BCL-2/JH translocation in peripheral blood lymphocytes of unexposed individuals: lack of seasonal variations in frequency and molecular features

Mutational patterns and their correlation to CHIP-related mutations and age in hematological malignancies

Comparison of the mutation frequencies and numbers of 122 genes in 3096 cases enables identification of “mutation-driven” entities.

Differences in mutation patterns in cases with or without CHIP-associated mutations across entities suggest differences in pathophysiology.

Acquired somatic mutations are crucial for the development of most cancers. We performed a comprehensive comparative analysis of the mutational landscapes and their correlation with CHIP-related (clonal hematopoiesis of indeterminate potential) mutations and patient age of 122 genes in 3096 cases of 28 different hematological malignancies. Differences were observed regarding (1) the median number of mutations (highest, median n = 4; lowest, n = 0); (2) specificity of certain mutations (high frequencies in atypical chronic myeloid leukemia [aCML; ASXL1, 86%], follicular lymphoma [FL; KMT2D, 87%; CREBBP, 73%], hairy cell lymphoma [BRAF, 100%], lymphoplasmacytic lymphoma [MYD88, 98%; CXCR4, 51%], myeloproliferative neoplasm [MPN; AK2, 68%]); (3) distribution of mutations (broad distribution within/across the myeloid/lymphoid lineage for TET2, ASXL1, DNMT3A, TP53, BCOR, and ETV6); (4) correlation of mutations with patient’s age (correlated with older age across entities: TET2, DNMT3A, ASXL1, TP53, EZH2, BCOR, GATA2, and IDH2; younger age: KIT, POT1, RAD21, U2AF2, and WT1); (5) correlation of mutation number per patient with age. Moreover, we observed high frequencies of mutations in RUNX1, SRSF2, IDH2, NRAS, and EZH2 in cases comprising at least 1 DTA (DNMT3A, TET2, ASXL1) mutation, whereas in cases without DTA mutations, TP53, KRAS, WT1, and SF3B1 were more frequent across entities, suggesting differences in pathophysiology. These results give further insight into the complex genetic landscape and the role of DTA mutations in hematological neoplasms and define mutation-driven entities (myelodysplastic syndrome/MPN overlap; secondary acute myeloid) in comparison with entities defined by chromosomal fusions (chronic myeloid leukemia; myeloid/lymphoid neoplasm with eosinophilia).

Novel Therapy Approaches to Follicular Lymphoma

Follicular lymphoma (FL) is the most common form of indolent non-Hodgkin lymphoma. It is a disease characterised by a long median overall survival and high response rates to currently available chemotherapy and anti-CD20 monoclonal antibody therapy combinations. However, for a sub-group of patients the disease behaves aggressively, fails to respond adequately to initial therapy or relapses early. For others, the disease becomes resistant following multiple lines of therapy, and despite recent advances the main cause of death for patients with FL remains their lymphoma. A wide landscape of novel therapies is emerging and the role of individual agents in the FL treatment paradigm is still being established. Some agents, including the cereblon modulator lenalidomide, the phosphatidylinositol 3-kinase inhibitors idelalisib, copanlisib and duvelisib, and the EZH2 inhibitor tazemetostat have received regulatory approval in the USA or European Union and have entered clinical practice for relapsed FL. Other developments, such as the emergence of immunotherapies including CAR-T cell therapy and bispecific antibodies, are expected to fundamentally change the approach to FL treatment in the future.

Follicular lymphoma

Follicular lymphoma (FL) is a systemic neoplasm of the lymphoid tissue displaying germinal centre (GC) B cell differentiation. FL represents ~5% of all haematological neoplasms and ~20-25% of all new non-Hodgkin lymphoma diagnoses in western countries. Tumorigenesis starts in precursor B cells and becomes full-blown tumour when the cells reach the GC maturation step. FL is preceded by an asymptomatic preclinical phase in which premalignant B cells carrying a t(14;18) chromosomal translocation accumulate additional genetic alterations, although not all of these cells progress to the tumour phase. FL is an indolent lymphoma with largely favourable outcomes, although a fraction of patients is at risk of disease progression and adverse outcomes. Outcomes for FL in the rituximab era are encouraging, with ~80% of patients having an overall survival of >10 years. Patients with relapsed FL have a wide range of treatment options, including several chemoimmunotherapy regimens, phosphoinositide 3-kinase inhibitors, and lenalidomide plus rituximab. Promising new treatment approaches include epigenetic therapeutics and immune approaches such as chimeric antigen receptor T cell therapy. The identification of patients at high risk who require alternative therapies to the current standard of care is a growing need that will help direct clinical trial research. This Primer discusses the epidemiology of FL, its molecular and cellular pathogenesis and its diagnosis, classification and treatment.

Follicular lymphoma-like B cells of uncertain significance (in situ follicular lymphoma) may infrequently progress, but precedes follicular lymphoma, is associated with other overt lymphomas and mimics follicular lymphoma in flow cytometric studies

In situ follicular lymphoma, more recently known as follicular lymphoma-like B cells of uncertain/undetermined significance is well accepted. However, the morphological criteria have evolved since it was first described and data are limited and conflicting regarding its clinical implications and whether the extent of involvement predicts an association with overt lymphoma. It is also unknown how often it will be identified by flow cytometric studies and how often it precedes overt follicular lymphomas. A multiparameter study of 31 biopsies with follicular lymphoma-like B cells of uncertain significance and 4 'benign' lymph node biopsies that preceded an overt follicular lymphoma was, therefore, performed. Fifty-two percent of biopsies with follicular lymphoma-like B cells were associated with a prior or concurrent lymphoma but only 6% subsequently developed lymphoma (median follow up 26 months). Neither the number, proportion or density of BCL2(+) germinal centers were associated with overt follicular lymphoma/diffuse large B-cell lymphoma. Flow cytometric studies identified follicular lymphoma-like B cells in 8 of 15 evaluable cases. The proportion but not the absolute number of BCL2(+) germinal centers was associated with the likelihood of positive flow cytometric studies (P<0.01). All 4 'benign' biopsies that preceded an overt follicular lymphoma demonstrated follicular lymphoma-like B cells. Thus, although few patients with follicular lymphoma-like B cells of uncertain significance progress within the follow-up period, it at least precedes many follicular lymphomas. The extent of involvement does not predict the occurrence of prior or concurrent lymphomas. Flow cytometric studies demonstrating follicular lymphoma-like B cells must not be over-interpreted as they may only reflect follicular lymphoma-like B cells.

Malignant or benign leukocytosis

Leukocytosis, or elevated WBC count, is a commonly encountered laboratory finding. Distinguishing malignant from benign leukocytosis is a critical step in the care of a patient, which initiates a vastly different decision tree. Confirmation of the complete blood cell count and the WBC differential is the first step. Examination of the PB smear is essential to confirming the automated blood cell differential or affirming the manual differential performed on the PB smear. Next is separation of the leukocytosis into a myeloid versus a lymphoid process. Distinguishing a reactive lymphoid proliferation from a lymphoproliferative disorder requires examination of lymphocyte morphology for pleomorphic lymphocytes versus a monomorphic population, with the latter favoring a lymphoproliferative neoplasm. Samples suspicious for lymphoproliferative disorders can be confirmed and characterized by flow cytometry, with molecular studies initiated in select cases; precursor lymphoid neoplasms (lymphoblasts) should trigger a BM examination. Myeloid leukocytosis triggers a differential diagnosis of myeloid leukemoid reactions versus myeloid malignancies. The manual differential is key, along with correct enumeration of blasts and blast equivalents, immature granulocytes, basophils, and eosinophils and identifying dysplasia to identify myeloid malignancies. Confirmation and characterization of myeloid malignancies should be performed with a BM examination and the appropriate ancillary studies. Myeloid leukemoid reactions commonly result from infections and show activated neutrophil changes on morphology; these should prompt evaluation for infection. Other causes of reactive myeloid leukocytoses are also discussed herein.

Early steps of follicular lymphoma pathogenesis

Follicular lymphoma (FL) pathogenesis is a complex and fascinating multi-hit process, escalating along successive derailments of the distinctive molecular and cellular mechanisms paving B-cell differentiation and activation. This progressive subversion of B-cell receptor diversification mechanisms and B-cell homeostasis likely occurs during a protracted preclinical phase of asymptomatic growth, in which premalignant clones already disseminate and establish "niches" in secondary lymphoid organs. Following FL diagnosis, a parallel indolent behavior is observed in most patients, slowly progressing over a period of many years, to eventually generate a highly refractory (and in some case transform into an aggressive subtype of) lymphoma. Novel insights in human germinal center B-cell biology recently allowed a more comprehensive understanding of the various illegitimate events sequentially involved in the premalignant progression phases. In this review, we will discuss how these new data have modified our perception of early FL pathogenesis, the new questions and challenges it opened up, and how this knowledge could impact on innovative programs of early detection, follow-up, and patient management.

Agricultural pesticide exposure and the molecular connection to lymphomagenesis

The t(14;18) translocation constitutes the initiating event of a causative cascade leading to follicular lymphoma (FL). t(14;18) translocations are present in blood from healthy individuals, but there is a trend of increased prevalence in farmers exposed to pesticides, a group recently associated with higher risk of t(14;18)⁺ non-Hodgkin's lymphoma development. A direct connection between agricultural pesticide use, t(14;18) in blood, and malignant progression, however, has not yet been demonstrated. We followed t(14;18) clonal evolution over 9 yr in a cohort of farmers exposed to pesticides. We show that exposed individuals bear particularly high t(14;18) frequencies in blood because of a dramatic clonal expansion of activated t(14;18)⁺ B cells. We further demonstrate that such t(14;18)⁺ clones recapitulate the hallmark features of developmentally blocked FL cells, with some displaying aberrant activation-induced cytidine deaminase activity linked to malignant progression. Collectively, our data establish that expanded t(14;18)⁺ clones constitute bona fide precursors at various stages of FL development, and provide a molecular connection between agricultural pesticide exposure, t(14;18) frequency in blood, and clonal progression.

Pathophysiological aspects of memory B-cell development

B cells follow two functionally distinct pathways of development: a classical germinal center (GC) T-dependent pathway in which diversification and maturation generate a slow, but virtually unlimited high-affinity response to cognate antigens; and a marginal zone (MZ) T-independent pathway providing a first line of 'innate-like' defense against specific pathogens. Cells populating these two distinct locations are the normal counterparts of two clinically important pathological entities, follicular lymphoma (FL) and MZ lymphoma (MZL). FL and MZ represent paradigms of two rising concepts of lymphomagenesis, protracted preclinical and antigen-driven lymphoproliferation, respectively. Integrating the mechanisms and functions of MZ and GC B cells and the distinctive features of their pathological counterparts should provide essential clues to the understanding of their malignant development, and should offer new insights into the design of effective treatments for B-cell lymphomas.

Follicular lymphoma-like B cells in healthy individuals: a novel intermediate step in early lymphomagenesis

Follicular lymphoma is one of the most common adult lymphoma, and remains virtually incurable despite its relatively indolent nature. t(14;18)(q32;q21) translocation, the genetic hallmark and early initiating event of follicular lymphoma (FL) pathogenesis, is also present at low frequency in the peripheral blood of healthy individuals. It has long been assumed that in healthy individuals t(14;18) is carried by circulating quiescent naive B cells, where its oncogenic potential would be restrained. Here, we question this current view and demonstrate that in healthy individuals, t(14;18) is actually carried by an expanding population of atypical B cells issued from germinal centers, displaying genotypic and phenotypic features of FL, and prone to constitute potent premalignant FL niches. These findings strongly impact both on the current understanding of disease progression and on the proper handling of t(14;18) frequency in blood as a potential early biomarker for lymphoma.

Characterization of the t(14;18) BCL2-IGH Translocation in Farmers Occupationally Exposed to Pesticides

Increasing incidence of non-Hodgkin's lymphoma have been associated repeatedly with farming occupation and particular attention focused on the role of pesticide exposure to potentially explain part of this trend. A genetic hallmark of non-Hodgkin's lymphoma is the presence of recurrent chromosomal translocations involving the immunoglobulin heavy chain gene. Of these, the t(14;18), which deregulates BCL2 expression and inhibits apoptosis, is the most frequent in follicular lymphoma and has been detected consistently in peripheral blood lymphocytes of healthy individuals. As BCL2-IGH translocation represents an early step of the malignant process, we evaluated the occurrence and molecular characteristics of BCL2-IGH translocation in 56 individuals occupationally exposed to pesticides in open field farming They were selected from a representative cohort of farmers with a well-defined assessment of pesticide exposure taking into account potential confounding factors, smoking, sunlight, and age. Our results suggest that occupational exposure to pesticides would increase BCL2-IGH prevalence together with the frequency of BCL2-IGH-bearing cells especially during the high pesticide use period. Distribution of BCL2 or IGH breakpoint positions seemed to be independent of pesticide exposure and was similar to those found in other healthy populations or lymphoma patients. Finally, these results provide additional evidence that BCL2-IGH translocation measurements could be a measure of acquired genetic instability in relation to genotoxic exposure in a gene directly relevant in term of lymphomagenesis.