Pathology Stephan Dirnhofer

“Aggressive” B-cell lymphoma

Patho-Basic 25. September 2018

Be aware - in Lymphoma

aggressive vs indolent

high grade versus low grade

large cell versus small cell

… does not mean the same!

• Lymphoblastisches Lymphom (LBL/B-ALL)

• Burkitt Lymphom (BL)

• Grosszellige B-Zell Lymphome (DLBCL, u.a.)

• High-grade B-Zell Lymphom (HGBCL)

– HGBCL, with MYC and BCL2 and/or BCL6 rearrangements

– HGBCL, NOS

«aggressive» BCL

• T-cell/histiocyte-rich large B-cell lymphoma

• Intravascular large B-cell lymphoma

• Primary DLBCL of the CNS

• Primary cutaneous DLBCL, leg-type

• Primary mediastinal (thymic) large B cell lymphoma

• EBV-positive DLBCL, NOS

• Large B cell lymphoma with IRF4 rearrangements

• DLBCL associated with chronic inflammation

• ALK+ large B-cell lymphoma

• Plasmablastic lymphoma

• HHV8-positive DLBCL

• Primary effusion lymphoma

• High grade B-cell lymphoma

HGBCL, with MYC and BCL2 and/or BCL6 rearrangements

HGBCL, NOS

• B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and cHL

• DLBCL, NOS

- Morphological variants: Centroblastic, Immunoblastic, Anaplastic

- Molecular subtypes: GCB-type, non GCB-type (ABC-type)

Large B-cell lymphomas – WHO 2017

6

• Most common lymphoma worldwide (30-40%)

• Heterogenous disease (morphology, phenotype, genotype, clinic)

• Majority cured by first-line treatment (R-CHOP)

• 30 - 40% of DLBCL relapse

• Relapse - worse outcome

• Identification of these patients needed

• Prognostic and/or predictive markers

Mareschal et al. 2015

DLBCL: the clinical problem

Nowakowski et al., J Natl Cancer Inst, 2016

Davies A., Hematology Am Soc Hematol Educ Program.,2017

Sehn & Cascoyne, Blood 2015

• Cell of origin (CoO) - classification: required

• Distinguish GCB from non‐GCB type DLBCL

• Methods: GEP, IHC, Nanostring…..

• IHC: any algorithm accepted (Hans, Visco, Tally, Choi…)

DLBCL, NOS: WHO-update 2017

COO Classification in the WHO Update 2017

“Insight into the diverseness of GCB and ABC DLBCL has led to the investigation

of more specific therapeutic strategies to mitigate the worse outcome among

those with ABC/non-GCB type DLBCL reported and prospective trials are ongoing

to determine if these therapies should be incorporated into clinical practice”.

“For this reason the revised classification will require the identification of these

two subtypes. With GEP still not a routine clinical test, the use of IHC algorithms

will be considered acceptable. While the Hans algorithm remains the most popular

and has a reasonable correlation with the GEP, other algorithms also may be used

(Visco, Choi, Tally,…)”.

Swerdlow et al. Blood 2016

Cell of Origin – Hype index

CoO-HI

2000 2005 2008 2018

Molecular subtypes of DLBCL: COO-classification

Nature, 2000

Wright et al., PNAS 2003 Rosenwald et al., J Exp Med 2003

Different prognosis of ABC & GCB DLBCL (R-CHOP)

Lenz et al., NEJM, 2008

Lymph2Cx-based COO Classification and Survival Analysis in the German HG Clinical Trails

Ricover 60 R-CHOP (>60-80 ys.)

R-MegaCHOEP (18-60 ys.)

COO may not be a prognostic marker in (all) clinical trials

Staiger et al., JCO 2017

Reddy et al;

Cell 2017

Reddy et al; Cell 2017

• 304 DLBCL

• WES, CNA, SV

• Coordinate genetic signatures (consensus clustering)

• 5 DLBCL subsets: C1 - C5

2018

Chapuy et al; Nature Medicine 2018

Outcome association of DLBCL

• Choice of method (GEP – NanoString – HTG – IHC)

• IHC: choice of algorithm (Hans, Visco, Tally, Choi…)

• Type of tissue (CNB)

CoO-testing: Practical Problems

CoO-testing: Concordance of IHC with GEP

• 70-90% (Hans - classifier)

• CD10 robust, MUM1 & BCL6 more variable

• High interlaboratory concordance for stainings and CoO-subtyping

de Jong D et al., J Clin Oncol 2007

Gutiérrez-García et al., Blood 2011

Lawrie et al., Histopathology 2012

MYC FISH

BCL2 & BCL6

FISH

DLBCL, NOS

CD10

GCB type

BCL6

MUM1

ABC type

-

+ DLBCL, NOS

“ single hit”

HGBCL

“double/ triple hit”

+

- +

-

+

-

ABC type

GCB type

-

+

Large B-cell lymphoma

Diagnostic Algorithm: “large B-cell lymphoma”

modified from: Gerlach and Dirnhofer; labmed 2018

Klapper et al; Der Pathologe 2018

Scott et al; Blood 2018

Reinke et al: Virchows Archive 2018

Do we really need CoO – classification?

21

No immediate clinical relevance

G. Lacoboni et al., Annals of Oncology 2018 Please note, cross trial comparisons should be interpreted with caution due to differences in inclusion criteria and patient populations

Press release available from: https://www.jnj.com/janssen-provides-update-on-imbruvica-ibrutinib-phase-3-phoenix-trial-

in-newly-diagnosed-non-germinal-center-b-cell-non-gcb-subtype-of-diffuse-large-b-cell-lymphoma-dlbcl

R-CHOP + lenalidomide R-CHOP

(historical comparison)

GCB

Non-GCB

wait for: DLC-002 (ROBUST) trial in ABC –

DLBCL

R-CHOP +/- lenalidomide

Outlook

• “Top down” solution

• Clinical studies will determine the further “fate” of CoO

• If “practice changing” study/studies published

– Methodological gold standard

– Proficiency testing for analytical variables

– Biopsy according to guidelines

May 30, 2018

Cell of Origin – Hype index

CoO-HI

2000 2005 2008 2018 2025

Thank you!

The PHOENIX study

2014

ABC/GCB prognostic relevance in R-CHOP

treated DLBCL – results of independent consortia

Author Method Prospective trial Prognostic

Lenz et al. (NEJM 2010)

Gene expression (Affymetrix)

No Yes

Visco et al. (Leukemia 2012)

Immuno-histochemsitry

No Yes

Copie-Bergman et al. (JCO 2009)

Immuno-histochemsitry

Yes No

Cunnigham et al. (Lancet 2013)

Immuno-histochemsitry

Yes No

Staiger et al. (JCO 2017)

Gene expression (Nanostring)

Yes No

Reddy et al. (Cell 2017)

Gene expression (RNA-Seq.)

No Yes

Slide, modified: Prof. W. Klapper, Kiel

Impact of Concurrent Expression of MYC and BCL2

Across Studies

Authors Number of

cases

%MYC/BCL2

positive

Significance Multivariate

Johnson 2012 307 18% P<.001 Significant

Green 2012 309 29% P<.001 Significant

Horn 2013 141 28% P<.001 Significant

Hu 2013 700 34% P<.001 Significant

Valera 2013 219 58% P<.001 Significant

Perry 2014 106 17% P<.001 Significant

Scott 2015 339 31% P<.001 Significant

Ye 2015 831 17% P<.001 Significant

S. Dirnhofer, Basel MYC BCL2

2018

• 574 DLBCL

• WES, RNA-seq., targeted amplicon resequencing, CNA

• 4 genetic subtypes (co-occurrence of genetic alterations)

MCD (MYD88 & CD79B)

BN2 (BCL6 & NOTCH2)

N1 (NOTCH1)

EZB (EZH2 & BCL2)

Schmitz et al; NEJM 2018

Schmitz et al; NEJM 2018

Chapuy et al; Nature Medicine 2018