MYC Gene Rearrangement Research Articles

Dose-adjusted EPOCH-R (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab) in untreated aggressive diffuse large B-cell lymphoma with MYC rearrangement: a prospective, multicentre, single-arm phase 2 study

MYC gene rearrangement is present in approximately 10% of aggressive B-cell lymphomas, with half also harbouring a BCL2 gene rearrangement. Multiple retrospective studies of R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone or prednisolone) have shown a worse outcome in patients with MYC rearrangement (alone or with rearrangement of BCL2 or BCL6, or both) than in patients without MYC rearrangement, and suggest improved outcomes after more intensive treatment. We aimed to determine the outcome of dose-adjusted EPOCH-R (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab; DA-EPOCH-R), an intensive infusional treatment regimen, in untreated aggressive B-cell lymphoma with MYC rearrangement. We present the final analysis of a prospective, multicentre, single-arm, phase 2 study of DA-EPOCH-R in patients with untreated aggressive B-cell lymphoma with MYC rearrangement. DA-EPOCH-R was scheduled to be administered with CNS prophylaxis for six cycles. Primary endpoints included event-free and overall survival. This study is registered with ClinicalTrials.gov (NCT01092182). 53 patients were enrolled, with median age of 61 years (range 29-80; IQR 50-70); 43 (81%) patients had stage III-IV disease and 26 (49%) had high-intermediate or high international prognostic index (IPI) scores. 19 patients had confirmed MYC rearrangement alone (single-hit) and 24 also had rearrangement of BCL2, BCL6, or both (double-hit), with similar characteristics between these two groups. After a median follow-up of 55·6 months (IQR 50·5-61·1), 48-month event-free survival was 71·0% (95% CI 56·5-81·4) and 48-month overall survival was 76·7% (95% CI 62·6-86·1) for all patients. Toxicity included grade 4 neutropenia in 160 (53%) of 301 cycles, grade 4 thrombocytopenia in 40 (13%) cycles, and any grade of fever with neutropenia in 56 (19%) cycles. There were three treatment-related deaths (all infections). In this study, DA-EPOCH-R produced durable remission in patients with MYC-rearranged aggressive B-cell lymphomas and should be considered for the treatment of these diseases. Cancer Trials Support Unit and Center for Cancer Research of the National Cancer Institute and Genentech.

Prognostic analysis of interim 18F-FDG PET/CT in patients with diffuse large B cell lymphoma after one cycle versus two cycles of chemotherapy

Objectives18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is routinely used in diffuse large B cell lymphoma (DLBCL) for staging, assessment of remission and recurrence, and estimation of therapeutic efficacy. In this study, we aimed to assess the role of an early interim PET/computed tomography (CT) in the evaluation of response in DLBCL.MethodsSixty primary DLBCL patients (31 females) were analyzed. Baseline and follow-up 18F-FDG PET/CT was performed in patients after one cycle (n = 30) and two cycles (n = 30) of chemotherapy. The ΔSUVmax% was calculated. Patients were additionally evaluated using the conventional Deauville five-point scale (D-5PS) system. Fluorescence in situ hybridization (FISH) was employed to characterize the MYC gene status. We determined the optimum cutoff value of ΔSUVmax% using receiver operating characteristic (ROC) analysis. Kaplan–Meier analysis was applied to test for the influence of prognostic values.ResultsThe optimal cutoff for the prediction of treatment outcome was a ΔSUVmax% of 57% (after one cycle) and 63% (after two cycles); we could not detect a difference in accuracy with respect to a PET scan performed after one cycle and two cycles of chemotherapy (P > 0.05). The ΔSUVmax% and the D-5PS (score 5) showed the highest prognostic value compared to a score of 3 and/or 4 (both after one cycle and two cycles). No significant difference in sensitivity, specificity, accuracy, or the area of under the curve (AUC) of ΔSUVmax% and D-5PS (score 5) was observed between PETs performed after one cycle or two cycles of therapy (P > 0.05). ΔSUVmax%, D-5PS (score 5), and MYC gene rearrangement correlated significantly (P < 0.001).ConclusionInterim 18F-FDG PET/CT after one cycle of chemotherapy is feasible and yields similar predictive results as compared to an interim 18F-FDG PET/CT after two cycles of chemotherapy in patients suffering from DLBCL. The combination of interim 18F-FDG PET/CT with the MYC gene diagnosis might provide increased prognostic value for DLBCL.

Rare cases of laboratory tests discrepancies in diagnostics of pediatric Burkitt lymphoma/leukemia

Introduction. The main features of bone marrow blasts cells in Burkitt lymphoma/leukemia (BL) are L3 morphology, mature immunophenotype of blasts with surface IgM expression, and presence of typical MYC gene rearrangements.The aim of the study was to show discrepancy examples in laboratory signs of BL.Patients and methods. 10 patients (8 boys and 2 girls) aged 1 to 18 years were included in the present study. The inclusion criterion was the identification of discrepancies between flow cytometric, morphological and cytogenetic data.Results. In 2 cases there were no rearrangements of the MYC gene. In 2 patients, the L2 morphological variant went against the presence of typical MYC gene rearrangements. In one case, undifferentiated blasts cells were described by morphology together with presence of surface IgM, and atypical genetics. In 8 patients, there was no expression of surface IgM. Of these, patients with absence of cytomorphological data cytometric and genetic data were controversial.Сonclusion. The cases presented in this study and the cases described in the literature demonstrate the importance of an attentive and comprehensive approach in evaluating the results of laboratory tests in the diagnosis of BL.

Plasmablastic lymphoma: current perspectives.

Plasmablastic lymphoma (PbL) is a rare and aggressive B-cell malignancy with large neoplastic cells, most of them resembling plasmablasts that have a CD20-negative phenotype. Although initially described as being associated with HIV, over the years it has also been identified in patients with solid organ transplant and immunocompetent patients. Little is known about molecular basis that drives PbL, and still its diagnosis remains challenging given its rarity. However, proper recognition of its clinical characteristics, localization, and morphological features can establish a correct diagnosis of PbL within the spectrum of CD20-negative large B-cell lymphomas (LBCLs). PbL is characterized by CD20 and PAX5 negativity together with the expression of CD38, CD138, MUM1/IRF4, Blimp1, and XBP1 plasmacytic differentiation markers. It is usually associated with Epstein–Barr virus infections, and MYC gene rearrangements. PbL should be carefully differentiated from other CD20-negative B-cell neoplasms, ie, primary effusion lymphoma, anaplastic lymphoma kinase-positive (ALK) large B-cell lymphoma, and LBCL in human herpesvirus 8-associated multicentric Castleman disease. Despite our improved understanding of this disease, its prognosis remains dismal with short overall survival. There is no standard of care for this entity. Several chemotherapy combinations have been used with hardly any differences on its outcome. Thus, new approaches with the addition of novel molecules are needed to overcome its poor prognosis. Our current understanding and knowledge of PbL relies primarily on case reports and small case series. In this review, we revise through an extensive literature search, the clinical and biological characteristics of this entity, and the potential therapeutic options.

Comparison of evaluation techniques, including digital image analysis, for MYC protein expression by immunohistochemical stain in aggressive B-cell lymphomas

Incorporation of an MYC immunohistochemical stain in the workup of large B-cell lymphomas has become common in hematopathology practice. Evaluation of this stain can be difficult because of staining heterogeneity and can have interobserver variability, particularly when performed on the entire tumor sections. We identified 87 cases of aggressive B-cell lymphoma (34 core needle and 53 excisional biopsies) and compared the following methods of MYC immunohistochemical staining evaluation: the original pathologist's interpretation, a systematic retrospective method of evaluation by manual analysis, and a retrospective method of evaluation by digital image analysis (using scanned slides analyzed via the Aperio Nuclear algorithm). Overall, concordance among these methods was around 80% with κ statistics showing good agreement. However, nearly one-third of our cases had a percent MYC positivity in the 30% to 50% range, and for these cases, concordance among the various methods was marginal/poor. This suggests limited utility as a prognostic or predictive marker using 40% as a cutoff value. In our series, core biopsy specimens were poor predictors of MYC gene rearrangement, and there was no association between MYC immunohistochemical stain and MYC gene gain/amplification. Our retrospective digital image analysis showed strong correlation in MYC percent positivity with our retrospective manual review (correlation coefficient of 0.90) and similar concordance to pathologist interpretation as among pathologists, suggesting that digital image analysis is a viable alternative to manual determination of MYC percent positivity. Digital image analysis provides further opportunities for more sophisticated and standardized scoring systems, which may be helpful in future prognostic/predictive studies.

CD30 expression and its correlation with MYC and BCL2 in de novo diffuse large B-cell lymphoma

AimCD30+ diffuse large B-cell lymphoma (DLBCL) has emerged as a new immunophenotypic variant of de novo DLBCLs. However, the prevalence of CD30 positivity is variable according to different studies, and...

Abstract 45: BTM-3528 potently induces G1/G0 cell cycle arrest and is efficacious in preclinical models of diffuse large B-cell lymphoma

Abstract Aberrant regulation of cell cycle control, integration of signals from oncogenic signaling pathways, and cancer cell metabolism play a key role in the pathogenesis of multiple hematologic malignancies and solid tumors. BTM-3528 is an orally available compound that causes concentration-dependent cell cycle arrest in the G0/G1 phase of the cell cycle, rapidly decreases cellular glutathione levels, induces expression of p21, and decreases expression of Cyclin D 1/3. BTM-3528 has no significant biochemical activity against a panel of known drug targets such as kinases (including cyclin-dependent kinases), G-protein coupled receptors, ion channels, and histone deacetylases. For the described study, the activity of BTM-3528 was evaluated in in vitro and in vivo models of diffuse large B-cell lymphoma (DLBCL). Profiling of BTM-3528 across a panel of hematologic and solid tumor cancer cell lines demonstrated potent antiproliferative activity against a select set of cancer cell types without effect on normal human cells. These included multiple DLBCL cell lines notably of germinal center B-cell (GCB) subtype. The majority of the DLBCL cell lines tested were characterized by Myc and Bcl-2 gene rearrangements or amplifications. Cell proliferation was 100% inhibited with IC50s ranging from 0.14 to 0.52 μM in these DLBCL cell lines. BTM-3528 induced apoptosis with caspase 3/7 activation and decreased Mcl1 protein expression at concentrations associated with cell growth inhibition. In vivo pharmacokinetic studies showed that BTM-3528 has excellent oral bioavailability with a murine t ½ of 6 hours. BTM-3528 was tested in a human subcutaneous DLBCL xenograft model (BJAB). Post tumor implantation, animals with tumors ≥ 250 mm3 were treated with BTM-3528 at the maximum tolerated dose of 75 mg/kg once daily orally for 14 days. Significant antitumor activity was observed after 3 days of treatment followed by sustained tumor regressions. Furthermore, following discontinuation of BTM-3528 after 14 days of treatment, sustained complete tumor regressions were maintained in 50% of the treated animals. Preliminary toxicology evaluation of BTM-3528 showed no adverse effect on hematopoiesis or hepatic function. Conclusion: BTM-3528 is a novel orally bioavailable compound with a unique mechanism of action based on G1/G0 cell cycle arrest and modulation of cancer cell metabolism. It shows significant activity and a favorable toxicity profile in in vitro and in vivo models of DLBCL. These results support the clinical development potential of BTM-3528 for the treatment of DLBCL. Citation Format: Matthew Kostura, Jedd Levine, Vibha Oza, Alan Cooper, Meztli Arguello, Peter W. White, Stephane Ciblat, Anthony Regina, Edith Bellavance, Martine Brault, Arshad Siddiqui, Michael Luther. BTM-3528 potently induces G1/G0 cell cycle arrest and is efficacious in preclinical models of diffuse large B-cell lymphoma [abstract]. In: Proceedings of the Second AACR Conference on Hematologic Malignancies: Translating Discoveries to Novel Therapies; May 6-9, 2017; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(24_Suppl):Abstract nr 45.

BCL2mRNA or protein abundance is superior to gene rearrangement status in predicting clinical outcomes in patients with diffuse large B‐cell lymphoma

Introduction: BCL2 is important in lymphomagenesis and represents a candidate biomarker in DLBCL. However, the optimal approach for ascertaining BCL2 status in biopsy specimens is uncertain. Here, we determined BCL2 rearrangement status by fluorescence in situ hybridization (FISH), mRNA abundance by NanoString, and protein abundance by immunohistochemistry (IHC) or quantitative immunofluorescence (IF) in pretreatment FFPE biopsy specimens to ascertain the most clinically meaningful measures. Methods: We identified 56 cases of de novo DLBCL treated with R-CHOP from which pretreatment FFPE biopsy samples were available. To quantify BCL2 expression by IF, digital images were created by scanning histology sections coimmunostained for BCL2 and CD20, then BCL2 fluorescence signals were quantified objectively in CD20-positive cells. Results: BCL2 rearrangement or, interestingly, increased copy number of BCL2 was associated with greater mRNA and protein abundance according to either IHC or IF (P < .005 for all comparisons). BCL2 mRNA abundance was associated with elevated protein abundance by IHC (P < .0001) and IF (rs = 0.65; P < .0001) (Figure 1). In contrast, MYC gene rearrangement, but not increased copy number, was associated with more MYC mRNA and more protein based on IHC (P < .005 for all comparisons). Elevated BCL2 expression was associated with a reduced complete response rate to R-CHOP (mRNA, P = .002; IHC, P = .03; IF, P = .03) and reduced overall survival (OS; mRNA, P = .045; Figure 1), whereas neither BCL2 rearrangement (P = .48), MYC rearrangement (P = .83), MYC mRNA (P = .08) or protein expression (P = .56), MYC/BCL2 “double-hit” (P = .75), nor “dual expression” status (P = .41) was associated with reduced OS. Keywords: “double-hit” lymphomas; BCL2; diffuse large B-cell lymphoma (DLBCL)

MYC Gene Rearrangements Are Closely Associated with Poor Survival of Diffuse Large B Cell Lymphoma with Hepatitis B Virus Infection

The aim of this study was to identify clinical adverse prognostic factors affecting overall survival (OS) of diffuse large B cell (DLBCL) patients with hepatitis B virus (HBV) infection. In this study, 30 DLBCL patients with HBV infection and 51 DLBCL patients with HBV-free were reviewed retrospectively. As of July 2016, the median follow-up period was 26.4 months (3.0~65.0 months). The median OS of patients in HBV infection group was 38.6 months, while that of patients in HBV-free group was not reached (P = 0.042); the median progression-free survival (PFS) of patients in HBV infection group was worse than that in HBV-free group, 18.5 months and 38.5 months (P = 0.118), respectively. The rate of MYC and BCL2 gene rearrangements in HBV infection group was significantly higher than that in HBV-free group, 20.0% versus 3.9% (P = 0.019) and 23.3% versus 5.9% (P = 0.021), respectively. Multivariable analysis indicated that IPI (P = 0.002), chemotherapy regimens (P = 0.017), and MYC gene rearrangements (P = 0.004) were independent adverse prognostic factors for all DLBCL patients in this study. Results demonstrated that the poor survival of DLBCL patients with HBV infection was closely involved in chemotherapy regimens, IPI, and MYC gene rearrangements.

Prognostic impact of MYC protein expression in central nervous system diffuse large B-cell lymphoma: comparison with MYC rearrangement and MYC mRNA expression

The prognostic role of MYC has been well documented in non-central nervous system diffuse large B-cell lymphoma; however, it remains controversial in central nervous system diffuse large B-cell lymphoma. To investigate the prognostic value of MYC, we analyzed the MYC protein expression by immunohistochemistry, mRNA expression by RNA in situ hybridization, and gene status by fluorescence in situ hybridization in 74 cases of central nervous system diffuse large B-cell lymphoma. Moreover, we examined the correlation between MYC translocation, mRNA expression, and protein expression. The mean percentage of MYC immunopositive cells was 49%. Using a 44% cutoff value, 49 (66%) cases showed MYC protein overexpression. The result of mRNA in situ hybridization using the RNA scope technology was obtained using the H-scoring system; the median value was 34.2. Using the cutoff value of 63.5, 16 (22%) cases showed MYC mRNA overexpression. MYC gene rearrangement was detected in five out of 68 (7%) cases. MYC translocation showed no statistically significant correlation with mRNA expression; however, all MYC translocation-positive cases showed MYC protein overexpression, with a higher mean percentage of MYC protein expression than that of translocation-negative cases (78 vs 48%, P=0.001). The level of MYC mRNA expression was moderately correlated with the level of MYC protein expression (P<0.001). The mean percentage of MYC protein expression in the high MYC mRNA group was higher than that in the low MYC mRNA group (70 vs 47%, P<0.001). A univariate analysis showed that age over 60 years, Eastern Cooperative Oncology Group (ECOG) performance status ≥2 and MYC protein overexpression were significantly associated with an increased risk of death. MYC translocation and MYC mRNA expression had no prognostic significance. On multivariate analysis, MYC protein overexpression and ECOG score retained prognostic significance.

Unfavorable Prognostic Impact of MYC Increased Copy Number (ICN) in Patients with Diffuse Large B-Cell and High-Grade Lymphoma Treated with Immuno-Chemotherapy (ICT)

Background: MYC rearrangements occur approximately in 5-15% of diffuse large B-cell lymphoma (DLBCL), and are known to unfavorably impact on patients (pts) survival, especially if associated to BCL2 or/and BCL6 rearrangements (double/triple-hit). Previous studies have shown that also a MYC gene ICN may confer a worse prognosis to these pts (Yoon, Histopathology 2008), but only few groups have transferred this observation into the clinical practice. However, this finding may account for those cases that, despite the absence of MYC rearrangements, show a similar aggressive clinical course. For this reason, a careful study of all aberrations involving MYC geneshould be widely applied. We report a single center experience on the clinical outcome of pts with MYC ICN in the setting of aggressive B-cell lymphoma.Methods: In the study period (Aug 2011-Aug 2015) we performed FISH analysis in all consecutive pts with de novo or transformed DLBCL or B-cell lymphoma, unclassifiable (BCLU) that displayed Ki67 >80% or intense bcl2 protein expression. Interphase FISH has been performed on 23 μm thick sections of formalin fixed paraffin embedded tissues, using splitsignal DNA probes (Dako) specific for the following loci: 8q24 (MYC), 18q21 (BCL2) and 3q27 (BCL6). For each sample, 60 evaluable nuclei with complete FISH signals were scored. ICN was considered when 3 or more copies of the gene studied were identified.Almost all pts with a MYC translocation have been treated according to Burkitt lymphoma (BL)-like regimens as first line therapy (FLT); pts with MYC ICN have been treated with BL-like regimens from 2013, whereas standard ICT (R-CHOP or R-CHOPlike) has been used for these pts diagnosed before 2013. Overall survival (OS) was evaluated by Kaplan Meier method.Results: In the 4-year study period, 317 consecutive pts were diagnosed with de novo or transformed DLBCL or BCLU. Twenty-one (7%) showed a translocation of MYC, in single (14%), double (67%) or triple hit (19%), with respect to BCL2 and BCL6 rearrangements. Interestingly, 8 (2.5%) pts with no MYC translocation showed MYC ICN, ranging from 3 up to 10 gene copies per cell. This aberrant gene copy number was observed in > 80% of the analyzed nuclei in 7 cases. The characteristics of the pts with MYC gene rearrangement or ICN are summarized in Table 1.Of the 8 pts with MYC ICN, 5 had de novo DLBCL, 2 had transformed DLBCL and 1 had BCLU. Seven pts also showed BCL2 and/or BCL6 rearrangement/ICN. Three pts were treated with standard ICT and 5 with a BLlike regimen. Two pts (25%) responded to the FLT, showing one complete and one partial remission (CR and PR, respectively); both received BLlike regimen. The patient with PR progressed after 7 months, and received a second line treatment likewise the 6 nonresponders to FLT. None of them had a response and eventually died, with a median OS of 10.5 months. Cause of death was lymphoma in all cases. The patient who obtained a CR was still in remission at 29 months from the end of the FLT. The survival of these pts, compared to pts with MYC rearrangement, is shown in Figure 1 (respectively 12% vs 57% at 2 years, p 0.04).Conclusion: These preliminary data show a dismal prognosis of pts with aggressive B cell lymphoma and MYC ICN, significantly worse than pts harboring a MYC translocation, independently of the treatment received. To better understand the genetic defect underlying this FISH pattern, further analysis using a specific centromere probe for chromosome 8 is ongoing on these and new cases. A previous study distinguished gain from amplification of MYC based on the number of gene copies, identifying 2 groups with different prognosis (Valera, Hematologica 2013). In our hands, there was a wider range of gene copy number in each patient, and the outcome was homogeneously poor. Overall, the biological consequence of this alteration is still to be fully explained, and only a few studies have addressed this point so far (Stasik, Hematologica 2010). Further investigation on larger cohort groups is necessary to confirm the unfavorable prognostic role of MYC ICN in aggressive B cell lymphoma. Such insights would help practitioners to determine more accurate therapeutic approaches, in order to improve the outcome of this specific subset of pts. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

MYC and BCL2 Gene Rearrangements in Comparison to MYC and BCL2 Protein Expression in AIDS-Related Diffuse Large B Cell Lymphomas

MYC and BCL2 Gene Rearrangements in Comparison to MYC and BCL2 Protein Expression in AIDS-Related Diffuse Large B Cell Lymphomas

Primary cardiac diffuse large B-cell lymphoma in immunocompetent patients: clinical, histologic, immunophenotypic, and genotypic features of 3 cases.

Primary cardiac lymphoma (PCL) is a rare extranodal lymphoma that involves only the heart and/or pericardium. Primary cardiac lymphoma is much less common in immunocompetent patients compared with those who are immunosuppressed. Patients with PCL have variable clinical manifestations that may lead to misdiagnosis and delay in treatment. Modern radiologic imaging now allows for earlier detection of these tumors. This study describes the clinical, histologic/cytologic, immunophenotypic, and molecular genetic findings for 3 immunocompetent patients with primary cardiac diffuse large B-cell lymphoma. All 3 patients had different initial clinical presentations. The neoplastic cells in all 3 cases were large in size, morphologically resembling diffuse large B-cell lymphoma. Neoplastic cells in 2 cases had non-germinal center (GC)-like (non-GC-like) and 1 case had GC-like immunophenotype. Neoplastic cells in all 3 cases showed C-MYC and BCL2 immunohistochemical protein coexpression. Neoplastic cells in 1 case showed double-hit MYC and BCL2 gene rearrangements, whereas another 1 case showed MYC gene rearrangement without BCL2 gene rearrangement. Epstein-Barr virus-encoded RNA was negative in the neoplastic cells in all 3 cases. All 3 patients received rituximab-based chemotherapy. Two patients subsequently had disease relapse at other extranodal sites at 10 and 24 months, respectively, whereas 1 patient was alive without disease at 9 months after diagnosis. If there is sufficient diagnostic tissue in these rare tumors, molecular studies should ideally be performed for prognostication and further patient management.

An unusual case of co-existing classic mantle cell lymphoma and transformed lymphoma with Burkitt-like features with leukemic presentation

Mantle cell lymphoma (MCL) is an aggressive mature B cell lymphoma characterized by the t(11;14) IGH-CCND1 translocation. The majority of the MCL harbors secondary genetic aberrations and the MYC gene rearrangement is occasionally detected. We reported a unique case of co-existence of a typical MCL and a transformed component with morphologic and immunophenotypic features resembling a Burkitt lymphoma in leukemic phase at disease presentation. Two distinct abnormal B cell populations were identified in the peripheral blood and bone marrow: a CD5+/CD10− population primarily in the peripheral blood (47.6 %) and a CD5−/CD10+ population predominantly in the marrow (83.8 %), which shared the same surface light chain restriction and identical immunoglobulin gene rearrangements. By cytogenetic studies, the CD10+ cells harbored both t(11;14) IGH-CCND1 and t(8;14) IGH-MYC whereas the CD5+ population only carried t(11;14) IGH-CCND1. The combined findings indicate that the Burkitt-like component represents a transformation from a typical MCL by acquiring t(8;14) and that the MYC rearrangement represents a secondary oncogenic event in MCL that drives the disease progression. This unique case described co-existence of clonally related MCL and a transformed component otherwise typical of a Burkitt lymphoma, both in leukemic phase at disease presentation, which provided direct evidence on the lymphomagenesis of MCL.

Immune-checkpoint expression in Epstein-Barr virus positive and negative plasmablastic lymphoma: a clinical and pathological study in 82 patients.

Plasmablastic lymphoma is a rare and aggressive diffuse large B-cell lymphoma commonly associated with Epstein-Barr virus co-infection that most often occurs in the context of human immunodeficiency virus infection. Therefore, its immune escape strategy may involve the upregulation of immune-checkpoint proteins allowing the tumor immune evasion. However, the expression of these molecules was poorly studied in this lymphoma. We have investigated 82 plasmablastic lymphoma cases of whom half were Epstein-Barr virus positive. Although they harbored similar pathological features, Epstein-Barr virus positive plasmablastic lymphomas showed a significant increase in MYC gene rearrangement and had a better 2-year event-free survival than Epstein-Barr virus negative cases (P=0.049). Immunostains for programmed cell death-1, programmed cell death-ligand 1, indole 2,3-dioxygenase and dendritic cell specific C-type lectin showed a high or moderate expression by the microenvironment cells in 60%-72% of cases, whereas CD163 was expressed in almost all cases. Tumor cells also expressed programmed cell death-1 and its ligand in 22.5% and 5% of cases, respectively. Both Epstein-Barr virus positive and negative plasmablastic lymphomas exhibited a high immune-checkpoint score showing that it involves several pathways of immune escape. However, Epstein-Barr virus positive lymphomas exhibited a higher expression of programmed cell death-1 and its ligand in both malignant cells and microenvironment as compared to Epstein-Barr virus negative cases. In conclusion, plasmablastic lymphoma expresses immune-checkpoint proteins through both malignant cells and the tumor microenvironment. The expression of programmed cell death-1 and its ligand constitutes a strong rationale for testing monoclonal antibodies in this often chemoresistant disease.

20 - MYC Gene Rearrangement in Plasma Cell Neoplasms

MYC gene rearrangements and amplification are known to be associated with aggressive disease in patients with acute leukemia and B-cell Non-Hodgkin lymphoma. Up to 15% of Plasma Cell Neoplasm (PCN) patients are reported to have MYC gene rearrangement with evidence indicating an associated poor prognosis and shortened survival ( 1 Walker B.A. Wardell C.P. Brioli A. et al. Translocations at 8q24 juxtapose MYC with genes that harbor superenhancers resulting in overexpression and poor prognosis in myeloma patients. Blood Cancer J. 2014; 4: e191https://doi.org/10.1038/bcj.2014.13 Crossref Scopus (117) Google Scholar ). While it has been historically associated with advanced disease, rearrangement of the gene has also now been identified in patients with “smoldering” myeloma or monoclonal gammopathy ( 2 Affer M. Chesi M. Chen W.D. et al. Promiscuous MYC locus rearrangements hijack enhancers but mostly super-enhancers to dysregulate MYC expression in multiple myeloma. Leukemia. 2014; 28: 1725-1735 Crossref Scopus (174) Google Scholar ).

New MYC IHC Classifier Integrating Quantitative Architecture Parameters to Predict MYC Gene Translocation in Diffuse Large B-Cell Lymphoma.

A new automated MYC IHC classifier based on bivariate logistic regression is presented. The predictor relies on image analysis developed with the open-source ImageJ platform. From a histologic section immunostained for MYC protein, 2 dimensionless quantitative variables are extracted: (a) relative distance between nuclei positive for MYC IHC based on euclidean minimum spanning tree graph and (b) coefficient of variation of the MYC IHC stain intensity among MYC IHC-positive nuclei. Distance between positive nuclei is suggested to inversely correlate MYC gene rearrangement status, whereas coefficient of variation is suggested to inversely correlate physiological regulation of MYC protein expression. The bivariate classifier was compared with 2 other MYC IHC classifiers (based on percentage of MYC IHC positive nuclei), all tested on 113 lymphomas including mostly diffuse large B-cell lymphomas with known MYC fluorescent in situ hybridization (FISH) status. The bivariate classifier strongly outperformed the “percentage of MYC IHC-positive nuclei” methods to predict MYC+ FISH status with 100% sensitivity (95% confidence interval, 94-100) associated with 80% specificity. The test is rapidly performed and might at a minimum provide primary IHC screening for MYC gene rearrangement status in diffuse large B-cell lymphomas. Furthermore, as this bivariate classifier actually predicts “permanent overexpressed MYC protein status,” it might identify nontranslocation-related chromosomal anomalies missed by FISH.

Clinical characteristics and prognosis of concurrent positive t(14; 18) and myc gene rearrangement in diffuse large B cell lymphoma

To study the incidence of positive t(14; 18) and myc gene rearrangement, and the clinical features and prognosis of concurrent positive t(14; 18) and myc gene rearrangement "double-hit lymphoma" (DHL) in diffuse large B cell lymphoma. The positive t(14; 18) and myc gene rearrangement in 106 cases of DLBCL were analyzed using interphase fluorescent in situ hybridization (FISH) technique. The expression of myc and bcl-2 proteins was determined by immunohistochemistry. The relationship of positive t(14; 18) and myc gene rearrangement with clinical features, pathogenesis and prognosis for the patients was analyzed. SPSS 16.0 software was used for statistical analysis. Among the 106 cases, there were 27 (25.5%) cases with positive t(14; 18) and 13 (12.3%) cases with myc gene rearrangement, and 7 cases (6.6%) of DLBCL with concurrent t(14; 18)-positive and myc gene rearrangement. A relationship was observed between positive t(14; 18) and myc gene rearrangement (P=0.019). The follow-up data showed that the 7 DHL patients were in age of 52-84 years, the International Prognostic Index (IPI) scores were 3 in two cases, 4 in four cases and 5 in one case, and the ECOG scores were 3 in all the 7 cases. Four patients had bone marrow involvement and were combined with leukemia. The survival time ranged from 0.5 to 6 months, with a median survival of 4 months. The univariate analysis showed that B symptom, Ann Arbor stage, ECOG score, LDH level, IPI score, immunophenotype, bcl-2 protein expression, myc protein expression, and myc gene rearrangement were all associated with poor prognosis (P<0.05 for all). The multivariate analysis using a COX proportional hazard model confirmed that ECOG score, bcl-2 protein expression, myc protein expression, myc gene rearrangement, and immunophenotype were independent prognostic factors affecting survival (P<0.05 for all), among them, the myc gene rearrangement was the strongest prognostic factor (OR=4.337, P<0.001). "Double-hit" DLBCL is rare and can be mainly identified only by molecular detection. Perhaps positive t(14; 18) and myc gene rearrangement play concurrent role in its "double-hit" pathogenesis. DHL are highly invasive, and most of DHL patients have poor prognosis. Further studies of larger case number are required to determine the pathologic features and the therapeutic strategy of this subgroup.

Diffuse Large B-Cell Lymphoma Version 1.2016.

Diffuse large B-cell lymphomas (DLBCL) are now considered a heterogeneous group of distinct molecular subtypes (germinal center B-cell DLBCL, activated B-cell DLBCL, and primary mediastinal large B-cell lymphoma (PMBL) with varied natural history and response to therapy. In addition, a subset of patients with DLBCL have concurrent MYC and/or BCL2 gene rearrangements (double-hit lymphomas; DHL) and others have a dual expression of both MYC and BCL2 proteins (double-expressing DLBCL; DEL). The standard of care for the treatment of patients with PMBL, DHL, or DEL has not been established. Adequate immunophenotyping and molecular testing (in selected circumstances) are necessary for the accurate diagnosis of different subtypes of DLBCL. The NCCN Guidelines included in this issue, part of the NCCN Guidelines for non-Hodgkin's lymphomas, address the diagnosis and management of DLBCL and its subtypes.

C-MYC and BCL2 translocation frequency in diffuse large B-cell lymphomas: A study of 97 patients.

Diffuse large B-cell lymphoma (DLBCL) is an aggressive non-Hodgkin lymphoma with marked biologic heterogeneity. MYC and BCL2 rearrangements have been reported in a proportion of DLBCLs, where they may be associated with an adverse clinical outcome. The aim of this study was to determine the frequency of MYC and BCL2 translocations in DLBCL and assess the prognostic impact in DLBCL patients. In the present study, we evaluated the expression patterns of CD 10, BCL6, and MUM 1 by immunohistochemistry in 121 cases with DLBCL in tissue microarray (TMA): 62 cases in germinal center B-cells (GCBs); and 59 cases in activated B-cells (ABCs) of which 60 were females and 61 were males. MYC and BCL2 rearrangements were investigated by interphase fluorescence in situ hybridization on TMAs in 97 DLBCLs. MYC rearrangements were observed in 11 of 97 cases. There was no association with other clinical features, including age, sex, and nodal/extranodal disease. MYC rearrangement was associated with significantly worse overall survival (P < 0.01). BCL2 rearrangements were observed in 14 of 97 cases. There was no association with other clinical features including age and sex. BCL2 rearrangement had a worse outcome (P < 0.01). MYC and BCL2 rearrangements were observed in 3 of 97 cases with the age of 53 (female), 53, 63 years old, respectively, died in 24, 18, and 35 months after the diagnosis. Two cases had primary nodal and one case primary extranodal presentations. All these patients had stage IV disease. We concluded that C-MYC and BCL2 may contribute to aggressive transformation, and more mechanism-based therapy should be explored. Targeted therapies involving these rearrangements and its associated pathways may change the fate of DLBCLs. Analysis of MYC gene rearrangement along with BCL2 is critical in the identification of high-risk patients with poor prognosis.