The REAL Classification

B-cell neoplasms

 I. Precursor B-cell neoplasm: precursor B-lymphoblastic

II. Peripheral B-cell neoplasms

    A. B-cell chronic lymphocytic leukemia/prolymphocytic

       leukemia/small lymphocytic lymphoma

    B. Lymphoplasmacytoid lymphoma/immunocytoma

    C. Mantle cell lymphoma

    D. Follicle center cell lymphoma, follicular

       1. Provisional cytologic grades: 

          I small cell,

          II mixed small and large cell, 

          III large cell

       2. Provisional subtype: diffuse, predominantly

          small cell type

    E. Marginal zone B-cell lymphoma

       1. Extranodal (MALT-type +/- monocytoid B cells)

       2. Provisional subtype: nodal (+/- monocytoid B cells)

    F. Provisional entity: splenic marginal zone lymphoma

       (+/- villous lymphocytes)

    G. Hairy cell leukemia

    H. Plasmacytoma/plasma cell myeloma

    I. Diffuse large B-cell lymphoma

       1. Subtype: primary mediastinal (thymic) B-cell lymphoma

    J. Burkitt's lymphoma

    K. Provisional entity: high-grade B-cell lymphoma, Burkitt-like

T-cell and putative NK-cell neoplasms

 I. Precursor T-cell neoplasm: precursor T-lymphoblastic


II. Peripheral T-cell and NK-cell neoplasms

    A. T-cell chronic lymphocytic leukemia / prolymphocytic leukemia

    B. Large granular lymphocyte leukemia

       1. T-cell type

       2. NK-cell type

    C. Mycosis fungoides/Sezary's syndrome

    D. Peripheral T-cell lymphomas, unspecified

       1. Provisional cytologic categories: 

          medium-sized cell, mixed medium and 

          large cell, large cell, lymphoepithelioid cell

       2. Provisional subtype: hepatosplenic gamma/delta T-cell lymphoma

       3. Provisional subtype: subcutaneous panniculitic T-cell lymphoma

    E. Angioimmunoblastic T-cell lymphoma

    F. Angiocentric lymphoma

    G. Intestinal T-cell lymphoma (+/- enteropathy associated)

    H. Adult T-cell lymphoma/leukemia

    I. Anaplastic large cell lymphoma

       1. CD30+ -cell type

       2. T-cell type

       3. Null-cell types

    J. Provisional entity: anaplastic large cell lymphoma,

Hodgkin's Disease (now known to be a B-cell neoplasm)

  I. Lymphocyte predominance

 II. Nodular sclerosis

III. Mixed cellularity

 IV. Lymphocyte depletion

  V. Provisional entity: lymphocyte-rich classical Hodgkin's disease

The REAL classification encompasses all the lymphoproliferative

The more than 20 clinicopathologic entities described here have been

by the US National Cancer Institute (NCI) into the more clinically
useful indolent 

or aggressive lymphomas as follows: 

PDQ modification of REAL Classification of lymphoproliferative diseases

  I. Plasma cell disorders (Refer to the PDQ summary

     on plasma cell neoplasm patient & physician)

     A. MGUS

     B. Plasmacytoma

        1. Bone

        2. Extramedullary

     C. Multiple myeloma

     D. Amyloidosis

 II. Hodgkin's Disease 

III. Indolent lymphoma/leukemia

     A. Follicle center cell lymphoma, follicular

        1. Grade I follicular small cleaved cell

        2. Grade II follicular mixed

        3. Grade III follicular large cell*

        4. Diffuse small cleaved cell

     B. Diffuse small lymphocytic lymphoma /chronic lymphocytic

        leukemia (Refer to the PDQ summary on chronic 

        lymphocytic leukemia patient & physician)      

        Distinguish: Prolymphocytic leukemia (aggressive)

                     Large granular lymphocytic leukemia

     C. Lymphoplasmacytoid/Waldenstrom's (Refer to the 

        PDQ summary on plasma cell neoplasm patient & physician)

     D. Marginal zone lymphoma

        1. MALT (extranodal)

        2. Monocytoid B-cell lymphoma (nodal)

        3. Splenic lymphoma with villous lymphocytes

     E. Hairy cell leukemia (Refer to the PDQ summary 

        on hairy cell leukemia patient & physician)

     F. Mycosis fungoides/Sezary syndrome

 IV. Aggressive lymphoma/leukemia

     A. Diffuse large cell lymphoma includes diffuse mixed cell,

        diffuse large cell, immunoblastic

        Distinguish: Primary mediastinal B-cell lymphoma

                     Anaplastic large cell lymphoma

                     Angiocentric lymphoma (includes 

                       nasal T-cell and pulmonary B-cell)

                     Angioimmunoblastic T-cell lymphoma

                     Peripheral T-cell lymphoma

                     Intestinal T-cell lymphoma

                     Intravascular lymphomatosis

    B. Burkitt's lymphoma /

          diffuse small non-cleaved cell lymphoma

    C. Lymphoblastic lymphoma / leukemia

    D. CNS lymphoma

    E. Adult T-cell leukemia/lymphoma

    F. Mantle cell lymphoma*

    G. Post-transplantation lymphoproliferative disorder

    H. AIDS-related lymphoma

    I. True histiocytic lymphoma

    J. Primary effusion lymphoma

* Controversial entity, aggressive and indolent natural history noted