Immunohistochemical prognostic biomarkers in diffuse large B cell lymphoma

Difuzni B krupnoćelijski limfom (DBKL) je najčešći limfoidni tumor i čini oko 30-40% svih non-Hodgkin limfoma (NHL) kod odraslih, sa petogodišnjim preživljavanjem oko 50%. Difuzni B krupnoćelijski limfom je bolest sa značajnom kliničkom, morfološkom, genetskom i molekularnom heterogenošću. Uprkos različitim kliničkim, morfološkim i molekularnim parametrima koji se koriste u klasifikaciji humanih maligniteta danas, pacijenti sa identičnom dijagnozom imaju značajno različit klinički tok bolesti i odgovor na terapiju. Iako je u poslednje dve decenije postignut značajan napredak u terapiji, dodavanjem rituximab-a standardnoj hemioterapiji, ishod bolesti je fatalan za skoro polovinu pacijenata sa DBKL. Mnoge studije su ispitivale prognostičke faktore koji bi predvideli preživljavanje i optimizovale terapijsku strategiju kod pacijenata sa DBKL. Do sada, samo se Internacionalni Prognostički Indeks (IPI), rutinski koristi kao prediktor preživljavanja kod bolesnika sa DBKL. Cilj našeg istraživanja je bio da se utvrdi klinički značaj i prognostička vrednost imunofenotipskih profila DBKL, baziranog na konceptu porekla ćelije (na osnovu algoritma Hans i saradnika): GCB i non-GCB, kao i analiza korelacije ovih grupa sa IPI, onkogenim, proliferativnim i markerima uključenim u apoptozu. Takođe, cilj je bio analiza ekspresije onkogenih, proliferativnih i markera uključenih u apoptozu i njihova korelacija sa ishodom bolesti. Analizirali smo imunohistohemijsku ekspresiju CD20, CD79α, CD3, CD5, CD10, bcl-2, bcl-6, MUM-1, CD138, CD30, HLA-DR, Survivin, BAX, p53, MYC i Ki 67 na parafinskim uzorcima biopsija 115 pacijenata sa DBKL koji su dijagnostikovani i lečeni na Institutu za Hematologiju Kliničkog Centra Srbije u Beogradu u periodu od 2000-2006. godine. Metoda fluorescentne in situ hibridizacije za MYC i bcl-2 urađena je na 67 uzoraka primenom metode tkivnog mikroniza (tissue microarray -TMA). Grupa analiziranih bolesnika je bila relativno mlada, sa posečnom starošću od 56 godina. Na prezentaciji, 85 (74%) pacijenata je bilo u III i IV kliničkom stadijumu, a 30 (26%) u I i II kliničkom stadijumu. Visok IPI je bio prisutan kod 54 (47%) pacijenta, B simptome je imalo 90 (78%), a povišenu LDH 74 (65%) pacijenta. U analiziranoj grupi pacijenata bilo je 106 (92,17%) DBKL NOS, (103 centroblastni, 1 imunoblastni, 2 anaplastična), 4 (3,47%) T ćelijama /histiocitima bogat B limfom, 2 (1,73%) primarna medijastinalna, 2 (1,73%) primarna DBKL centralnog nervnog sistema i 1 (0,86%) intravaskularni...Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma with significant clinical, morphologic, immunohistochemical, and molecular heterogeneity. In the last two decades there has been a significant improvement in the outcome of these patients after the addition of rituximab to the standard chemotherapy. Despite major advances in treatment of DLBCL, approximately one third of patients progress or die, suggesting the existence of additional oncogenic events. By now, only the International Prognostic Index (IPI), based on 5 independent clinical and laboratory parameters, was routinely used as a predictor of survival. However, a substantial variability in outcome has been observed despite IPI subgroups. The aim of the study was to identify new immunohistochemical prognostic biomarkers in diffuse large B cell lymphoma and to evaluate the prognostic value of the immunohistochemical (IHC) algorithm based on the cell-of-origin (COO) concept, and BCL2 and MYC protein expression and gene alterations in DLBCL patients treated with CHOP or R-CHOP chemotherapy, and to correlate these parameters with IPI. We analyzed immunohistochemical expression of CD20, CD79α, CD3, CD5, CD10, bcl-2, bcl-6, MUM-1, CD138, CD30, HLA-DR, Survivin, BAX, p53, MYC and Ki 67 on paraffin-embedded formaline fixed tumor samples from 115 patients with DLBCL, diagnosed and treated at the Clinic for Haemathology, Clinical Center of Serbia, over a five year period. Fluorescence in Situ hybridization for MYC and BCL2 gene alterations was performed on 67 samples using TMA. The cohort consisted of relatively young patients with a median age of 56 years. High IPI was present in 54 (47%) patients, advanced Ann Arbor stage (III-IV) in 85 (74%), B-symptoms in 90 (78%), and high serum LDH levels in 74 (65%) patients. In the cohort, there were 106 (92,17%) DLBCL NOS, (103 centroblastic, 1 immunoblastic, 2 anaplastic), 4 (3,47%) T cell rich B lymphoma, 2 (1,73%) mediastinal large B cell lymphoma, 2 (1,73%) CNS lymphoma and 1 (0,86%) intravascular type. DLBCL with centroblastic morphology (103), were selected to provide morphological homogeneity of the cases, and according to the Hans algorithm, a GCB phenotype was observed in 28 (27%) and non-GCB in 75 (72%) cases. Forty six (44,66%) patients received CHOP or CHOP- like therapy, and 57 (55,33%) patients received R-CHOP therapy..

Extramedullary plasmacytoma of the tongue base: A rare presentation of head and neck plasmacytoma

Introduction. Special entities like solitary bone plasmocytoma (SBP) or extramedullary plasmacytoma (EMP) can be found in a less than 5% of patients with plasma cell disorders. EMP of the tongue represents very rare localization of the head and neck plasmacytoma. Case report. We report a case of 78-years-old woman who developed EMP of the tongue base detected by the magnetic resonance imaging (MRI) of the head and neck region. Immunohistochemical profile of the tumor tissue biopsy (CD38, IgG, kappa positivity) indicated diagnosis of EMP. The diagnosis was established with additional staging which confirmed the absence of other manifestation of the disease. The patient was treated with 40 Gy of radiotherapy in 20 doses resulting in the achievement of the complete remission of the disease. This case was discussed with the reference to the literature. Conclusion. EMP of the tongue base is a very rare entity of plasma cell dyscrasias. Appropriate irradiation results in the achievement of a long-term remission and a potential cure of the disease

The emergence of non-secretory multiple myeloma during the non-cytotoxic treatment of essential thrombocythemia: A case report

Introduction. The emergence of multiple myeloma as a second malignancy in patients with essential thrombocythemia is extremely rare. Several cases have been published so far, pointing out the impact of a cytotoxic effect during treatment of essential thrombocythemia on the development of multiple myeloma. Case presentation. We report the case of a 52-year-old Caucasian man who presented to our hospital because of leukocytosis, a slightly decreased hemoglobin level and thrombocytosis. After a complete hematological work-up, essential thrombocythemia was diagnosed. The patient was included in a multicenter clinical study, treated with anagrelide and his platelet counts were maintained in the normal range for more than 3 years. A sudden drop in his hemoglobin level with normal leukocyte and platelet count occurred at the same time as a back pain. Magnetic resonance imaging of his spine revealed the existence of a pathological fracture of Th4, the collapse of the upper edge of Th7 and osteolytic lesions of multiple thoracic vertebrae. Repeated hematological examinations, including bone biopsy with immunohistochemistry, disclosed diagnosis of multiple myeloma of the non-secretory type. Conclusions: To the best of our knowledge this is the first published case in which multiple myeloma developed during the treatment of essential thrombocythemia with the non-cytotoxic drug anagrelide. Our attempts to find a common origin for the coexistence of multiple myeloma and essential thrombocythemia have not confirmed the genetic basis of their appearance. Further studies are needed to determine the biological impact of this coexistence

Systemic mastocytosis: Case report with literature review

Introduction. Mastocytosis is a clonal neoplastic disorder of the mast cells. The clinical signs and symptoms of mastocytosis are heterogeneous ranging from indolent disease with a longterm survival to a highly aggressive neoplasm with survival of about 6 months. Systemic mastocytosis (SM) is characterized by mastocyte infiltration of one or more organs, with or without skin involvment. Case Outline. The presented patient presents a highly challenging diagnostic and therapeutic case. A 46-year-old man was referred to our Centre due to the 7-year-long history of hepatosplenomegaly and mild thrombocytopenia. Ultrasound examination showed hepatosplenomegaly (liver 170 mm; spleen 200 mm), platelet count was 90Č109/L, serum tryptase level was elevated and bone marrow biopsy showed infiltration with mast cells (CD117, CD25 and mast cell tryptase positive). Our patient was diagnosed with aggressive systemic mastocytosis (SM) according to WHO Classification (2008), although the clinical course of the disease was indolent, without complications for more than 7 years. Because of the ‘intermediate’ course, this patient was referred to as smouldering or intermediate SM and was not treated with cytostatics. Conclusion. Utilizing the established criteria, indolent SM can be discriminated from the aggressive subvariants of SM in most cases. However, a small group of patients, like our case belongs to the „grey zone“. Therapeutic approach to these patients is individual and prognosis is uncertain

Prognostic significance of new biological markers in chronic lymphocytic leukaemia

Introduction. Chronic lymphocytic leukaemia is a disease with heterogeneous clinical course and outcome. Some patients have a progressive course of the disease and require therapy immediately after the diagnosis, while others have a stable form without the need for treatment. Recently, two new biological markers, the expression of CD38 antigen and ZAP-70 have shown independent significance in the prognosis in CLL patients. Objective. The aim of our study was to evaluate the clinical value of CD38 antigen and ZAP-70 expression as predictors of the disease progression and to analyze the correlation of these markers with other B-CLL prognostic markers. Methods. We assessed the expression of CD38 antigens by flow cytometry on peripheral blood samples and the expression of ZAP-70 by immunohistochemistry on formalin-fixed bone marrow (BM) biopsies in 40 newly diagnosed B-CLL patients. Disease progression was defined by the period elapsed from diagnosis to the time to first treatment (TFT). Results. Expression of CD38 antigen correlated positively with ZAP-70 expression (Pearson, r=0.476; p=0.002). Also, correlation analysis results showed that a positive expression of CD38 and ZAP-70 statistically significantly correlated with unfavourable classical prognostic parameters, such as advanced Binet stage C, diffuse BM infiltration, increased lactate-dehydrogenase and beta-2 microglobulin serum levels. Patients with positive expression of CD38 antigen and ZAP-70 had a shorter TFT (log rank, 0.003 vs. 0.049). Conclusion. Both new biological markers were shown to have an exceptional significance in the prediction of prognosis in CLL patients

Contribution of comorbidities and grade of bone marrow fibrosis to the prognosis of survival in patients with primary myelofibrosis

The widely used current International Prognostic Scoring System (IPSS) for primary myelofibrosis (PMF) is based on clinical parameters. The objective of this study was to identify additional prognostic factors at the time of diagnosis, which could have an impact on the future treatment of patients with PMF. We conducted a study of 131 consecutive PMF patients with median follow-up of 44 months. Data on baseline demographics, clinical and laboratory parameters, IPSS, grade of bone marrow fibrosis (MF), as well as influence of concomitant comorbidities were analyzed in terms of survival. Comorbidity was assessed using the Adult Comorbidity Evaluation-27 (ACE-27) score and the hematopoietic cell transplantation comorbidity index. An improved prognostic model of survival was obtained by deploying the MF and ACE-27 to the IPSS. A multivariable regression analyses confirmed the statistical significance of IPSS (P lt 0.001, HR 3.754, 95 % CI 2.130-6.615), MF gt 1 (P = 0.001, HR 2.694, 95 % CI 1.466-4.951) and ACE-27 (P lt 0.001, HR 4.141, 95 % CI 2.322-7.386) in predicting the survival of patients with PMF. When the IPSS was modified with MF and ACE-27, the final prognostic model for overall survival was stratified as low (score 0-1), intermediate (score 2-3) and high risk (score 4-6) with median survival of not reached, 115 and 22 months, respectively (P lt 0.001). Our findings indicate that the combination of histological changes, comorbidity assessment and clinical parameters at the time of diagnosis allows better discrimination of patients in survival prognostic groups and helps to identify high-risk patients for a poor outcome