Small, Blue, and Somewhat Painful Thoughts on approaching and making - - PowerPoint PPT Presentation

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Small, Blue, and Somewhat Painful Thoughts on approaching and making - - PowerPoint PPT Presentation

Jun 02, 2023 6 likes •683 views

Small, Blue, and Somewhat Painful Thoughts on approaching and making sense of lymphoid infiltrates in the GI tract Scott R. Owens, MD Whats the problem? Unique issues in GI Gross endoscopic description Small pieces of

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Small, Blue, and Somewhat Painful

Thoughts on approaching and making sense of lymphoid infiltrates in the GI tract

Scott R. Owens, MD

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What’s the problem?

Unique issues in GI

  • “Gross” ≈ endoscopic description
  • Small pieces of tissue
  • Inflammatory conditions can result in

lymphoproliferative disorders… and confound diagnosis

– “Acquired MALT”

  • Normal lymphoid tissue can give rise to

lymphoproliferative disorders…and confound diagnosis!

– “Native MALT”

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Distribution of GI Lymphoma

55-65% 20-35% 7-20% Rare!

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About that MALT…

Peyer’s patch (native)

  • H. pylori gastritis (acquired)
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What’s my approach?

  • When wondering about a lymphoid infiltrate,

I’ve found it’s best to play “DUMB” –Destructive? –Unusual location and/or morphology? –Monotonous? –Big?

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What does normal look like?

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Any of these look DUMB to you?

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How about this?

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DUMB?

  • Destructive?
  • Unusual location and/or morphology?
  • Monotonous?
  • Big?
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CD20

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BCL-2

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MALT lymphoma

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Here’s another

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DUMB?

  • Destructive?
  • Unusual location and/or morphology?
  • Monotonous?
  • Big?
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CD20

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CD5

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Cyclin-D1

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Mantle cell lymphoma

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Next!

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DUMB?

  • Destructive?
  • Unusual location and/or morphology?
  • Monotonous?
  • Big?
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CD20

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Diffuse large B cell lymphoma

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Tired yet?

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DUMB?

  • Destructive?
  • Unusual location and/or morphology?
  • Monotonous?
  • Big?
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CD20

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CD3

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BCL-6

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CD21

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BCL-2

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Ki-67

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(Large) benign germinal center

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Be careful with BCL-2

BCL-2

http://opm.phar.umich.edu/images/proteins/1g5m.gif

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What expresses BCL-2?

  • T-cells
  • Plasma cells
  • Normal mantle cells
  • Primary follicles
  • Lots of different lymphomas

– Including (but not limited to) follicular lymphoma

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What should be BCL-2 negative?

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My Approach

  • Use BCL-2 for cases where differential is

reactive follicles vs. follicular lymphoma

– Otherwise, must match up staining with T-cells, mantle cells, etc., etc.

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Enough, already!

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DUMB?

  • Destructive?
  • Unusual location and/or morphology?
  • Monotonous?
  • Big?
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CD20

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Kappa

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MALT lymphoma

(patient also had it in stomach)

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Staining rationale

  • Small cells: CD3, CD5, CD20, (often) CD43

– Follicular structures?BCL-6/CD10, BCL-2 – CD5+, angulated cells, polyps?cyclin-D1 – Possible plasma cell component?kappa/lambda – T cells?(many) more T cell markers

  • Big cells: CD3, CD20, CD43

– DLBCL?germinal center vs. activated B cell

  • Potentially molecular assays for “double hit” lymphoma
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DUMB!

  • Destructive?
  • Unusual location and/or morphology?
  • Monotonous?
  • Big?
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Thank you!