national consultation center for haematopathology in slovakia: … · 2014. 5. 12. · national...

Lymfómová skupina Slovenska

Biology of aggressive mature B-cell lymphomas

Lukáš Plank

National Consultation Center for Haematopathology in Slovakia:

Department of Pathology, Jessenius Faculty of Medicine, Comenius University & University Hospital

and Martin´s Biopsy Center, Ltd.


Biologic classification = „grading“ of ML

§ grade of biological aggressivness = grade of malignancy

Biology of Non-Hodgkin Lymphomas

WHO 2008 Previously

Indolent Low grade Low grade

Aggressive / highly aggressive

High grade malignant

Intermediate

High grade


Indolent lymphomas Aggressive and highly aggressive lymphomasL LB/ALL

§ low grade malignancy

§ low proliferation fraction

and slow growth

§ long term survival

§ but non-curable

§ possible

watch and wait strategy

§ high grade malignancy

§ high proliferation fraction

and rapid growth

§ immediate and/or aggressive

Tx required

§ potentially curable

Characteristics of aggressive NHL


Indolent NHL Aggressive NHL Highly aggressive NHL CLL/SLL LBCL / DLBCL LB/ALL FL G1-2 FL G3 (G3a, G3b) BL LPL MCL BCLU MZBL, etc.

Non-Hodgkin mature B-cell lymphomas

§ LB/ALL: lymphoblastic lymphoma/acute lymphoblastic leukemia § DLBCL: diffuse large B-cell lymphoma § BL : Burkitt lymphoma § BCLU: B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and BL

Ø abbreviations


Indolent NHL Aggressive NHL Highly aggressive NHL CLL/SLL DLBCL LB/ALL

FL G1-2 FL G3 (G3a, G3b) BL LPL MCL BCLU MZBL, etc.

Aggressive lymphomas from peripheral (mature) B-cells

§ LB/ALL: lymphoblastic lymphoma/acute lymphoblastic leukemia § DLBCL: diffuse large B-cell lymphoma § BL : Burkitt lymphoma § BCLU: B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and BL

Ø abbreviations

common

rare

Lymfómová skupina Slovenska Increasing incidence of ML: e.g. British data

Lymfómová skupina Slovenska Incidence of aggressive B-cell ML: US, UK and Slovak populations

Rate per 100.000 person/year (Morton et al., Blood 2006)

1992-2001

2004-2011

DLBCL: 25-40% of all

Lymfómová skupina Slovenska Incidence of aggressive B-cell ML: US, UK and Slovak populations

Rate per 100.000 person/year (Morton et al., Blood 2006)

1992-2001

2004-2011

2007

C83 in Slovakia: approx. 300 newly diagnosed patients / year


Assessment of their aggressivness

Ø parameters identified / identifiable by biopsy tissue analyses:

Ø parameters identified / identifiable by clinical @ laboratory approaches:

a) parameters of tumour cells: - extent, growth patterns and topography of ML infiltrate - histocytology (small vs large cells) - mitotic activity index (MAI) and proliferation Ki-67 index - IHC: phenotype - molecular and genetical parameters

to be discussed by next presentations ..., e.g.: - clinical (manifestation, extent, etc.), - biochemical, haematological, etc. data, incl. IPIs, aaIPI, etc. - therapeutical response, progression, remission, ....

b) parameters of microenvironment, immune response ... : - TAMs (1st and 2nd type) - T-cell response - cross-signalling with niche, etc.

Lymfómová skupina Slovenska Aggressive B- cell lymphomas: criterias of the classification

b) ETIOPATHOGENESIS

c) SITE OF ORIGIN

d) PATIENT´S AGE

e) IMMUNE STATUS

a) WHO @ HISTOGENESIS

DLBCL BL

BCLU


b) ETIOPATHOGENESIS

c) SITE OF ORIGIN

d) PATIENT´S AGE

e) IMMUNE STATUS


DLBCL BL

BCLU

primary, de novo: all

secondary (transformation): DLBCL, BCLU


b) ETIOPATHOGENESIS

c) SITE OF ORIGIN

d) PATIENT´S AGE

e) IMMUNE STATUS


DLBCL BL

BCLU

primary, de novo secondary (transformation)

primary nodal: all

primary EN - organ specific: all


b) ETIOPATHOGENESIS

c) SITE OF ORIGIN

d) PATIENT´S AGE

e) IMMUNE STATUS


DLBCL BL

BCLU


primary nodal primary EN – organ specific

pediatric: BL, DLBCL

adults: DLBCL, BCLU, BL


b) ETIOPATHOGENESIS

c) SITE OF ORIGIN

d) PATIENT´S AGE

e) IMMUNE STATUS


DLBCL BL

BCLU


primary nodal primary EN – organ specific

pediatric adults

immunocompetent patients: all

immunocompromised patients (incl. ID): all


3 major clinical types

(diffuse) large B-cell lymphomas (DLBCL)

Burkitt lymphoma

B-cell lymphoma, unclassifiable (BCLU), with features intermediate between DLBCL and BL



diffuse growth in all environments „large“ B-cells


(Diffuse) Large B-cell lymphoma (s)

NOS: not otherwise specified, GCB – germinal center B-cell type, ABC – activated B-cell type, GEP: gene expression profile, HHV – human herpes virus

DLBCL variants, types and subtypes

Other large B-cell MLs

DLBCL, NOS - morphologic variants

of immunocompetent patient

centroblastic immunoblastic anaplastic

DLBCL associated with chronic inflammations Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma Lymphomatoid granulomatosis ALK-positive large B-cell lymphoma DLBCL, NOS – GEP / IHC types

GCB type / ABC type GCB type / non-GCB type

DLBCL subtypes of immunocompromised patient T-cell/Histiocyte rich large B-cell lymphoma Primary CNS DLBCL Primary cutaneous DLBCL, leg type EBV-positive DLBCL of the elderly

Plasmablastic lymphoma Primary effusion lymphoma Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease

Ø abbreviations

different biologic manifestation and course


C-o-o (cell of origin): DLBCL, NOS

§ histologic type

prognostically not significant


§ histologic type

prognostically not significant

§ assignment of DLBCL into coo groups by GEP: prognostically significant

Wright et al., 2003



DLBCL: Molecular pathogenesis and coo

Lossos JCO 2005, many others


§ Non-GCB patients: worse prognosis than in GCB group (Rosenwald et al., 2002)

§ GCB type: bcl2+ expression - negative prognostic value (Grace et al., 2006; Xu Y et al., 2001).

CD10+ bcl6+

C-o-o (cell of origin): DLBCL, NOS, IHC

Hans et al., 2004

CD10- MUM1

GCB phenotype

CD10+/BCL6+ CD10/BCL6- CD10-/BCL6+/MUM1-

non- GCB phenotype

CD10-/BCL6- CD10-/BCL6+/MUM1+


§ other IHC subtyping approaches:

Muris et al., (2006); Colom et al., (2003); Choi et al., (2009); Meyer et al., (2010), Tally (2011), etc.

Choi et al., 2009

GCB

GCET1+/MUM1-

GCET1-/CD10+

GCET1-/CD10-/BCL6+/FOXP1-

non- GCB

GCET1+/MUM1+

GCET1-/CD10-/BCL6-

GCET1-/CD10-/BCL6+/FOXP1+

C-o-o (cell of origin): DLBCL, NOS, IHC

§ semiquantitative cut off values – varying rates of concordance

§ centralized consensus review necessary

§ therapeutical decisions not based on IHC phenotyping



Lymph2CX assay for GEP: § A 20-gene expression-based assay robustly assign COO subtypes of DLBCL using FFPE tissue § correlation with IHC phenotyping


(Diffuse) Large B-cell lymphoma (s)

NOS: not otherwise specified, GCB – germinal center B-cell type, ABC – activated B-cell type, GEP: gene expression profile, HHV – human herpes virus

DLBCL variants, types and subtypes


DLBCL, NOS - morphologic variants

of immunocompetent patient

centroblastic immunoblastic anaplastic

DLBCL associated with chronic inflammations Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma Lymphomatoid granulomatosis ALK-positive large B-cell lymphoma DLBCL, NOS – GEP / IHC types

GCB type / ABC type GCB type / non-GCB type

DLBCL subtypes of immunocompromised patient T-cell/Histiocyte rich large B-cell lymphoma Primary CNS DLBCL Primary cutaneous DLBCL, leg type EBV-positive DLBCL of the elderly

Plasmablastic lymphoma Primary effusion lymphoma Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease

Ø abbreviations


DLBCL subtypes - Dx criteria T-cell/Histiocyte rich large B-cell lymphoma Primary CNS DLBCL Primary cutaneous DLBCL, leg type EBV-positive DLBCL of the elderly

morphology organ/pattern-related etiology


DLBCL subtypes - Dx criteria T-cell/Histiocyte rich large B-cell lymphoma Primary CNS DLBCL Primary cutaneous DLBCL, leg type EBV-positive DLBCL of the elderly

morphology organ/pattern-related etiology

CD20+

Primary CNS DLBCL Primary cutaneous DLBCL, leg type

MUM1+



of immunocompetent patient DLBCL associated with chronic inflammations Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma Lymphomatoid granulomatosis ALK-positive large B-cell lymphoma

of immunocompromised patient Plasmablastic lymphoma Primary effusion lymphoma Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease



of immunocompetent patient DLBCL associated with chronic inflammations Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma Lymphomatoid granulomatosis ALK-positive large B-cell lymphoma

of immunocompromised patient Plasmablastic lymphoma Primary effusion lymphoma Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease

CD20+

ALK+

CD138+

CD20+

Primary mediastinal LyGr CD20+

Fusion gene CLTC-ALK




Burkitt lymphoma



Burkitt lymphoma classification

Burkitt lymphoma patient´s age clinical

manifestation clinical variants

children lymphoma mass rapidly enlarging, EN sites common

sporadic

young adults leukemic (FAB: ALL L3)

endemic

ID-associated

§ in contrast to previous classifications,

in the recent one (2008) defined in a restricted sense,

however:

§ definition by histology + IHC + molecular signature

§ sporadic + endemic: highly aggressive, but potentially curable

§ always de novo lymphoma (?)

Dr. Denis Burkitt


Burkitt lymphoma: histology + IHC

PAX5 CD20

bcl6

CD10

Ki-67

myc


Burkitt lymphoma: genetics

§ chr. 8q24 + 14q32

most cases MYC translocation 8q24 to the IgH region = t(8;14)(q24;q32):

LSI IGH/MYC + CEP8 Tri Color Dual Fusion Translocation

Probe (Vysis)

§ other cases 8q24 + chr. 22 / 2: t(8;22)(q24;q11) or t(2;8)(p12;q24)

§ up to 10% of cases no MYC translocation by FISH (other techniques !)

§ no rearrangement of CCND1, BCL2, BCL6

MYC Split Signal (Dako)


Burkitt lymphoma - leukemic presentation

§ previously ALL L3 sec. FAB classification

§ starry sky pattern often lost (different microenvironment)




Burkitt lymphoma (s)




§ heterogenous / provisional category for cases not meeting the Dx criteria

(morphologic and/or genetic) for BL or DLBCL

§ „time-out“ to collect new data + to verify new definitions

§ aggressive lymphomas that are even more rare than BL, mainly adults

§ own series of 137 large B-cell ML examined by i-FISH (FFPE) - detection of MYC, BCL and BCL6 gene rearrangement: § 10 (7.3%) cases with concordant rearrangement: 1 double hit BCLU: MYC + BCL2 4 double hit BCLU: MYC + BCL6 5 tripple hit BCLU: MYC + BCL2 + BCL6



§ either: morphology intermediate, high proliferation fraction, phenotype

consistent with BL

§ or: morphology of BL, but atypical (non-BL) pheno- or genotypic

features § but not: - morphology of DLBCL + MYC rearrangement = DLBCL - or otherwise typical BL without demonstrable MYC rearrangement = BL



§ aggressive disease, advanced stage,

common involvement of EN sites, bone marrow and CNS involvement

§ resistant to multiple-agent Tx, poor prognosis

§ double hit lymphoma survival measured in months

Ki-67

bcl6 CD10 myc

DLBCL-like morphology bcl2 MYC + BCL2 > MYC + BCL6


MYC Split Signal

(Dako)

LSI IGH/MYC + CEP8 Tri Color Dual Fusion Translocation

probe (Vysis)

LSI IGH/BCL2 Dual Color Dual Fusion Translocation probe

(Vysis)

IgH / MYC fusion + IgH rearrangement

IgH / BCL2 fusion

BCLU - double hit: MYC + BCL2 rearranged

MYC rearrangement


§ Take home message

DLBCL

definition (!), children + young adults, common EN

NOS: GCB vs non-GCB

DLBCL subtypes

other LBCL

N vs EN = site-, etiology-, age- , etc. specificity

BL

+ role of Dx pathology: identification of Tx targets

BCLU not meeting the criteria for DLBCL or BL, either MYC or BCL 2 rearrangement

genetics: double / tripple hit


Possible targets for Tx: B-cell antigens

Ø Monoclonal Abs against CD20 and CD22 - cytotoxicity mechanisms: ADCC, CDC

type I (via apoptosis ), type II (via direct cell death)

induction of cell death of CD22-expressing cells

www.biooncology.com

CD22 CD20


Possible targets for Tx

Ø Monoclonal Abs against CD20 and CD22 - cytotoxicity mechanisms: ADCC, CDC

type I (via apoptosis ), type II (via direct cell death)

induction of cell death of CD22-expressing cells

www.biooncology.com

CD22 CD20

Ø CD30 as a target in CD30+ DLBCL


Bcl2: a member of anti-apoptotic family proteins

mTOR: a member of PI3K cell survival pathway

The shutdown of cell survival signalling The inhibition of inhibitors of apoptosis

www.biooncology.com

Possible targets for Tx


Thanks to my co-workers, clinical partners and patients

§ Lymphoma Dx and identification of biologic parameters = puzzle


§ Biopsy diagnosis : P. Szépe, T. Balhárek, J. Marcinek, J. Mičák, P. Vašeková § IHC: Z. Kviatkovska, J. Cáliková, V. Šichtová

Thanks to my co-workers, clinical partners and patients

§ FISH: T. Balhárek, A. Farkašová, M. Barthová, Ľ. Janáková,

§ Lymphoma Dx and identification of biologic parameters = puzzle

J

national consultation center for haematopathology in slovakia: … · 2014. 5. 12. · national...

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