Abstract
Myeloid cell nuclear differentiation antigen (MNDA) is normally expressed on myelomonocytic cells and a subset of B lymphocytes. It was found to be differentially expressed between nodal marginal zone lymphoma (MZL) and follicular lymphoma (FL). However, MNDA has not been widely used as a diagnostic marker in clinical practice. To validate its utility, we studied the expression of MNDA by immunohistochemistry in 313 cases of small B-cell lymphomas. Our results showed that MNDA was positive in 77.9% of MZL, 21.9% of mantle cell lymphoma, 28.9% of small lymphocytic lymphoma/chronic lymphocytic leukemia, 2.6% of FL, and 25% of lymphoplasmacytic lymphoma. MNDA positivity varied from 68.0% to 84.0% among the 3 MZL subtypes, with extranodal MZL having the highest percentage. There was a statistically significant difference in MNDA expression between MZL and FL, mantle cell lymphoma, small lymphocytic lymphoma/chronic lymphocytic leukemia, or lymphoplasmacytic lymphoma. CD43 expression was slightly more frequent in MNDA-negative MZL than in MNDA-positive MZL. Combined use of CD43 and MNDA improved the diagnostic sensitivity for MZL from 77.9% to 87.8%. There was a trend of positive correlation between MNDA and p53 in MZL. In conclusion, MNDA is preferentially expressed in MZL among small B-cell lymphomas and it is a useful marker for the differentiation of MZL and FL.
Key Words: myeloid cell nuclear differentiation antigen, marginal zone lymphoma, small mature B-cell lymphoma, CD43
Small B-cell lymphomas (SBCLs) are a diverse group of non-Hodgkin lymphomas that are classified based on morphology, immunophenotype, and cytogenetic or molecular features.1 Among the SBCLs, marginal zone lymphoma (MZL) is a heterogenous entity that has overlapping features with other SBCLs or reactive conditions. MZL is often a diagnosis of exclusion as there is a lack of specific diagnostic markers. For example, one of the diagnostic challenges is to differentiate MZL with follicular colonization from follicular lymphoma (FL).2–5 Using a subtractive hybridization approach, myeloid cell nuclear differentiation antigen (MNDA) was identified as one of the differentially expressed genes between nodal marginal zone lymphoma (NMZL) and FL.6 MNDA is a nuclear protein that plays an important role in cell proliferation, differentiation, and apoptosis.7 Its expression is restrictive to myelomonocytic cells and a subset of B lymphocytes in normal lymphoid tissues.8 Previous studies have shown that MNDA can be useful in the differentiation of MZL and FL.6,8–10 However, it has not been widely used as a diagnostic marker in clinical practice. To evaluate its clinical utility, we studied the expression of MNDA in 313 cases of SBCLs.
MATERIALS AND METHODS
This study has been approved by the Institutional Review Board of Northwell Health. Our pathology database was retrospectively searched for SBCL cases. We identified 313 cases which were diagnosed in our institution and had available materials for immunohistochemical (IHC) study including 154 MZL, 77 FL, 45 small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL), 32 mantle cell lymphoma (MCL), 4 lymphoplasmacytic lymphoma (LPL), and 1 hairy cell leukemia. The cases were collected during a 3-year period. Additional MZL cases were collected from another 4 years which leads to a total of 154 MZL cases being collected from 7 consecutive years. The FL group included 58 grade 1-2 and 19 grade 3A or 3B cases. The biopsy sites included lymph node and a variety of extranodal tissues from gastrointestinal tract, mesentery, lung, pleura, urinary bladder, parotid gland, nasopharynx, orbit, and bone marrow. Diagnoses of cases were made according to the 2016 WHO Fourth Edition classification of Tumours of Haematopoietic and Lymphoid Tissues1 and International Consensus Classification of Lymphoid Neoplasm (ICC).11 Also, 10 reactive lymph nodes, 10 tonsils, and 3 spleens were included to study the normal expression pattern.
IHC studies were performed following the standard protocols. Formalin-fixed, paraffin-embedded tissue sections were stained with monoclonal mouse anti-human MNDA antibody (253A) (Abcam; ab188566, 1:100 dilution), CD43 (Ventana; clone L60) and p53 (DAKO; clone DO-7) on a Ventana Ultra with an OptiView Amplification Kit and an OptiView DAB IHC Detection Kit (Roche Ventana Medical Systems). For MNDA interpretation, nuclear staining in >30% of tumor cells was considered positive. p53 staining was scored as positive when >30% cells showed nuclear stain. All IHC stains were reviewed by 3 hematopathologists.
Statistical analysis was performed using SPSS 20.0. The difference of MNDA expression between MZL and other subtypes of SBCL as well as the correlation between p53 and MNDA expression were performed using χ2 and Fisher exact analysis. A significant difference was accepted at P-value <0.05.
RESULTS
MNDA Expression in Normal Lymphoid Tissues
MNDA expression was studied by IHC using a commercial anti-MNDA monoclonal antibody. In normal lymphoid tissues, MNDA showed a nuclear staining pattern with the strongest expression in myelomonocytic cells, which was often used as an internal positive control. MNDA was expressed with a much lower intensity in lymphocytes which was restrictive to the B cells in primary follicles and mantle zones of secondary follicles in lymph node and tonsil. In spleen, MNDA expression was expressed by the marginal zone of secondary follicles. However, MNDA was negative in other cell types, including germinal center B cells, T cells, and plasma cells (Fig. 1).
FIGURE 1.
Expression of myeloid nuclear differentiation antigen in a benign lymph node. A (×10) and C (×40) show a lymph node with follicular hyperplasia. B (×10) and D (×40) show dim myeloid nuclear differentiation antigen staining in B cells in the mantle and marginal zones of the follicles. The myeloid cells show strong myeloid nuclear differentiation antigen expression.
MNDA Expression in SBCLs
Table 1 summarizes the results of MNDA expression in 313 cases of SBCLs and representative images are shown in (Figures 2 and 3). Overall, 46% (144/313) of the total cases were positive for MNDA. Of the cases, MNDA was positive in 77.9% (120/154) of MZL including 68.0% (34/50) of NMZL, 84.0% (79/94) of extranodal marginal zone lymphoma (EMZL), and 70.0% (7/10) of splenic marginal zone lymphoma (SMZL). In contrast, only 2.6% (2/77) of FL was positive for MNDA. One of the positive FL cases was grade 3B with a diffuse large B-cell lymphoma component. In addition, MNDA was positive in 21.9 % (7/32) of MCL, 28.9% (13/45) of SLL/CLL, and 25.0% (1/4) of LPL. The only hairy cell leukemia case in this cohort was also positive for MNDA. There was a statistically significant difference for MNDA expression between MZL and FL (P<0.00001), MCL (P<0.00001), SLL/CLL (P<0.00001), or LPL (P<0.01). The specificity of MNDA in differentiating MZL from FL is 97.4%; the specificity of MNDA in differentiating MZL from SLL/CLL and MCL is 74.0%.
TABLE 1.
MNDA Expression Results in Various Small Mature B-Cell Lymphomas
| n (%) | ||||
|---|---|---|---|---|
| Diagnosis | No. cases | MNDA+ | MNDA− | P |
| MZL | 154 | 120 (77.9) | 34 (22.1) | |
| NMZL | 5049 | 34 (68.0) | 16 (32.07) | |
| EMZL | 94 | 79 (84.0) | 15 (16.0) | |
| SMZL | 1011 | 7 (70) | 3 (30) | |
| FL | 77 | 2 (2.6) | 75 (97.4) | <0.00001 |
| MCL | 32 | 7 (21.9) | 25 (78.1) | <0.00001 |
| SLL/CLL | 45 | 13 (28.9) | 32 (71.1) | <0.00001 |
| LPL | 4 | 1 (25.0) | 3 (75.0) | <0.01 |
| HCL | 1 | 1 (100.0) | 0 (0.0) | >0.05* |
| Total | 313 | 144 (46.0) | 169 (54.0) | |
EMZL indicates extranodal marginal zone lymphoma; FL, follicular lymphoma; HCL; hairy cell leukemia; LPL, lymphoplasmacytic lymphoma; MCL, mantle cell lymphoma; MNDA, myeloid cell nuclear differentiation antigen; MZL, marginal zone lymphoma; NMZL, nodal marginal zone lymphoma; SLL/CLL, small lymphocytic lymphoma/chronic lymphocytic leukemia; SMZL, splenic marginal zone lymphoma.
Statistical analysis was performed using χ2 test.
Statistical analysis was performed using the Fisher exact test.
FIGURE 2.
Lack of expression of myeloid nuclear differentiation antigen in the majority of chronic lymphocytic leukemia, follicular lymphoma, and mantle cell lymphoma cases. A case of chronic lymphocytic leukemia (top row, ×40; A, B), follicular lymphoma (middle row, ×40; C, D) and mantle cell lymphoma (last row, ×40; E, F), respectively, show myeloid nuclear differentiation antigen expression in residual mantle zone in follicular lymphoma and rare myeloid cells. The neoplastic cells are negative for myeloid nuclear differentiation antigen.
FIGURE 3.
Hematoxylin and eosin and expression of myeloid nuclear differentiation antigen in follicular lymphoma, marginal zone lymphoma, and splenic marginal zone lymphoma. A and B, ×40 shows the only high-grade follicular lymphoma with strong myeloid nuclear differentiation antigen expression. C and D, ×40 shows a case of nodal marginal zone lymphoma with moderate to strong expression of myeloid nuclear differentiation antigen. E, ×5 and F, ×10 show a splenic marginal zone lymphoma case with myeloid nuclear differentiation antigen expression in neoplastic B cells in the expanded marginal zones of the follicles. The germinal center B cells in splenic marginal zone lymphoma are negative for myeloid nuclear differentiation antigen.
Correlation Between MNDA and CD43 Expression
Of the 154 MZL cases, 131 had available information for both MNDA and CD43. CD43 was positive in 41.2% of MZL cases, including 53.7% of NMZL, 38.9% of EMZL, and 10.0%of SMZL cases. CD43 expression was slightly more frequent in the MNDA-negative MZL group 48.8% than in the MNDA-positive MZL group 40.2% (Table 2). The difference for CD43 expression between MNDA-positive MZL and MNDA-negative MZL is not statistically significant (P>0.05). A combination of MNDA and CD43 resulted in a sensitivity of 87.8% for the diagnosis of MZL.
TABLE 2.
CD43 and MNDA Expression in MZL
| n/N (%) | ||
|---|---|---|
| Diagnosis | MNDA+CD43+ | MNDA−CD43+ |
| MZL (n=131) | 41/102 (40.2) | 13/29 (44.8) |
| NMZL (n=4140) | 14/27 (51.9) | 8/14 (57.1) |
| EMZL (n=80) | 26/68 (38.2) | 5/12 (41.7) |
| SMZL (n=1011) | 1/7 (14.2) | 0/3 (0.0) |
EMZL indicates extranodal marginal zone lymphoma; MNDA, myeloid cell nuclear differentiation antigen; MZL, marginal zone lymphoma; NMZL, nodal marginal zone lymphoma; SMZL, splenic marginal zone lymphoma.
Correlation Between MNDA and p53 Expression
p53 expression was observed in 41.2% of MNDA-positive MZL and 18.2% of MNDA-negative MZL cases, respectively. A trend of positive correlation between p53 and MNDA was observed in MZL though it was statistically insignificant (P=0.05) (Table 3). In addition, the MNDA-positive grade 3B FL case showed strong p53 expression. Three of 4 MNDA-positive SLL/CLL cases with complex karyotype expressed p53. All the MNDA-positive MCL cases were positive for p53 (Fig. 4).
TABLE 3.
p53 Expression in Marginal Zone Lymphoma
| p53+ | p53− | P | |
|---|---|---|---|
| MNDA+ | 28 | 40 | 0.05 |
| MNDA− | 4 | 18 | |
| Total | 32 | 58 |
MNDA indicates myeloid cell nuclear differentiation antigen.
Statistical analysis was performed using the χ2 test.
FIGURE 4.
Expression of myeloid nuclear differentiation antigen and p53. A, ×10 shows an extranodal marginal zone lymphoma involving the gastrointestinal tract. B and C, ×40 demonstrate myeloid nuclear differentiation antigen and p53 expression in the lymphoma cells. D–F, Grade 3 follicular lymphoma expressing myeloid nuclear differentiation antigen and p53, respectively (all pictures at ×40).
DISCUSSION
There are 3 common WHO-defined entities of MZL: NMZL, EMZL, and SMZL.1 MZL is generally a CD5-negative and CD10-negative SBCL. Since only a subset of MZL expresses CD43, it is often problematic to differentiate MZL from reactive lymphoid hyperplasia. CD5 is observed in a minority of MZL cases, which renders it difficult to differentiate MZL from SLL/CLL. Differential expression of CD10, BCL-6, BCL-2, and MUM-1 in the lymphoid follicles can aid to differentiate between MZL and FL. However, the diagnosis becomes challenging with CD10-negative FL to assess whether it is MZL with follicular colonization or FL.4,5 Human germinal center-associated lymphoma and LIM-domain only 2 (LMO2) are 2 additional markers that can be used to provide evidence of a follicle center B-cell immunophenotype when CD10 and BCL-6 are negative or indeterminate.12 Given the histologic and immunophenotypic heterogeneity in MZL, it is important to identify new diagnostic markers.
It has been previously shown that MNDA is differentially expressed between MZL and FL.6,8–10 As is seen in Table 4, MNDA showed a significant difference between MZL and FL in all the studies. However, MNDA expression in the other SBCL subtypes varied significantly among these studies, which could be due to case selection or different sources of antibody. To validate these findings and further evaluate the utility of MNDA in the diagnosis of MZL, we performed a retrospective study of MNDA expression in a large cohort of SBCLs. First, we studied the expression of MNDA in normal lymphoid tissues, which showed a restrictive expression in the B cells of the primary follicle and mantle/marginal zone of the secondary follicle. In clinical practice, it is often challenging to differentiate primary follicles in lymphoid hyperplasia from SBCL given their morphologic similarity. MNDA expression in the primary follicle was previously reported as potential pitfall in the differential diagnosis with MZL.14 We observed that in primary follicular hyperplasia, MNDA expression was confined to follicles, while MNDA-positive cells always showed infiltrative pattern involving interfollicular areas, germinal centers in SBCLs. Based on our experiences, these expression patterns are very useful in differentiating primary follicle from SBCL, especially when combined with other markers such as LEF-1, cyclin D1, BCL-6. Second, this study showed that MNDA was positive in the majority of MZL cases with the highest frequency in EMZL, which is helpful for diagnosis as EMZL is the most heterogenous subtype among MZL subtypes. On the contrary, MNDA is rarely positive in FL and only positive in a subset of SLL/CLL, MCL, and LPL. Statistical analysis revealed a significant difference between MZL and FL, MCL, SLL/CLL, or LPL. The findings suggest that MNDA is useful in differentiating MZL from other SBCL subtypes. However, MNDA has a lower specificity for differentiating MZL from non-FL SCBLs than for differentiating MZL from FL. Therefore, it should be used with caution in clinical practice for diagnosing MZL when the differential diagnoses include non-FL SCBLs. Third, CD43 is expressed on a small subset of normal B cells but is often positive in SCBLs other than low-grade FL.13 As a result, CD43 is generally used as an aberrant B-cell marker to differentiate lymphoproliferative process from reactive conditions. However, CD43 is less useful in the diagnosis of MZL as it is only positive in a subset of MZL. In this study, we assessed the relationship between CD43 and MNDA in MZL, which showed that CD43 was slightly more frequent in MNDA-negative group than in MNDA-positive group and that a combined use of MNDA and CD43 can significantly improve the sensitivity for the diagnosis of MZL.
TABLE 4.
Comparison of Myeloid Cell Nuclear Differentiation Antigen Expression With the Previous Studies
| n/N (%) | ||||
|---|---|---|---|---|
| Type of lymphoma | Kanellis et al6 | Metcalf and colleagues9,10 | Wang and colleagues10,13 | This study |
| NMZL | 43/57 (75.0) | 16/24 (66.7) | 12/22 (54.0) | 34/50 (68.0) |
| EMZL | 19/20 (95.0) | 27/44 (61.4) | 21/31 (68.0) | 79/94 (84.0) |
| SMZL | 20/20 (100.0) | 5/21 (23.8) | 18/26 (69.0) | 7/10 (70.0) |
| FL | 9/184 (5.0) | 6/110 (5.5) | 3/14 (21.0) | 2/77 (2.6) |
| MCL | 61/74 (82.0) | 9/140 (6.4) | 7/9 (78.0) | 7/32 (21.9) |
| SLL/CLL | 23/35 (65.0) | 4/31 (12.9) | 8/15 (53.0) | 13/45 (28.9) |
EMZL indicates extranodal marginal zone lymphoma; FL, follicular lymphoma; MCL, mantle cell lymphoma; NMZL, nodal marginal zone lymphoma; SLL/CLL, small lymphocytic lymphoma/chronic lymphocytic leukemia; SMZL, splenic marginal zone lymphoma.
Studies showed that nuclear expression of MNDA can inhibit cellular apoptosis.15,16 MNDA is a member of IFI200 gene family whose members share similar functional domains. Some IFI200 members were shown to interact with p53 and induce cell growth arrest in a p53-dependent manner.17 This suggests that MNDA may have similar functions. In addition, it was previously observed that deletion 17q or p53 protein expression was associated with a high proliferation index and aggressive clinical behavior in MZL.18–20 Furthermore, MNDA expression was observed in FL with a higher histologic grade and DLBCL. These findings suggest that MNDA expression may be associated with an unfavorable prognosis. To explore this possibility, we studied the relationship between MNDA and p53 and showed a trend of positive correlation between MNDA and p53 in MZL. In addition, p53 expression was also seen in other MNDA-positive SBCLs with histologic or cytogenetic features suggestive of aggressive behaviors. These results suggest that MNDA may have prognostic values in SBCLs. However, further studies are needed to validate these findings.
In conclusion, this study demonstrated that MNDA is expressed with high frequency in MZL, and can be used with CD43 and other diagnostic markers. Its limited expression in FL as compared with MZL was particularly helpful for the differentiation of these 2 types of lymphoma.
Footnotes
N.G., X.Z., and S.S.-F.: wrote the manuscript. N.G., S.R., H.S., K.L.S., and S.S.-F.: analyzed the dataset. P.H., X.Z., and S.S.-F.: interpreted the histopathologic pictures and immunohistochemical stains.
The authors declare no conflict of interest.
Contributor Information
Neha Gupta, Email: drng2009@gmail.com.
Sudarhana Roychoudry, Email: sroychoudh@northwell.edu.
Kristin L. Sticco, Email: ksticco@northwell.edu.
Peihong Hsu, Email: phsu@northwell.edu.
Xinmin Zhang, Email: xzhang2@northwell.edu.
Silvat Sheikh-Fayyaz, Email: ssheikh@northwell.edu.
REFERENCES
- 1.Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumors of Haematopoietic and Lymphoid Tissues Revised, 4th ed. IARC; 2017. [Google Scholar]
- 2.Molina TJ, Lin P, Swerdlow SH, et al. Marginal zone lymphomas with plasmacytic differentiation and related disorders. Am J Clin Pathol. 2011;136:211–225. [DOI] [PubMed] [Google Scholar]
- 3.Camacho FI, Algara P, Mollejo M, et al. Nodal marginal zone lymphoma: a heterogeneous tumor: a comprehensive analysis of a series of 27 cases. Am J Surg Pathol. 2003;27:762–771. [DOI] [PubMed] [Google Scholar]
- 4.Naresh KN. Nodal marginal zone B-cell lymphoma with prominent follicular colonization-difficulties in diagnosis: a study of 15 cases. Histopathology. 2008;52:331–339. [DOI] [PubMed] [Google Scholar]
- 5.Kojima M, Nakamura S, Murase T, et al. Follicular colonization of nodal marginal-zone B-cell lymphoma resembling follicular lymphoma: report of 6 cases. Int J Surg Pathol. 2005;13:73–78. [DOI] [PubMed] [Google Scholar]
- 6.Kanellis G, Roncador G, Arribas A, et al. Identification of MNDA as a new marker for nodal marginal zone lymphoma. Leukemia. 2009;23:1847–1857. [DOI] [PubMed] [Google Scholar]
- 7.Johnstone RW, Trapani JA. Transcription and growth regulatory functions of the HIN-200 family of proteins. Mol Cell Biol. 1999;19:5833–5838. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Miranda RN, Briggs RC, Shults K, et al. Immunocytochemical analysis of MNDA in tissue sections and sorted normal bone marrow cells documents expression only in maturing normal and neoplastic myelomonocytic cells and a subset of normal and neoplastic B lymphocytes. Hum Pathol. 1999;30:1040–1049. [DOI] [PubMed] [Google Scholar]
- 9.Metcalf RA, Ahmad Monabati A, Vyas M, et al. Myeloid cell nuclear differentiation antigen is expressed in a subset of marginal zone lymphomas and is useful in the differential diagnosis with follicular lymphoma. Hum Pathol. 2014;45:1730–1736. [DOI] [PubMed] [Google Scholar]
- 10.Wang Z, Cook JR. IRTA1 and MNDA Expression in marginal zone lymphoma utility in differential diagnosis and implications for classification. Am J Clin Pathol. 2019;151:337–343. [DOI] [PubMed] [Google Scholar]
- 11.Campo E, Jaffe ES, Cook JR, et al. The International Consensus Classification of Mature Lymphoid Neoplasms: a report from the Clinical Advisory Committee. Blood. 2022;140:1229–1253. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Boyd SD, Natkunam Y, Allen JR, et al. Selective immunophenotyping for diagnosis of B-cell neoplasms: immunohistochemistry and flow cytometry strategies and results. Appl Immunohistochem Mol Morphol. 2013;21:116–131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lai R, Weiss LM, Chang KL, et al. Frequency of CD43 expression in non-Hodgkin lymphoma. A survey of 742 cases and further characterization of rare CD43+ follicular lymphomas. Am J Clin Pathol. 1999;111:488–494. [DOI] [PubMed] [Google Scholar]
- 14.Manohar V, Peerani R, Tan B, et al. Myeloid cell nuclear differentiation antigen (MNDA) positivity in primary follicles: potential pitfall in the differentiation diagnosis with marginal zone lymphoma. Appl Immunohistochem Mol Morphol. 2020;28:384–388. [DOI] [PubMed] [Google Scholar]
- 15.Fotouhi-Ardakani N, El Kebir D, Pierre-Charles N, et al. Role for myeloid nuclear differentiation antigen in the regulation of neutrophil apoptosis during sepsis. Am J Respir Crit Care Med. 2010;182:341–350. [DOI] [PubMed] [Google Scholar]
- 16.Briggs RC, Shults KE, Flye LA, et al. Dysregulated human myeloid nuclear differentiation antigen expression in myelodysplastic syndromes: evidence for a role in apoptosis. Cancer Res. 2006;66:4645–4651. [DOI] [PubMed] [Google Scholar]
- 17.Asefa B, Dermott JM, Kaldis P, et al. p205, A potential tumor suppressor inhibits cell proliferation via multiple pathways of cell cycle regulation. FEBS Lett. 2006;580:1205–1214. [DOI] [PubMed] [Google Scholar]
- 18.Gruszka-Westwood AM, Hamoudi RA, Matutes E, et al. p53 abnormalities in splenic lymphoma with villous lymphocytes. Blood. 2001;97:3552–3558. [DOI] [PubMed] [Google Scholar]
- 19.Imamura J, Miyoshi J, Koeffler HP. P53 in hematologic malignancies. Blood. 1994;84:2412–2421. [PubMed] [Google Scholar]
- 20.Zeggai S, Harir N, Tou A, et al. Immunohistochemistry and scoring of Ki-67 proliferative index and p53 expression in gastric B cell lymphoma from Northern African population: a pilot study. J Gastrointest Oncol. 2016;7:462–468. [DOI] [PMC free article] [PubMed] [Google Scholar]