What Makes the Lymphoid Proliferation Associated with Infectious Agents Unique?

January 14, 2022

Information

January 13, 2022

Yale Pathology Grand Rounds

Kikkeri N. Naresh, MD

ID7353

To CiteDCA Citation Guide

00:00It's my great pleasure to introduce
00:02Doctor Naresh, Carrie to Yale Yale grants.
00:06Naresh completed his Bachelor of
00:08Medicine and Bachelor of Surgery
00:11at Government Government Medical
00:12College where he also received.
00:15Also received my in clinical pathology
00:17he he then did his training in pathology
00:21theology at the prestigious Jipmer Institute.
00:24Nourish began his his anger at Tata
00:27Memorial Hospital where he quickly
00:29rose and banged to become.
00:31Full professor in in pathology,
00:33he moved in 2004 to London,
00:35where he was a professor and a
00:37professor in the cellular and
00:39molecular pathology Imperial Condon.
00:43In 2020 actually move the middle
00:47to pandemic pandemic.
00:48He professor and section head of
00:50pathology in the Clinical Research
00:52Division Vision Hutchinson Cancer Center
00:54with appointment at the University
00:56of Washington Department of Labor.
01:01Now Russia has authored over 250
01:03original manuscripts and use scripts
01:05with on the biology of lymphoma.
01:07Developing new items to improve lymphoma,
01:09lymphoma and the study of the
01:12lymphoma lymphoma microenvironment.
01:14His other research in research
01:15interest in a focus in lymphoma
01:17causing infectious agents which is
01:19the topic of his talk to talk today.
01:21In addition to his extensive scholarship,
01:24nourish has taken on leadership roles
01:25in several roles in several large
01:27internationals including our next edition
01:29of The Who in Hematopathology mythology.
01:32Atlas of Blood Cancer
01:34Genomics which has met him.
01:36Please join please join me in a rush to yell.
01:38Thank you,
01:40thank you Mina.
01:41It's been a pleasure and thanks for
01:43inviting me and it gives me great
01:46pleasure to give this presentation.
01:47Obviously I would have loved to
01:50be there in person but under the
01:52current prevailing circumstances I
01:54think this is the best we can do.
01:57And I chose this topic of lymphoid
02:01proliferations in infectious agents.
02:03Because over a period of time though,
02:05my lymphoma research across many different
02:08types of lymphomas has gone ahead.
02:10This is something which I started with.
02:12My research started with a particular
02:14aspect of Epstein Barr virus in
02:17Hodgkin lymphoma and later on I've
02:19had opportunity to work on post
02:21transplant lymphoproliferative and
02:24then the HIV associated lymphomas
02:26and my interest in infectious agents
02:29and informers has been kept alive
02:31through these research opportunities.
02:34So.
02:41So this was the first work of mine,
02:44which really caught a lot of
02:46attention but also gave me a
02:48very good platform to continue my
02:50research in the field of lymphomas.
02:52And this was when we were looking
02:56at Hodgkin lymphoma and that was
02:57the early time when Eber in situ
02:59hybridization had come into place and
03:01then we were looking at proliferation.
03:02At that time we didn't use Key 67,
03:04we were using something called
03:06proliferation cell nuclear antigen
03:08and thing that struck me was.
03:10That Hodgkin's which worry baby
03:14positive those had a higher P CNA
03:17expression in the Reed Sternberg cells.
03:20And if you can see that those cases
03:23those which were PC and a low had
03:25nearly 50% cases for EBV negative
03:28but those which were PC and a high
03:31most of them worry be positive.
03:33So then we let on to the hypothesis
03:36thinking that expression of PC keeps
03:39maintains the Reed Sternberg cells.
03:41In cell cycle,
03:42although it goes through a cell cycle
03:44called endocytosis or endo reduplication,
03:47but that makes the cells more
03:50susceptible to chemotherapy.
03:51And then we looked at the outcomes
03:53in these patients and patients.
03:55With EBV,
03:56positive Hodgkin lymphoma did
03:58exclude mean much better than
04:01those which worry be negative.
04:03Again.
04:04If you look at subsequent to our publication,
04:07there have been many other studies
04:09which have come from different
04:10parts of the world and different
04:12people have had different reasons.
04:14Some people have in many parts the Western.
04:17You know Western Europe and in the US
04:19people have shown that EBV positive disease.
04:21How about Porter survival?
04:22But in the setting of the developing
04:24country with these patients are all
04:26from India eBay be positive disease
04:28had a superior survival to EBV,
04:30negative disease and also.
04:32And this was independent of patients
04:35age and stage of Hodgkin lymphoma.
04:38We also showed at the same time
04:40that almost 98% I think only there
04:44was only one case out of the 50
04:46cases of pediatric Hodgkin lymphoma
04:48which was even with negative the
04:49rest of the 49 or 50 cases.
04:51Bloody may be positive,
04:53so you may be positive ITI was is
04:55very high in the pediatric setting,
04:57especially in a developing
05:00country like India.
05:01So this was the first one which really
05:04led on to this part of my research and
05:07then I will take you through other areas,
05:10partly from translational research and and
05:13most and quite a lot of clinical aspects.
05:16So if you look at infectious
05:18agents in lymphoid proliferations,
05:20we have a list of viruses.
05:21EBV was the first to be recognized then.
05:23Of course we have the Kaposi sarcoma virus,
05:26or the human herpes type age.
05:28Then hepatitis C and hepatitis
05:30B virus human T cell leukemia.
05:33Wireless one HTLV one and human
05:36immunodeficiency virus or HIV,
05:37but we can't forget the bacteria
05:40which can associated with them for
05:42proliferations like the Helicobacter
05:44campylobacter gorilla and chlamydia.
05:46I'm not going to be discussing these.
05:48I'll primarily restrict my
05:50discussion to ebb and HP,
05:52and partly I will touch on STL.
05:56So if you look at infectious
05:57agents in these disorders,
05:59we have a set of diseases where
06:01the infectious agent is present
06:03within the neoplastic cells.
06:05Classic examples that are EBV
06:07HHV 8 and HTLV one and there are
06:11others where infectious agents are
06:13present outside of the neoplastic
06:15cells like HIV like Helicobacter
06:17hepatitis virus C so on and so
06:20forth where the the tumor cell
06:23itself is not infected by the virus.
06:26And if you look at again,
06:28this is a mix of different types
06:30of lymphoid proliferations.
06:32You have some acute and
06:33non malignant conditions,
06:34like the infectious mononucleosis
06:36we have heard about this and
06:38learned about this for many years.
06:40I'm not going to develop much time on
06:42this and then we have other chronic
06:44and non malignant or polyclonal
06:46diseases like chronic active infection,
06:48multicentric Castleman disease in the
06:50HIV studying and with HV-8 HTLV 1 carriers,
06:54States and associated gastritis.
06:56These are all polyclonal,
06:58non malignant proliferations.
07:00Again,
07:00the question about malignancy and being
07:04non malignant it it gets into a grey
07:07area with with chronic active infection.
07:10We will discuss that and then we
07:12have what we currently call as
07:15polymorphic lymphoproliferative
07:16disorders and these these came to
07:19light and was best exemplified in the
07:21post transplant setting but now more
07:24and more we recognize this across other.
07:26Immune deficiency areas.
07:28Then we also have lymphomas allow quite a
07:32few are full blown lymphomas which many
07:35of these lymphomas look like what one
07:37would see in an immune competent setting.
07:40So if you put them as those
07:43where the informatics agent is.
07:47Is always associated with the
07:49disease is likely be positive.
07:51Diffuse large B cell lymphoma
07:54lymphomatoid granulomatosis fibron
07:55associated DLBCL primary effusion.
07:58Lymphoma so on and so forth.
08:00All these diseases are always
08:03associated with the infectious agent.
08:06Then we have a set of diseases where.
08:09Some of them are proportion of them
08:11are associated with infectious agent,
08:13and the rest are not,
08:14and you have the marginal zone
08:16lymphoma diffuse large B cell lymphoma,
08:18plasmablastic lymphoma, Burkitt lymphoma,
08:20plastic Hodgkin lymphoma,
08:22so on and so forth.
08:23There only a proportion of cases are
08:25in positive for the infectious agent
08:27then you have some cases where very
08:30rarely an association has been found
08:32like you as a follicular lymphoma.
08:34Rare follicular lymphoma sorry
08:36be associated in SL where you
08:38can have a hot skin like.
08:41Richter transformation,
08:42which can be be positive.
08:44Then you also have very rarely.
08:45You can have another dominant optical
08:48lymphoma which is EBV associated.
08:51So I'm going to discuss these
08:53entities and these situations
08:56from different perspectives,
08:57partly and videology and pathogenesis.
09:00Then a few of the aspects of
09:02genomics and and immune aspects.
09:04Then we will spend a bit of time
09:06about apology and immunophenotype
09:08diagnosis or the criteria for
09:10diagnosis how these impact on
09:12classification and how these impact
09:14on outcomes and follow up.
09:17So first,
09:18if we take Epstein Barr virus and Burkitt
09:21lymphoma. This was Burkitt when he,
09:24in his initial descriptions and subsequent
09:26to that we appreciated the Burkitt lymphoma,
09:29the endemic form of Burkitt lymphoma
09:31is seen in a specific Equatorial band
09:35across the world which includes parts of
09:38South America and parts of Equatorial
09:41Africa and most of these are difficult.
09:44Look at the incidents even within Africa.
09:47You will see like places like Nigeria
09:50and Uganda which are within the band.
09:52Just be across the equator between the Tropic
09:56of Cancer and the Tropic of Capricorn.
09:58Those have a very high incidence,
10:00whereas outside of those areas,
10:02like if you look at Namibia,
10:04if you look at Zimbabwe you have a lower
10:07incidence and again this is data from 1988.
10:10If you look at the current data it is
10:14slightly diluted and partly diluted
10:16and partly changed because of the HIV.
10:18Epidemic now in South Africa and Bob
10:21with the incidence might have gone
10:23higher because of the HIV association,
10:25but before the HIV epidemic one could
10:29see that Uganda and Nigeria had a much
10:33higher incidence compared to the rest
10:35of African countries and rest of the
10:37world and in endemic Burkitt lymphoma.
10:41Almost all cases are EBV positive,
10:43whereas outside the endemic areas
10:45only about 25 to 30% REB positive.
10:48So if you look at it association
10:51within Berkman Firma,
10:52it's gotta a differential geographic
10:55distribution like an African,
10:57nearly hundred.
10:57When I say Africa here in Equatorial Africa,
11:00nearly 100% of them are EBV positive,
11:02but as when you come outside of Africa,
11:04it varies from 25% to some areas,
11:07like in South America,
11:08where it can be nearly 50% in like
11:11in Mexico is around 50%,
11:12but in the he could in the belt
11:14that I showed you it can be higher
11:17than 50% and the same thing is true
11:18if you look at Hodgkin lymphoma.
11:20And not all Hodgkin's are associated
11:22with EBV, and if in Africa,
11:24again in the same regions,
11:26you will see most of them on
11:27eBay be positive,
11:28but outside of Africa and some parts
11:31of South America you have variable
11:34incidence of EB within the Hodgkin
11:37lymphoma in the classic Hodgkin lymphoma.
11:40So what all these things do tell us is easy.
11:43Be really relevant for neoplastic,
11:46for lymphoma Genesis.
11:48In any of these slim firms,
11:50so that has always been questioned,
11:51because not every single case of
11:54an EBV associated lymphoma is
11:57associated with Debbie.
11:59And again this has got an impact
12:01on the distribution of patients.
12:03Like if you look at EBV positive diseases
12:06from from England and here you can see.
12:09But even the positive disease,
12:11you get a very early peak in the in the very
12:14early on in the in the 1st and 2nd decades.
12:17You can have EBV positive disease.
12:19Then you have a a second peak around
12:2140 or 50 years and then a third
12:24peak in the 6th and 7th decade.
12:26Whereas when you look at EB
12:28negative diseases,
12:29you have a single pick somewhere
12:31in the early adulthood
12:33between the 20s and 30s and then the
12:36incidence decreases and if you put them.
12:40Across the world, if you see you have
12:42so you got even the positive disease
12:44comes with three peaks and even with
12:46negative disease is a single peak.
12:48So many people have actually questioned.
12:50Purely based on epidemiology.
12:52Whether you have EBV positive,
12:54Hodgkin lymphoma ribbon,
12:56negative Hodgkin lymphoma similarly
12:59positive Burkitt lymphoma,
13:00EBV negative Burkitt lymphoma would be
13:03the right way to classify these diseases.
13:06And again, now this kind of
13:08classification is getting some
13:10more traction because of genomics.
13:13And the same thing is true if you
13:15look at the HTLV 1 HTLV 1 positive
13:18aitl is again seen in specific
13:20areas across the world,
13:21but in today's migration and and with
13:25the immigration that happens one should
13:27not be surprised if one sees an HTLV
13:31positive ATL outside these endemic
13:33areas like where I used to work in the UK.
13:37It was we used to
13:38frequently see cases of ATL.
13:40Most of the patients were
13:42of Caribbean origin.
13:43And somewhere off of African origin,
13:45but most were of Caribbean knowledge.
13:47So similarly in the US there is.
13:51There are many cases of ATL
13:54which go underdiagnosed because
13:56it shall be one is not tested.
13:59If you look at when we come to pathogenesis
14:02of how does EBV contribute to the
14:04classic example is Burkitt lymphoma.
14:07Often we think that EBV doesn't
14:09act on its own, along with EBV.
14:11You have cofactors like malaria and
14:13HIV which results in enhanced B
14:16cell activation and proliferation,
14:18and when these activities going
14:20on in the general center,
14:21you have these translate translocation
14:24of immuno globulin and C.
14:26MYC occurs.
14:27Usually most of these cells are expected.
14:30Don't die,
14:30but some of these cells because of
14:34Debbie Gene products can can survive
14:36and these gene products will suppress
14:39the appetite ossis program and these
14:41cells go on to become Burkitt lymphoma.
14:44Of course,
14:44this is a very simplistic view,
14:46but if you again look at the within,
14:49if you look at the the breakpoints in
14:51the C MYC and in the immuno global
14:54engine you do see differences between
14:56African Burkitt lymphoma and the non
14:58endemic sporadic Burkitt lymphoma.
15:00In the African Burkitt lymphoma,
15:03the endemic Burkitt lymphoma
15:05within the immunoglobulin gene the
15:08the break is in the J region,
15:10whereas in the non endemic Burkitt
15:12lymphoma most of them have a break.
15:13In this which region.
15:15So when you put this on to
15:17the what could happen,
15:18where does the J region more
15:21susceptible for a translocation
15:22it would appear that most of
15:25the African Burkitt lymphoma,
15:26the translocation is likely to
15:28happen in the bone marrow,
15:29whereas in most of the non endemic Burkitt.
15:31Comma,
15:32it should be happening in the
15:34germinal center when the class
15:35switch recombination occurs.
15:37So there are these kind of differences
15:39even at A at a genetic level.
15:42This was a recognized way back in
15:44the early late 90s and early 2000s.
15:49So with all these things in mind,
15:50so does how does EBV really contribute
15:53to the pathogenesis of lymphomas?
15:55So I'm going to present to you
15:57three pieces of information of
15:59evidence which would support that.
16:02EB is crucial for lymphoma Genesis.
16:06We and others have shown that
16:08the association reduces the need
16:10for additional somatic mutations
16:11in the host genome for lymphoma,
16:14GENESIS 2 AKA,
16:15and we have also shown that that
16:17altered the genome is far more potent,
16:20and Informa Genesis than EB0
16:24which is not altered.
16:25Then we have also shown that type
16:28EB is far more oncogenic than
16:31type BEPB and I will take you
16:33through these pieces of evidence.
16:34So currently what we?
16:35I believe is that when EBV
16:37infection occurs on a beat cell,
16:40most of these cells are under the
16:42control of teasel both CD four
16:44and CD 8 positive T cells and it
16:46goes into a steady state where
16:48you have a latent infection,
16:50very low level infection of memory
16:52B cells are persistent infection,
16:55but some change within the IBD
16:57is likely to happen,
16:59and this is important for making the cell
17:02not susceptible to the T cell control.
17:05And giving rise to EBV positive lymphoma.
17:12So this is 1.
17:13This is a work which we did on
17:16posttransplant lymphoproliferative disorders,
17:18primarily.
17:18Here you can see these are EBP negative.
17:21This is a mutational landscape
17:23of EBV negative, diffuse,
17:24large B cell lymphoma and here is
17:26the mutational landscape of EBV.
17:28Positive, diffuse,
17:29large B cell lymphoma and you can
17:31easily recognize that the number
17:33of mutations seen in EBV positive
17:36DLBCL is far fewer than EB negative.
17:38If you flash piece or lymphoma,
17:40thereby suggesting that if we can.
17:43Substitute the role of many driver gene
17:46mutations in the development of lymphoma.
17:50The same thing is true what we see
17:53what we saw in post transplant
17:54studying is also true outside
17:56of the post transplant study.
17:57When you look at me positive,
17:59diffuse large B cell lymphoma,
18:00there's a lower mutational
18:01burden as compared to EBV.
18:03Negative issues,
18:04large piece of lymphoma and again EBV.
18:06Positivity is almost mutually exclusive
18:09with mediate mutations or CD 79 eight
18:11mutations and often it involves the
18:14alterations in Africa be wind and
18:16L6 taxed at both way and there are
18:19some specific mutations that occur.
18:21Positive ITI fueled large pizza
18:23lymphoma which makes it quite unique.
18:26When you look at EBV positive
18:30Burkitt lymphoma similar.
18:32A similar trend occurs.
18:33The driver gene mutations
18:34may be positive bucketing for
18:36mice far fewer than he may be.
18:38Negative Burkitt lymphoma.
18:40Of course,
18:41other mutations within the which
18:43are non driver mutations occurring
18:45as a result of activation induced
18:47cited in that is far more frequent
18:50in positive Burkitt lymphoma,
18:52again bringing to question that
18:53this may be because EBV gives a
18:56proliferative advantage within
18:57the germinal center and are those
19:00cells to survive,
19:01but the driver gene mutations are far fewer.
19:03Any positive bucket info?
19:06Another piece of evidence which we looked
19:09at was to look at the EBD subtypes in
19:12post transplant EBV positive PTLD Sandy.
19:15Be positive HIV influence
19:17within the PTLD setting.
19:20Most of the positive Pete Liz harbored
19:24Taipei EBV virus whereas in HIV, HIV.
19:29Already infamous,
19:30there was an even distribution
19:33between Taipei and Taipei,
19:35but more importantly what we saw was
19:37those cases which are associated with
19:40type B had a very long period of HIV
19:43positive ITI before they developed lymphoma,
19:45so we tend to we from this we
19:49hypothesize that Taipei is far
19:51more on Pjanic than type P.
19:53Then we let down to look at mutations
19:57within the IBD and we identified.
20:00And we showed that in a in
20:02a mouse model having EBV.
20:063B Knockout would make the
20:10mouse susceptible for lymphoma.
20:13For the development of a lymphoma,
20:14here are mice.
20:15The three types of my swan which
20:17are infected with the wild type web
20:20and then when it was infected with
20:22Aetna Trib Knockout virus and then
20:25in another step we reintroduced Abner
20:273B from into the stock out and you
20:30can see that 50% of the mice were
20:33infected with ethnicity knockout
20:35developed lymphomas whereas those which were.
20:38Infected with the wild type virus or
20:40the revertant virus did not develop
20:42any lymphomas in spleen and then
20:44we also went on to look at human
20:47lymphomas to look at Abernathy B
20:49mutations and a large variety of
20:51AB positive human infamous showed
20:53mutations in their blood 3B.
20:56And here are the.
20:58Photomicrographs that we saw in
20:59in this in the spleens of these
21:02mice and here is the the white,
21:04those which are infected wild
21:06type virus and those which are
21:08infected with the revertant viruses.
21:11And here is the one with the knockout
21:13in the knockout mouse we found that
21:15there is a proliferation of what would
21:17be very similar to an EB positive
21:19monomorphic diffuse large B cell lymphoma.
21:22And which were richly be positive,
21:24large B cells and very low in T cells.
21:28Then we did some experiments to see
21:30why are they so few T cells in the
21:33knockout mice and we could show that
21:36they they had very little chemokine.
21:38CXCL 10 and CXCL 10, which was
21:41required for attracting the T cells,
21:44was absent in the knockout mice.
21:46And if we supplemented with
21:49lten this could be reverted so.
21:52Not only was EBV responsible,
21:54but the microenvironment which it
21:55induced or which we which it suppressed
21:58while responsible for the development
22:00of diffuse large B cell lymphoma's.
22:02Then we went on to look at differences in
22:06microenvironment in HIV positive classic.
22:09Of course here it is difficult
22:11because almost all HIV positive,
22:13classic Hodgkin lymphoma or EBV positive,
22:16so we had a set of HIV positive EBV
22:19positive classic article Informa.
22:21We tried to compare that.
22:23With HIV negative EBV negative
22:25classic Hodgkin lymphoma,
22:27not only did we find differences in the
22:30numbers of the microenvironment cells,
22:33but there was a difference
22:34in the in the type of cells.
22:36We found a unique population of CD
22:388 foxp 3 positive cells in the HIV
22:41positive setting which we did not see
22:43in the HIV negative set and similarly
22:45we found that there were more CD 57.
22:49There were fewer CD 57 positive cells.
22:51There was fewer plasmacytoid dendritic cells.
22:54Facility 123 positive cells
22:56in the HIV positive setting,
22:58so the microenvironment of EBV
23:01positive disease is different.
23:03We also then went on to look in the
23:05post transplant setting comparing
23:07post transplant diffuse large B
23:09cell lymphoma with the immune
23:11competent diffuse large B cell
23:12lymphoma and there were more T cells,
23:15particularly CD 8 positive T cells
23:17in the post transplant EBV positive
23:19diffuse large B cell lymphoma
23:21this and if you look at these we
23:23wanted to make sure that these were
23:25not easy be infected T cells and
23:27these T cells look larger.
23:29They look more stimulated
23:30but and they are clearly EBV
23:32negative and when we looked at.
23:35Whether there was clonal expansion
23:37of these reactive T cell populations,
23:39we could demonstrate that in a
23:41good proportion of post transplant
23:43liver proliferative disorders,
23:45there was a monoclonal expansion of T cells,
23:48which possibly those which were
23:50reactive to the to the EBV present
23:53in the monoclonal B cell population.
23:57Similar stories are similar kind
24:00of of pathogenic involvement of
24:03hedge viatour or Kaposi sarcoma
24:07herpesvirus also been identified.
24:09Much of this work has come from other
24:13investigators for the major investigator
24:15in this area is Ethel Merman.
24:17Tough.
24:18Along with Amy Chapman,
24:20who have shown that the key uncle
24:23proteins of the HP 8 drives the
24:25lymphoma Genesis which includes the
24:27Lana Lana protein than the recycling
24:30and we flip and various other key
24:33uncle proteins are responsible
24:34for this kind of lymphoma genesis,
24:36which happens in the study.
24:40But when we look at the lymphoid
24:42lesions within the which are
24:43associated with infectious agents,
24:45we see a variety and and a whole
24:48range of aggressiveness and disease.
24:51Biology.
24:52At one end of the spectrum you
24:54have self limiting diseases like
24:57infectious mono nucleosis are very
24:59benign conditions like the EBV
25:02positive cutaneous ulcer of the
25:04positive German or Tropic LPD.
25:07Then you have something which
25:09falls in the Gray zone.
25:10Like the immediate positive polymorphous
25:13lymphoproliferative disorder,
25:14the Castleman disease inflammatory
25:16granulomatosis fibron associated
25:18diffuse large B cell lymphoma,
25:20chronic active EBV infection.
25:22Then you have the classic lymphomas
25:24without associated with infectious agents,
25:27and then you have some very aggressive
25:28disease like the Burkitt lymphoma,
25:30plasmablastic lymphoma,
25:30so on and so forth.
25:33I also what is important with these diseases.
25:35There is a risk of overdiagnosis,
25:37we know for a long time that
25:39infectious mononucleosis can
25:40be misdiagnosed as a lymphoma.
25:41And so also is true about the
25:44positive cricket aneus ulcer or
25:47associate Germany Tropic disease.
25:49So understanding these diseases is
25:51important from the point of view
25:54of recognizing them properly and
25:56not overdosing them as them first.
25:58I, I think most of you know very
26:01well about infectious mononucleosis,
26:03and I will skip this slide.
26:07Even the positive continuous also is is
26:09a is an important entity to recognize,
26:12because this have a very indolent behavior.
26:14These are circumscribed,
26:16painful but shadow.
26:17Shallow ulcer ative lesions which
26:19frequently occur in the orphan genetic
26:22causes skin or gastrointestinal tract most.
26:24It's not only mean it can be
26:26associated with the variety of immune
26:29suppressive conditions like medication
26:31associated like with methotrexate.
26:33Sometimes it can be just age related,
26:35immune senescence.
26:35It can occur in the background of.
26:37Community post transplantation.
26:38Also, it can occur with various malignancies.
26:42You can see a patient with lymphoma
26:44developing, ambiguities also,
26:45and many of these regress spontaneously,
26:48and some of them respond to withdrawal of
26:52immune suppression or immune reconstitution.
26:54And classically,
26:55this has a polymorphous infiltrate,
26:58and it got a typical large B cells,
27:00and some of them can resemble
27:02Hodgkin Reed Sternberg cells.
27:04It shows strong CD 30 Andy Barr expression.
27:07Many of the things in the past
27:08which might have been called as
27:10extranodal are because of *******.
27:11Informa need to be revisited
27:13whether there's many of them could
27:16be EBV positive Catania's ulcers.
27:18They can also explicitly 15,
27:21and they often express opto,
27:23but most of them lack Bob.
27:24One city Trinity expression
27:26is usually reduced,
27:28and typically there's a band of CD 3
27:30positive T cells and the periphery,
27:32and if one does clonality,
27:33there can be plotted both
27:36immunoglobulin or diesel gene
27:38rearrangements and nearly one half
27:40of them progress spontaneously.
27:42These are some of the pictures from
27:44the publication by Stephen Dodge
27:46Channel and you can see here is a
27:49shallow ulcer and the periphery
27:51you have a diesel infiltrate but
27:53towards the ulcer you see large.
27:55EBV positive B cells,
27:56which can show an article clone,
27:59another monoclonal expansion of TRB cells.
28:02And here's another case which shows
28:04not only CD 30 positivity but
28:06also profound city 15 expression.
28:12This is an entity which we for a
28:15long time we appreciated polymorphic
28:17type of post, transplant liver,
28:19proliferative disorders,
28:19but now more and more.
28:21We are seeing this in outside
28:24of the post transplant setting.
28:26We can see that in in the setting
28:29of autoimmune diseases or therapy
28:31related immune deficiency,
28:33but rarely we can also see it
28:34in the setting of a child here
28:36architecture of the node of the
28:38extra node log lesion is a faced.
28:41There's a heterogeneous of polymorphous.
28:43Infiltrate of immune cells,
28:45which includes B cells which has got a
28:48full spectrum of B cell differentiation.
28:50You will see large immuno blasts.
28:52You will see plasma cells so the whole
28:55range of visual differentiation is seen
28:57within this polymorphous infiltrate.
28:59And many of these large beetles can have
29:01features of Hodgkin Reed Sternberg cells.
29:03And these are EBV positive.
29:05Most often some people debate whether there
29:08could be any be negative polymorphous LPD,
29:10but defining that can be difficult.
29:13And distinguishing them from other
29:17reactive conditions can be difficult
29:19even with positive disease is
29:21more easily identified,
29:22and they can.
29:23Also, it can have monoclonal article,
29:26clonal proliferation of B cells and
29:29both nodal and external deliberations
29:32are presentations are known and
29:34some of them may also present with.
29:37For history cytosis.
29:39I'll take you through a few examples and
29:42I think it brings out the issues well.
29:45Here is a woman in 60s who had been
29:48treated with pancreatic cancer two
29:50years prior to this presentation
29:52and patient presented with fever and
29:54weight loss of three months duration,
29:57and there was a large periodic
29:59mass sub in centimeter dimension
30:02and patient also had right axilla
30:05re lymph adenopathy and needle
30:07core biopsy was undertake.
30:09And here you can see on on the left
30:12you can see predominantly small
30:13to medium sized cells and on the
30:15right you see amidst these small
30:17to medium sized cells you see some
30:19cells which look like mononuclear.
30:21Hodgkin cells are lacunar cells.
30:23You also know fields were completely
30:26lacking in this infiltrate and
30:28plasma cells were also not too many.
30:30And you can see these cells are
30:32rich in T cells.
30:33And they are predominantly city
30:358 positive T cells and there were
30:38many evil positive cells.
30:40You have some larger Lieber positive cells.
30:43And many smaller evil positive cells.
30:45And then we did further and you also
30:48had large CD 20 positive cells which
30:50were also both positive and these
30:52cells for CD30 and CD15 and Oct 2000.
30:55So there were some areas,
30:57those things which looked like
30:58Hodgkin's cells had a phenotype not
31:01too different from Hodgkin apart
31:03from strong expression of CD 20.
31:05Oneba as you see here,
31:07many cells are even positive and this
31:10includes both large cells like Hodgkin.
31:12Look like large cells and many
31:14smaller cells and medium sized cells.
31:16And when we did double state you
31:19can see that.
31:20These large cells libre positive CD,
31:22three negative but many of the
31:25small and medium sized
31:26cells were CD three and Eva dual positive.
31:29And here you can see that many of
31:31the smaller and medium sized Eber
31:33positive cells are CD 8 positive.
31:36So here's a situation where you
31:38have both CD 8 positive either
31:40positive cells and other facts.
31:43Fire CD 20 positive either positive
31:45cells and this is a classic exam
31:48and we try to we also undertook.
31:50Immunoglobulin T cell receptor gene
31:52rearrangement studies and we could
31:54not identify any particular clone,
31:56and the patients EBV levels waxed and vein.
31:59Then it fell off on its own,
32:00so this is a classic case of a
32:02polymorphism for polar disorder,
32:04with some features overlapping with a
32:06chronic EBV infection of the T cell type.
32:09And then there are some features
32:11which raises the possibility of
32:13an evolving fortune like process.
32:15However,
32:15this patient was not treated
32:17for any Hodgkin lymphoma,
32:19but eventually within two months time
32:21patient developed a treatment related.
32:23I could buy leukemia,
32:25but so this gives you an impression in a
32:28patient with a post Trump a patient who
32:30had been treated for pancreatic cancer,
32:32had a reduced immune.
32:36Capacity and then develop an EBV positive
32:41polymorphous lymphoproliferative disorder.
32:42In contrast to that,
32:44here is another case where the
32:45fact is a is a man in 60s who
32:47presented with pancytopenia with
32:49a clinical diagnosis of HLH.
32:51I had lower hemoglobin at a low white
32:53cell count and a low platelets and
32:56bone marrow investigations were done
32:59which showed a hypercellular marrow
33:02with trilineage hematopoiesis flow on.
33:04The peripheral blood showed that
33:05there was an increase in the cur
33:07gamma delta T cells and the same
33:09thing was also there in bone marrow
33:11and these cells were a bit larger.
33:13Here are the flow plots focus
33:15on the red cells here.
33:16These were larger cells with a
33:19slightly higher side scatter and
33:21these were gamma delta T cells.
33:23Which were CD,
33:24four negative and CD eight was
33:27mostly negative of weak CD 8 and
33:29these were CD 56 positive cells and
33:33CD five was completely negative.
33:35And here's the border from the patient
33:37and you can see there were an atypical,
33:39slightly larger lymphoid infiltrate
33:41which you can see here with CD3.
33:45These are the lymphoid cells and
33:47then this was CD 3 positive and
33:49this here is evil and here you
33:51can see with a double strain.
33:53These were not only CD 8.
33:54Positive,
33:55but these were also CD 56 positive
33:57CD 3 positive and CD 56 positive
34:00either positive cells and this is a
34:03classic example of a chronic active
34:06EBV infection of CD8 Gamma Delta type
34:09and we can see the viral levels of
34:12waxed and waned in this patient and
34:15patient did with conservative measures.
34:18Patient did quite well.
34:21So. We move on to a few other
34:24TB positive lymphomas, like.
34:25Here is I want to discuss about it.
34:27Be positive diffuse large B cell lymphoma.
34:31For the definition of EBV, positive,
34:33diffuse, large B cell lymphoma,
34:34there should be no history of a
34:37previous and informal or of any
34:39inborn or acquired immune deficiency.
34:41But age is not a criteria.
34:44And the the disease should not fulfill
34:47any criteria for other EBV positive news
34:50for proliferative disorders like you
34:52can't have limited granulomatosis or it
34:55should not be a plasmablastic lymphoma.
34:57So when you exclude all those things,
35:00what remains would be easy.
35:02Be positive. That would be be positive,
35:04diffuse large B cell lymphoma.
35:06Most of these patients are over the age
35:07of 50 years, but age is not a criterion.
35:10It can happen even in patients less
35:11than 50 years of age and a peak.
35:13Incidences in the 7th and the.
35:158 decades.
35:17More than 50% of the patients present
35:20with a high IPI and a High E Cox scope,
35:23and as I said earlier,
35:24they show a lower mutational burden
35:26as compared to maybe negative diffuse
35:28large B cell lymphoma's and frequently
35:31show over expression of PD L1 and
35:34they may also harbor structural
35:37variations in PDL one and PDL 2
35:40Chainz 2 subsets are identified,
35:43one is a polymorphous variant and
35:45other one is a monomorphic variant.
35:47The polymorphic variant is important
35:48to recognize because this can be
35:51misdiagnosed as a Hodgkin lymphoma.
35:52Other type of lymphomas.
35:54Here you have large transform cells,
35:56immuno blast including cells resembling Reed,
36:00Sternberg cells all inside predominant
36:01cells and these are seen in a very
36:05polymorphous background of small lymphocytes,
36:07plasma cells histiocytes.
36:08So you can see that there is an
36:10overlapping in overlap in the differential
36:13diagnosis with a polymorphous
36:15lymphoproliferative disorder.
36:16And other lymphomas.
36:17It can be also be mistaken for a
36:19T cell rich piece of lymphoma if
36:22the baby is not tested often,
36:23you see I'm just centric and the
36:26destructive areas and you have extensive
36:28coagulative necrosis and they can be CD 30.
36:31Positive City 15 can also be positive.
36:33Often you have a latency of
36:35type 2 and rarely of type 3.
36:38By type two I would mean that they
36:40should also be expressing LMP one and
36:42Type 3 in addition to Eber and LMP.
36:45One they would express.
36:47Who?
36:48Again, the impact on outcomes is
36:50not very clear in the Asian setting,
36:53EBV positive,
36:53diffuse large B cell lymphoma
36:55as adverse prognosis.
36:56The Neb negative diffuse large
36:58B cell lymphoma.
37:00Here is an example.
37:01He can see there are areas of neck
37:03regulative necrosis.
37:04Then here's the viability areas,
37:06and these cells can be
37:08quite polymorphic in nature.
37:10There are many other cells,
37:11including granulocytes,
37:13plasma cells,
37:14lymphocytes along with large atypical cells.
37:18Sorry and these are CD 20 positive,
37:21either positive and there are many
37:24histiocytes which are brought out
37:26by City 68 are here and then if you
37:29look light chain restriction study,
37:30there's a lot of background but these
37:33cells clearly show capital light
37:34chain restriction and they often have
37:36a non germinal center phenotype.
37:38Mum 1 positive there were negative for
37:41city 10 and possibly for BCL 6 and
37:44they have a high key 67 expression.
37:46In contrast to this,
37:48this is another EBV positive lymphoma,
37:50but in a completely different
37:52clinical context.
37:52This is a patient at 7070 year old lady
37:56who presented with an adrenal mass
37:58so that hemorrhagic mass and there
38:00was a a pseudo cyst with brown fluid,
38:03and when we accept when we examine
38:06multiple blocks from the pseudo cyst,
38:08there were some areas where we see
38:10these kind of large atypical cells
38:12and these large atypical cells.
38:14As you can see here, these were all.
38:16Keep a positive and they are they
38:18had a non germinal center phenotype.
38:21They were seen in 20 probably Mum 1
38:23positive but negative for CD 10 and
38:24six and a very high K 67 expression.
38:27It's important not to call these AB
38:30positive diffuse large B cell lymphoma.
38:32This is a fibron associated EBV positive
38:36large B cell lymphoma that these have
38:39a very different disease cause most
38:41of these don't require any chemotherapy.
38:44They do exceedingly well.
38:47Rarely be negative cases have
38:49also been described here.
38:51These two muscles are sit
38:54within the mesh of fibrin.
38:56And you can also get these in in
38:59catheters and whenever you have a
39:01thrombus within within that thrombus,
39:04we can get these EBV positive large B cells.
39:07So it occurs in specific clinical context and
39:10one has to be careful not to over diagnosis.
39:14Inflammation is very little as you can,
39:16as you saw in this particular case
39:18they have immuno plastic features
39:20and they have a non GC phenotype.
39:23The CD ten negative mum 1 positive
39:26six can be positive in some cases.
39:28And they can rarely express City 138,
39:31and they have a very favorable outcome.
39:34And accession alone is sufficient
39:36in most of these cases.
39:38In contrast to this season,
39:40here is a very aggressive
39:41EBV positive lymphoma.
39:43The Plasmablastic lymphoma,
39:44which is got diffused in a plastic
39:46which shows diffused in a plastic
39:48proliferation of tumor cells,
39:50which I've got plasmacytic features,
39:52typically occurs in an extranodal
39:53setting occurring in the oral cavity
39:56and other mucosal sites rarely
39:57can also occur in in lymph nodes,
40:00it classically occurs.
40:03It typically occurs in the
40:04HIV positive patient,
40:05but can also occur outside the HIV study.
40:08And can also occur in
40:10post transplant patients.
40:11It can also occur in in elderly people.
40:14Some may occur as a transformational event.
40:18In a previous case of follicular
40:20lymphoma or CLL and rarely following
40:22CD 19 CAR T cell therapy again.
40:25Patients present with advanced stage
40:27with advanced with a high IPI.
40:30Nearly 60% of Kesari be associated
40:33and those which are EBR associate
40:35typically have latency type one
40:37or type 280% of the cases of
40:40associated case or HIV positive.
40:42And rarely we can get in
40:45between negative cases.
40:46You running HIV studying rarely.
40:48It can be even be negative and
40:49milk translocation is present in
40:51nearly 80% of these patients.
40:53In of these cases,
40:55they typically suppress the Bissell
40:57program that negative facility,
40:5920 packs file and city 45 and they
41:02expressed a plasma cell program.
41:04The positive facility 138 city
41:0738 blimp one mom one XBP one
41:10and they express light chains.
41:11They express imina globulin.
41:13They you can demonstrate your globulin.
41:16Restriction like chain restriction and
41:19they can rarely also express CD 56,
41:21so often one would think the CD 56
41:24expression would be a good way to
41:26distinguish this from plasmablastic myeloma,
41:28but they can rarely be positive,
41:30or city 56 cyclin D1 expression would
41:32be negative in these cases and that
41:35could be a useful marker if present.
41:37They are more indicative of a
41:39plasmablastic myeloma mic is often
41:41positive because these carry MC
41:43transportation. PDL one is often positive.
41:46They show loss of MHC Class 2 expression
41:49and K 67 expression is usually very high.
41:52This is a classic example of
41:55Blossom plasmablastic lymphoma.
41:56You can see these are blast immuno
41:59blaster plasmablasts and these
42:01are typically as I said CD 138
42:04positive and it can very easily
42:06demonstrate like to instructions.
42:07Yet scapolite chin restricted.
42:11As against the Plasmablastic lymphoma,
42:13you have the. Just create associated.
42:17Sorry before I go into situate associated
42:19lymphoma is worthwhile to discuss
42:22situate associated Castleman disease.
42:26This occurs usually in HIV positive patients.
42:28Nearly 80% of them are HIV positive.
42:31Rarely it can occur in HIV negative
42:34setting in in specific areas,
42:36but most of them are HIV positive.
42:38Typically these patients are in.
42:41That early 40s in middle aged
42:43patients and have relatively low
42:46or undetectable HIV viral loads.
42:48So CD 4 counts are reasonably OK.
42:50These patients milk there's a huge male
42:53predominance and different morphologies.
42:55Those of Castleman disease
42:57of plasmacytic type,
42:58other mixed mixed pattern and they are
43:01you classically see plasmablasts which
43:04are medium to large sized lymphoid cells
43:07with nuclei and amphiphilic cytoplasm,
43:10and these cells are.
43:11Being typically in the mantle zones,
43:13but rarely they can be seen
43:15in into follicular interest.
43:16They can be intrafollicular,
43:18perifollicular, and these lymph nodes.
43:20One it's important to recognize
43:22that many of these lymph nodes
43:24can have foci of Kaposi sarcoma.
43:26When these patients are treated with anti CD,
43:3020 Kaposi sarcoma tends to explode so
43:32it's important to recognize that if
43:35the patients also have Kaposi sarcoma.
43:38Alchemize also concomitantly treated.
43:42This the the,
43:43the number and the density of
43:45copper brass can be very variable.
43:47It can be few or it can form large
43:50sheets like what people used to
43:52describe as micro infamous in the
43:53past and these plasmablasts our
43:55mum one and blimp and positive.
43:57But they often are negative for CD,
44:0020 have very low expression of CD 20 and
44:03they typically laxity 1:30 at expression.
44:06The express IG M and they are Lambda
44:08light chain restricted though there
44:10are Lambda light chain restricted.
44:12They are not born.
44:13Well, there polyclonal,
44:14so they're monotypic,
44:15but polyclonal and patients
44:17usually have a detectable plasma,
44:20which case which we are judged
44:22by DNA and that's a useful
44:24marker outside of the Histology.
44:25Here is a typical case where you
44:28can see castlemans like features.
44:30You got follicles which somewhat
44:32resemble the they had in vascular
44:34type of Castleman disease.
44:35But more importantly you have
44:37plasma cells in the inter,
44:39follicular and medullary areas.
44:41These plasma cells are.
44:43Are not plasmablasts,
44:44they're reactive plasma cells,
44:46which are both Kappa and
44:47Lambda light chain positive,
44:49but the typical plasmablasts are
44:50seen here in the mantle zone.
44:53As you can see here,
44:54and these are huge,
44:568 positive and CD 21 will highlight
44:58this FTC meshworks and here with you
45:01can identify plasmablasts in the mantle
45:04cell and these are IG M positive and
45:06their Lambda light chain restricted,
45:08whereas the plasma cells in
45:10the interfollicular area.
45:11Those are normal reactive plasma cells.
45:15Siri 20 this patients respond extremely
45:18well for anti CD 20 treatment.
45:21So one of the questions is always been if
45:23these plasma Blaster CD twenty negative.
45:24How do they respond?
45:25So we went on to do some double
45:27stains and here you can show that
45:29while most of the plasma blasts are
45:31negative like here is positive plasma
45:33blast which is negative for CD20.
45:36A good proportion of them
45:38show expression of CD 20
45:40and some of them can be quite weak.
45:43Then we also went on to look at.
45:46In these lymph nodes,
45:47many of these lymph nodes show
45:49follicular dendritic cell mesh works.
45:52Here is Brown is in the HV
45:54Atlanta one and red is CD 20,
45:58city 21 and you can see many of
46:01the follicular dendritic cell
46:02processes also show the Lana protein.
46:05So obviously the nuclei of these
46:08are negative for Lana one,
46:10it's only the cytoplasmic processes
46:11that are showing Lana one positive ITI.
46:14So there by suggesting that you have.
46:16In a subset of metric Castleman disease,
46:18that is presentation of Lana,
46:20one on the FTC's.
46:22So then we went on to look at,
46:24make some associations.
46:25We showed that those cases will have
46:28a lower load of huge positive plasma
46:32blasts are more likely to have HSV
46:36positivity in the FDC processes,
46:39and these cases also had fewer CD 3
46:41positive T cells within these follicles.
46:43So there was an inverse correlation
46:46between the number eventuate.
46:47All the new cells.
46:49And presence of antigen on the
46:52left and this this positively
46:54correlated with the number of T
46:56cells within the folly truths.
46:58As I said,
46:59there can be microscopic Kaposi sarcoma.
47:01Here is the lymph node capsule of a
47:03patient with multicentric Castleman disease
47:05showing microscopic Kaposi sarcoma.
47:11A good a good proportion of patients
47:13of multicentric Castleman disease also
47:15present with primary effusion lymphoma,
47:17and typically these are serious effusions,
47:19but some cases and more,
47:21and many of them will not have any solid
47:24tumor analysis but a subset of them
47:26present with solid tumor masses and
47:28and these may not have any effusions,
47:31and these are called extra cavitary,
47:32primary fusion infamous,
47:34and these patients usually have
47:36a low CD 4 count in contrast to
47:38multicentric Castleman disease.
47:40And though most of these are seen in HIV,
47:43positive patients rarely just can
47:45be seen in other immune suppression
47:47settings like the post transplant setting
47:50operations with immune sentences,
47:52and again typical ages 40 to 50.
47:54Rarely you can see this outside of
47:56the HIV setting in the in endemic
47:59areas like the Sub Saharan Africa
48:01and Mediterranean,
48:02and they're accompanied by at the
48:04same time by Kaposi sarcoma and the
48:06Multicentric Castleman disease.
48:08In nearly one half of cases.
48:12Here the self the important thing about
48:14this entity is they are dually infected
48:17both with HHV 8 and Epstein Barr virus,
48:20but largely the malignant
48:22process is driven by.
48:25So by Minister chemistry you can
48:28demonstrate edges and by in situ
48:30hybridization you can identify Eva.
48:31You usually the EBV latency is type one,
48:34so you'll be LMP.
48:36One is usually absent in these cells.
48:38This again a large amount of plastic
48:41cells are plastic plastic cells and
48:43they show prominent and aplasia cells
48:45can resemble Reed Sternberg cells.
48:47And again,
48:47like in the plasmablastic lymphoma,
48:49there is suppression of the bezel
48:51program and what you see is often
48:53a plasma cell program with.
48:55It's only 138 mum one and blimp,
48:58but unlike the plasmablastic lymphomas,
49:00these do not express immunoglobulin so
49:03the immuno globulin negative and some of
49:06them can express aberrant T cell antigens.
49:09Nearly a third of them do that.
49:11And here is a typical case of an
49:13extra cavitary primary effusion.
49:15Lymphoma showing on a plastic or
49:17even a plastic type cells which
49:19are positive for in this case it
49:21was CD 45 positive but most often
49:23city 45 is also negative.
49:25CD 38 and mum one were positive and you
49:28can see there is minimal expression
49:31of 79 and a proportion of cells.
49:33Express CD 30.
49:35Most importantly,
49:36these cells are dually infected with EBV,
49:39demonstrated by Eva and Batch
49:41were demonstrated by LENOVA.
49:45And more, many of them
49:48also overexpressed PDL 1.
49:50So we do not know whether all of these
49:53carry structural abnormalities in PDL one,
49:56but most of them have overexpression of PDL.
50:01There is also another entity
50:02known as the case.
50:03Such great positive diffuse
50:04large B cell lymphoma.
50:06Most of these men can
50:08develop in patients who.
50:10Have been of who had medical
50:12centric Castleman disease.
50:14These patients are
50:15profound immune deficiency.
50:16The most of them are HIV positive.
50:18Rarely it occurs in other other immune
50:21compromised settings are very rarely.
50:23It can occur.
50:24Non immune compromised setting and
50:26this is singley infected with HPV.
50:28There is no infection in these
50:30patients and characteristically
50:31involves lymph nodes and spleen.
50:33Same areas where Multicentric
50:36Castleman disease presents.
50:38They are variably positive of 45 and 20.
50:41Unlike the Multicentric Castleman disease,
50:43they express AGM and Lambda light chains.
50:48So this is quite a rare disease.
50:50You can and look if we
50:52move on to the next entity,
50:54which is extremely exceedingly uncommon,
50:57but it's important to know about this
50:59because this is a perfectly benign disease.
51:03Here we got cake and EBV positive.
51:08This can be again Dooley infected by EBV
51:11and what's known as the Associated German
51:15or Tropic lymphoproliferative disorder.
51:17Most of these patients are HIV negative.
51:19They present with neck,
51:21lymph adenopathy and they are asymptomatic.
51:23Here the germinal centers are partially
51:26or completely replaced by large blasts
51:28which are as I said ebb and positive.
51:31They are mum 1 positive.
51:33They've got many features which
51:35could be similar to the similar to
51:39the primary effusion lymphoma but
51:41these cells are right within the.
51:45In the germinal centers and the important
51:47difference from the primary effusion,
51:48enforma is that they express
51:51monotypic immunoglobulin expression
51:52is seen in nearly 2/3 of cases,
51:54whereas in primary effusion lymphoma you
51:57can't demonstrate him in a globe date,
51:59and if you do PCR study for immuno
52:02globulin gene rearrangement,
52:04they're calling clonal and
52:05expressing itself is sufficient,
52:07and prognosis is excellent in these patients.
52:11There's another entity which
52:12people need to be aware of.
52:14Many of the patients are nearly
52:16one in 10 patients of MULTICENTRIC.
52:18Castleman disease can develop
52:20hemophagocytic invoice cytosis,
52:22and if you get a spleen,
52:23or if you get one metal in these patients,
52:25you can explain.
52:26You can see this in the red bulk you
52:29have active phagocytosis occurring
52:31and you also see this positive
52:33plasma blast in the surrounding
52:35areas and the same thing happens
52:38also in the bone marrow you can see.
52:41Active phagocytosis along with presence
52:43of these kind eventuate positive
52:46plasmablasts and this these patients
52:48can have if they are not treated well.
52:52They can have pork survival.
52:54I just want to touch for the next
52:56few couple of minutes on HTLV one,
52:58which is quite a rare entity,
53:00but people have to recognize
53:02that this is underdiagnosed in.
53:04In 2018 there was a a study came
53:06out from the National Cancer
53:08Database which showed that mycosis
53:11fungoides occurring in patients.
53:13I'm sorry,
53:14330 positive proteinous infamous
53:15occurring in African American
53:17patients have portal survival.
53:20This could be true,
53:20but in all none of these patients
53:22they still be one was tested.
53:24Around the same time you had,
53:26there was another study which came
53:27out from the Miami group which showed
53:30that ATL is indistinguishable from
53:32many of the common teasel informers.
53:34So any T cell lymphoma one has to
53:37keep in mind that the likelihood of
53:39HTLV one and exclude the possibility
53:42of HTLV 1 by serology.
53:44Otherwise one could easily miss,
53:47diagnose and aitl as some other
53:50T cell lymphoma.
53:51ATL is divided into four groups.
53:54When he was a cute group
53:55and their infamous group,
53:56then you have the chronic group
53:58and the smoldering type of aitl,
53:59the genomic.
54:00They're all genomic differences
54:02between these four groups
54:04and the genomic differences also have
54:07an implication on outcomes like the IRF
54:094 mutations has a very patient of ATL,
54:12which I had a four mutations
54:13have a very poor survival.
54:15Those will start 3 mutations are
54:17typically seen in the indolent type of
54:19ATL and they have a much better survive.
54:22So again, now people have come
54:24up with genomic skills in ATL.
54:26Much of this work has come from Japan
54:29and the genomic subsets also correlate
54:32with the clinical subsets and and and
54:36there are clear indicators of survival.
54:39I'll just, I think this is the
54:41last case I'm going to show and
54:43I will end with this here.
54:44The HIV positive patient who was
54:46referred for an allogeneic transplant.
54:48This was in London and patient had
54:50already received two courses of ice,
54:52and when bullmer investigations
54:53were being done,
54:54we saw these kind of abnormal cells
54:57and these cells were CD 3 positive.
54:59There were CD 4 positive in 25
55:01positive and most of them were CD,
55:03eight negative and on flow you
55:05can see that these were having
55:08lower expression of CD3 or CD to.
55:10Positive and there were no CD 4
55:12positive but CD eight negative and
55:14you can see City 25 was positive in
55:17these cells and CD seven was negative.
55:20So these for ATL cells and these
55:22sometimes can be difficult to
55:23diagnose in peripheral red where you
55:25have the question of whether it's
55:27an ATL or a chronic HTLV 1 carrier.
55:29In contrast to that case,
55:31here is a peripheral blood from a
55:32patient with cousin STLV 1 carrier.
55:34Here are the blue cells you can
55:36see with lower expression of CD
55:38three and these for CD 4 positive.
55:40And you can see reduced expression
55:43of CD5 and importantly these four
55:45CD 25 positive and CD 26 negative
55:48and also CD seven negative.
55:51So this is for the patient with
55:52chronic HSV 1 carrier and that
55:54distinction can be quite difficult.
55:56One may have to do southern blot for STL.
55:58We want to show that there is a
56:00monoclonal HTLV one or they're in the
56:03process from a chronic infection to ATL,
56:06that is integration of the virus.
56:08It can be a single integration,
56:09sometimes there can be more
56:11than one integration.
56:12And that's important to recognize the ATL
56:15and distinguish that from chronic carrier.
56:19So in the last couple of minutes I
56:21just want to give you an update on
56:23The Who classification of tumors.
56:25So this is in general about
56:28the classification of tumor.
56:29This is managed by the classification
56:31of tumours,
56:32editorial board and this has got
56:34a chair or the head of the WHL
56:37classification of tumors. Dr.
56:38Ian Cree, who is a pathologist himself.
56:41Then it has got.
56:42Standing members,
56:43these are standing members are common
56:46across different globe books and
56:48these are nominated by major societies
56:50and involving cancer diagnosis
56:52and they serve on a 3 year term.
56:55Then you have the expert editorial
56:57board members for each
56:59of these, each of the blue books and the
57:02current guideline for these for being an
57:04expert member is that people can't be
57:06on this board for more than two books.
57:09That's the maximum if you serve on one book,
57:11you can. So when a second book, but we can't.
57:14So beyond two books and all members
57:17have equal status and this is the
57:20decisions are made more by consensus.
57:22There is it's not,
57:24there is no hierarchy within the
57:27tutorial board and members are
57:28chosen based on their expertise and
57:30and also geography if possible.
57:32Like there is a positive attempt
57:34is made to be inclusive to include
57:36people from across the world.
57:39And the current WHO classification
57:41has 25 expert editors and one of
57:44them and has about 380 authors,
57:47and these authors include not just
57:50hematopathologist, but they have clinicians,
57:52hematologists, oncologists.
57:53We got, geneticists, epidemiologists.
57:56All of them are authors. Most of the major.
58:00Major chapters have got.
58:06Otters are beyond just being
58:09hematopathologist and across these I mean,
58:11these 380 authors come from 31 different
58:14countries, so there's a much wider
58:17representation of across the world,
58:18so the the timelines and the way
58:21we are progressing. This was fast.
58:23We, you know, the editorial board,
58:25at least the editorial board members
58:27were contacted. In February,
58:29we had a very pre meet in April 2021.
58:32That was the first time we got
58:34to know who were the other.
58:35In total board members and then we had a
58:38content meeting which happened in November,
58:40so part of it we could not complete.
58:42So the T cell lymphomas could not
58:45be discussed because we had three
58:46full days 12 hour meetings each day
58:48for three days and we are still left
58:50with some chapters which were left
58:53and that's being discussed next week.
58:56And I mean that was the November
58:582224 meeting.
58:59So we have a third editorial
59:01meeting in in in January,
59:03but we are likely to have another
59:05meeting sometime in in spring and
59:08we are hoping that the towards the
59:10end of the of the year we will
59:12have the publication coming out.
59:14So possibly by October November we
59:17should be having the 5th edition
59:19of The Who classification.
59:22I'll stop that and I'm happy to
59:25take questions.
59:28Sorry, I think I took a little
59:30longer than I expected. I would thank
59:32you. So thank you so much for
59:35that overview and really,
59:37really fascinating case.
59:39Needed cases. Allow all the
59:42people currently onto to essence,
59:46especially trainees.
59:47Please feel free to pop up
59:49with question with question.
59:56See, there's something on the chat,
59:58see if there's any question.
60:00Those oh those are CME credits. OK so I have
01:00:05a question why that was a a great talk.
01:00:08I really appreciated that
01:00:10my my question is about
01:00:12you know the latency versus
01:00:14lytic cycles of EBV,
01:00:15and that how that plays into lymphoma,
01:00:17Genesis, and I know historically,
01:00:20we've always talking about these latency
01:00:22programs and eborn Debnath course or latency.
01:00:25Genes, but recently there's been a
01:00:27lot more suggestion that the lytic
01:00:29replication of the virus in the near
01:00:31term before you know diagnosis is actually,
01:00:34you know, very relevant for
01:00:37for lymphoma Genesis.
01:00:38So just your thoughts on sort of how
01:00:41that sort of might integrate into
01:00:43these classifications or pathogenesis.
01:00:46Yeah, good that you asked the question,
01:00:49if you use the one you see proportion
01:00:52of cells which are in the lytic phase.
01:00:56And the question that comes up is.
01:00:58Those cells which are in the lytic phase.
01:01:00Can they infect other cells?
01:01:03And can you have multiple EBV
01:01:07positive lymphoma clones occurring
01:01:10within a particular tumor?
01:01:13In most of the. B cell lymphoma's.
01:01:16At least people have not much work
01:01:18has actually happened, though.
01:01:19People have shown that there is a subset
01:01:22of cells which are in the lytic phase.
01:01:24But how that would impinge on
01:01:27the evolution of the tuba.
01:01:29I think it is far from clear.
01:01:34I'm probably the lytic.
01:01:36Phase is important also because
01:01:38if you follow these patients.
01:01:40It is only latent TB you wouldn't
01:01:43see arising EBV viral level in the
01:01:46serum and the very fact that the
01:01:48plasma levels keep increasing and
01:01:50correlates with the tumor load.
01:01:52It means that there is a subset of cells
01:01:54where they are lytic infected exactly.
01:01:57Yeah and also the the fascinating
01:01:59question also comes up is if
01:02:01there was a way to convert the
01:02:03latent virus into a lytic virus.
01:02:05Can you steal the kill the lymphoma
01:02:07cell instead of treating patient with
01:02:09all the chemotherapeutic agents?
01:02:11If you can just trigger.
01:02:12And change the latency into lytic,
01:02:15or whether the baby itself
01:02:16can kill the tumor cells.
01:02:18But that has been just
01:02:19a fascinating question,
01:02:20but nobody has ever done it.
01:02:24Thank you, thank you. I
01:02:27have a question. This is Jeff Squire.
01:02:31You described the mutations
01:02:34in EBV in EBV genome,
01:02:36in Burkitt's. And wondering whether there are
01:02:40mutations? Found another
01:02:42EBV associated lymphomas
01:02:45and also you described cytokine
01:02:49suppression in Burkitt's,
01:02:50and I wonder how widespread that
01:02:53is among other. Yeah, that's us.
01:02:57Regarding the Abner 3B mutations,
01:02:59which we showed,
01:03:00we showed that across not just Burkitt
01:03:02lymphoma but also in diffuse large B
01:03:05cell lymphoma and in post transplant
01:03:07lymphoproliferative disorders so that actors,
01:03:09even outside of the bucket, look firmer.
01:03:12Whereas this cytokine thing that
01:03:13I showed you was purely in in the
01:03:16mouse model we have not been able to
01:03:20show SL 10 differences in patients.
01:03:27OK, so that's a rather dramatic
01:03:29finding, so it seems to be a
01:03:32consistent mutation and ended
01:03:363833 B mutations we have.
01:03:37We have been able to show
01:03:38outside of the work as well
01:03:40and and how. How prevalent
01:03:42is that? Is it a friend?
01:03:44Most cases? Yeah, we evaluated in about
01:03:4640 cases and if I remember correctly.
01:03:49More than half of them had mutations
01:03:52and these patients were from.
01:03:54All over the world now.
01:03:56I mean, we had patients from
01:03:58Australia to UK to Africa,
01:04:00collected from different
01:04:02parts of the world and also.
01:04:04One of The thing is important.
01:04:06Recently my my friend Lorenzo Lucchini.
01:04:09He showed a variety of lymphomas
01:04:12where using RNA scope they could
01:04:15show remnants of EB virus even even
01:04:17in those which were ever negative.
01:04:20So there is a possibility
01:04:22not only mutations occur,
01:04:23but eventually many tumors
01:04:25may lose the baby virus.
01:04:27So what we currently consider
01:04:29as EBV negative disease,
01:04:30a subset of them may not be be
01:04:33negative when from inception, yes.
01:04:36Thank you, thank you.
01:04:46So I think we're over 6 minutes over.
01:04:49I just wanted to thank you so much for
01:04:53took a little long I could have.
01:04:55Cut down on my great thank you. Thank you
01:04:59to the next meeting.
01:05:00Thank you, thank you. Thank you very much.
01:05:03Thank you, bye.