High-grade Diffuse Large B-cell Research Articles

49. Cryptic Triple Hit Lymphoma: What's hiding in those chromosomes? A chromosome, FISH and microarray story

High-grade B-cell lymphoma with concurrent MYC, BCL2, and BCL6 rearrangements (i.e. Triple Hit Lymphoma (TH)) is an aggressive lymphoma generally detected by conventional cytogenetics and/or FISH. We present a patient referred for high grade diffuse large B-cell lymphoma with a complex karyotype. The diagnosis was consistent with follicular lymphoma and clonal evolution, based only on the karyotype analysis. Dual fusion and breakapart (BAP) FISH strategies and microarray testing were required to diagnosis TH lymphoma. The karyotype included a t(14;18) with an extra derivative 14 (no normal 14), a t(3;22)(q27;q11.2), a t(2;6) and trisomy 8. IGH/BCL2 FISH identified three fusions, consistent with the novel double derivative (14)t(14;18) and derivative 18. BCL2 -BAP FISH showed one germline fusion, a 3’ signal and two 5’ signals rather than the typical evolution related extra 3’ signal, but consistent with the double derivative 14. MYC-BAP FISH showed three un-rearranged fusions discordant with the double fusion IGH/MYC result. This apparent incongruence could be explained by an IGH insertion into MYC which was confirmed by metaphase FISH. The BCL6 FISH was also atypical with 2 germ line fusions and a small extra 5’ BCL6 signal. Since the microarray showed no 3q27 gain, a balanced rearrangement between the 5’BCL6 promotor and the lambda-light gene at 22q11.2 was concluded. Copy neutral LOH (CN-LOH) of 14q32.13->qter in the array analysis (spanning IGH) supports mitotic recombination based clonal evolution for the novel double derivative 14, consistent with a reversal of the common oncogenic fusion derivative. A second CN-LOH region was observed spanning distal 6p, although the driver gene for that evolution is not clear. In summary, the TH would have been missed without multiple disciplinary ancillary testing, highlighting their importance in accurately evaluating complex clones in facilitating optimal patient care and management.

The Frequency of Double Expresser in Selected Cases of High Grade Diffuse Large B-Cell Lymphomas.

Background:Diffuse large B-cell lymphomas (DLBCL) are fast-growing non-Hodgkin lymphomas that affect B-lymphocytes. Double expressor DLBCL is the concomitant expression of Myc and Bcl-2 proteins during lymphomas which results in poor prognosis of patients. This study aimed to determine the frequency of double expresser in high grade diffuse large B-cell lymphomas. Materials and Methods :The study was conducted on 74 cases (54 males (68.4%) and 20 females (25.3%)) of DLBCL between August 2018 to January 2019. The mean age of the 74 patients was 51.7 years + 18.5. Expression of proteins c-Myc, Bcl-2 and Bcl-6 were evaluated by immunohistochemistry. The involvement of primary lymph node was reported in 38 cases (51.3%) whereas, extra nodal site was observed in 22 cases (29.7%). Among the primary sites, the cervical lymph node enlargement was the most frequent site of presentation. Results:The rearrangement pattern was studied among 74 patients, 35 (47%) were found to have either one of the rearrangements i.e. Myc, Bcl-2, or Bcl-6. On the other hand, 14 (18.9%) had shown double rearrangements i.e. Bcl-2 and c-Myc (11 cases) and Bcl-6 and c-Myc (3 cases). The Bcl-2 and Bcl-6 rearrangements were demonstrated by 12 cases whereas 2 cases (2.7%) indicated all three types of rearrangements i.e. c-Myc, Bcl-2, and Bcl-6. In 11 cases the Bcl-2 and c-Myc rearrangements were found to be Bcl-2 > 50% and c-Myc > 40% and demonstrating the overall frequency of double expressers as 14.8%. The prognosis of the mentioned cases was extremely poor, median survival of 10 months. Conclusion: The concurrent expression of Bcl-2 and c-Myc was found to be 14% (level of expression for Bcl-2 > 50% and c-Myc > 40%) which is potentially a significant health burden and an emerging threat.

Progressive severe dyspnea and hypoxia due to primary thyroid lymphoma: steroid administration may be life-saving

Primary Thyroid lymphoma is an uncommon malignancy, which can rarely cause severe dyspnea. Its commonly difficultly diagnosed and rapid diagnosis and management may be lifesaving. Here we report a case presented with sudden thyroid growth and severe dyspnea, who was diagnosed as primary thyroid lymphoma. A 70-year-old woman applied with fatigue, rapidly enlarged goitre and severe progressive dyspnea. She had severe hypoxemia with an artery oxygen saturation of 59.2% and arterial PO2 of 33.9 mmHg. The ultrasound of the neck showed an enlarged thyroid gland with a mass in the left lobe. After admission to the hospital her dyspnea worsened and oxygen and bronchodilator treatment gave no benefit. IV methylprednisolone was administered, and the patient’s symptoms partially improved. Meanwhile in spite of supportive therapy, the patient underwent urgent surgery for acute airway obstruction and thyroidectomy was performed. After surgery the diagnosis was high grade diffuse large B-cell non-Hodgkin’s lymphoma.

Bilateral hydrocele. Uncommon clinical presentation of primary testicular lymphoma in the elderly.

Primary testicular lymphoma (PLT) represents 5% of testis tumors, the incidence increases in patients older than 60 years of age. Bilateral hydrocele is an unusual clinical presentation. Relapse in the central nervous system and in the contralateral testis is often observed. The US shows hypoechoic nodular lesions with a complete structural involvement of didymus and hypervascularization at Color Doppler. Orchiectomy should be performed in all cases as it is indispensable for the histopathological diagnosis and to characterize the immunophenotypic features. The most common histotype is diffuse large-B cell lymphoma. Combined biological approach and chemotherapy with rituximab and doxorubicin has radically changed the prognosis of disease. The authors report two patients of 81 and 82 years-old who referred for evaluation of massive bilateral hydrocele causing severe limitation of deambulation. Negative cytological findings for neoplastic cells in the scrotal effusion made difficult the differential diagnosis between inflammatory and malignant disease. Histopathologic findings made a diagnosis of high grade diffuse large B-cell NHL, respectively stage IV-E and stage III-E. The 82 years old patient was treated with 6 chemotherapy cycles of rituximab, cyclophosphamide, vincristine, prednisone. The exitus was dued to the umbilical hernia complications. In the 81 years old patient, cognitive deficit and severe impairment of general conditions constituted an absolute contraindication to polychemotherapy treatment. Rapid tumor progression led the patient to exitus 2 months after diagnosis. In both patients the delayed diagnosis of PLT was probably due to the reduction of welfare protection in the elderly with adverse social conditions.

Primary Uterine Cervical High-Grade Follicular Lymphoma and Diffuse Large B-Cell Lymphoma: A Case Report and Review of Literature

Primary Uterine Cervical High-Grade Follicular Lymphoma and Diffuse Large B-Cell Lymphoma: A Case Report and Review of Literature

Abstract #526: Rare Case of Severe Symptomatic Hypercalcemia in Patient with Concomitant Primary Hyperparathyroidism and High Grade Diffuse Large B-Cell Lymphoma

Abstract #526: Rare Case of Severe Symptomatic Hypercalcemia in Patient with Concomitant Primary Hyperparathyroidism and High Grade Diffuse Large B-Cell Lymphoma

Dose-Adjusted EPOCH +/- Rituximab in Older Patients with High Grade Diffuse Large B-Cell Lymphoma, Burkitt and T-Cell Lymphoma: An Effective Regimen with Acceptable Toxicity Profile

Background: NHL is a disease of older adults and henceforth the oncology community will be increasingly confronted with the challenges of the older lymphoma patient (pt). Phase II data demonstrates dose-adjusted (DA)-EPOCH +/- rituximab is efficacious in high grade and aggressive NHL (J Clin Oncol. 2008 Jun 1;26(16): 2717-24). Additionally, infusional doxorubicin may confer greater safety in elderly pts compared with bolus delivery. A Phase III trial (NCT00118209) comparing DA-R-EPOCH and R-CHOP has been completed, but the results are not currently available. To date, there is limited data on efficacy and safety in elderly patients treated with DA-R-EPOCH. We explored our single center experience to inform therapeutic choices in older adults.Methods: We retrospectively reviewed all pts treated with EPOCH at MSKCC from 2003 to 2014, identifying 181 pts in total, of which 54 pts > 60 yrs (out of 73 pts >60 yr) received DA-EPOCH at initial diagnosis. Data was available regarding their baseline characteristics, dose adjustments/treatment modifications, hospitalizations, and disease related outcomes for all pts. Outcome measures included progression free (PFS) and overall survival (OS), hospitalizations, and dose adjustments.Results: Of 54 patients, histologies included DLBCL (n=42, 78%), T-cell lymphoma (n=8, 15%), and Burkitt lymphoma (BL) (n=4, 7%). The median age of all patients was 70.5 yrs (range 61-93 yrs), with 54% female. Prior malignancy was present in 31% and baseline LVEF was >55% in 98% of pts. For DLBCL patients (n=42): median age 72 yrs (61-92 yr), M:F 24:18, Stage I/II v. III/IV: 21% v. 79%, aaIPI 0-1 v. 2-3: 24% v 76%; cell of origin (Hans) GC/ABC/unknown: 43%/52%/5%. Ki67%: median 90% (range 20-100%). T-cell pts (n=8): median age 68 yrs (61-75 yr), female 50%, histology ATLL(n=4), PTCL (n=3), ALCL ALK- (n=1); 100% adv. stage; BL pts (n=4): ages 65, 69, 82, 81 yrs, 1 early stage, 3 adv. stage, 1 low risk, 3 high risk.Rituximab was given in 96% of b-cell NHL. Peg-GCSF/GCSF was used with each cycle of EPOCH. A full 6 cycles of EPOCH was completed 52% of the time and dose adjusted in 66% of pts with a median of 4 adjusted cycles/pt (range 1-6). Dose increases occurred in 30% of pts, dose decreases 26%; 11% of pts started at dose level -1.Safety: Cardiac events occurred in 22% of pts, with 2 pts experiencing anthracycline induced cardiomyopathy/CHF, the remainder included G ≥3 arrhythmias (n=6) or chest pain/angina (n=4) without change in EF. Hospitalization for G≥3 toxicity occurred in 68.5% (n=37) of pts (41% more than once): neutropenic fever/infection (n=19/9), AKI/dehydration (n=7), syncope (n=2); Treatment related mortality was 4% (n=2).Outcomes: With a median followup of 1.5 yrs, 33 of 54 pts remain progression free (DLBCL 30/42, TCL 1/8, BL 2/4, p=0.007). For all pts, median PFS and OS have not been reached: PFS and OS at 1.5 yr is 57% and 66%, respectively. For DLBCL pts, median PFS and OS is not reached: PFS and OS at 1.5 yr is 69% and 78%, respectively. In log-rank analysis: aaIPI (p=.15), Stage (p=.08) and cell of origin (p=.35) did not predict OS; aaIPI (p=.05) and stage (p=.04) predicted PFS, but cell of origin was not significant. There was no significant difference in outcome based on dose adjustments.Conclusions: DA-EPOCH +/- R is an effective treatment option for pts > 60 yrs with advanced stage, high risk DLBCL; Hospitalizations for toxicity were frequent, but TRM was low. Cardiomyopathy was infrequent. Dedicated efforts to explore initial dose-reductions and optimal number of cycles in this older pt population would be beneficial. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Occurrence of B-cell lymphomas in patients with activated phosphoinositide 3-kinase δ syndrome

Occurrence of B-cell lymphomas in patients with activated phosphoinositide 3-kinase δ syndrome

Abstract 1034: Upregulation of Ezh2 expression correlates with higher tumor proliferation and grade in non-Hodgkin's B- and T-cell lymphoma

Abstract Polycomb group (PcG) proteins are involved in regulation of hematopoiesis, which include two main members Ezh2 and Bmi-1. Reports on their expression levels in different subtypes of malignant lymphoma and role in lymphomagensis and tumor progression are rather limited. To address this issue, we analyzed a total of 197 patient samples including 10 samples of Hodgkin lymphoma (HL), 109 of B-cell lymphoma (BCL) and 78 of T-cell lymphoma (TCL) by immunohistochemistry. The results showed overall expression in HL, BCL and TCL to be 90%, 56.9% and 84.6% for Ezh2 and 90%, 82.5% and 84.6% for Bmi-1 respectively. Among BCL, highest Ezh2 positivity was seen in Burkitt's lymphoma (BL) followed by high-grade follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL). In TCL, Ezh2 expression was observed in all subtypes and seemed more homogenous. Difference in its expression between aggressive and indolent subtypes of BCL was statistically significant (p= 0.000∼0.010). On the other hand, Bmi-1 was rather more consistently expressed in both BCL and TCL up to 100% in 7 subtypes. Difference in its expression between aggressive and indolent subtypes was statistically insignificant. Ki67 showed strong positive correlation with Ezh2 in BCL (Correlation coefficient (Co) =0.983, p= 0.000) and moderate correlation in TCL (Co=0 .629, p= 0.000). This correlation could not be detected in case of Bmi1. These data suggest that out of the two Polycomb group (PcG) proteins, only Ezh2 correlates with tumor proliferation and signals a more aggressive nature. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1034. doi:1538-7445.AM2012-1034

Primary central nervous system lymphoma: A profile of 26 cases from western India

Primary central nervous system (CNS) lymphoma (PCNSL) is a rare malignant non-Hodgkin's lymphoma and it accounts for 1% of all intracranial tumors. Only a few PCNSL studies have been reported from India, and studies on prognostic factors determining outcome, or evaluation of the response to currently accepted treatment, are lacking. This study attempts to further delineate the clinical, radiological and pathological profile of PCNSL in India, to evaluate response to treatment and to assess usefulness of the International Extranodal Lymphoma Study Group (IELSG) score. All patients with pathologically proven PCNSL admitted over three years at a large tertiary care institution were studied. Clinical features, IELSG prognostic score, imaging and pathological features, and response to treatment were evaluated. Results were analyzed using chi 2 test. Of 26 patients found, all except two were immunocompetent. Median age at diagnosis was 59 years. Focal deficits (76.9%) and neuropsychiatric symptoms (57.6%) were the commonest presenting complaints. Except for one case, at least some contrast enhancement was seen in brain lesions of all patients. Pathological studies showed high grade diffuse large B-cell (DLBCL) histology in 96.2% of patients. Of 22 patients who received methotrexate (MTX) based chemotherapy with/without radiotherapy; six died, with a response rate of 72.7%. Median survival was 10 months. Median follow-up duration was 14.5 months. Four patients developed treatment-related cognitive decline. All six patients with IELSG score of 4/5 died, while all 16 patients with a score of 0-3 survived. PCNSL presents most commonly in the sixth decade with focal neurological deficit, behavioral symptoms and cognitive decline. High grade DLBCL is the commonest histological subtype. Steroids should ideally be withheld until biopsy as they may confound the diagnosis. Most immunocompetent patients respond well to high dose MTX-based chemotherapy with/without radiation. High IELSG scores correlate with worse prognosis in patients with PCNSL.

Antiribosomal-P protein antibodies in a patient with systemic lupus erythematosus and non-Hodgkin’s lymphoma: more than coincidental finding?

Patients with systemic lupus erythematosus (SLE) are at an increased risk of lymphomas, but mechanisms underlying this association are obscure. Recently, it has been shown that antiribosomal-P protein (anti-P) antibodies cross-react with phospholipids and enhance the production of cytokines which may influence lymphomagenesis. We report a 46-year-old woman who suffered high grade diffuse large B-cell non-Hodgkin's lymphoma (DLBCL) 28 months after the diagnosis of SLE. Development of lymphoma was associated with occurrence of serum monoclonal IgM, and pronounced prolongation of phospholipid-dependent clotting tests. Anti-P IgG antibodies were highly positive both on HEp-2 cells and in ELISA test. Anticardiolipin, anti-beta2 glycoprotein I, and antiprothrombin IgM antibodies have also been found in high concentrations. Complete remission of DLBCL and SLE, with normalisation of clotting tests, and disappearance of M component was achieved with administration of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone. The progression of SLE to DLBCL associated with presence of anti-P antibodies has not been previously reported. This association may not be coincidental, but further investigations are required to confirm this hypothesis.

Posttransplant Lymphoproliferative Disorder Followed by Hodgkins Disease in a Renal Transplant Recipient

Posttransplant lymphoproliferative disorder (PTLD) is an uncommon but potentially fatal complication affecting 1% to 3% of renal transplant recipients. The term “PTLD” encompasses a spectrum of disorders ranging from polyclonal lymphoproliferation to monoclonal lymphomas, which are often Epstein-Barr virus (EBV) positive, aggressive B-cell non-Hodgkins lymphomas but Hodgkins lymphomas can also arise in this setting. We report a patient who developed mixed cellularity Hodgkins lymphoma 1 year after treatment for diffuse large B cell lymphoma arising post renal transplantation. A 34-year-old gentleman received a cadaveric renal transplant in August 1996 for end stage renal failure of unknown cause. Posttransplant immune suppression was with ciclosporin and prednisolone. He presented in September 2002 with a lump in the left axilla, which on further investigations was shown to be EBV positive high grade diffuse large B-cell lymphoma (stage IB). He went into remission with withdrawal of immune suppression and six courses of R-CHOP chemotherapy (rituximab, cyclophosphamide, daunorubicin, vincristine, prednisolone) with subsequent radiotherapy to a residual lymph node mass in the left axilla. Immune suppression with ciclosporin and prednisolone was reinstituted in view of deteriorating renal function. In July 2004, he presented with sweats and progressively enlarging lymph nodes in the right axilla. A biopsy confirmed mixed cellularity Hodgkins disease. Some of the RS cells showed positivity for EBV. He was staged as having IB disease. He was treated with two cycles of ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) in December 2004 and this was followed by radiotherapy to the right axilla in January 2005. He remains well and in complete remission 39 months posttreatment and has never suffered any episodes of graft rejection, though we have been unable to reduce the dose of prednisolone to less than 5 mg because of deterioration renal function. Hodgkin's lymphoma arising as a second PTLD, after treatment for an initial PTLD, is a very rare occurrence. There are only four such cases reported in literature, all occurring in the pediatric solid organ transplant setting. Initial PTLD was of the polymorphic subtype in three and “Hodgkins-like” in the fourth reported case (Table 1).TABLE 1: Clinical information of posttransplant Hodgkins lymphoma subsequent to other subtypes of PTLDThe treatment of Hodgkins disease after PTLD raises problems in terms of use of anthracylines and cardiotoxicity. In the four cases previously reported (Table 1), the PTLD had responded to withdrawal of immunosuppression or antiviral therapy and α interferon. Hodgkins disease was subsequently treated with cyclophosphamide, vincristine, prednisone and procarbazine/adriamycin, bleomycin and vinblastine in two cases, mechlorethamine, vincristine, prednisone, procarbazine in one case and unspecified chemotherapy in one case. One patient with recurrent Hodgkins disease had six cycles of ABVD. During relapse he had an unspecified number of cycles of ABVD after which adriamycin was substituted and bleomycin was stopped in view of cardiac and lung toxicity (5). De novo limited stage Hodgkins disease is normally treated with 4 to 6 cycles of combination therapy. Cardiac toxicity resulting from cumulative anthracycline therapy is generally seen at doses above 450 to 500 mg/m2. The cumulative anthracycline dosage our patient received with CHOP and ABVD chemotherapy was 400 mg/m2. In view of limited stage disease and concern about anthracycline induced cardiomyopathy, he discontinued chemotherapy after two cycles of ABVD, after which he received radiotherapy. Recommendations for managing similar patients cannot be made based on a single case. There is no evidence to suggest that chemotherapy for diffuse large B cell lymphoma increases the risk of subsequent Hodgkins disease. All the cases reported so far have responded to conventional chemotherapy though the long-term outcome in these patients is not known. Common clonality is suggested by the temporal relation between the non-Hodgkins lymphoma and Hodgkins disease and also because both tumors were EBV positive, though conclusive evidence for this is not available. Anand Lokare Sridhar Chaganti Department of Haematology University Hospital Birmingham NHS Foundation Trust Birmingham, United Kingdom Graham Lipkin Department of Nephrology University Hospital Birmingham NHS Foundation Trust Birmingham, United Kingdom Claudia Roberts Department of Cellular Pathology University Hospital Birmingham NHS Foundation Trust Birmingham, United Kingdom Prem Mahendra Department of Haematology University Hospital Birmingham NHS Foundation Trust Birmingham, United Kingdom

A Proteomic Approach to Discovery of Candidate Proteins Involved in the Transformation of Follicular Lymphoma.

Background: Follicular lymphoma (FL) undergoes transformation to a high grade diffuse large B-cell lymphoma (tr-DLBCL) in about 50% of patients. During transformation, a more virulent subclone of tumor cells emerges, leading to a rapidly progressive clinical course and resistance to therapy. The identification of proteins involved in transformation is critical for understanding the mechanism of transformation and developing molecularly targeted therapy. In this study, we compared protein expression between grade 1- FL (G1-FL) and tr-DLBCL using 2D-gel electrophoresis and Western blot analysis.Design: Frozen tissue and frozen cells were obtained from the Department of Pathology, Oregon Health and Science University tumor bank. The protein expression profiles of 3 G1-FL and 3 tr-DLBCL were compared using 2D-gel electrophoresis. Protein identification was done using a MALDI mass spectrometer. Frozen cells of an additional 11 non-paired GI-FL and 11 non-paired tr-DLBCL, and 2 pairs of G1-FL and tr-DLBCL specimens were used for Western blot confirmation of the initial 2D-gel findings.Results: 2D-gel analysis and MALDI protein identification revealed 14 differentially expressed proteins between G1-FL and tr-DLBCL (figure 1), all of which are known to play important roles in cellular energy/metabolic pathways, signal transduction pathways, and protein and nuclear synthesis. The two most differentially expressed proteins on 2D-gel analysis were superoxide dismutase (MnSOD2) and growth factor receptor bound protein 2 (Grb2). Western blot analysis of MnSOD2 and Grb2 confirmed their relative over- or under-expression in frozen cells from multiple additional clinical lymphoma samples, including 2 paired- and 22 non-paired G1-FL and tr-DLBCL. Both 2D-gel analysis and Western Blot showed a significantly higher level of expression of MnSOD2 and a lower expression of Grb2 expression in tr-DLBCL (figure 2).Summary: Using proteomic profiling, confirmed by Western blot analysis of clinical G1-FL and tr-DLBCL samples, we have confirmed 2 proteins (MnSOD2 and Grb2) that are expressed at significantly different levels in G1-FL and DLBCL. MnSOD2 is capable of protecting cells from reactive oxygen species and regulating signal transduction pathways to influence cell growth and apoptosis. Inhibition of MnSOD2 has been shown in studies of several cancer cell lines to render cancer cells more susceptible to apoptosis. Grb2 is a member of a critical signaling pathway leading to Ras activation in hematopoietic cells. Both proteins may play a critical role in FL transformation. These proteins have the potential to be therapeutic drug targets, diagnostic and/or prognostic markers, or biomarkers for monitoring therapeutic response. [Display omitted] [Display omitted]