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© 2016 JOURNAL OF CLINICAL SCIENCES | PUBLISHED BY WOLTERS KLUWER - MEDKNOWPage | 58
The contemporary management of these neoplasms
requires that they are accurately diagnosed, classified by
sub‑typing according to the WHO system of classification.[9]
This classification is a multiparametric approach requiring
clinical, morphological, immunological, cytogenetic,
and molecular techniques. The impact of this has been
reflected in the resource‑rich settings where treatment
of those malignancies is increasingly associated with
unprecedented rates of long‑term cure and control. The
contemporary diagnosis of lymphoma remains a major
challenge in sub‑Saharan Africa, due to inadequate
facilities, despite its perceived increase as a result of HIV
endemicity in the region.[10]
In most tertiary centers across sub‑Saharan countries, the
only standard for tissue diagnosis is still the morphology
of the cells as they appear under hematoxylin and
eosin (H and E) stains of formalin fixed paraffin‑embedded
INTRODUCTION
Lymphomas are a heterogeneous group of neoplasms of
lymphoid tissues, each with distinct clinicopathological
features and varying response to treatment.
Although, the paucity of information on lymphoma in
sub‑Saharan Africa makes accurate estimates difficult, the
finding of Ferlay et al.[1]
indicated that of all the cancers
occurringinsub‑SaharanAfrica,hematolymphoidmalignancies
have emerged as a major cause of morbidity and mortality
with lymphomas and other hematologic malignancies such
as leukemia and multiple myeloma together accounted for
8.7% of incident cancer diagnoses and 9.9% of cancer deaths
in 2008. Annual incidence as low as 30,000 and as high as
278,000ofnonHodgkinlymphoma(NHL)havebeenreported
insub‑SaharanAfricamakingittobeoneofthemostcommon
cancersintheregion.[2,3]
Literaturereviewshowedthatinmost
Nigerian Tertiary Hospitals, lymphomas, mostly NHL ranked
among the leading cancers.[4‑8]
The challenges of lymphoma diagnosis in a Tertiary
Hospital in Lagos, Nigeria
Olakanmi Ralph Akinde, Charles Chidozie Anunobi, Oluseye Vincent Osunkalu1
, Adekoyejo Abiodun Phillips,
Olatunji Micheal Afolayan2
Departments of Anatomic and Molecular Pathology, 1
Haematology and Blood Transfusion and 2
Surgery, College of Medicine,
University of Lagos, Lagos, Nigeria
ABSTRACT
Background: In most tertiary centers across sub‑Saharan countries, hematoxylin and
eosin (H and E) stained slide is the main method of diagnosing lymphomas, and this has been
found to be inadequate in diagnostic hematological malignancies. Aim and Objectives: To
review the diagnostic utility and limitations of H and E, tissue diagnostic modality of solid
hematolymphoid malignancies. Materials and Methods: The diagnosis based on both
morphology and immunohistochemistry (IHC) assessments were compared with those based
solelyonmorphology. Results: Of all, the116 casesof lymphomas,only32 (27.6%)werecorrectly
diagnosed and subtyped by morphologywhile 53 (46%) caseswerediagnosed to be lymphomas
but could not be subtyped by morphology. Nineteen (16.4%) cases were wrongly subtyped. Five
casesof reactivelesionswerewronglydiagnosedasmalignantlymphoma.Conclusion:Thisstudy
makes a case for the mandatory use of IHC in the diagnosis of suspected cases of lymphomas.
Key words: Challenges, diagnosis, immunohistochemistry, lymphoma, reactive lesions
Address for correspondence:
Dr. Olakanmi Ralph Akinde,
Department of Anatomic and
Molecular Pathology,
College of Medicine, University of
Lagos, Lagos, Nigeria.
E‑mail: kindusy@yahoo.com
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DOI:
10.4103/2408-7408.179679
How to cite this article: Akinde OR, Anunobi CC, Osunkalu OV,
Phillips AA, Afolayan OM. The challenges of lymphoma diagnosis
in a Tertiary Hospital in Lagos, Nigeria. J Clin Sci 2016;13:58-71.
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Akinde, et al.: Lymphoma; developing countries; diagnostic challenge
JOURNAL OF CLINICAL SCIENCES, VOLUME 13, NUMBER 2, APRIL-JUNE 2016 Page | 59
lymphoid tissue.[10]
Although this is an important historic
basic diagnostic modality, it is limited and cannot be used
alonewithoutothercontemporarydiagnosticmodalitiesin
lymphoma diagnosis and classification, even with special
stains such as Giemsa, methyl green pyronin, reticulin
periodic acid‑Schiff which can neither differentiate B from
T‑cells nor be of prognostic/therapeutic markers.
The key findings of the international network for cancer
treatment and research, which convened a panel that
visited national referral hospitals in Nigeria, Kenya,
Ghana Tanzania and Uganda to evaluate infrastructure
for diagnosing lymphoma, indicated highly variable
equipment and personnel as well as overused suboptimal
fine needle aspiration specimen, variable turnaround time,
variable histology and cytology preparations with lower
standards than developed countries.[11]
They reported
on the nonexistence of immunohistochemistry (IHC),
cytogenetics, and molecular and fluorescence in situ
hybridization techniques, which are core elements
in diagnostic hematopathology in developed worlds.
Therefore, the tendencies for lymphoma over and missed
diagnosis in those centers are unavoidably high.
Although morphology remains the cornerstone for the
diagnosis of HL, the morphology complexity of NHL often
hampers the pathologist’s ability to differentiate benign
from malignant disease correctly.[12,13]
Histologic subtyping
with the help of immunohistochemical characterization
of the tumor cells has resulted in the level of distinction
between lymphomas subtypes which were not previously
possible. With the use of IHC reactive lymphoid lesions
could be differentiated from malignant lymphomas with
reactive pattern and poorly differentiated carcinomas,
melanoma and sarcomas could also be differentiated from
someanaplasticformoflymphomas.Lymphomasshouldbe
identified among the round blue cell tumors of childhood.
Evenwithinthelymphomas,themorphologyheterogeneity
and resemblance demand more than H and E, for diagnosis,
classificationandpropermanagement.Today,thediagnosis
and classification of lymphoma rely heavily on the
determinationofcelllineage,maturation,andfunctionbased
onantigenexpressionaswellasgeneticanalysisinaddition
to the morphology and clinical features. This has made IHC
and cytogenetics become an integral part of diagnostic
hematopathology and is required for the contemporary
treatment, prognostication. and research. For this reason,
manyinstitutionsoftenopttoengagethediagnosticservices
of foreign laboratories for lymphoma cases. However, this
option is associated with the disadvantages of tissue loss in
transit, delay in reporting, additional expense and does not
enable learning opportunity.
In this study, our aim and objective are to review the utility
and limitations of H and E, tissue diagnostic modality that
is available for the diagnosis of lymphomas in our center
as it occurs in most of the resource‑poor laboratories in
sub‑Saharan Africa and to highlight the diagnostic utility
of basic antibody panels that can be used to improve on
the diagnostic limitations of H and E, assessment of solid
hematolymphoid malignancies.
MATERIALS AND METHODS
This study is a retrospective study of 133 cases. Among
these were 114 cases of malignant lymphoma, two cases
of metastatic lesions and 13 cases of benign proliferative
lesions but suspected for malignancy. These assessments
were based on the morphologic features of the H and E,
stainedsectionsofformalinfixedparaffinembeddedtissue
in the Department of Anatomic and Molecular Pathology,
LagosUniversityTeachingHospitalLagos,Nigeria,between
2009 and 2012. Patient data were extracted from the case
notes and request forms of the patients. The formalin fixed
paraffin embedded tissue blocks and H and E, stained
slides were selected, and each case was reviewed. New
sections were made when the slides were not seen or
suboptimal for assessment. The tissue blocks and slides
were at different occasions sent for consultation at the
Department of Cellular Pathology, Queen’s Hospital, Rom
Valley, Romford, Essex.
The impressions of the second opinion on those samples
based on morphology and IHC were compared with our
impression based on morphology alone. Using the diagnosis
of the second opinion as standard, our diagnoses were
categorized into one of the followings:
1. Appropriately diagnosed as lymphoma subtype by
morphology
2. Thosecasescorrectlydiagnosedaslymphomabutcould
not be subtyped by morphology
3. Diagnosed as lymphomas but inappropriately
subtyped (named as a different type of lymphoma)
4. Truly reactive lesions among the equivocally reactive
cases
5. Cases of equivocal reactive lesions which were
diagnosed to be lymphoma by morphology and IHC
6. Cases diagnosed to be lymphoma but turned out to be
nonlymphomatous neoplasm
7. Cases diagnosed to be nonlymphomas but turned out
to be lymphoid malignancy
8. Cases that were truly nonlymphoid malignancy.
RESULTS
Of a total of 133 cases sent for the second opinion, only
four could not be processed due to suboptimal tissue
preservation. Among the remaining 129 cases, there were
116 cases of lymphomas, 13 cases of reactive lesions.
Of the lymphomas, HL constituted 18 (15.5%) and NHL
98 (84.5%). The NHL was made up of 75 (76.5%) and
23 cases (23.5%)ofB‑ andT‑celltypesofNHLsrespectively.
The HL were all of classical type, made up of six cases

JOURNAL OF CLINICAL SCIENCES, VOLUME 13, NUMBER 2, APRIL-JUNE 2016Page | 60
each of nodular sclerosis and mixed cellularity as well as
three cases each of lymphocyte‑depleted and lymphocyte
rich. Figure 1 shows the distribution of different types of
lymphoma seen in this study whereas Table 1 shows the
distribution of the categories of lymphoma diagnoses by
morphology alone against different types of lymphomas
by morphology and IHC.
Only 32 (27.6%) cases of suspected lymphomas were
correctly diagnosed and subtyped by morphology. These
were made up of six cases each of diffuse large B‑cell
lymphoma (DLBL)andsmalllymphocyticlymphoma (SLL),
all the six cases of Burkitt’s lymphoma (BL), one case of
lymphoblastic lymphoma as well as 13 cases of classical
HL made of nodular sclerosis Hodgkin’s lymphoma (NSHL)
(5), mixed cellularity Hodgkin’s lymphoma (MCHL)
(4) and two cases each of; lymphocyte rich Hodgkin’s
lymphoma/lymphocyte rich and lymphocyte depleted
Hodgkin’s lymphoma (LRHL and LDHL).
Fifty‑eight cases were correctly diagnosed to be lymphomas
but could not be subtyped by morphology alone. These
were diagnosed by second opinion to be DLBL (17),
SLL (6), follicular lymphoma (FL) (6), mantle cell
lymphoma (MCL) (4), three cases each of marginal zone
lymphoma and mucosal‑associated lymphoid tissue
lymphoma and five cases of precursor lymphomas of which
T‑celltypewas4.Italsoconsistsof8 casesofperipheralT‑cell
lymphoma (PTCL), 3 mycoses fungoides (MF), two cases of
MCHL,andonecaseofanaplasticlargecelllymphoma (ALCL).
Nineteen cases of morphologically diagnosed lymphoma
were wrongly subtyped. Among this group were DLBL (9)
and one case each of ALCL, PTCL, Precursor T cell
lymphoma (Prec‑T), Mycosis fungoides (MF), Follicular
lymphoma (FL), MCL, PL, SHL, LRHL and LDHL.
FivecasesofreactivelesionsbyIHCwerewronglydiagnosed
tobemalignantlymphoma.Theseweremadeoftwocasesof
CastlemandiseasediagnosedtobeSLL,twocasesofreactive
hyperplasia which were diagnosed as FL, and one case of
chronic sclerosing sialadenitis diagnosed as HL.
Of the 13 cases of nonneoplastic lesions by H and E,
morphology alone, eight cases were correctly diagnosed
while five cases were wrongly diagnosed as lymphomas.
ThelatterconsistsoffourcaseofSLLwhichwerediagnosed
to be reactive (2) and tuberculous (2) and also one case of
PTCL diagnosed as reactive lesions.
Two cases of lymphomas were wrongly diagnosed by
morphology assessment to be metastatic carcinoma.
Figures 2‑10 shows the micrographs of the H and E,
microscopy and IHC staining patterns of the various types
of lymphomas seen in this study.
DISCUSSION
The study showed that a low percentage (27.6%) of the
0
5
10
15
20
25
30
35
Category 1
DLBL
BL
FL
SLL
MCL
MZL
MALT
PLAS
PREB
ALCL
PTCL
MF
Figure 1: The frequency distribution of various subtypes of lymphoma.
DLBL = Diffuse large B-cell lymphoma, BL = Burkitt’s lymphoma,
FL = Follicular lymphoma, SLL = Small lymphocytic lymphoma,
MCL = Mantle cell lymphoma, MZL = Marginal zone lymphoma, MALT =
Mucosal associated lymphoid tissue, PLAS = Peripheral T cell lymphoma,
PREB = Precursor B cell lymphoma, ALCL = Anaplastic large cell
lymphoma, PTCL = Peripheral T-cell lymphoma, MF = Mycoses fungoides
Table 1: The various subtypes of lymphoma and categories of morphologic diagnosis
DLBL BL FL SLL MCL MZL MALT PLAS PREB ALCL PTCL MF Prec‑T MCHL NHSL LRHL LDHL CD Reactive Total
Correctly diagnosed 6 6 6 1 4 5 2 2 32
Diagnosed as lymphoma
but unspecified
17 6 6 4 3 3 1 1 8 3 4 2 58
Lymphoma but wrongly
subtyped
9 1 1 1 1 1 1 1 1 1 1 19
Lymphoma misdiagnoses
as reactive
4 1 5
Reactive but diagnosed
as lymphoma
2 3 5
Correctly diagnosed as
reactive
8 8
Lymphoma but diagnosed
as metastatic lymphoma
2 2
Total 32 6 7 16 5 3 3 2 1 4 10 4 5 6 6 3 3 2 11 129
DLBL=Diffuse large B‑cell lymphoma, BL=Burkitt’s lymphoma, FL=Follicular lymphoma,SLL=Small lymphocytic lymphoma, MCL=Mantle cell lymphoma, MZL=Marginal zone
lymphoma,ALCL=Anaplastic large cell lymphoma, PTCL=PeripheralT‑cell lymphoma, MF=Mycoses fungoides, MCHL=Mixed cellularity Hodgkin’s lymphoma, NHSL=Nodular
sclerosis Hodgkin’s lymphoma, LRHL=Lymphocyte rich Hodgkin’s lymphoma, LDHL=Lymphocyte depleted Hodgkin’s lymphoma, PLAS=Plasmablastic lymphoma, PREB=Precursor
B cell lymphoma, MALT=Mucosal associated lymphoid tissue

Figure 2: Burkitt lymphoma
Figure 3: Diffuse large B-cell lymphoma
lymphomasdiagnosedbyIHCcouldbecorrectlydiagnosed
by H and E, morphology alone. This diagnostic limitation
with regards to lymphoreticular neoplasms buttresses
the important role of IHC in addition to morphology in
diagnostic hemato‑oncology. This limitation is supported
by reviewed literatures on lymphoma from various
centers in sub‑Saharan countries[3,5‑7]
as most lymphomas
in these studies could not be classified. In the study of
Jaffe et al.,[12,13]
it was observed that histologic appearance
alone may not be a reliable indicator of immunologic
markers. However, the importance of morphology
in surgical pathology must be stressed as a good

Figure 4: Chronic sialadenitis
Figure 5: Anaplastic large cell lymphoma

Figure 6a: Hodgkin’s lymphoma (nodular sclerosis)
Figure 6b: Hodgkin’s lymphoma (mixed cellularity)
morphologic assessment is required for the selection
of appropriate antibody panels for IHC assessment.
When a lymphoid neoplasm presents with conventional
morphological features both architecturally and typical
cellular contents, aided by good tissue preservation
and processing, morphology assessment could provide
adequate and important diagnostic information that
could lead to a correct diagnosis (Figures of Diffuse
Large B cell lymphoma (DLBCL), FL, BL). This fact was
demonstrated by this study with regards to all cases of
the BL which were correctly diagnosed by morphology.
The high diagnostic efficiency of morphology in BL could
have been due to the facts that all the cases were of usual
clinical presentation and conventional morphology. The

morphologic appearance of its variants would have been
associated with some diagnostic challenges that will
require IHC. Cases of BL almost always demonstrate
about 100% proliferation index and show positivity, in
addition to the B‑cell antigen, for CD10, BCL6 but are
usually negative for CD5, CD23, and BCL2[14]
[Figure 2].
It is suggested that cases with acceptable morphology
with moderate but with strong reactivity to BCL2 should
be classified in this category if the cells are positive
for BCL6, CD10, and are MUM/IRF‑4 negative.[14]
The
reactivity of the tumor cells to CD10 and BCL2 usually
have a roughly reciprocal relationship in the two variants
of BL.[15]
CD43 serves to distinguish the two as it is almost
always positive in Burkitt lymphoma and less than half
the time in Burkitt like lymphomas. It was not possible
to demonstrate the relationship of this tumor with
Epstein–Barr virus (EBV) that have been documented to
have an important role in its etiopathogenesis for a long
time in the sub‑Saharan Africa.[16]
Only 6 (18.8%) out of
a total number of 32 cases of DLBCL were successfully
Figure 7: B-cell small lymphocytic lymphoma
Figure 8: Reactive hyperplasia

subtyped by histology while the majority (53%)
could not be sub‑typed. Jaffe et al.[12]
in their study on
morphologic sub‑classifications of diffuse NHL showed
that histopathologic sub‑classification could correctly
predict immunologic phenotype in only 61% of cases,
suggesting that in such cases of lymphomas, histological
appearance alone may not be a reliable indicator of
immunologic surface markers. Therefore, IHC becomes
essential in diagnosing any form of obviously malignant
lymphoreticular lesions as mere lymphoma or NHL is of
no therapeutic, prognostic or research relevance.
The common lymphomas, DLBL, FL, and SLL, could be
conveniently diagnosed and classified at least using the
criteria of the working formulation for clinical use which
is mainly based on architectural pattern and cellular
morphology.[17]
The presence of LH cells in LPHL, RS or its
variantsincaseofclassicalHLCHLandproliferationcenters
in SLL and follicular architecture in FL should permit an
accurate diagnosis. In addition, in case of conventional
DLBCL [Figure 3], correct morphological assessment is not
impossible with the presence of diffusely disposed large
cells with nuclei size larger than that of macrophages or
to normal lymphocytes.[18]
However, lymphoma diagnosis
withoutIHCwillnotprovideanevidence‑basedtherapeutic
and prognostic indicators for the disease.
Recognizingthemalignantnatureofdiffuselargelymphoid
cellproliferationusuallydoesnotposediagnosticchallenge,
but distinguishing such from nonlymphoid neoplasms
such as poorly differentiated carcinomas, melanomas
and sarcomas as well as their correct sub‑typing into a
specific lymphoproliferative lesion such as DLBCL, ALCL,
HL, anaplastic plasmacytoma, myeloid sarcoma, etc., which
can present predominantly as large cell neoplasm, can
be very challenging without IHC. The large proportion of
DLBL (58%)thatwerediagnosedaslymphomaunspecified
and those that were wrongly sub‑typed (28%) are an
indication of the limitation of H and E, microscopy alone
in the definitive diagnosis of lymphoma in this study.
The morphologic heterogeneity of DLBCL could cause
diagnostic difficulty such as was seen in the three cases
of the DLBL. The presence of significant population of
immunoblasts and atypical large RS like cells could lead
to the morphological interpretation of HL without IHC and
even a times can be confused with a reactive lesion with
fulminant immunoblastic proliferation as in infectious
mononucleosis. Likewise, this morphological variance
would explain the reason why nine cases of DLBCL were
wronglydiagnosedasBL (twocases)andSLL (threecases),
HL (3) and lymphoplasmacytic lymphoma (one case). In
addition, this limitation will explain the case of suspected
HL involving the parotid gland that was confirmed to be
a chronic sialdenitis [Figure 4] due to the presence of
distorted glands resembling atypical/Reed–Steinberg
like cells. Therefore, because of the marked overlap in the
cytologic features of lesions with large cell proliferation,
IHC is essential for their definitive diagnosis.
Guided by the morphology and architectural pattern
of the tumor cells, a small primary panel of antibody
selection from LCA, CD3, CD20, CD79, CD10, CD15, CD30,
BCL2, AE1/AE3, MIB 1, TdT, synatophisin, melan A, and
sometimes a 2nd
panel of smaller markers such as PAX 5,
MUM1, CD138, CD56, CD57, lysozyme, Alk 1, EMA will
provide almost all important diagnostic clues to the cell
type of the large cells. The positivity of the large cells for
CD20/CD79a, a B lineage marker, supports the diagnosis
of DLBCL [Figure 3] while its negativity may indicate ALCL
and CH, although about 10–20% cases of CHL could be
heterogeneous for CD20.[19]
Also the positivity of the large
cellsforCD3 supportedT‑cellneoplasmlikeALCL [Figure 5]
or PTCL, though not commonly of large cell morphology.
Although, most cases of the HL in this study were correctly
Figure 9: Toxoplasmosis

diagnosed by morphology alone, three cases were wrongly
diagnosed by morphology as DLBCL. The study identified
the use of CD15 and CD30 to be complementary for the
diagnosis of CHL as those cases of CHL that were negative
for CD30 were CD15 positive [Figure 6]. CD30 positivity
alone but with positivity for EBV will be in support of CHL
rather than DLBCL or ALCL, which can be CD30 positive
but rarely EBV positive.[20‑22]
The absence of NLPHL, a
sub‑type of HL with a favorable prognosis even after
being transformed into DLBCL and HL, in rare occasions,
is in agreement with the finding in literatures that it is
not common, constituting about 2–7% of HL.[23]
Clinical
finding supported by morphology alone could be enough
to make a clear‑cut distinction between NLPHL and CHL.
Differentiating NLPHL from CHL and T‑cell/histiocytic
riched DLBCL by IHC may necessitate the use of IHC for
therapeutic purpose as LPHL is managed differently.[24,25]
SLL constituted a large proportion among the lymphoma
of small cell morphology sent for IHC and this could be
explained by its higher frequency among lymphoma of
small cell type and corroborates the fact that despite the
presence of the usual morphology (fairly uniform tumor
cells, presence of prolymphocytes, few immunoblasts,
and regularity of the nuclear membrane) appropriate
morphological diagnosis could be difficult. The presence of
Figure 10: Follicular lymphoma

polymorphous small lymphoid infiltrates and absence of or
indistinct prolymphocyte centers could constitute a pitfall
in the diagnosis of SLL and it differentiation from PTCL
and reactive lymphoid lesions. This could be responsible
for the six cases of SLL that were recognized as lymphoma
but were not typed. The positivity of the tumor cells for
CD20, CD23, and CD5 is essential for the diagnosis of
SLL [Figure 7]. Lymphoproliferative lesions with intense
small cell infiltrate admixed intimately with large cells
either in diffuse or expansible parafollicular hyperplasia
could erroneously be viewed as a polymorphous infiltrate
rather than being pleomorphic and hence diagnosed as
reactive lesion as it occurred in four cases in this study.
The expression of aberrant markers such as CD5, BCL2
and CD43 in B‑cells usually and always indicate neoplasm
rather than a reactive process [Figure 8]. This in addition
to the presence of morphologic features in keeping with
neoplastic lesions such as nuclear atypia, cytoplasmic
clearing,polymorphism,follicleswiththeabsenceofmantle
zone and indistinct sinuses should guide in diagnostic
decision.[26]
When a lymph node is partially involved
in the neoplastic process or have a focus of necrosis, a
polymorphous infiltrate may be seen. Although none of
the SLL was wrongly diagnosed as DLBL, the presence of
abundant para immunoblasts in SLL or viewing a small
sample size with focal predominance of fairly large cells
such as prolymphocytes and paraimmunoblasts which are
usual accompaniments of SLL may mimic immunoblasts
and hence an impression of DLBCL by the unwary.
On morphologic basis, making accurate diagnosis of
follicular lymphoma should not pose much difficult task
except in cases with unusual histologic appearance.
However, lymphoid lesions could show barely discernible
follicularity due to increase in the number of interfollicular
centroblasts and centrocytes and intense T‑lymphocytic
infiltration thereby making it difficult differentiating
malignant from reactive processes. An accurate diagnosis
will require clarification by IHC [Figure 10]. Loss of
immunoarchitecture of the lymph node due to alteration
in the cellular components of the follicles, absence of
polarity, absence of starry sky like appearance of tangible
bodymacrophagesandlowmitoticactivitywillsupportthe
diagnosisoffollicularneoplasticproliferations.[27]
However,
inthecaseofin situFL,orpartiallyinvolvedlymphnodes,as
seeninoneoftheunspecifiedlymphomainthisstudy,these
features might not be convincing enough and hence giving
an impression of a reactive lesion [Figure 11]. In children
and in some reactive changes such as HIV, the mantle
zone might also be attenuated creating an impression of
a neoplastic lesion.
ThisstudyalsoshowedthelimitationofH and E,morphology
aloneinthediagnosisofMCL,asthefourcasesofMCLwere
diagnosed as small cell lymphomas unspecified and the
only one specified was wrongly called SLL. Although MCL
is seen as a low‑grade lymphoma morphologically, it is
a clinically aggressive lymphoma and these patients will
not benefit from the therapeutic modalities of indolent
lymphoma portrayed by the morphologic appearance of
the cells.[27‑29]
Like SLL, MCL cells are known to display
small cells but with oval or angulated nuclei, and usually
of monotonous cell population that usually disposed
in nodular pattern and show hyalinization of the blood
vessels. However, in some cases owning to some intrinsic
features of the tumor cells or poor fixation, the nuclei can
be rounded like SLL. The reactivity of the tumor cells with
cyclin D1, CD20, and CD23 is diagnostic of MCL [Figure 12].
From this study, there is no morphologic appearance that
is pathognomonic of each of the various lymphomas with
small cell morphology. Each of the tumors can display
discrepancy in their conventional cellular appearances and
be disposed in pseudo follicular, vague nodularity as well
as diffuse and parafollicular patterns, thereby mimicking
one another and sometimes difficult to differentiate from
reactivelesions.IHC,asshowninthisstudy,isaninvaluable
diagnostic means of sorting out these lymphomas. With
the use of small panels from B‑cell markers like CD20
or CD19, CD5, CD23, CD10, BCL2, BCL6, and cyclin D1
as well as CD43, the diagnostic dilemma associated with
lymphomas of small B‑cell variants could be solved to a
very large extent.[30,31]
SLL shows positivity with CD5 and
CD23 but negative for CD10 and BCL6 which were positive
for FL, while cyclin D1 will be positive in MCL but not in the
previous two. The loss of normal immune‑architecture and
expression of aberrant B‑cell markers such as CD5, CD43
and cyclin D1 as well as BCL2 in neoplastic proliferations
are helpful in distinguishing them from benign lesions.[32‑34]
The study showed that although the malignant nature of
lymphoblastic lymphomas [Figure 13] was recognized by
morphology in all the cases but the lesions could not be
subtyped as B‑ or T‑cell in origin because these two have
subtle and subjective morphological differences. A panel of
antibody consisting of CD3 (cyt), CD5, CD20/CD79a, and
CD34, TdT, CD99 were useful to differentiate the cells into
B‑ or T‑cell types as well as to exclude mature lymphomas
with morphological resemblance such as blastoid MCL, BL,
and DLBCL. Immature B‑ and T‑cell are positive for TdT
and CD43 but the B‑cell are usually negative for CD20 and
CD45 while immature T‑cell are surface CD3 negative.[35,36]
Unlike the B‑cell NHL, the study showed that, as
already documented in the literature, the diagnosis and
classification of T‑NHL is more complicated by its diverse
morphological types, extensive inflammatory background
andnonspecificantigen profileaswell aspoorhistogenesis
of the tumor cells.[37]
With the exception of ALCL and AIBL,
most cases of nodal T‑cell lymphomas are poorly defined
andarecategorizedunderabigumbrellacalledPTCLwhich
constitutes about 50% of mature T‑cell lymphomas as seen
in this study. Out of the 10 cases of the PTCL, eight were
suspectedforlymphomaandtwocasesweremisdiagnosed

Figure 11: Partial (in situ) folicullar lymphoma

as tuberculosis and SLL. PTCL is a waste basket diagnosis
where all types of T‑cell lymphoma that could not be
classified as an entity by clinical and morphological means
are dumped, thereby accounting for its heterogenous
morphology. The association of T‑cell lymphomas with
abundant mixed inflammatory background could lead to
the diagnosis of a reactive lesion as seen in this study. The
limitation of H and E, morphology alone in the diagnostic
hematopathology was also reflected in the diagnosis of
ALCL [Figure 4] as this could be misdiagnosed as HL or
anaplastic carcinoma most probably due to the presence
of atypical large cells. With a small panel of markers
consisting of CD20, CD3, CD15, CD30 and cytokeratin,
these tumors could be differentiated with ease. Positivity
of the large cells for cytokeratin will exclude lymphoma
while staining with CD3 often excludes HL as well as
DLBCL.[26,37‑39]
Occasionally,inadditiontothese,stainingfor
Alk1 and EMA (ALCL positive), PAX5 and EBV (HL positive)
Figure 12: Mantle cell lymphoma
Figure 13: B-cell lymphoblastic lymphoma

might be required as the second panel if necessary.
Additional antibody panel, consisting of CD4, CD8, CD7
as well as markers for cytotoxic granules (lysozyme,
perforin, TIA, granzyme) might also be required in cases
of T‑cell lymphoma. The polymorphous morphology and
presence of equivocal atypical small cell seen in most T‑cell
especially the PTCL might cause confusion between T‑cell
lymphomas and reactive lesions in which the reactive cell
are predominantly T‑cell response. Unlike diffuse B‑cell
proliferativelesions,wherethelossofimmunoarchitecture
is usually in support of lymphoma, such diffuse T‑cell
proliferation can be seen in reactive lymphoid lesion with
predominant T‑cell infiltrate. In this case identification
of loss of pan T‑cell markers like CD2, CD3, CD5, CD7,
or expression of aberrant markers such as ALK1, CD56
(in nodal lesions) as well as double negativity or positivity
for CD4 and CD8 by the tumor cells are needed to exclude
such reactive lesions.[26]
This study showed that among lymphoid lesions that can
pose serious diagnostic challenge using morphology as
the sole diagnostic tool is Castleman disease [Figure 14].
All the three cases seen in this study were not correctly
diagnosed. This is most probably due to its nonconversant
diagnostic features and less frequently due to the fact that
it can mimic or be associated with lymphomas. The usual
morphology of expanded mantle with onion skin pattern
and presence of hyalinized vessels and plasma cells will
assist in its diagnosis. The diagnostic accuracy can be
improved with IHC as the follicules will be BCL2 negative
and the mantle zone cells BCL2 positive. In addition, the
plasma cell will show polyclonal immunoglobulin light
chain.
CONCLUSION
This study demonstrated that, although morphology
remains the cornerstone for the diagnosis of lymphomas,
the morphologic complexity of NHL often hampers the
pathologist’s ability to differentiate benign from malignant
disease correctly. Histologic subtyping with the help of
immunohistochemical characterization of the tumor cells
will help to distinguish between lymphomas subtypes,
differentiate between reactive and nonreactive malignant
lymphoidlesionsandidentifypoorlydifferentiatedmalignant
nonlymphoidneoplasms.Werecommendthatzonalcenters
should be established in resource poor countries such as
Nigeriawherefacilitiesforaccuratediagnosisoflymphomas
are made available as this will improve therapeutic and
prognostic values as well as enhancing contemporary
researches in areas of lymphoreticular diseases.
Acknowledgment
We express our gratitude to Prof. AAF Banjo of The
Department of Anatomic and Molecular Pathology, College
of Medicine, University of Lagos, the management of The
Specialist Laboratory for allowing us to use their materials
for this study and for their professional guide. We also
acknowledged the consultancy services provided by
Dr. Uche Igbokwe of The Department of Cellular Pathology,
Queen‘s Hospital Rom Valley, United Kingdom.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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