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Boltežar L, Rožman S, Gašljević G, Grčar Kuzmanov B, Jezeršek Novaković B. Do Double-Expressor High-Grade B-Cell Lymphomas Really Need Intensified Treatment? A Report from the Real-Life Series of High-Grade B-Cell Lymphomas Treated with Different Therapeutic Protocols at the Institute of Oncology Ljubljana. Biomedicines 2024; 12:275. [PMID: 38397877 PMCID: PMC10886998 DOI: 10.3390/biomedicines12020275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/13/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
High-grade B-cell lymphomas with MYC and BCL2 and/or BCL6 rearrangements are known for their aggressive clinical course and so are the ones with MYC and BCL2 protein overexpression. The optimal therapy for these lymphomas remains to be elucidated. A retrospective analysis of all diffuse large B-cell lymphomas and high-grade B-cell lymphomas with MYC and BCL2 and/or BCL6 rearrangements diagnosed between 2017 and 2021 at the Institute of Oncology Ljubljana, Slovenia, has been performed. Only patients with double-expressor lymphoma (DEL), double-hit lymphoma (DHL), or triple-hit lymphoma (THL) were included. Demographic and clinical parameters were assessed, as well as progression-free survival (PFS) and overall survival (OS). In total, 161 cases out of 309 (161/309; 52,1%) were classified as DEL. Sixteen patients had DHL, MYC/BCL2 rearrangement was observed in eleven patients, and MYC/BCL6 rearrangement was observed in five patients. Five patients were diagnosed with THL. Out of 154 patients (according to inclusion/exclusion criteria) included in further evaluation, one-hundred and thirty-five patients had double-expressor lymphoma (DEL), sixteen patients had DHL, and three patients had THL. In total, 169 patients were treated with R-CHOP, 10 with R-CHOP and intermediate-dose methotrexate, 19 with R-DA-EPOCH, and 16 with other regimens. The median follow-up was 22 months. The 5-year OS for the whole DEL group was 57.1% (95% CI 45.9-68.3%) and the 5-year PFS was 76.5% (95% CI 72.6-80.4%). The log-rank test disclosed no differences in survival between treatment groups (p = 0.712) while the high-risk international prognostic index (IPI) carried a significantly higher risk of death (HR 7.68, 95% CI 2.32-25.49, p = 0.001). The 5-year OS for DHL patients was 32.4% (95% CI 16.6-48.2%) while all three TH patients were deceased or lost to follow-up. Our analyses of real-life data disclose that the R-CHOP protocol with CNS prophylaxis is a successful and curative treatment for a substantial proportion of DEL patients.
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Affiliation(s)
- Lučka Boltežar
- Division of Medical Oncology, Institute of Oncology, Zaloška Cesta 2, 1000 Ljubljana, Slovenia;
- Medical Faculty, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia
| | - Samo Rožman
- Pharmacy, Institute of Oncology, Zaloška Cesta 2, 1000 Ljubljana, Slovenia;
| | - Gorana Gašljević
- Department of Pathology, Institute of Oncology, Zaloška Cesta 2, 1000 Ljubljana, Slovenia; (G.G.); (B.G.K.)
| | - Biljana Grčar Kuzmanov
- Department of Pathology, Institute of Oncology, Zaloška Cesta 2, 1000 Ljubljana, Slovenia; (G.G.); (B.G.K.)
| | - Barbara Jezeršek Novaković
- Division of Medical Oncology, Institute of Oncology, Zaloška Cesta 2, 1000 Ljubljana, Slovenia;
- Medical Faculty, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia
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Balikó A, Szakács Z, Kajtár B, Ritter Z, Gyenesei A, Farkas N, Kereskai L, Vályi-Nagy I, Alizadeh H, Pajor L. Clinicopathological analysis of diffuse large B-cell lymphoma using molecular biomarkers: a retrospective analysis from 7 Hungarian centers. Front Oncol 2023; 13:1224733. [PMID: 37746254 PMCID: PMC10514474 DOI: 10.3389/fonc.2023.1224733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Background The clinical and genetic heterogeneity of diffuse large B-cell lymphoma (DLBCL) presents distinct challenges in predicting response to therapy and overall prognosis. The main objective of this study was to assess the application of the immunohistochemistry- and interphase fluorescence in situ hybridization (FISH)-based molecular markers in the diagnosis of DLBCL and its prognostic value in patients treated with rituximab-based immunochemotherapy. Methods This is a multicenter, retrospective study, which analyzed data from 7 Hungarian hematology centers. Eligible patients were adults, had a histologically confirmed diagnosis of DLBCL, were treated with rituximab-based immunochemotherapy in the first line, and had available clinicopathological data including International Prognostic Index (IPI). On the specimens, immunohistochemistry and FISH methods were performed. Germinal center B-cell like (GCB) and non-GCB subtypes were classified by the Hans algorithm. Outcomes included overall survival (OS), event-free survival (EFS), and EFS at 2 years (EFS24). For survival analysis, we used Kaplan-Meier curves with the log-rank test and multivariate Cox regression. Results A total of 247 DLBCL cases were included. Cases were positive for MYC, BCL2, BCL6, and MUM1 expression in 52.1%, 66.2%, 72.6%, and 77.8%, respectively. BCL6 translocation, BCL2 gene copy number (GCN) gain, IGH::MYC translocation, MYC GCN gain, IGH::BCL2 translocation, and BCL6 GCN gain were detected in 21.4%, 14.1%, 7.3%, 1.8%, 7.3%, and 0.9%, respectively. At a median follow-up of 52 months, 140 patients (56.7%) had disease progression or relapse. The Kaplan-Meier estimate for EFS24 was 56.2% (CI: 50.4-62.8%). In univariate analysis, only IPI and BCL6 expression were significant predictors of both OS and EFS, whereas MUM1 predicted EFS only. In multivariate analysis, the IPI score was a significant independent negative, whereas MIB-1 and BCL6 protein expressions were significant independent positive predictors of both OS and EFS. Conclusion In our study, we found that only IPI, BCL6 protein expression and MIB-1 protein expression are independent predictors of survival outcomes in DLBCL. We did not find any difference in survival by GCB vs. non-GCB subtypes. These findings may improve prognostication in DLBCL and can contribute to designing further research in the area.
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Affiliation(s)
- Anett Balikó
- Tolna County Balassa János Hospital, Szekszárd, ;Hungary
- PhD Doctoral School – Interdisciplinary Medical Sciences (D93), Medical School, University of Pécs, Pécs, ;Hungary
| | - Zsolt Szakács
- First Department of Medicine, Medical School, University of Pécs, Pécs, ;Hungary
| | - Béla Kajtár
- Department of Pathology, Medical School, University of Pécs, Pécs, ;Hungary
| | - Zsombor Ritter
- Department of Medical Imaging, Medical School, University of Pécs, Pécs, ;Hungary
| | - Attila Gyenesei
- Szentágothai Research Centre, University of Pécs, Pécs, ;Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, ;Hungary
| | - László Kereskai
- Department of Pathology, Medical School, University of Pécs, Pécs, ;Hungary
| | - István Vályi-Nagy
- South-Pest Hospital Centre – National Institute for Infectology and Haematology, Budapest, ;Hungary
| | - Hussain Alizadeh
- First Department of Medicine, Medical School, University of Pécs, Pécs, ;Hungary
| | - László Pajor
- Department of Pathology, Medical School, University of Pécs, Pécs, ;Hungary
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Wang Y, Liu D, Zhang X, Zhang M, Li S, Feng X, Dong M, Ma S, Qian S, Wang Z, Zhang Y, Wang P, Mei S, Chen Q. MYC overexpression but not MYC/BCL2 double expression predicts survival in bulky mass diffuse large B-cell lymphoma patients. Cancer Med 2023; 12:18568-18577. [PMID: 37641492 PMCID: PMC10557898 DOI: 10.1002/cam4.6463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE The prognostic factors for diffuse large B-cell lymphoma (DLBCL) have been fully explored, but prognostic information for bulky mass DLBCL patients is limited. This study aimed to analyze the prognostic value of MYC protein expression and other biological parameters in bulky mass DLBCL patients. METHODS We defined a bulky mass as a maximum tumor diameter ≥7.5 cm and studied 227 patients with de novo bulky mass DLBCL. RESULTS In all patients with bulky mass DLBCL, the 1-year and 3-year OS rates were 72.7% and 57.1%, respectively, and the 1-year and 3-year PFS rates were 52.0% and 42.5%, respectively. The MYC overexpression group (n = 140) showed significantly worse overall survival (OS; p = 0.019) and progression-free survival (PFS; p = 0.001) than the non-MYC overexpression group (n = 87). Subgroup analyses demonstrated that the MYC overexpression group was associated with inferior OS and PFS in the subgroups with the International Prognostic Index score of 3-5 (OS: p = 0.011; PFS: p < 0.001), Ann Arbor stage 3-4 (OS: p = 0.014; PFS: p < 0.001) and GCB subtype (OS: p = 0.014; PFS: p = 0.010). Consolidation radiotherapy improved OS and PFS in patients with bulky mass DLBCL (OS: p = 0.008; PFS: p = 0.004) as well as in those with MYC overexpression (OS: p = 0.001; PFS: p = 0.001). The prognostic value of MYC overexpression was maintained in a multivariate model adjusted for the International Prognostic Index. CONCLUSION MYC overexpression is a poor predictor for bulky mass DLBCL patients. Consolidation radiotherapy for residual disease after induction therapy may improve outcomes for patients with bulky mass DLBCL.
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Affiliation(s)
- Yanjie Wang
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Donglin Liu
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Xudong Zhang
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Mingzhi Zhang
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Shenglei Li
- Department of PathologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Xiaoyan Feng
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Meng Dong
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Shanshan Ma
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Siyu Qian
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Zeyuan Wang
- Department of PathologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Yue Zhang
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Pengyuan Wang
- Department of Medical OncologyXuchang Central HospitalXuchangChina
| | - Shuhao Mei
- Department of HematologyXuchang Central HospitalXuchangChina
| | - Qingjiang Chen
- Department of Oncology, Henan Province Lymphoma Treatment CenterThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
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Vodicka P, Klener P, Trneny M. Diffuse Large B-Cell Lymphoma (DLBCL): Early Patient Management and Emerging Treatment Options. Onco Targets Ther 2022; 15:1481-1501. [PMID: 36510607 PMCID: PMC9739046 DOI: 10.2147/ott.s326632] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/29/2022] [Indexed: 12/07/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) represents a curable disease with a 60-70% chance of cure with current R-CHOP chemoimmunotherapy. However, 30-40% of patients are refractory or relapsing. Many attempts failed to improve the outcome of DLBCL patients, including the intensification of R-CHOP regimen, consolidation, or maintenance therapy since the introduction of R-CHOP in 2000. Better understanding of both molecular biology of lymphoma cells and the tumor microenvironment raised the hope for future improvement of DLBCL patients' survival. Novel molecular findings have initiated clinical trials exploring targeted therapy based on driver genetic alterations with an intent to improve survival of high-risk subsets of patients. But the preliminary results remain ambiguous. The approach "agnostic" to specific molecular alterations of lymphoma cell includes antibody-drug conjugates (especially polatuzumab vedotin), immunotherapy comprising different antibodies with immunomodulatory effect (tafasitamab, lenalidomide), and T-cell engaging therapy (bispecific antibodies, early use of CAR T-cell). This approach could increase the cure rates and change the current therapeutic paradigm. However, better prognostic stratification, smarter designs of clinical trials, modification of endpoints including the use of ctDNA are needed. This review covers the complexity of DLBCL management.
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Affiliation(s)
- Prokop Vodicka
- First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Klener
- First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Marek Trneny
- First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Othman T, Penaloza J, Zhang S, Daniel CE, Gaut D, Oliai C, Brem EA, Baweja A, Ly J, Reid J, Pinter-Brown L, Lee M, Abdulhaq H, Tuscano J. R-CHOP Vs DA-EPOCH-R for Double-Expressor Lymphoma: A University of California Hematologic Malignancies Consortium Retrospective Analysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e947-e957. [PMID: 35858904 DOI: 10.1016/j.clml.2022.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Managing double-expressor lymphomas (DEL) is controversial given the dearth of data and lack of standardized guidelines on this high-risk subset of lymphomas. No prospective and few retrospective studies limited by either their sample size or short follow-up address the question of initial treatment of choice for DEL. We performed the largest analysis to date exploring R-CHOP vs DA-EPOCH-R in DEL. METHODS Adults with DEL diagnosed from 6/2012-2/2021 at 4 unique sites were retrospectively analyzed. Progression-free survival (PFS) was the primary endpoint. Key secondary endpoints include overall survival (OS), overall and complete response rates (ORR and CRR), cumulative incidence of relapse, and autologous hematopoietic cell transplantation (autoHCT) utilization. RESULTS 155 patients were included, 61 treated with R-CHOP and 94 with DA-EPOCH-R. 3-year PFS and OS were similar between R-CHOP and DA-EPOCH-R, 33.2% vs 57.2%,(P = .063), and 72.2% vs 71.6% (P = .43) after median follow-up times of 2.43 and 2.89 years, respectively. Patients <65 had improved PFS with DA-EPOCH-R, hazard ratio 0.41 (P = .01). CRR and ORR rates were also similar. Relapse rates were not statistically different, 51.9% vs 28.6% (P = .069). AutoHCT utilization was higher with R-CHOP vs DA-EPOCH-R, 23.0% vs 8.5% (P = .017). CONCLUSIONS Our findings do not support the use of DA-EPOCH-R over R-CHOP for DEL. Patients <65 years may experience longer PFS with DA-EPOCH-R, but limitations to the analysis make this interpretation difficult.
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Affiliation(s)
- Tamer Othman
- University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Juan Penaloza
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA
| | - Shiliang Zhang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Claire E Daniel
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Daria Gaut
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Caspian Oliai
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Elizabeth A Brem
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, Orange, CA
| | - Abinav Baweja
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, Orange, CA
| | - Jane Ly
- University of California Irvine Department of Pathology and Laboratory Medicine, Orange, CA
| | - Jack Reid
- University of California Irvine Department of Pathology and Laboratory Medicine, Orange, CA
| | - Lauren Pinter-Brown
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, Orange, CA
| | - Matthew Lee
- Department of Medicine, University of California San Francisco, Fresno campus. Fresno, CA
| | - Haifaa Abdulhaq
- Department of Medicine, University of California San Francisco, Fresno campus. Fresno, CA
| | - Joseph Tuscano
- University of California Davis Comprehensive Cancer Center, Sacramento, CA.
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Zhan J, Yang S, Zhang W, Zhou D, Zhang Y, Wang W, Wei C. DA-EPOCH-R improves the prognosis of patients with double-expressor lymphoma: A single-center retrospective study and meta-analysis. Medicine (Baltimore) 2022; 101:e30620. [PMID: 36197215 PMCID: PMC9509123 DOI: 10.1097/md.0000000000030620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/17/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Double-expressor lymphoma (DEL) is associated with a poor prognosis. The standard treatment for patients with DEL remains controversial. A comparison of the safety and feasibility of R-CHOP and DA-EPOCH-R as the first-line therapy for patients with DEL is urgently needed. METHODS The clinical and treatment outcomes of 75 DEL patients were retrospectively analyzed. The role of DA-EPOCH-R was determined and compared to that of R-CHOP in DEL patients. PubMed, Embase, the Cochrane Central Library, and ClinicalTrials.gov were systematically searched up to November 1, 2021 and were evaluated by Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Articles comparing DA-EPOCH-R versus R-CHOP in patients with DEL were included. RESULTS Overall, 49 and 26 DEL patients received R-CHOP and DA-EPOCH-R, respectively. Although the difference in response for patients who received R-CHOP and DA-EPOCH-R was not significant (P = .347), DA-EPOCH-R may improve the prognosis compared to R-CHOP (P = .056 for progression-free survival [PFS], P = .009 for overall survival [OS]). A systematic review and meta-analysis including 412 DEL patients in six articles were conducted. The event rate for 3-year PFS was significantly lower in patients receiving DA-EPOCH-R treatment than in those undergoing R-CHOP treatment (OR = 0.63, 95% CI = 0.42-0.94, P = .02), whereas no statistically significant difference was found in the HRs for both PFS and OS or the event rate for 3-year OS. CONCLUSION The results of this study indicated that DA-EPOCH-R might improve the prognosis of DEL patients compared with R-CHOP.
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Affiliation(s)
- Jing Zhan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shijie Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chong Wei
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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DLBCL 1L—What to Expect beyond R-CHOP? Cancers (Basel) 2022; 14:cancers14061453. [PMID: 35326604 PMCID: PMC8946010 DOI: 10.3390/cancers14061453] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive non-Hodgkin’s lymphoma. About two-thirds of patients are cured by the first-line (1L) standard of care (SOC), the R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) immunochemotherapy protocol. The profound molecular heterogeneity of DLBCL is the underlying reason why many patients, despite improved next-line options, eventually succumb to the disease. Hence, enhancing the efficacy of 1L treatment is critical for improving long-term outcomes in DLBCL. A plethora of novel treatment options with potential in later lines is currently under evaluation in 1L settings. We summarize here the established and emerging strategies for newly diagnosed DLBCL and emphasize the need for individualized treatment decisions. Abstract The R-CHOP immunochemotherapy protocol has been the first-line (1L) standard of care (SOC) for diffuse large B-cell lymphoma (DLBCL) patients for decades and is curative in approximately two-thirds of patients. Numerous randomized phase III trials, most of them in an “R-CHOP ± X” design, failed to further improve outcomes. This was mainly due to increased toxicity, the large proportion of patients not in need of more than R-CHOP, and the extensive molecular heterogeneity of the disease, raising the bar for “one-size-fits-all” concepts. Recently, an R-CHP regimen extended by the anti-CD79b antibody–drug conjugate (ADC) Polatuzumab Vedotin proved superior to R-CHOP in terms of progression-free survival (PFS) in the POLARIX phase III trial. Moreover, a number of targeted agents, especially the Bruton’s tyrosine kinase (BTK) inhibitor Ibrutinib, seem to have activity in certain patient subsets in 1L and are currently being tested in front-line regimens. Chimeric antigen receptor (CAR) T-cells, achieving remarkable results in ≥3L scenarios, are being exploited in earlier lines of therapy, while T-cell-engaging bispecific antibodies emerge as conceptual competitors of CAR T-cells. Hence, we present here the findings and lessons learnt from phase III 1L trials and piloting phase II studies in relapsed/refractory (R/R) and 1L settings, and survey chemotherapy-free regimens with respect to their efficacy and future potential in 1L. Novel agents and their mode of action will be discussed in light of the molecular landscape of DLBCL and personalized 1L perspectives for the challenging patient population not cured by the SOC.
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D'Angelo CR, Hanel W, Chen Y, Yu M, Yang D, Guo L, Karmali R, Burkart M, Ciccosanti C, David K, Risch Z, Murga-Zamalloa C, Devata S, Wilcox R, Savani M, Courville EL, Bachanova V, Rabinovich E, Peace D, Osman F, Epperla N, Kenkre VP. Impact of initial chemotherapy regimen on outcomes for patients with double-expressor lymphoma: A multi-center analysis. Hematol Oncol 2021; 39:473-482. [PMID: 34347909 DOI: 10.1002/hon.2902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/12/2022]
Abstract
Diffuse large B-cell lymphoma featuring overexpression of MYC and B-Cell Lymphoma 2 (double expressor lymphoma, DEL) is associated with poor outcomes. Existing evidence suggesting improved outcomes for DEL with the use of more intensive regimens than R-CHOP is restricted to younger patients and based on limited evidence from low patient numbers. We retrospectively evaluated the impact of intensive frontline regimens versus R-CHOP in a multicenter analysis across 7 academic medical centers in the United States. We collected 90 cases of DEL, 46 out of 90 patients (51%) received R-CHOP and 44/90 (49%) received an intensive regimen, which was predominantly DA-EPOCH-R. Treatment cohorts were evenly balanced for demographics and disease characteristics, though the intensive group had a higher lactate dehydrogenase (LDH, 326 vs. 230 U/L p = 0.06) and presence of B-symptoms (50% vs. 22%, p = 0.01) compared to the R-CHOP cohort. There was no difference in PFS (median 53 vs. 38 months, p = 0.49) or overall survival (67 vs. not reached months, p = 0.14) between the R-CHOP and intensive therapy cohorts, respectively. On multivariate analysis, intensive therapy was associated with a hazard ratio of 2.35 (95% CI 0.74-7.41), though this was not statistically significant. Additionally, a subgroup analysis of intermediate high-risk lymphoma defined by IPI ≥3 did not identify a difference in survival outcomes between regimens. We conclude that in our multi-center cohort there is no evidence supporting the use of intensive regimens over R-CHOP, suggesting that R-CHOP remains the standard of care for treating DEL.
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Affiliation(s)
- Christopher R D'Angelo
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Walter Hanel
- Department of Internal Medicine, Division of Hematology/Oncology, The Ohio State University Hospital, Columbus, Ohio, USA
| | - Yi Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Menggang Yu
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David Yang
- Department of Pathology, University of Wisconsin Carbone Cancer Center Madison, Wisconsin, USA
| | - Ling Guo
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Madelyn Burkart
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Colleen Ciccosanti
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kevin David
- Division of Hematology/Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Zachary Risch
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | | | - Sumana Devata
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ryan Wilcox
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Malvi Savani
- Division of Hematology and Oncology, Department of Medicine, University of Arizona Cancer Center, Tucson, Arizona, USA
| | | | - Veronika Bachanova
- Department of Internal Medicine, Division of Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emma Rabinovich
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - David Peace
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fauzia Osman
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Narendranath Epperla
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Vaishalee P Kenkre
- Department of Pathology, University of Wisconsin Carbone Cancer Center Madison, Wisconsin, USA
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Hwang J, Suh C, Kim K, Kim H, Kim AI, Craig JW, Chen KX, Roberson J, Guenette JP, Huang RY. The Incidence and Treatment Response of Double Expression of MYC and BCL2 in Patients with Diffuse Large B-Cell Lymphoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:3369. [PMID: 34282799 PMCID: PMC8268769 DOI: 10.3390/cancers13133369] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/02/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022] Open
Abstract
MYC/BCL2 protein co-expression (i.e., double expressor) has been shown to be a negative predictor of outcome in diffuse large B-cell lymphoma (DLBCL). We aimed to establish the incidence of double expressor status in patients with de novo DLBCL and identify the predictive value of this biomarker on treatment response through systematic review and meta-analysis. PubMed and Embase were searched for studies published through December 2019 that reported proportions of double expressor DLBCL. The pooled proportions of MYC and BCL2 expression, both alone and in combination, were computed using the inverse variance method for calculating weights and by the DerSimonian-Laird method. The pooled odds ratios (ORs) of complete remission (CR) rate were calculated, and meta-regression analysis was conducted to explore heterogeneity. Forty-one studies (7054 patients) were included. The pooled incidence of double expressor status in DLBCL was 23% (95% confidence interval [CI], 20-26%), with an adjusted estimate of 31% (95% CI, 27-36%). Neither MYC/BCL2 protein cutoff values, race, mean, or median age of included patients, or overall study quality was a significant factor of heterogeneity (p ≥ 0.20). Cases without double expressor status demonstrated a higher probability of CR to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone treatment (OR, 2.69; 95% CI, 1.55-4.67). Our results reaffirm the predictive power of this important biomarker.
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Affiliation(s)
- Jisun Hwang
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Gyeonggi-do, Korea;
| | - Chonghyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul 05505, Korea; (K.K.); (H.K.)
| | - Kyungwon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul 05505, Korea; (K.K.); (H.K.)
| | - Hosung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul 05505, Korea; (K.K.); (H.K.)
| | - Austin I. Kim
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA;
| | - Jeffrey W. Craig
- Centre for Lymphoid Cancer, British Columbia Cancer, Vancouver, BC V5Z 4E6, Canada;
| | - Ke Xun Chen
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
| | - Joel Roberson
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
| | - Jeffrey P. Guenette
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
| | - Raymond Y. Huang
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
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10
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Safety and Efficacy of Replacing Vindesine with Vincristine in R-ACVBP Regimen for the Treatment of Large B Cell Lymphomas. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:711-719. [PMID: 34140260 DOI: 10.1016/j.clml.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intensified immunochemotherapy with rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (R-ACVBP) improves outcomes in younger adults with diffuse large B-cell lymphomas (DLBCL) compared with R-CHOP. Due to vindesine unavailability, we assessed the safety and efficacy of replacing vindesine with vincristine in a modified R-ACVBP protocol (mR-ACVBP). METHODS This is a retrospective study including all consecutive adult patients with newly diagnosed DLBCL who received first-line mR-ACVBP. Vindesine was replaced with vincristine 1.5 mg on days 1 and 5 of each cycle. Responders continued with published R-ACVBP consolidation. Patients with inadequate response on interim imaging were offered consolidative autologous stem cell transplantation. RESULTS We identified 56 patients with DLBCL, with a median age of 41 years (range, 21-67). Thirty-seven (66%) patients had an age-adjusted International Prognostic Index of ≥ 2. Complete response was achieved in 41 (80%) patients and partial response in 6 (12%). The most common adverse events during induction were anemia (91%), febrile neutropenia (64%; grade 4 in 46%), thrombocytopenia (39%), and mucositis (21%). Peripheral neuropathy was encountered in 7 (12%) patients (grade 3; n = 1). Two deaths from septic shock were reported in patients with initial poor performance status. After a median follow-up of 17 months, the 2-year progression-free survival and overall survival rates were 86% and 87%, respectively. CONCLUSION The replacement of vindesine with vincristine in mR-ACVBP seems feasible, with manageable adverse events and excellent 2-year progression-free survival. These data need validation in larger prospective trials.
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11
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Candelaria M, Dueñas-Gonzalez A. Rituximab in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in diffuse large B-cell lymphoma. Ther Adv Hematol 2021; 12:2040620721989579. [PMID: 33796235 PMCID: PMC7970687 DOI: 10.1177/2040620721989579] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/04/2021] [Indexed: 01/05/2023] Open
Abstract
Background Diffuse large B-cell lymphoma (DLBCL) is the most frequent non-Hodgkin lymphoma worldwide. The current standard of care is chemoimmunotherapy with an R-CHOP regimen. We aim to review the role of this regimen after two decades of being the standard of care. Methods A comprehensive literature review of DLBCL, including the epidemiology, trials defining R-CHOP as the standard of care, as well as dose intensification and dose reduction schemes. Additionally, we briefly review the development of rituximab biosimilars and the addition of targeted drugs to R-CHOP in clinical trials. Discussion R-CHOP cures approximately 70% of DLBCL patients. Dose-dense regimens do not show a benefit in response and increase toxicity. Dose reduction, particularly in elderly patients or with comorbidities, may be a treatment option. DLBCL constitutes a group of diseases that activate different biological pathways. Matching specific treatments to a defined genetic alteration is under development. Rituximab biosimilars have become available to a broader population, particularly in developing countries, where access to treatment is limited because of economic resources. Conclusion DLBCL landscape is heterogeneous. R-CHOP immunochemotherapy has been a standard of care for two decades and cures approximately 70% of cases. Molecular characterization of patients is evolving and may have critical therapeutic implications.
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Affiliation(s)
- Myrna Candelaria
- Clinical Research, Instituto Nacional de Cancerología México, Av San Fernando 22, Col Sección XVI, Tlalpan, 14370, Mexico City, Mexico
| | - Alfonso Dueñas-Gonzalez
- Instituto de Investigaciones Biomédicas, UNAM/Instituto Nacional de Cancerología México, Unit of Biomedical Research on Cancer, Mexico City, Mexico
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12
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COO and MYC/BCL2 status do not predict outcome among patients with stage I/II DLBCL: a retrospective multicenter study. Blood Adv 2020; 3:2013-2021. [PMID: 31285189 DOI: 10.1182/bloodadvances.2019000251] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/09/2019] [Indexed: 02/02/2023] Open
Abstract
In advanced-stage diffuse large B-cell lymphoma (DLBCL), the presence of an activated B-cell phenotype or a non-germinal center (GCB) phenotype, coexpression of MYC and BCL2 by immunohistochemistry, and the cooccurrence of MYC and BCL2 or BCL6 rearrangements are associated with inferior outcomes. It is unclear whether these variables remain prognostic in stage I/II patients. In this retrospective study, we evaluated the prognostic impact of cell of origin (COO), as well as dual-expressor (DE) status and molecular double-hit (DH) status, in stage I/II DLBCL by positron emission tomography with computed tomography (PET-CT). A total of 211 patients treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)-like regimens, with or without radiotherapy, was included. The median follow-up in the entire cohort was 4 years (range, 0.4-9.4), with estimated 4-year progression-free survival (PFS) and overall survival (OS) rates of 85% (95% confidence interval [CI], 79-89) and 88% (95% CI, 83-92), respectively. By univariable analysis, DE (PFS: hazard ratio [HR], 1.27; 95% CI, 0.58-2.81, P = .55 and OS: HR, 1.40; 95% CI, 0.60-3.30; P = .44), DH (PFS: HR, 1.21; 95% CI, 0.27-5.31; P = .80 and OS: HR, 0.61; 95% CI, 0.08-4.73; P = .64), and non-GCB status (PFS: HR, 1.59; 95% CI, 0.83-3.03; P = .16 and OS: HR, 1.80; 95% CI, 0.89-3.67; P = .10) were associated with poorer outcomes. In patients with PET-CT-defined stage I/II DLBCL treated with R-CHOP-like therapy, with or without radiation, COO and DE and DH status were not significantly associated with inferior PFS or OS.
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13
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Li S, Wang Z, Lin L, Wu Z, Yu Q, Gao F, Zhang J, Xu Y. BCL6 Rearrangement Indicates Poor Prognosis in Diffuse Large B-cell Lymphoma Patients: A Meta-analysis of Cohort Studies. J Cancer 2019; 10:530-538. [PMID: 30719149 PMCID: PMC6360306 DOI: 10.7150/jca.25732] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 10/03/2018] [Indexed: 12/19/2022] Open
Abstract
BCL6 (3q27) rearrangement is the most frequent chromosomal abnormality in diffuse large B-cell lymphoma (DLBCL). Previously, studies on the association between BCL6 rearrangement and DLBCL outcome remain controversial. Here we systematically reviewed literatures to identify the prognostic significance of BCL6 rearrangement in DLBCL. Meta-analytic methods are used to obtain pooled estimates of the association between BCL6 rearrangement and prognosis in DLBCL patients treated with different chemotherapy regimens. A total of 22 studies are enrolled in the cohort, involving 3037 patients. BCL6 rearrangement is verified to be negatively associated with overall survival (OS) (HR=1.36, p=0.000), but not with progression-free survival (PFS). Moreover, the subgroup analyses show that BCL6 rearrangement is prognostic only in DLBCLs treated with rituximab-containing regimens.
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Affiliation(s)
- Shu Li
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhan Wang
- Center for Orthopaedic Research, Orthopaedics Research Institute of Zhejiang University, Department of Orthopaedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Liming Lin
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhaoxing Wu
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Qingfeng Yu
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Feiqiong Gao
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jiawei Zhang
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yang Xu
- Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
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14
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Peroja P, Pedersen M, Mantere T, Nørgaard P, Peltonen J, Haapasaari KM, Böhm J, Jantunen E, Turpeenniemi-Hujanen T, Rapakko K, Karihtala P, Soini Y, Vasala K, Kuittinen O. Mutation of TP53, translocation analysis and immunohistochemical expression of MYC, BCL-2 and BCL-6 in patients with DLBCL treated with R-CHOP. Sci Rep 2018; 8:14814. [PMID: 30287880 PMCID: PMC6172218 DOI: 10.1038/s41598-018-33230-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/21/2018] [Indexed: 11/25/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma with diverse outcomes. Concurrent translocation of MYC and BCL-2 and/or BCL-6, and concurrent immunohistochemical (IHC) high expression of MYC and BCL-2, have been linked to unfavorable treatment responses. TP53-mutated DLBCL has also been linked to worse outcome. Our aim was to evaluate the aforementioned issues in a cohort of 155 patients uniformly treated with R-CHOP-like therapies. We performed direct sequencing of TP53 exons 5, 6, 7 and 8 as well as fluorescence in-situ hybridization (FISH) of MYC, BCL-2 and BCL-6, and IHC of MYC, BCL-2 and BCL-6. In multivariate analysis, TP53 mutations in L3 and loop-sheet helix (LSH) associated with a risk ratio (RR) of disease-specific survival (DSS) of 8.779 (p = 0.022) and a RR of disease-free survival (DFS) of 10.498 (p = 0.011). In IHC analysis BCL-2 overexpression was associated with inferior DFS (p = 0.002) and DSS (p = 0.002). DLBCL with BCL-2 and MYC overexpression conferred inferior survival in all patients (DSS, p = 0.038 and DFS, p = 0.011) and in patients with non-GC phenotype (DSS (p = 0.013) and DFS (p = 0.010). Our results imply that in DLBCL, the location of TP53 mutations and IHC analysis of BCL-2 and MYC might have a role in the assessment of prognosis.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols
- Cyclophosphamide
- Doxorubicin
- Female
- Gene Expression Profiling
- Humans
- Immunohistochemistry
- In Situ Hybridization, Fluorescence
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Middle Aged
- Prednisone
- Proto-Oncogene Proteins c-bcl-2/analysis
- Proto-Oncogene Proteins c-bcl-6/analysis
- Proto-Oncogene Proteins c-myc/analysis
- Rituximab
- Sequence Analysis, DNA
- Survival Analysis
- Translocation, Genetic
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
- Vincristine
- Young Adult
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Affiliation(s)
- Pekka Peroja
- Department of Oncology and Radiotherapy, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Mette Pedersen
- Department of Pathology, Herlev and Gentofte University Hospital, University of Copenhagen, Herlev, Denmark
| | - Tuomo Mantere
- Laboratory of Genetics, Northern Finland Laboratory Centre NordLab Oulu, Oulu, Finland
| | - Peter Nørgaard
- Department of Pathology, Herlev and Gentofte University Hospital, University of Copenhagen, Herlev, Denmark
| | - Jenni Peltonen
- Department of Oncology and Radiotherapy, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland
| | | | - Jan Böhm
- Department of Pathology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Esa Jantunen
- Department of Medicine, University of Eastern Finland/Clinical Medicine, Kuopio University Hospital, Siun Sote -North Carelia Central, Kuopio, Finland
| | - Taina Turpeenniemi-Hujanen
- Department of Oncology and Radiotherapy, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Katrin Rapakko
- Laboratory of Genetics, Northern Finland Laboratory Centre NordLab Oulu, Oulu, Finland
| | - Peeter Karihtala
- Department of Oncology and Radiotherapy, Cancer and Translational Medicine Research Unit, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland.
| | - Ylermi Soini
- Department of Pathology, University of Oulu and Medical Research Center, Oulu, Finland
- Department of Pathology, Kuopio University Hospital, Kuopio, Finland
| | - Kaija Vasala
- Department of Oncology and Radiotherapy, Central Finland Central Hospital, Jyväskylä, Finland
| | - Outi Kuittinen
- University of Eastern Finland, Faculty of Health Medicine, Institute of Clinical Medicine Oncology, Kuopio University Hospital, Kuopio, Finland
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