiao R, Woda BA, Yu H. Five important advances in hematopathology. Arch Pathol Lab Med. 2014; 138(3): 410-9. PubMed

Vardiman J, et al. Myeloproliferative Neoplasms. In Swerdlow SH, et al. WHO Classification of Tumours of Hematopoietic and Lymphoid Tissues, revised 4th. Lyon, France: IARC Press, 2017.

Wilcox RA. Cutaneous B-cell lymphomas: 2015 update on diagnosis, risk-stratification, and management. Am J Hematol. 2015; 90(1): 73-6. PubMed

Resources from the ARUP Institute for Clinical and Experimental Pathology®

Bahler DW, Szankasi P, Kulkarni S, Tubbs RR, Cook JR, Swerdlow SH. Use of similar immunoglobulin VH gene segments by MALT lymphomas of the ocular adnexa. Mod Pathol. 2009; 22(6): 833-8. PubMed

Barth MJ, Goldman S, Smith L, Perkins S, Shiramizu B, Gross TG, Harrison L, Sanger W, Geyer MB, Giulino-Roth L, Cairo MS. Rituximab pharmacokinetics in children and adolescents with de novo intermediate and advanced mature B-cell lymphoma/leukaemia: a Children's Oncology Group report. Br J Haematol. 2013; 162(5): 678-83. PubMed

Bouska A, Bi C, Lone W, Zhang W, Kedwaii A, Heavican T, Lachel CM, Yu J, Ferro R, Eldorghamy N, Greiner TC, Vose J, Weisenburger DD, Gascoyne RD, Rosenwald A, Ott G, Campo E, Rimsza LM, Jaffe ES, Braziel RM, Siebert R, Miles RR, Dave S, Reddy A, Delabie J, Staudt LM, Song JY, McKeithan TW, Fu K, Green M, Chan WC, Iqbal J. Adult high-grade B-cell lymphoma with Burkitt lymphoma signature: genomic features and potential therapeutic targets. Blood. 2017; 130(16): 1819-1831. PubMed

Deffenbacher KE, Iqbal J, Sanger W, Shen Y, Lachel C, Liu Z, Liu Y, Lim MS, Perkins SL, Fu K, Smith L, Lynch J, Staudt LM, Rimsza LM, Jaffe E, Rosenwald A, Ott GK, Delabie J, Campo E, Gascoyne RD, Cairo MS, Weisenburger DD, Greiner TC, Gross TG, Chan WC. Molecular distinctions between pediatric and adult mature B-cell non-Hodgkin lymphomas identified through genomic profiling. Blood. 2012; 119(16): 3757-66. PubMed

Galardy PJ, Hochberg J, Perkins SL, Harrison L, Goldman S, Cairo MS. Rasburicase in the prevention of laboratory/clinical tumour lysis syndrome in children with advanced mature B-NHL: a Children's Oncology Group Report. Br J Haematol. 2013; 163(3): 365-72. PubMed

Gerrard M, Waxman IM, Sposto R, Auperin A, Perkins SL, Goldman S, Harrison L, Pinkerton R, McCarthy K, Raphael M, Patte C, Cairo MS, French-American-British/Lymphome Malins de Burkitt 96 (FAB/LMB 96) International Study Committee. Outcome and pathologic classification of children and adolescents with mediastinal large B-cell lymphoma treated with FAB/LMB96 mature B-NHL therapy. Blood. 2013; 121(2): 278-85. PubMed

Gomez-Gelvez JC, Salama ME, Perkins SL, Leavitt M, Inamdar KV. Prognostic Impact of Tumor Microenvironment in Diffuse Large B-Cell Lymphoma Uniformly Treated With R-CHOP Chemotherapy. Am J Clin Pathol. 2016; 145(4): 514-23. PubMed

Kiel MJ, Velusamy T, Betz BL, Zhao L, Weigelin HG, Chiang MY, Huebner-Chan DR, Bailey NG, Yang DT, Bhagat G, Miranda RN, Bahler DW, Medeiros J, Lim MS, Elenitoba-Johnson KS. Whole-genome sequencing identifies recurrent somatic NOTCH2 mutations in splenic marginal zone lymphoma. J Exp Med. 2012; 209(9): 1553-65. PubMed

Klinger M, Zheng J, Elenitoba-Johnson KS, Perkins SL, Faham M, Bahler DW. Next-generation IgVH sequencing CLL-like monoclonal B-cell lymphocytosis reveals frequent oligoclonality and ongoing hypermutation. Leukemia. 2016; 30(5): 1055-61. PubMed

Lee S, Day NS, Miles RR, Perkins SL, Lim MS, Ayello J, van de Ven C, Harrison L, El-Mallawany NK, Goldman S, Cairo MS. Comparative genomic expression signatures of signal transduction pathways and targets in paediatric Burkitt lymphoma: a Children's Oncology Group report. Br J Haematol. 2017; 177(4): 601-611. PubMed

Leventaki V, Rodic V, Tripp SR, Bayerl MG, Perkins SL, Barnette P, Schiffman JD, Miles RR. TP53 pathway analysis in paediatric Burkitt lymphoma reveals increased MDM4 expression as the only TP53 pathway abnormality detected in a subset of cases. Br J Haematol. 2012; 158(6): 763-71. PubMed

Liew M, Rowe L, Clement PW, Miles RR, Salama ME. Validation of break-apart and fusion MYC probes using a digital fluorescence in situ hybridization capture and imaging system. J Pathol Inform. 2016; 7: 20. PubMed

Meyer JA, Zhou D, Mason CC, Downie JM, Rodic V, Abromowitch M, Wistinghausen B, Termuhlen AM, Angiolillo AL, Perkins SL, Lones MA, Barnette P, Schiffman JD, Miles RR. Genomic characterization of pediatric B-lymphoblastic lymphoma and B-lymphoblastic leukemia using formalin-fixed tissues. Pediatr Blood Cancer. 2016; PubMed

Meznarich J, Miles R, Paxton CN, Afify Z. Pediatric B-Cell Lymphoma With Lymphoblastic Morphology, TdT Expression, MYC Rearrangement, and Features Overlapping With Burkitt Lymphoma. Pediatr Blood Cancer. 2016; 63(5): 938-40. PubMed

Miles RR, Shah RK, Frazer K. Molecular genetics of childhood, adolescent and young adult non-Hodgkin lymphoma. Br J Haematol. 2016; 173(4): 582-96. PubMed

Swierczek S, Nausova J, Jelinek J, Liu E, Roda P, Kucerova J, Jarosova M, Urbankova H, Indrak K, Prchal JT, Divoky V. Concomitant JAK2 V617F-positive polycythemia vera and B-cell chronic lymphocytic leukemia in three patients originating from two separate hematopoietic stem cells. Am J Hematol. 2013; 88(2): 157-8. PubMed

Szankasi P, Reading S, Vaughn CP, Prchal JT, Bahler DW, Kelley TW. A quantitative allele-specific PCR test for the BRAF V600E mutation using a single heterozygous control plasmid for quantitation: a model for qPCR testing without standard curves. J Mol Diagn. 2013; 15(2): 248-54. PubMed

Zhou D, Paxton CN, Kelley TW, Afify Z, South ST, Miles RR. Two Unrelated Burkitt Lymphomas Seven Years Apart in a Patient With X-Linked Lymphoproliferative Disease Type 1 (XLP1). Am J Clin Pathol. 2016; 146(2): 248-53. PubMed

Educational Videos

Last Update: October 2019

B-Cell Lymphomas

Key Points

Double- and Triple-Hit Lymphomas

Diagnosis

Indications for Testing

Laboratory Testing

Histology

Genetic Testing

Other Testing

Prognosis

Differential Diagnosis

Monitoring

Background

Epidemiology

Classification

Mature B-cell Neoplasms (WHO, 2016)

Risk Factors

Clinical Presentation

Selected Lymphoma Subtypes (Based on WHO, 2016)

ARUP Lab Tests

Medical Experts

References

Guidelines

General References

Resources from the ARUP Institute for Clinical and Experimental Pathology®

ARUP Laboratories

ARUP Websites

ARUP Consult


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B-Cell Lymphomas

Key Points

Double- and Triple-Hit Lymphomas

Diagnosis

Indications for Testing

Laboratory Testing

Histology

Genetic Testing

Other Testing

Prognosis

Differential Diagnosis

Monitoring

Background

Epidemiology

Classification

Mature B-cell Neoplasms (WHO, 2016)

Risk Factors

Clinical Presentation

Selected Lymphoma Subtypes (Based on WHO, 2016)

ARUP Lab Tests

Medical Experts

References

Guidelines

General References

Resources from the ARUP Institute for Clinical and Experimental Pathology®

ARUP Laboratories

ARUP Websites

ARUP Consult