Strong p53 Expression Is an Independent Predictor of Outcome in De Novo Diffuse Large B Cell Lymphoma (DLBCL) Treated with Either CHOP or CHOP-R.

Abstract Background: The addition of rituximab to CHOP (CHOP-R) chemotherapy has resulted in an improved outcome for patients with DLBCL and has recently been shown to diminish the prognostic impact of two recognized biomarkers, namely Bcl-2 and Bcl-6. In the CHOP era, p53 mutations in DLBCL were associated with an aggressive clinical course and shortened survival. Using immunohistochemistry and mutational analysis, p53 over-expression and mutational status were examined in a population-based cohort of DLBCL patients treated with CHOP or CHOP-R (Sehn et al, J Clin Oncol2005; 23: 5027–33). Method: We analyzed 155 patients from a total cohort of 292 patients based on available paraffin blocks with sufficient tissue for interpretable immunohistochemistry for all antigens. All were initial diagnostic biopsies of de novo DLBCL cases accrued between 1999 and 2002 at the BCCA. HIV+ patients or those with active secondary malignancies were excluded. Tissue microarrays (TMA) were built using duplicate 0.6mm cores from paraffin embedded formalin fixed (FFPE) diagnostic biopsies and stained with antibodies against CD10, Bcl-6, MUM1, Bcl-2, p53 and p21. DLBCL cases were assigned to GCB or non-GCB subgroups based on the method of Hans et al., Blood 103: 275–82 (2004). Strong nuclear expression of the p53 antibody (clone DO7) was defined as high intensity (3/3) expression in >50% of the malignant cells. The p53 gene mutational analysis was performed on this subset of cases with DNA extracted from FFPE samples using the AmpliChip™ p53 test (developed in Roche Molecular Systems, Inc.). Results: Patients were treated with either CHOP (n = 77) or CHOP-R (n = 78). Their clinical characteristics, including the IPI factors, were evenly matched. The two treatment cohorts represent consecutive eras of therapy and thus the median follow-up of living patients was 5.1 and 4.0 y for CHOP vs CHOP-R, respectively. Of the 155 patients, 75 had a GCB phenotype and 80 non-GCB, with similar distribution in both treatment groups. There were 19 strong p53-positive cases (19/155 or 12.3%). Ten p53-positive cases were GCB and 9 were non-GCB. All 19 strong p53-positive cases were negative for p21 expression and 16/17 analyzable cases had p53 mutations. Univariate analysis of the entire cohort (n = 155) revealed that both IPI and p53 expression were of prognostic importance (p < 0.0001). In multivariate analysis, strong p53 and IPI were independent predictors of OS (p = 0.005 and p < 0.0001, respectively). Importantly, when analyzed by treatment era, strong p53 expression remained significant in both CHOP (p=0.015) and CHOP-R groups (p=0.012). Conclusion: Strong p53 protein expression correlates with p53 mutations and is an independent prognostic factor for patients with DLBCL even when treated with CHOP-R. p53 mutations were found in both GCB and non-GCB subtypes. Importantly the prognostic impact of p53 is not diminished in the era of CHOP-R, identifying a subgroup of patients with inferior survival. Overall Survival for 155 DLBCL Based on p53 Status Overall Survival for 155 DLBCL Based on p53 Status

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Both Discordant and Concordant Bone Marrow (BM) Involvement Predict for a Poorer Outcome Independent of the IPI in Patients with Diffuse Large B-Cell Lymphoma (DLBCL) Treated with R-CHOP.

Blood ◽

10.1182/blood.v110.11.1559.1559 ◽

2007 ◽

Vol 110 (11) ◽

pp. 1559-1559

Author(s):

Laurie H. Sehn ◽

Mukesh Chhanabhai ◽

Suman Singh ◽

Wayne Saville ◽

Dan Matso ◽

...

Keyword(s):

De Novo ◽

Clinical Information ◽

B Cell Lymphoma ◽

Standard Of Care ◽

Aggressive Lymphoma ◽

Similar Distribution ◽

Prognostic Impact ◽

Current Standard ◽

Chop Regimen ◽

Entire Cohort

Abstract Recently, it has been suggested that concordant but not discordant BM involvement is a negative predictor of outcome in DLBCL patients treated with CHOP (Chung et al, Blood 2007). The significance of BM involvement in pts treated in the current era of therapy including rituximab has not been fully examined. We evaluated the prognostic impact of BM involvement in DLBCL patients treated with the current standard of care, R-CHOP. Patients: We identified 282 patients with biopsy proven de novo DLBCL treated in British Columbia (BC) with an R-CHOP regimen between 01/01/2001 and 01/01/2005 with complete clinical information and staging bone marrows available for review. Cases were identified using the Lymphoid Cancer Database of the BC Cancer Agency. Median follow-up is 44 mos (range 1–77). Results: 234/282 (83%) had a negative staging BM, 27 pts (10%) had a positive BM with concordant histology (Con-BM) and 21 (7%) had a positive BM with discordant histology (Dis-BM) with predominantly small B-cells present. Clinical characteristics for the entire cohort were as follows: median age 64 y (range 18–88); 66% male; 65% stage III/IV; 39% PS>1; 51% elevated LDH; 31% >1 extranodal site. IPI risk factors: 10% 0; 42% 1–2; 48% 3–5. In addition to higher stage and greater extranodal involvement, pts with a positive BM were more likely to have a higher LDH and a poorer PS than pts with a negative BM. Compared to pts with Con-BM, pts with Dis-BM were more likely to be elderly, but otherwise exhibited a similar distribution of clinical prognostic factors. The Kaplan-Meier 4-year PFS was significantly worse for pts with both Dis-BM (32%) and Con-BM (46%) involvement compared to pts with a negative BM (75%) (p<0.0001) (see Figure). Similarly, 4-year overall survival was significantly worse for pts with Dis-BM and Con-BM involvement (53% and 54%) compared to pts with a negative BM (74%) (p=0.005). All patients with Dis-BM involvement who developed progressive or relapsed disease were believed to have progression of their aggressive lymphoma based on clinical behavior or biopsy proof. In a multivariate analysis controlling for the IPI, BM involvement (Dis-BM and Con-BM) remained an independent predictor of PFS (p=0.03). Conclusions: In DLBCL pts treated with R-CHOP, both discordant and concordant BM involvement predict for a poorer outcome independent of the IPI. It is possible that pts with DLBCL and discordant BM involvement represent a subset of pts with transformed disease which is inherently less treatment-sensitive. Figure Figure

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Addition of Rituximab (R) to CHOP Improves Survival in the Non-GCB Subtype of Diffuse Large B Cell Lymphoma (DLBCL).

Blood ◽

10.1182/blood.v108.11.816.816 ◽

2006 ◽

Vol 108 (11) ◽

pp. 816-816 ◽

Cited By ~ 3

Author(s):

Pedro Farinha ◽

Laurie Sehn ◽

Brian Skinnider ◽

Joseph M. Connors ◽

Randy D. Gascoyne

Keyword(s):

Overall Survival ◽

B Cell ◽

De Novo ◽

Univariate Analysis ◽

B Cell Lymphoma ◽

Cell Of Origin ◽

Chop Chemotherapy ◽

Entire Study ◽

Survival Difference

Abstract Background: The cell of origin (COO) distinction provides a prognostic and biologically relevant subclassification of DLBCL. Germinal center B cell (GCB) and non-GCB subtypes were originally characterized by gene expression studies and subsequently validated at the protein level by Hans et al., Blood 193: 275–82 (2004). The addition of R to CHOP chemotherapy has been shown to improve the outcome of patients with DLBCL. The underlying mechanism(s) responsible for this effect is largely unknown. However, it is known that R may preferentially prevent chemotherapy failure in DLBCLs that express Bcl-2 protein or fail to express Bcl-6 (Mounier et al., Blood101: 4279–84 2003, Winter et al., Blood107: 4207–13 2006). Bcl-2 over-expression and absence of Bcl-6 is more common in the non-GCB subtype. Thus, R may benefit mostly non-GCB lymphomas. To test this hypothesis we assessed the clinical impact of CHOP-R vs CHOP in DLBCL distinguished by COO subtypes. Method: We identified 163 patients with DLBCL treated with either CHOP or CHOP-R with available paraffin blocks and interpretable immuno-staining. All were de novo DLBCL cases diagnosed between 1999 and 2002 at the BCCA. The two treatment cohorts represent consecutive eras of therapy (Sehn et al., JCO2005; 23: 5027–33), and thus the median follow-up of living patients was 5.1 and 4.0 y for CHOP and CHOP-R, respectively. HIV+ patients or those with active secondary malignancies were excluded. Tissue microarrays (TMA) were built using duplicate 0.6mm cores from paraffin embedded formalin fixed (FFPE) tissues and stained with antibodies against CD10, Bcl-6, MUM1, and Bcl-2. The COO distinction was determined using the method of Hans. Results: Patients were treated with either CHOP (81) or CHOP-R (82). Their clinical characteristics, including the IPI, were evenly matched. The median follow-up of living patients was 4.4 y. The IPI was predictive of overall survival (OS) (p<0.0001) for the entire study population. Six cases had uninterpretable immunostains resulting in 74 cases with a GCB phenotype and 83 with a non-GCB phenotype (n = 157). Overall, 71% and 75% of the cases over-expressed Bcl-2 and Bcl-6, respectively. Bcl-2 protein was expressed in 70% GCB cases and 73% non-GCB (p= 0.72). Bcl-6 was expressed in 96% GCB cases and 63% non-GCB cases (p<0.0001). In univariate analysis, the addition of R was associated with a better prognosis in the non-GCB cases (p=0.02), but not in the GCB cases (p=0.3). This survival difference was not solely explained by either Bcl-2 or Bcl-6 expression. The addition of R to CHOP chemotherapy and IPI were independent predictors of OS in non-GCB DLBCL (p=0.02; p=0.016, respectively). The addition of R was also of prognostic importance in the lymphomas over-expressing Bcl-2 (p=0.0081). Conclusion: Immuno-chemotherapy using CHOP-R is associated with better OS in DLBCL, due largely to its effect on the non-GCB subgroup. Although Bcl-2 expression does not contribute to the determination of COO distinctions, the OS of Bcl-2-positive DLBCL patients is significantly improved by the addition of R. These results provide insight into the possible mechanisms by which R exerts its beneficial therapeutic effect. Overall Survival for 157 DLBCL Based on Cell of Origin Overall Survival for 157 DLBCL Based on Cell of Origin

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High Skp2 Expression Is an Independent Predictor of Unfavorable Outcome in 333 Patients with Diffuse Large B Cell Lymphoma (DLBCL).

Blood ◽

10.1182/blood.v110.11.1560.1560 ◽

2007 ◽

Vol 110 (11) ◽

pp. 1560-1560

Author(s):

Ritsuko Seki ◽

Koichi Ohshima ◽

Fumio Kawano ◽

Toshihiko Murayama ◽

Yukiyoshi Moriuchi ◽

...

Keyword(s):

Clinical Stage ◽

Combined Treatment ◽

B Cell Lymphoma ◽

Similar Distribution ◽

Prognostic Impact ◽

Advanced Clinical Stage ◽

Treatment Groups ◽

Skp2 Expression ◽

New Treatment

Abstract The addition of rituximab to CHOP (CHOP-R) chemotherapy has resulted in an improved outcome for patients with DLBCL and has recently been shown to diminish the prognostic impact of several recognized biomarkers. S-phase kinase-associated protein 2 (Skp2) is a proto-oncogene that has been shown to be expressed in a number of tumors. We have reported that Skp2 expression in tumor cells is an unfavorable prognostic factor in DLBCL. In the present study, we investigated the significance of Skp2 expression in the patients with DLBCL treated with CHOP or CHOP-R. DLBCL patients (333 cases) were entered into this study, based on the availability of paraffin blocks for interpretable immunohistochemistry for all antigens (CD10, Bcl-6, MUM1, Bcl-2, Skp2). All patients were treated with either CHOP (201) or CHOP-R (132) from 1996 to 2005, and were diagnosed as having DLBCL at the twenty different hospitals. All specimens were histopathologically reviewed before entering into this study. Their clinical characteristics, including either the IPI or R-IPI factors, were evenly matched. The median follow-up of living patients was 3.7 and 2.1 y for CHOP vs CHOP-R, respectively. DLBCL were assigned to GCB subtype (40.8%: 136/333) or non-GCB subtype (59.2%: 197/333) based on the method of Hans et al., Blood 103: 275–82 (2004), with similar distribution in both treatment groups. Expression of bcl-6 (p<0.05) or GCB subtypes (p<0.05) was associated with better overall survival (OS), whereas expression of bcl-2 (p<0.05) was associated with worse OS in CHOP treatment group. The addition of R was associated with an improved survival in the non-GCB subtype and resulted in same as that of GCB subtype. The survival benefit of both low Bcl-2 and high Bcl-6 expressions diminished in combined treatment with R to CHOP. There were 97 patients with high Skp2 expression (>60% positive cells) (97/333: 29.1%). High Skp2 expression was found in both GCB subtype (28.6%) and non-GCB subtype (30.3%). In advanced clinical stage or extranodal involvement (>2), the patients with high Skp2 expression had worse survival than those with low Skp2 expression (p<0.05). Interestingly, in CHOP-R group, high Skp2 expression was the strong biomarker of worse prognosis (p<0.05). DLBCL patients with high Skp2 expression did not benefit from the addition of R to CHOP. Therefore, Skp2 may be a useful prognostic marker in recent rituximab era. The new treatment strategy is necessary for the DLBCL patients with high Skp2 expression. Figure Figure

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MYC Translocations and Expression Are Clinically Important in R-CHOP Treated Patients with De Novo DLBCL.

Blood ◽

10.1182/blood.v114.22.1100.1100 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1100-1100

Author(s):

Nathalie A. Johnson ◽

Susanna Ben-Neriah ◽

Kerry J. Savage ◽

Tang Lee ◽

Douglas E. Horsman ◽

...

Keyword(s):

Protein Expression ◽

B Cell ◽

Research Funding ◽

De Novo ◽

Cell Lymphoma ◽

Molecular Subtype ◽

B Cell Lymphoma ◽

Prognostic Impact ◽

Statistical Software ◽

Bcl2 Protein

Abstract Abstract 1100 Poster Board I-122 Background MYC, an oncogene associated with cellular proliferation, is deregulated as a result of chromosomal translocation in Burkitt lymphoma (BL), and in 8-12% of diffuse large B cell lymphomas (DLBCL). In 2006, 2 studies defined the molecular features of BL and DLBCL by gene expression profiling (GEP) (Dave, NEJM 2006; Hummel, NEJM 2006) and identified a subset of cases that resembled DLBCL by morphology, but by GEP, expressed MYC and MYC target genes similar to classical BL, i.e. molecular BL (mBL) signature. The clinical outcome of these cases is poorly defined. More recently, MYC expression and MYC translocations (MYC tr+) have been associated with an inferior overall survival (OS) in de novo DLBCL patients (pts) treated with R-CHOP (Rimsza, Blood 2008; Savage, Blood 2009) but the prognostic impact of BCL2 protein expression and concurrent BCL2 translocations (BCL2 tr+) is poorly understood. We investigated the prognostic impact of the presence of a mBL signature by GEP, high MYC mRNA expression, and the presence of a MYC tr+ with or without a concurrent BCL2 tr+ in DLBCL pts treated uniformly with R-CHOP. Methods 315 samples were reviewed by a panel of expert hematopathologists and classified according to the WHO 2008 criteria. Pts with high grade B cell lymphoma otherwise unclassifiable, BL, primary mediastinal B cell lymphoma (PMBCL), T-cell-rich B cell lymphoma and pts that were not treated with R-CHOP were excluded from this analysis. The remaining 259 DLBCL samples were subjected to GEP as previously described (Lenz, NEJM 2008). Tissue microarrays (TMA) were constructed in cases with available paraffin material. 184 had successful GEP arrays, 186 were included on a TMA and 151 cases were assessed on both platforms. Presence of a mBL signature was determined according to the method described by Dave (NEJM 2006). MYC expression was determined using log normalized expression values from Affymetrix U133 Plus 2.0 probe set id 202431_s_at and dichotomized into high versus low expression using a cut off threshold determined by the statistical software X-Tile (http://www.tissuearray.org/rimmlab/). The presence of MYC tr+ or BCL2 tr+ was determined by fluorescence in situ hybridization (FISH) using MYC and BCL2 breakapart probes (Abbott) on TMAs. BCL2 protein expression was determined by immunohistochemistry (IHC) using clone 124 (Dako). Correlation between variables and association with OS was performed by Pearson Chi-Square, Kaplan-Meier and Cox regression analysis using SPSS statistical software. Results A mBL signature was found in 4/184 samples (2%). One case was MYC tr+, one was MYC tr-, and the MYC translocation status was unknown in the remaining 2 cases. All 4 pts with a mBL had a complete response to R-CHOP lasting >2 years after diagnosis. MYC tr+, BCL2 tr+ or concurrent MYC tr+/ BCL2 tr+ were present in 12%, 20% and 4% of 186 DLBCL cases, respectively. BCL2 tr+ were predominately found in the germinal center B cell (GCB) molecular subtype (36%) compared to the activated B cell (ABC) or unclassifiable (U) subtypes (4% and 19%, p=0.0001) but were not associated with an inferior OS. In contrast, MYC tr+ were not associated with a specific molecular subtype (GCB 15%, ABC 8%, U 19%, p=0.2) but were associated with an inferior OS (p=0.0078). When dichotomizing patients with MYC tr+ according to the BCL2 status, pts with concurrent MYC tr+/ BCL2 tr+ (4%) and pts with MYC tr+ and BCL2 protein-positive biopsies (7%) had a markedly inferior OS compared to pts with MYC tr+ and BCL2 protein-negative biopsies or pts with no MYC tr (median OS 7 months vs. not reached, both p < 0.00001). The presence of MYC tr+ correlated with high MYC expression in 6/16 (38%) MYC tr+ cases whereas high MYC expression was present in 5/111 (5%) MYC tr- cases (p=0.0001). High MYC expression alone was also associated with an inferior OS (p<0.00001). In multivariate analysis, high MYC mRNA expression, concurrent MYC tr+/ BCL2 tr+, and the IPI were independent predictors of OS (p=0.04, p=0.05, p=0.007, respectively). Conclusion MYC expression, as prognostic marker in DLBCL, should be investigated in routine clinical practice. Cytogenetic analysis to determine MYC and BCL2 translocation status by FISH and/or karyotype of de novo DLBCL samples, and BCL2 protein expression by IHC are clinically indicated to identify a group of high-risk pts that may benefit from up-front intensified therapy. Disclosures Connors: Roche Canada: Research Funding. Gascoyne:Roche Canada: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

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CD30 Immunohistochemical Expression In Diffuse Large B-Cell Lymphoma Is Associated With Decreased Overall Survival and The Non-Germinal Center Molecular Subtype

Blood ◽

10.1182/blood.v122.21.4318.4318 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4318-4318 ◽

Cited By ~ 9

Author(s):

Angela M. B. Collie ◽

Brian T. Hill ◽

Elena A. Manilich ◽

Mitchell R Smith ◽

Eric D. Hsi

Keyword(s):

Overall Survival ◽

B Cell ◽

Poor Prognosis ◽

De Novo ◽

Cell Lymphoma ◽

Molecular Subtype ◽

B Cell Lymphoma ◽

Cell Of Origin ◽

Immunohistochemical Expression ◽

Large B Cell Lymphoma

Abstract Background Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease entity with multiple potential prognostic biomarkers. Cell of origin (COO) molecular subtype classification using gene expression profiling with microarrays and immunohistochemical expression of CD30 have been examined as potential prognostic markers, often with conflicting results. A recent study demonstrated that patients with CD30-positive DLBCL had better prognosis compared to patients with CD30-negative DLBCL and had a distinct gene expression profile (Hu S et al. Blood. 121(14): 2715-24, 2013). In addition, due to the development of targeted therapies such as an anti-CD30 monoclonal antibody drug conjugate, the identification and prognostic relevance of this biomarker has potential therapeutic impact. We evaluated CD30 expression, determined by immunohistochemistry, in a cohort of de novo DLBCL cases at our institution and examined cell of origin molecular subtype in the CD30-positive and CD30-negative groups. Design 94 adult patients with de novo DLBCL uniformly treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) as first line therapy were identified at The Cleveland Clinic. Clinical data was collected for these patients. A tissue microarray was created and stained with antibodies to CD10, CD20, CD30, BCL-6, and MUM-1. COO subtype was determined for the Hans algorithm in all cases. CD30 was considered positive when expression was seen in ≥ 20% of tumor cells. Results There were no significant differences in sex, age, IPI score, or stage between patients in the CD30-positive and CD30-negative groups. The median age of the DLBCL cohort was 63 years (range 17-91 years) with a male : female ratio of 1:1.1. 54% of patients had stage III or IV disease. Median follow-up was 58 months. 9 of 94 DLBCL samples (9.6%) were positive for CD30 by immunohistochemistry. By Kaplan-Meier analysis, the CD30-positive cases showed a decreased overall survival compared to the CD30-negative cases (Figure 1, p=0.044). Multivariate analysis using a Cox proportional hazard model confirmed that CD30 expression was independent of IPI and a significant factor for overall survival (hazard ratio = 3.05; 95% confidence interval = 1.12-8.30; p = 0.0291). All 9 of the CD30-positive DLBCL samples were of the non-germinal center B-cell-like (NGC) subtype using the Hans immunohistochemical algorithm, which was significantly more than the CD30-negative samples (42/85) (p = 0.003). Conclusion CD30 expression was associated with poor prognosis in our cohort, in contrast to recent studies. However, CD30 expression was highly associated with the NGC subtype of DLBCL and might contribute to the pathogenesis of these lymphomas through NF-κB activation. Given the poor prognosis of NGC DLBCLs, targeting CD30 in DLBCL should be explored. Disclosures: No relevant conflicts of interest to declare.

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Effect of addition of rituximab to CHOP on survival of patients in both the GCB and non-GCB subgroups of diffuse large B-cell lymphoma

Journal of Clinical Oncology ◽

10.1200/jco.2007.25.18_suppl.8040 ◽

2007 ◽

Vol 25 (18_suppl) ◽

pp. 8040-8040 ◽

Cited By ~ 1

Author(s):

K. Fu ◽

K. D. Perry ◽

L. M. Smith ◽

C. P. Hans ◽

T. C. Greiner ◽

...

Keyword(s):

Overall Survival ◽

B Cell ◽

De Novo ◽

Cell Lymphoma ◽

Prognostic Significance ◽

B Cell Lymphoma ◽

Rank Test ◽

Cell Of Origin ◽

Large B Cell Lymphoma ◽

Large B Cell

8040 Background: Diffuse large B-cell lymphoma (DLBCL) includes at least two prognostically important subgroups, i.e. germinal center B-cell (GCB) and activated B-cell (ABC) DLBCL, which were initially characterized by gene expression profiling and subsequently validated by immunostaining. Bcl-2 has also been identified as a prognostic indicator in the ABC subgroup. However, with the addition of rituximab (R) to standard chemotherapy, the prognostic significance of this subclassification of DLBCL is unclear. Methods: We studied 119 cases of de novo DLBCL including 70 cases treated with R-CHOP and 49 cases treated with CHOP. The cases were assigned to either the GCB or non-GCB subgroups using the methodology described by Hans et al (Blood 2004; 103:275). Characteristics of the patients were compared using the Chi-square test. Overall survival (OS) and event-free survival (EFS) were estimated using the Kaplan Meier method and compared with the log-rank test. Results: The median age of the 119 patients was 67 years, ranging from 20 to 90 years, and there were 62 males and 57 females. The clinical characteristics of patients treated with CHOP versus R-CHOP, including the IPI, were comparable. R-CHOP was more effective than CHOP with improved 5-year EFS (63% vs 41%, p=0.013) and OS (78% vs 47%, p<0.001). In both patient groups treated with R-CHOP or CHOP, the GCB subgroup had a significantly better 5-year EFS and OS compared to the non-GCB subgroup (OS: 91% vs 64% for R-CHOP, p=0.0073; 67% vs 31% for CHOP, p=0.034, respectively). Additionally, both the GCB and non-GCB subgroups treated with R-CHOP had a significantly improved OS compared to their respective subgroups receiving CHOP alone (GCB, p=0.015; non-GCB, p=0.019). Bcl-2 expression was not a significant predictor in either the GCB or non-GCB subgroups treated with R-CHOP (OS, GCB: p=0.32; non-GCB: p=0.43). Conclusions: In this retrospective study, we demonstrate that subclassification based on the cell of origin continues to have prognostic significance in patients with DLBCL treated with R-CHOP. Addition of rituximab to CHOP improves the overall survival of patients with DLBCL in both the GCB and non-GCB subgroups. No significant financial relationships to disclose.

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Prognostic Impact of the Interaction between DNMT3A mutation and Internal Tandem Duplication of the FLT3 Gene (FLT3-ITD) in Patients with De Novo Mutated NPM1 (NPM1mut) acute Myeloid Leukemia

Blood ◽

10.1182/blood-2018-99-115337 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1492-1492

Author(s):

Guadalupe Oñate ◽

Ana Garrido ◽

Jordi Esteve ◽

Rosa Coll ◽

Montserrat Arnan Sangerman ◽

...

Keyword(s):

Overall Survival ◽

Acute Myeloid Leukemia ◽

Complete Remission ◽

Myeloid Leukemia ◽

De Novo ◽

Prognostic Impact ◽

Intermediate Risk ◽

Mutational Status ◽

De Novo Aml ◽

Acute Myeloid

Abstract Introduction The association of NPM1mut and FLT3-ITD in de novo acute myeloid leukemia (AML) with intermediate-risk cytogenetics has different prognostic impact depending on the FLT3 allelic burden. Previous studies published by our cooperative group showed that patients with de novo AML of intermediate-risk cytogenetics with NPM1mut and FLT3-ITD low ratio (<0.5, FLT3low) at diagnosis presented an overall survival and relapse rate similar to those with NPM1mut and FLT3wt. Therefore, in the CETLAM-2012 protocol, patients with FLT3low NPM1mut AML are not considered for allogenic hematopoietic stem cell transplant (allo-HSCT) in first complete remission (CR1). Recent studies suggest that the co-occurrence of DNMT3A mutation in FLT3-ITD NPM1mut AML patients confers a worse prognosis regardless of FLT3-ITD ratio. We analysed our data to determine whether these findings were confirmed in our cohort, specifically in the low FLT3-ITD ratio patients, since this could have therapeutic implications. Methods and patients A total of 163 patients with de novo AML, intermediate-risk cytogenetics and NPM1mut were analysed (median age 53 years (18-72); male:female 72:91 (0.79)). Eighty patients (49%) harboured an FLT3-ITD, with a high allelic ratio in 42 of 76 patients with available ITD/wt ratio (55%). They were included in the AML-2003 (n=49) and AML-2012 (n=114) CETLAM protocols. Proportion of patients undergoing alloHSCT in CR1 is detailed in table 1. Bone marrow samples from diagnosis were studied for DNMT3A mutations as previously described. The definition of complete remission (CR), overall survival (OS), leukemia-free survival (LFS) and risk of relapse (RR) followed recommended ELN criteria. The Kaplan-Meier method was used to estimate the distribution of LFS and OS, for RR cumulative incidence was used. Results Out of the 163 patients with AML of intermediate risk cytogenetics and NPM1mut, 78 presented DNMT3A mutations (48%). Of these, 62 (79%) presented mutations in codon R882 or corresponded to DNA insertions/deletions while 16 (21%) harboured missense mutations. Presence of DNMT3A mutation did not associate with FLT3-ITD (ITD/85 DNMT3Awt vs ITD/78 DNMT3Amut, p=0.394). In the entire cohort, 5-year OS, LFS and RR were 58±4.5%, 59±4.6% and 27±13.9%. FLT3-ITD ratio confirmed its prognostic impact when analysing FLT3wt (n=83) vs FLT3low (n=34) vs FLT3high (n=42) patients (5-year OS of 68±6% vs 62±8.7% vs 37±8.6%; p=0.002; and 5-year RR of 18±9.4% vs 27±16.1% vs 41±23.2%; p=0.023). On the contrary, DNMT3Amut did not exert any effect on overall outcome (5-yr OS DNMT3Awt vs DNMT3Amut 61±6.2% vs 55±6.2%; p=0.234) When DNTM3A mutational status was considered, the impact of FLT3-ITD on outcome was mitigated in wild-type DNMT3A population. Thus, we found that DNMT3Awt patients presented no statistical differences in OS according to FLT3 mutational status or ratio: FLT3wt (n=46) vs FLT3-ITD (n=39) was 67±8.5% vs 57±8.2%; p=0.122, whereas FLT3wt (n=46) vs FLT3low (n=18) vs. FLT3high (n=19) was 67±8.5% vs. 66±11.5% vs 46±11.8%; p=0.088 (image 1A).This was also seen in relation to LFS and RR according to FLT3 ratio: 5-yr LFS of FLT3wt vs FLT3low vs FLT3high was 72±7.9% vs 61±12.6% vs 51±13.4%; p=0.244 and 5-year RR of the same groups: 19±8.8% vs 26±12.5% vs 27±21.9%; p=0.724 (image 2A). In the DNMT3Amut group, patients with FLT3-ITD (n=41) presented shorter OS than those with FLT3wt (n=37) with an OS of 37±10.7% vs 69±7.8%; p=0.028. When FLT3 ratio was considered, FLT3wt (n=37) vs FLT3low (n=16) vs FLT3high (n=23) showed an OS of 69±7.8% vs. 58±13.2% vs 27±13.1%; p=0.038 (image 1B). Similar results were seen in LFS according to FLT3 ratio (FLT3wt (n=29) vs FLT3low (n=16) vs FLT3high (n=20) 71±8.6% vs 53±12.9% vs 18±13.8%; p=0.012). Finally, we observed significant differences in the 5-year RR when considering DNMT3Amut patients in relation to FLT3 ratio (FLT3wt vs FLT3low vs FLT3high 18±10.6% vs 27±20% vs 54±28.8%; p=0.021)(image 2B). Conclusions In this study, patients with NPM1mut and FLT3-ITDlow presented a similar outcome to patients with NPM1mut and FLT3wt regardless of DNMT3A mutational status. These results support the modification of alloHCST policy in CR1 in CETLAM-2012, which do not consider alloHSCT for patients with FLT3low. On the other hand, concurrence of DNMT3A mutation may have an added negative effect in patients with NPM1mut and FLT3-ITDhigh, which should be further confirmed in larger studies. Disclosures No relevant conflicts of interest to declare.

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Co-expression of MYC and BCL2 in diffuse large B-cell lymphoma

IIUM Medical Journal Malaysia ◽

10.31436/imjm.v15i1.1267 ◽

2016 ◽

Vol 15 (1) ◽

Author(s):

Naznin Muhammad ◽

Ahmad Toha Samsudin ◽

Norlelawati A.Talib ◽

Aung Gyi ◽

Norra Harun ◽

...

Keyword(s):

B Cell ◽

De Novo ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Queen Elizabeth Hospital ◽

Prognostic Impact ◽

Large B Cell Lymphoma ◽

Formalin Fixed Paraffin Embedded ◽

Diagnostic Work ◽

Large B Cell

Introduction: Diffuse large B-cell lymphoma (DLBCL) is the most common type of nonHodgkin lymphoma. The pathogenesis of DLBCL is complex because it involves at least two different pathways, a de novo pathway and a transformation pathway. MYC and BCL2 oncogenes are 2 key regulators implicated in the pathogenesis. DLBCL with concurrent expression of MYC and BCL2 has been shown to be clinically aggressive and confers a worse prognosis. MYC detection by immunohistochemistry is however not performed in a routine diagnostic work up of DLBCL cases. This study examined the presence of MYC and BCL2 proteins by immunohistochemistry in patients diagnosed to have DLBCL. Methods: This retrospective study involved patients diagnosed to have DLBCL at Tengku Ampuan Afzan Hospital, Kuantan, Pahang (Year 2009-2011) and Queen Elizabeth Hospital, Kota Kinabalu, Sabah Malaysia (Year 2012-2014). Immunohistochemistry for MCY and BCL2 were performed on sections of formalin fixed paraffin embedded tissue blocks. Results: There were 91 cases analyzed. Forty-nine cases (53.8%) exhibited concurrent expression of MYC and BCL2 proteins. In about one third of the cases, positivity was confined to BCL2. In 4 cases (4.4%) only MYC was expressed while in 9 cases (9.9%) both markers were negative. Overall about 60% and 85% of the cases were positive for MYC and BCL2 respectively. Conclusions: Approximately half of DLBCL case studied co-express MYC and BCL2. Prospective studies to look at the clinical significance and prognostic impact of this finding are advocated.

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No Prognostic Impact of p53 and P-Glycoprotein Expression in Patients with Diffuse Large B-Cell Lymphoma

ISRN Oncology ◽

10.5402/2011/670358 ◽

2011 ◽

Vol 2011 ◽

pp. 1-6

Author(s):

Pairaya Rujirojindakul ◽

Kumpol Aiempanakit ◽

Kanita Kayasut ◽

Arnuparp Lekhakula ◽

Hutcha Sriplung

Keyword(s):

De Novo ◽

Performance Status ◽

Survival Rates ◽

Disease Free Survival ◽

Poor Performance ◽

B Cell Lymphoma ◽

Poor Performance Status ◽

Prognostic Impact ◽

P Glycoprotein ◽

Formalin Fixed Paraffin Embedded

The aim of this study was to determine the clinical significances of p53 and p-glycoprotein (P-gp) expression on outcome predictors for patients with DLBC. We assessed the immunohistochemical expression of p53 and P-gp using formalin-fixed, paraffin-embedded specimens in 108 patients diagnosed with de novo DLBC. A high expression of p53 was found in 53.7% of the patients. No expression of P-gp was demonstrated in any of the specimens. There were no significant differences in the complete remission (CR) rate (P=0.79), overall survival (OS) (P=0.73), or disease-free survival (DFS) (P=31) between the p53-positive and p53-negative groups. The final model from multivariate analysis that revealed poor performance status was significantly associated with CR (P<0.001) and OS (P<0.001). Moreover, the advanced stage was a significant predictor of DFS (P=0.03). This study demonstrated no impact of the expression of p53 on either response or survival rates.

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Comprehensive Biomarker and Genomic Analysis Identifies p53 Status as the Major Determinant of Response to MDM2 Inhibitors in Chronic Lymphocytic Leukemia.

Blood ◽

10.1182/blood.v110.11.224.224 ◽

2007 ◽

Vol 110 (11) ◽

pp. 224-224

Author(s):

Sami N. Malek ◽

Peter Ouillette ◽

Lisa Kujawski ◽

Sanjeev Shangary ◽

Moshe Talpaz ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Ex Vivo ◽

Lymphocytic Leukemia ◽

Major Determinant ◽

P53 Mutations ◽

P53 Expression ◽

Ic50 Values ◽

P53 Status ◽

Mdm2 Inhibitor ◽

Inhibitor Treatment

Abstract To understand determinants of sensitivity or resistance to MDM2 inhibitor therapy in chronic lymphocytic leukemia (CLL), we comprehensively analyzed highly pure CD19+ cells derived from 106 CLL patients for response to the MDM2 inhibitors MI-63 and Nutlin3 ex vivo and correlated these responses with clinically important biomarkers, including hierarchical FISH, IgVH-mutations and ZAP70 expression. P53 exons 5–9 were sequenced for all cases, and p53 induction pre- and post-inhibitor treatment was determined by immunoblotting for all 106 samples. Furthermore, we employed high-density 50kSNP-arrays to analyze changes of copy number and allele status, including that of p53 on chromosome 17p, in 171 CLL patients and correlated this finding with p53 mutations and p53 expression. Patient-derived samples were incubated for 36 hours with both inhibitors in parallel and apoptotic (annexin-V) and necrotic cell death (PI) was assayed for all incubations using flow cytometry. IC50 values were calculated using XL-fit. Nineteen CLL cases demonstrated either p53 mutations or aberrant expression and all were relatively resistant to MDM2 inhibitor treatment; eighty-seven cases had functional p53 and all but 3 cases demonstrated sensitivity to MDM2 inhibitor treatment. Very few cases with functional p53 demonstrated IC50 values for both inhibitors that were within the range of p53 mutant cases. Del17p patient samples were resistant to MDM2 inhibitor-mediated cell kill, while all other CLL biomarker-based subgroups appeared equally sensitive. Univariate time to first therapy (TTFT) estimates demonstrated a statistically significant (p=0.02 using the log-rank test) shorter TTFT for the group of 19 CLL cases with aberrant p53 function as opposed to the group of 87 cases with functional p53. Importantly, TTFT analysis for the 87 patients with functional p53 found that patients with low IC50 values (high sensitivity to MDM2 inhibitors) had more aggressive CLL (shorter TTFT), identifying for the first time a susceptible target group for these inhibitors that demonstrates aggressive disease and wt p53. In conclusion, the results of these studies conclusively demonstrate that p53 status is the major determinant of response to MDM2 inhibitors in CLL. Additional defects in the p53 regulatory cascade do not appear operational in this leukemia. This comprehensive dataset provides supportive rationale for the design of early phase human trials using these compounds and supports ex vivo measurements of p53 induction pre- and post-MDM2 inhibitor treatment as part of future trial schemas.

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