Club de Linfomas

Santander, Abril 2013

Dra Yolanda Castro

Dr Javier Menárguez

Hospital General Universitario Gregorio Marañón

Madrid

: • Varón 68 años de edad, natural de Ucrania.

• V->IX/10:

linfocitosis asintomática, micropoliadenopatías periféricas, sin

megalias.

14.9 Hb, 250000 plaqs, 14100 leuc 61% lfs (25% talla media).

Citometría SP: 2 poblaciones B patologicas:

1) (22%): sλ(low)/CD19/20/5/25/38+, CD79b/23/FMC7-;

2) (14%): sk/CD19/20/22/79b/5/38+, CD23/FMC7-

Asp MO: 3/5; 0% blastos; 46% lfs; 29% talla media-grande. Bp MO

(10B20883): 3/5 Infiltracion SLP BG LLC-like: CD20(h)/79a/5/Bcl2+;

cIg/IgD/CD3/10/23/43/138/Ciclina D1-).

Citometria MO: CD19/20/5+, CD23-.

V-IX 2010 (SP)

IX/10. Citogenética:

47,XY,+12 [2]

46,XY,der(8)t(8;12,?)(p21:q?;q12;?),del(14(q22q32) [7]

47,idem,+der(12)ins(12;?)(q12;?) [3]

46,XY [8]

Resumen: células normales y clones celulares, relacionados entre sí, con

alteraciones cromosómicas numéricas y estructurales: material extra del cr

12 y deleción intersticial del cr 14 (ambas asociadas con SLP en

progresión).

FISH:

- t(18;var)+ (25%: señal extra Bcl2); t(8;var)+ (9%: señal extra MYC).

- t(14;18), 3qvar, IgH-.

PCR IgH+ (TCR PC).

Diagnóstico: SLP B BG NOS, indolente Seguimiento.

• X/11: Bazo: 14 cm (homogéneo)

• IX/12: Ucrania: Sindrome constitucional (2 meses), leucocitosis elevada y bazo de 18 cm. Biopsia adenopatía axilar (Ucrania; 12B20107): LM de la Zona Marginal con cels grandes B: CD20+ CD5/23/Ciclina D1-

Revision en nuestro Centro: 11.7 Hb, VCM 85, 0.57% retic, 189000 plaqs, 122500 leuc, 3% nts, 30% lfs, 66% blastos. FSP: 90% cels grandes. Asp MO: 4/5; 83% lfs; 0% blastos; DC: SLP BG en Transformación (¿CB?) Citometria MO: 83% lfs. 2 poblaciones: - 1) (60%): sk/CD19/20/22/79ab/5/25/FMC7+, CD23-; - 2) (23%): CD19/20/2/5/25/38+, sIg/CD79b/23/FMC7-

. Dg: SLP B NOS, en Transformación.

.

CD5+ = 1 punto

CD23+ = 1 punto

FMC7- = 1 punto

CD79b- = 1 punto

Igs+ low = 1 punto

3, 4, 5 puntos = LLC

≤ 2 puntos = no LLC

Sistema de puntuación LLC,

(Matutes)

CD19 CD20

CD3 CD22

Población naranja: CD19+, CD20w, CD23-, CD5+, FMC7-, CD79b-, sIgs- Puntuación: 3

Población roja: CD19+, CD20+, CD23-, CD5+, FMC7+, CD79b+, sKappa+ Puntuación: 1

CD23 CD10 CD79b

CD5 FMC7 λ

IX/12: MO

Cariotipo: no crece (0 metafases)

FISH:

- t(18;var)+ (BCL2) (15%) t(8;var)+ (MYC) (60%).

- t(14;18), 3qvar, IgH-.

- Panel LLC (13q, +12, 11q, 17p): negativo

Ki67

CD20

CD3

CD5

CD43

Bcl2

Lambda

Kappa

IgM

IgD

CD10

Bcl6

CD23

Adenopatía

• cIgM(K,L-)/CD20/79a/5/Bcl6(low)/Bcl2-

• CD43+?

• IgD/CD3/10/30/38/MUM1/p53-

• Ki67: bajo (<15%)

• HIS/IHQ mRNA Kappa y Lambda:-

• No Citometría

• PCR: IgH+ (FR3x2), Igλ(x1)+ (Igk y TCRγ, PC)

• FISH: MYC t(8;var) y t(18;var)+; t(3;var)-

IX/10.

Citogenética

47,XY,+12 [2]

46,XY,der(8)t(8;12,?)(p21:q?;q12;?),del(14(q22q32) [7]

47,idem,+der(12)ins(12;?)(q12;?) [3]

46,XY [8]

Resumen: células normales y clones relacionados entre sí, con

alteraciones cromosómicas numéricas y estructurales: material extra cr 12

y deleción intersticial cr 14 (ambas asociadas con SLP en progresión).

FISH:

- t(18;var)+ (25%: señal extra Bcl2); t(8;var)+ (9%: señal extra MYC).

- t(14;18), 3qvar, IgH-

BCL2+

IGH-

16%

BCL2+

MYC+

IGH-

9%

Evolución clonal

Septiembre 2010 Septiembre 2012

BCL2+

MYC+

IGH-

15%

MYC+

45%

MYC+

?

BCL2+

IGH-

25%

MYC+

IGH-

9%

BCL2+

IGH-

15%

MYC+

IGH-

60%

Septiembre 2010

Septiembre 2012

Citometría: poblaciones sk y sλ.

Datos topográficos preliminares FISH parafina (ganglio)

Pendiente tincion IHQ C-MYC (ganglio)

IX/12: MO

FISH:

- t(18;var)+ (BCL2) (15%) t(8;var)+ (MYC) (60%).

- t(14;18), 3qvar, IgH-.

- Panel LLC (13q, +12, 11q, 17p): negativo

- t(22;var) (cadenas λ)+ (sondas split)

- t(2;var) (cadenas k)-.

DD

• LLC: citología, pseudo-pseudofolículos..,

Fenotipo SP/MO.

• LM Folicular:

- negatividad para IgD, CD23, CD43-

- expresión débil de Bcl6

- redes de células dendriticas en nódulos

- reordenamiento gen Bcl2

Reordenamientos gen Bcl2

• En general, a IgH: t(14;18) (q32;q21)

• Ráramente: genes cadenas ligeras Igs

- gen Igk: t(2;18)(p11;q21)

- gen Igλ: t(18;22)(q21;q11)

• Excepcionalmente, a otro gen:

- t(2;18)(q11.2;q21.33) 5'AFF3/3'BCL2

(Impera et al, Oncogene 2008, 27, 6187-90)

Reordenamientos Bcl2 en LLC

• 1990 (grupo Tsujimoto J Exp Med): 3/32 LLC reordenamientos Bcl2IgL (1K/2λ) en 5’ upstream Bcl2 (mbr/mcr-)

• 1991 (grupo de Kluin, Blood): 3/44 casos LLC. 2/3; CD5+ reordenamiento en 5’ upstream Bcl2; 1/3 CD5- reordenamiento mbr (¿LLC?)

• 2007 (grupo NWM Chicago, AMJP): 1/111 LLC: t(14;18).

• 2011 (grupo francés, AJBR): 75 LLC con reordenamientos Bcl2: 62 IgH, 2 Igk, 11 Igλ.

Traslocaciones genes Igs en LLC

• Raras (<5-10%)

• Partners: BCL2 (19q13) > BCL3 >

BCL11A (2p11) y MYC (8q24)

• Pronóstico diferente

Reordenamientos Bcl2 en

Linfomas Foliculares

• genes IgL: escasos y mal documentados

• Generalmente, a mbr y mcr (BCL2), no en

5’ upstream.

SLP asociados a reordenamientos variantes BCl2.

• Cancer Genet Cytogenet. 2005 Feb;157(1):12-7.

• Variant t(14;18) in malignant lymphoma: a report of seven cases.

• Bentley G, Palutke M, Mohamed AN.

• Department of Pathology, Detroit Medical Center, Wayne State University School of Medicine, Hutzel Professional Building, 4727 St. Antoine Boulevard, Suite 411, Detroit, MI 48201, USA

• .

• Abstract

The BCL2 gene was identified through molecular analysis of the breakpoints involved in the t(14;18)(q32;q21) found in the majority of follicular lymphomas (FL). Variant translocations leading to juxtaposing of the BCL2 with either the IGK or IGL gene have been recognized in B-cell malignant lymphoma, although they are rare. We identified seven lymphoma cases that had variant translocations. Three cases had simple translocations involving two chromosomal regions: t(18;22)(q21;q11.2) in two cases and t(2;18)(p11.2;q21) in the third case. Complex translocations affecting more than two chromosomes were seen in the remaining four cases. Fluorescence in situ hybridization using the LSI IGH/BCL2 DNA probes revealed rearrangements of the BCL2 gene locus in all cases. In addition, expression of BCL2 protein was seen in all cases; only five of the seven cases expressed BCL6 protein. Morphologically, the lymphomas were categorized as B-cell follicular lymphoma in six cases and in the seventh case as diffuse large cell lymphoma (Richter syndrome) transformed from preexisting chronic lymphocytic leukemia (CLL). In case 2, the variant t(18;22) was seen as a secondary aberration evolving from a trisomy 12 clone. The findings revealed that BCL2 rearrangements in some malignant lymphomas occur through variant simple or complex chromosomal translocations, but always involving the IGH, IGK, or IGL chromosomal site. In addition, fluorescence in situ hybridization proved to be an important tool in evaluating these cases by showing IGH/BCL2 gene fusion or repositioning of the BCL2 gene.

MYC sí tiene partners alternativos a genes de Igs

• Leukemia (2007) 21, 515–523.

• Mapping of MYC breakpoints in 8q24 rearrangements involving non-immunoglobulin partners in B-cell lymphomas

• P Bertrand1, C Bastard1, C Maingonnat1, F Jardin1, C Maisonneuve1, M-N Courel1, P Ruminy1, J-M Picquenot1 and H Tilly1

• 1Groupe d'Etude des Proliférations Lymphoïdes, Centre Henri Becquerel, INSERM U614, IFRMP23, Rouen, France

• Abstract

• Chromosomal translocations joining the immunoglobulin (IG) and MYC genes have been extensively reported in Burkitt's and non-Burkitt's lymphomas but data concerning MYC rearrangements with non-IG partners are scarce. In this study, 8q24 breakpoints from 17 B-cell lymphomas involving non-IG loci were mapped by fluorescence in situ hybridization (FISH). In seven cases the breakpoint was inside a small region encompassing MYC: in one t(7;8)(p12;q24) and two t(3;8)(q27;q24), it was telomeric to MYC whereas in four cases, one t(2;8)(p15;q24) and three t(8;9)(q24;p13) it was located in a 85 kb region encompassing MYC. In these seven cases, partner regions identified by FISH contained genes known to be involved in lymphomagenesis, namely BCL6, BCL11A, PAX5 and IKAROS. Breakpoints were cloned in two t(8;9)(q24;p13), 2.5 and 7 kb downstream from MYC and several hundred kb 5' to PAX5 on chromosome 9, joining MYC to ZCCHC7 and to ZBTB5 exon 2, two genes encoding zinc-finger proteins. In these seven cases, MYC expression measured by quantitative reverse transcription-polymerase chain reaction (RT-PCR) was significantly higher when compared to that of patients without 8q24 rearrangement (P=0.006). These results suggest that these rearrangements are the consequence of a non-random process targeting MYC together with non-IG genes involved in lymphocyte differentiation and lymphoma progression.

• Verosimílmente, el gen Igλ debería estar

translocado con BCL2 y más que con

MYC (o quizás, con ambos).

Diagnóstico

• SLP B NOS (¿x2?) (LLC atípica vs LM

Folicular…) en transformación

(¿double hit-like?).

Evolución

QTP (R-CHOPx6).

.

II/13:

RC ganglionar, disminución de esplenomegalia (TAC).

11.3 Hb, 3.94% retic, 151000 plaqs, 5300 leuc, 31% lfs.

Asp/Bp MO: 4/5- ¿RC? (4% lfs, 3% blastos).

. Valoración de Consolidación (TASPE).

Agradecimientos

• Servicio Hematología HGUGM (Citología,

Citometria, Biología Molecular)

• Laboratorio Citogenética Hospital del Mar,

Barcelona (Blanca Espinet)

• Servicio Patología FJD (Madrid)