PA RT O N E

T H E N O R M A L LY M P H N O D E

The lymph nodes are major components of the lymphatic sys- processing of antigens. The lymph nodes exhibit a complex ar-
tem clustered in small groups or chains at strategic locations, chitecture in which a variety of cell populations are arranged
where they drain the lymphatic vessels of various anatomic re- in distinct interfacing compartments. This provides a favorable
gions. The drainage involves not only the mechanical filtration environment in which the various cellular components can pro-
of the foreign bodies in the lymph but also the recognition and cess antigens, interact, and generate the immune response.

Paracortex

Trabeculum Medullary sinus

Efferent lymphatic
Subcapsular
sinus

Artery

Vein
Capsule

Postcapillary
(high endothelial)
venules
Capillary
supply
Medullary
cords

Follicle of cortex
Afferent lymphatic
CHAPTER 1 ■ THE NORMAL LYMPH NODE
ANATOMY STRUCTURE
In the lymphatic pathway, lymph nodes are peripheral lym-
phoid organs connected to the circulation by afferent and effer- Cortical Area
ent lymphatics (Fig. 1.1). These ovoid, round, or bean-shaped
nodular formations, composed of dense accumulations of The cortical area, or superficial cortex (Fig. 1.3), includes the
lymphoid tissue, vary in size from 2 to 20 mm and average lymphoid follicles with their germinal centers. The cortical area
15 mm in longitudinal diameter (1,2) (Fig. 1.2). Normally, represents the bursa-dependent, B-cell area of the lymph node,
lymph nodes are not palpable. They become detectable as a associated mainly with mechanisms of humoral immunity. The
result of intense immune reactions or tumor metastasis. The primary lymphoid follicles are round nodules, averaging 1 mm
cut surface is gray-pink, soft, and homogeneous. A diameter in diameter; the longer axis of each is oriented at a right angle
larger than 3 cm, a firm consistency, and a white and nodular to the lymph node capsule (5). The secondary or reactive lym-
cut surface are features suggestive of neoplasia. The charac- phoid follicles comprise a peripheral area or mantle of closely
teristics of each group of lymph nodes vary in relation to age packed, small lymphocytes and the centrally located germinal
and site in the body; for example, mesenteric nodes have wider centers. The latter include a population of lymphoid cells in var-
medullary cords and sinuses, whereas peripheral nodes, par- ious stages of maturation, supportive reticulum cells, dendritic
ticularly those draining areas of active antigenic stimulation, reticulum cells (DRCs), and histiocytes that often exhibit active
such as the neck and abdomen, have larger and more numer- phagocytosis. The germinal centers vary in size, enlarging sub-
ous germinal centers. Peripheral nodes are also more numerous stantially under conditions of antigenic stimulation (Fig. 1.4)
in younger than in older persons and are absent in newborns The primary follicles are composed of a homogeneous cell pop-
(3). ulation of small, darkly staining, inactive lymphocytes. They
become secondary follicles when stimulated by antigens and
include well-developed germinal centers composed of paler-
staining, heterogeneous populations of cells. These predom-
FUNCTIONS inantly include B lymphocytes, small and large, cleaved and
noncleaved, in addition to a few scattered T lymphocytes (Fig.
The major functions of lymph nodes are lymphopoiesis, fil- 1.5). The lymphocytes of the mantle zones are all of the B-cell
tration of lymph, and processing of antigens. The immune type. The outer layers of the mantle zone are less tightly packed,
response takes place in an integrated lymphoid system that and the cells, still of B-cell type, have more cytoplasm, and form
includes the lymph nodes, spleen, and mucosa-associated the marginal zone. This zone, which appears distinct in the re-
lymphoid tissues (MALT). All lymphoid cells originate in the active follicles of the spleen, is not well formed in the lymph
bone marrow; B cells mature in the bone marrow, whereas T nodes, where it is often indistinguishable from the mantle zone
cells migrate to the thymus, where they undergo further dif- because the cells of the two zones are mixed (6). The secondary
ferentiation. From these primary lymphoid organs, B and T follicles include in their reactive germinal centers the follow-
cells colonize the secondary lymphoid organs: the lymph nodes, ing types of cells: centroblasts, centrocytes, small lymphocytes,
where they respond to antigens in body tissues; the spleen, tingible-body macrophages, and DRCs. In their reactive phase,
where they monitor antigens in the circulating blood; and the the germinal centers exhibit a dark zone oriented toward the
MALT, where they act as a defense against antigens in the mu- center of the lymph node that is composed predominantly of
cosae and skin (4). centroblasts and a light zone oriented toward the periphery

2
 Chapter 1: The Normal Lymph Node 3

Paracortex

Trabeculum Medullary sinus

Efferent lymphatic
Subcapsular
sinus

Artery

Vein
Capsule

Postcapillary
(high endothelial)
venules
Capillary
supply
Medullary
cords

FIGURE 1.1. The structure of the lymph

node. From Stevens A, Lowe J. Lymph
nodes. In: Stevens A, Lowe J. Histology.
Follicle of cortex London: Gower Medical Publications, 1992:
Afferent lymphatic 90–95, with permission.

of the lymph node that is composed predominantly of cen- troblasts and centrocytes exclusively express the aminopepti-
trocytes. (Figs. 1.5–1.8). As they migrate through the germinal dase CD10 (CALLA) marker (7). Centrocytes with unfavorable
center, naive B-lymphocytes transform into centroblasts, which mutations resulting in low affinity for antigen are eliminated
proliferate rapidly as shown by the numerous mitoses and by by apoptosis. In contrast, centrocytes with high-affinity Ig sur-
their immunostaining with the proliferation marker Ki-67 (7). vive and progress further into differentiation toward memory
They move to the light zone by differentiating into centrocytes, cells or plasma cells. The memory cells migrate to the marginal
most of which die by apoptosis. The remnants of karyopy- zone, the plasma cells to the medulla and from there to various
knosis and karyorrhexis are then engulfed by tingible-body organs and tissues (7–9). The zonation and orientation of fol-
macrophages that are scattered throughout the reactive germi- licles is not always noticeable, being dependent on the phase of
nal center, producing the characteristic starry-sky aspect. Cen- immune reaction and on the sectioning of the lymph node (8).

FIGURE 1.2. Tridimensional model of lymph node to-

pography. C, cortical area; PC, paracortical area; LF, lym-
phoid follicles; GC, germinal center. Central area is the
medulla. From Cottier H, Turk J, Sobin L. A proposal for
a standardized system of reporting human lymph node
morphology in relation to immunological function. Bull
World Health Organ 1972;47:375–408, with permission.
4 Part One: The Normal Lymph Node

FIGURE 1.3. Capsule (ca), marginal sinus (SCS), and cortical area (cx) of lymph node. Sinus endothelium
(en) is continuous at capsular side and interrupted on parenchymal side where lymphocytes (arrow) pass
through. cf, reticular fibers; ma, macrophages; I, small; ml, large lymphocytes. From Olah I, Röhlich P,
Törö I. Lymph node. In: Ultrastructure of lymphoid organs. Philadelphia: JB Lippincott Co, 1975:216–
255, with permission.

PRIMARY B BLASTS

MANTLE
ZONE

DARK CENTROBLASTS
ZONE
FDC
BASAL
LIGHT CENTROCYTES
ZONE Mφ
FDC

SECONDARY B BLASTS

FDC
APICAL
LIGHT
ZONE

PLASMA CELLS MEMORY B-CELLS

FIGURE 1.5. The structure of a lymphoid follicle indicating the dif-

ferentiation of B cells during their passage through the germinal cen-
FIGURE 1.4. Reactive lymph node with enlarged, irregularly shaped ter. From Roitt I. The anatomy of the immune response. In: Essential
secondary follicles and germinal centers. Hematoxylin, phloxine, and immunology. London: Blackwell Science, 1997:152–167, with permis-
saffron stain. sion.
 Chapter 1: The Normal Lymph Node 5

FIGURE 1.8. Reactive germinal center includes centroblasts, centro-

cytes, tingible-body macrophages, small (T-cells) lymphocytes, fre-
quent mitoses. Hematoxylin, phloxine, and saffron stain.

cells and postcapillary venules. The paracortex represents the

thymus-dependent area, and the lymphoid cells are predomi-
FIGURE 1.6. Secondary follicle with reactive germinal center. Dark nantly of T-cell types. They have undergone differentiation in
zone of centroblasts (upper right) and light zone of centrocytes (center, the cortex of the thymus by rearrangement of the T-cell re-
lower left). Mantle zone. Hematoxylin, phloxine, and saffron stain.
ceptor gene and then from the thymic medulla to the lymph
node paracortex (7). They may be small or large, representing
various stages of cellular transformation. Like B lymphocytes,
they are mature, naı̈ve lymphocytes that may become activated
Paracortical Area in response to antigenic stimulation (Fig. 1.10), change into
immunoblasts and undergo active proliferation, or enter the
The paracortical area, or deep cortex (Fig. 1.9), is the densely pool of circulating lymphocytes (7). In addition to T cells, the
cellular area beneath the cortex that extends between the lym- paracortex contains the interdigitating cells (IDCs), which ini-
phoid follicles, forming regular interdigitations from the cap- tially present antigens to lymphoid cells and thus play an es-
sule to the corticomedullary junction. It includes lymphoid sential role in initiating the immune response (4,8). When
the IDCs are present in large numbers, the mixture of these
larger, paler cells with the smaller, darker lymphocytes results
in the typical “mottled” aspect of the reactive paracortical areas
(Fig. 1.11).

Medullary Area
The medulla (Fig. 1.12) is the main site of plasma cell pro-
liferation, differentiation, and production of antibodies. It is
composed of cords of cells that include lymphocytes, plasma-
cytoid lymphocytes, plasmablasts, and mature plasma cells in
various proportions. Under intense antigenic stimulation, the
medullary cords may extend deep into the cortex.
The plasma cells lose their CD20 surface markers and syn-
thesize antibodies that are carried by lymph into the general cir-
culation. They contain intracytoplasmic immunoglobulins of
various classes, with κ and λ light chains in a ratio of approx-
imately 2:1 (8). The cords of plasma cells and their precursors
are separated by wide medullary sinuses, which, in addition
to the percolating lymph, also contain numerous monocytes,
plasma cells, macrophages, and mast cells.

CELLS
Lymphoid Cells
FIGURE 1.7. Reactive germinal center. Dark zone of centroblasts
(lower center) light zone of centrocytes (upper center). Small lympho- The lymph node parenchyma includes different populations of
cytes of mantle zone (lower right). Hematoxylin, phloxine, and saffron lymphoid cells in various stages of differentiation and activa-
stain. tion lying on or moving through the supporting framework
6 Part One: The Normal Lymph Node

FIGURE 1.9. Cortical area with germinal center (gc) and paracortical area (dcx) of lymph node. cap, cap-
illary; hev, venule; lb, large lymphocytes; rc, reticular cell; ma, macrophage. Arrows indicate lymphocytes
migrating through endothelium. ×1,100. From Olah I, Röhlich P, Törö I. Lymph node. In: Ultrastructure
of lymphoid organs. Philadelphia: JB Lippincott Co, 1975:216–255, with permission.

FIGURE 1.10. Section of cervical

lymph node with architecture and
normal cytologic appearance. Small,
nonactivated lymphocytes; medium-
sized and large, activated lympho-
cytes; and a few histiocytes are
admixed in various proportions.
×3,300.
 Chapter 1: The Normal Lymph Node 7

not become activated by encounter with antigen, they reenter

the general circulation within a matter of hours via the efferent
lymphatics (5). The cell diameter averages 6 μm and the diam-
eter of the round nucleus is about 5 μm, so that the nuclear-to-
cytoplasmic ratio is very high (1). Under light microscopy, the
nucleus is dense and appears structureless, and the cytoplasm
is just a thin, perinuclear rim. Under the electron microscope,
the nucleus is formed almost entirely of highly condensed het-
erochromatin; the cytoplasm contains a large number of sin-
gle ribosomes, a small Golgi body, several mitochondria, and
few strands of endoplasmic reticulum (10–12) (Fig. 1.13). The
surface shows shallow indentations and occasional short mi-
crovilli. Activated lymphocytes are considerably larger, have a
greater amount of cytoplasm containing polyribosomes (11), a
moderately large Golgi apparatus, multiple mitochondria, and
a large nucleus with prominent nucleoli (Fig. 1.14). Medium-
sized lymphocytes reflect the transition between nonactivated
FIGURE 1.11. Paracortical area in stimulated lymph node with ad- and activated lymphocytes. The B cells display on their surface
mixture of small dark lymphocytes and larger, paler interdigitating cells membrane immunoglobulins that can be visualized by stain-
around a reactive follicle resulting in a “mottled” aspect. Hematoxylin, ing with fluorescein-labeled (Fig. 1.15) or peroxidase-labeled
phloxine, and saffron stain. (Fig. 1.16) antihuman immunoglobulin antisera, in addition to
strong complement (C3) receptors (13–16).
The primary follicle contains mainly small and medium-size
of the stroma. They comprise the main populations of B cells, B cells that represent naı̈ve, inactivated lymphocytes express-
T cells, and plasma cells, each with multiple subpopulations. ing IgM+ and IgD+ or their surface as well as the CD5 marker
The lymphoid cells include small, medium-sized, and large lym- (9). The secondary follicle is characterized by its germinal cen-
phocytes in various proportions (3). Small lymphocytes, also ter and contains B cells in various stages of reaction to antigens
designated as mature or circulating lymphocytes, are nonac- (Fig. 1.17). In the dark zones, the centroblasts, which express
tivated cells. They are the naı̈ve B lymphocytes that populate a small amount of IgM on their surface, enter a phase of a
the primary follicles and the mantle zones (9). After entering high degree of mitotic activity and differentiate into centro-
the lymph node through the postcapillary venules, if they do cytes, which begin secreting immunoglobulins and move to the

FIGURE 1.12. Medullary area (ma) of lymph node. Medullary cords (cd) with mature plasma cells ( p);
medullary sinus (s) in continuation with efferent lymphatic vessel (el). ca, capsule; cf, reticular fibers; en,
sinus endothelium; l, lymphocytes. ×1,100. From Olah I, Röhlich P, Törö I. Lymph node. In: Ultrastructure
of lymphoid organs. Philadelphia: JB Lippincott Co, 1975:216–255, with permission.
8 Part One: The Normal Lymph Node

FIGURE 1.15. B lymphocyte with membrane IgG in immunofluores-

cence. Ring-shaped granular membrane fluorescence after staining with
fluorescein isothiocyanate-labeled goat antihuman IgG antiserum.

FIGURE 1.13. Small, nonactivated lymphocyte, 4 to 5 μm in diame-

ter, with microvilli, small amount of cytoplasm, sparse organelles, and
nucleus with heterochromatin. ×13,800.

opposite pole of the germinal centers to form the light zones

(4,11,12) (Figs. 1.5–1.7). Among the many reacting cells in
germinal centers, those that are best fitted to the particu-
lar antigens are selected for proliferation, whereas the oth-
ers are promptly destroyed (9,17). As a result, the reacting
germinal centers contain numerous cells in mitosis next to
large numbers of cells in apoptosis. In the process of cell

FIGURE 1.16. B lymphocyte with fine, continuous surface deposition

of peroxidase after immunostaining with anti-IgG antibody, which in-
dicates the presence of membrane immunoglobulins. ×8,400.

CLEAVED NON-CLEAVED

FIGURE 1.17. Small and large cleaved (centrocytes) and noncleaved

FIGURE 1.14. Activated lymphocyte, 10 to 12 μm in diameter, with (centroblasts) lymphoid cells of germinal centers. From Lukes RJ,
microvilli, more abundant cytoplasm and organelles, and nucleus with Collins RD. New approaches to the classification of the lymphomata.
prominent nucleolus. ×13,800. Br J Cancer 1975;31[Suppl II]:1–28, with permission.
 Chapter 1: The Normal Lymph Node 9

FIGURE 1.18. Lymph node with reactive follicular hyperplasia shows

absence of BCL-2 activity in the proliferating cells of the germinal
centers in contrast to the BCL-2 positive mantle zone cells. BCL- FIGURE 1.20. Centroblasts in germinal center selectively immunos-
2/peroxidase stain. tained for CD10 marker. CD10 antibody/peroxidase stain.

selection through apoptosis, the bcl-2 gene product is essential. monoclonal B-cell lymphomas. All B cells, naı̈ve cells, centro-
As an inhibitor of apoptosis, bcl-2 is shut off in the reactive blasts, centrocytes, mantle cells, marginal cells, memory cells
germinal center to permit the elimination of cells unfit for the express the pan–B-cell markers CD19, CD20, CD22, and
immune response (Fig. 1.18). The extensive cell death releases CD79a (Fig. 1.19). The centroblasts also express the CD10
numerous DNA nuclear fragments, which constitute the tin- marker (Fig. 1.20).
gible bodies that are then picked up by phagocytic histiocytes T cells also enter the lymph nodes via the high endothelial
(Fig. 1.8). In contrast, in follicular lymphoma, bcl-2 activity venules and, unless activated, they leave it after 6 to 8 hours
present in the center of follicles prevents apoptosis and favors through the efferent lymphatics. All T cells express pan–T-cell
uncontrolled proliferation. markers CD3, CD5, and CD7 (Figs. 1.21 and 1.22). A small
The selected centroblasts continue to undergo mitosis at number of small T cells, mainly CD4+, are scattered within
high rates and develop cell clones that differentiate into cen- the follicles where, through secretion of cytokines, promote
trocytes, upregulate the formation of membrane immunoglob- and modulate the reaction of the germinal center (7). Most T
ulins, and switch from IgM+ to IgA+ or IgG+. They aggre- cells are confined to the paracortical areas, which represent the
gate in the light zone of the center, from where some become T-cell territory (Fig. 1.20). Most of the cells are small T lympho-
memory B cells, which reside in the mantle zone of the follicle, cytes, which, depending on their cell membrane glycoprotein
while others differentiate further into plasmablasts and plasma markers, belong to one of three major cell populations: CD4+
cells that migrate to the medullary area of the lymph node helper T cells (Fig. 1.23), CD8+ suppressor T cells (Fig. 1.24),
(4,9). Thus, naı̈ve B cells, once activated by antigen, mature and NK+ natural killer cells. The T-cell types can be identified
and proliferate to produce an expanded population of identi- with specific anti-CD (cluster of differentiation) monoclonal
cal plasma cells that recognize the same antigen. Normal lymph antibodies. Like B cells, T cells in lymph nodes may become
nodes contain 20% to 35% immunoglobulin-bearing cells activated, forming T immunoblasts. Once activated, they en-
in a cell suspension, a proportion that may increase to 80% large, proliferate, and expand to produce a clone that dissemi-
in some types of reactive follicular hyperplasia and to 100% in nates through the general circulation to peripheral sites, where

FIGURE 1.21. Lymph node T cells highlighted by immunostaining for

FIGURE 1.19. Lymph node B cells highlighted by immunostaining for CD3 pan–T-cell marker. Perifollicular areas, scattered T cells in germi-
CD20 pan–B-cell marker. Follicular germinal centers, mantle zones, nal centers, and their absence in the mantle zones. CD3/peroxidase
and scattered B cells in perifollicular areas. L26/peroxidase stain. stain.
10 Part One: The Normal Lymph Node

FIGURE 1.22. Cortical area of lymph node with T cells in parafollic- FIGURE 1.24. T cells in the same parafollicular areas expressing CD8
ular areas immunostained for CD5 marker. CD5 antibody/peroxidase marker. CD8 antibody/peroxidase stain.
stain.

most of their activity takes place (5). They resemble the B im- cess or modulate them, and present them to the B lymphocytes
munoblasts, having more cytoplasm than inactive T cells and within the follicle (7,19). Because they retain the antigens on
a larger, round nucleus with one central nucleolus or an ir- their surface, they provide a long-lasting reaction to the anti-
regularly shaped nucleus with two to three marginal nucleoli. gen that is relevant to the immune memory (8). DRCs are dif-
Most mature T cells express the αβ chains of the T-cell receptor ficult to recognize under the light microscope. The cytoplasm
(TCR), whereas a small number of T cells express the γ δ chains is not discernible, but the cell processes are visible with im-
of the TCR. munohistochemical staining. The nucleus is large and irregular
or elongated with an inconspicuous nucleolus. The cell pro-
cesses are linked with those of other DRCs by desmosomes
Accessory Cells that form networks on which the lymphocytes are located (8).
Their immunophenotype is CD21+, HLA-DR+, CD1a (Leu-
Immunologic accessory cells consist of a variety of mono- 6)+, and protein S100+ (18–21). Interdigitating reticulum cells
cytic/histiocytic cells that are part of the mononuclear phago- are present mostly in the paracortex and interact with T lym-
cyte system (18) (Fig. 1.9). They originate in the bone marrow phocytes. These cells are large, with a nucleus that has deep
and migrate to peripheral tissues, from which they reach the clefts and folds and inconspicuous nucleoli. The cytoplasm is
lymph nodes through lymph and blood. Among the accessory abundant, pale, and ill-defined. When present in large numbers,
cells, DRCs and interdigitating reticulum cells (IRCs) play im- the IDCs produce the mottled aspect of the paracortical area
portant roles in processing antigens and presenting them to (8). Like the Langerhans cells of the dermis, from which they
lymphocytes. Dendritic reticulum cells are present in germi- appear to originate, the IRCs contain intracytoplasmic Birbeck
nal centers and interact with B lymphocytes (Fig. 1.25). Their granules that are visible under the electron microscope. Their
role is to trap circulating antigens that arrive in the form of im- immunophenotype is HLA-DR+, CD1a (Leu-6)+, and protein
mune complexes (such as antigen–antibody-complement), pro- S100+ (22,23).

FIGURE 1.25. Lymphoid follicle with dendritic reticulum cell net-

FIGURE 1.23. T cells in the same parafollicular areas expressing CD4 work. Interconnecting cell processes outlined by selective CD21 im-
marker. CD4 antibody/peroxidase stain. munostaining. CD21/peroxidase stain.
 Chapter 1: The Normal Lymph Node 11

FIGURE 1.27. Reactive lymph node with markedly distended

marginal and cortical sinuses. Hematoxylin, phloxine, and saffron
stain.

FIGURE 1.26. Histiocyte with abundant cytoplasm, lipid vacuoles,

lysosomes, cell processes, and nucleus with fine euchromatin. ×14,400.
are narrow sinuses connecting the first two types. The sinuses,
with the exception of the larger ones, are difficult to visualize
with the usual stains. The cortical sinuses have highly convo-
Histiocytes, derived from circulating monocytes, may un- luted shapes and numerous fine extensions, whereas the lining
der stimulatory conditions accumulate in the lymph node si- endothelial cells are very thin and pale-staining (5). In the si-
nuses or diffusely infiltrate the paracortical area. They are large nus lumina are many active macrophages (Fig. 1.28), anchored
cells with indistinct borders; the cytoplasm, neither strongly ba- to the sinus wall, and numerous lymphocytes, plasma cells,
sophilic nor pyroninophilic, helps in distinguishing histiocytes immunoblasts, and occasional polymorphonuclear leukocytes.
from large lymphoid cells (3). Their irregular shape is a conse- The phagocytic apparatus of the sinuses filters the lymph, re-
quence of pseudopodal processes that enable histiocytes to con- taining foreign bodies, and plays an important role in antigen
tact and engulf foreign material, thereby developing into active binding. The passage of lymph and cells from one chain of
macrophages (24). Histiocytes resemble reticulum cells; how- lymph nodes to the next is a means by which the immune re-
ever, they can be distinguished by electron microscopy. Histio- sponse is conveyed from the peripheral to the more central
cytes have an abundance of primary and secondary lysosomes lymph nodes (2).
in addition to a large Golgi complex, some mitochondria, and
a few strands of endoplasmic reticulum (1) (Fig. 1.26). De-
pending on their reactive stage, histiocytes may include numer-
ous phagosomes and engulf foreign material. In the germinal BLOOD VESSELS
centers of reactive secondary follicles, histiocytes phagocytose
The blood supply, which is also the main route of incoming
apoptotic nuclear debris, forming characteristic tingible-body
lymphocytes, is brought into the lymph node by one or more ar-
macrophages. Soluble and particulate antigenic proteins are
terioles. They enter the node through the hilus and then divide
also engulfed by lymph node histiocytes and subsequently pre-
into branches in the medulla, ramifying further into capillary
sented to lymphoid cells for antigen identification and initia-
networks in the cortex and paracortex (Fig. 1.29). The blood
tion of antibody production. Under specific stimulation, histi-
vessels are structurally similar to those of other organs, with the
ocytes may transform into epithelioid cells, acquire secretory
functions, and participate in the formation of granulomas (25).
Morphologically and functionally, lymph node histiocytes, like
the reticulum cells (dendritic and interdigitating), belong to the
mononuclear phagocyte system (18,24,25).

LYMPHATIC SINUSES
The lymphatic sinuses (Figs. 1.3, 1.8, and 1.11) carry the lymph
from the afferent lymphatics on the convex surface of the lymph
node through the lymphoid parenchyma into the efferent lym-
phatics in the lymph node hilus. They vary in size and cell
composition according to functional demands (1) (Fig. 1.27).
They are passages through the fine network of reticulin fibers
lined by endothelial cells (retothelial cells, littoral cells) inter-
connected by desmosomes (10). According to some investiga-
tors, endothelial cells are flattened reticular cells, a concept sup-
ported by the finding of reticulin fibrils in continuation with the
endothelial cells traversing the sinus lumina (2). The system of
sinuses includes the marginal or subcapsular sinus, labyrinthic FIGURE 1.28. Reactive lymph node with distended sinuses containing
medullary sinuses, and intermediary or cortical sinuses, which numerous CD68+ macrophages. CD68/peroxidase stain.
12 Part One: The Normal Lymph Node

afferent lymph

B cell proliferation post capillary venule

(follicle)

cell proliferation
(paracortex)
cortex
(B zone)

paracortex
(T zone)

medulla

efferent lymph

FIGURE 1.29. Blood vessel and lymphatic circulation in the lymph node.

exception of the postcapillary venules of the paracortical areas. phoid cells. They are intimately connected to the fine network
These vessels are lined by tall endothelial cells that are tightly of reticulin fibrils that originate from them.
bound together by close interdigitations. The endothelial cells
bear specialized lymphocyte homing receptors that are recog-
nized by circulating lymphocytes (5). Frequently, lymphocytes HISTOCHEMISTRY
are seen passing through the cytoplasm of endothelial cells (10)
because the postcapillary venules are the site of lymphocyte Histiocytes and macrophages can be identified by cytochemical
migration from the circulating blood into the lymphoid tissue stainings for nonspecific esterase (26), acid phosphatase (27),
(2,5). The blood vessels of the superficial cortex and medulla peroxidase, and other lysosomal enzymes.
are not specialized and so do not allow the exit of lymphocytes
(5).

SUPPORTING FRAMEWORK
OR STROMA
The lymph node capsule, trabeculae, and a network of reticular
cells and reticulin fibers comprise the supporting framework,
or stroma. Fibroblasts are the predominant cells of the capsule
and trabeculae; however, these structures also include smooth
muscle cells, nerves with Schwann cells, and blood vessels with
pericytes (1). The reticulin fibers are thin, delicate fibrils of type
III collagen about 20 nm in diameter (5). In lymph nodes, they
form the main extracellular matrix and maintain the structure
by linkage to the fibrous trabeculae, and they are reinforced
by fine collagen fibers. The reticulin framework supports the
lymphoid cells and therefore is obscured by them on regular
stainings, but it can be visualized with silver impregnation tech-
niques (Gomori staining) (Fig. 1.30). The reticular (reticulum)
cells have varied shapes, frequently elongated, with long den- FIGURE 1.30. Reticulin fiber network of lymph node. Gomori silver
dritic processes extending for great distances between the lym- stain.
 Chapter 1: The Normal Lymph Node 13

IMMUNOHISTOCHEMISTRY Blood Vessels

The various cell populations of lymph nodes can be identified The endothelial cells of blood vessels stain with antibodies for
with monoclonal antibodies produced to match the character- CD31 and CD34.
istic epitopes expressed on their membranes. Monoclonality
also can be demonstrated under certain conditions with the
use of immunohistochemical stainings (28,29). CHECKLIST
NORMAL LYMPH NODE
Cortical Area
■ FRAMEWORK
The lymphoid follicles, which are the main component of the ■ Capsule
cortical area, are composed of a variety of B cells that stain with ■ Fibrous trabeculae
the pan–B-cell antibodies CD19, CD20, CD22, and CD79a ■ Reticulin network
(Fig. 1.19). The centroblasts express CD10 (Fig. 1.20). The ■ CORTICAL AREA
germinal center cells also express Bcl-6 a nucleoprotein; thus, ■ Lymphoid follicles
the staining is nuclear. Activated B or T cells stain with CD30 r Primary
(30). The naı̈ve B cells in primary follicles and mantle zones are r Secondary
CD5+ and have surface IgM and IgD. The B centroblasts have ■ Germinal centers
surface IgM, which in centrocytes shifts to IgG and rarely IgA. r B cells
IgD is present on mantle cells, but not on germinal center cells. r Centroblasts: dark zones
The B cells also express immunoglobulin κ and λ light chains in r Centrocytes: light zones
a ratio of 2:1. Monoclonality of immunoglobulin light chains r T cells: small, inactivated
indicates the existence of neoplastic cell clones. Therefore, the r Tingible-body macrophages
demonstration of an identical light chain κ or λ on all lymph r Dendritic reticulum cells
node B cells is of great diagnostic importance; however, the ■ Mantle zone: memory B cells
immunohistochemical staining is reliable only on fresh, unfixed ■ Marginal zone: monocytoid cells
cells in flow cytometry or frozen sections (8,28,29). The bcl-2 ■ PARACORTICAL AREA
protein is present on mantle cells but not on the centroblasts ■ T cells
and centrocytes of the germinal centers, which undergo the r Small, inactivated
normal cycle of apoptosis (Fig. 1.18). A positive stain for bcl-2 r Large, immunoblasts
by the cells in the center of follicles indicates the suppression
of apoptosis, a feature diagnostic of lymphoma (31–33). ■ MEDULLARY AREA
The small lymphocytes scattered throughout the follicles are ■ Plasmablasts
T cells that stain with monoclonal antibodies for CD3, CD5, ■ Plasma cells
CD7, CD43 (Figs. 1.21, 1.22), and CD4 or CD8 (Fig. 1.23. ■ LYMPHATIC SINUSES
1.24). The tingible-body macrophages stain with monoclonal ■ Marginal
antibodies for CD11b, CD35, and CD68. The DRCs stain with ■ Cortical
monoclonal antibodies for CD21, CD35, C3b, and C3d (34) ■ Medullary
(Fig. 1.25). ■ BLOOD VESSELS
■ Arteries
■ Veins
Paracortical Area ■ Capillaries
■ High endothelial postcapillary venules
Those T cells that are the predominant cells of the paracortex
are usually small lymphocytes staining with antibodies that
recognize pan–T-cell markers such as CD2, CD3, CD5, CD7,
CD43, and HLA-DR (Fig. 1.22). The ratio of CD4+ helper
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