BACKGROUND:It is now well established that Hodgkin cells are clonal B cells with a CD30 and CD15 phenotype. However, on immunohistochemistry, in our experience and the experience of others, CD20 positivity in an otherwise typical classical Hodgkin\u27s Lymphoma is not uncommon and if associated with CD15 negativity poses a potential diagnostic trap and is likely to be called B-NHL.OBJECTIVE:To assess the frequency of B-cell related antigens CD20 and CD79a in classical Hodgkin\u27s Lymphoma.MATERIALS AND METHODS:A total of 91 consecutive cases of classical Hodgkin\u27s Lymphoma were analyzed for co-expression of CD20 and CD79a. Both males and females of all ages were included in this study. All cases of nodular lymphocyte predominant Hodgkin\u27s Lymphoma were excluded. All the cases were stained with a panel of antibodies including LCA, CD20, CD79a, CD30, CD15, CD3, EMA and Alk. Protein.RESULTS:All 91 cases of classical Hodgkin\u27s Lymphoma showed negativity for LCA and positivity for CD30. Eighteen cases (19.8%) showed distinct membrane staining with CD20 in most of the large atypical cells. However, out of these, only 7 cases (7.7%) showed CD79a co-expression, which was largely focal. CD15 negativity with CD20 positivity was seen in 7 (7.7%) cases of otherwise typical classical Hodgkin\u27s LymphomaCONCLUSIONS/RECOMMENDATIONS:CD20 expression is frequent in classical Hodgkin\u27s Lymphoma and our results are in consensus with reported literature on this subject. In these cases, LCA negativity of large cells was extremely useful in clinching the right diagnosis

Ahmed, Shahid

Barakzai, Muhammad Abrar

English

eCommons@AKU

eCommons@AKUDepartment of Pathology and Laboratory Medicine Medical College, PakistanJanuary 2009CD20 positivity in classical hodgkin's lymphoma:diagnostic challenge or targeting opportunity.Muhammad Abrar BarakzaiAga Khan UniversityShahid AhmedAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiolPart of the Microbiology Commons, and the Pathology CommonsRecommended CitationBarakzai, M., Ahmed, S. (2009). CD20 positivity in classical hodgkin's lymphoma: diagnostic challenge or targeting opportunity..Indian Journal of Pathology & Microbiology, 52(1), 6-9.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/693/14/2018 CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targeting opportunity Barakzai MA, Pervez S - Indian J Pathol …http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=1;spage=6;epage=9;aulast=Barakzai 1/5Home About us Instructions Submission Subscribe Advertise Contact e-Alerts Ahead Of Print Login Users Online: 968       ORIGINAL ARTICLE     Year : 2009  |  Volume : 52  |  Issue : 1  |  Page : 6-9CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targeting opportunityMuhammad Abrar Barakzai, Shahid Pervez Department of Pathology/Microbiology, Section of Histopathology, Aga Khan University Hospital, Karachi, Pakistan  Click here for correspondence address and email         Abstract  Background: It is now well established that Hodgkin cells are clonal B cells with a CD30 and CD15 phenotype.However, on immunohistochemistry, in our experience and the experience of others, CD20 positivity in an otherwisetypical classical Hodgkin's Lymphoma is not uncommon and if associated with CD15 negativity poses a potentialdiagnostic trap and is likely to be called B-NHL. Objective: To assess the frequency of B-cell related antigens CD20and CD79a in classical Hodgkin's Lymphoma. Materials and Methods: A total of 91 consecutive cases of classicalHodgkin's Lymphoma were analyzed for co-expression of CD20 and CD79a. Both males and females of all ages wereincluded in this study. All cases of nodular lymphocyte predominant Hodgkin's Lymphoma were excluded. All the caseswere stained with a panel of antibodies including LCA, CD20, CD79a, CD30, CD15, CD3, EMA and Alk. Protein.Results: All 91 cases of classical Hodgkin's Lymphoma showed negativity for LCA and positivity for CD30. Eighteencases (19.8%) showed distinct membrane staining with CD20 in most of the large atypical cells. However, out of these,only 7 cases (7.7%) showed CD79a co-expression, which was largely focal. CD15 negativity with CD20 positivity wasseen in 7 (7.7%) cases of otherwise typical classical Hodgkin's Lymphoma. Conclusions/Recommendations: CD20expression is frequent in classical Hodgkin's Lymphoma and our results are in consensus with reported literature on thissubject. In these cases, LCA negativity of large cells was extremely useful in clinching the right diagnosis.Keywords: Hodgkin′s lymphoma, immunohistochemistryHow to cite this article: Barakzai MA, Pervez S. CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targetingopportunity. Indian J Pathol Microbiol 2009;52:6-9 How to cite this URL: Barakzai MA, Pervez S. CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targetingopportunity. Indian J Pathol Microbiol [serial online] 2009 [cited 2018 Mar 14];52:6-9. Availablefrom: http://www.ijpmonline.org/text.asp?2009/52/1/6/44952      Introduction    Hodgkin's Lymphoma (HL), formerly known as Hodgkin's disease, is a type of lymphoma first described by Thomas   Search          Similar in PUBMED   Search Pubmed forBarakzai MAPervez S   Search in Google ScholarforBarakzai MAPervez S Related articlesHodgkin's lymphomaimmunohistochemistry    Email Alert *    Add to My List ** Registration required (free)       Abstract    Introduction    Aim of Study    Materials and Me...    Results    Discussion    Conclusion    References    Article Figures    Article Tables  Article Access Statistics    Viewed 14982        Printed 226        Emailed 14        PDF Downloaded 1253        Comments [Add]        Cited by others 2    Journal is indexed with MEDLINE/Index Medicus, PubMed and Science Citation Index Expanded3/14/2018 CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targeting opportunity Barakzai MA, Pervez S - Indian J Pathol …http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=1;spage=6;epage=9;aulast=Barakzai 2/5Hodgkin in 1832. [1] HL is characterized clinically by the orderly spread of disease from one lymph node group toanother and by the development of B symptoms with advanced disease. Pathologically, the disease is characterized bythe presence of Classic  Reed-Sternberg cells More Details and its variants [Figure 1]. HL was one of the first cancers tobe rendered curable by combination chemotherapy, hence diagnostic accuracy. In almost all classical HL cases,neoplastic cells express CD30 and approximately 70% of these co-express CD15. [2]   The vast majority of HL, both classical Hodgkin's lymphoma (cHL) and nodular lymphocyte predominant Hodgkin'slymphoma (NLPHL), are known to be of B-cell origin.[3] However, the reasons for incomplete development of the B-cell phenotype and lack of immunoglobulin expression in cHL have not been explained fully. Crippling immunoglobulingene mutations are suggested to be the cause of absent immunoglobin expression in cHL. [4] However, recent work hasfocused on the impaired activation of the immunoglobulin promoter secondary to defective interaction with or lack ofexpression of transcription factors as the dominant mechanisms. [5]  However, in our experience and the experience of others, a number of cases of cHL do show positivity for B-cellmarkers and in particular for CD20. This adds to diagnostic difficulties, particularly with these cases because theyinclude T-cell rich B-cell lymphoma (TCRBCL), anaplastic large-cell lymphoma (ALCL) and peripheral T-celllymphoma (PTCL). However, on the other hand, this expression of CD20 may be exploited for anti-CD20 therapy.      Aim of Study    The aim of this study is to assess expression of the B-cell-related antigens CD20 and CD79a in cHL by implying acomprehensive antibody panel.  Inclusion criteria  Only the cases of cHL were included in the study.  Exclusion criteria  The cases of NLPHL were excluded from the study.      Materials and Methods    A total of 91 consecutive biopsy-proven cHL cases were included in the study. All cases were stained with a panel ofantibodies including the following:  LCA (CD45 clone 2B11 + PD7/26, monoclonal mouse anti-human Dako cytomation)  CD20 (clone L26 monoclonal mouse anti-human CD20cy Dako cytomation)  CD79a (clone JCB117 monoclonal mouse anti-human CD79a Dako cytomation)  CD3 (polyclonal rabbit anti-human CD3 Dako cytomation)  CD30 (clone Ber-H2 monoclonal mouse anti-human CD30 Dako cytomation)  CD15 (CD15 clone SPM490 mouse monoclonal antibody, Thermo Scientific, Lab Vision Corporation U.S.A.)  EMA (clone E29 monoclonal mouse anti-human epithelial membrane antigen)  ALK Protein (clone ALK 1 monoclonal mouse anti-human CD246 ALK protein Dako cytomation)  All tissue samples were fixed in 10% buffered formalin processed routinely and embedded in paraffin. Sections of 3-4µm were cut and mounted on positively charged super frost slides and dried in an oven for 1 hour at 60ºC. The sectionswere then deparaffinized in xylene and rehydrated in graded ethanol. For epitope retrieval, the tissue sections wereheated in Tris EDTA (pH 9.0) for 16 minutes at 450 W in a scientific microwave oven. After the heat-induced epitoperetrieval procedure, the sections were cooled down gradually to room temperature and washed with running tap water.Endogenous peroxidase was blocked by incubating the tissue in 3% hydrogen peroxide at room temperature for 10minutes and washed with distilled water. The tissue samples were incubated with primary antibodies for 30 minutes atroom temperature. After incubation with primary antibodies, immune detection was performed with the 2-steppolylabeling method using the envision system (Dako) with diaminobenzidine (DAB) chromogen as a substrate. AfterDAB, the slides were counter stained by hematoxlin and finally were mounted with distrine-pthaline xyline (DPX).      Results    Out of 91 cases of cHL, 70 cases were from males and 21 were from females. Of these 91 cases, 40 (44%) cases were of1 Year100 GAds by Google1Free  DownloadHide Your Identity  With SrchSafe!SrchSafe2Free  DownloadBlock Unwanted  Ads With  AdShield. Free To  Use Forever!AdShield3/14/2018 CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targeting opportunity Barakzai MA, Pervez S - Indian J Pathol …http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=1;spage=6;epage=9;aulast=Barakzai 3/5the cHL nodular sclerosis type, 47 (51%) were of the cHL mixed cellularity type and 4 (4.4%) cases were of the cHLlymphocytic rich type. All these 91 cases (100%) showed negativity for LCA and positivity for CD30 [Bar Chart 1]. Thestaining for CD30 was predominantly membranous with perinuclear golgi positivity in most cases [Figure 2]. Out of 91cases, 84 cases (92.3%) also showed membranous and or golgi positivity for CD15 [Figure 3] and 18 cases (19.8%)showed distinct membrane staining with CD20 [Figure 4] in most of the large atypical Hodgkin's cells. In relation to thesubtypes of classical Hodgkin's lymphoma, 8 out of 40 (20%) were nodular sclerosis, 8 out of 47 (17%) were mixedcellularity cases and 2 out of 4 (50%) cases of lymphocytic rich type showed positivity for CD20 [Table 1]. Of the 18cases showing CD20 positivity, only 7 cases (7.7%) also showed CD79a co-expression, which was largely focal andmembranous [Figure 5]. None of the CD20 negative cases showed CD79a positivity. CD15 negativity with CD20positivity was seen in 7 (7.7%) cases of otherwise typical cHL. The background reactive population was mostlycomposed of mature T cells intermixed with histiocytes, plasma cells and polymorphs (neutrophils and eosinophils).      Discussion    In practice, the diagnosis of Hodgkin's Lymphoma rather seems straightforward but cells resembling Reed-Sternbergcells have been described in various other entities including Non-Hodgkin's Lymphoma (NHL) and virus associatedlymphadenopathies. Immunohistochemical stains, in particular CD30 and CD15, are used routinely for confirmation andresolve difficult cases. [2]  Problems arise, however, in those cases where CD15 is either negative or only focally positive with strong diffusemembranous CD20 positivity. In these cases, large B cell lymphoma (T cell /histiocytic rich) also comes into differentialdiagnosis as this tumor usually also co-expresses CD30 (an activation marker not specific for HL) and rarely CD15 aswell. In this situation, we go back to time tested H and E to seek further clinical information in particular about thepattern of disease. In addition, in these cases we also critically evaluate the LCA pattern as positivity in classical HL ishighly unusual. Antibodies for EBV like LMP are also useful as many cases of classical HL do show nuclear stainingwith this antibody.   In this study, we have seen about 20% reactivity with CD20 in cHL in contrast with the German lymphoma study group.von Wasielewski et al . [6] has reported a frequency of CD20 positivity of 4.8% among 1751 patients with cHD. Inanother study by Portlock et al . in 2004, 28 (11%) out of 248 cases showed CD20 positivity with the distinct membranestaining; however, occasional golgi zone staining was also observed, which was not seen in our study. [7]  In this study, only 7 cases (7.7%) showed CD79a co-expression, which was largely focal and membranous. Our findingswere in agreement with the finding observed by Tzankov et al . [8] Tzankov observed that out of 330 cases CD20 wasexpressed in 25% of cases and CD79a was observed in 7% of cases, respectively. CD20 and 79a were co-expressed in16 cases ( P <0.005).  George et al . [9] observed that CD20 was expressed by Hodgkin and Reed-Sternberg cells in 22% of patients. In anotherstudy, Tzankov et al . [10] observed that Hodgkin's and Reed-Sternberg cells expressed CD20 antigen positivity in 20%(24 of 119) of the cases. In these studies, the percent of CD20 positivity was in agreement with our study.   More recently, interest in using anti-CD20 in cHL expressing CD20 has been revived; however, its utility in bigger trialsis yet to be seen. Monoclonal antibody IDEC-C2B8 (Rituximab) has been shown to be highly effective in the treatmentof NHL. [11] More intensive doxorubicin containing regimens have been given along with Rituximab (anti-CD20antibody) to patients showing CD20 positivity in RS cells. [12]  In another study, a 375 mg/m 2 dose of Rituximab was given once a week for 4 weeks to a patient who had relapsedafter six cycles of doxorubicin-bleomycin-vinblastin-dacarbazine (ABVD) and cyclophosphamid-vincristine-procarbazine-prednison (COPP) regimens. Treatment was well tolerated and a complete remission was achieved 2months later. [13]   Kirchner et al . [14] have used Rituximab in a case of transformation of HL to high-grade NHL. Fourteen months later,the patient was still in complete remission including the absence of B symptoms. [14] However, the results of prospectivestudies in this setting are yet to be reported.      Conclusion    CD20 expression is frequent in cHL and our results are in consensus with reported literature on this subject. In thesecases, LCA negativity of large cells is very useful in clinching the right diagnosis. The potential of giving anti-CD20 incHL with CD20 co-expression for therapeutic purposes is exciting but requires further verification in robust studies.      References   1. Hodgkin T. On some morbid appearances of the absorbent glands and spleen. Med Chir Soc Tr 1832;17:68.      2. Pileri SA, Ascani S, Leoncini L, Sabattini E, Zinzani PL, Piccaluga PP, et al . Hodgkin's lymphoma: Thepathologist's viewpoint. J Clin Pathol 2002;55:162-76.     [PUBMED]  [FULLTEXT]3/14/2018 CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targeting opportunity Barakzai MA, Pervez S - Indian J Pathol …http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=1;spage=6;epage=9;aulast=Barakzai 4/5Check 23. Hummel M, Ziemann K, Lammett H, Pileri S, Sabattini E, Stein H. Hodgkin's disease with monoclonal andpolyclonal populations of Reed-Sternberg cells. N Engl J Med 1995;333:901-6.      4. Kanzler H, Kuppers R, Hansmann ML, Rajewsky K. Hodgkin and Reed-sternberg cells in Hodgkin's diseaserepresent the outgrowth of a dominant tumor clone drive from (Crippled) germinal center B-Cells. J Exp Med1996;184:1495-505.      5. Marafioti T, Hummel M, Foss HD, Laumen H, Korbjuhn P, Anagnostopoulos I, et al . Hodgkin and Reed-Sternberg cells represent expansion of a single clone originating from a germinal center B-cell with functionalimmunoglobin gene rearrangements but defective immunoglobulin transcription. Blood 2000;95:1443-50.     [PUBMED]  [FULLTEXT]6. Von Wasielewski R, Mengel M, Fischer R, Hansmann ML, Hubner K, Franklin J, et al . Classical Hodgkin'sdisease: Clinical impact of the immunophenotype. Am J Pathol 1997;151:1123-30.      7. Portlock CS, Donnelly GB, Qin J, Straus D, Yahalom J, Zelenetz A, et al . Adverse prognostic significance ofCD20 positive Reed-Sternberg cells in classical Hodgkin's disease. Br J Haematol 2004;125:701-8.     [PUBMED]  [FULLTEXT]8. Tzankov A, Zimpfer A, Pehrs AC, Lugli A, Went P, Maurer R, et al . Expression of B-cell markers in classicalHodgkin lymphoma: a tissue microarray analysis of 330 cases. Mod Pathol 2003;16:1141-7.    [PUBMED]  [FULLTEXT]9. Rassidakis GZ, Medeiros LJ, Viviani S, Bonfante V, Nadali GP, Vassilakopoulos TP, et al . CD20 Expression inHodgkin and reed-sternberg cells of classical Hodgkin's Disease: Associations with presenting features andclinical outcome. J Clin Oncol 2002;20:1278-87.    [PUBMED]  [FULLTEXT]10. Tzankov A, Krugmann J, Fend F, Fischhofer M, Greil R, Dirnhofer S. Prognostic significance of CD20 expressionin classical Hodgkin lymphoma: A clinicopathological study of 119 cases. Clin Cancer Res 2003;9:1381-6.    [PUBMED]  [FULLTEXT]11. Chow KU, Sommerlad WD, Boehrer S, Schneider B, Seipelt G, Rummel MJ, et al . Anti-CD20 antibody (IDEC-C2B8, rituximab) enhances efficacy of cytotoxic drugs on neoplastic lymphocytes in vitro: role of cytokines,complement and caspases. Haematologica 2002;87:33-43.    [PUBMED]  [FULLTEXT]12. Piro LD, White CA, Grillo-López AJ, Janakiraman N, Saven A, Beck TM, et al . Extended Rituximab (anti-CD20monoclonal antibody) therapy for relapsed or refractory low-grade or follicular non-Hodgkin's lymphoma. AnnOncol 1999;10:619-21.       13. Al-Ali HK, Wittekind C, Niederwieser D. Complete remission of relapsed mixed cellularity Hodgkin's diseasetreated with rituximab. Dtsch Med Wochenschr 2007;132:1688-91.    [PUBMED]  [FULLTEXT]14. Kirchner EM, Ebsen M, Kirchner J, Theegarten D, Voigtmann R. Transformation of Hodgkin's disease to high-grade B-cell lymphoma: Remission after Rituximab monotherapy. Ann Oncol 2001;12:1169-71.    [PUBMED]  [FULLTEXT] Correspondence Address: Muhammad Abrar Barakzai Department of Pathology and Microbiology, Section of Histopathology, Aga Khan University, Hospital, Stadium Road,P.O. Box 3500, Karachi 74800  Pakistan Source of Support: None, Conflict of Interest: None DOI: 10.4103/0377-4929.44952       Figures   [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]        Tables   [Table 1] This article has been cited by1 Mediastinal lymphomas: Primary Mediastinal (Thymic) Large B-cell Lymphoma versus classicalHodgkin lymphoma, histopathologic dilemma solved?Shahid Pervez,Ranish Deedar Ali KhawajaPathology - Research and Practice. 2010; 206(6): 365[Pubmed] | [DOI]2 Mediastinal lymphomas: Primary Mediastinal (Thymic) Large B-cell Lymphoma versus classical3/14/2018 CD20 positivity in classical Hodgkin's lymphoma: Diagnostic challenge or targeting opportunity Barakzai MA, Pervez S - Indian J Pathol …http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=1;spage=6;epage=9;aulast=Barakzai 5/5Hodgkin lymphoma, histopathologic dilemma solved?Pervez, S., Deedar Ali Khawaja, R.Pathology Research and Practice. 2010; 206(6): 365-367[Pubmed]       Sitemap | Advertise | What's New | Feedback | Disclaimer© 2008 Indian Journal of Pathology and Microbiology | Published by Wolters Kluwer - MedknowOnline since 5th April, 2008Editorial and Ethics Policies    ISSN: Print -0377-4929, Online - 0974-5130  

CD20 positivity in classical hodgkin\u27s lymphoma: diagnostic challenge or targeting opportunity.

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CD20 positivity in classical hodgkin\u27s lymphoma: diagnostic challenge or targeting opportunity.

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