1
Q
Capsule of lymph node
A
thin, fibrous (thickened/fibrotic in reactive or neoplastic conditions)
EX) Nodular sclerosis Hodgkin Lymphoma
2
Q
Cortex of lymph node
A
contains lymphoid follicles (primary and secondary) and paracortex (interfollicular T cell zone)
3
Q
Secondary follicle
A
mostly B cells
a. Mantle zone = small cells surrounding germinal center
- All B cells, small, uniform, tightly packed
- CD20 (also CD 19 and 22) = B cell marker (highlights mantle zone B cells and germinal center B cells)
b. Germinal center: inner side
- Dark zone = mostly B cells (centroblasts)
- Light zone = mixed B cells (centrocytes), T cells, macrophages, and other cells
- BCL6 and CD10: markers specifically expressed in normal germinal B cells and derived lymphomas
4
Q
Paracortex
A
mixed cell populations, mostly T cells
CD3 (also CD4, 5, 8)= T cell marker - shows them abundant in paracortex and scattered in germinal center
5
Q
Sinuses
A
subcapsular, cortical, and medullary
1.Contain lymphocytes, plasma cells, and histiocytes
6
Q
Lymphoma: Immature B cells:8c
A
B cell Acute Lymphoblastic Leukemia or Lymphoblastic Lymphoma (B-ALL/LBL)
7
Q
Lymphoma: Mantle cell
A
Mantle Cell lymphoma
8
Q
Lymphoma: Germinal Center B-Cell (3)
A
- Follicular Lymphoma
- Hodgkin Lymphoma
- Burkitt Lymphoma
9
Q
Lymphoma: Pre or Post-Germinal Center B cell
A
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)
10
Q
Lymphoma: Plasma cell myeloma
A
Plasma cell myeloma (multiple myeloma)
11
Q
Lymphadenopathy and associated diseases (3)
A
lymph nodes of abnormal size, number or consistency
Associated diseases:
- CLL/SLL
- Follicular lymphoma - asymptomatic except for lymphadenopathy → late stage diagnosis usually
- Mantle Cell Lymphoma (MCL)
12
Q
WHO classification of lymphomas (5)
A
Morphology, immunophenotype, genetic findings, location, and age
13
Q
Clinical features of CLL and SLL
A
- CLL = most common leukemia (30% of all leukemias)
a. Predominantly peripheral blood lymphocytosis - SLL = 7% of Non-Hodgkin Lymphoma
a. Predominantly extramedullary involvement (nodes) - Median 65 years, male predominance (2:1 over females)
- Present asymptomatic, or mildly symptomatic
14
Q
Morphology of CLL and SLL
A
- Mature Lymphocytosis > 5 x10^9/L sustained for at least 3 months
- Monocloncal B cell with immature phenotype
- CLL cells: small, round nuclei, clumped chromatin
- Lymph node involvement: effacement of nodal architecture with diffuse infiltration
15
Q
Immunophenotype CLL and SLL
A
- Positive: CD5 and CD23 (t cell marker expressed by B cells - unique to this lymphoma),, CD19 (B cell)
- Weak: CD20, surface immunoglobulin, CD22, CD11c
- Negative: CD10, FMC7
16
Q
Genetic alteration CLL and SLL (4)
A
- Deletion of 13q14
- Trisomy chr12
- Deletion 11q22-23
- Deletion 17p13
17
Q
On a scale from 1-10, how much of a bitch is Charlie?
A
15***
*** Question adapted from USMLE Step I 2015 edition
18
Q
Clinical features of follicular lymphoma (4)
- origin
- age
- Location
- stage of presentation
A
- Lymphoma of germinal center B cell origin
- Mostly Adults (median 60 years), male = female
- Location: lymph nodes mostly - also spleen, bone marrow, GI, skin
- Usually present with widespread stage III or IV disease at diagnosis
a. Asymptomatic except for lymphadenopathy
19
Q
Morphology of follicular lymphoma
A
1.Neoplastic follicles, uniform in size, evenly distributed in lymph node cortex and medulla
No tingible body macrophages, no dark zone or light zone
20
Q
Immunophenotype of follicular lymphoma:
Positive for?
Negative for?
A
Positive For:
a. B-cell markers: CD19+, CD20+
b. BCL2+ positive (normally NO BCL2 in germinal center B cells)
c. Germinal center B-cell marker: CD10 and BCL6
2.Negative: CD5, CD23
21
Q
Genetic alteration for follicular lymphoma
A
- t(14:18) in 75-90% of cases
a. BCL2 gene (chr18) placed under influence of IGH promoter on chr14 → persistent expression in B cells → Lymphoma
22
Q
Clinical features of mantle cell lymphoma (6):
- % of NHL
- median age
- M:F ratio
- Location
- Stage
- Aggressiveness
A
- 3-10% of NHL
- Median age = 60 years
- M:F = 2:1
- Location: mostly lymph nodes - also spleen, bone marrow, GI
- Presents as stage III or IV with lymphadenopathy, hepatosplenomegaly
a. Can have bone marrow involvement
6. Moderately aggressive (in contrast to other small B-cell lymphomas)
23
Q
Morphology of mantle cell lymphoma (3)
A
- Effacement of lymph node architecture
- Diffuse infiltration of lymphoma cells in node
- Tumor cells: small-medium size, irregular nuclei, small nucleoli
24
Q
Immunophenotype mantle cell lymphoma:
Positive for?
Negative for?
A
Positive for:
a.B-cell markers: CD19, CD20
b. CD5, which is also positive in CLL/SLL (typically not expressed by B cells, but MCL B cells do express CD5)
c. Cyclin D1 (BCL1), which is negative in most of other B-cell lymphomas
Negative for:
a. CD23, which is positive in CLL/SLL
b. Germinal center B-cell markers: CD10, BCL6
25
Genetic alteration mantle cell lymphoma
t(11:14) involving BCL1 gene on 11q13 and IGH gene on 14q32
26
I'm sorry Charlie, I didn't mean to hurt your feelings
I know you are sensitive
27
Clinical features of Burkitt lymphoma (BL) (3)
1. Highly aggressive
2. Presents at extranodal sites or as leukemic form
3. Mostly in children or young adults
28
Endemic BL
- geographic location
- age
- involvement
- % EBV positive
a. Malaria belt in Africa
b. Childhood malignancy (4-7 years of age)
c. Involves jaw or abdomen
d. 95% EBV positive
29
Sporadic BL
- age
- involvement
- % EBV infection
a. Mostly in children and young adults
b. Mostly in ileocecal area
c. 30% EBV infection
30
Immunodeficiency BL
HIV patients
a.30% EBV infection
31
Morphology of Burkitt lymphoma cells
Medium sized, round nuclei, one or several small nucleoli, deeply basophilic cytoplasm with vacuoles
-Diffuse infiltration of monomorphic, medium sized cells with “starry sky” pattern
32
Immunophenotype Burkitt lymphoma:
Positive for:
Negative for:
Positive for:
a. B cell Markers: CD19, CD20
b. Germinal Center B-cell markers: CD10, BCL6
c. High proliferation index
d. EBV positive in endemic BL (sometimes + in sporadic/immune)
e. MYC gene
Negative for: CD5, CD23, BCL2, TdT
33
Genetic alteration Burkitt Lymphoma
t(8;14) - juxtaposes MYC gene at 8q24 next to IGH promoter
34
Clinical features of diffuse large B-cell lymphoma:
1. size
2. % NHL cases
3. age
4. m:f
5. where does it grow
6. aggressiveness
7. treat
8. different types?
1. Diffuse proliferation of medium to large-sized neoplastic B cells
2. Most common type of non-Hodgkin’s Lymphoma (31% of cases)
3. Median age = 64 years
4. Slight male predominance
5. Rapidly growing nodal (70% of the time) and extranodal (30% of the time) tumor
6. More aggressive than other low-grade B-cell lymphomas
7. Potentially curable with standard chemo (46% survival)
8. Many different types of large B-cell lymphoma
35
Morphology of diffuse large b cell lymphoma
1. Complete effacement of architecture of lymph nodes by diffuse lymphoma cell infiltrates
2. Large-sized lymphoma cells, with nuclear size greater than histiocyte nucleus or small lymphocyte
36
Immunophenotype diffuse large B cell lymphoma
B-cell markers positive: CD19+, CD20+
37
Indolent (causing little to no pain) lymphomas
Small B-cell lymphomas mostly indolent (except MCL)
1. CLL/SLL
2. Follicular Lymphoma
38
Aggressive lymphomas
i. MCL = moderately aggressive
| ii. Diffuse Large B-Cell Lymphoma (slightly more aggressive than other low-grade B-cell lymphomas)
39
Highly aggressive lymphomas
Burkitt’s Lymphoma - highly aggressive but potentially curable (60% cure)
40
4 common types of lymphomas in adults
i. CLL/SLL
ii. Follicular Lymphoma (FL)
iii. Mantle Cell Lymphoma (MCL)
iv. Diffuse Large B-Cell Lymphoma
41
Common types of lymphomas in children
Burkitt’s Lymphoma (endemic and sporadic)
42
BCL2 gene arrangement
Overexpression of BCL2 → massive follicular lymphoid hyperplasia, but not enough to cause neoplastic transformation
Normally no BCL2 in germinal center B cells
Follicular Lymphoma: BCL2 gene (chr18) placed under influence of IGH promoter on chr14 → persistent expression in B cells
43
BCL1 gene arrangement
involved in cell-cycle progression
1. Cyclin D1 binds CDK4 and CDK6 → phosphorylation of Rb → release E2F1-3 transcription factors → activate genes that are required for cell cycle progression → G1/S transition → cell divides
2. Mantle Cell Lymphoma:
a. Strongly/diffusely positive Cyclin D1 (BCL1) (which is negative in most of other B-cell lymphomas)
44
MYC gene arrangement
TF, overexpression can induce carcinogenesis of lymphoma development
Burkitt's Lymphoma
45
Type IV immunopathology
examples?
T cell mediated immunity and delayed hypersensitivity
DO NOT require B cells - antibody is NOT involved in primary process
EX) rejection of allografts, graft vs. host disease (the reverse of allograft rejection), (+) TB skin test, resistance to Mycobacterium tuberculosis, resistance to fungal infections, contact dermatitis, etc.
46
TB skin testing
If patient is TB+...
1) Mantoux skin test, 0.1 ml of PPD (purified protein derivative) preparation of M. tuberculosis antigens (tuberculin)
2) Injected intradermally →
3) antigen taken up by local APCs, onto MHC class II
4) IF patient has anti-TB Th1 memory cells → secrete IFN-y, attract macrophages → firm, raised induration
47
_________ are the predominant cells present in biopsied site at 48 hrs if TB infection is present
Macrophages
48
Why are tiny doses of TB skin tests NOT immunizing?
antigen needed to elicit a positive reaction in an immune person is MUCH LESS than needed to immunize
49
Why would a person have a false positive PPD test?
If they had the TB immunization (given in foreign countries, but not US)
50
Poison Ivy exposure: immunization phase
Initiation of immune response following first exposure
1) Contact dermatitis with oil Toxicodendron radicans → compound penetrates skin and becomes associated with MHC on APCs
2) APC → lymph node → present MHC+antigen to THo → develop into/proliferate Th1 and Th17 cells → create memory T cells
3) By the time you became immunized, antigen may be gone already, and you may have never noticed
51
Poison Ive Effector Phase
Elicitation of a reaction in a person who is ALREADY immunized
1) Months later, encounter poison ivy again
2) Oil on skin → MHC on APCs → memory T cells rapidly expand and get activated in area of contact
3) Memory T cells have a lower activation threshold - less antigen for elicitation of reaction
4) → secrete IFN-y → attract macrophages → firm red area of inflammation in 6-12 hours, peak at 24-48 hours = DELAYED-type hypersensitivity
52
Why would a small chemical or peptide not need to be processed through an APC to be presented by an APC to T cells?
Typically: Processing of antigen required to reduce antigen to an epitope-sized particle capable of interacting with the MHC.
1) BUT if antigen is already reduced to the size of the epitope, as with small chemicals or peptides, it may associate directly with the MHC without processing.
2) Antigens can also bind to a peptide which is then presented on an MHC
53
HLA-B*5701 and HIV drug abacavir
Abacavir = nucleoside reverse transcriptase inhibitor
HLA-B*5701 = class I MHC
Abacavir hypersensitivity syndrome → drug induced autoimmune reaction
T cell immune response
Now we test for HLA-B*5701 allele before offering drug
54
How do we measure T cell immunity in vitro?
Whole blood or isolated WBCs (T cells + APCs) incubated with antigen in cell culture → observe cell proliferation, cell size, DNA synthesis, cytokines
EX) QuantiFERON-TB Gold test
55
QuantiFERON-TB Gold test
1) Purified TB human-specific antigen (NOT cow like in PPD) proteins added to sample of whole blood (in vitro)
2) Incubated → IFN-y levels measured with ELISA
Test negative in people vaccinated with BCG (cow TB)→ can distinguish between infection and previous immunization.
Test positive if sufficient T cells against human M. tuberculosis
56
First set graft reaction
Graft rejection in 10-20 days
5-10% of recipient’s T cells recognize the graft MHCs as self MHC+antigen → become activated → produce more anti-graft Th1 and CTL → rejection
Typical pathway of rejection
57
Second set graft rejection
Faster rejection with second exposure - due to T cell memory developed during first exposure
Rejected in 5-10 days
58
Hyperacute Rejection
- Graft rejected before it even has time to “heal in.”
- “White graft” reaction because graft stays white and bloodless.
- Results from development of abs against histocompatibility antigens
- Common with xenografts
59
The brain is _______, but not ___________
antigenic, but not immunogenic
60
Why is the brain antigenic, but not immunogenic?
No brain protein presented in thymus for negative selection of anti-brain T cells
→ anti-brain T-cells exist in everyone’s T-cell repertoire, BUT are rarely stimulated, b/c brain well defended and well protected.
IF T-cells somehow stimulated against the brain --> becomes immunogenic → T cells will attack it
61
What are some examples of the brain becoming immunogenic?
| 2
- Meat packing plant: inhaled pig brain particles --> pig brain presented to T cells --> cross reacted with human brain --> T cells start attacking human brain
- MS: researcher got brain in a cut --> gradual encephalopathy
62
Sjogren Syndrome: autoimmune reaction against ________ involving _______
exocrine glands (tears, saliva)
CTL
63
Type 1 Diabetes involves _______ cells and _______ and is associated with HLA-____ and _____
T cells
ab creating to B-cells in pancreatic insnulin-producing islets
HLA-DQ2 and DQ8
64
Rheumatoid Arthritis
most common autoimmune disease
exact pathogenesis not known, but we know that Rheumatoid factor makes human IgG agglutinate
Rituximab is an effective treatment (CD20 inhibitor)
65
Three conditions must be met for graft versus host disease to occur
1) Graft must contain immunocompetent T-cells (even BM has mature T cells)
2) There must be at least one antigen in host which graft’s T-cells can recognize
3) Host must be relatively immunoincompetent or unable for genetic reasons to recognize the graft’s MHC antigens.
66
Acute GvHD
presentation?
treatment?
develops in 2-10 weeks after BM transplant
Maculopapular skin rash, diarrhea, hepatic inflammation with jaundice, infections
Treat with anti-inflammatory drugs (corticosteroids, immunosuppressives)
67
Chronic GvHD
develops in months to years
Can occur even in patient with perfect HLA match
--> Against minor histocompatibility antigens
Chronically activated T cells pouring out cytokines → compromised regulation → autoimmunity can result
68
Graft-Versus-Leukemia Phenomenon
Leukemia patient stops responding to conventional therapy → LARGE doses of drugs or radiation (myeloablative - destroys all bone marrow) → take marrow from best matched allogeneic donor
Least GvHD with BM from themselves stored pre-treatment or T-depleted allogeneic marrow, BUT higher rate of leukemia relapse
Graft vs. Leukemia reaction thought to be important part of the success of the bone marrow transplant
Maximize GvL, minimize GvH
69
Th2 Cells in Immunopathology
Th2 cells found in periphery of certain inflammatory and infectious states, especially asthma and chronic worm infestations
Activate M2 macrophages and eosinophils → fibrosis (chronic), more intense inflammation
70
Plasma Cell Neoplasms:
Clonal proliferation of _________ that secrete _________. can present with ________ or _______ tumors
Ig-producing plasma cells from bone marrow
a SINGLE class of Ig
Bone marrow or extramedullary tumors
71
Morphological features in plasma cell myeloma (2)
Rouleaux formation when M protein markedly elevated
Plasma cells found on blood smears
72
Clinical features of plasma cell myeloma (multiple myeloma)
1) Secondary involvement of other organs possible
2) Can be asymptomatic to highly aggressive
3) Presents as bone pain in back or extremities
4) 90% of patients over 50 years of age
73
Radiographic findings of plasma cell myeloma (2)
Lytic lesions
Osteoporosis or fractures (vertebra, pelvis, skull, rib, femur, proximal humerus)
74
Lab findings of plasma cell myeloma (3)
M protein in serum or urine - protein electrophoresis
Associated symptoms (CRAB - hypercalcemia, renal insufficiency, anemia, bone lesions)
Monoclonal plasma cells in marrow (> 10%)
75
Solitary Plasmacytoma of bone
Localized tumor of bone composed of clonal plasma cells similar to those of plasma cell myeloma
NO bone marrow involvement
SINGLE bone lesion of monoclonal plasma cells
NO other bone lesions, NO M protein, normal Ig levels, NO myeloma related symptoms
76
Extraosseous Plasmacytoma
Localized plasma cell tumors that arise outside the bone marrow
Common in upper respiratory tract (nasal passages, sinuses, oropharynx, larynx)
Mean age of diagnosis is 55 years, ⅔ male
77
MGUS = Monoclonal Gammopathy of Undetermined Significance
Presence of ______ with NO evidence of...
monoclonal Ig (M protein) in serum or urine
NO evidence of plasma cell myeloma [NO lytic bone lesions,
78
Both solitary plasmacytoma and extraosseous plasma cytoma have normal __________
normal serum M protein
no other bone lesions
No myeloma related symptoms
79
MGUS is a precursor of ___________
plasma cell myeloma
80
Smoldering/Indolent myeloma
Associated symptoms (CRAB - hypercalcemia, renal insufficiency, anemia, bone lesions)
81
Classical Hodgkin Lymphoma (CHL) is a proliferation of __________ which stain + for _____ and _____ but NOT ______
germinal center B-cells
CD30+, CD15+, CD45-
82
Classical Hodgkin Lymphoma (CHL) includes 4 subtypes
Nodular Sclerosis
Lymphocyte Rich
Mixed Cellularity
Lymphocyte Depleted
83
Nodular Sclerosis CHL:
Occurs at what age/sex?
Where in the body?
Most frequent subtype of CHL
Mostly in young adults (females)
Typically occurs above the diaphragm
84
Morphology of Nodular sclerosis (3)
Thickened lymph node capsule
Nodular areas surrounded by broad bands of collagen
Lacunar cells
85
Lymphocyte-Rich CHL (4)
5% of CHLs
Nodular growth pattern with residual germ centers
Few RS cells
Best prognosis
86
Mixed Cellularity CHL (5)
- Any age
- Second most common CHL
- Below or on both sides of the diaphragm
- Lack broad bands of collagen seen in nodular sclerosis CHL
- EBV+ 75%
87
Lymphocyte Depleted CHL (4)
- Less than 1% of CHLs
- Numerous RS cells - anaplastic and bizarre appearing
- Usually EBV+
- Worst prognosis
88
Reed-Sternberg Cells are typically present in ________
CHL
89
Reed-Sternberg Cells stain + for ______ and _____, but - for __________
CD30+, CD15+, CD45-
90
Reed-Sternberg Cell morphology
Large (10x size of lymphocytes), contains multiple nuclei or large lobulated nucleus
Nuclei show accentuated membrane, pale chromatin, single large eosinophilic viral-inclusion-like nucleus
Ample and amphophilic cytoplasm
91
TGF-B + IL-6 is secreted when ________ and cause Tho cells in Peyer's Patches to differentiate into...
aggressive invaders cause epithelial cells to secrete IL-6
Th1, Th2, Th17 and suppress Treg
92
TGF-B + IL-10 is secreted in __________ and cause Tho cells in Peyer's Patches to differentiate into...
the normal gut
Treg
93
Why do we want a lot of Tregs in our gut Peyer's Patches normally?
Want lots of Treg in gut- constant exposure to bacteria and food derived non-pathogenic potential immunogens coming through M cells of gut
94
Chronic Frustrated Immune Response
immune system can’t get rid of foreign antigen → remains chronically active
NOT autoimmune
95
Crohns disease
small intestine (terminal ileum), fistulas common, patchy areas infection interspersed with healthy ones
96
Ulcerative Collitis
large intestine, can erode surface leading to bleeding
97
In both CD and UC there is a...
dysregulated T cell immune responses to commensal bacteria
Th1, Th17, and Th2 activated against normal commensal organisms
98
What influences IBD occurence
Environment
Genetics (163 loci associated with increased risk)
bad luck
99
Gluten
found in certain grains (wheat, rye barley) = antigen T cell responds to
Very branched, contain lots of prolines
Can return gut to normal by avoiding gluten
100
Antibody involvement in Celiac Disease
IgA ab made to tTg2 when it is covalently linked to gluten “antigen”
Abs not pathogenic in gut - T cell response causes symptoms in gut
Abs to tTG3 (cross reactive with tTG2) can cause skin symptoms (Dermatomyositis)
101
T cell involvement in Celiac Disease
tTG2 + gluten peptide (gliadin) taken up into B cells and presented to T cells → autoimmune response to tTG2
T cell immunity to gluten (gliadin) peptides → chronic inflam
102
HLA alleles ______ and _____ are associated with celiac disease because...
HLA-DQ2 and HLA-DQ8
DQ8 and DQ2 are weirdly shaped so are good at presenting gliadin which is also weirdly shaped (prolines) to T cells
BUT not all HLA-DQ2 or 8 people get Celiac
103
Autoimmune aspect of Celiac Disease
Must break down gluten with tTG2
Short lived intermediate covalently linking tTG2 and gluten → autoantibodies made to tTG2 and tTG2 presented to T cells
104
Non-autoimmune aspects celiac
NOT an autoimmune disease because it is a foreign antigen (gluten)
T-cells respond to gluten (antigen) causing chronic inflammation
105
tTG2
enzyme
Makes protein cross-links through glutamines
In some people it couples to, but can’t release, digestion-resistant glutamine-rich gliadin (wheat) peptides → becomes B-cell autoantigen
Foreign + self hybrid antigen mechanism
106
Chronic Beryllium Disease
Pulmonary inflammatory and fibrotic disease caused by exposure to inhaled Beryllium dust (miners, machinists, nuclear industry)
Be becomes covalently linked to normal peptides in blood → creates novel epitopes to which Th1 response is made → Th2 response later (scarring)
Be cannot be removed by macrophages → chronic, even though it was a single exposure
No way to get Be out of the body
107
Psoriasis
Chronic Frustrated Immune Response
involves TH17 (IL-17 and IL-23 especially)
108
Peridontal Disease
Chronic Frustrated Immune Response
bugs get into gingival crevice, T cells can’t get there so you get chronic inflammatory disease (T cells can’t get the upper hand)
109
Hygiene Hypothesis
Trying to explain why there is an increase in allergy and asthma in rich countries and less increase in poor countries
Exposure to environmental dirt and infections helps immune system mature normally, BUT lack of exposure can leave a child in an infantile state
Not enough evidence to support it
110
Old Friends Hypothesis
Certain harmless microorganisms have been in humans for so long we rely on their presence to instruct our immune systems not to overreact against commensals or low-grade pathogens
Adequate exposure to these “old friends” → develop balance between activation and regulation
Inadequate old friend exposure, “old friendless” → too few Tregs, and too many Th1, Th2, Th17 response to some benign organism
111
Switch Th1/Th2/Th17 to Treg instead?
Treat with Whipworms
Increase in Treg in the gut can suppress Th1, Th17, and Th2 responses
Treg suppression is NOT antigen specific, many nearby T cells down-regulated or do not differentiate into effectors
Blood and Lymph
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