|Year : 2014 | Volume
| Issue : 2 | Page : 75-78
Anaplastic lymphoma kinase-positive large B-cell lymphoma: Unusual clinical and immunophenotypic features
Komal S Galani, Vijaya S Gadage, PG Subramanian, Sridhar Epari, Sitaram Ghogale, Sumeet Gujral
Department of Pathology, Hematopathology Laboratory, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||18-Dec-2014|
Hematopathology Laboratory, 727, Annexe Building, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma (ALK+ LBCL) is a rare subtype of diffuse large B-cell lymphoma. It is characterized by plasmacytic differentiation and cytoplasmic ALK positivity. Immunophenotype of ALK+ LBCL defines the terminally differentiated B-lineage cell characterized by the absence of B-cell antigens and expression of antigen associated with plasma cell differentiation. It is characterized by an aggressive behavior and poor response to standard chemotherapy. Advanced clinical stage and extranodal disease are associated with worse survival. We present a very rare case of ALK+ LBCL in a young immunocompetent lady who presented with multiple subcutaneous nodules and discuss the role of flow cytometry for prompt and accurate confirmation of the diagnosis.
Keywords: Anaplastic lymphoma kinase positive, flow cytometry, large B-cell lymphoma
|How to cite this article:|
Galani KS, Gadage VS, Subramanian P G, Epari S, Ghogale S, Gujral S. Anaplastic lymphoma kinase-positive large B-cell lymphoma: Unusual clinical and immunophenotypic features. Indian J Dermatopathol Diagn Dermatol 2014;1:75-8
|How to cite this URL:|
Galani KS, Gadage VS, Subramanian P G, Epari S, Ghogale S, Gujral S. Anaplastic lymphoma kinase-positive large B-cell lymphoma: Unusual clinical and immunophenotypic features. Indian J Dermatopathol Diagn Dermatol [serial online] 2014 [cited 2020 Jan 21];1:75-8. Available from: http://www.ijdpdd.com/text.asp?2014/1/2/75/147298
| Introduction|| |
Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma (ALK+ LBCL) was first described by Delsol and colleagues in 1997  and is now listed as a distinct entity in the 2008 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues.  ALK+ LBCL is an aggressive tumor with a poor response to conventional therapies. Although it appears to be very rare, it may, in fact, be underrecognized due to its morphologic and immunophenotypic overlap with other hematologic and nonhematologic entities. Awareness of this diagnosis, particularly in a new era of ALK inhibitor therapies, is necessary for hematopathologists as well as general surgical pathologists. We report a case of ALK+ LBCL presenting as multiple cutaneous nodules in a young immunocompetent female and discuss its detailed flow cytometry and immunohistochemical findings.
| Case Report|| |
A 27-year-old female presented with generalized lymphadenopathy and multiple, well-defined, circumscribed, firm, mobile subcutaneous swellings all over the body [Figure 1]a and b since 3 months. The overlying skin was unremarkable. Eastern Cooperative Oncology Group Performance score at presentation was grade I. Complete blood counts (CBC) showed anemia (hemoglobin 7.4 g/dl) and normal white cell count and platelets. Liver and renal function tests including serum protein levels were within normal range. Hence, protein electrophoresis was not done. Serum lactate dehydrogenase (LDH; 1305 IU/l) and β2-microglobulin (8.99 mg/l) levels were markedly raised. Serology for viral markers (HIV, hepatitis B and C) was negative. Fine needle aspiration (FNA) was done from subcutaneous nodule on the arm. Smears showed monomorphic population of large nucleolated cells with plasmablastic morphology [Figure 1]c and d. FNA was collected in phosphate-buffered saline (PBS) for immunophenotypic analysis (IPA) by flow cytometry, which was performed on BD-FACS Canto II, Chicago, analyzer using forward scatter (FSC)-versus-side scatter (SSC) gating strategy. Various fluorochrome (FITC/PE/PerCP.Cy-5.5/PE-Cy5/APC) conjugated monoclonal antibodies like CD45, CD20, CD22, CD19, CD10, CD79b, FMC7, CD38, CD138, kappa, lambda, CD56, CD57, CD3, CD4, CD8, CD5, CD7, CD2, CD30, and ALK1 were used in combinations. The tumor cells had higher FSC-versus-SCC as compared to normal lymphocytes [Figure 2]. Tumor cells were negative for pan B and T-cell markers, but they expressed CD38 with kappa light chain restriction and demonstrated coexpression of intracytoplasmic ALK1 and CD138. Tumor cells also expressed CD4, CD10, and IgM, while they were negative for CD56, CD57, and CD30. A diagnosis of ALK+ LBCL was rendered.
|Figure 1: Multiple subcutaneous nodules on (a) neck and (b) chest wall. (c and d) Fine needle cytology smears showing plasmablastic morphology (Wright's stain; ×100 and ×400)|
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|Figure 2: ALK+ LBCL: Flow cytometry performed on aspirate from subcutaneous nodule. Tumor cells (in green) show high FSC and express CD138, CD38, cytoplasmic ALK, kappa, IgM, CD10, and CD4 [reactive lymphocytes (in blue), CD3 positive]|
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Cervical lymph node biopsy [Figure 3]a showed effacement of architecture by sheets of large tumor cells with eccentric nuclei with prominent nucleoli, i.e, immunoblastic/plasmablastic morphology [Figure 3]c, which were immunopositive for CD45RB/leukocyte common antigen (LCA) [Figure 3]b, CD138 (heterogeneous and weak), epithelial membrane antigen (EMA), ALK protein (granular intracytoplasmic) [Figure 3]b, Bcl2, CD10, and showed kappa light chain restriction, and were negative for CD20, CD79a, CD3, CD5, CD30, CD56, and cyclin D1.
|Figure 3: ALK+ LBCL: (a) Low power view of lymph node (H and E, ×40). (b) Diffusely positive CD45 stain. (c) Tumor cells have plasmacytoid appearance and prominent nucleoli (H and E, ×400). (d) Alk-1 immunostaining - granular intracytoplasmic (×400)|
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Tumor cells constituted 56% of the total cells in the bone marrow aspirate. Trephine biopsy revealed scanty hypercellular marrow with interstitial pattern of involvement. Positron emission tomography (PET) scan revealed generalized lymphadenopathy with bilateral ovarian masses (measuring 6.7 × 7 cm), lung parenchymal deposits, and multiple subcutaneous nodules with maximum standardized uptake value (SUV) 14.0. Subsequently, the patient was staged as IV A with extranodal presentation by Ann Arbor staging system. She was put on for MCP 841 protocol. After 4 months of treatment, PET-CT scan revealed persistent disease at multiple nodal and extra-nodal sites with new soft tissue lesions, suggesting disease progression. The patient was lost to follow-up.
| Discussion|| |
Delsol et al. reported ALK expression in B-cell Non Hodgkin's Lymphoma (NHL) in 1997 and described a rare form of LBCL composed of monomorphic immunoblast-like cells that resembled anaplastic large cell lymphoma (ALCL) but lacked CD30 expression.  ALK+ LBCL frequently expresses plasma cell phenotype with expression of CD138, CD38, MUM1, while being negative for pan B and T-cell markers. , It expresses cytoplasmic immunoglobulins, CD4, CD57, and shows light chain restriction. It is characteristically negative for CD30, but expresses EMA and cytoplasmic granular ALK1. ,,,, Oncio et al. described two cases of NPM-ALK-positive plasmablastic lymphomas (PBLs) which differed markedly in their ALK staining pattern, showing diffuse staining versus a membrane and speckled pattern. 
ALK+ LBCL represents less than 1% of diffuse large B-cell lymphoma (DLBCL). ,, It has been reported in immunocompetent patients of all age groups (age range: 9-70 years and median age: 36 years) with male preponderance. ,, It has an aggressive clinical course being the advanced stage (III/IV) with extranodal presentation (48%), in comparison to a classical DLBCL. ,,,, Most common extranodal sites of involvement are nasopharynx, tongue, stomach, bone, and soft tissues; however, skin involvement is extremely rare. , The index case is a young female with extensive disease presenting as subcutaneous nodules and involving ovary, lung parenchyma, and bone marrow. An extensive Medline search revealed only 45 such reported cases so far and this is the third case from India.
ALK+ LBCL morphologically simulates other subtypes of NHLs like ALCL (ALK+ T/null cell), PBL, primary effusion lymphoma (PEL), and plasmablastic myeloma. , Plasma cell marker MUM1 is positive in all these NHLs including ALCL, while CD138 and CD38 are positive in all these NHLs except ALCL.  PBL remains the closest morphological and immunophenotypic mimicker of ALK+ LBCL, but in contrast, it is commonly seen in immunodeficient/HIV+ patients. 
Characteristically, all these NHL subtypes are negative for CD20.  However, few have reported expression of CD20 and CD79a in only 11% and 18% of cases of ALK+ LBCL, respectively. , The expression of either CD56 or cyclin D1 raises a suspicion for multiple myeloma (MM).  CD30 negativity excludes the diagnosis of CD30+ ALCL (ALK+/−, T/null type), other DLBCL, PBL, and PEL. , PBL frequently expresses Ebstein-Barr Virus- Ebstein-Barr virus encoded small RNAs (EBV-EBER) in 60-70% cases (100% in HIV+ cases), while PEL is exclusively associated with HHV-8.  ALK+ LBCL could also be misdiagnosed morphologically as poorly differentiated carcinoma, the latter being EMA positive and CD45 negative. ,
Differentiating it from carcinoma is important as the management protocol in lymphoma is non-surgical.
In the present case, flow cytometric (FCM) analysis confirmed the diagnosis by coexpression of cytoplasmic ALK with plasma cell markers. Interestingly, CD138 and CD38 were expressed strongly as intracytoplasmic markers than their surface expression. Also, FCM analysis showed expression of IgM with aberrant expression of CD10 and CD4. ALK+ LBCL is known to express intracytoplasmic immunoglobulin, usually IgA and rarely IgG. , Aberrant CD10 expression, as seen in our case, has not been reported as yet. ,,,,, Our case also showed aberrant CD4 expression by flow cytometry which is described in up to 40% cases without much prognostic significance. ,, Though Beltran et al. found better survival with CD4 expression, only occasional study reports the role of FCM in diagnosis of ALK+ LBCL. ,
The most common gene rearrangement is between clathrin and ALK [t (2;17) (p23;q23)], resulting in the CLTC-ALK chimeric protein, although other fusions have been described. The study conducted by Valera et al.  indicated that ALK+ LBCLs express a complete plasmablastic differentiation program but, contrary to PBLs, do not have MYC rearrangements. Signal transducer and activator of transcription 3 (STAT3) is constantly activated and may be an alternative mechanism to promote MYC expression in these tumors. The relevance of the ALK/STAT3 pathway in the pathogenesis of ALK+ LBCLs may offer an attractive target for new therapies.  These tumors show poor response to Cyclophosphamide, Hydroxy-daunorubicin, Oncovin and Prednisone (CHOP) or CHOP-like regimen. , Being CD20 negative, rituximab is unlikely to improve the outcome. ,,, Considering extensive involvement of extranodal sites in the present case, the patient is being treated with an intensive chemotherapy regimen- similar to that given in acute lymphoblastic leukemia, viz. MCP 841 protocol.  The recent introduction of the small molecule ALK inhibitor, crizotinib, may provide a potential new therapeutic option for patients with this disease. ,
| Conclusion|| |
ALK+ LBCL is a rare, aggressive B-cell lymphoma with characteristic morphologic, immunophenotypic, and cytogenetic/molecular findings. This case highlights an extensive extranodal involvement of ALK+ LBCL including subcutaneous nodules, ovary, and lung parenchyma and unusual expression of IgM, CD4 and CD10 expression. Awareness of this entity is important among dermatologists, hematopathologists, and general surgical pathologists. Although response to conventional therapy has been poor, the possibility of a targeted therapy provides an intriguing option for patients with this disease.
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[Figure 1], [Figure 2], [Figure 3]