|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
Prepublished online as a Blood First Edition Paper on August 8, 2002; DOI 10.1182/blood-2002-04-1286.
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
From the Departments of Pathology and Hematology,
Hospital Clínic, Institut de Recerca Biomèdica August Pi
i Sunyer, University of Barcelona, Barcelona, Spain; and
Institute of Hematology, Policlinico Monteluce, University of Perugia,
Italy.
To analyze the relationship between immunophenotyping profile and
main clinicopathological features and outcome in diffuse large B-cell
lymphoma (DLBCL), we studied 128 patients (59 men, 69 women; median age
65 years) consecutively diagnosed with de novo DLBCL in a single
institution. Cells from each patient were immunostained with
CD20, CD79a, CD5, CD10, bcl-6, MUM1, CD138, bcl-2, p53, p27,
and Ki-67 antibodies. Four immunophenotyping profiles were
distinguished according to the pattern of differentiation: germinal
center-CD10+ (GC-CD10+;
CD10+/Bcl-6+/MUM1 Diffuse large B-cell lymphoma (DLBCL) is the most
common type of lymphoma in Western countries, representing about one
third of these disorders.1 Although DLBCL is usually
considered as a specific category, the diversity in the clinical
presentation, morphology, genetic and molecular alterations strongly
suggests that these tumors represent a heterogeneous group of neoplasms rather than a single clinicopathological entity.2 In fact, the biological and clinical heterogeneity of DLBCLs has already been
recognized in the Revised European-American Lymphoid (REAL) and
World Health Organization (WHO) classifications.3,4
However, the different approaches to separate nosological entities
within DLBCLs have failed, owing in part to their lack of
reproducibility. Delineation of the possible different categories of
DLBCL with clinical relevance may help to identify groups of patients
with distinct clinical presentation and outcome who may benefit from specific treatments. About one half of DLBCL patients can be cured with
current therapies, but most of the remaining half eventually die of the
disease. Clinical prognostic systems, including the International
Prognostic Index (IPI),5 although useful to assess overall
prognosis, embrace patients with heterogeneous prognoses. It is likely
that the prognostic assessment of patients with DLBCL might be improved
by using biological features.
During the last decade, most studies dealing with the heterogeneity of
DLBCL have focused on morphologic features, individual protein
expression, or molecular alterations. The significance of morphological
variants, including immunoblastic lymphoma, remains controversial. The
low reproducibility of histopathologic criteria and the lack of
objective immunophenotypic or genetic features have made it impossible
to build up new categories on this basis. On the other hand, the
expression of individual antigens related to different stages of B-cell
differentiation, including CD5, CD10, bcl-6, MUM1/IRF4, and CD138, may
help to define groups of tumors with different clinical and
pathological characteristics.6-10 In fact, some studies
have observed a potential prognostic value of the individual expression
of these antigens.11-14 More recently, the global
expression profile of DLBCL has been analyzed by means of cDNA and
oligonucleotide microarrays.15-17 Two main gene
patterns have been characterized according to the germinal center (GC) or post-GC (activated B-cell) origin. Besides the different biological behavior, these groups show marked differences in terms of
clinical features and outcome. However, the potential clinical value of the stage of differentiation of DLBCL defined by the immunophenotypic profile is not known. In addition to morphological and phenotypic characteristics, several oncogenic and proliferation-related genes, such as bcl-2, bcl-6, p53, and p27, have been identified as potential prognostic factors in these tumors, with conflicting results among different studies.10,14,18-28
The aims of this study were to determine the clinical significance and
prognostic value of different immunophenotypic profiles related to
germinal and postgerminal cell differentiation in DLBCL defined by a
relatively small number of single antigens, and to investigate the
possible relationship of these groups of tumors with different
oncogenic and proliferative markers in a homogeneous series of patients
diagnosed and treated in a single institution.
Patients
The median age of the patients was 65 years (range, 22-93 years); 59 were men and 69 were women. Main characteristics of the patients at
diagnosis are listed in Table 1. Primary
extranodal origin (excluding 14 patients with primary ORL area
involvement) was shown in 50 cases (39%). Overall, advanced stage
(III/IV) was observed in 64 cases (50%) and extranodal involvement in
90 (70%), including bone marrow infiltration in 22 (17%). Of 115 patients with available data, 63 (55%) presented with high serum lactic acid dehydrogenase (LDH) levels, whereas the distribution according to the International Prognostic Index (IPI) was the following: low risk, 37 cases (31%); low/intermediate risk, 26 cases
(22%); high/intermediate risk, 22 cases (19%); high risk, 33 cases
(28%); and nonassessable, 10 cases. The main initial and evolutional
variables, including the histologic parameters indicated below, were
recorded and analyzed for prognosis.
Staging maneuvers included thoracic, abdominal, and pelvic computed
tomography (CT) scans, as well as bone marrow biopsies. All
the patients were treated homogeneously with combination chemotherapy: adriamycin-containing regimens (in most cases CHOP [cyclophosphamide, adriamycin, vincristine, and prednisone]) in 110 patients
(86%) and combination chemotherapy without adriamycin in the remaining 18 patients. Posttherapy restaging consisted of the repetition of the
previously abnormal tests and/or biopsies. Response was assessed
according to conventional criteria.29 Overall, 74 patients (58%) achieved a complete response (CR), 14 (11%) achieved a partial response, and 41 (32%) failed to respond to treatment. After
a median follow-up of 6.5 years (range, 0.2-12.8 years) for alive patients, 72 patients had died. The 5-year overall survival (OS) was
43% (95% confidence interval [CI], 34%-52%; Figure
1).
Histologic features The diagnosis of DLCL was based on the criteria established in the WHO classification. Histologic slides were reviewed in all cases by 2 observers (L.C. and E.C.). Morphological subclassification was performed according to the following categories, based on slight modifications of the updated Kiel classification criteria30: centroblastic 90% or more of tumor cells
were typical centroblasts; polymorphic centroblasticthe proportion of
immunoblasts ranged from 10% to 90% of tumor cells; and
immunoblastic90% or more of tumor cells were immunoblasts. In
addition, DLBCLs were considered plasmablastic when the tumor cells
expressed a plasma cell differentiation phenotype (CD20 ,
CD79a+) with immunoblastic large cell lymphoma morphology.
For comparisons among different groups in the statistical analysis,
polymorphic centroblastic lymphomas were further subclassified into
cases with 50% or less or more than 50% immunoblasts. The former were included in the group of centroblastic DLBCLs, whereas the latter cases, with more than 50% immunoblasts, were added to the
immunoblastic subgroup. Finally, cases that did not fulfill
morphological criteria were considered not further classifiable.
Immunohistochemistry The panel of monoclonal antibodies included antibodies against the following antigens: CD20, CD79a, CD3, CD5, CD10, MUM1, CD138, bcl-2, bcl-6, Ki-67, p53, and p27. In Table 2, the antibodies and the immunohistochemical conditions of use are detailed. B-cell lineage was assigned to cases with CD20 and/or CD79a positivity. A variable number of accompanying mature T cells was seen in each case. Five-micrometer paraffin sections from formalin-fixed material were dehydrated and deparaffinized according to standard procedures. A previous step of heat-induced antigen retrieval was used for CD10, bcl-2, bcl-6, MUM1, Ki-67, p53, and p27 in all cases. After incubation with the primary antibodies, the immunoreaction was developed in an automated TechMate 500 (Dako, Glostrup, Denmark), using the Dako Envision+ System peroxidase technique, with diaminobenzidine (DAB) as chromogen. The slides were counterstained with Mayer hematoxylin.
All samples were evaluated in a semiquantitative way after the observers studied the whole immunostained slide, scoring at least 200 cells in well-preserved areas. Samples were stratified into 5 groups: 1 (0% to fewer than 10% of tumor cells were stained), 2 (10% to 25% positive cells), 3 (26% to 50% positive cells), 4 (51% to 75% positive cells), and 5 (more than 75% positive cells). CD10, bcl-6, MUM1, CD138, and p27 expression were considered positive when the score was 3 or higher (more than 25%). MUM1 positivity was considered only when tumor cells presented nuclear staining, although in some cases the cytoplasm was also stained. Finally, p53 expression was scored as positive if more than 10% of the tumor cells had nuclear staining (score 2 or higher). Tumor proliferation was analyzed by 2 different methods: (1) analysis of mitotic index, considering a cutoff of 25 mitoses per 10 high-power fields (HPFs), and (2) proliferative index, assessed by Ki-67 immunostaining. As detailed in Table 3, the patients were
clustered into 4 groups according to immunophenotypic profile in order
to assess the pattern of differentiation: germinal center origin with
CD10 positivity (GC-CD10+;
CD10+/bcl-6+/MUM1
Rearrangement of bcl-2/JH DNA was extracted from paraffin-embedded tissues in 51 cases and from frozen tissues in 6 cases. In 23 samples, DNA was isolated from both frozen and paraffin-embedded tissues. DNA was isolated from frozen tissues by proteinase K/RNase treatment and phenol extraction, whereas tissue sections from formalin specimens were first deparaffinized with xylene and dehydrated with ethanol and then DNA was extracted by the standard proteinase K routine methods. Detection of the t(14;18) involving the bcl-2 major breakpoint region (MBR) and minor cluster region (mcr) was performed by polymerase chain reaction (PCR) in a Model 2400 thermal cycler (Applied Biosystems, Foster City, CA) using standard buffer conditions. Primers used were MBR: 5' TTA GAG AGT TGC TTT ACG TGG CCT G 3' and JH: 5' ACC TGA GGA GAC GGT GAC C 3' for the MBR, and MC9: 5' TCT TGC AGG GTC TTT AAG CAG 3' and JH for the mcr. A regimen of 35 cycles of denaturation for 1 minute at 94°C, annealing for 1 minute at 57°C, and elongation for 1 minute at 72°C was used in both reactions. Products were separated by electrophoresis on a 2% agarose gel and visualized under ultraviolet light following ethidium bromide staining.Statistical analysis Categorical data were compared by Fisher exact test, 2-sided P, whereas for ordinal data, nonparametric tests were used. Bonferroni correction for multiple comparisons was applied when necessary. The actuarial survival analysis was performed according to the method described by Kaplan and Meier31 and the curves were compared by log-rank test.32 The multivariate analysis was performed with the Cox stepwise proportional hazards model.33
Morphological study The 128 DLBCLs were classified as follows: centroblastic, 49 (38%); centroblastic polymorphic with 50% or fewer immunoblasts, 18 (14%); centroblastic polymorphic with more than 50% immunoblasts, 15 (12%); immunoblastic, 12 (9%); plasmablastic, 3 (2%); other, 3 (2%; 2 of these patients had pleomorphic DLBCLs and 1 had a T cell-rich DLBCL). The remaining 28 DLBCLs were not otherwise classifiable, since they did not fulfill the criteria of any of the above-mentioned subgroups.Immunophenotypic profile The immunohistochemical expression of single antigens is detailed in Table 4. Patients expressing MUM1 more frequently presented with immunoblastic morphology (more than 50% immunoblasts) than did those who were MUM1-negative (37% vs 17%; P = .04), whereas, on the contrary, patients who were CD10 positive more often showed centroblastic morphology (50% or fewer immunoblasts) than did CD10-negative patients (91% vs 65%; P = .03).
The distribution of the patients according to the immunophenotypic
patterns previously described (Table 3) was as follows: GC-CD10+ profile, 24 patients (19%); GC-CD10 A significant relationship was found between the morphology and the
immunophenotypic profile of the patients (Table
5). Patients with pGC profiles more
frequently showed an immunoblastic morphology (more than 50%
immunoblasts; 18[39%] of 46 patients) than did GC-CD10
Rearrangement of bcl-2/JH Rearrangement of bcl-2/JH was assessed in 57 patients. Seven patients showed bcl-2/JH rearrangement at MBR (4 patients) or mcr (3 patients). All 7 patients with bcl-2/JH were GC-CD10+ patients (7 of 17); the incidence of bcl-2/JH rearrangement was 41%, 0%, and 0% for GC-CD10+, GC-CD10, and pGC
patients, respectively (P < .001) (Table 5). In addition, bcl-2/JH rearrangement was associated with CD10 expression (7 of 20 CD10-positive patients; P < .001), independently of MBR or mcr involvement (P = .008 and P = .028,
respectively), but not with bcl-6, MUM1, CD138, or bcl-2 expression.
Proliferative activity analysis Overall, 92 of the 118 assessable patients (78%) showed a mitotic index higher than 25 mitoses per 10 HPFs. No differences were found among morphologic subtypes or differentiation profile groups according to the mitotic index. The proliferative index, as assessed by Ki-67, was 25% or lower in 10 patients, 26% to 50% in 9 patients, 51% to 75% in 39 patients, and higher than 75% in 66 patients. The Ki-67 index of GC-CD10+ patients was significantly lower (Ki-67 < 25% in 29% of the patients) than that of GC-CD10 patients (Ki-67 < 25% in 3% of the patients;
P = .02) and pGC patients (Ki-67 < 25% in 2% of the
patients; P = .001).
Clinical features The main clinical features of the patients are described in "Patients and methods" and listed in Table 1. When the clinical features were analyzed according to the patterns of differentiation (GC-CD10+, GC-CD10, and pGC), as summarized
in Table 6, GC-CD10
patients more often exhibited a primary extranodal origin, excluding Waldeyer ring areas (59%) than did GC-CD10+ patients
(50%; P = .09) and pGC patients (29%;
P = .02). Moreover, patients with GC-CD10
lymphomas more frequently had a localized Ann Arbor stage (I or II),
normal serum LDH levels, and low- or low/intermediate-risk IPI than
did pGC patients. On the other hand, 73% of GC-CD10+
patients presented in an advanced stage (III or IV), in contrast to
30% of GC-CD10 patients (P = .004).
Patients in whom bcl-2 expression was positive (> 25%), compared with those in whom bcl-2 expression was negative, more frequently presented with advanced Ann Arbor stage (59% vs 40%; P = .04) and high-intermediate or high risk IPI (54% vs 34%; P = .06). No other clinical relationship was observed. Response to treatment and outcome: prognostic analysis As described above, the complete response (CR) rate was 57% in the present series. The following variables predicted CR achievement (Table 7): ambulatory performance status (ECOG < 2); absence of bulky disease; early Ann Arbor stage; no bone marrow involvement; normal serum albumin, LDH, and 2-microglobulin levels; and IPI. No single-antigen expression
predicted response to therapy. The CR rate according to differentiation
pattern was 50%, 69%, and 55% for GC-CD10+,
GC-CD10, and pGC groups, respectively; these differences
did not reach statistical significance. In addition, no significant
difference was found according to any morphologic subtype.
Five-year OS was 43% (95% CI, 34%-52%; Figure 1). Unfavorable
clinical variables for OS were age older than 60 years
(P = .004), presence of B symptoms (P = .05),
poor performance status (ECOG > 2; P = .00001),
presence of bulky disease (P = .001), advanced Ann Arbor
stage (III-IV; P = .00002), extranodal involvement at
more than 1 site (P = .004), bone marrow involvement
(P = .01), low serum albumin levels
(P = .02), high serum LDH levels (P = .007),
and high
Finally, to assess the clinical interest of bcl-2 expression, a
multivariate analysis was performed including all the significant variables predicting OS in the univariate analysis, namely, age (< 60
years vs > 60 years]), B symptoms, performance status (ECOG < 2 vs
ECOG
DLBCLs are a heterogeneous group of neoplasms in which previous morphological, phenotypic, genetic, and molecular studies have not been able to identify well-defined disease entities with clinical and therapeutic relevance. Gene expression profile examined by microarray technology has identified 2 main groups of DLBCLs: those in which the expression profile was similar to that of normal GC B cells (the so-called GC-like DLBCLs) and those with an expression pattern similar to that of in vitro-activated peripheral blood B cells (activated B-like DLBCLs).15 Besides the biological significance of these profiles as representative of different cell origins, striking differences in the outcomes of patients according to expression profile were initially reported by Alizadeh et al15 and more recently confirmed in a larger series of patients by Rosenwald et al,17 with patients having activated B-like lymphomas having a worse prognosis. An additional study using a different oligonucleotide microarray also identified these 2 groups of DLBCLs but was not able to confirm the prognostic significance of these categories.16 In addition, these microarray studies have identified different series of genes with predictive survival value independent of the IPI and the cell-of-origin category of the tumors.16,17 These interesting results lead to the question of how the microarray-based studies could be extended, using methods more widely available in clinical practice. In the present study, we evaluated the clinical and prognostic significance of the phenotypic profile related to a germinal or postgerminal follicular center differentiation stage in a large series of patients with DLBCL, and we used conventional immunophenotyping techniques to evaluate the possible impact of different oncogenic and proliferative markers on the biological behavior of the tumor. For these purposes, we selected some of the most representative antigens related to the differentiation profiles: CD10 and bcl-6 as GC markers and MUM1 and CD138 as markers associated with a B-cell post-GC profile. In addition, we studied other oncogenic and proliferative proteins, such as bcl-2, p53, p27, and Ki-67. Although the expression profile related to the stage of differentiation was not of prognostic significance in this series of tumors, these subgroups of DLBCLs were associated with different clinicopathological features of the patients, suggesting that these subgroups may represent different biological entities. In addition, bcl-2 overexpression was an independent prognostic parameter in these tumors, indicating that factors other than the differentiation profile may influence the biological behavior of DLBCLs. Two of the antigens included in this study, CD10 and bcl-6, are normally expressed in follicular GCs and were also identified by cDNA microarray analysis as preferentially expressed in GC-derived DLBCLs. In addition, CD10 expression in DLBCL has also been associated with the presence of the t(14;18) translocation, indicating a possible origin of these tumors in germinal center-derived cells,34-36 as occurred in our tested patients, where bcl-2 rearrangement was associated with CD10 expression and GC-CD10+ patients. All our patients expressing CD10 were also positive for bcl-6, whereas a group of patients with bcl-6-positive tumors did not express CD10. Interestingly, patients with a CG CD10+ profile presented with more disseminated disease and frequently showed a centroblastic morphology, suggesting that these tumors may represent a diffuse large-cell variant of follicular lymphomas, which also present frequently with advanced stages. The bcl-6 gene is normally expressed in B and CD4+ T cells
of the follicular GCs, and it is necessary for GC
formation.37,38 Rearrangements and point mutations of this
gene have been detected in a number of DLBCLs, with conflicting results
regarding their relationship with extranodal origin and their potential
prognostic significance.39,40 Bcl-6 protein is expressed
in the vast majority of follicular lymphomas and in 70% to 95% of
DLBCLs, and this expression is apparently not related to gene
alterations. Bcl-6 mRNA expression also segregates with other germinal
center cell markers identified by microarray analysis, suggesting that
DLBCLs expressing bcl-6 may originate in this type of cell. Bcl-6
protein and mRNA overexpression in DLBCL has been recently associated with a better prognosis.14 In our study, bcl-6 expression
was identified in 91 (72%) of the tumors; 24 of these patients
coexpressed CD10, 39 were positive for bcl-6 and MUM1, and 30 had a
restricted bcl-6 reactivity. The group of patients with restricted
expression of bcl-6 (GC-CD10 MUM1/IRF4 is a novel member of the interferon regulatory factor (IRF) family of genes41-43 that plays an important role in the regulation of gene expression in response to signaling by interferons and other cytokines.44-46 In normal B cells, MUM1 and bcl-6 have a pattern of mutually exclusive positivity.47 Moreover, the absence of expression of MUM1 in IgD+/IgM+ follicle mantle cells,47 the absence of plasma cells and the marked reduction of serum immunoglobulins in IRF4-/- mice,48 and the segregation of MUM1 mRNA expression into activated B-like DLBCLs by microarray analysis15 have suggested a role for this gene in terminal phases of B-cell differentiation, and also its importance in recognizing post-GC DLBCLs. On the basis of these findings, MUM1-positive tumors in our study were assigned to a post-GC stage of differentiation. In our study, MUM1 expression was detected in 68 patients (54%), and 39 (57%) of the 68 coexpressed bcl-6. These findings are similar to those of previous studies in which MUM1 expression was observed in 51% to 75% of DLBCLs and, contrary to normal cells, coexpression with bcl6 was detected in about 50% of patients.47 The pGC phenotype was significantly associated with an immunoblastic morphology of the tumors and a primary nodal presentation. One of the most important issues in DLBCL is to refine the standard
prognostic scores, including IPI, which are mainly based on clinical
parameters. Activated B-cell-like tumors, as defined by
microarrays,15,17 had an unfavorable outcome. In
the present series, although patients with pGC tumors showed a lower CR
rate and OS than those with GC-CD10 In summary, the differentiation patterns, as assessed by immunophenotyping, were associated with particular clinicopathological features of patients with DLBCL. However, in the present series, these profiles were not the essential variable in determining the outcome of DLBCL patients.
We thank Montse Sánchez for excellent technical assistance. Montse Sánchez was supported in part by Dako.
Submitted May 6, 2002; accepted July 26, 2002.
Prepublished online as Blood First Edition Paper, August 8, 2002; DOI 10.1182/blood-2002-04-1286.
Supported in part by grant SAF 02/3261 from the Comisión Interministerial de Ciencia y Tecnología (CICYT); grant FIS 99/189 from the Fondo de Investigación Sanitaria, Spain; grant AR02/37k from the Deutsche Josep Carreras Leukämie-Stiftung eV, and a grant from the Associazione Italiana per la Ricerca sul Cancro (AIRC).
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Reprints: A. López-Guillermo, Department of Hematology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain; e-mail: alopezg{at}clinic.ub.es.
1.
A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma.
The Non-Hodgkin's Lymphoma Classification Project.
Blood.
1997;89:3909-3918 2. Pasqualucci L, Neumeister P, Goossens T, et al. Hypermutation of multiple proto-oncogenes in B-cell diffuse large-cell lymphomas. Nature. 2001;412:341-346[CrossRef][Medline] [Order article via Infotrieve].
3.
Harris NL, Jaffe ES, Stein H, et al.
A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group.
Blood.
1994;84:1361-1392 4. Gatter KC, Warnke RA. Diffuse large B-cell lymphoma. In: Jaffe ES,Harris NL,Stein H,Vardiman JW, eds. WHO Classification of Tumors. Pathology and Genetics of Tumors of Haematopoietic and Lymphoid Tissues. Lyon, France: International Agency for Research on Cancer (IARC) Press; 2001:171-174.
5.
The International Non-Hodgkin's Lymphoma Prognostic Factors Project.
A predictive model for aggressive non-Hodgkin's lymphoma.
N Engl J Med.
1993;329:987-994 6. King BE, Chen C, Locker J, et al. Immunophenotypic and genotypic markers of follicular center cell neoplasia in diffuse large B-cell lymphoma. Mod Pathol. 2000;13:1219-1231[CrossRef][Medline] [Order article via Infotrieve].
7.
Carbone A, Gaidano G, Gloghini A, et al.
Differential expression of Bcl-6, CD138/Syndecan-1, and Epstein-Barr virus-encoded latent membrane protein-1 identifies distinct histogenetic subsets of acquired immunodeficiency syndrome-related non-Hodgkin's lymphomas.
Blood.
1998;91:747-755 8. Dogan A, Bagdi E, Munson P, Isaacson PG. CD10 and Bcl-6 expression in paraffin sections of normal lymphoid tissue and B-cell lymphomas. Am J Surg Pathol. 2000;24:846-852[CrossRef][Medline] [Order article via Infotrieve]. 9. Ree HJ, Yang WI, Kim CW, et al. Coexpression of Bcl-6 and CD10 in diffuse large B-cell lymphomas: significance of Bcl-6 expression patterns in identifying germinal center B-cell lymphoma. Hum Pathol. 2001;32:954-962[CrossRef][Medline] [Order article via Infotrieve].
10.
Barrans SL, Carter I, Owen RG, et al.
Germinal center phenotype and bcl-2 expression combined with the International Prognostic Index improves patient risk stratification in diffuse large B-cell lymphoma.
Blood.
2002;99:1136-1143
11.
Harada S, Suzuki R, Uehira K, et al.
Molecular and immunological dissection of diffuse large B cell lymphoma: CD5+, and CD5 12. Ohshima K, Kawasaki C, Muta H, et al. CD10 and Bcl10 expression in diffuse large B-cell lymphoma: CD10 is a marker of improved prognosis. Histopathology. 2001;39:156-162[CrossRef][Medline] [Order article via Infotrieve].
13.
Uherova P, Ross CW, Schnitzer B, Singleton TP, Finn WG.
The clinical significance of CD10 antigen expression in diffuse large B-cell lymphoma.
Am J Clin Pathol.
2001;115:582-584
14.
Lossos IS, Jones CD, Warnke R, et al.
Expression of a single gene, BCL-6, strongly predicts survival in patients with diffuse large B-cell lymphoma.
Blood.
2001;98:945-951 15. Alizadeh AA, Elsen MB, Davis RE, et al. Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling. Nature. 2000;403:503-511[CrossRef][Medline] [Order article via Infotrieve]. 16. Shipp MA, Ross KN, Tamayo P, et al. Diffuse large B-cell lymphoma outcome prediction by gene-expression profiling and supervised machine learning. Nature Med. 2002;8:68-74[CrossRef][Medline] [Order article via Infotrieve].
17.
Rosenwald A, Wright G, Chan WC, et al.
The use of molecular profiling to predict survival after chemotherapy for diffuse large-B-cell lymphoma.
N Engl J Med.
2002;346:1937-1947
18.
Hermine O, Haioun C, Lepage E, et al.
Prognostic significance of bcl-2 protein expression in aggressive non-Hodgkin's lymphoma.
Blood.
1996;87:265-272
19.
Hill ME, MacLennan KA, Cunningham DC, et al.
Prognostic significance of BCL-2 expression and bcl-2 major breakpoint region rearrangement in diffuse large cell non-Hodgkin's lymphoma: a British National Lymphoma Investigation study.
Blood.
1996;88:1046-1051
20.
Kramer MH, Hemans J, Parker J, et al.
Clinical significance of bcl-2 and p53 protein expression in diffuse large B-cell lymphoma: a population-based study.
J Clin Oncol.
1996;14:2131-2138
21.
Gascoyne RD, Adomat SA, Krajewski S, et al.
Prognostic significance of Bcl-2 protein expression and Bcl-2 gene rearrangement in diffuse aggressive non-Hodgkin's lymphoma.
Blood.
1997;90:244-251
22.
Kramer MH, Hermans J, Wijburg E, et al.
Clinical relevance of BCL-2, BCL-6, and MYC rearrangements in diffuse large B-cell lymphoma.
Blood.
1998;92:3152-3162 23. Tang SC, Visser L, Hepperle B, Hanson J, Poppema S. Clinical significance of bcl-2 MBR gene rearrangement and protein expression in diffuse large-cell non-Hodgkin's lymphoma: an analysis of 83 cases. J Clin Oncol. 1994;12:149-154[Abstract].
24.
Offit K, Lo Coco F, Louie DC, et al.
Rearrangement of the bcl-6 gene as a prognostic marker in diffuse large-cell lymphoma.
N Engl J Med.
1994;331:74-80 25. Piris MA, Pezzella F, Martinez-Montero JC, et al. p53 and bcl-2 expression in high-grade B-cell lymphomas: correlation with survival time. Br J Cancer. 1994;69:337-341[Medline] [Order article via Infotrieve].
26.
Erlanson M, Portin C, Linderholm B, Lindh J, Roos G, Landberg G.
Expression of cyclin E and the cyclin-dependent kinase inhibitor p27 in malignant lymphomas 27. Ferreri AJM, Ponzoni M, Pruneri G, et al. Immunoreactivity for p27KIP1 and cyclin E is an independent predictor of survival in primary gastric non-Hodgkin's lymphoma. Int J Cancer. 2001;94:599-604[CrossRef][Medline] [Order article via Infotrieve]. 28. Saez A, Sanchez E, Sanchez-Beato M, et al. p27KIP1 is abnormally expressed in diffuse large B-cell lymphomas and is associated with an adverse clinical outcome. Br J Cancer. 1999;80:1427-1434[CrossRef][Medline] [Order article via Infotrieve].
29.
Cheson BD, Horning SJ, Coiffier B, et al.
Report of an international workshop to standardize response criteria for non-Hodgkin's lymphoma.
J Clin Oncol.
1999;17:1244-1253 30. Stansfeld AG, Diebold J, Kapanci Y, et al. Updated Kiel classification for lymphomas [letter]. Lancet. 1988;1:292-293[Medline] [Order article via Infotrieve]. 31. Kaplan GL, Meier P. Non-parametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457-481[CrossRef].
32.
Peto R, Pike MC.
Conservatism of the approximation 33. Cox DR. Regression models and life tables. J R Stat Assoc. 1972;34:187-220. 34. Fang J-M, Finn WG, Hussong JW, Goolsby CL, Cubbon AR, Variakojis D. CD10 antigen expression correlates with the t(14;18)(q32;q21) major breakpoint region in diffuse large B-cell lymphoma. Mod Pathol. 1999;12:295-300[Medline] [Order article via Infotrieve].
35.
Huang JZ, Sanger WG, Greiner TC, et al.
The t(14;18) defines a unique subset of diffuse large B-cell lymphoma with a germinal center B-cell gene expression profile.
Blood.
2002;99:2285-2290
36.
Xu Y, McKenna RW, Molberg KH, Kroft SH.
Clinicopathological analysis of CD10+ and CD10 37. Ye BH, Cattoretti G, Shen Q, et al. The BCL-6 proto-oncogene controls germinal-centre formation and Th2-type inflammation. Nat Genet. 1997;16:161-170[CrossRef][Medline] [Order article via Infotrieve].
38.
Dent AL, Shaffer AL, Yu X, Allman D, Staudt LM.
Control of inflammation, cytokine expression, and germinal center formation by BCL-6.
Science.
1997;276:589-592
39.
Capello D, Vitolo U, Pasqualucci L, et al.
Distribution and pattern of bcl-6 mutations throughout the spectrum of B-cell neoplasia.
Blood.
2000;95:651-659 40. Kawasaki C, Ohshim K, Suzumiya J, et al. Rearrangements of bcl-1, bcl-2, bcl-6, and c-myc in diffuse large B-cell lymphomas. Leuk Lymphoma. 2001;42:1099-1106[Medline] [Order article via Infotrieve]. 41. Grossman A, Mittrucker HW, Nocholl J, et al. Cloning of human lymphocyte-specific regulatory factor (hLSIRF/hIRF4) and mapping of the gene to 6p23-p25. Genomics. 1996;37:229-233[CrossRef][Medline] [Order article via Infotrieve].
42.
Eisenbeis CF, Singh H, Storb U.
Pip, a novel IRF family member, is a lymphoid-specific, PU.1-dependent transcriptional activator.
Genes Dev.
1995;9:1377-1387
43.
Matsuyama T, Grossman A, Mittrucker HW, et al.
Molecular cloning of LSIRF, a lymphoid-specific member of the interferon regulatory factor family that binds the interferon-stimulated response element (ISRE).
Nucleic Acids Res.
1995;23:2127-2136 44. Yamagata T, Nishida J, Tanaka S, et al. A novel interferon regulatory factor family transcription factor, ICSAT/Pip/LSIRF, that negatively regulates the activity of interferon-regulated genes. Mol Cell Biol. 1996;16:1283-1294[Abstract]. 45. Tsuboi K, Iida S, Inagaki H, et al. MUM1/IRF4 expression as a frequent event in mature lymphoid malignancies. Leukemia. 2000;14:449-456[CrossRef][Medline] [Order article via Infotrieve]. 46. Natkunam Y, Warnke RA, Montgomery K, Falini B, van de Rijn M. Analysis of MUM1/IRF4 protein expression using tissue microarrays and immunohistochemistry. Mod Pathol. 2001;14:686-694[CrossRef][Medline] [Order article via Infotrieve].
47.
Falini B, Fizzotti M, Pucciarini A, et al.
A monoclonal antibody (MUM1p) detects expression of the MUM1/IRF4 protein in a subset of germinal center B cells, and activated T cells.
Blood.
2000;95:2084-2092 48. Mittrucker HW, Matsuyama T, Grossman A, et al. Requirement for the transcription factor LSIRF/IRF4 for mature B and T lymphocyte function. Science. 1997;275:1075-1083[CrossRef].
© 2003 by The American Society of Hematology.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
 |
|
  H.-W. Bernd, M. Ziepert, C. Thorns, W. Klapper, H.-H. Wacker, M. Hummel, H. Stein, M.-L. Hansmann, G. Ott, A. Rosenwald, et al. Loss of HLA-DR expression and immunoblastic morphology predict adverse outcome in diffuse large B-cell lymphoma - analyses of cases from two prospective randomized clinical trials Haematologica, November 1, 2009; 94(11): 1569 - 1580. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E C Obermann, M Csato, S Dirnhofer, and A Tzankov BCL2 gene aberration as an IPI-independent marker for poor outcome in non-germinal-centre diffuse large B cell lymphoma J. Clin. Pathol., October 1, 2009; 62(10): 903 - 907. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. W.L. Choi, D. D. Weisenburger, T. C. Greiner, M. A. Piris, A. H. Banham, J. Delabie, R. M. Braziel, H. Geng, J. Iqbal, G. Lenz, et al. A New Immunostain Algorithm Classifies Diffuse Large B-Cell Lymphoma into Molecular Subtypes with High Accuracy Clin. Cancer Res., September 1, 2009; 15(17): 5494 - 5502. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D de Jong, W Xie, A Rosenwald, M Chhanabhai, P Gaulard, W Klapper, A Lee, B Sander, C Thorns, E Campo, et al. Immunohistochemical prognostic markers in diffuse large B-cell lymphoma: validation of tissue microarray as a prerequisite for broad clinical applications (a study from the Lunenburg Lymphoma Biomarker Consortium) J. Clin. Pathol., February 1, 2009; 62(2): 128 - 138. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Amara, M. Trimeche, S. Ziadi, A. Laatiri, M. Hachana, and S. Korbi Prognostic significance of aberrant promoter hypermethylation of CpG islands in patients with diffuse large B-cell lymphomas Ann. Onc., October 1, 2008; 19(10): 1774 - 1786. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Garcia-Herrera, L. Colomo, M. Camos, J. Carreras, O. Balague, A. Martinez, A. Lopez-Guillermo, T. Estrach, and E. Campo Primary Cutaneous Small/Medium CD4+ T-Cell Lymphomas: A Heterogeneous Group of Tumors With Different Clinicopathologic Features and Outcome J. Clin. Oncol., July 10, 2008; 26(20): 3364 - 3371. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Nakamura, H. Ye, C. M. Bacon, A. Goatly, H. Liu, L. Kerr, A. H. Banham, B. Streubel, T. Yao, M. Tsuneyoshi, et al. Translocations Involving the Immunoglobulin Heavy Chain Gene Locus Predict Better Survival in Gastric Diffuse Large B-Cell Lymphoma Clin. Cancer Res., May 15, 2008; 14(10): 3002 - 3010. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Dierlamm, E. M. Murga Penas, S. Bentink, S. Wessendorf, H. Berger, M. Hummel, W. Klapper, D. Lenze, A. Rosenwald, E. Haralambieva, et al. Gain of chromosome region 18q21 including the MALT1 gene is associated with the activated B-cell-like gene expression subtype and increased BCL2 gene dosage and protein expression in diffuse large B-cell lymphoma Haematologica, May 1, 2008; 93(5): 688 - 696. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Morel, P. Gaulard, C. Gisselbrecht, C. Ferme, G. Salles, H. Tilly, J. Briere, M. C. Copin, P. Lederlin, O. Hermine, et al. Autologous stem-cell transplantation as consolidation therapy for diffuse large B-cell lymphoma patients with overexpression of bcl-2 protein. Results of the Groupe d'Etude des Lymphomes de l'Adulte (GELA) trial LNH98-B2 Ann. Onc., March 1, 2008; 19(3): 560 - 565. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Natkunam, P. Farinha, E. D. Hsi, C. P. Hans, R. Tibshirani, L. H. Sehn, J. M. Connors, D. Gratzinger, M. Rosado, S. Zhao, et al. LMO2 Protein Expression Predicts Survival in Patients With Diffuse Large B-Cell Lymphoma Treated With Anthracycline-Based Chemotherapy With and Without Rituximab J. Clin. Oncol., January 20, 2008; 26(3): 447 - 454. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B Lofstrom, C Backlin, C Sundstrom, A Ekbom, and I E Lundberg A closer look at non-Hodgkin's lymphoma cases in a national Swedish systemic lupus erythematosus cohort: a nested case-control study Ann Rheum Dis, December 1, 2007; 66(12): 1627 - 1632. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. A. Ramos-Vara, M. A. Miller, and V. E. O. Valli Immunohistochemical Detection of Multiple Myeloma 1/Interferon Regulatory Factor 4 (MUM1/IRF-4) in Canine Plasmacytoma: Comparison with CD79a and CD20 Vet. Pathol., November 1, 2007; 44(6): 875 - 884. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Dupuis, P. Gaulard, F. Hemery, E. Itti, C. Gisselbrecht, A. Rahmouni, C. Copie-Bergman, J. Briere, T. E. Gnaoui, I. Gaillard, et al. Respective prognostic values of germinal center phenotype and early 18fluorodeoxyglucose-positron emission tomography scanning in previously untreated patients with diffuse large B-cell lymphoma Haematologica, June 1, 2007; 92(6): 778 - 783. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Nyman, M. Adde, M.-L. Karjalainen-Lindsberg, M. Taskinen, M. Berglund, R.-M. Amini, C. Blomqvist, G. Enblad, and S. Leppa Prognostic impact of immunohistochemically defined germinal center phenotype in diffuse large B-cell lymphoma patients treated with immunochemotherapy Blood, June 1, 2007; 109(11): 4930 - 4935. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H Veelken, S Vik Dannheim, J Schulte Moenting, U. Martens, J Finke, and A Schmitt-Graeff Immunophenotype as prognostic factor for diffuse large B-cell lymphoma in patients undergoing clinical risk-adapted therapy Ann. Onc., May 1, 2007; 18(5): 931 - 939. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. de Jong, A. Rosenwald, M. Chhanabhai, P. Gaulard, W. Klapper, A. Lee, B. Sander, C. Thorns, E. Campo, T. Molina, et al. Immunohistochemical Prognostic Markers in Diffuse Large B-Cell Lymphoma: Validation of Tissue Microarray As a Prerequisite for Broad Clinical Applications--A Study From the Lunenburg Lymphoma Biomarker Consortium J. Clin. Oncol., March 1, 2007; 25(7): 805 - 812. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Natkunam, S. Zhao, D. Y. Mason, J. Chen, B. Taidi, M. Jones, A. S. Hammer, S. Hamilton Dutoit, I. S. Lossos, and R. Levy The oncoprotein LMO2 is expressed in normal germinal-center B cells and in human B-cell lymphomas Blood, February 15, 2007; 109(4): 1636 - 1642. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. van Imhoff, E.-J. G. Boerma, B. van der Holt, E. Schuuring, L. F. Verdonck, H. C. Kluin-Nelemans, and P. M. Kluin Prognostic Impact of Germinal Center-Associated Proteins and Chromosomal Breakpoints in Poor-Risk Diffuse Large B-Cell Lymphoma J. Clin. Oncol., September 1, 2006; 24(25): 4135 - 4142. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. N. Winter, E. A. Weller, S. J. Horning, M. Krajewska, D. Variakojis, T. M. Habermann, R. I. Fisher, P. J. Kurtin, W. R. Macon, M. Chhanabhai, et al. Prognostic significance of Bcl-6 protein expression in DLBCL treated with CHOP or R-CHOP: a prospective correlative study Blood, June 1, 2006; 107(11): 4207 - 4213. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. Oschlies, W. Klapper, M. Zimmermann, M. Krams, H.-H. Wacker, B. Burkhardt, L. Harder, R. Siebert, A. Reiter, and R. Parwaresch Diffuse large B-cell lymphoma in pediatric patients belongs predominantly to the germinal-center type B-cell lymphomas: a clinicopathologic analysis of cases included in the German BFM (Berlin-Frankfurt-Munster) Multicenter Trial Blood, May 15, 2006; 107(10): 4047 - 4052. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. S. Lossos and D. Morgensztern Prognostic Biomarkers in Diffuse Large B-Cell Lymphoma J. Clin. Oncol., February 20, 2006; 24(6): 995 - 1007. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Iqbal, V. T. Neppalli, G. Wright, B. J. Dave, D. E. Horsman, A. Rosenwald, J. Lynch, C. P. Hans, D. D. Weisenburger, T. C. Greiner, et al. BCL2 Expression Is a Prognostic Marker for the Activated B-Cell-Like Type of Diffuse Large B-Cell Lymphoma J. Clin. Oncol., February 20, 2006; 24(6): 961 - 968. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.-H. Lin, K.-T. Kuo, S.-S. Chuang, S.-H. Kuo, J. H. Chang, K.-C. Chang, H.-C. Hsu, H.-F. Tien, and A.-L. Cheng Comparison of the Expression and Prognostic Significance of Differentiation Markers between Diffuse Large B-Cell Lymphoma of Central Nervous System Origin and Peripheral Nodal Origin Clin. Cancer Res., February 15, 2006; 12(4): 1152 - 1156. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. H. Sehn Optimal Use of Prognostic Factors in Non-Hodgkin Lymphoma Hematology, January 1, 2006; 2006(1): 295 - 302. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Camilleri-Broet, E. Criniere, P. Broet, V. Delwail, K. Mokhtari, A. Moreau, M. Kujas, M. Raphael, W. Iraqi, C. Sautes-Fridman, et al. A uniform activated B-cell-like immunophenotype might explain the poor prognosis of primary central nervous system lymphomas: analysis of 83 cases Blood, January 1, 2006; 107(1): 190 - 196. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. De Paepe, R. Achten, G. Verhoef, I. Wlodarska, M. Stul, V. Vanhentenrijk, M. Praet, and C. De Wolf-Peeters Large Cleaved and Immunoblastic Lymphoma May Represent Two Distinct Clinicopathologic Entities Within the Group of Diffuse Large B-Cell Lymphomas J. Clin. Oncol., October 1, 2005; 23(28): 7060 - 7068. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Hoffmann, M. Tiemann, C. Schrader, D. Janssen, E. Wolf, M. Vierbuchen, R. Parwaresch, K. Ernestus, A. Plettenberg, A. Stoehr, et al. AIDS-related B-cell lymphoma (ARL): correlation of prognosis with differentiation profiles assessed by immunophenotyping Blood, September 1, 2005; 106(5): 1762 - 1769. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Natkunam, I. S. Lossos, B. Taidi, S. Zhao, X. Lu, F. Ding, A. S. Hammer, T. Marafioti, G. E. Byrne Jr, S. Levy, et al. Expression of the human germinal center-associated lymphoma (HGAL) protein, a new marker of germinal center B-cell derivation Blood, May 15, 2005; 105(10): 3979 - 3986. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Lopez-Guillermo, L. Colomo, M. Jimenez, F. Bosch, N. Villamor, L. Arenillas, A. Muntanola, S. Montoto, E. Gine, D. Colomer, et al. Diffuse Large B-Cell Lymphoma: Clinical and Biological Characterization and Outcome According to the Nodal or Extranodal Primary Origin J. Clin. Oncol., April 20, 2005; 23(12): 2797 - 2804. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Bea, L. Colomo, A. Lopez-Guillermo, I. Salaverria, X. Puig, M. Pinyol, S. Rives, E. Montserrat, and E. Campo Clinicopathologic Significance and Prognostic Value of Chromosomal Imbalances in Diffuse Large B-Cell Lymphomas J. Clin. Oncol., September 1, 2004; 22(17): 3498 - 3506. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I. S. Lossos, D. K. Czerwinski, A. A. Alizadeh, M. A. Wechser, R. Tibshirani, D. Botstein, and R. Levy Prediction of Survival in Diffuse Large-B-Cell Lymphoma Based on the Expression of Six Genes N. Engl. J. Med., April 29, 2004; 350(18): 1828 - 1837. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. P. Hans, D. D. Weisenburger, T. C. Greiner, R. D. Gascoyne, J. Delabie, G. Ott, H. K. Muller-Hermelink, E. Campo, R. M. Braziel, E. S. Jaffe, et al. Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray Blood, January 1, 2004; 103(1): 275 - 282. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
 |
 |
|||||||
 |
 |
 |
 |
 |
 |
 |
 |
||
| Copyright © 2003 by American Society of Hematology Online ISSN: 1528-0020 | |||||||||
Top
Abstract
Introduction
2), bulky disease, Ann Arbor stage (I/II vs III/IV), extranodal involvement (< 2 sites vs 
(O-E)2/E in the log-rank test for survival data or tumour incidence data.
Biometrics.
1973;29:759-784.