Microenvironmental immune cell alterations across the spectrum of nodular lymphocyte predominant Hodgkin lymphoma and T-cell/histiocyte-rich large B-cell lymphoma.

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is a rare type of B-cell lymphoma with good prognosis and distinct clinicopathologic features. The hallmark histological feature is the presence of malignant lymphocyte predominant (LP) cells embedded within nodules predominantly composed of small B-lymphocytes. Immunoarchitectural variations from these classic nodules could occur. The clinical and pathological significance of NLPHL with variant patterns is, however, uncertain and controversial. Some oncologists and pathologists consider variant atypical nodules to represent a simple localized overgrowth of the LP cells without significant pathological or clinical implications. Other oncologists, however, suggest that they might represent a different biological behavior in the form of intranodal progression with early transformation into large B-cell lymphoma. Therefore, NLPHLs with variant atypical patterns represent a more aggressive clinical course and an indicator of a higher risk of recurrence that warrants a more aggressive treatment even in the early stages. We performed a retrospective review study to investigate the prevalence and importance of atypical nodules in NLPHL. We found seven cases of NLPHL, three (43%) of which showed variant patterns with different immunoarchitectural features from the classic nodules of NLPHL. We did not find clinical or prognostic differences between the two groups of classic nodules of NLPHL and atypical variant nodules of NLPHL. The significance of which, however, cannot be drawn from this small case series. Therefore, further larger scale studies are warranted. In addition, pathologists should be aware of this phenomenon to avoid overcalling these cases as high-grade lymphomas.

Unraveling the Transcriptional Landscape of Nodular Lymphocyte-Predominant Hodgkin Lymphoma and T-Cell/Histiocyte Rich Large B-Cell Lymphoma: Impact of Tumor Microenvironment and Checkpoint Gene Expression

Different molecular pathways are believed to be involved in the pathogenesis of classic Hodgkin lymphoma as opposed to non-Hodgkin lymphoma. Antiapoptotic mechanisms have been proposed for classic Hodgkin lymphoma, including expression of the cellular Fas-associated death domain-like interleukin-1beta-converting enzyme inhibitory protein (c-FLIP), which plays a critical role in resistance to CD95/Fas-mediated apoptosis. In this study, we compare the expression of c-FLIP in the neoplastic cells of classic Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma cases. Sixteen cases of classic Hodgkin lymphoma and 19 cases of nodular lymphocyte-predominant Hodgkin lymphoma were reviewed. Of 16 classic Hodgkin lymphoma cases, 13 cases (81%) were c-FLIP-positive, compared with 6 of 19 (32%) nodular lymphocyte-predominant Hodgkin lymphoma cases. Strong cytoplasmic staining was seen in 7 of 13 c-FLIP-positive classic Hodgkin lymphoma cases, in contrast with only 2 of 6 c-FLIP-positive nodular lymphocyte-predominant Hodgkin lymphoma cases. The 2 cases of nodular lymphocyte-predominant Hodgkin lymphoma with strong c-FLIP expression were associated with transformation to large B-cell lymphoma. An additional 15 cases of diffuse large B-cell lymphoma were studied for c-FLIP expression. All but 1 were c-FLIP-positive. In conclusion, we detected c-FLIP in a significantly lower proportion of nodular lymphocyte-predominant Hodgkin lymphoma cases compared with classic Hodgkin lymphoma cases. Therefore, c-FLIP expression may not be the major mechanism of pathogenesis in nodular lymphocyte-predominant Hodgkin lymphoma. However, strong c-FLIP expression in nodular lymphocyte-predominant Hodgkin lymphoma was associated with transformation to large B-cell lymphoma in 2 cases. c-FLIP expression is not limited to Hodgkin lymphoma, because the majority of diffuse large B-cell lymphoma cases tested were strongly c-FLIP-positive.

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is a rare B-cell lymphoma considered to be of germinal center (GC) derivation. Studies on immunoglobulin expression have been few, and post-switch immunoglobulin (IgG) has been identified in the majority of cases examined thus far. We reviewed 180 cases of NLPHL and observed the unexpected expression of IgD in 27% of cases. IgD is usually coexpressed with IgM in naive B cells but can also be seen as IgD-only in centroblasts (CD38-positive) or memory B cells (CD27-positive). We asked whether IgD-positive NLPHL differed from cases of NLPHL negative for IgD. Clinically, the IgD-positive cases presented at a younger median age (21 vs. 44 years) and had a striking male predominance (male-to-female ratio, 23:1 vs. 1.5:1). Cervical lymph nodes were more frequently involved (56% vs. 18.2%). L&H cells were localized in a predominantly extrafollicular distribution in the majority of IgD-positive cases (69%). The IgD-positive cases did not coexpress IgM or CD27 (a marker associated with memory B cells), and nearly all (93%) were weakly positive for CD38, supporting a GC derivation. The expression of Bcl-6, BOB.1, Oct2, and SWAP-70 was similar in the two groups. However, PU.1 expression was seen in 60% of the IgD-positive cases in contrast to 86% of the IgD-negative cases. The absence of PU.1 staining correlated with more L&H cells in an extrafollicular distribution, weakening the use of this marker in the differential diagnosis with T-cell rich/histiocyte rich B-cell lymphomas. To study IgD expression in "de-novo" T-cell rich/histiocyte rich B-cell lymphomas, we analyzed 20 cases and all but one were negative. In conclusion, cases of IgD-positive NLPHL do not differ from IgD-negative cases regarding cellular derivation and most other immunophenotypic characteristics. However, IgD-positive NLPHL exhibits distinctive clinical features, and more often involves the interfollicular region in a background relatively rich in T cells. IgD positivity may represent an additional useful marker in the diagnosis of NLPHL.

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is characterized by neoplastic lymphocyte-predominant cells frequently rimmed by CD3+/CD57+/programmed death receptor-1 (PD-1)+ T cells. Because of the rarity of lymphocyte-predominant cells in most cases, flow cytometric studies on NLPHL often fail to show evidence of malignancy. To evaluate the diagnostic utility of PD-1 in detecting NLPHL by flow cytometry, in conjunction with the CD4:CD8 ratio and the percentage of T cells doubly positive for CD4 and CD8. Flow cytometric data obtained from cases of NLPHL (n = 10), classic Hodgkin lymphoma (n = 20), B-cell non-Hodgkin lymphoma (n = 22), T-cell non-Hodgkin lymphoma (n = 5), benign lymphoid lesions (n = 20), angioimmunoblastic T-cell lymphomas (n = 6) and T-cell/histiocyte-rich large B-cell lymphomas (n = 2) were analyzed and compared. Compared with the other groups, NLPHL showed significantly higher values in the following parameters: CD4:CD8 ratio, percentage of T cells doubly positive for CD4 and CD8, percentage of PD-1-positive T cells, and median fluorescence intensity of PD-1 expression in the doubly positive for CD4 and CD8 subset. Using a scoring system (0-4) based on arbitrary cutoffs for these 4 parameters, all 10 NLPHL cases scored 3 or higher, as compared with only 3 cases from the other groups, producing an overall sensitivity of 100% and a specificity of 96% (72 of 75). Two of the 3 outliers were non-Hodgkin lymphoma, and both showed definitive immunophenotypic abnormalities leading to the correct diagnosis. The remaining outlier was a case of T-cell/histiocyte-rich large B-cell lymphoma. The inclusion of anti-PD-1 in flow cytometry is useful for detecting NLPHL in fresh tissue samples, most of which would have otherwise been labeled as nondiagnostic or reactive lymphoid processes.

Outcomes of Nodular Lymphocyte Predominant Hodgkin's Lymphoma (NLPHL) Patients Treated with R-CHOP.

Treatment Patterns and Outcomes in Adolescent and Young Adults with Nodular Lymphocyte Predominant Hodgkin Lymphoma: An Impact Cohort Population-Based Study

Experience and Outcome of Patients with Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL) over 8 Years

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a distinct Hodgkin lymphoma subtype composed of few neoplastic lymphocyte-predominant (LP) cells in a background of reactive small B and T cells. We have seen occasional NLPHL cases that contain background T cells with prominent cytologic atypia, raising the differential diagnosis of peripheral T-cell lymphoma not otherwise specified (PTCL-NOS) or a composite lymphoma. We sought to characterize the clinicopathologic features of such cases. Eleven NLPHL cases with atypical T cells diagnosed from 1977 to 2010 were identified at 2 institutions and compared with 24 control NLPHL cases lacking atypical T cells. All 9 male patients and 2 female patients presented with localized peripheral lymphadenopathy. In comparison with control patients, they were younger (median age, 13.8 vs. 36.1 y; P=0.015), with more frequent cervical lymph node involvement (54.5% vs. 8.3%, P=0.015). In all 11 cases, areas of NLPHL with typical B-cell-rich nodules containing LP cells were present. Nine cases contained sheets of atypical T cells surrounding primary and secondary follicles in a pattern mimicking the T-zone pattern of PTCL-NOS; the remaining 2 cases contained atypical T cells presented as large clusters at the periphery of B-cell-rich nodules. In all cases, the atypical T-cell-rich areas contained rare scattered LP cells, which were IgD in 5 of 7 cases (71.4%). The atypical T cells showed no pan-T-cell antigen loss or aberrant T-cell antigen expression in any case, and polymerase chain reaction or Southern blot analysis showed no evidence of T-cell clonality in 6 cases tested. The atypical T cells exhibited a variable immunophenotype with respect to germinal center, follicular T-helper, T-regulatory, and cytotoxic T-cell markers. Among 8 patients with clinical follow-up (median follow-up: 6.4 y), 5 patients had recurrent NLPHL at 6 months to 12 years after diagnosis and 6 patients are alive without disease at 9 months to 18 years after diagnosis. In comparison with control patients, NLPHL patients with atypical T cells were more likely to develop recurrent NLPHL (71.4% vs. 13.6%, P=0.008) and to have a shorter time to relapse (P=0.04). Our findings suggest that some cases of NLPHL, occurring predominantly in younger patients, contain prominent populations of morphologically atypical T cells that may raise the possibility of concurrent nodal involvement by PTCL-NOS, a rare diagnosis in children. The clinical behavior of these cases appears similar to that of NLPHL with T-cell-rich diffuse areas, with a higher risk of disease recurrence and no difference in overall survival; however, this finding warrants confirmation in studies of larger numbers of patients.

The NLPHL Tumor Microenvironment Is Markedly Enriched in the Tigit and PD-1 Signalling Axes Compared to Classical Hodgkin Lymphoma

Objective: The purpose of our study is to investigate the utility of immunohistochemical expression of GATA3 and STAT6 in differentiating Classic Hodgkin Lymphoma (CHL) from Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL). Material and Methods: We approached database of Shaukat Khanum Memorial Cancer Hospital and Research Centre and selected a total of 79 CHLs and 15 NLPHLs diagnosed either on Trucut biopsy or excision biopsy diagnosed during the time 2020-2021. One slide from each of these 94 cases was stained with GATA3 and STAT6 independently and pattern of staining (either nuclear or cytoplasmic or dual nuclear and cytoplasmic) was accessed. Results: 75/79(95%) cases of CHL were positive for GATA3 staining [60/79(75.9%) cases showed nuclear GATA3 staining, 15/79(18.9%) cases showed both nuclear and cytoplasmic staining] and 4/79(5%) CHL cases were negative for GATA3. 15/15(100%) cases of NLPHL were negative for GATA3[12/15(80%) cases showed no staining and 3/15(20%) cases showed only cytoplasmic blush]. 65/79(82%) cases of CHL were positive for STAT6[17/79(21.5%) cases showed nuclear STAT6 expression, 48/79(60.7%) cases showed both nuclear and cytoplasmic staining], and 14/79(18%) cases of CHL were negative for STAT6 expression [8/79(10%) cases showed only cytoplasmic staining and 6/79(8%) showed neither nuclear nor cytoplasmic staining]. 14/15(93.3%) cases of NLPHL were negative for STAT6[5/79(33.3%) cases showed only cytoplasmic staining and 9/15(60%) cases showed no staining] and 1/15(6.7%) case of NLPHL was positive for STAT6[showed nuclear STAT6 staining]. Conclusion: Nuclear staining of GATA3 and STAT6 either alone or in combination with cytoplasmic staining can be used to differentiate CHL from NLPHL. GATA3 effectively excludes NLPHL with 100% negative predictive value. Keywords: GATA3, STAT6, Classic Hodgkin lymphoma, Nodular lymphocyte predominant Hodgkin lymphoma

Outcomes of Histological Variants of Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL): A Single-Center Retrospective Study

8566 Background: Nodular lymphocyte predominant Hodgkin Lymphoma (NLPHL) accounts for approximately 5% of all HL. Although the prognosis of patients of NPHL is typically excellent, previous observations have suggested that there is a higher risk of transformation to diffuse large B cell lymphoma (DLBCL) than in classical HL. However, in many studies, follow-up has been limited and this event can occur years later. We evaluated the frequency of transformation in all patients diagnosed with NLPHL at the British Columbia Cancer Agency (BCCA) over a 40 y period. Methods: The Lymphoid Cancer Database of the BCCA was searched to identify all patients with NLPHL between 1965 and 2006. 149 cases of NLPHL were identified; 4 were excluded due to composite pathology with DLBCL at diagnosis, leaving 145 cases for this analysis. Results: Cases of NLPHL had the following characteristics at diagnosis: median age 36 y; 72% male; 70% stage I /II; 10% B symptoms; 88% normal LDH; 92% PS of 0/1. Patients with limited stage disease received radiotherapy (RT) alone (56%) or chemotherapy ± RT (44%). Patients with advanced stage disease received MOPP-like or ABVD-like chemotherapy ± RT. With a median follow-up of 8.2 y (1.4 y- 38 y), 15 (10%) cases of transformation to DLBCL have occurred (12 DLBCL; 2 T-cell rich B-cell lymphoma; 1 unknown). The median age at transformation was 49 y (26 y-76 y), 13 (87%) were males, 14 (93%) had stage III/IV disease and 9 (60%) had an elevated LDH. Transformation was more likely in those with stage III/IV disease (p=.015), B symptoms (p=.007) or poor performance status (p=.025) at diagnosis. The median time to transformation to DLBCL was 9.9 years (.34y to 19.6 years). The risk of transformation to DLBCL at 10 y is 7% and the projected risk at 20 y is 22%. Conclusions: The risk of transformation in NLPHL to DLBCL is substantial and underappreciated. In this population-based study it was more often seen in patients with advanced stage, poor PS and B symptoms at diagnosis. Given that transformation can occur years after the primary diagnosis of LPHL, long-term follow-up of these individuals is necessary to accurately estimate the risk of development of secondary DLBCL. No significant financial relationships to disclose.

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a slowly progressing neoplasm with a favourable prognosis. However, in a minority of cases (3-12%) it progresses to a clonally related diffuse large B-cell lymphoma (DLBCL), diagnosed between 6 months and 24 years after NLPHL. This study investigated six cases of NLPHL and DLBCL at the same location. The patients were five men and one woman. In four cases, the site was an axillary lymph node, and in two it was inguinal. In all cases, NLPHL areas had typical morphological and immunophenotypic features. DLBCL involvement was multifocal, diffuse, and characterized by large centroblastic and anaplastic cells. Immunohistochemical studies showed DLBCL cells to be positive for CD20, CD45, and BCL6. In one case, DLBCL cells were positive for BCL2, and in two cases they were positive for MUM-1. There were no networks of follicular dendritic cells (FDC) associated with DLBCL. Rosettes of PD-1-positive and CD57-positive cells surrounding malignant cells in NLPHL were absent in DLBCL. All the cases were negative for Epstein-Barr virus. No translocations involving MYC were identified in DLBCL. Treatment and outcome were known in four cases. All of these patients were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), and this was followed by clinical remission (CR). In adequately sampled tumors, DLBCL can be associated with NLPHL at diagnosis. Diffuse architecture, loss of FDC networks, sometimes immunophenotype shift are characteristics of DLBCL associated with NLPHL. Treatment with R-CHOP usually leads to CR.

Tumor Microenvironment In Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL) Influences Occurrence of Relapses and Progression to Large Cell Lymphoma