Rituximab with dose-adjusted EPOCH as first-line treatment in patients with highly aggressive diffuse large B-cell lymphoma and autologous stem cell transplantation in selected patients.

AIM: To assess the benefit of rituximab with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-DA-EPOCH) regimen as a first-line treatment for patients with diffuse large B-cell lymphoma (DLBCL) presenting with unfavorable or aggressive features, and autologous stem cell transplantation (ASCT) as a part of the first-line treatment for selected DLBCL patients with additional aggressive features. METHODS: We retrospectively analyzed 75 newly diagnosed DLBCL patients with Ki-67+≥80% or International Prognostic Index ≥2 who were treated with R-DA-EPOCH between 2005 and 2015. Of 24 DLBCL patients with additional aggressive features (Ki-67+≥90% or age-adjusted IPI≥2) who were planned to receive consolidation with ASCT, 17 patients underwent the procedure. We determined the overall response rate (ORR), complete remission (CR), partial remission (PR), 5-year overall survival (OS), and progression free survival (PFS) in all DLBCL patients and specifically those planned to receive ASCT. RESULTS: All 75 patients included in the analysis started one or more cycles of therapy. The ORR, CR, and PR rates were 80%, 55%, and 25%, respectively. The response was non-evaluable in 10 of 75 patients due to treatment discontinuation. The OS and PFS rates for all 75 patients were 70% and 61%, respectively, and 80% and 79%, respectively, for 24 planned-to-receive-ASCT patients. Age (≤65 vs >65 years) had no prognostic impact on OS and PFS (P=0.994 and P=0.827, respectively). CONCLUSION: Our retrospective analysis of one of the largest DLBCL patient cohorts outside the US National Cancer Institute showed that R-DA-EPOCH is a very effective therapeutic option as a first-line treatment of DLBCL patients with unfavorable prognostic features irrespective of their age. ASCT provided additional benefit for DLBCL patients with additional aggressive features.

Follicular and mantle cell lymphoma characteristics present simultaneously in the same lymph node.

Follicular lymphoma is composed of clonal germinal center B cells. It shows a follicular pattern lacking mantle zones, with a network of interfollicular dendritic cells. Transformation to more aggressive lymphomas is documented, but the only connections to mantle cell lymphoma are described cases of composite lymphoma consisting of these 2 entities. We discuss here a case of a lymph node harboring CD20, CD10, BCL2, BCL6, cyclin D1, CD5, Ki67, and SOX11 with CD21, showing an almost intact network of dendritic cells in one part of a lymph node, and CD20, CD5, SOX11, BCL6, cyclin D1, CD10, Ki67, and CD21 cells restricted to the mantle area in another part of the same lymph node. Both parts of the lymph node had BCL2 rearrangement, a lack of t(11:14)(q13;q32), the presence of SOX11 expression, and the same clonal band. The described case suggests heterogenous development of small cell lymphomas and indicates the possibility of differentiation regression.

Prognostic significance of survivin and caspase-3 immunohistochemical expression in patients with diffuse large B-cell lymphoma treated with rituximab and CHOP.

Survivin is an inhibitor of apoptosis whose expression may be associated with inferior outcome in patients with diffuse large B-cell lymphoma (DLBCL) treated without rituximab. Caspase-3 is the final caspase of the apoptotic cascade and its pattern of expression may also be related to patients' outcome. In this study we investigated immunohistochemical expression of survivin and caspase-3 (CPP32) in 57 patients with DLBCL treated with rituximab and CHOP (R-CHOP). According to previously published criteria, we separately analyzed correlation of different types of survivin expression with patients' outcome. Nuclear survivin was expressed in only 26% of cases, cytoplasmic survivin was expressed in 81% of cases while application of immunoreactivity scoring system yielded 58% of survivin positive cases. Caspase-3 was expressed in 77% of cases. There were no significant correlations between any type of survivin expression and response to treatment or survival of the patients. The expression of caspase-3 was also not associated with patients' outcome. We conclude that survivin and caspase-3 have no significant prognostic significance in patients with DLBCL treated with R-CHOP.

Detection of t(14;18) by PCR of IgH/BCL2 fusion gene in follicular lymphoma from archived cytological smears.

According to WHO classification follicular lymphoma (FL) is a neoplasm composed of follicle centre (germinal centre) B-cells, which usually has at least a partially follicular pattern. Bone marrow (BM) infiltration by lymphoma occurs in 40-70% of cases at the time of diagnosis. The characteristic chromosomal translocation of follicular lymphoma is t(14;18)(q32;q21) with transposition of BCL2 oncogene to the regulatory region of immunoglobulin heavy chain gene IgH. Aim of this study was to determine the frequency of PCR detection of IgH/BCL2 in DNA samples isolated from archival cytological slides of lymph node aspirates, bone marrow and/or peripheral blood (PB) obtained from patients with histologically confirmed follicular lymphoma using primers and protocol proposed by BIOMED-2 consortium. We also compared molecular with cytomorphological findings in bone marrow/peripheral blood and tested this method of detection of IgH/BCL2 molecular marker in monitoring minimal residual disease (MRD) in routine clinical setting. DNA was successfully isolated from all archival cytological slides obtained by fine needle aspiration of lymph nodes as well as from 75% of smears of bone marrow aspirates from 19 patients. Fusion oncogene was detected in 10 of 19 patients (52%). For patients with PCR IgH/BCL2 positive lymph nodes, molecular test found BM infiltration in 5 cases (83%), while cytomorphology detected infiltration in three of eight cases (37%) available for comparison. May-Grünwald-Giemsa stained cytological smears can be used for PCR-based ancillary methods and the rate of detection of IgH/BCL2 rearrangement is similar to results reported for paraffin-embedded tissues. For patients with detectable baseline molecular marker, PCR is a highly suitable method for detection of bone marrow involvement and monitoring MRD.

Cytogenetics of multiple myeloma.

Great studies of multiple myeloma (MM) strongly suggested that specific chromosomal changes are of prognostic significance in patients with MM1. We have performed cytogenetic analysis and recently fluorescent in situ hybridization (FISH) on 43 cases of MM. Clonal chromosomal changes were present in 24 (56%) cases. Hyperdiploid karyotype was found in 12 (50%) cases, hypodiploid in 8 (33%) cases, and 4 (17%) cases had a pseudodiploid karyotype. The most common numerical abnormalities were gains of whole chromosomes 15, 11, 3 and 6. Whole chromosome losses were also frequent involving chromosomes X, 13, 14, and 8. Most cases showed also structural rearrangements 71% (n = 17): del(1p), dup(1q), del(5q), del(13q), del(17p) and t(11;14)(q13;q32) (n = 4, 17%). Chromosome -13/13q deletion was found in 42% (n = 10) cases; complete loss of 13 was observed in 67% (n = 7) cases, whereas 33% (n = 3) had interstitial deletions. In the majority of the cases there was a mixture of abnormal and normal metaphases.

Misleading presentations of malignant breast diseases--role of clinical cytology.

We described two examples with misleading presentations to draw attention to the role of clinical cytology as apart of multidisciplinary approach to breast lesions. In the first case--Paget's disease of the nipple, there was no obvious clinical and radiological evidence of breast cancer, while the second case--primary non-Hodgkin lymphoma of the breast imitated advanced breast carcinoma. The question is whether accurate and fast diagnoses can be made without cytological examinations. It must be kept in mind that first-hand clinical information and contact with the patient is necessary in rendering accurate cytological diagnoses.

Lack of prognostic significance of the germinal-center phenotype in diffuse large B-cell lymphoma patients treated with CHOP-like chemotherapy with and without rituximab.

The influence of the germinal-center B-cell (GCB) and the non-GCB phenotypes of diffuse large B-cell lymphoma (DLBCL) on the outcome of 92 patients treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like chemotherapy, with or without rituximab was determined in this study. The differentiation between the GCB and non-GCB types was arrived at by immunohistochemistry using previously published criteria. Thirty-nine patients had the GCB and 53 had the non-GCB type of DLBCL. Forty-nine patients were treated with rituximab and chemotherapy; 43 were treated with chemotherapy alone. The GCB and non-GCB group did not differ in their international prognostic index factors and score, presence of bulky disease, or frequency of rituximab treatment. Median follow-up of the surviving patients was carried out for 37 months. There was no difference between the GCB and non-GCB groups in both overall response rates (67 vs. 70%, respectively) and estimated rates of 3-year event-free (46 vs. 49%, respectively) and overall (54 vs. 56%, respectively) survival. In addition, no differences of the outcomes were observed between the subgroups treated with or without rituximab. The patients of this study with immunohistochemically determined GCB-type DLBCL did not have an improved prognosis, irrespective of whether they had received rituximab or not.

FOXP1 and BCL2 show similar immunoenzymatic pattern in bone marrow trephines of chronic lymphocytic leukemia patients.

Indolent B lymphoproliferative disorder, chronic lymphocytic leukemia (CLL) represents one of the most common hematologic diseases in the Western world. Although there are many disease development markers known so far, for example, B-cell lymphoma/leukemia (BCL) 2, new ones are needed for better understanding course of the disease. FOXP1 is known to be strongly expressed after B-cell activation. Its essential role in B-cell development suggested that it could also have a role in a various tumor B-cells. We have analyzed 74 bone marrow samples from B-CLL patients for presence of FOXP1 and its gene aberrations in tumor cells. Our results showed presence of FOXP1 protein mostly in the same tumor cells as BCL2 protein, and their specific immunostaining pattern. Diffuse immunostaining pattern of both proteins is present in patients with higher clinical stages of B-CLL and with some other markers that indicate worse outcome of the disease. Thus, FOXP1 and/or BCL2 immunostaining of bone marrow trephine sections could serve as an immunohistochemical marker in B-CLL.

CD43 expression is an adverse prognostic factor in diffuse large B-Cell lymphoma.

BACKGROUND: CD43 is a transmembrane glycoprotein expressed in different hematopoietic cells, including some subsets of B lymphocytes. About a quarter of diffuse large B-cell lymphomas (DLBCLs) express CD43, but its prognostic significance is unknown. PATIENTS AND METHODS: We analyzed the prognostic effect of immunohistochemically determined CD43 expression in 119 patients with newly diagnosed DLBCL. All were treated with CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone)-like chemotherapy, 57 without and 62 with rituximab. RESULTS: A total of 31 DLBCL cases (26%) expressed CD43. Patients with CD43+ and CD43- lymphomas did not differ regarding sex, International Prognostic Index (IPI) factors and score, rituximab treatment, presence of bulky disease, or germinal center subtype. Median follow-up was 45 months. Patients with CD43+ DLBCL had significantly lower complete response rates (59% vs. 80%; P = .019), 2-year event-free survival (EFS) rates (34% vs. 64%; P = .003), and overall survival (OS) rates (45% vs. 76%; P = .002). The prognostic significance of CD43 expression was retained in multivariate analysis (relative risk [RR] 2.04; P = .013 for EFS; RR 2.17; P = .016 for OS). In subgroup analysis, the effect of CD43 expression was significant in patients treated with rituximab and those with low IPI, whereas it was not reached in patients treated without rituximab. The effect was not observed in patients with high IPI. CONCLUSION: These results indicate that CD43 expression is an important independent adverse prognostic factor in DLBCL.

FOXP1 expression in monoclonal gammopathy of undetermined significance and multiple myeloma.

Multiple myeloma (MM) is a clonal disorder of terminally differentiated B cells. In some cases the premalignant state is monoclonal gammopathy of undetermined significance (MGUS). Neoplastic plasma cells in both entities carry multiple and complex chromosomal abnormalities that make understanding of the disease development difficult. New insight into malignant mechanisms that underlie multiple myeloma may come from forkhead box P1 transcription factor (FOXP1) analysis in neoplastic plasma cells. FOXP1 is known to be important for B-cell maturation and differentiation and could play a significant role in plasma cell tumors. The purpose of the present study was therefore to analyze FOXP1 protein presence and FOXP1 gene abnormalities in 13 cases of MGUS and 60 cases of MM. It was found that FOXP1 protein was expressed in neoplastic plasma cells, unlike in their normal counterparts, and that additional FOXP1 gene copies could be found in both MGUS and MM. Based on FOXP1 presence in MM and its role in diffuse large B-cell lymphoma and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, FOXP1 might play an important role in plasma cell neoplasm.

Immunohistochemical analysis of ZAP-70 expression in chronic lymphocytic leukemia.

This paper shows a protocol for the detection of ZAP-70 expression in B-CLL (B cell chronic lymphocytic leukemia) tumor cells by common immunohistochemical methods. The study was conducted on bone marrow trephine biopsies from 62 B-CLL patients at the time of diagnosis. Immunohistochemical reactions based on peroxidase and alkaline phosphatase reactions were used, as well as double immunofluorescent labeling for ZAP-70 detection as an indirect marker of mutated and unmutated CLL. Clinical relevance of the ZAP-70 expression detection method was assessed using chi2 test between ZAP-70 positivity data and other known prognostic factors, i.e., clinical and cytogenetics data. ZAP-70 was detected in 13 out of 62 patients. Statistically significant results were obtained for ZAP-70 positive cases and known indicators of worse prognosis. Immunohistochemical analysis supported by double immunofluorescent labeling, as shown here, is an easy and reliable technique for the detection of ZAP-70 expression in B-CLL tumor cells applicable in every hematopathology laboratory.

Bone marrow renin-angiotensin system expression in polycythemia vera and essential thrombocythemia depends on JAK2 mutational status.

Recent observations raise possibility for constitutively active, mutated JAK2 to modulate expression of RAS genes in CMPD. We analyzed the expression of AGT, renin, AT2R1 and ACE genes in normal and bone marrows of PV and ET patients with the respect to the presence of V617F JAK2 mutation. PV and ET had different expression patterns of major RAS components compared to normal BM which was primarily associated with the JAK2V617F mutation and less with PV or ET disease phenotype. However, AT2R1 was exclusively markedly upregulated only in PV, while ET showed moderate expression irrespective of the JAK2 mutational status.

FCgammaRIIIA and FCgammaRIIA polymorphisms are not associated with response to rituximab and CHOP in patients with diffuse large B-cell lymphoma.

We investigated the association ofFcgammaRIIIaa and FcgRIIa polymorphisms and response to R-CHOP in 58 patients with diffuse large B-cell lymphoma (DLBCL). FcgammaRIIIa and FcgRIIa polymorphisms did not influence response, event-free or overall survival. These results suggest that ADCC via FcgammaRIIIa and FcgammaRIIa may not be the major mechanism of activity of the R-CHOP combination in DLBCL.

[90Y-ibritumomab tiuxetan in patients with follicular lymphoma relapsing or refractory to rituximab]. / 90Y-ibritumomab tiuksetan u bolesnika s refraktornim folikularnim limfomom ili u relapsu nakon rituksimaba.

Radioimmunotherapy is a new antineoplastic treatment modality combining the effects of irradiation and monoclonal antibodies. 90Y-ibritumomab tiuxetan is a monoclonal antibody directed against the CD20 antigen to which a radioactive isotope of yttrium is attached, used for treating follicular lymphomas (FL). Using this compound we treated 8 patients with FL relapsing or refractory to combinations of rituximab and chemotherapy. Severe neutropenia developed in 5, and severe thrombocytopenia and anemia in 3 patients. Serious infections developed in 2 patients, one died. Six patients responded to treatment, 4 are still in remission after a median follow-up of 15 months, 2 died of lymphoma. Best response was achieved in low-risk patients with a low tumor burden. 90Y-ibritumomab tiuxetan is an effective treatment for FL with significant hematological toxicity and a high price.