—  SYMPOSIUM #20  —

Hodgkin Lymphoma: Diagnostic and Biological Insights
Moderators: Dr. Philippe Gaulard and Dr. Nancy Lee Harris

Section 5 - Hodgkin Lymphoma: Diagnostic and Biological Insights

Harald Stein
Institute of Pathology
Universitätsmedizin Berlin
Charité Campus Benjamin Franklin


The mystery which surrounded Hodgkin lymphoma (HL) for more than 150 years is dissipating although new findings raise new questions. Today we know the following:
  • The cytokine receptor CD30 of the TNF-receptor family is the most specific molecular marker for Hodgkin- and Reed-Sternberg cells. However, CD30 is not restricted in its expression to Hodgkin- and Reed-Sternberg cells. It also occurs on the tumor cells of anaplastic large cell lymphomas, diffuse large B-cell lymphomas of the anaplastic variant, enteropathy-type T-cell lymphomas with anaplastic differentiation and others. Outside the lymphoid systems CD30 is expressed on embryonal carcinomas. In normal lymphoid tissues CD30 is only detectable on few perifollicular blasts. In germinal centres CD30 might be expressed by blastoid cells located at the margin of the light zone. [1, 2, 3]

  • HLs are composed of two different disease entities i.e. nodular lymphocyte predominant HL (nLPHL) and classical HL. These two HL entities can be – thanks to differences in the immunophenotype of the tumour cells –distinguished from each other with 100% reliability in all instances. The atypical cells of classical HL, i.e. the Hodgkin- and Reed-Sternberg cells, are positive for CD30, CD15 and lack B-cell antigens in all or most instances respectively. In contrast, the dysplastic cells of nLPHD (usually termed as L&H or popcorn cells) express CD20, CD75, Oct2 and J-chain and are devoid of CD30 and CD15 in all or most instances respectively. There are also differences in the growth patterns which can be highlighted by immunohistochemical reactions for follicular dendritic cells using anti-CD21 antibodies. [3]

  • A novel subtype of classical HL: In the late 90ies a new subtype of classical HL has been identified by immunophenotyping, i.e. nodular lymphocyte-rich classical HL (LRCHL). The knowledge of the diagnostic criteria of this subtype is important since it is easily confused with nLPHL on H&E histology. The separation of LRCHL from nLPHL is only reliably possible by immunophenotypting. [4]

  • Differential diagnostic aspects: The major differential diagnosis of classical HL is its separation from anaplastic large cell lymphoma (ALCL), diffuse large B-cell lymphoma of anaplastic variant and primary mediastinal B-cell lymphoma. Most helpful for the differential diagnosis between classical HL and ALCL are the B-cell lineage maintenance transcription factor PAX5, CD43 and the anaplastic lymphoma kinase (ALK). PAX5 is expressed - although at a lower level as in reactive B cells - on Hodgkin- and Reed-Sternberg cells of more than 95% of classical HL cases in difference to ALCL where PAX5 is consistently absent. CD43 and ALK do not occur on Hodgkin-and Reed-Sternberg cells but are expressed on most or at least half of the ALCL respectively. The Hodgkin- and Reed-Sternberg cells of classical HL differ immunophenotypically from diffuse large B-cell lymphomas of analplastic variant and primary mediastinal B-cell lymphoma in that the latter consistently express B-cell antigens as well Oct2 and BOB.1. A very important differential diagnosis is between classical HL which has only focally affected lymphoid tissue and reactive increase of CD30-positive blasts. Classical HL should be diagnosed only if the CD30-positive cells have the morphological features of mononuclear Hodgkin or multinuclear Reed-Sternberg cells. [3, 5]

  • Clinical behaviour: Classical HL was a fatal disease till the 60ies. Over 90% of the patients died within 3 to 4 years. This has dramatically changed with the introduction of polychemotherapy. The most advanced polychemotherapy regimen BEACOPP has increased the long-term remission rate to over 90% even in advanced stages. nLPHL is an indolent disease which tends to repetitious relapses. Its treatment with anti-CD20 antibodies proved to be efficient. A major advantage of this treatment modality is the avoidance of the side effects of polychemotherapy. It appears as if patients with nLPHL were over-treated in the past. [6, 7]

  • Clonality of the atypical cells in HL: Both types of HD are a clonal lymphoproliferative disorders which start with one single transformed lymphoid cell. This finding induced the WHO to regard Hodgkin's disease as a true lymphoiod neoplasm and rename Hodgkin's disease into Hodgkin lymphoma (HL). [8, 9, 10, 11]

  • Cellular derivation: Single cell studies have demonstrated that the tumour cells of LPHL are derived from B-cells in 100% and of classical HL in 98-99% of the cases. In the residual classical HL cases the tumour cells originate from T cells. [9, 11, 12, 13]

  • The differentiation stage of the B cells from which LPHL and classical HL of B-cell type originates has been identified as that of the germinal centre B cells. [14]

  • Lack of immunoglobulin expression: The tumour cells of classical HL have lost their capacity to express immunoglobulin (Ig) in all and B-cell antigens in most instances and instead express B-cell inappropriate antigens like GATA3, T-bet, CD2, CD3, CD4, and others in varying frequencies. [9, 12, 15, 16]

  • Cause of the non-expression of Ig : This is due to a defect in the transcription machinery in which down-regulation of the transcription factors Oct2, BOB.1, PU.1 and epigenetic factors are involved. [17, 18, 19, 20]

  • Extinction of the B-cell expression program. This in conjunction with the expression of B-cell inappropriate proteins is – at least partially – due to intrinsic inhibition of the transcription factor E2A by HLH proteins ABF-1 and Id2. [16]

  • Deregulated pathways: Several pathways are dregulated, e.g. CD30, NF-kB, AP-1 and Notch-1. [21, 22, 23, 24, 25, 26]

  • Effects of deregulated pathways: The result of the deregulated pathways is the up-regulation of several anti-apoptotic molecules (e.g. TRAF1, XIAP, cIAP2, c-FLIP, pro-proliferative molecules cyclin D2 and certain chemokine receptors, e.g. CCR7. [27, 28, 29, 30, 31, 32]

  • Preferential dissemination in lymph nodes: The up-regulation of the chemokine receptor CCR7 in Hodgkin and Reed-Sternberg cells appears to be mainly responsible for growing in lymph nodes and not in extranodal sites. [32]
An important question which is not yet clarified is why HLs respond so well to polychemotherapy and Non-Hodgkin lymphomas not.

References
  1. Stein H, Mason DY, Gerdes J, O'Connor N, Wainscoat J, Pallesen G, Gatter K, Falini B, Delsol G, Lemke H, et al. The expression of the Hodgkin's disease associated antigen Ki-1 in reactive and neoplastic lymphoid tissue: evidence that Reed-Sternberg cells and histiocytic malignancies are derived from activated lymphoid cells. Blood. 1985 Oct;66(4):848-58.

  2. Durkop H, Latza U, Hummel M, Eitelbach F, Seed B, Stein H. Molecular cloning and expression of a new member of the nerve growth factor receptor family that is characteristic for Hodgkin's disease. Cell. 1992 Feb 7;68(3):421-7.

  3. Stein H, Delsol G, Pileri SA, et al. Hodgkin lymphoma. In: Jaffe ES, Harris NL, Stein H, Vardiman J, eds. World Health Organisation (WHO) Classification of Tumours-Pathology & Genetics-Tumours of Haematopoietic and Lymphoid Tissues. Lyon: IARC Press (International Agency for Research on Cancer); 2001:237-253.

  4. Anagnostopoulos I, Hansmann ML, Franssila K, Harris M, Harris NL, Jaffe ES, Han J, van Krieken JM, Poppema S, Marafioti T, Franklin J, Sextro M, Diehl V, Stein H. European Task Force on Lymphoma project on lymphocyte predominance Hodgkin disease: histologic and immunohistologic analysis of submitted cases reveals 2 types of Hodgkin disease with a nodular growth pattern and abundant lymphocytes. Blood. 2000 Sep 1;96(5):1889-99.

  5. Loddenkemper C, Anagnostopoulos I, Hummel M, Johrens-Leder K, Foss HD, Jundt F, Wirth T, Dorken B, Stein H. Differential Emu enhancer activity and expression of BOB.1/OBF.1, Oct2, PU.1, and immunoglobulin in reactive B-cell populations, B-cell non-Hodgkin lymphomas, and Hodgkin lymphomas. J Pathol. 2004 Jan;202(1):60-9.

  6. Diehl V, Franklin J, Hasenclever D, Tesch H, Pfreundschuh M, Lathan B, Paulus U, Sieber M, Rueffer JU, Sextro M, Engert A, Wolf J, Hermann R, Holmer L, Stappert-Jahn U, Winnerlein-Trump E, Wulf G, Krause S, Glunz A, von Kalle K, Bischoff H, Haedicke C, Duehmke E, Georgii A, Loeffler M. BEACOPP, a new dose-escalated and accelerated regimen, is at least as effective as COPP/ABVD in patients with advanced-stage Hodgkin's lymphoma: interim report from a trial of the German Hodgkin's Lymphoma Study Group. J Clin Oncol. 1998 Dec;16(12):3810-21.

  7. Diehl V, Franklin J, Pfreundschuh M, Lathan B, Paulus U, Hasenclever D, Tesch H, Herrmann R, Dorken B, Muller-Hermelink HK, Duhmke E, Loeffler M; German Hodgkin's Lymphoma Study Group.Standard and increased-dose BEACOPP chemotherapy compared with COPP-ABVD for advanced Hodgkin's disease. N Engl J Med. 2003 Jun 12;348(24):2386-95. Erratum in: N Engl J Med. 2005 Aug 18;353(7):744. dosage error in text.

  8. Kanzler H, Kuppers R, Hansmann ML, Rajewsky K. Hodgkin and Reed-Sternberg cells in Hodgkin's disease represent the outgrowth of a dominant tumor clone derived from (crippled) germinal center B cells. J Exp Med. 1996;184:1495-1505.

  9. Marafioti T, Hummel M, Foss HD, et al. Hodgkin and Reed-Sternberg cells represent an expansion of a single clone originating from a germinal center B-cell with functional immunoglobulin gene rearrangements but defective immunoglobulin transcription. Blood. 2000;95:1443-1450.

  10. Marafioti T, Hummel M, Anagnostopoulos I, Foss HD, Falini B, Delsol G, Isaacson PG, Pileri S, Stein H.

  11. Origin of nodular lymphocyte-predominant Hodgkin's disease from a clonal expansion of highly mutated germinal-center B cells. N Engl J Med. 1997 Aug 14;337(7):453-8.

  12. Seitz V, Hummel M, Marafioti T, Anagnostopoulos I, Assaf C, Stein H. Detection of clonal T-cell receptor gamma-chain gene rearrangements in Reed-Sternberg cells of classic Hodgkin disease. Blood. 2000 May 15;95(10):3020-4.

  13. Muschen M, Rajewsky K, Brauninger A, Baur AS, Oudejans JJ, Roers A, Hansmann ML, Kuppers R. Rare occurrence of classical Hodgkin's disease as a T cell lymphoma. J Exp Med. 2000 Jan 17;191(2):387-94.

  14. Marafioti T, Hummel M, Anagnostopoulos I, Foss HD, Huhn D, Stein H. Classical Hodgkin's disease and follicular lymphoma originating from the same germinal center B cell. J Clin Oncol. 1999 Dec;17(12):3804-9.

  15. Schwering I, Brauninger A, Klein U, Jungnickel B, Tinguely M, Diehl V, Hansmann ML, Dalla-Favera R, Rajewsky K, Kuppers R. Loss of the B-lineage-specific gene expression program in Hodgkin and Reed-Sternberg cells of Hodgkin lymphoma. Blood. 2003 Feb 15;101(4):1505-12. Epub 2002 Sep 26

  16. Mathas S, Janz M, Hummel F, Hummel M, Wollert-Wulf B, Lusatis S, Anagnostopoulos I, Lietz A, Sigvardsson M, Jundt F, Johrens K, Bommert K, Stein H, Dorken B. Intrinsic inhibition of transcription factor E2A by HLH proteins ABF-1 and Id2 mediates reprogramming of neoplastic B cells in Hodgkin lymphoma. Nat Immunol. 2006 Feb;7(2):207-15.

  17. Theil J, Laumen H, Marafioti T, Hummel M, Lenz G, Wirth T, Stein H. Defective octamer-dependent transcription is responsible for silenced immunoglobulin transcription in Reed-Sternberg cells. Blood. 2001 May 15;97(10):3191-6.

  18. Stein H, Marafioti T, Foss HD, Laumen H, Hummel M, Anagnostopoulos I, Wirth T, Demel G, Falini B. Down-regulation of BOB.1/OBF.1 and Oct2 in classical Hodgkin disease but not in lymphocyte predominant Hodgkin disease correlates with immunoglobulin transcription. Blood. 2001 Jan 15;97(2):496-501.

  19. Jundt F, Kley K, Anagnostopoulos I, Schulze Probsting K, Greiner A, Mathas S, Scheidereit C, Wirth T, Stein H, Dorken B. Loss of PU.1 expression is associated with defective immunoglobulin transcription in Hodgkin and Reed-Sternberg cells of classical Hodgkin disease.Blood. 2002 Apr 15;99(8):3060-2.

  20. Ushmorov A, Ritz O, Hummel M, Leithauser F, Moller P, Stein H, Wirth T. Epigenetic silencing of the immunoglobulin heavy-chain gene in classical Hodgkin lymphoma-derived cell lines contributes to the loss of immunoglobulin expression. Blood. 2004 Nov 15;104(10):3326-34.

  21. Bargou RC, Leng C, Krappmann D, et al. High-level nuclear NF-kappa B and Oct-2 is a common feature of cultured Hodgkin/Reed-Sternberg cells. Blood. 1996;87:4340-4347.

  22. Emmerich F, Meiser M, Hummel M, Demel G, Foss HD, Jundt F, Mathas S, Krappmann D, Scheidereit C, Stein H, Dorken B. Overexpression of I kappa B alpha without inhibition of NF-kappaB activity and mutations in the I kappa B alpha gene in Reed-Sternberg cells. Blood. 1999 Nov 1;94(9):3129-34.

  23. Skinnider BF, Elia AJ, Gascoyne RD, Trumper LH, von Bonin F, Kapp U, Patterson B, Snow BE, Mak TW. Interleukin 13 and interleukin 13 receptor are frequently expressed by Hodgkin and Reed-Sternberg cells of Hodgkin lymphoma.Blood. 2001 Jan 1;97(1):250-5.

  24. Skinnider BF, Elia AJ, Gascoyne RD, Patterson B, Trumper L, Kapp U, Mak TW. Signal transducer and activator of transcription 6 is frequently activated in Hodgkin and Reed-Sternberg cells of Hodgkin lymphoma. Blood. 2002 Jan 15;99(2):618-26.

  25. Mathas S, Hinz M, Anagnostopoulos I, et al. Aberrantly expressed c-Jun and JunB are a hallmark of Hodgkin lymphoma cells, stimulate proliferation and synergize with NF-kappa B. EMBO J. 2002;21:4104-4113.

  26. Jundt F, Anagnostopoulos I, Forster R, Mathas S, Stein H, Dorken B. Activated Notch1 signaling promotes tumor cell proliferation and survival in Hodgkin and anaplastic large cell lymphoma. Blood. 2002 May 1;99(9):3398-403

  27. Durkop H, Foss HD, Demel G, Klotzbach H, Hahn C, Stein H. Tumor necrosis factor receptor-associated factor 1 is overexpressed in Reed-Sternberg cells of Hodgkin's disease and Epstein-Barr virus-transformed lymphoid cells. Blood. 1999 Jan 15;93(2):617-23.

  28. Durkop H, Hirsch B, Hahn C, Foss HD, Stein H. Differential expression and function of A20 and TRAF1 in Hodgkin lymphoma and anaplastic large cell lymphoma and their induction by CD30 stimulation. J Pathol. 2003 Jun;200(2):229-39.

  29. Durkop H, Hirsch B, Hahn C, Stein H. cIAP2 is highly expressed in Hodgkin-Reed-Sternberg cells and inhibits apoptosis by interfering with constitutively active caspase-3. J Mol Med. 2006 Feb;84(2):132-41.

  30. Hinz M, Lemke P, Anagnostopoulos I, et al. Nuclear factor kappaB-dependent gene expression profiling of Hodgkin's disease tumor cells, pathogenetic significance, and link to constitutive signal transducer and activator of transcription 5a activity. J Exp Med. 2002;196:605-617.

  31. Mathas S, Lietz A, Anagnostopoulos I, Hummel F, Wiesner B, Janz M, Jundt F, Hirsch B, Johrens-Leder K, Vornlocher HP, Bommert K, Stein H, Dorken B.: c-FLIP mediates resistance of Hodgkin/Reed-Sternberg cells to death receptor-induced apoptosis. J Exp Med. 2004 Apr 19;199(8):1041-52.

  32. Hopken UE, Foss HD, Meyer D, Hinz M, Leder K, Stein H, Lipp M. Up-regulation of the chemokine receptor CCR7 in classical but not in lymphocyte-predominant Hodgkin disease correlates with distinct dissemination of neoplastic cells in lymphoid organs. Blood. 2002 Feb 15;99(4):1109-16