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Gullickson C, Kersun L, Reilly A, Seif A, Chehab L. Isolated central nervous system relapse in two adolescents with primary mediastinal large B-cell lymphoma after treatment with R-DA-EPOCH. Pediatr Blood Cancer 2024; 71:e31065. [PMID: 38721853 DOI: 10.1002/pbc.31065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/27/2024] [Indexed: 06/27/2024]
Abstract
The addition of rituximab to standard regimens for primary mediastinal large B-cell lymphoma (PMBCL) has significantly improved overall survival. However, the optimal management of isolated central nervous system (CNS) relapse and role of CNS prophylaxis remains undefined. We present cases of two adolescents with PMBCL who developed isolated CNS relapses. While isolated CNS relapse may be managed with high-dose chemotherapy and autologous stem cell transplant with or without CNS radiotherapy, review of these cases and the literature highlight the need for further work to define risk factors for CNS relapse, and identify patients who may benefit from CNS prophylaxis.
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Affiliation(s)
- Cricket Gullickson
- Department of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie Kersun
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anne Reilly
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alix Seif
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leena Chehab
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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2
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Singh A, Obiorah IE. Aggressive non-Hodgkin lymphoma in the pediatric and young adult population; diagnostic and molecular pearls of wisdom. Semin Diagn Pathol 2023; 40:392-400. [PMID: 37400280 DOI: 10.1053/j.semdp.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023]
Abstract
Mature non-Hodgkin lymphomas (NHLs) of the pediatric and young adults(PYA), including Burkitt lymphoma (BL), diffuse large B cell lymphoma (DLBCL), high-grade B cell lymphoma (HGBCL), primary mediastinal large B cell lymphoma (PMBL) and anaplastic large cell lymphoma (ALCL), generally have excellent prognosis compared to the adult population. BL, DLBCL and HGBCL are usually of germinal center (GCB) origin in the PYA population. PMBL neither belongs to the GCB nor the activated B cell subtype and is associated with a poorer outcome than BL or DLBCL of comparable stage. Anaplastic large cell lymphoma is the most frequent peripheral T cell lymphoma occurring in the PYA and accounts for 10-15% of childhood NHL. Most pediatric ALCL, unlike in the adult, demonstrate expression of anaplastic lymphoma kinase (ALK). In recent years, the understanding of the biology and molecular features of these aggressive lymphomas has increased tremendously. This has led to reclassification of newer PYA entities including Burkitt-like lymphoma with 11q aberration. In this review, we will discuss the current progress discovered in frequently encountered aggressive NHLs in the PYA, highlighting the clinical, pathologic and molecular features that aid in the diagnosis of these aggressive lymphomas. We will be updating the new concepts and terminologies used in the new classification systems.
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Affiliation(s)
- Amrit Singh
- Department of Pathology , University of Virginia Health, Charlottesville, VA, 22903, United States
| | - Ifeyinwa E Obiorah
- Department of Pathology , University of Virginia Health, Charlottesville, VA, 22903, United States.
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3
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Halahleh K, Yaseen A, Muradi I, Al-Ibraheem A, Sultan I, Ma’koseh M. Outcome of Primary Mediastinal Large B Cell Lymphoma Treated with RCHOP. J Blood Med 2023; 14:147-157. [PMID: 36846350 PMCID: PMC9952517 DOI: 10.2147/jbm.s393180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/12/2023] [Indexed: 02/22/2023] Open
Abstract
Purpose Primary mediastinal large B-cell Lymphoma (PMLBCL) is a rare aggressive lymphoma with unique clinical, pathological, and molecular features. The optimal frontline therapy is subject of ongoing debate. Our study aims to evaluate the outcomes of PMLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) at King Hussein Cancer Center. Patients and Methods Adult patients >18 years of age with PMLBCL treated with RCHOP from January 2011 to July 2020 were identified. All demographics, disease and treatment related variables were retrospectively collected. Correlations of clinical and laboratory variables with progression-free survival (PFS) and overall survival (OS) were determined by univariate and multivariate analyses using backward stepwise Cox regression models. The PFS and OS were plotted using Kaplan‒Meier curves. Results 49 patients were included with a median age of 29 years. 14 (28.6%) had stage III or IV, 31 (63.3%) had mediastinal bulky disease. International prognostic index (IPI) was 0-1 in 35 (71.4%). Radiotherapy was given to 32 (65.3%) patients. End of treatment (EOT) response was complete (CR) in 32 (65.3%), partial response (PR) in 8 (16.3%) and progressive disease (PD) in 9 (18.4%). Patients who achieved CR at EOT, compared favorably with those who did not in regard to 4-year OS (92.5% vs 26.9%, p=<0.001). Overall objective response to salvage chemotherapies was 26.7%. At a median follow-up of 46 months, 4-year PFS and OS were 60% and 71% respectively. In multivariate analysis, IPI > one correlated with the EOT response (p=0.009), PFS (p=0.004) and OS (p= 0.019). Conclusion In PMLBCL, RCHOP chemotherapy backbone in the frontline therapy is suboptimal but can be used in patients with low IPI. Adapting more intensive chemoimmunotherapy regimens may be considered for patients with high IPI. Salvage chemotherapy has limited activity in patients with relapsed or refractory disease.
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Affiliation(s)
- Khalid Halahleh
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Abeer Yaseen
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Isra Muradi
- Department of Medicine, University of Tripoli, Tripoli, Libya
| | - Akram Al-Ibraheem
- Department of Nuclear Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Iyad Sultan
- Department of Pediatric Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad Ma’koseh
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan,Correspondence: Mohammad Ma’koseh, Department of Internal Medicine, King Hussein Cancer Center, Queen Rania Al Abdullah Street, P.O. Box 1269, Amman, 11941, Jordan, Tel +962-6 5300460, Ext 1146, Email
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4
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A Pregnancy Case of Primary Mediastinal Large B Cell Lymphoma with Superior Vena Cava Syndrome. Case Rep Obstet Gynecol 2022; 2021:3438230. [PMID: 34976421 PMCID: PMC8716195 DOI: 10.1155/2021/3438230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022] Open
Abstract
Primary mediastinal large B cell lymphoma (PMLBCL) is a subtype of non-Hodgkin's lymphoma which presents rarely in pregnancy. It is an aggressive tumour that is associated with symptoms of superior vena cava (SVC) compression and airway compromise such as dyspnoea, facial and arm swelling, cough, or chest pain. Timely diagnosis is imperative to optimising patient outcomes and reducing both maternal and fetal morbidity and mortality. We report a case of a 33-year-old woman diagnosed with PMLBCL who presented at 33-week gestation with SVC obstruction to 1 mm in diameter. After multidisciplinary team discussion regarding maternal and fetal implications of management options, we proceeded to a caesarean section and initiated chemotherapy postdelivery. Lower segment caesarean section was uncomplicated, and she underwent a cycle of R-CHOEP followed by 5 cycles of DA-EPOCH. Eighteen months since the completion of the chemotherapy, the disease remained in remission.
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5
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Outcomes after first-line immunochemotherapy for primary mediastinal B-cell lymphoma: a LYSA study. Blood Adv 2021; 5:3862-3872. [PMID: 34461634 DOI: 10.1182/bloodadvances.2021004778] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/04/2021] [Indexed: 11/20/2022] Open
Abstract
Primary mediastinal B-cell lymphoma (PMBL) is a rare type of aggressive lymphoma typically affecting young female patients. The first-line standard of care remains debated. We performed a large multicenter retrospective study in 25 centers in France and Belgium to describe PMBL patient outcomes after first-line treatment in real-life settings. A total of 313 patients were enrolled and received rituximab (R) plus ACVBP (doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone) (n = 180) or CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) delivered every 14 days (R-CHOP14, n = 76) or 21 days (R-CHOP21, n = 57) and consolidation strategies in modalities that varied according to time and institution, mainly guided by positron emission tomography. Consolidation autologous stem cell transplantation was performed for 46 (25.6%), 24 (31.6%), and 1 (1.8%) patient in the R-ACVBP, R-CHOP14, and R-CHOP21 groups, respectively (P < .001); only 17 (5.4%) patients received mediastinal radiotherapy. The end-of-treatment complete metabolic response rates were 86.3%, 86.8%, and 76.6% (P = .23) in the R-ACVBP, R-CHOP14, and R-CHOP21 groups. The median follow-up was 44 months, and the R-ACVBP, R-CHOP14, and R-CHOP21 three-year progression-free survival probabilities were 89.4% (95% confidence interval [CI], 84.8-94.2), 89.4% (95% CI, 82.7-96.6), and 74.7% (95% CI, 64-87.1) (P = .018). A baseline total metabolic tumor volume (TMTV) ≥360 cm3 was associated with a lower progression-free survival (hazard ratio, 2.18; 95% CI, 1.05-4.53). Excess febrile neutropenia (24.4% vs 5.3% vs 5.3%; P < .001) and mucositis (22.8% vs 3.9% vs 1.8%; P < .001) were observed with R-ACVBP compared with the R-CHOP regimens. Patients with PMBL treated with dose-dense immunochemotherapy without radiotherapy have excellent outcomes. R-ACVBP acute toxicity was higher than that of R-CHOP14. Our data confirmed the prognostic importance of baseline TMTV.
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Ondrejka SL, Ott G. How I Diagnose Primary Mediastinal (Thymic) Large B-Cell Lymphoma. Am J Clin Pathol 2021; 156:497-512. [PMID: 34398178 DOI: 10.1093/ajcp/aqab122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/28/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Primary mediastinal (thymic) large B-cell lymphoma (PMBL) is an uncommon large B-cell neoplasm recognized by the World Health Organization as a distinct entity on the basis of its unique clinical features, histogenesis, phenotype, and pathogenetic mechanisms. The diagnosis of PMBL can be challenging because of features that may overlap with other (Hodgkin and non-Hodgkin) lymphoma types. This review describes our approach to the diagnosis of PMBL. METHODS Two cases are presented to illustrate how we diagnose PMBL and separate PMBL from related histologic and biological mimickers, such as Hodgkin lymphoma and gray zone lymphoma. RESULTS A diagnosis of PMBL requires correlation of morphology and immunophenotype with clinical and staging data. Gene expression analysis is not typically performed in clinical labs but has expanded our understanding of the functional pathways underlying this disease and helped identify biomarkers that can be translated to diagnostic practice and possibly to future therapeutic options. CONCLUSIONS PMBL and closely related entities can pose diagnostic challenges. It is important to understand the borders between PMBL and other closely related lymphoma types so that patients receive successful primary treatment with curative intent.
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Affiliation(s)
- Sarah L Ondrejka
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - German Ott
- Department of Clinical Pathology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
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7
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Ahmed Z, Afridi SS, Shahid Z, Zamani Z, Rehman S, Aiman W, Khan M, Mir MA, Awan FT, Anwer F, Iftikhar R. Primary Mediastinal B-Cell Lymphoma: A 2021 Update on Genetics, Diagnosis, and Novel Therapeutics. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e865-e875. [PMID: 34330673 DOI: 10.1016/j.clml.2021.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/08/2021] [Accepted: 06/19/2021] [Indexed: 12/21/2022]
Abstract
Primary mediastinal large B-cell lymphoma (PMBCL) is an aggressive B-cell lymphoma arising from thymic B-cells having clinicopathologic features distinct from systemic diffuse large B-cell lymphoma (DLBCL). PMBCL comprises 2% to 4% of all non-Hodgkin lymphomas (NHL), 7% of DLBCL and seen predominantly in young females with a median age of 35 years at diagnosis. The annual incidence of PMBCL is 0.4 per million with a 5-year survival rate exceeding 70% with improving supportive care and genetic characterization of the disease. Pathogenesis involves dysregulation of Janus kinase-signal transducer and activator of transcription (JAK-STAT), nuclear factor-kB (NF-kB) pathways and amplification of the 9p24.1 region of chromosome 9. PMBCL patients have a prolonged life expectancy necessitating the need for treatment approaches that are based on maximizing cure with minimal long-term toxicity. Due to rarity and its recognition as a distinct entity, therapeutic decisions are guided by clinical presentation, clinician and center experience, and analysis of patients with PMBCL within DLBCL registries. Historically R-CHOP has been the usual first line treatment for PMBCL followed by involved site radiotherapy (ISRT), however clinical practice varies across centers with emerging consensus to avoid upfront RT by utilizing dose intense regimens (DA-EPOCH-R) in younger and fit patients. Prognosis of relapsed refractory PMBCL not responding to salvage chemotherapy is dismal, however there are many emerging options including Brentuximab Vedotin, immune check point inhibitors and chimeric antigen receptor T-cell therapy. In this article, we focus on the pathogenesis, current and evolving treatments, and provide recommendations for optimal management of patients with PMBCL.
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Affiliation(s)
- Zahoor Ahmed
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Safa Saadat Afridi
- Department of Internal Medicine, Khyber Medical College Peshawar, Peshawar, Pakistan
| | | | - Zarlakhta Zamani
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Sana Rehman
- Shaikh Khalifa Bin Zayyed al Nahyan Medical and Dental College, Lahore, Pakistan
| | - Wajeeha Aiman
- Department of Internal Medicine, Nishtar Medical College, Multan, Pakistan
| | - Maryam Khan
- Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan
| | | | - Farrukh T Awan
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Faiz Anwer
- Hematology, Oncology, Stem Cell Transplantation, Multiple Myeloma Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Raheel Iftikhar
- Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan.
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8
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Takyar J, Raut M, Borse R, Balakumaran A, Sehgal M. Relapsed/refractory primary mediastinal large B-cell lymphoma: a structured review of epidemiology, treatment guidelines and real-world treatment practices. Expert Rev Hematol 2020; 13:275-287. [DOI: 10.1080/17474086.2020.1716725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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9
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Malenda A, Kołkowska‐Leśniak A, Puła B, Długosz‐Danecka M, Chełstowska M, Końska A, Giza A, Lech‐Marańda E, Jurczak W, Warzocha K. Outcomes of treatment with dose‐adjusted EPOCH‐R or R‐CHOP in primary mediastinal large B‐cell lymphoma. Eur J Haematol 2019; 104:59-66. [DOI: 10.1111/ejh.13337] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/21/2019] [Accepted: 10/01/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Agata Malenda
- Department of Hematology Institute of Hematology and Transfusion Medicine Warsaw Poland
| | | | - Bartosz Puła
- Department of Hematology Institute of Hematology and Transfusion Medicine Warsaw Poland
| | | | - Monika Chełstowska
- Department of Hematology Institute of Hematology and Transfusion Medicine Warsaw Poland
| | - Agnieszka Końska
- Department of Hematology Institute of Hematology and Transfusion Medicine Warsaw Poland
| | - Agnieszka Giza
- Department of Hematology Jagiellonian University Cracow Poland
| | - Ewa Lech‐Marańda
- Department of Hematology Institute of Hematology and Transfusion Medicine Warsaw Poland
- Department of Hematology and Transfusion Medicine Centre of Postgraduate Medicine Warsaw Poland
| | | | - Krzysztof Warzocha
- Department of Hematology Institute of Hematology and Transfusion Medicine Warsaw Poland
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10
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Alhejazi A, Motabi I, Sagheir A, Alzahrani M, Dada R, Al-Mansour M, Alhashmi H, Kandil M. Primary Mediastinal Large B-Cell Lymphoma: Saudi Lymphoma Group's Clinical Practice Guidelines for Diagnosis, Management and Follow-up. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 7:231-233. [PMID: 31543751 PMCID: PMC6734725 DOI: 10.4103/sjmms.sjmms_106_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/12/2019] [Accepted: 07/23/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Ayman Alhejazi
- Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs-Central Region, Riyadh, Saudi Arabia
| | - Ibraheem Motabi
- Department of Adult Hematology and BMT, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmed Sagheir
- Oncology Institute, John Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Musa Alzahrani
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reyad Dada
- Department of Oncology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mubarak Al-Mansour
- Department of Oncology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Hani Alhashmi
- Adult Hematology and Stem Cell Transplantation Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Magdy Kandil
- Medical Oncology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.,Clinical Oncology Department, Cairo University, Giza, Egypt
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11
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Baseline PET features to predict prognosis in primary mediastinal B cell lymphoma: a comparative analysis of different methods for measuring baseline metabolic tumour volume. Eur J Nucl Med Mol Imaging 2019; 46:1334-1344. [DOI: 10.1007/s00259-019-04286-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/06/2019] [Indexed: 12/28/2022]
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12
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Cwynarski K, Marzolini MAV, Barrington SF, Follows G, Illidge T, Stern S, Davies A. The management of primary mediastinal B‐cell lymphoma: a British Society for Haematology Good Practice Paper. Br J Haematol 2019; 185:402-409. [DOI: 10.1111/bjh.15731] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Kate Cwynarski
- Department of Haematology University College London Hospitals NHS Foundation TrustLondonUK
| | - Maria A. V. Marzolini
- Department of Haematology University College London Hospitals NHS Foundation TrustLondonUK
| | - Sally F. Barrington
- King's College London and Guy's and St Thomas’ PET Centre School of Biomedical Engineering and Imaging Sciences King's College London King's Health Partners LondonUK
| | - George Follows
- Department of Haematology Addenbrooke's Hospital CambridgeUK
| | - Timothy Illidge
- Department of Clinical Oncology Christie Hospital ManchesterUK
| | - Simon Stern
- Department of Haematology St Helier Hospital CarshaltonUK
| | - Andrew Davies
- Department of Medical Oncology Southampton General Hospital Southampton UK
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13
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Buchholtz ML, Bücklein V, Brendel M, Paal M. Superior vena cava syndrome related to mediastinal lymphoma in late pregnancy: A case report. Case Rep Womens Health 2018; 19:e00065. [PMID: 30094193 PMCID: PMC6071368 DOI: 10.1016/j.crwh.2018.e00065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/18/2018] [Accepted: 05/23/2018] [Indexed: 11/26/2022] Open
Abstract
We report the initial diagnosis in a 28-year-old nulliparous woman of a primary mediastinal B-cell lymphoma in late pregnancy. For several weeks the patient had had symptoms of mediastinal obstruction, such as dyspnea, cough, swelling of the face and upper limbs. However, these symptoms had been misattributed to the pregnancy and a common cold. Due to a rapid decline in the patient's cardiovascular performance, she was transferred to the closest perinatal center in the 34th week of pregnancy, whereupon a cesarean section was performed. The diagnosis of a primary mediastinal B-cell lymphoma was made postpartum from a biopsy. This case emphasizes the importance of timely antenatal investigation in pregnant women with symptoms consistent with mediastinal obstruction. Thoracic ultrasonography can be a valuable tool for the detection of tumor-associated pleural and pericardial effusions. The incidence of primary mediastinal B-cell lymphoma (PMBCL) is disproportionately high in women of reproductive age. The diagnosis is made at a median age of 35 years. Physiological changes during pregnancy can mask mediastinal malignancies since both conditions share similar clinical signs. Symptoms of mediastinal obstruction during pregnancy should therefore lead to immediate diagnostic workup. Thoracic ultrasound examination can aid in the diagnosis of lymphoma-associated pleural and pericardial effusions.
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Affiliation(s)
- M L Buchholtz
- Institute of Laboratory Medicine, University Hospital, LMU, Munich, Germany
| | - V Bücklein
- Department of Internal Medicine III, University Hospital, LMU, Munich, Germany
| | - M Brendel
- Department of Nuclear Medicine, University Hospital, LMU, Munich, Germany
| | - M Paal
- Institute of Laboratory Medicine, University Hospital, LMU, Munich, Germany
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14
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Ceriani L, Milan L, Martelli M, Ferreri AJM, Cascione L, Zinzani PL, Di Rocco A, Conconi A, Stathis A, Cavalli F, Bellei M, Cozens K, Porro E, Giovanella L, Johnson PW, Zucca E. Metabolic heterogeneity on baseline 18FDG-PET/CT scan is a predictor of outcome in primary mediastinal B-cell lymphoma. Blood 2018; 132:179-186. [PMID: 29720487 DOI: 10.1182/blood-2018-01-826958] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/05/2018] [Indexed: 12/19/2022] Open
Abstract
An important unmet need in the management of primary mediastinal B-cell lymphoma (PMBCL) is to identify the patients for whom first-line therapy will fail to intervene before the lymphoma becomes refractory. High heterogeneity of intratumoral 18F-fluorodeoxyglucose (18FDG) uptake distribution on positron emission tomography/computed tomography (PET/CT) scans has been suggested as a possible marker of chemoresistance in solid tumors. In the present study, we investigated the prognostic value of metabolic heterogeneity (MH) in 103 patients with PMBCL prospectively enrolled in the International Extranodal Lymphoma Study Group (IELSG) 26 study, aimed at clarifying the role of PET in this lymphoma subtype. MH was estimated using the area under curve of cumulative standardized uptake value-volume histogram (AUC-CSH) method. Progression-free survival at 5 years was 94% vs 73% in low- and high-MH groups, respectively (P = .0001). In a Cox model of progression-free survival including dichotomized MH, metabolic tumor volume, total lesion glycolysis (TLG), international prognostic index, and tumor bulk (mediastinal mass > 10 cm), as well as age as a continuous variable, only TLG (P < .001) and MH (P < .001) retained statistical significance. Using these 2 features to construct a simple prognostic model resulted in early and accurate (positive predictive value, 89%; negative predictive value, ≥90%) identification of patients at high risk for progression at a point that would allow the use of risk-adapted treatments. This may provide an important opportunity for the design of future trials aimed at helping the minority of patients who harbor chemorefractory PMBCL. The study is registered at ClinicalTrials.gov as NCT00944567.
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Affiliation(s)
- Luca Ceriani
- Nuclear Medicine and PET/CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Lisa Milan
- Nuclear Medicine and PET/CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Maurizio Martelli
- Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Andrés J M Ferreri
- Department of Onco-Hematology, Unit of Lymphoid Malignancies, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Pier Luigi Zinzani
- Institute of Hematology "Seràgnoli", University of Bologna, Bologna Italy
| | - Alice Di Rocco
- Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | | | - Anastasios Stathis
- Division of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | | | - Monica Bellei
- Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Elena Porro
- Institute of Oncology Research, Bellinzona, Switzerland
| | - Luca Giovanella
- Nuclear Medicine and PET/CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Peter W Johnson
- Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom; and
| | - Emanuele Zucca
- Institute of Oncology Research, Bellinzona, Switzerland
- Division of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Medical Oncology, University of Bern, Bern, Switzerland
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15
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Zhang W, Zhou Y, Xu XQ, Kong LY, Xu H, Yu TF, Shi HB, Feng Q. A Whole-Tumor Histogram Analysis of Apparent Diffusion Coefficient Maps for Differentiating Thymic Carcinoma from Lymphoma. Korean J Radiol 2018. [PMID: 29520195 PMCID: PMC5840066 DOI: 10.3348/kjr.2018.19.2.358] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To assess the performance of a whole-tumor histogram analysis of apparent diffusion coefficient (ADC) maps in differentiating thymic carcinoma from lymphoma, and compare it with that of a commonly used hot-spot region-of-interest (ROI)-based ADC measurement. Materials and Methods Diffusion weighted imaging data of 15 patients with thymic carcinoma and 13 patients with lymphoma were retrospectively collected and processed with a mono-exponential model. ADC measurements were performed by using a histogram-based and hot-spot-ROI-based approach. In the histogram-based approach, the following parameters were generated: mean ADC (ADCmean), median ADC (ADCmedian), 10th and 90th percentile of ADC (ADC10 and ADC90), kurtosis, and skewness. The difference in ADCs between thymic carcinoma and lymphoma was compared using a t test. Receiver operating characteristic analyses were conducted to determine and compare the differentiating performance of ADCs. Results Lymphoma demonstrated significantly lower ADCmean, ADCmedian, ADC10, ADC90, and hot-spot-ROI-based mean ADC than those found in thymic carcinoma (all p values < 0.05). There were no differences found in the kurtosis (p = 0.412) and skewness (p = 0.273). The ADC10 demonstrated optimal differentiating performance (cut-off value, 0.403 × 10-3 mm2/s; area under the receiver operating characteristic curve [AUC], 0.977; sensitivity, 92.3%; specificity, 93.3%), followed by the ADCmean, ADCmedian, ADC90, and hot-spot-ROI-based mean ADC. The AUC of ADC10 was significantly higher than that of the hot spot ROI based ADC (0.977 vs. 0.797, p = 0.036). Conclusion Compared with the commonly used hot spot ROI based ADC measurement, a histogram analysis of ADC maps can improve the differentiating performance between thymic carcinoma and lymphoma.
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Affiliation(s)
- Wei Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yue Zhou
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Ling-Yan Kong
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Hai Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Tong-Fu Yu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Hai-Bin Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qing Feng
- Department of Nutrition and Food Hygiene, School of Public Health, Nanjing Medical University, Nanjing 211166, China
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16
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Abstract
Primary mediastinal B-cell lymphoma (PMBCL) is a subtype of non-Hodgkin’s lymphoma, which occurs rarely in pregnancy. We present a case of a pregnant 22-year-old female who presented with syncope and dyspnea. Computed tomography (CT) chest showed an anterior mediastinal mass, and its biopsy showed PMBCL. Since she was in her second trimester, we decided to treat her with rituximab-cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP). Our case emphasizes the safety of chemotherapy in the second and third trimesters, with good maternal and fetal outcomes.
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Affiliation(s)
- Sidra Khalid
- Internal Medicine Residency, Fairview Hospital, Cleveland Clinic, USA
| | - Aariez Khalid
- Bachelor of Science (biomedical Science), University of Guelph
| | - Hamed Daw
- Department of Hematology and Oncology, Fairview Hospital, Cleveland Clinic, USA
| | - Praful Maroo
- Cardiology, Fairview Hospital, Cleveland Clinic, USA
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17
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Ceriani L, Barrington S, Biggi A, Malkowski B, Metser U, Versari A, Martelli M, Davies A, Johnson PW, Zucca E, Chauvie S. Training improves the interobserver agreement of the expert positron emission tomography review panel in primary mediastinal B-cell lymphoma: interim analysis in the ongoing International Extranodal Lymphoma Study Group-37 study. Hematol Oncol 2017; 35:548-553. [PMID: 27545416 DOI: 10.1002/hon.2339] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 02/11/2024]
Abstract
The International Extranodal Lymphoma Study Group (IELSG)-37 is a prospective randomized trial assessing the role of consolidation mediastinal radiotherapy after immunochemotherapy to patients with newly diagnosed primary mediastinal large B-cell lymphoma (PMBCL). It is a positron emission tomography (PET) response-guided study where patients obtaining a complete metabolic response on an end-of-therapy PET-computed tomography (CT) scan evaluated by a central review are randomized to receive radiotherapy or no further treatment. The aims of this study were to measure agreement between reviewers reporting PET-CT scans for this trial and to determine the effect of training upon concordance rates. The review panel comprised 6 experienced nuclear physicians who read PET-CT scans using the 5-point Deauville scale. Interobserver agreement (IOA) was measured at 4 time points: after a blinded review of a "training set" of 20 patients with PMBCL from the previous IELSG-26 study (phase 1); after the first 10 clinical cases enrolled in the IELSG-37 (phase 2); and after 2 further groups of 50 (phase 3) and 40 clinical cases (phase 4). After feedback from the training set and the first 10 cases, a meeting was held to discuss interpretation, and a detailed set of instructions for the review procedure was agreed and acted upon. Between 2012 and 2014, the first 100 patients were reviewed. Using Deauville score 3 as the cutoff for a complete metabolic response, the overall IOA among the reviewers was good (Krippendorff α = 0.72.) The binary concordance between pairs of reviewers (Cohen κ) ranged from 0.60 to 0.78. The IOA, initially moderate, improved progressively from phase 1 to 4 (Krippendorff α from 0.53 to 0.81; Cohen κ from 0.35-0.72 to 0.77-0.87). Our experience indicates that the agreement among "expert" nuclear physicians reporting PMBCL, even using standardized criteria, was only moderate when the study began. However, agreement improved using a harmonization process, which included a training exercise with discussion of points leading to disagreement and compiling practical rules to sit alongside commonly adopted interpretation criteria.
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Affiliation(s)
- Luca Ceriani
- Nuclear Medicine and PET-CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Sally Barrington
- Division of Imaging, King's College London, PET Center, Guy & St Thomas' Hospital, London, UK
| | - Alberto Biggi
- Nuclear Medicine Unit, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | - Bogdan Malkowski
- Department of Nuclear Medicine, Oncology Center, Bydgoszcz, PET and Molecular Imaging Department, Collegium Medicum, Nicolaus Copernicus University, Toruń, Poland
| | - Ur Metser
- Division of Molecular Imaging, Joint Department of Medical Imaging, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Annibale Versari
- Nuclear Medicine Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Maurizio Martelli
- Department of Cellular Biotechnologies and Haematology, Sapienza University, Rome, Italy
| | - Andrew Davies
- Cancer Research UK Centre, University of Southampton, Southampton, UK
| | - Peter W Johnson
- Cancer Research UK Centre, University of Southampton, Southampton, UK
| | - Emanuele Zucca
- Oncology Department, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Stéphane Chauvie
- Medical Physics Unit, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
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18
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Cherian S, Fromm JR. Evaluation of primary mediastinal large B cell lymphoma by flow cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:459-467. [DOI: 10.1002/cyto.b.21544] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/17/2017] [Accepted: 07/18/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Sindhu Cherian
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Jonathan R. Fromm
- Department of Laboratory Medicine; University of Washington; Seattle Washington
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19
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Grange B, Callet-Bauchu E, Salles G, Sujobert P. Advances in the role of cytogenetic analysis in the molecular diagnosis of B-cell lymphomas. Expert Rev Mol Diagn 2017; 17:623-632. [DOI: 10.1080/14737159.2017.1327811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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20
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Abstract
Primary pulmonary lymphomas represent a pathologically heterogeneous group of disorders that often share imaging features, which include peribronchovascular nodules and masses or areas of nonresolving consolidation. Primary mediastinal B-cell lymphoma is an extranodal non-Hodgkin lymphoma seen in younger patients that has imaging and pathologic features that demonstrate some degree of overlap with Hodgkin lymphoma. Primary lymphomas of the pleural space are rare and associated with concomitant viral infections.
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21
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Ceriani L, Martelli M, Gospodarowicz MK, Ricardi U, Ferreri AJM, Chiappella A, Stelitano C, Balzarotti M, Cabrera ME, Cunningham D, Guarini A, Zinzani PL, Giovanella L, Johnson PWM, Zucca E. Positron Emission Tomography/Computed Tomography Assessment After Immunochemotherapy and Irradiation Using the Lugano Classification Criteria in the IELSG-26 Study of Primary Mediastinal B-Cell Lymphoma. Int J Radiat Oncol Biol Phys 2017; 97:42-49. [PMID: 27839910 DOI: 10.1016/j.ijrobp.2016.09.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/10/2016] [Accepted: 09/21/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess the predictive value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) for disease recurrence after immunochemotherapy (R-CHT) and mediastinal irradiation (RT), using the recently published criteria of the Lugano classification to predict outcomes for patients with primary mediastinal large B-cell lymphoma. METHODS AND MATERIALS Among 125 patients prospectively enrolled in the IELSG-26 study, 88 were eligible for central review of PET/CT scans after completion of RT. Responses were evaluated using the 5-point Deauville scale at the end of induction R-CHT and after consolidation RT. According to the Lugano classification, a complete metabolic response (CMR) was defined by a Deauville score (DS) ≤3. RESULTS The CMR (DS1, -2, or -3) rate increased from 74% (65 patients) after R-CHT to 89% (78 patients) after consolidation RT. Among the 10 patients (11%) with persistently positive scans, the residual uptake after RT was slightly higher than the liver uptake in 6 patients (DS4; 7%) and markedly higher in 4 patients (DS5; 4%): these patients had a significantly poorer 5-year progression-free survival and overall survival. At a median follow-up of 60 months (range, 35-107 months), no patients with a CMR after RT have relapsed. Among the 10 patients who did not reach a CMR, 3 of the 4 patients (positive predictive value, 75%) with DS5 after RT had subsequent disease progression (within the RT volume in all cases) and died. All patients with DS4 had good outcomes without recurrence. CONCLUSIONS All the patients obtaining a CMR defined as DS ≤3 remained progression-free at 5 years, confirming the excellent negative predictive value of the Lugano classification criteria in primary mediastinal large B-cell lymphoma patients. The few patients with DS4 also had an excellent outcome, suggesting that they do not necessarily require additional therapy, because the residual 18F-fluorodeoxyglucose uptake may not reflect persistent lymphoma.
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Affiliation(s)
- Luca Ceriani
- Nuclear Medicine and PET-CT Center, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
| | - Maurizio Martelli
- Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | | | | | - Andrés J M Ferreri
- Unit of Lymphoid Malignancies, Department of Onco-Hematology, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milano, Italy
| | - Annalisa Chiappella
- Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Caterina Stelitano
- Hematology, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | | | - Maria E Cabrera
- Hematology, Hospital del Salvador, Universidad de Chile, Santiago, Chile
| | - David Cunningham
- Department of Medicine, The Royal Marsden National Health Service Foundation Trust, London and Surrey, United Kingdom
| | - Attilio Guarini
- Hematology Unit, Istituto Nazionale Tumori Giovanni Paolo II IRCCS, Bari, Italy
| | - Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Luca Giovanella
- Nuclear Medicine and PET-CT Center, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Peter W M Johnson
- Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom
| | - Emanuele Zucca
- Oncology Department, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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22
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Bergkvist KS, Nørgaard MA, Bøgsted M, Schmitz A, Nyegaard M, Gaihede M, Bæch J, Grønholdt ML, Jensen FS, Johansen P, Urup T, El-Galaly TC, Madsen J, Bødker JS, Dybkær K, Johnsen HE. Characterization of memory B cells from thymus and its impact for DLBCL classification. Exp Hematol 2016; 44:982-990.e11. [PMID: 27297329 DOI: 10.1016/j.exphem.2016.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 05/09/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
Abstract
The rare memory B cells in thymus (Thy) are considered the cells of origin for primary mediastinal large B-cell lymphoma. The objectives of the present study were to characterize the normal memory B-cell compartment in Thy and to support its association with primary mediastinal B-cell lymphoma. Seven paired human tissue samples from Thy and sternum bone marrow (BM) were harvested during cardiac surgery. B-cell subsets were phenotyped by Euroflow standard and fluorescence-activated cell sorting for microarray analysis on the Human Exon 1.0 ST Arrays platform. Differentially expressed genes between Thy and BM memory B cells were identified and correlated with the molecular subclasses of diffuse large B-cell lymphoma. Within Thy, 4% (median; range 2%-14%) of the CD45(+) hematopoietic cells were CD19(+) B cells, with a major fraction being CD27(+)/CD38(-) memory B cells (median 80%, range 76%-93%). The BM contained 14% (median; range 3%-27%), of which only a minor fraction (median 5%, range 2%-10%) were memory B cells. Global gene expression analysis of the memory B-cell subsets from the two compartments identified 133 genes upregulated in Thy, including AICDA, REL, STAT1, TNF family, SLAMF1, CD80, and CD86. In addition, exons 4 and 5 in the 3' end of AICDA were more highly expressed in Thy than in BM. The Thy memory B-cell gene profile was overexpressed in primary mediastinal B-cell lymphoma compared with other diffuse large B-cell lymphoma subclasses. The present study describes a Thy memory B-cell subset and its gene profile correlated with primary mediastinal B-cell lymphomas, suggesting origin from Thy memory B cells.
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Affiliation(s)
| | - Martin Agge Nørgaard
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Bøgsted
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Alexander Schmitz
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Nyegaard
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Gaihede
- Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Otolaryngology, Head and Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - John Bæch
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Preben Johansen
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Urup
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jakob Madsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Julie Støve Bødker
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Karen Dybkær
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hans Erik Johnsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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23
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Abstract
Thymoma is the most common primary malignancy of the anterior mediastinum and the most common thymic epithelial neoplasm, but it is a rare tumor that constitutes less than 1% of adult malignancies. Computed tomography (CT) is currently the imaging modality of choice for distinguishing thymoma from other anterior mediastinal masses, characterizing the primary tumor, and staging the disease. However, magnetic resonance imaging is also effective in evaluating and characterizing anterior mediastinal masses and staging thymoma in patients with contraindications to contrast-material-enhanced CT such as contrast allergy and/or renal failure.
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Affiliation(s)
- Brett W Carter
- Section of Thoracic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030-4008, USA.
| | - Marcelo F K Benveniste
- Section of Thoracic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030-4008, USA
| | - Mylene T Truong
- Section of Thoracic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030-4008, USA
| | - Edith M Marom
- Section of Thoracic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030-4008, USA
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24
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Cavalli F, Ceriani L, Zucca E. Functional Imaging Using 18-Fluorodeoxyglucose PET in the Management of Primary Mediastinal Large B-Cell Lymphoma: The Contributions of the International Extranodal Lymphoma Study Group. Am Soc Clin Oncol Educ Book 2016; 35:e368-75. [PMID: 27249743 DOI: 10.1200/edbk_159037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Primary mediastinal large B-cell lymphoma (PMLBCL) is recognized as a distinct disease entity. Treatment outcomes appear better than in other diffuse large B-cell lymphoma (DLBCL) types, partly because of their earlier stage at presentation and the younger age of most patients. If initial treatment fails, however, the results of salvage chemotherapy and myeloablative treatment are poor. The need to avoid relapses after initial therapy has led to controversy over the extent of front-line therapy, particularly whether consolidation radiotherapy to the mediastinum is always required and whether the 18-fluorodeoxyglucose ((18)F-FDG) uptake detected by PET-CT scan can be used to determine its requirements. Functional imaging using PET-CT generally allows distinguishing of residual mediastinal masses containing active lymphoma from those with only sclerotic material remaining. The International Extranodal Lymphoma Study Group (IELSG) conducted the prospective IELSG-26 study, which showed that a five-point visual scale can be used to define metabolic response after immunochemotherapy and that a cut point based on liver uptake discriminates effectively between high or low risk of failure, with 5-year progression-free survival (PFS) of 99% versus 68% and 5-year overall survival (OS) of 100% versus 83%. This study also showed that a baseline quantitative PET parameter, namely the total lesion glycolysis describing the metabolic tumor burden, can be a powerful predictor of PMLBCL outcomes and warrants further validation as a biomarker. The ongoing IELSG-37 randomized study addresses the need for consolidation mediastinal radiotherapy in patients in whom a complete metabolic response (CMR) can be seen on PET scans after standard immunochemotherapy.
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Affiliation(s)
- Franco Cavalli
- From the Oncology Institute of Southern Switzerland, Lymphoma Unit-Ospedale San Giovanni, Bellinzona, Switzerland
| | - Luca Ceriani
- From the Oncology Institute of Southern Switzerland, Lymphoma Unit-Ospedale San Giovanni, Bellinzona, Switzerland
| | - Emanuele Zucca
- From the Oncology Institute of Southern Switzerland, Lymphoma Unit-Ospedale San Giovanni, Bellinzona, Switzerland
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25
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Using the pathology report in initial treatment decisions for diffuse large B-cell lymphoma: time for a precision medicine approach. Hematology 2015; 2015:618-24. [DOI: 10.1182/asheducation-2015.1.618] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non Hodgkin lymphoma in the Western world, and is potentially curable with standard R-CHOP chemoimmunotherapy. Historically, clinical risk assessments provided prognostic information, but did not define treatment approach. We are now in an era where the heterogeneity of DLBCL is defined genetically and molecularly, and rational subset-specific therapeutic targets are guiding clinical trials. Primary mediastinal DLBCL is a unique clinicopathologic entity, and alternatives to R-CHOP may confer superior outcome. Rearrangement of the myc oncogene occurs in ∼10% of patients with DLBCL, and confers a very poor prognosis with standard R-CHOP, particularly when there is concomitant rearrangement of bcl-2, a condition referred to as “double-hit” DLBCL. A larger subset of DLBCL demonstrates overexpression of both myc and bcl-2 by immunohistochemistry. Cell of origin, determined by gene expression analysis, immunohistochemistry algorithms, or a novel Lymph2Cx platform, provides prognostic information, and guides therapeutic decisions in both relapsed and de novo disease. This article will define specific subsets of DLBCL and provide subtype-specific treatment options, including novel approaches under investigation. Understanding these key features of the pathology report, and limitations of these assays defining subsets of DLBCL, allows for an evolving precision medicine approach to this disease.
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26
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Weinberg OK, Rodig SJ, Pozdnyakova O, Ren L, Arber DA, Ohgami RS. Surface Light Chain Expression in Primary Mediastinal Large B-Cell Lymphomas by Multiparameter Flow Cytometry. Am J Clin Pathol 2015; 144:635-41. [PMID: 26386085 DOI: 10.1309/ajcp3q1dhwkcqrwy] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES Primary mediastinal large B-cell lymphoma (PMLBL) is an aggressive B-cell lymphoma typically localized to the mediastinum. To date, no study has undertaken a comprehensive analysis of this entity by multiparameter flow cytometry. METHODS Cases of PMLBL with diagnostic flow cytometry were identified from pathology databases of Boston Children's Hospital, Brigham and Women's Hospital, and Stanford Hospital. RESULTS Most of these patients with PMLBL were women with a median age of 30 years who had stage 1 disease that lacked bone marrow involvement. By flow cytometry, 50% of all PMLBLs showed restricted surface immunoglobulin expression. When comparing patients with PMLBL by the absence or presence of surface light chain immunoglobulins, no differences were seen in the morphologic appearance; expression of CD23, CD30, or CD10; age at presentation; or clinical stage (P > .5 for all). In addition, both groups showed similarly good survival outcomes and were alive at last follow-up (11/14 [79%]; P = .542). CONCLUSIONS This multi-institutional study demonstrates that 50% of PMLBLs can present with clonal surface light chain expression and that PMLBL is more immunophenotypically diverse than previously described. Furthermore, our findings suggest that the absence or presence of surface light chains should not be used as criteria for diagnosis in this disease.
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Affiliation(s)
| | | | | | - Li Ren
- Stanford University, Stanford, CA
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27
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Wang J, Liu X, Ma F, Huang M, Kallychurn YS, Hu C. Role of radiotherapy in the treatment of primary mediastinal large B-cell lymphoma. Oncol Lett 2015; 10:2925-2930. [PMID: 26722265 DOI: 10.3892/ol.2015.3700] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 07/28/2015] [Indexed: 11/06/2022] Open
Abstract
The role of radiotherapy (RT) in the treatment of primary mediastinal large B-cell lymphoma (PMLBCL) is unclear. In the present study, a retrospective analysis of 63 patients with PMLBCL treated with or without RT was performed to evaluate the role of RT. Clinical outcomes were calculated using the Kaplan-Meier method and were compared between patients who did and did not receive RT, using the log-rank test. A multivariate analysis was performed using Cox proportional hazards model. After chemotherapy, 35 patients received RT, and RT was found to be associated with significantly improved 5-year overall survival (OS) (87 vs. 58%; P=0.001) and 5-year progression-free survival (PFS) (75 vs. 39%; P=0.001) rates compared with patients without RT. The subgroup analysis on 35 patients who received rituximab plus chemotherapy showed that RT did not improve the 5-year OS (88 vs. 92%; P=0.814) or the 5-year PFS (78 vs. 65%; P=0.511) rates compared with patients without RT. On multivariate analysis, RT and the addition of rituximab were predictive of increased OS [RT: Hazard ratio (HR), 0.157; P=0.018; rituximab: HR, 0.156; P=0.009] and PFS (RT: HR 0.111, P=0.001; Rituximab: HR 0.231, P=0.002) rates. However, the role of RT in PMLBCL in the rituximab era is unclear. Further investigation of the role of RT in the era of targeted therapy is required.
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Affiliation(s)
- Jingjing Wang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Xianling Liu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Fang Ma
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Ming Huang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Yashpal Singh Kallychurn
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Chunhong Hu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
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Utility of baseline 18FDG-PET/CT functional parameters in defining prognosis of primary mediastinal (thymic) large B-cell lymphoma. Blood 2015; 126:950-6. [DOI: 10.1182/blood-2014-12-616474] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/24/2015] [Indexed: 12/11/2022] Open
Abstract
Key Points
18FDG PET/CT is a very important staging tool for patients with PMBCL. Metabolic activity defined by TLG on the baseline PET scan is a powerful predictor of PMBCL outcome.
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[Pathology of the mediastinum. Case 1. Primary mediastinal large B-cell lymphoma]. Ann Pathol 2015; 35:211-7. [PMID: 26004308 DOI: 10.1016/j.annpat.2015.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 11/22/2022]
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Luminari S, Ceriani L, Dührsen U. FDG-PET(CT)-adapted trials in non-Hodgkin lymphoma. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0125-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brentuximab vedotin demonstrates objective responses in a phase 2 study of relapsed/refractory DLBCL with variable CD30 expression. Blood 2015; 125:1394-402. [DOI: 10.1182/blood-2014-09-598763] [Citation(s) in RCA: 199] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Key PointsBrentuximab vedotin was active in DLBCL across a range of CD30 expression levels, and objective responses occurred in 44% of patients.
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Expression of programmed cell death 1 ligand 2 (PD-L2) is a distinguishing feature of primary mediastinal (thymic) large B-cell lymphoma and associated with PDCD1LG2 copy gain. Am J Surg Pathol 2015; 38:1715-23. [PMID: 25025450 DOI: 10.1097/pas.0000000000000297] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Primary mediastinal (thymic) large B-cell lymphoma (PMBL) and diffuse large B-cell lymphoma (DLBCL) are tumors with distinct clinical and molecular characteristics that are difficult to distinguish by histopathologic and phenotypic analyses alone. Programmed cell death 1 ligand 2 (PD-L2) is a cell surface protein expressed by activated macrophages and dendritic cells that binds PD-1 on T cells to inhibit immune responses. Amplification and/or translocations involving chromosome 9p24.1, a region that includes PDCD1LG2-encoding PD-L2, is a common event in PMBL but not DLBCL and suggests that PD-L2 expression might be a distinguishing feature of PMBL. We developed an assay for the immunohistochemical detection of PD-L2 protein in fixed biopsy specimens (PD-L2 IHC), which we applied to a cohort of PMBLs and DLBCLs. For a subset of cases, we correlated the results of PD-L2 IHC with PDCD1LG2 copy number (CN) as determined by quantitative polymerase chain reaction. Twenty-three of 32 (72%) PMBLs but only 1 of 37 (3%) DLBCLs were positive by PD-L2 IHC. Among PMBLs with PDCD1LG2 CN gain, all were positive by PD-L2 IHC. One PMBL without CN gain was positive by PD-L2 IHC. When expressed in PMBL, PD-L2 was restricted to tumor cells and not detected on intratumoral macrophages. We conclude that PD-L2 protein is robustly expressed by the majority of PMBLs but only rare DLBCLs and often associated with PDCD1LG2 copy gain. PD-L2 IHC may serve as a useful ancillary test for distinguishing PMBL from DLBCL and for the rational selection of patients for therapeutic antibodies that inhibit PD-1 signaling.
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Drexler HG, Ehrentraut S, Nagel S, Eberth S, MacLeod RAF. Malignant hematopoietic cell lines: in vitro models for the study of primary mediastinal B-cell lymphomas. Leuk Res 2014; 39:18-29. [PMID: 25480038 DOI: 10.1016/j.leukres.2014.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/30/2014] [Accepted: 11/05/2014] [Indexed: 11/27/2022]
Abstract
Primary mediastinal B-cell lymphoma (PMBL) is a highly aggressive disease with a unique set of biological, clinical, morphological, immunological and in particular genetic features that in the molecular era of defining lymphomas clearly distinguishes it as a separate entity from other diffuse large B-cell lymphomas (DLBCL). A precise molecular diagnosis of PMBL can be achieved by gene expression profiling. The signature gene expression profile of PMBL is more closely related to classic Hodgkin lymphoma (cHL) than to other DLBCL subgroups. A number of common genetic aberrations in PMBL and cHL further underscore their close relationship. To investigate the pathobiology of lymphomas in depth, many groups have turned to cell lines that are suitable models facilitating molecular studies and providing unique insights. For the purposes of the current perspective, we focus on four bona fide PMBL-derived cell lines (FARAGE, KARPAS-1106, MEDB-1, U-2940) that we identified and validated as such through hierarchical cluster analysis among a large collection of leukemia-lymphoma cell lines. These gene expression profiles showed that the four PMBL cell lines represent a distinct entity and are most similar to cHL cell lines, confirming derivation from a related cell type. A validated cell line resource for PMBL should assist those seeking druggable targets in this entity. This review aims to provide a comprehensive overview of the currently available cellular models for the study of PMBL.
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Affiliation(s)
- Hans G Drexler
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Dept. Human and Animal Cell Lines, Braunschweig, Germany.
| | - Stefan Ehrentraut
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Dept. Human and Animal Cell Lines, Braunschweig, Germany
| | - Stefan Nagel
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Dept. Human and Animal Cell Lines, Braunschweig, Germany
| | - Sonja Eberth
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Dept. Human and Animal Cell Lines, Braunschweig, Germany
| | - Roderick A F MacLeod
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Dept. Human and Animal Cell Lines, Braunschweig, Germany
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Nagle SJ, Chong EA, Chekol S, Shah NN, Nasta SD, Glatstein E, Plastaras JP, Torigian DA, Schuster SJ, Svoboda J. The role of FDG-PET imaging as a prognostic marker of outcome in primary mediastinal B-cell lymphoma. Cancer Med 2014; 4:7-15. [PMID: 25205600 PMCID: PMC4312112 DOI: 10.1002/cam4.322] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/15/2014] [Accepted: 07/22/2014] [Indexed: 11/22/2022] Open
Abstract
Primary mediastinal B-cell lymphoma (PMBL) is a subtype of diffuse large B-cell lymphoma (DLBCL) that arises in the mediastinum from B-cells of thymic origin. Optimal management of patients with PMBL remains controversial. The present study evaluates outcomes of 27 PMBL patients treated with R-CHOP with or without radiation therapy (RT). It investigates the role of both interim and posttreatment fluorodeoxyglucose-positron emission tomography (FDG-PET) as prognostic markers of outcome. Additionally, it assesses postprogression therapies in the six patients who had progressive disease. At a median follow-up of 41.5 months (range: 6.1–147.2 months), OS was 95.5% (95% CI = 71.9–99.4) and progression-free survival (PFS) was 70.4% (95% CI = 49.4–83.9) for the entire cohort. The negative predictive values of interim and posttreatment FDG-PET scans were both 100%. Patients who failed initial therapy and were treated with salvage regimens and autologous stem cell transplantation (ASCT) all achieved and maintained CR. PMBL patients can achieve excellent outcomes with minimal toxicities when treated with R-CHOP with or without RT. Negative interim and negative posttreatment FDG-PET results identified PMBL patients who achieve long-term remission. However, the significance of both positive interim and positive posttreatment FDG-PET results needs to be better defined. Those who failed initial therapy were successfully treated with salvage regimens and ASCT.
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Affiliation(s)
- Sarah J Nagle
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Primary mediastinal B-cell lymphoma (PMBCL) is a relatively rare lymphoma subtype affecting mainly young adults. Its molecular signature and clinical features resemble classical Hodgkin lymphoma. The optimal chemotherapy for this lymphoma subtype has not been established. The addition of rituximab to anthracycline based chemotherapy improved response rates and survival. Many centers use R-CHOP as standard treatment, but the role of the intensified regimens and consolidation radiotherapy has to be clarified. Recent data coming from retrospective analyses and an ongoing prospective study addressing the problem of consolidation radiotherapy will help to better identify risk groups and apply risk-adapted and effective treatment strategies. The latest research has helped to understand molecular mechanisms of PMBCL pathogenesis and indicated targets of directed therapy for the future.
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Affiliation(s)
- Anna Dabrowska-Iwanicka
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie Institute and Oncology Centre, 5 WK Roentgen Str, 02-781 Warszawa, Poland
| | - Jan A. Walewski
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie Institute and Oncology Centre, 5 WK Roentgen Str, 02-781 Warszawa, Poland
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Gronier H, Terriou L, Robin G, Wacrenier A, Leroy-Martin B, Lefebvre C, Vinatier D, Morschhauser F, Decanter C. Detection of non-Hodgkin's lymphoma in ovarian cortex pieces during the process of cryopreservation. J Assist Reprod Genet 2014; 31:1251-5. [PMID: 25022359 DOI: 10.1007/s10815-014-0292-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/02/2014] [Indexed: 12/18/2022] Open
Affiliation(s)
- Héloïse Gronier
- Service de Gynécologie Endocrinienne et de Médecine de la Reproduction, Hôpital Jeanne de Flandre, CHRU de Lille, 3 avenue Eugène Avinée, 59037, Lille Cedex, France,
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Martelli M, Ceriani L, Zucca E, Zinzani PL, Ferreri AJM, Vitolo U, Stelitano C, Brusamolino E, Cabras MG, Rigacci L, Balzarotti M, Salvi F, Montoto S, Lopez-Guillermo A, Finolezzi E, Pileri SA, Davies A, Cavalli F, Giovanella L, Johnson PWM. [18F]fluorodeoxyglucose positron emission tomography predicts survival after chemoimmunotherapy for primary mediastinal large B-cell lymphoma: results of the International Extranodal Lymphoma Study Group IELSG-26 Study. J Clin Oncol 2014; 32:1769-75. [PMID: 24799481 DOI: 10.1200/jco.2013.51.7524] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the role of [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) after rituximab and anthracycline-containing chemoimmunotherapy in patients with primary mediastinal large B-cell lymphoma (PMLBCL). PATIENTS AND METHODS Among 125 patients prospectively enrolled, 115 were eligible for central review of PET/CT scans at the completion of standard chemoimmunotherapy, by using a five-point scale. Consolidation radiotherapy (RT) was permitted and given to 102 patients. RESULTS Fifty-four patients (47%) achieved a complete metabolic response (CMR), defined as a completely negative scan or with residual [18F]FDG activity below the mediastinal blood pool (MBP) uptake. In the remaining 61 patients (53%), the residual uptake was higher than MBP uptake but below the liver uptake in 27 (23%), slightly higher than the liver uptake in 24 (21%), and markedly higher in 10 (9%). CMR after chemoimmunotherapy predicted higher 5-year progression-free survival (PFS; 98% v 82%; P=.0044) and overall survival (OS; 100% v 91%; P=.0298). Patients with residual uptake higher than MBP uptake but below liver uptake had equally good outcomes without any recurrence. Using the liver uptake as cutoff for PET positivity (boundary of score, 3 to 4) discriminated most effectively between high or low risk of failure, with 5-year PFS of 99% versus 68% (P<.001) and 5-year OS of 100% versus 83% (P<.001). CONCLUSION More than 90% of patients are projected to be alive and progression-free at 5 years, despite a low CMR rate (47%) after chemoimmunotherapy. This study provides a basis for using PET/CT to define the role of RT in PMLBCL.
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Affiliation(s)
- Maurizio Martelli
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Luca Ceriani
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Emanuele Zucca
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain.
| | - Pier Luigi Zinzani
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Andrés J M Ferreri
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Umberto Vitolo
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Caterina Stelitano
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Ercole Brusamolino
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Maria Giuseppina Cabras
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Luigi Rigacci
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Monica Balzarotti
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Flavia Salvi
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Silvia Montoto
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Armando Lopez-Guillermo
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Erica Finolezzi
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Stefano A Pileri
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Andrew Davies
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Franco Cavalli
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Luca Giovanella
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
| | - Peter W M Johnson
- Maurizio Martelli and Erica Finolezzi, Sapienza University, Rome; Pier Luigi Zinzani and Stefano A. Pileri, Policlinico S. Orsola-Malpighi, Bologna; Andrés J.M. Ferreri, San Raffaele Scientific Institute, Milan; Umberto Vitolo, Azienda Ospedaliera S. Giovanni Battista, Torino; Caterina Stelitano, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria; Ercole Brusamolino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia; Maria Giuseppina Cabras, Ospedale Businco, Cagliari; Luigi Rigacci, Policlinico Careggi, Florence; Monica Balzarotti, IRCCS Humanitas, Rozzano; Flavia Salvi, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Luca Ceriani, Emanuele Zucca, Franco Cavalli, and Luca Giovanella, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Silvia Montoto, Barts Cancer Institute, London; Andrew Davies and Peter W.M. Johnson, University of Southampton, Southampton, United Kingdom; and Armando Lopez-Guillermo, Hospital Clinic, Barcelona, Spain
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Avigdor A, Sirotkin T, Kedmi M, Ribakovsy E, Berkowicz M, Davidovitz Y, Kneller A, Merkel D, Volchek Y, Davidson T, Goshen E, Apter S, Shimoni A, Ben-Bassat I, Nagler A. The impact of R-VACOP-B and interim FDG-PET/CT on outcome in primary mediastinal large B cell lymphoma. Ann Hematol 2014; 93:1297-304. [PMID: 24595734 DOI: 10.1007/s00277-014-2043-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/19/2014] [Indexed: 12/22/2022]
Abstract
The choice of a rituximab-based regimen and the prognostic significance of interim 2-[fluorine-18]fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) in primary mediastinal large B cell lymphoma (PMBCL) are debatable. We evaluated the clinical features and outcomes of 95 consecutive patients with PMBCL who were treated between 1985 and 2009. Forty-three patients received rituximab-based chemotherapy, R-VACOP-B (N = 30) or R-CHOP21 (N = 13), whereas 52 patients were treated with VACOP-B (N = 47) or CHOP21 (N = 5). Radiotherapy was not given. Patients who received rituximab had a 5-year progression-free survival (PFS) of 79 % and overall survival (OS) of 97 % compared with 58 % (p = 0.06) and 88 % (p = 0.2), respectively, without rituximab. Five-year PFS in patients treated with R-VACOP-B, R-CHOP21, VACOP-B, and CHOP21 were 83, 69, 62, and 20 %, respectively (p = 0.039). However, direct comparison showed that the difference between PFS rates in patients receiving R-VACOP-B compared to R-CHOP21 was not statistically significant (p = 0.3). None of the standard clinical risk factors predicted for PFS and OS in patients receiving rituximab (R)-chemotherapy. Mid-interim FDG-PET/CT scans were performed in 30/43 patients who received R-chemotherapy. The negative predictive values of mid-PET activity were high (100 % for R-VACOP-B and 86 % for R-CHOP21) while the positive predictive values (PPV) were relatively low (30 and 75 %, respectively). Despite the low PPV, the 5-year PFS for mid-PET-negative patients (N = 16) was significantly higher (94 %) than that for mid-PET-positive (N = 14) patients (57 %, p = 0.015). This retrospective analysis demonstrates that the superiority of VACOP-B over CHOP21 for treatment of PMBCL disappeared once rituximab was added. The potential benefit of using interim PET activity as a guide for continuing therapy in patients with PMBCL remains unclear due to the relatively low PPV.
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Affiliation(s)
- Abraham Avigdor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 5265601, Israel,
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Recurrent somatic mutations of PTPN1 in primary mediastinal B cell lymphoma and Hodgkin lymphoma. Nat Genet 2014; 46:329-35. [PMID: 24531327 DOI: 10.1038/ng.2900] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 01/24/2014] [Indexed: 12/20/2022]
Abstract
Classical Hodgkin lymphoma and primary mediastinal B cell lymphoma (PMBCL) are related lymphomas sharing pathological, molecular and clinical characteristics. Here we discovered by whole-genome and whole-transcriptome sequencing recurrent somatic coding-sequence mutations in the PTPN1 gene. Mutations were found in 6 of 30 (20%) Hodgkin lymphoma cases, in 6 of 9 (67%) Hodgkin lymphoma-derived cell lines, in 17 of 77 (22%) PMBCL cases and in 1 of 3 (33%) PMBCL-derived cell lines, consisting of nonsense, missense and frameshift mutations. We demonstrate that PTPN1 mutations lead to reduced phosphatase activity and increased phosphorylation of JAK-STAT pathway members. Moreover, silencing of PTPN1 by RNA interference in Hodgkin lymphoma cell line KM-H2 resulted in hyperphosphorylation and overexpression of downstream oncogenic targets. Our data establish PTPN1 mutations as new drivers in lymphomagenesis.
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Abstract
Non-Hodgkin's Lymphoma (NHL) rarely presents during pregnancy and primary mediastinal large B-cell lymphoma (PMLBCL) accounts for approximately 2.5% of patients with NHL. The case of a 22-year-old woman who was diagnosed with Stage IIA PMLBCL during week 13 of her intrauterine pregnancy is described. The staging consisted in computed tomography (CT) of the chest and magnetic resonance imaging (MRI) of the abdomen and pelvis. She was managed with R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) for a total of six cycles and, because of the early presentation during the second trimester, she received the entire chemotherapy course during the pregnancy. She delivered a healthy baby at 34 weeks of pregnancy and a 18FDG-PET/CT scan demonstrated complete remission after delivery. After 20 months of follow up she remains with no evidence of disease and her 1-year-old son has shown no developmental delays or physical abnormalities. PMLBCL, although an uncommon subgroup of DLBCL, may present during pregnancy and R-CHOP should be considered as one suitable option in this complex scenario.
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Aberrant expression of the dendritic cell marker TNFAIP2 by the malignant cells of Hodgkin lymphoma and primary mediastinal large B-cell lymphoma distinguishes these tumor types from morphologically and phenotypically similar lymphomas. Am J Surg Pathol 2011; 35:1531-9. [PMID: 21921781 DOI: 10.1097/pas.0b013e31822bd476] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tumor necrosis factor-α-inducible protein-2 (TNFAIP2) is a protein upregulated in cultured cells treated with tumor necrosis factor α (TNF), but its expression in normal and neoplastic tissues remains largely unknown. Here, we use standard immunohistochemical techniques to demonstrate that TNFAIP2 is normally expressed by follicular dendritic cells, interdigitating dendritic cells, and macrophages but not by lymphoid cells in secondary lymphoid tissues. Consistent with this expression pattern, we found strong TNFAIP2 staining of tumor cells in 4 of 4 cases (100%) of follicular dendritic cell sarcoma and in 3 of 3 cases (100%) of histiocytic sarcoma. Although TNFAIP2 is not expressed by the small and intermediate-sized neoplastic B cells comprising follicular lymphoma, small lymphocytic lymphoma, mantle cell lymphoma, or marginal zone lymphoma, we observed strong TNFAIP2 staining of the large, neoplastic cells in 31 of 31 cases (100%) of classical Hodgkin lymphoma, in 12 of 12 cases (100%) of nodular lymphocyte-predominant Hodgkin lymphoma, and in 27 of 31 cases (87%) of primary mediastinal (thymic) large B-cell lymphoma. In contrast, TNFAIP2 was expressed by malignant cells in only 2 of 45 cases (4%) of diffuse large B-cell lymphoma, not otherwise specified, in 2 of 18 cases (11%) of Burkitt lymphoma, and in 1 of 19 cases (5%) of anaplastic large cell lymphoma. Further analysis indicates that TNFAIP2, as a single diagnostic marker, is more sensitive (sensitivity=87%) and specific (specificity=96%) than TRAF1, nuclear cRel, or CD23 for distinguishing the malignant B cells of primary mediastinal (thymic) large B-cell lymphoma from those of its morphologic and immunophenotypic mimic, diffuse large B-cell lymphoma, not otherwise specified. Thus, TNFAIP2 may serve as a useful new marker of dendritic and histiocytic sarcomas, the aberrant expression of which in the malignant cells of classical Hodgkin lymphoma and primary mediastinal (thymic) large B-cell lymphoma serves to distinguish these tumors from other large cell lymphomas in routine clinical practice.
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Chaudhry I, Bojal S, Poovathumkadavil A, Amr SS. Role of surgery after chemotherapy in B-cell lymphoma of thymus causing airway compression and right ventricle outflow tract obstruction. Ann Thorac Surg 2011; 92:1120-2. [PMID: 21871316 DOI: 10.1016/j.athoracsur.2011.02.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 02/10/2011] [Accepted: 02/17/2011] [Indexed: 11/19/2022]
Abstract
Primary B-cell lymphoma of thymus is uncommon. We describe the case of a 23-year-old woman with a history of shortness of breath and distended neck veins of 1-month duration. A chest roentgenogram and computed tomographic chest scan of the showed a large anterior mediastinal mass. Tru-cut biopsy revealed primary B-cell lymphoma of thymus. She underwent chemotherapy with no symptomatic improvement. Post-chemotherapy computed tomographic scan of the chest showed no appreciable reduction in tumor size. Surgical excision was carried out with excellent results.
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Affiliation(s)
- Ikram Chaudhry
- Division of Thoracic Surgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia.
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Primary mediastinal large B-cell lymphoma (PMLBCL) in Chinese patients: clinical characteristics and prognostic factors. Int J Hematol 2011; 94:178-184. [DOI: 10.1007/s12185-011-0898-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 07/05/2011] [Accepted: 07/05/2011] [Indexed: 12/31/2022]
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Abstract
Primary mediastinal large B-cell lymphoma (PMBCL) is a recognized non-Hodgkin lymphoma entity with unique pathologic, clinical, and molecular characteristics distinct from those of other diffuse large B-cell lymphomas. Immunohistochemical characterization and molecular studies strongly suggest that PMBCL is of germinal center or postgerminal center origin. Pivotal gene expression profiling work defined major deregulated pathway activities that overlap with Hodgkin lymphoma and prompted a more detailed analysis of candidate genes. In particular, the nuclear factor-κB and the Janus Kinase-Signal Transducer and Activator of Transcription signaling pathways are targeted by multiple genomic hits, and constitutive activity of both pathways can be considered molecular hallmark alterations of PMBCL. Moreover, data are emerging giving unique insight into remodeling of the epigenome that affects transcriptional regulation of a multitude of genes. More recently, the tumor microenvironment of PMBCL has shifted into focus based on a number of gene perturbations altering expression of surface molecules that contribute to immune escape. These findings highlight the importance of immune privilege in the pathogenesis of PMBCL and suggest that disrupting crosstalk between the tumor cells and the microenvironment might be a rational new therapeutic target in conjunction with traditional treatment strategies.
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Hutchinson CB, Wang E. Primary mediastinal (thymic) large B-cell lymphoma: a short review with brief discussion of mediastinal gray zone lymphoma. Arch Pathol Lab Med 2011; 135:394-8. [PMID: 21366467 DOI: 10.5858/2009-0463-rsr.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Primary mediastinal (thymic) large B-cell lymphoma (PMBCL) is a subtype of diffuse large B-cell lymphoma (DLBCL). It commonly presents as a bulky lesion in the anterior-superior mediastinum with symptoms related to local invasion or compression. Microscopic examination typically shows infiltration of medium-large cells surrounded by collagen fibrosis. The neoplastic cells express B-cell markers, and CD30 often shows heterogeneous staining. Comparative genomic hybridization has identified gains in loci of 9p24 and 2p15 as well as Xp11.4-21 and Xq24-26. Amplification of REL and BCL11A at 2p as well as elevated expression of JAK2, PDL1, and PDL2 at 9p has been demonstrated. Nodular sclerosis classic Hodgkin lymphoma needs to be differentiated from PMBCL and cases with overlapped features have been described as mediastinal gray zone lymphoma. Primary mediastinal (thymic) large B-cell lymphoma carries a favorable prognosis in comparison to conventional DLBCL.
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Primary mediastinal large B-cell lymphoma (thymic lymphoma) imaged with F-18 FDG PET-CT. Clin Nucl Med 2010; 35:421-4. [PMID: 20479590 DOI: 10.1097/rlu.0b013e3181db4d33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gualco G, Weiss LM, Barber GN, Bacchi CE. T-cell leukemia 1 expression in nodal Epstein-Barr virus-negative diffuse large B-cell lymphoma and primary mediastinal B-cell lymphoma. Hum Pathol 2010; 41:1238-44. [PMID: 20382409 DOI: 10.1016/j.humpath.2010.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 01/14/2010] [Accepted: 01/22/2010] [Indexed: 01/16/2023]
Abstract
The physiologic expression of the product of the proto-oncogene TCL1 (T-cell leukemia 1) is primarily restricted to early embryonic cells. In nonneoplastic B cells, the expression of TCL1 is determined by the differentiation step with silencing at the germinal center stage. TCL1 protein is overexpressed in a wide variety of human diseases. It has been shown that TCL1 is a powerful B-cell oncogene, which has been implicated in the pathogenesis of various types of mature B-cell lymphomas. There is no comparative information in the literature addressing the expression of TCL1 in pediatric and adult nodal diffuse large B-cell lymphoma or primary mediastinal large B-cell lymphoma. We studied 55 cases of adult and pediatric diffuse large B-cell lymphoma and primary mediastinal large B-cell lymphoma to analyze the phenotypic profile of these lymphomas, including TCL1 expression, and its relationship with clinical outcome in different age groups. The cases were analyzed by immunohistochemistry for the expression of TCL1, CD10, BCL-2, BCL-6, and MUM1. We also evaluated c-MYC translocation by fluorescence in situ hybridization. TCL1 was observed in 11 cases, 5 pediatric and 6 adult cases, all but one diffuse large B-cell lymphoma. Pediatric cases showed a significant association between TCL1 expression, high proliferative index, and presence of c-MYC translocation. TCL1 positivity was predominantly found in germinal center phenotype diffuse large B-cell lymphoma. Overall survival was worse in adult TCL1-positive cases than pediatric ones. Primary mediastinal large B-cell lymphomas infrequently expressed TCL1 in both age groups.
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