Plasticity in Classical Hodgkin Composite Lymphomas: A Systematic Review

SIMPLE SUMMARY: Composite/synchronous lymphoma is a rare entity, for which the histopathological diagnosis is difficult due to the co-occurrence of at least two lymphomas, sometimes mixed in the same anatomical site. In the present review, we gathered available data on composite lymphomas associating a classical Hodgkin lymphoma (cHL) with another lymphoma. We report the clinical, histopathological, immunohistochemical, and molecular data for each composite lymphoma. These data reinforce the hypothesis of a common clonal origin and a transdifferentiation phenomenon during lymphomagenesis. One of the greatest challenges for the pathologist is to differentiate real Hodgkin cells of cHL from Hodgkin-like cells associated with a non-Hodgkin lymphoma, in order to individualize both contingents for the diagnosis. In contrast, the clinician’s challenge is to optimally treat these rare composite pathologies as a single clinical entity. This review could thus be a useful diagnostic support for pathologists and could help clinicians improve management of these uncommon lymphomas. ABSTRACT: The co-occurrence of several lymphomas in a patient defines composite/synchronous lymphoma. A common cellular origin has been reported for both contingents of such entities. In the present review, we aimed to gather the available data on composite lymphomas associating a classical Hodgkin lymphoma (cHL) with another lymphoma, to better understand the plasticity of mature B and T-cells. This review highlights that >70% of patients with a composite lymphoma are ≥55 years old, with a male predominance. The most reported associations are cHL with follicular lymphoma or diffuse large B-cell lymphoma, with over 130 cases reported. The cHL contingent is often of mixed cellularity type, with a more frequent focal/weak CD20 expression (30% to 55.6%) compared to de novo cHL, suggesting a particular pathophysiology. Moreover, Hodgkin cells may express specific markers of the associated lymphoma (e.g., BCL2/BCL6 for follicular lymphoma and Cyclin D1 for mantle cell lymphoma), sometimes combined with common BCL2/BCL6 or CCND1 rearrangements, respectively. In addition, both contingents may share similar IgH/IgK rearrangements and identical pathogenic variants, reinforcing the hypothesis of a common clonal origin. Finally, cHL appears to be endowed with a greater plasticity than previously thought, supporting a common clonal origin and a transdifferentiation process during lymphomagenesis of composite lymphomas.