Primary Central Nervous System Diffuse Large B-cell Lymphoma Research Articles

Immunohistochemical overexpression of BCL-2 protein predicts an inferior survival in patients with primary central nervous system diffuse large B-cell lymphoma

This study was designed to analyze the clinical characteristics and prognostic value of c-MYC and BCL-2 proteins expression in patients with primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL).82 patients newly diagnosed with PCNS-DLBCL, from January 2008 to November 2018, were enrolled in this study. Clinical characteristics, immunohistochemical features, laboratory examinations, and treatment outcome were analyzed among these patients.Among these 82 cases, 45 were males (54.9%) and 37 were females (45.1%). Age ranged from 16 to 78 years old, and 29 patients (35.4%) were elder than 60 years old, with median age at 57 years old. According to Hans classification, 25 were accounted for origin of germinal center B-cell (GCB) subtype (30.5%) and 49 were accounted for non-GCB subtype (59.8%), respectively. Eight patients were unclassified due to lack of detailed pathological results. The median survival of these 82 patients was 30 months, and 1-year, 3-year, and 5-year overall survival (OS) rate was 59.7%, 44.6%, and 34.1%, respectively. Patients treated with sequential HD-MTX based chemotherapies showed a superior prognosis than those without. In combination with rituximab, the outcome was further improved. The median OS was 55 months in HD-MTX + R group, 27 months in HD-MTX group, and 9 months in other groups, respectively. Univariate analysis identified age ≥60, ECOG score ≥ 2 points, and overexpression of BCL-2 protein (≥85%) were adverse prognostic factors for OS. Co-expression of c-MYC (≥40%) and BCL-2 (≥50%) proteins was associated with poor ECOG score, high Ki-67 expression, and trended towards an inferior outcome. Gender, lesion location, number of lesions, lactic dehydrogenase (LDH), cell of origin, BCL-6 protein expression, expression of c-MYC protein alone and Ki-67 ≥85% had no significant impact on OS.In patients with PCNS-DLBCL, age ≥60 years old, ECOG score ≥2 points, and overexpression of BCL-2 protein (≥85%) were associated with a poor survival. HD-MTX based chemotherapies in combination with rituximab could improve the prognosis.

Cytological diagnosis of vitreoretinal lymphomas: A case series.

To assess the cytological diagnosis and follow-up of patients suffering from vitreoretinal lymphoma (VRL) diagnosed in our institution. From January 2010 to June 2017, we collected 15 patients with VRL. Twelve patients had diffuse large B-cell lymphoma (DLBCL); of these, 11 had primary central nervous system (CNS) DLBCL, one had ocular localisation of follicular lymphoma, one had extranodal NK/T-cell nasal type lymphoma and one had chronic lymphocytic leukaemia. The results of the cytological examination (cell morphology and immunocytochemistry) of the vitreous fluid were available for 9/15 VRL. The interleukin-10/-6 ratio was >1 in eight of 12 DLBCL. Molecular testing was useful in 6/15 cases (clonality evaluation or MYD88 L265P mutation testing). Eight out of 11 primary CNS DLBCL patients had CNS involvement, with 22-month progression-free survival. In our series, only two out of 11 CNS DLBCL patients died of disease after 2 and 5years, respectively. The short delay to assert the diagnosis of VRL could explain the quite good prognosis in our series, which highlights the need to consider a diagnosis of DLBCL as first step. The cytological features, as a reliable way to identify VRL, must always guide the choice of techniques for further investigations given the small amount of vitreous fluid available for analysis.

BCL2 expression is associated with a poor prognosis independent of cellular origin in primary central nervous system diffuse large B-cell lymphoma.

Primary central nervous system diffuse large B-cell lymphoma (CNS-DLBCL) is a distinct clinicopathological entity with a poor prognosis. Concurrent MYC and BCL2 overexpression predicts inferior prognosis in systemic DLBCL, although their prognostic significance remains unclear in primary CNS-DLBCL. Pretreatment diagnostic biopsy samples were retrospectively evaluated for 79 patients with primary CNS-DLBCL who were treated between January 2001 and December 2017. Histological and immunohistochemical testing were performed to evaluate the patients' statuses for various markers, which were also evaluated for associations with survival outcomes. According to the Hans criteria, 26 patients (32.9%) had the germinal center B-cell subtype and 53 patients (67.1%) had the activated B-cell subtype. Forty-one cases (51.9%) were positive for MYC (expression of ≥ 40%), 33 cases (41.8%) were positive for BCL2 (expression of ≥ 70%), 22 patients (27.8%) were positive for both MYC and BCL2, and 27 patients (34.2%) were negative for both MYC and BCL2. There were no significant differences in survival between the germinal center and activated B-cell subtypes. Furthermore, MYC positivity was not associated with overall survival (p = 0.369) or progression-free survival (PFS) (p = 0.253). However, BCL2 positivity was significantly associated with poor overall survival (p = 0.039) and PFS (p = 0.036). Co-expression of MYC and BCL2 was not associated with survival. Our data suggest that evaluating BCL2 expression may help predict the prognosis in cases of primary CNS-DLBCL.

Survival of patients with primary central nervous system diffuse large B-cell lymphoma: impact of gene aberrations and protein overexpression of bcl-2 and C-MYC, and selection of chemotherapy regimens

Objective: To investigate the impact of clinicopathological features, gene rearrangements and protein expression of bcl-6, bcl-2, C-MYC and chemotherapy regime on the prognosis of patients with primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL). Methods: Thirty-three cases of PCNS-DLBCL diagnosed from January 2006 to December 2016 at Zhejiang Cancer Hospital were collected. The expression of CD10, bcl-6, bcl-2, MUM1 and MYC were detected by immunohistochemical staining (IHC). The presence of EB virus was detected by in situ hybridization(EBER). Copy number variation (ICN) and translocation status of bcl-6, bcl-2 and C-MYC genes were detected by fluorescence in situ hybridization (FISH). The relationship between the above indexes and the prognosis was analyzed by univariate, bivariate survival analysis and multiple Cox hazard regression analysis. Results: The study included 33 patients of PCNS-DLBCL, without evidence of primary or secondary immunodeficient disease. Male to female ratio was 1.36∶1.00, and the average age was 56 years. Twenty cases had single lesion while 13 had multiple lesions. Deep brain involvement was seen in 12 cases. All patients underwent partial or total tumor resection. Five patients received whole brain post-surgery radiotherapy, nine patients received high-dose methotrexate (HD-MTX) based chemotherapy, and 12 patients received whole-brain radiotherapy combined with HD-MTX based chemotherapy. Severn patients received no further treatment and rituximab was used in 8 patients. According to the Hans model, 27 cases were classified as non-GCB subtypes (81.8%). Bcl-2 was positive in 25 cases (75.8%, 25/33) and highly expressed in 8 (24.2%). MYC was positive in 12 cases (36.4%) and double expression of bcl-2 and MYC was seen in 6 cases. EBER positive rate was 10.0%(3/30), all of which had multiple lesions. Two bcl-6 gene translocations and 3 amplifications were found in 28 patients. Two translocations, 3 ICN or with both bcl-2 gene translocation and ICN were found in 30 patients. Four ICNs of C-MYC gene were found in 28 patients. Elevated protein in cerebrospinal fluid (CSF) was found in 13 patients. LDH increased in 10 cases. Follow-up period was 2-90 months with the average survival time of (23.0±3.7) months and two-year survival rate of 39.0%. Univariate survival analysis showed that overexpression of bcl-2 protein (≥70%) and MYC protein (≥40%), bcl-2 gene abnormality (including copy number increase and translocation), C-MYC gene copy number increased were adverse factors for survival. C-MYC/ bcl-2 gene double hit was seen in 2 cases. Bivariate survival analysis found that of bcl-2/MYC protein double expression and bcl-2 and C-MYC genes double aberration were significantly associated with adverse outcomes. Cox multivariate risk regression analysis found that gender, cerebrospinal fluid protein increasing, and ICN of C-MYC gene were independent poor prognostic factors. DH-MTX based comprehensive chemotherapy was associated with better prognosis. Conclusions: Double hit at genomic level (copy number variations and gene rearrangements) and double protein expression of bcl-2 and C-MYC in PCNS-DLBCL are significantly associated with an adverse outcome. DH-MTX based comprehensive treatment may prolong the patient survival.

Primary central nervous system diffuse large B-cell lymphoma shows an activated B-cell-like phenotype with co-expression of C-MYC, BCL-2, and BCL-6

Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma, whose main prognostic factor is closely related to germinal center B-cell-like subtype (GCB- DLBCL) or activated B-cell-like type (non-GCB-DLBCL). The most common type of primary central nervous system lymphoma is diffuse large B-cell type with poor prognosis and the reason is unclear. This study aims to stratify primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL) according to the cell-of-origin (COO) and to investigate the multiple proteins expression of C-MYC, BCL-6, BCL-2, TP53, further to elucidate the reason why primary central nervous system diffuse large B-cell lymphoma possesses a poor clinical outcome as well. Nineteen cases of primary central nervous system DLBCL were stratified according to immunostaining algorithms of Hans, Choi and Meyer (Tally) and we investigated the multiple proteins expression of C-MYC, BCL-6, BCL-2, TP53. The Epstein-Barr virus and Borna disease virus infection were also detected. Among nineteen cases, most (15–17 cases) were assigned to the activated B-cell-like subtype, highly expression of C-MYC (15 cases, 78.9%), BCL-2 (10 cases, 52.6%), BCL-6 (15 cases, 78.9%). Unfortunately, two cases were positive for PD-L1 while PD-L2 was not expressed in any case. Two cases infected with BDV but no one infected with EBV. In conclusion, most primary central nervous system DLBCLs show an activated B-cell-like subtype characteristic and have multiple expressions of C-MYC, BCL-2, BCL-6 protein, these features might be significant factor to predict the outcome and guide treatment of PCNS-DLBCLs.

PD1 and PDL1 expression in primary central nervous system diffuse large B-cell lymphoma are frequent and expression of PD1 predicts poor survival.

Primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL) is a rare and aggressive type of diffuse large B-cell lymphoma (DLBCL) whit poorly understood pathogenesis. Finding biomarkers associated with patient survival may be important for understanding its physiopathology and to develop new therapeutic approaches. We investigated 32 PCNS-DLBCL from immunocompetent patients for BCL2, CMYC, LMO2, and P53 expression and for cytogenetic aberrations of BCL2, BCL6, and MYC genes, all known for their prognostic value in systemic DLBCL (s-DLBCL). We analyzed PD1 and PDL1 protein expression in both tumor infiltrating lymphocytes (TILs) and tumor cells. Finally, we searched for correlation between biological data and clinical course. The PCNS-DLBCL expressed BCL2, CMYC, LMO2, and P53 at similar frequency than s-DLBCL but without significant prognostic on survival. None cases harbored aberrations involving BCL2 and MYC gene whereas BCL6 abnormalities were present in 20.7% of cases but without value on survival. Expression of PD1 in TILs and PDL1 in tumor cells was observed at higher rates than in s-DLBCL (58% and 37%, respectively). The PD1 expression in TILs correlated with PDL1 expression in tumor cells (P=.001). Presence of PD1 positive TILs was associated with poorer overall survival (P=.011). Patients with PDL1 overexpression tended to better response to chemotherapy (P=.23). In conclusion PCNS-DLBCL pathogenesis differs from s-DLBCL without prognostic value of the phenotypic and cytogenetic parameters known for their pejorative impact in the latter. The PD1/PDL1 pathway plays a strong role in PCNS-DLBCL and represents an attractive target for this aggressive lymphoma.

CD30 Expression in Diffuse Large B-Cell Lymphoma (DLBCL) Correlates with Non-GCB Subtype but Does Not Have Prognostic Impact in Patients Treated with First Line R-CHOP/R-CHOP-like

Background: DLBCL is a heterogeneous disease with 30% of patients presenting as refractory/relapsing disease following R-CHOP treatment. Therefore, new prognostic factors to identify the poor-risk population and alternative therapies for them are needed. CD30 is a member of the tumour necrosis factor receptor (TNFR) super family and is expressed by several types of T- and B-cell non-Hodgkin lymphomas. Brentuximab vedotin, an anti CD30 antibody, is used in clinical practice for Hodgkin lymphoma and systemic anaplastic large cell lymphoma. The significance of CD30 expression in DLBCL remains unknown. We aimed to study the expression of CD30 in a large cohort of the novo DLBCL patients homogeneously treated with R-CHOP or R-CHOP-like protocols to evaluate its correlation with clinical and biological characteristics at diagnosis and its impact in clinical outcome.Methods: we prospectively registered 155 patients diagnosed of DLBCL between January 2012 to December 2015 in our center. Twenty-one patients with primary central nervous system DLBCL, transformed lymphoma or post-transplant DLBCL were excluded from the study. Anatomopathology review was performed in all cases, and 14 cases with not enough histological tissue to perform additional staining were also excluded. Immunohistochemistry was performed in 120 cases on 4 microns' paraffin sections using routine protocols,CD30 expression was analyzed using the antibodyCD30 clone BerH2, dilution 1:30; Dako; staining in more than 10% of the malignant cells was considered positive. Samples were classified as germinal center B-cell-like (GCB) vs. non-GCB subtypes by immunohistochemistry according to Hans algorithm. Univariate analyses were assessed by Chi square test. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analyses for progression-free survival (PFS) were assessed Cox proportional hazard regression model.Results: among the 120 cases analyzed, CD30 was expressed in 40 (33.3%). Clinical and biological characteristics at disease presentation are shown in Table 1. The expression of CD30 was significantly higher in the non-GCB subtype cases (p=0.0001). One hundred and six patients were homogeneously treated with R-CHOP (100 patients) or R-CHOP-like (1 R-COMP, 2 Burkitt scheme, 1 GA101-CHOP and 2 R-Bortezomib-CAP), and were included in the outcome analyses. Response rates and survival of this subgroup of patients are shown in Table 2. With a median follow-up of 16.4 months, no differences were found neither in PFS or OS between CD30 positive and CD30 negative patients (Table 2). In the multivariate analyses including the following independent variables: gender, B-symptoms, Bulky mass (>5cm), cell of origin (GCB vs non-GCB), International Prognostic Index (IPI) and CD30 expression, IPI 3-5 was de only factor significantly related with poor PFS (HR 2.92, 95% CI:1.18-7.24, p=0.02).Conclusion: CD30 is expressed in one third of DLBCL patients, in whom an anti-CD30 therapy could be used. CD30 expression is significantly higher in patients with non-CGB DLBCL, however and in our experience, its expression does not influence either response to R-CHOP or R-CHOP- like therapy or survival. [Display omitted] [Display omitted] DisclosuresGonzalez Barca:Gilead: Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Speakers Bureau.

Primary central nervous system diffuse large B cell lymphoma: a clinicopathologic and molecular study

Objective: To investigate clinicopathologic characteristics, immunophenotype and EB virus-related molecular genetic alterations in primary central nervous system diffuse large B cell lymphoma (DLBCL) along with correlation with clinical prognosis. Methods: A total of 30 cases of primary central nervous system DLBCL were retrospectively studied by retrieving clinical data, histological evaluation and immunophenotyping by EnVision two steps methods. The expression of EBER mRNA was detected by in situ hybridization and bcl-2, bcl-6 and C-MYC gene abnormalities were analyzed by interphase fluorescence in situ hybridization. Results: The cases included 18 males and 12 females (sex ratio of 1.5∶1.0) with an age ranging from 24 to 78 years (average age of 52 years, the median age of 53 years). The single primary clinical presentation was focal neurologic deficits. Tumor locations were supratentorial (21 cases), subtentorial (7 cases), involving both locations in 2 cases. Diffuse growth pattern was observed with large lymphoid cells mostly resembling centroblasts with abundant basophilic cytoplasm with oval to round, vesicular nuclei containing fine chromatin. An angiocentric and angiodestructive growth pattern was also present. Other features included perivascular space invasion. Immunohistochemical staining using a panel of CD10, bcl-6 and MUM1, six cases were germinal center-like (GCB) and 24 cases were non-germinal central-like (non-GCB). The positive rates of bcl-2, bcl-6 and C-MYC were 53.3% (16/30), 80.0% (24/30) and 20.0% (6/30), respectively. Genetic alterations were detected by FISH and the gene arrangement rates of bcl-2, bcl-6 and C-MYC were 3.3% (1/30), 16.7% (5/30) and 3.3% (1/30), respectively. There were 19 cases in stage 0-1 disease and 11 cases had stage 2-3 disease. Postoperative follow-up for average 13.6 months showed the median survival of 10 months, one-year survival of 46.7% and 16 patients died within a year. Conclusions: The clinical prognosis of primary central nerve system DLBCL depends on age, clinical performence status score, IPI score, immune classification and treatment. Patients typically progress rapidly with the high mortality within one year of diagnosis. Surgical resection combined with high-dose methotrexate or cytarabine chemotherapy offer the best treatment option.

Expression of OCT4 and SALL4 in Diffuse Large B-cell Lymphoma: An Analysis of 145 Consecutive Cases and Testicular Lymphomas.

OCT4 and SALL4 are transcription factors within a complex network that functions to maintain pluripotency in primitive stem cells and germ cells. Nuclear expression of OCT4 is widely cited as sensitive and specific for primary and metastatic germ cell tumors and is commonly used in the diagnosis of central nervous system (CNS) germinomas. Studies have failed to systematically examine the expression of OCT4 or SALL4 in diffuse large B-cell lymphoma (DLBCL), although this entity enters the morphologic differential diagnosis of some germ cell tumors. A retrospective review was conducted on 145 consecutive cases of DLBCL and testicular lymphoma to evaluate the prevalence of OCT4 and SALL4 expression. Nuclear OCT4 expression was present in 2/11 (18%) testicular DLBCLs and 6/134 (4.5%) nontesticular DLBCLs. Most OCT4 cases demonstrated moderate to strong expression in >50% of neoplastic cells. Rare, weak nuclear SALL4 expression was detected in only 3 nontesticular DLBCLs. Within the extratesticular DLBCL group, 2/6 (33%) primary CNS DLBCLs expressed nuclear OCT4. In addition, OCT4 DLBCL showed an overall predilection toward non-germinal center B-cell phenotype (7/8; 88%) and had a higher than expected rate of CD5 coexpression (4/8, 50%). These results are cautionary against using OCT4 as a sole marker of germ cell differentiation in testicular and extratesticular sites, especially in the CNS. The apparent associations of OCT4 expression with primary CNS DLBCL, non-germinal center B-cell phenotype, and CD5 coexpression raise the question of whether OCT4 expression in DLBCL may reflect more aggressive biology.

Akt activation confers an inferior survival in patients with activated B-cell subtype of diffuse large B-cell lymphoma: a report from The International DLBCL Rituximab-CHOP Consortium Program

Context Akt plays an essential role in diverse cellular processes such as cell proliferation, cell growth and apoptosis. Dysregulation of Akt signaling has been shown to correlate with an inferior survival in patients with a number of solid tumors and some hematologic malignances. The prognostic significance of Akt expression and the gene expression profile of Akt activation in diffuse large B-cell lymphoma (DLBCL) have not been thoroughly assessed. Objective In this study, we investigated Akt activation and analyzed its prognostic importance in a large cohort of patients with de novo DLBCL treated with R-CHOP immunochemotherapy. We also characterized the gene expression profile of DLBCL with activated Akt. Patients The study group consisted of 493 DLBCL patients treated with R-CHOP. These cases were organized as a part of the International DLBCL R-CHOP Consortium Program Study, and diagnosed according to the WHO criteria. Patients with primary mediastinal large B-cell lymphoma, primary cutaneous DLBCL, primary central nervous system DLBCL, and DLBCLs transformed from a low-grade B-cell lymphoma or associated with HIV infection were excluded. Methods Immunohistochemical studies (IHC) were performed in formalin-fixed paraffin-embedded sections of tissue microarrays to evaluate the expression of phosphorylated (activated) Akt and other relevant markers. Genetic alterations were examined by FISH for MYC , BCL-2 , and BCL-6 translocations and sequencing for TP53 mutation. Gene expression profiling (GEP) was performed to characterize the gene expression profile in Akt-activated DLBCL. The cell-of-origin (COO) subtypes were determined by GEP (gold standard) and IHC. Results Phosphorylated (activated) Akt (pAkt) expression was detected in 98 of 493 (20%) DLBCL tumors including 49 of 253 (19%) GCB DLBCL and 49 of 240 (20%) ABC DLBCL. In the GCB subtype, MYC, BCL-2 and MYC/BCL-2 translocations were more frequently found in pAkt+ DLBCL compared with pAkt- DLBCL ( P =0.04, 0.007 and 0.03, respectively). In contrast, translocations of these genes were rare and detected equally in pAkt+ and pAkt- subgroups within the ABC subtype ( P =0.7, 0.9 and 0.9, respectively). In the GCB group, TP53 mutation frequency was similar between pAkt+ and pAkt- DLBCL ( P =0.45). In contrast, TP53 mutations were significantly less frequent in ABC group (5% versus 22%; P = 0.01). Akt activation predicted a poorer survival, but the negative prognostic impact of Akt activation was significant in the ABC (5-year survival rate: 44% in pAkt+ versus 65% in pAkt-; P =0.01; 5-year PFS: 40% in pAkt+ versus 59% in pAkt-; P =0.01), but not GCB subtype (5-year survival rate: 67% in pAkt+ versus 74% in pAkt-, P =0.31; 5-year PFS rate: 61% in pAkt+ versus 69% in pAkt-, P =0.27). The negative impact of Akt activation appeared to be independent of Myc/Bcl-2 expression and TP53 mutation. In multivariate analysis, pAkt expression was an independent predictor of poorer OS (HR=2.72, 95% CI, 1.50-4.98, P =0.001) and PFS (HR=2.16, 95% CI, 1.22-3.82, P =0.008) in patients with ABC wild type- TP53 . In addition, AKT1 mRNA expression conferred significantly poor survival in DLBCL. Gene expression profiling revealed a distinct high-risk signature characterized by increased expression of multiple pro-survival genes (6 of 16 up-regulated genes; 40%) and decreased expression of genes encoding tumor suppressors (5 of 20 down-regulated genes; 25%) in pAkt+ ABC DLBCL. Conclusions Akt is activated in DLBCL, is equally distributed in COO subtypes, and has prognostic significance in patients with ABC DLBCL. Given the promising anti-lymphoma activity of Akt inhibitors in clinical trials, these findings may have clinical implications for DLBCL patients. Akt activation may be useful for prognostic stratification and could serve as a biomarker to guide patient selection and predict response to targeted anti-Akt therapy. Disclosures No relevant conflicts of interest to declare.

MYC protein expression is associated with poor prognosis in primary diffuse large B-cell lymphoma of the central nervous system.

MYC and BCL2 gene translocations and protein expression have recently demonstrated to be of prognostic significance in systemic diffuse large B-cell lymphoma (DLBCL). However, their role in primary central nervous system DLBCL (CNS-DLBCL) prognosis has been scarcely analyzed. We studied the immunophenotype, the status of the MYC, BCL2, and BCL6 genes and the clinical features of a series of 42 CNS-DLBCL and evaluated their prognostic significance. We found high MYC protein expression in 43% of cases, and this was associated with lower overall survival (OS). Cases with concurrent expression of MYC and BCL2 showed a lower OS, although the difference did not reach statistical significance. Translocations involving the MYC or BCL2 genes were not detected. The BCL6 gene was frequently translocated, but was unrelated to survival. We conclude that MYC protein expression detected by immunohistochemistry identifies a CNS-DLBCL subset with worse prognosis and may contribute to a more accurate risk stratification of CNS-DLBCL patients.

Akt Activation Confers an Inferior Survival in Patients with Activated B-Cell Subtype of Diffuse Large B-Cell Lymphoma: A Report from the International DLBCL Rituximab-CHOP Consortium Program

ContextAkt plays an essential role in diverse cellular processes such as cell proliferation, cell growth and apoptosis. Dysregulation of Akt signaling has been shown to correlate with an inferior survival in patients with a number of solid tumors and some hematologic malignances. The prognostic significance of Akt expression and the gene expression profile of Akt activation in diffuse large B-cell lymphoma (DLBCL) have not been thoroughly assessed.ObjectiveIn this study, we investigated Akt activation and analyzed its prognostic importance in a large cohort of patients with de novoDLBCL treated with R-CHOP immunochemotherapy. We also characterized the gene expression profile of DLBCL with activated Akt.PatientsThe study group consisted of 493 DLBCL patients treated with R-CHOP. These cases were organized as a part of the International DLBCL R-CHOP Consortium Program Study, and diagnosed according to the WHO criteria. Patients with primary mediastinal large B-cell lymphoma, primary cutaneous DLBCL, primary central nervous system DLBCL, and DLBCLs transformed from a low-grade B-cell lymphoma or associated with HIV infection were excluded.MethodsImmunohistochemical studies (IHC) were performed in formalin-fixed paraffin-embedded sections of tissue microarrays to evaluate the expression of phosphorylated (activated) Akt and other relevant markers. Genetic alterations were examined by FISH for MYC, BCL-2, and BCL-6 translocations and sequencing for TP53 mutation. Gene expression profiling (GEP) was performed to characterize the gene expression profile in Akt-activated DLBCL. The cell-of-origin (COO) subtypes were determined by GEP (gold standard) and IHC.ResultsPhosphorylated (activated) Akt (pAkt) expression was detected in 98 of 493 (20%) DLBCL tumors including 49 of 253 (19%) GCB DLBCL and 49 of 240 (20%) ABC DLBCL. In the GCB subtype, MYC, BCL-2 and MYC/BCL-2 translocations were more frequently found in pAkt+ DLBCL compared with pAkt- DLBCL (P=0.04, 0.007 and 0.03, respectively). In contrast, translocations of these genes were rare and detected equally in pAkt+ and pAkt- subgroups within the ABC subtype (P=0.7, 0.9 and 0.9, respectively). In the GCB group, TP53 mutation frequency was similar between pAkt+ and pAkt- DLBCL (P=0.45). In contrast, TP53 mutations were significantly less frequent in ABC group (5% versus 22%; P= 0.01). Akt activation predicted a poorer survival, but the negative prognostic impact of Akt activation was significant in the ABC (5-year survival rate: 44% in pAkt+ versus 65% in pAkt-; P=0.01; 5-year PFS: 40% in pAkt+ versus 59% in pAkt-; P=0.01), but not GCB subtype (5-year survival rate: 67% in pAkt+ versus 74% in pAkt-, P=0.31; 5-year PFS rate: 61% in pAkt+ versus 69% in pAkt-, P=0.27). The negative impact of Akt activation appeared to be independent of Myc/Bcl-2 expression and TP53 mutation. In multivariate analysis, pAkt expression was an independent predictor of poorer OS (HR=2.72, 95% CI, 1.50-4.98, P=0.001) and PFS (HR=2.16, 95% CI, 1.22-3.82, P=0.008) in patients with ABC wild type-TP53. In addition, AKT1 mRNA expression conferred significantly poor survival in DLBCL. Gene expression profiling revealed a distinct high-risk signature characterized by increased expression of multiple pro-survival genes (6 of 16 up-regulated genes; 40%) and decreased expression of genes encoding tumor suppressors (5 of 20 down-regulated genes; 25%) in pAkt+ ABC DLBCL.ConclusionsAkt is activated in DLBCL, is equally distributed in COO subtypes, and has prognostic significance in patients with ABC DLBCL. Given the promising anti-lymphoma activity of Akt inhibitors in clinical trials, these findings may have clinical implications for DLBCL patients. Akt activation may be useful for prognostic stratification and could serve as a biomarker to guide patient selection and predict response to targeted anti-Akt therapy. DisclosuresNo relevant conflicts of interest to declare.

Combined treatment of rituximab, idarubicin, dexamethasone, cytarabine, methotrexate with radiotherapy for primary central nervous system lymphoma

The overall response rates and long-term survival of primary central nervous system lymphoma (PCNSL) are still significantly inferior to the results achieved in similar subtypes of extranodal non-Hodgkin's lymphoma. It is clearly necessary to investigate new therapeutic methods on PCNSL. We encountered three patients histologically documented PCNSL as diffuse large B-cell lymphoma (DLBCL). They were treated with R-IDARAM which comprised rituximab, idarubicin, dexamethasone, cytarabine and methotrexate. Patient 1 received stereotactic brachytherapy (SBT) prior to chemotherapy performed with iodine-125 seeds (cumulative therapeutic dose 50 Gy). After six cycles of R-IDARAM at 3-weekly intervals, radiotherapy was applied at a dosage of 2000–4000 cGy in conventional schedule (180 or 200 cGy/day) to whole brain or spinal cord in all patients. Complete remission (CR) was achieved after first two cycles of R-IDARAM in all patients. All three patients remained in CR at the time of this report with a median duration of follow-up of 23 months (ranging from 13 to 41 months). Three patients have been alive for 41, 13, 16 months respectively until now. The patient with the longest survival time was the one given SBT prior to chemotherapy. This study suggests that R-IDARAM combining with radiotherapy maybe a high effective regimen in PCNSL patients especially those with primary central nervous system DLBCL. A comprehensive treatment combining internal radiotherapy by SBT, modified R-IDARAM and followed reduced external radiotherapy may be a new treatment concept for PCNSL with higher efficiency and lower toxicity.

Statin Use Improves Overall Survival and Time to Treatment Failure in Patients with Primary CNS Lymphoma.

Abstract 2496Poster Board II-473 Background:HMG-CoA reductase inhibitors (statins) have been used to treat hypercholesterolemia and hyperlipidemia for over 20 years. Statins competitively inhibit HMG-CoA reductase thereby blocking the synthesis of mevalonate. They directly inhibit synthesis of steroid hormones and cholesterol but also indirectly inhibit prenylation and ubiqitination. As all currently marketed statins are lipophillic, with the exception of Pravachol (pravastatin), several therapeutic trials have attempted to exploit these indirect actions to treat both neoplastic (glioblastoma, anaplastic astrocytoma) and degenerative (Alzheimer's, Parkinson's) neurologic disease. We studied the impact of incidentally prescribed statins on high-risk patients with primary central nervous system diffuse large B cell lymphoma (PCNSL). Methods:We used an IRB-approved clinicopathologic database, derived from comprehensive tumor registry data at the Massachusetts General Hospital, to identify all patients diagnosed with primary central nervous system lymphoma (PCNSL) between 1991 and 2007 (n=118). We excluded pediatric patients, patients who did not receive curative treatment and patients who failed to achieve a CR with initial therapy. Automated analysis of billing and medication administration records was used to identify the administration of statins to these patients. We compared the outcome of patients who were receiving statins to controls with PCNSL who did not receive statins. We excluded patients who did not receive statins within the time interval from 6 months prior to 2 years after their PCNSL diagnosis. As only a single statin pt was less than 50 we excluded all pts below this age from the cases and controls. All patients received high dose MTX based therapy. Overall survival (OS) was calculated from the date of first methotrexate. Results:Median age of statin patients was 66 yrs (range 52 – 76); median age of controls was 66 years (range 50 - 86). Nine patients were on atorvastatin, 9 were on simvastatin, 1 each were on pravastatin, rosuvastatin and fluvastatin. At a median follow-up of 47.5 months, concurrent statin therapy was associated with improved OS (62% vs. 37%)(p=0.04 Log-rank test). The median OS for all statin patients > 50 years old (n=21) was 60 months versus 37 months for all other patients > 50 years old (n=67) (p=<0.005 t-test two tailed). Conclusions:Concurrent prescription of HMG-CoA reductase inhibitors is associated with improved outcome in patients with high risk PCNSL compared to controls. Prospective controlled trials will be required to validate this observation. [Display omitted] Disclosures:Hochberg:Amgen: Speakers Bureau; Biogen-Idec: Speakers Bureau; Genentech: Speakers Bureau; Enzon: Speakers Bureau.

Primary diffuse large B-cell lymphoma of central nervous system belongs to activated B-cell-like subgroup: a study of 47 cases

To investigate the histogenetic origin of primary central nervous system diffuse large B-cell lymphoma (DLBCL) with respect to the stage of B-cell differentiation, and identification of the relevant prognostic markers. Immunohistochemical staining (EnVision method) for CD10, bcl-6, MUM-1, CD138 and FOXP1 antigens was performed on 47 paraffin-embedded sections. CD10, bcl-6, MUM-1 and FOXP1 expression in the tumor cells were 6.4%, 53.2%, 91.5% and 93.6% respectively. There was no expression of CD138 in all the cases. Among the 47 patients, 43 cases (91.5%) showed an activated B-cell-like (ABC) phenotype: 21 (44.7%) were bcl-6+ and MUM-1+, suggesting an "activated germinal center (GC) B-cell-like" in origin; 22 (46.8%) were exclusively MUM-1+, suggesting an "activated non-GCB" in origin. No significant correlation of the classification and FOXP1 expression found on the outcome (P=0.279 and P=0.154). Most primary central nervous system DLBCL are shown belonging to the ABC subgroup, suggesting that primary central nervous system DLBCL is quite similar to a DLBCL subset, which is derived from late GC to early post-GC B cell. The classification and FOXP1 expression do not show prognostic value in primary central nervous system DLBCL.

Activated B-cell immunophenotype might be associated with poor prognosis of primary central nervous system lymphomas

Primary central nervous system (PCNS) diffuse large B-cell lymphoma (DLBCL) is an aggressive form of non-Hodgkin's lymphoma whose growth is restricted to the central nervous system and eye. Primary CNS DLBCL has a poor prognosis relative to other extranodal DLBCL. Recently DLBCL has been subclassified as germinal and non-germinal center B-cell types using microarray. Germinal center B-cell DLBCL is associated with better prognosis compared to non-germinal center B-cell group. The objective of the study was to subcategorize the PCNS DLBCL into germinal center and non-germinal center DLBCL using immunohistochemistry and to correlate its prognostic significance. 21 immunocompetent patients were diagnosed with PCNS DLBCL over last 20 years at William Beaumont Hospital. Clinical data on outcome were collected and their specimens were retrieved. Immunohistochemical staining was done using markers, CD20, CD10, Bcl-6, MUM-1, MIB-1, Bcl-2 and by molecular analysis of the immunoglobulin heavy chain gene (IgH) variable region. Immunohistochemistry showed 1/21 (positive cases/examined cases) for CD10, 19/21 for Bcl-6, 19/21 for MUM-1 and 15/21 for Bcl-2. The expression pattern of CD10(-) MUM-1(+) is corresponded to the non-germinal center DLBCL. The MIB-1 index ranged from 40--80% with a mean of 57%, indicating a high proliferation of lymphoma cells. The IgH gene variable region analysis showed monoclonality in 15 of 21 cases (71%). Primary CNS DLBCL has a non-germinal center B-cell phenotype in majority of cases and has a high Bcl-2 positivity and MIB-1 index. These features might be associated with poor prognosis.

Expression of p53, c-Myc, or Bcl-6 suggests a poor prognosis in primary central nervous system diffuse large B-cell lymphoma among immunocompetent individuals.

Primary central nervous system (CNS) diffuse large B-cell lymphoma (DLBCL) in immunocompetent individuals, although rare, has been rising in incidence. Currently, no reliable prognostic markers are available for these individuals. To study the implications of expression of a panel of oncogenic proteins (Bcl-2, Bcl-6, and c-Myc) and p53 for predicting clinical outcome, particularly overall survival, in immunocompetent individuals with primary CNS DLBCL. Fourteen primary CNS DLBCL cases were retrospectively studied by immunohistochemistry on formalin-fixed, paraffin-embedded sections for the expression of c-Myc, Bcl-2, Bcl-6, and p53. The overall frequencies of expression for p53, c-Myc, Bcl-2, and Bcl-6 in these cases were 29%, 50%, 71%, and 57%, respectively. Cases with expression of p53, c-Myc, or Bcl-6 had a poorer overall survival than those without (Kaplan-Meier survival analysis: 50% cumulative overall survival, 2 months vs 30-60 months, P =.02, log-rank test; 9-16 months vs 21-60 months, P =.03, log-rank test; and 9-16 months vs 21-60 months, P =.16, log-rank test, respectively). The expression of Bcl-2 or proliferation activity by MIB-1 showed no correlation with overall survival. Likewise, the clinical parameters, including age, location of tumors, multiplicity of tumor lesions, and lactase dehydrogenase levels revealed no impact on overall survival. Our results suggest that patients with expression of p53, c-Myc, or Bcl-6 have a poorer overall survival than those without. Since traditional prognostic markers in non-CNS DLBCL, such as staging and International Prognostic Index scores, are not applicable to primary CNS DLBCL, evaluation of p53, c-Myc, and Bcl-6 by immunohistochemistry may be warranted as part of prognostic evaluation in immunocompetent patients with primary CNS DLBCL. Further studies are indicated to confirm our observations.