Survival In Classical Hodgkin Lymphoma Research Articles

Immunohistochemical expression of vitamin D receptor and forkhead box P3 in classic Hodgkin lymphoma: correlation with clinical and pathologic findings

BackgroundExpression of forkhead box P3 (FOXP3), a key regulator of T-cell function, in the tumor immune microenvironment is related to survival in classic Hodgkin lymphoma (CHL). Vitamin D receptor (VDR), a transcription factor agonists have been shown to induce FOXP3 expression in T-cells and enhance recruitment of these cells to the inflammatory sites. VDR expression is CHL has been described. However, there is no data on expression of VDR in context of quantity of FOXP3 positive cells in CHL.MethodsWe examined and correlated immunohistochemical expression of VDR and FOXP3 along with clinical and pathology findings in 29 cases of CHL.ResultsVDR was expressed in Hodgkin Reed-Sternberg (HRS) cells and background lymphocytes and FOXP3 was expressed in background lymphocytes. 82% of CHL cases, regardless of the subtype, expressed VDR and in majority of the cases, VDR expression was directly proportional to the quantity of FOXP3 expressing lymphocytes in the tumor microenvironment. In cases with higher clinical stage (III/IV), only 28.5% of cases diffusely expressed VDR and FOXP3 compared to 71.4% showing focal positivity. Whereas in cases with lower clinical stages (I/II), the expression pattern of VDR and FOXP3 was almost similar (41.6% diffuse versus 33.3% focal). Interestingly, focal VDR and FOXP3 expression pattern was significantly higher among males. Mixed cellularity cases showed predilection for focal VDR and FOXP3 expression (80% cases); whereas nodular sclerosis subtype had focal and diffuse VDR and FOXP3 expression patterns in similar proportion. Cases with diffuse VDR and FOXP3 expression were less likely to have bone marrow involvement. Epstein Barr virus- encoded small RNA (EBER) positive cases were predominantly focally positive (80%) for VDR and FOXP3.ConclusionsIn summary, quantity of FOXP3 positive T-cells in CHL microenvironment seems to correlate with VDR expression. Clinical stage show a trend of inverse correlation with expression of VDR and quantity of FOXP3 positive T-cells. These findings suggest that VDR could be a possible prognostic and therapeutic target in CHL.

Primary therapy and relative survival in classical Hodgkin lymphoma: a nationwide population-based study in the Netherlands, 1989-2017.

Population-based studies of classical Hodgkin lymphoma (cHL) in contemporary clinical practice are scarce. The aim of this nationwide population-based study is to assess trends in primary therapy and relative survival (RS) during 1989-2017. We included 9,985 patients with cHL. Radiotherapy alone was virtually not applied as from 2000 among patients aged 18-69 years with stage I/II disease, following the broader application of chemotherapy combined with radiotherapy. Chemotherapy only was the preferred treatment for patients with stage III/IV disease. Throughout the entire study period, around 20% of patients aged ≥70 years across all disease stages received no anti-neoplastic therapy. The most considerable improvements in 5-year RS were confined to patients aged 18-59 years. Five-year RS for patients with stage I/II disease diagnosed during 2010-2017 was 99%, 98%, 100%, 93%, 84%, and 61% for patients aged 18-29, 30-39, 40-49, 50-59, 60-69, and ≥70 years, respectively. The corresponding estimates for stage III/IV disease were 96%, 92%, 90%, 80%, 58%, and 46%. Collectively, the improvements in survival likely relate to advances in cHL management. These achievements, however, do not seem to translate into significant benefits for patients ≥60 years. Therefore, novel therapies are urgently needed to reduce excess mortality in elderly cHL patients.

Prognostic Impact of Tumor-Associated Macrophages on Survival Is Checkpoint Dependent in Classical Hodgkin Lymphoma.

Tumor microenvironment and immune escape affect pathogenesis and survival in classical Hodgkin lymphoma (cHL). While tumor-associated macrophage (TAM) content has been associated with poor outcomes, macrophage-derived determinants with clinical impact have remained undefined. Here, we have used multiplex immunohistochemistry and digital image analysis to characterize TAM immunophenotypes with regard to expression of checkpoint molecules programmed cell death ligand 1 (PD-L1) and indoleamine 2,3-dioxygenase 1 (IDO-1) from the diagnostic tumor tissue samples of 130 cHL patients, and correlated the findings with clinical characteristics and survival. We show that a large proportion of TAMs express PD-L1 (CD68+, median 32%; M2 type CD163+, median 22%), whereas the proportion of TAMs expressing IDO-1 is lower (CD68+, median 5.5%; CD163+, median 1.4%). A high proportion of PD-L1 and IDO-1 expressing TAMs from all TAMs (CD68+), or from CD163+ TAMs, is associated with inferior outcome. In multivariate analysis with age and stage, high proportions of PD-L1+ and IDO-1+ TAMs remain independent prognostic factors for freedom from treatment failure (PD-L1+CD68+/CD68+, HR = 2.63, 95% CI 1.17–5.88, p = 0.019; IDO-1+CD68+/CD68+, HR = 2.48, 95% CI 1.03–5.95, p = 0.042). In contrast, proportions of PD-L1+ tumor cells, all TAMs or PD-L1− and IDO-1− TAMs are not associated with outcome. The findings implicate that adverse prognostic impact of TAMs is checkpoint-dependent in cHL.

Reverse signaling via PD-L1 supports malignant cell growth and survival in classical Hodgkin lymphoma

Treatment with programmed death-1 (PD-1) blocking antibodies results in high overall response rates in refractory and relapsed classical Hodgkin lymphoma (cHL) patients, indicating that PD-1/PD-1 ligand interactions are integral to progression of this disease. Given the genetically driven increased PD-L1/2 expression in HL, we hypothesized that reverse signaling through PD-1 ligands may be a potential mechanism contributing to the growth and survival of Hodgkin Reed–Sternberg (HRS) cells in cHL. Our data show that engagement of PD-L1 using an agonistic monoclonal antibody increases cell survival and proliferation and reduces apoptosis in HL cell lines. We show that HL patients have significantly higher serum levels of soluble PD-1 than healthy controls, and find that both membrane-bound and soluble forms of PD-1 are able to induce PD-L1 reverse signaling in HL cell lines. PD-L1 signaling, which is associated with activation of the MAPK pathway and increased mitochondrial oxygen consumption, is reversed by PD-1 blockade. In summary, our data identify inhibition of reverse signaling through PD-L1 as an additional mechanism that accounts for clinical responses to PD-1 blockade in cHL.

Socioeconomic Disparities Affect Survival of Classical Hodgkin Lymphoma in a Statewide Cancer Registry Analysis

Introduction:Low socioeconomic status (SES) has been shown to shorten survival in classical Hodgkin lymphoma (cHL). We sought to determine if differences in outcome of cHL varied according to SES and geographic setting in a population-based analysis.Methods:All adult patients diagnosed in 2000-2014 with cHL were collected through Kentucky Cancer Registry (KCR). Baseline SES and clinical variables were collected. Pearson Chi-square, log-rank, and cox regression tests were utilized. To minimize selection bias, cases with less than 6 months survival after cancer diagnosis were excluded.Results:A total of 1075 cHL patients were included, of which 605 (56.3%) were early stage vs. 405 (37.7%) were advanced stage. Most patients were under age 50 (63.2%) with a male predominance (55.4%). Nodular sclerosis was the most common histology (57.6%). Therapy consisted of chemotherapy alone in 729 (67.8%) patients, while 222 (20.7%) had received both chemotherapy and radiation. 633 (58.8%) lived in metro areas. Metro-area residents were more likely to come from non-Appalachian counties (93.7%), have more advanced education (76.8%) and have private insurance (60.1%) than non-metro-area residents (41.2%) (p<0.0001). There were no differences in age, gender, stage and histology at presentation according to geographic setting. Patients living in metro-area had a better OS by bivariate analysis (p=0.01) (Figure 1). A multivariate analysis identified age <50, early stage, privately insured, non-lymphocyte-depleted histology, and treatment with combined chemo-radiation as independent factors favoring an improved OS.Conclusion:Our study shows that despite the absence of differences in presenting clinical variables based on SES or geographic setting, significant discrepancies in outcome are observed. This disparity in outcomes may have been affected by differences in access to or quality of care delivery and may widen with the introduction of more costly novel interventions. DisclosuresNo relevant conflicts of interest to declare.

PiwiRNA-651 as marker of treatment response and survival in classical Hodgkin lymphoma.

PiwiRNAs, small non-coding RNAs processed by Piwi proteins, are involved in maintaining genome stability in germline cells. Recently, piwiRNA expression has been identified in some tumors. We have examined the potential reactivation of the Piwi/piwiRNA pathway in classical Hodgkin lymphoma (cHL). We found that Piwi proteins and three selected piwiRNAs, including piR-651, were expressed in cHL patients and cell lines, indicating that the Piwi/piwiRNA pathway is active in cHL. Interestingly, low levels of piR-651 were associated with lack of complete response to first-line treatment, as well as shorter disease-free and overall survival in a cohort of 94 cHL patients. At diagnosis, piR-651 was underexpressed in cHL serum samples compared to healthy controls, while after complete remission, piR-651 levels increased to levels similar to healthy controls. This is the first evidence that piwiRNAs are active in tumor and serum samples and impact prognosis in cHL.

Association of Gene Expression Profiling, Interim PET, EBV Status and PD-L1 Expression in Classical Hodgkin Lymphoma

IntroductionA challenge in the management of classical Hodgkin lymphoma (CHL) is selecting treatment which will maximise success while minimising treatment side effects. The international Response Adapted Therapy in Hodgkin Lymphoma (RATHL) trial (NCT00678327) demonstrated that treatment may be successfully adapted based on positron emission tomography (PET-CT) scan results after 2 cycles (PET2) of ABVD chemotherapy in advanced CHL. This approach however delays risk stratification meaning some patients may be over or under treated and therefore a baseline predictor is highly desirable. A gene expression-based model performed on RNA from formalin-fixed paraffin-embedded tissue (FFPET) biopsies on the Nanostring platform (Scott et al, J Clin Oncol 2013; 31:692-700) has been published. In addition Steidl et al used gene expression profiling (GEP) to correlate tumour-associated macrophages with survival in CHL (Steidl et al, NEJM 2010; 10:875-885). In order to explore whether GEP at baseline could be used in combination with PET2 results to predict outcome, these published gene signatures were explored on the DASL platform in a series of CHL cases and correlated with PET2 response. Recently, PD-1 ligand (PD-L1) on the cell surface of Reed-Sternberg cells (the hallmark cells of CHL) has been demonstrated to co-opt the PD-1 pathway allowing immune evasion (Green et al, Blood 2010;116:3268-77). Therefore this was also performed by immunohistochemistry (IHC) and GEP as well as assessment of EBV status.Methods50 patients with CHL were identified, with at least 2 years of follow up, diagnosed between 2008 and 2013. Deauville scores at PET2 were determined. IHC consistent with CHL, including: CD3, CD19, CD20, CD30, CD79, BOB-1, OCT-2, MUM1 and TARC was performed on 3mm FFPET lymph node sections, and reported by two independent observers. Latent Epstein-Barr virus (EBV) infection was determined by IHC for LMP-1 expression and in-situ hybridisation using fluorescein-labelled peptide nucleic acid probes (Dako, K5201). PD-L1 expression was determined by IHC using a rabbit monoclonal antibody (Cell Signaling Technology, E1L3N, #13684). Three to five 5mm sections of FFPET were used for RNA extraction using the Ambion RecoverAll™ kit standard protocol. GEP was quantified using Illumina's whole genome cDNA-mediated annealing, selection, extension, and ligation Assay (WG-DASL). 61 genes of interest were analysed for significance in the difference in gene expression between groups and included genes from the two recently reported GEP predictor tools in CHL (Steidl et al, 2010, Scott et al 2013) as well as PD-1 and PD-L1. The Mann-Whitney test was used to assess the significance in the difference between means (significant if p<0.05).ResultsA statistically significant difference in EBV status was found between PET negative (Deauville scores 1-3) and PET positive (Deauville scores 4-5) groups (Fisher's exact test: P-Value = 0.028). All patients who were EBV positive had a negative PET2 scan. GEP using WG-DASL revealed that only 2 genes of those reported in recent predictor models (Steidl et al 2010, Scott et al 2013) were expressed at significantly different levels between PET negative and PET positive patients (GLUL, RNF144B), both with increased expression in the PET2 positive group. There was no significant difference between PD-L1 expression and PET scores, CD274 gene expression and outcome. Assessment as to whether samples would cluster into groups according to PET positivity or PD-L1 expression status by unsupervised cluster analysis using four recently reported B cell lymphoma gene signatures (Monti et al, Blood 2005; 5:1851-61, Care et al, PloS one 2013; 2: e55895) was performed, but no significant grouping was found.ConclusionGEP on the DASL platform was not able to predict PET response. The original models were trained on outcome and therefore retraining of the GEP model based on PET response is likely to be required. EBV status was found to be predictive of PET response but this could not be correlated with other biomarkers to predict outcome. Although PD-1 and PD-L1 targeted therapy has shown exciting results in patients with CHL, PD-L1 IHC expression and CD274 gene expression, did not correlate with PET2 response or outcome. Baseline biomarkers capable of identifying patients likely to benefit from targeted treatment needs to be further investigated in proposed clinical trials. DisclosuresNo relevant conflicts of interest to declare.

CSF1R Protein Expression in Reactive Lymphoid Tissues and Lymphoma: Its Relevance in Classical Hodgkin Lymphoma.

Tumour-associated macrophages (TAMs) have been associated with survival in classic Hodgkin lymphoma (cHL) and other lymphoma types. The maturation and differentiation of tissue macrophages depends upon interactions between colony-stimulating factor 1 receptor (CSF1R) and its ligands. There remains, however, a lack of consistent information on CSF1R expression in TAMs. A new monoclonal antibody, FER216, was generated to investigate CSF1R protein distribution in formalin fixed tissue samples from 24 reactive lymphoid tissues and 187 different lymphoma types. We also analysed the distribution of CSF1R+, CD68+ and CD163+ macrophages by double immunostaining, and studied the relationship between CSF1R expression and survival in an independent series of 249 cHL patients. CSF1R+ TAMs were less frequent in B-cell lymphocytic leukaemia and lymphoblastic B-cell lymphoma than in diffuse large B-cell lymphoma, peripheral T-cell lymphoma, angioimmunoblastic T-cell lymphoma and cHL. HRS cells in cHL and, with the exception of three cases of anaplastic large cell lymphoma, the neoplastic cells in NHLs, lacked detectable CSF1R protein. A CSF1R+ enriched microenvironment in cHL was associated with shorter survival in an independent series of 249 cHL patients. CSF1R pathway activation was evident in the cHL and inactivation of this pathway could be a potential therapeutic target in cHL cases.

Infused autograft lymphocyte to monocyte ratio predicts survival in classical Hodgkin lymphoma.

The infused autograft lymphocyte to monocyte ratio (A-LMR) as a surrogate marker of host immunity (ie, absolute lymphocyte count) and CD14+ HLA-DRlow/neg immunosuppressive monocytes (ie, absolute monocyte count) is a prognostic factor for patients with diffuse large B-cell lymphoma after autologous peripheral hematopoietic stem cell transplantation (APHSCT). Thus, we set out to investigate if A-LMR can also affect survival post-APHSCT in classical Hodgkin lymphoma. From 1994 to 2012, 183 patients with classical Hodgkin lymphoma who underwent APHSCT were studied. The patients were randomly divided into a training set (n=122) and a validation set (n=61). The receiver operating characteristic and area under the curve identified an A-LMR ≥1 as the best cut-off value and validated by the k-fold cross-validation in the training set. Multivariate analysis showed A-LMR to be an independent prognostic factor for survival in the training set. Patients with an A-LMR ≥1.0 experienced a superior overall survival (OS) versus patients with an A-LMR <1.0 (median OS not reached versus 40.4 months, 5-year OS rates of 86% [95% CI 72–93] versus 43% [95% CI 28–58], P<0.0001, respectively) in the training set. In the validation set, an A-LMR ≥1 showed a median OS of not reached versus 41.4 months for an A-LMR <1, 5-year OS rates of 90% (95% CI 73–97) versus 48% (95% CI 28–68; P<0.0001). A-LMR provides a platform to engineer an autograft versus tumor effect to improve clinical outcomes in patients with classical Hodgkin lymphoma undergoing APHSCT.

Infused Autograft Lymphocyte to Monocyte Ratio and Survival in Classical Hodgkin Lymphoma

Infused autograft absolute lymphocyte count (A-ALC) is a prognostic factor for survival post-autologous peripheral hematopoietic stem cell transplantation (APHSCT) for lymphoma. Myeloid-derived suppressor cells (MDSCs) affect tumor growth by suppression of host anti-tumor immunity. Thus, we set out to investigate if the infused autograft lymphocyte /monocyte ratio (A-LMR), as a biomarker of host immunity (i.e., lymphocytes) and MDSCs (i.e., monocytes), affects survival post-APHSCT in patients with classical Hodgkin lymphoma (cHL). Only patients that collected their stem cells through the peripheral blood were included in the study. From 1994 to 2012, 183 cHL patients qualified for the study. The 183 patients were randomly divided into a training set (n = 122) and a validation set (n = 61). Receiver operating characteristic and area under the curve (AUC) identified an A-LMR ≥ 1 as the best cut-off value (AUC = 0.8, p < 0.01) and validated by the k-fold cross-validation (AUC = 0.8) in the training set. Multivariate analysis showed A-LMR to be an independent prognostic factor for survival in the training set. Patients with an A-LMR ≥ 1.0 experienced a superior overall survival (OS) versus patients with an A-LMR < 1.0 (median OS was not reached vs 40.4 months, 5-year OS rates of 86% (95 CI, 72%-93%) vs 43% (95 CI, 28-58 %), p < 0.0001, respectively) in the training set. In the validation set, an A-LMR ≥ 1 showed a median OS of not reached vs 41.8 months for an A-LMR < 1, 5 year OS rates of 90% (95 CI, 73%-97%) vs 48% (95 CI, 29-68%), p < 0.0001, respectively. A-LMR provides a platform to engineer an immunocompetent autograft to improve clinical outcomes in cHL patients undergoing APHSCT. DisclosuresNo relevant conflicts of interest to declare.

CD68 staining correlates with the size of residual mass but not with survival in classical Hodgkin lymphoma

The prognostic role of CD68 tumor-associated macrophages in classic Hodgkin lymphoma (cHL) remains controversial. We stained diagnostic biopsies and scored for CD68 using the PGM1 antibody among 98 consecutive patients with cHL from our center followed over a median of 45 months for progression-free survival (PFS). Among 79 patients we assessed interim and post-treatment positron emission tomography-computed tomography (PET-CT). Residual mass (RM) size was based on the greatest diameter of the largest mass seen in post-treatment imaging, and percent reduction was calculated by comparing RM size with its greatest pretreatment diameter. We found a significant association between CD68 positivity and absolute size of initial disease mass (p = 0.014) and residual mass at the end of therapy (p = 0.006) but no association was observed with interim PET-CT results or PFS. Our findings suggest that macrophages may influence tumor size by altering the microenvironment. This study does not support a prognostic role of CD68 positivity in predicting survival.

The absolute lymphocyte to monocyte ratio is associated with poor prognosis in classical Hodgkin lymphoma patients younger than 60 years of age.

Recent studies suggest that absolute lymphocyte count, absolute monocyte count and their ratio [lymphocyte/monocyte ratio (LMR)] at diagnosis may predict survival in classical Hodgkin lymphoma (cHL). Here, we investigated the prognostic significance of LMR in cHL patients in relation to age of patients. Subjects included 351 cHL patients (age range from 4 to 84 years, median age 34 years, sex ratio 1.58) who had been followed-up for a median period of 59 months (range, 0.1-245 months). The estimated 5-year overall survival (OS) rate was 86.8%. Subgroup analysis was performed according to patients' age; non-elderly group (<60 years of age) versus elderly group (≥60 years of age). There was no significant difference in the level of absolute lymphocyte count, absolute monocyte count or LMR between the age groups. Using receiver operating characteristic curve analysis, the optimal cut-off value of LMR for the entire cohort was determined at 2.8, whereas the optimal cut-off for the elderly group was 2.2. In the non-elderly group (<60 years old), patients with LMR <2.8 had significantly lower OS or lymphoma-specific survival compared with those with LMR ≥2.8 (p < 0.001, both). In contrast, neither the LMR value of 2.8 or 2.2 predicted survival in the elderly group. In multivariate analysis, LMR remained a significant prognostic factor for OS (p = 0.049). The results of our analysis suggest that low LMR is associated with poor OS in patients of <60 years old.

Cytokine gene polymorphisms and progression-free survival in classical Hodgkin lymphoma by EBV status: Results from two independent cohorts

BackgroundCytokines are important immune mediators of classical Hodgkin lymphoma (CHL) pathogenesis, and circulating levels at diagnosis may help predict prognosis. Germline single nucleotide polymorphisms (SNPs) in immune genes have been correlated with cytokine production and function. MethodsWe investigated whether selected germline SNPs in IL10 (rs1800890, rs1800896, rs1800871, rs1800872), TNFA (rs1800629), IL6 (rs1800795), ILRN (rs419598), INFG (rs2430561) and CCL17 (rs223828) were associated with circulating levels of related cytokines at diagnosis and progression-free survival (PFS) in CHL. Patients were from France (GELA, N=464; median age=32years) and the United States (Iowa/Mayo Specialized Program Of Research Excellence [SPORE], N=239; median age=38years); 22% of 346 CHL cases with EBV tumor status were positive. ResultsThere was no association with any of the SNPs with cytokine levels. Overall, there was no association of any of the SNPs with PFS. In exploratory analyses by EBV status, TNFA rs1800629 (HRAA/AG=2.41; 95%CI, 1.17–4.94) was associated with PFS in EBV-negative GELA patients, with similar trends in the SPORE patients (HRAA/AG=1.63; 95%CI, 0.61–4.40). In a meta-analysis of the two studies, TNFA (HRAA/AG=2.11; 95%CI, 1.18–3.77; P=0.01) was statistically significant, and further adjustment for the international prognostic system did not alter this result. ConclusionsThis study showed that germline variation in TNFA was associated with CHL prognosis for EBV-negative patients, which will require confirmation. These results support broader studies on the differential impact of genetic variation in immune genes on EBV-positive vs. EBV-negative CHL pathogenesis.

Peripheral blood absolute lymphocyte/monocyte ratio recovery during ABVD treatment cycles predicts clinical outcomes in classical Hodgkin lymphoma

The peripheral blood absolute lymphocyte/monocyte count ratio at diagnosis (ALC/AMC-DX) predicts survival in classical Hodgkin lymphoma (cHL). However, a limitation of the ALC/AMC-DX is the inability to assess sequentially the host/tumor interaction during treatment. Therefore, we retrospectively examined the ALC/AMC ratio, as a surrogate marker of host immunity (ALC) and tumor microenvironment (AMC), at each adriamycin, bleomycin, vinblastine and dacarbazine treatment cycle as a predictor for clinical outcomes. From 1990 until 2008, 190 cHL patients were diagnosed, treated and followed at Mayo Clinic Rochester and qualified for the study. The ALC/AMC ratio at each treatment cycle was a predictor for overall survival (OS) and progression-free survival (PFS). An ALC/AMC ratio ⩾1.1 versus ALC/AMC <1.1 during treatment cycles was an independent predictor for OS (hazard ratio (HR)=0.14; 95% confidence interval (CI): 0.04–0.40; P<0.0002) and for PFS (HR=0.19; 95% CI: 0.05–0.82; P<0.03). The ALC/AMC ratio during treatment cycles is a predictor for survival and provides a platform to develop therapeutic modalities to manipulate the ALC/AMC ratio during chemotherapy to improve clinical outcomes in cHL.

Absolute Lymphocyte/Monocyte Ratio at Diagnosis and Interim Positron-Emission Tomography Predict Survival in Classical Hodgkin Lymphoma

Interim Positron-Emission Tomography (int-PET) and the peripheral blood absolute lymphocyte/monocyte ratio at di- agnosis (ALC/AMC-DX) have been shown to be predictors for progression-free survival (PFS) and time to progression (TTP) in classical Hodgkin lymphoma (cHL). Therefore, we studied if the combination of ALC/AMC-DX and the (int-PET) can further stratified PFS and TTP in cHL patients. Patients were required to be diagnosed, treated, and followed with int-PET at Mayo Clinic, Rochester, Minnesota. From 2000 until 2008, 111 cHL patients qualified for the study. The median follow-up was 2.8 years (range: 0.3 - 10.4 years). Patients with a negative int-PET (N = 98) pre- sented with a higher ALC/AMC-DX (median of 2.32, range: 0.26 - 37.5) compared with patients with a positive int-PET (N = 13) (median of 0.9, range: 0.29 - 3.10), p 1.1. Group 1 experienced superior PFS and TTP in comparison with the other groups. In conclusion, the combination of ALC/AMC-DX and the int-PET provides a simple model to assess clinical outcomes in cHL.

Increased Tumor Infiltrating FOXP3+ Regulatory T-Cells Are Associated with Improved Survival in Classical Hodgkin Lymphoma.

Background: Regulatory T-cells (Tregs), a CD4+, CD25+, FOXP3+ subset, appear to modulate the tumor microenvironment in lymphoma. Using FOXP3 expression as a marker of Tregs, single series have suggested that higher numbers of tumor infiltrating FOXP3+ cells are associated with improved survival in both follicular lymphoma and classical Hodgkin lymphoma (cHL). However, neither of these findings has been confirmed by separate studies and, in fact, contradictory data exists. We sought to evaluate potential correlations between the number of FOXP3+ cells in the tumor microenvironment and patient outcome.Methods: 98 previously untreated cHL patients, biopsied and treated with curative intent at the Cleveland Clinic, were studied. FOXP3 was assessed by immunohistochemistry (Abcam) and quantitated as the number of positive cells per high power field (hpf), averaged over 5 fields. Histology was evaluated and medical records were reviewed for clinical features (including gender, age, stage, B symptoms, bulk, number of sites and IPS), lymphoma progression and death.Results: The mean number of FOXP3+ cells (±standard deviation) was 41.7 ± 33.9 cells/hpf, and the median number was 36.4 cells/hpf (range 0–152.0 cells/hpf). Higher numbers of FOXP3+ T-cells were associated with age<45 (P=.02), stage I–II (P=.01), and IPS≤2 (P=.06) [Wilcoxon rank sum test]. 28 of the 98 patients (29%) have progressed and/or died and 20 (20%) have died. The estimated 5-year failure free survival (FFS) and overall survival (OS) are 76%±4% and 86%±4%, respectively. 70 patients remain alive with no evidence of disease at a median follow-up of 8.6 years (range 0.9–19.9 years). Recursive partitioning demonstrated an optimal cutoff of 25 FOXP3+ cells/hpf for analysis of outcome. Overall, 43 patients (44%) had a mean of <25.0 FOXP3+ cells/hpf and 55 (56%) had 25.0 or more. In univariate analysis, higher numbers of FOXP3+ T-cells in the tumor microenvironment were associated with better FFS; estimated 5-year FFS was 91% ± 4% for patients with >25.0 FOXP3+ cells/hpf compared to 81% ± 6% for patients with <25.0 (P=.05, generalized Wilcoxon test). There was also a trend towards improved OS (P=.10). In multivariate analysis, the number of FOXP3+ T-cells remained an independent predictor, even after adjusting for age, stage, and IPS ( P<.05). Kaplan-Meier curves for FFS and OS stratified by FOXP3+ “status” are shown in Figures 1 and 2.Conclusion: FOXP3+ T cells are a favorable prognostic marker in cHL and reflect the importance of the immune response thus providing rationale for the use of immunomodulatory therapies in these patients. [Display omitted] [Display omitted]