Prognostic significance of T-cell or cytotoxic molecules phenotype in classical Hodgkin's lymphoma: a clinicopathologic study

CD68 and CD163 as prognostic factors for Korean patients with Hodgkin lymphoma

BACKGROUND

Limited progress had been made in prognostic stratification of patients with Hodgkin lymphoma (HL) until recent studies suggested that the number of CD68-expressing macrophages is prognostic in classical HL. However, its significance in Asian patients with HL has not been explored yet perhaps because of its low incidence in Asia.

METHODS

In this work, we performed immunohistochemical analysis of CD163, as well as CD68, in 144 Korean patients with HL treated between November 1990 and December 2009 in a single center. The relative percentages of CD68+ and CD163+ cells with respect to the overall cellularity (CD68 index and CD163 index, respectively) were correlated with clinical outcomes.

RESULTS

Both high CD68 and CD163 indices (>20%) were associated with a rise in treatment-related deaths and poorer event-free survival (P = 0.009 and P = 0.0023, respectively), disease-specific survival (P = 0.011 and P = 0.001), and overall survival (P = 0.023 and P = 0.001). In particular, a high CD163 index was related to lower complete response (CR) rate (P = 0.022) and shorter duration of CR (P = 0.030).

CONCLUSIONS

High index of either CD68 or CD163 (>20%) is significantly correlated with poor prognosis in Korean patients with HL. CD163, a specific marker of macrophages, seems to be another prognostic factor for classical HL.

Cytotoxic molecule-positive classical Hodgkin's lymphoma: a clinicopathological comparison with cytotoxic molecule-positive peripheral T-cell lymphoma of not otherwise specified type

BACKGROUND

Classical Hodgkin's lymphoma is characterized by Hodgkin and Reed Sternberg cells, which are of B-cell origin in many cases. We recently highlighted the adverse prognostic significance of cytotoxic molecule expression in patients with classical Hodgkin's lymphoma. However, the clinical characteristics of cytotoxic molecule-positive classical Hodgkin's lymphoma remain controversial.

DESIGN AND METHODS

We investigated the clinicopathological profiles of 32 patients with cytotoxic molecule-positive Hodgkin's lymphoma, comprising 23 with nodular sclerosis and 9 with mixed cellularity, and compared these profiles with those of 55 patients with cytotoxic molecule-positive nodal peripheral T-cell lymphoma, not otherwise specified and 439 patients with cytotoxic molecule-negative Hodgkin's lymphoma.

RESULTS

The patients with cytotoxic molecule-positive Hodgkin's lymphoma consisted of 20 men and 12 women with a median age of 50 years (range, 19 to 81). All these patients had lymphadenopathy at presentation, and 14 showed mediastinal involvement. Physical findings included hepatomegaly and splenomegaly in six patients each. Four patients had a bulky mass, and nine showed stage IV disease. The tumor cells of patients with cytotoxic molecule-positive Hodgkin's lymphoma had a prototypic immunophenotype of CD15(+) CD30(+) CD45RO(-) fascin(+), with positivity for Epstein-Barr virus in 39% of cases. All patients were negative for Pax5. In comparison with patients with cytotoxic molecule-positive nodal peripheral T-cell lymphomas, not otherwise specified, patients with cytotoxic-positive Hodgkin's lymphoma had relatively mild clinical symptoms, similar to those of patients with cytotoxic molecule-negative Hodgkin's lymphoma. Regarding prognosis, the survival of patients with cytotoxic molecule-positive Hodgkin's lymphoma was worse than that of patients with cytotoxic molecule-negative Hodgkin's lymphoma (P = 0.0003) but better than that of patients with cytotoxic molecule-positive peripheral T-cell lymphomas, not otherwise specified (P = 0.002).

CONCLUSIONS

Cytotoxic molecule-positive Hodgkin's lymphoma is characterized by an unfavorable prognosis, even if its clinicopathological features are within the boundaries of classical Hodgkin's lymphoma. More effective chemotherapy for cytotoxic molecule-positive Hodgkin's lymphoma is clearly required.

Molecular Pathogenesis of Hodgkin's Lymphoma: Increasing Evidence of the Importance of the Microenvironment

Hodgkin's lymphoma (HL) represents the most common subtype of malignant lymphoma in young people in the Western world. Most patients can be cured with modern treatment strategies, although approximately 20% will die after relapse or progressive disease. The histologic hallmark of the disease is the presence of the characteristic Hodgkin Reed-Sternberg (HRS) cells in classical HL and so-called lymphocyte-predominant (LP) cells in nodular lymphocyte-predominant HL. HL is unique among all cancers because malignant cells are greatly outnumbered by reactive cells in the tumor microenvironment and make up only approximately 1% of the tumor. Expression of a variety of cytokines and chemokines by the HRS and LP cells is believed to be the driving force for an abnormal immune response, perpetuated by additional factors secreted by reactive cells in the microenvironment that help maintain the inflammatory milieu. The malignant HRS and LP cells manipulate the microenvironment, permitting them to develop their malignant phenotype fully and evade host immune attack. Gene expression signatures derived from non-neoplastic cells correlate well with response to initial and subsequent therapies, reflecting their functional relevance. Recent biomarker studies have added texture to clinical outcome predictors, and their incorporation into prognostic models may improve our understanding of the biologic correlates of treatment failure. Moreover, recent preclinical and clinical studies have demonstrated that the tumor microenvironment represents a promising therapeutic target, raising hope that novel treatment strategies focused on the interface between malignant and reactive cells will soon emerge.

A case of systemic anaplastic large cell lymphoma with 'Hodgkin-like' appearance and skin involvement mimicking lymphomatoid papulosis

We report a unique case of the CD30+ anaplastic large cell lymphoma (ALCL). A 44-year-old Japanese male presented with lymphadenopathy followed by skin involvement. Initially, a swollen cervical lymph node was recognized in 1989 and relapsed in 1991, which was histologically diagnosed as Hodgkin disease of nodular sclerotic type. In 1996, he presented ulcerative cutaneous nodules and swollen lymph nodes in his left inguinal region, which was then diagnosed with CD30+ ALCL. Both the lymphadenopathy and the skin lesion had been completely remitted by combining chemotherapy followed by radiotherapy. Thereafter, he had relapsing and remitting episodes of multiple papules and nodules on his face, trunk and extremities for 10 years. Repeated histopathological examination revealed similar tumor cell proliferation in the papules/nodules of the skin. Essentially similar immunohistochemical features, including CD30 and granzyme B expression, but not anaplastic lymphoma kinase (ALK), strongly suggested that all these tumors were sequential expression of one disease continued for 19 years. This case was finally diagnosed as CD30+ ALCL with unique skin involvement mimicking lymphomatoid papulosis (LyP).

Diagnosis of Nodal Peripheral T-Cell Lymphomas

Lymph node-based peripheral T-cell lymphomas are rare and exhibit a morphologic spectrum that overlaps with reactive lymphoid hyperplasia, B-cell lymphomas, and Hodgkin lymphoma, presenting a diagnostic challenge. This review focuses on the major categories of lymph node-based peripheral T-cell lymphomas recognized by the 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues. Diagnostic strategies for approaching T-cell neoplasms using a combined clinical, morphologic, immunophenotypic, and genetic approach are presented. Practical information to aid in distinguishing peripheral T-cell lymphomas from other hematologic malignancies and benign conditions is provided.

The role of cytotoxic and regulatory T cells in relapsed/refractory Hodgkin lymphoma

Recent data suggests the presence of cytotoxic (TIA-1 and granzyme B+) and regulatory T-cells (FOXP3+) in classical Hodgkin lymphoma (cHL) tissues has been shown to correlate with poor overall survival in mainly diagnostic biopsies. By tissue microarray analyses, we extend this observation to a cohort of relapsed/refractory cHL tissue biopsies and analyze immunohistochemical expression of FOXP3, TIA-1, and granzyme B in the inflammatory background and the tumor microenvironment. High expression of TIA-1 (>50%) correlated with poor overall survival (P<0.0001), low expression of FOXP3 (<25%) correlated with poor overall survival (P<0.01), and combined high TIA-1 (>50%) and low FOXP3 (<25%) correlated with poor overall survival (P<0.0001). Expression of cytotoxic and regulatory T-cells shows prognostic significance in the relapsed/refractory clinical setting of cHL.

PAX5-positive T-cell anaplastic large cell lymphomas associated with extra copies of the PAX5 gene locus

Cell lineage is the major criterion by which lymphomas are classified. Immunohistochemistry has greatly facilitated lymphoma diagnosis by detecting expression of lineage-associated antigens. However, loss or aberrant expression of these antigens may present diagnostic challenges. Anaplastic large cell lymphoma is a T-cell lymphoma that shows morphologic and phenotypic overlap with classical Hodgkin's lymphoma, which is a tumor of B-cell derivation. Staining for the B-cell transcription factor, paired box 5 (PAX5), has been suggested to be helpful in this differential, as it is positive in most classical Hodgkin's lymphomas, but absent in anaplastic large cell lymphomas. In this study we report four systemic T-cell anaplastic large cell lymphomas that were positive for PAX5 by immunohistochemistry, with weak staining intensity similar to that observed in classical Hodgkin's lymphoma. All diagnoses were confirmed by a combination of morphologic, phenotypic, and molecular criteria. Three cases were anaplastic lymphoma kinase (ALK) negative and one was ALK positive. PAX5 immunohistochemistry was negative in 198 additional peripheral T-cell lymphomas, including 66 anaplastic large cell lymphomas. Unexpectedly, although PAX5 translocations were absent, all evaluable PAX5-positive anaplastic large cell lymphomas showed extra copies of the PAX5 gene locus by fluorescence in situ hybridization (FISH). In contrast, only 4% of PAX5-negative peripheral T-cell lymphomas had extra copies of PAX5. We conclude that aberrant expression of PAX5 occurs rarely in T-cell anaplastic large cell lymphomas, and may be associated with extra copies of the PAX5 gene. PAX5-positive lymphomas with morphologic features overlapping different lymphoma types should be evaluated with an extensive immunohistochemical panel and/or molecular studies to avoid diagnostic errors that could lead to inappropriate treatment. As PAX5 overexpression causes T-cell neoplasms in experimental models, PAX5 may have contributed to lymphomagenesis in our cases.

Prognostic analysis and a new risk model for Hodgkin lymphoma in Japan

The Japan Clinical Oncology Group conducted two multicenter phase II trials in 200 patients with advanced Hodgkin lymphoma (HL) in the 1990s. Among 181 patients whose histopathological specimens were available and reviewed by 6 hematopathologists, 167 (92.3%) were diagnosed with HL. Five-year overall survival (OS) among these 167 patients was 88.3%, including 89.2% among nodular sclerosis and 82.2% among mixed cellularity cases. International prognostic score was not closely associated with OS. Seven unfavorable prognostic factors for OS on univariate analysis were male, B symptoms, clinical stage of III or IV, elevated serum LDH, elevated alkaline phosphatase, elevated beta2-microglobulin, and pathological subtype (mixed cellularity and lymphocyte depletion). On multivariate analysis, male [HR 3.30 (95% CI 1.15-9.52, p = 0.027)] and elevated serum LDH [HR 2.41 (95% CI 1.07-5.43, p = 0.034)] were independent factors for OS. Based on these prognostic factors, the 5-year OS was 95.7% in the low-risk group (no adverse factor), 87.9% in the intermediate-risk group (1 adverse factor) and 73.3% in the high-risk group (2 adverse factors). This simple prognostic model for HL warrants further validation studies.

Hodgkin lymphoma: an update on its biology with new insights into classification

In the past few years, there has been a greater understanding of the spectrum and biology of Hodgkin lymphoma (HL). In standard texts, HL is classified as 2 distinct entities, namely nodular lymphocyte-predominant HL and classical HL (CHL). However, recent evidence suggests that CHL is not a single disease. Although the mixed cellularity and lymphocyte-depleted subtypes might be part of a biologic continuum, the nodular sclerosis subtype has a distinct epidemiology, clinical presentation, and histology. Nodular sclerosis HL might also be related to primary mediastinal B-cell lymphoma and mediastinal gray-zone lymphomas. We present an update on the pathobiology of HL and discuss these biologic and clinical differences in this review.

Systematic analysis of immune infiltrates in high-grade serous ovarian cancer reveals CD20, FoxP3 and TIA-1 as positive prognostic factors

Background

Tumor-infiltrating T cells are associated with survival in epithelial ovarian cancer (EOC), but their functional status is poorly understood, especially relative to the different risk categories and histological subtypes of EOC.

Methodology/Principal Findings

Tissue microarrays containing high-grade serous, endometrioid, mucinous and clear cell tumors were analyzed immunohistochemically for the presence of lymphocytes, dendritic cells, neutrophils, macrophages, MHC class I and II, and various markers of activation and inflammation. In high-grade serous tumors from optimally debulked patients, positive associations were seen between intraepithelial cells expressing CD3, CD4, CD8, CD45RO, CD25, TIA-1, Granzyme B, FoxP3, CD20, and CD68, as well as expression of MHC class I and II by tumor cells. Disease-specific survival was positively associated with the markers CD8, CD3, FoxP3, TIA-1, CD20, MHC class I and class II. In other histological subtypes, immune infiltrates were less prevalent, and the only markers associated with survival were MHC class II (positive association in endometrioid cases) and myeloperoxidase (negative association in clear cell cases).

Conclusions/Significance

Host immune responses to EOC vary widely according to histological subtype and the extent of residual disease. TIA-1, FoxP3 and CD20 emerge as new positive prognostic factors in high-grade serous EOC from optimally debulked patients.

Age-related Epstein-Barr virus (EBV)-associated B-cell lymphoproliferative disorders: comparison with EBV-positive classic Hodgkin lymphoma in elderly patients

Age-related Epstein-Barr virus-associated B-cell lymphoproliferative disorder (aEBVLPD) is a disease group characterized by EBV-associated large B-cell lymphoma in elderly without predisposing immunodeficiency. In nearly one- third of cases, aEBVLPD occurs as a polymorphous subtype with reactive cell-rich components, bearing a morphologic similarity to classic Hodgkin lymphoma (cHL). The aim of this study was to clarify clinicopathologic differences between the polymorphic subtype of aEBVLPD (n = 34) and EBV(+) cHL (n = 108) in patients aged 50 years or older. Results showed that aEBVLPD was more closely associated with aggressive clinical parameters than cHL, with a higher age at onset (71 vs 63 years); lower male predominance (male-female ratio, 1.4 vs 3.3); and a higher rate of involvement of the skin (18% vs 2%), gastrointestinal tract (15% vs 4%), and lung (12% vs 2%). aEBVLPD was histopathologically characterized by a higher ratio of geographic necrosis, greater increase (> 30%) in cytotoxic T cells among background lymphocytes, higher positivity for CD20 and EBNA2, and absence of CD15 expression. As predicted by the clinical profile, aEBVLPD had a significantly poorer prognosis than EBV(+) cHL (P < .001). The polymorphous subtype of aEBVLPD constitutes an aggressive group with an immune response distinct from EBV(+) cHL, and requires the development of innovative therapeutic strategies.

Biologic features of Hodgkin lymphoma and the development of biologic prognostic factors in Hodgkin lymphoma: tumor and microenvironment

Classical Hodgkin lymphoma is now recognised as a B-cell lymphoma. Improved therapy has increased cure rates dramatically; however, relapse and death still occurs in a minority of patients. Much has been learned about the biology of Hodgkin and Reed Sternberg cells and their interactions with the microenvironment, which has informed studies exploring biologic markers that may improve upon clinical prognostic models. This manuscript reviews recent advances in our understanding of the pathobiology of cHL with an emphasis on biologic prognostic markers.

A clinicopathological study of nm23-H1 expression in classical Hodgkin's lymphoma

BACKGROUND

We carried out immunohistochemistry to examine the expression of nm23-H1 in Hodgkin and Reed-Sternberg cells in patients with classical Hodgkin's lymphoma (CHL).

PATIENTS AND METHODS

We evaluated 128 patients with CHL [87 patients with nodular sclerosis (NS) and 41 patients with mixed cellularity (MC)] for CD15, CD20, Ki-67, EBER, TIA-1, and nm23-H1 by immunohistochemistry.

RESULTS

CD15 was expressed in 79%, CD20 in 11%, Ki-67 in 93%, EBER in 34%, TIA-1 in 11%, and nm23-H1 in 60% of the CHL patients. NS patients showed a significantly higher rate of nm23-H1 expression than MC patients (P < 0.001). The serum nm23-H1 level was significantly higher in patients with positive nm23 expression. Univariate analysis showed that stage IV, poor performance status, low hemoglobin level, low serum albumin level, age of 45 years or older, TIA-1-positive status, and nm23-H1-positive status were associated with significantly shorter progression-free survival. Multivariate analysis with these factors showed TIA-1 and cytoplasmic nm23-H1 expression to be significant and independent prognostic factors.

CONCLUSIONS

Our results indicate that nm23-H1 expression is a prognostic factor for CHL and that it is as important as serum nm23-H1, both of which are useful for planning the treatment strategy.

Age-related Epstein-Barr virus-associated B-cell lymphoproliferative disorders: special references to lymphomas surrounding this newly recognized clinicopathologic disease

Epstein-Barr virus (EBV) is associated with some disease entities of malignant lymphomas, including Burkitt lymphoma, Hodgkin lymphoma, immunodeficiency-associated lymphoproliferative disorders (LPD), and a part of diffuse large B-cell lymphoma. We have recently identified a series of elderly patients with EBV-associated (or EBV(+)) B-cell LPD (B-LPD) showing similarities in many respects to immunodeficiency-associated LPD, although no evidence of underlying immunodeficiency was found. Therefore, the nosological category of senile or age-related EBV(+) B-LPD has been proposed for those patients. A larger series of patients with this disease revealed that the relative ratios of such EBV(+) B-LPD to all diffuse large B-cell lymphoma cases were higher with increasing with age, reaching a peak (20-30%) at > or =90 years of age, with a median of 71 years, providing additional evidence for our assertion that this disease may be related to immunological deterioration as a result of the aging process. This new disease entity is characterized pathologically by centroblasts, immunoblasts, and Hodgkin and Reed-Sternberg-like giant cells with a varying degree of reactive components, often posing therapeutic and diagnostic problems for hematologists and pathologists, respectively. The aim of the present review is to briefly summarize the overall clinicopathological profile of this newly recognized age-related (also called 'senile') EBV(+) B-LPD and EBV(+) Hodgkin lymphoma for a practical diagnostic approach.

World Health Organization and beyond: new aspects in the pathology of an old disease

Hodgkin's lymphoma is a highly enigmatic lymphoma disease that still covers most of its secrets up to now. Much effort has been made to successfully wrest at least some of the pathogenetic particularities. The current diagnostic criteria are well established allowing hemato-pathologists to make a clear-cut distinction from other lymphomas in almost all cases. Although classic Hodgkin's lymphoma is curable in the vast majority of cases by treatment with highly aggressive drugs with or without radiotherapy, further molecular studies may lead to the identification of therapeutic targets that enable a more tailored treatment with fewer side effects.

The number of tumour-infiltrating TIA-1+ cytotoxic T cells but not FOXP3+ regulatory T cells predicts outcome in diffuse large B-cell lymphoma

The prognostic significance of tumour-infiltrating lymphocytes (TILs) in patients with diffuse large B-cell lymphoma (DLBCL) remains controversial. Furthermore, the possible impact of regulatory T cells (T(regs)) on survival in DLBCL is still unknown. We performed a retrospective study on the immunohistochemical expression of cytotoxic cells and T(regs), and their correlation with survival in 195 DLBCL patients. Patients with a small number of cytotoxic T-cell intracytoplasmic antigen-1 (TIA-1)+ T cells (< or =260 cells/mm(2) tumour area; n = 52) had significantly better outcome than patients with a large number (>260 cells/mm(2); n = 143); progression-free survival (PFS) at 5 years was 67% vs. 50% (P = 0.03) and overall survival (OS) was 73% vs. 57% (P = 0.03). In multivariate analysis, the low TIA-1+ group still had a better PFS (relative risk 0.75, 95% confidence interval 0.31-0.99; P = 0.05). The number of forkhead box protein 3 (FOXP3)+ T(regs) had no influence on PFS (P = 0.89) or OS (P = 0.75). These results suggest that immunohistochemical analysis of cytotoxic T cells at time of diagnosis could provide additional prognostic information. The lack of correlation between the number of FOXP3+ cells and survival could possibly indicate that tumour-infiltrating T(regs) are of less clinical importance in DLBCL. However, these findings need to be explored in functional studies.