Recognizing Biologic and Clinical Subsets in B-cell Lymphoma

Recognizing Biologic and Clinical Subsets
in B-Cell Lymphoma: ASH 2010
Randy D. Gascoyne, MD
BC Cancer Agency
Vancouver, Canada

Follicular Lymphoma (FL)

Morphologic Heterogeneity in FL
Completely follicular Marginal zone differentiation Follicular & diffuse
Grade 1 FL Grade 2 FL Grade 3B FL

The Natural History of Follicular NHL is Changing
Overall Survival on Sequential SWOG Trials
100%
8 0%
60%
40 %
CHOP + Monoclonal Antibody
ProMace
CHOP
20%
0%
0 2 4 6 8 10
Years After Registration
Fisher RI, et al. J Clin Oncol. 2005;23:8447-8452.

Prognostic Factors in FL?
IR1, IR2, interfollicular CD4
T-cells, follicular FOXP3
Treg, PD1 cells,
macrophages, mast cells,
FDCs, MVD
Malignant
B-cells
Treatment
Clinical Factors
BCL2/BAK ratio, MUM1, p53
Ki67 rate, loss of p16,
+7, +X, del1p36, del17p
del6q, aUPD 1p36/16p
MYC translocations
Non-neoplastic
cells in the
microenvironment
Host (germline)
genetics (SNPs)
FcR3a, IL8, IL2, IL12B
IL1RN, C1qA

Microenvironment
Benign
Malignant
T
MZ
T
M
B
T
B
T
M
M
B
M
Fb
Follicular
dendritic cells
Benign
B-cells
GC
T-cells
Fibroblasts, reticular cells
Macrophages
Vessels (endothelium & pericytes)

Probability of OS
Risk of Transformation
FOXP3 Patterns
FL cases with a follicular pattern of Treg cells showed inferior OS
(P < 0.0001) and a higher risk for transformation (P = 0.005)
1.0
1.0
.8
.6
Diffuse (n = 64)
.8
.6
P = 0.005
Follicular (n = 38)
.4
.2
0.0
0
P < 0.0001
5
10
Follicular (n = 38)
15
20
.4
.2
0.0
0
5
10
Diffuse (n = 64)
15
20
Years
Years
Farinha P, et al. Blood. 2010;115:289-295.

Probability of OS
Risk of Transformation
Microvessel Density
Cases with increased angiogenesis at the time of diagnosis
have inferior overall survival and are at increased risk to
transform to aggressive histology lymphomas
1.0
1.0
.8
Low MVD (n = 63)
.8
.6
.6
High MVD (n = 21)
.4
High MVD (n = 21)
.4
Low MVD (n = 63)
.2
0.0
0
P = 0.0001
5
10
Years
15
20
.2
0.0
0
5
10
Years
P = 0.012
15 20
Farinha P, et al. Haematologica. Published online August 26, 2010.

Follicular Lymphoma Survival from Diagnosis
With and Without Transformation
1.0
0.8
Without transformation (n = 430)
0.6
0.4
0.2 With transformation (n = 170)
0.0
0
P < 0.0001
5
10 15
20
Overall survival (years)
Al-Tourah AJ, et al. J Clin Oncol. 2008;26:5165-5169.

Biomarkers Predicting FL Transformation
Increased Risk
Follicular lymphoma, grade 1
- Chromosomal gains +7, +12q13-14, +18q
- Chromosomal losses del1p36, del6q23,
-17p13, -9p21
- aUPD 1p36.3 and 16p; MYC translocations
- Diffuse areas, high proliferation rate
- Follicular Treg cells, intrafollicular CD4 +
T-cells, immature FDC
- Increased MVD
Reduced Risk
- Pure follicular architecture
- Low proliferation rate (Ki67)
- Mature FDC phenotype
- Diffuse pattern of Treg cells
- Decreased microvessel density (MVD)
Diffuse large B-cell lymphoma

The Impact of Therapy on FL
CD4
Intrafollicular CD4 + T-cells
Biopsies obtained
prior to therapy
reflect differences in
basic biology in FL
Treatment
CD4
Interfollicular CD4 + T-cells
Uniform Rx
Results are
interpretable
R-Chemo
Variable Rx
Prognosis implies outcome following
therapy and treatments used are lymphotoxic and
differentially visited upon the neoplastic
B-cells vs immune cells in the
microenvironment
Results are
difficult
to interpret
Relander T, et al. J Clin Oncol. 2010;28:2902-2913.

The Future in FL
• Develop a list of robust biomarkers that can be
used at the time of diagnosis to predict the bad
actors and those at-risk to transform early
• Determine those factors of value in the current
era of R-chemo
• Await the biologic correlates of rituximab
failure/resistance (RESORT trial, others?)
• Await discovery resulting from large-scale
sequencing efforts in FL; these data will add
texture to the molecular predictors, but will
require the analysis of purified FL B-cells

Mantle Cell Lymphoma

Molecular Pathogenesis of MCL
Naïve
B-cell
Germline
Early MCL Classical MCL Blastoid MCL
CCND1
ATM
CHK2
t(11;14)
Cyclin D1
ATM
CHK2
INK4A/CDK4/RB
ARF/MDM2/p53
RB1
p27
Complex
karyotype
High proliferation
Adapted from Jares P, et al. Nat Rev Cancer. 2007;7:750-762.

Proliferation Signature Average in MCL
Quartile 1 Quartile 2 Quartile 3 Quartile 4
Rosenwald A, et al. Cancer Cell. 2003;3:185-197.

Quantitative Measurement of Proliferation
Predicts Length of Survival Following
Diagnosis of Mantle Cell Lymphoma
5.07 X 10 -9
Rosenwald A, et al. Cancer Cell. 2003;3:185-197.

The Future in MCL
• Proliferation remains the cornerstone of
outcome prediction in MCL
• Next-generation sequencing may reveal
important insights in MCL biology and should
provide new targets for therapy and
improvements to outcome prediction

Diffuse Large B-Cell Lymphoma
(DLBCL)

Morphological Heterogeneity in DLBCL
Centroblastic Immunoblastic Plasmablastic
PMBCL Anaplastic T-Cell/Histiocyte-Rich

Dissecting a Cancer into Molecularly and Clinically
Significant Subgroups Based on Gene Expression Profiling
DLBCL treated
with CHOP
Rosenwald A, et al. N Engl J Med.
2002;346:1937-1947.

Genetic Alterations are Characteristic of Molecular
Subtypes of DLBCL
DLBCL treated
with R-CHOP
GCB
DLBCL
ABC
DLBCL
PMBCL
c-rel amplification (2p)
BCL2 translocation
BCL6 translocation
Constitutive NF-B
16% 0% 25%
42% 0% 0%
11% 22% 0%
- + +
MYC translocation
14%
9% 0%
Gain/amp chromosome 9p
0% 6% 43%
Lenz G, et al. Proc Natl Acad Sci
USA.2008;105:13520-13525.

Mutations of Specific Genes Distinguish the Molecular
Subtypes of DLBCL
DLBCL treated
with R-CHOP
GCB
DLBCL
ABC
DLBCL
PMBCL
EZH2 mutations* 22% 0% 0%
CARD11 mutations
TNFAIP3 mutations
4% 10% 0%
2% 24% 0%
BLIMP1 mutations
0%
24% 0%
STAT6 mutations
0% 0% 36%
CD79b mutations † 21%
0% 0%
*Morin RD, et al. Nat Genet.
2010;43:181-185; † Davis RE,
et al. Nature. 2010;463:88-92.

Cell-of-Origin Distinctions Reveal Different Survival
Characteristics in DLBCL Treated With R-CHOP
DLBCL treated
with R-CHOP
3-year
Survival
PMBCL
GCB DLBCL
ABC DLBCL
90%
85%
56%
Lenz G, et al. N Engl J Med. 2008;359:2313-2323.

Prognostic Factors in DLBCL?
Malignant
B-cells
Treatment
MYC translocations,
BCL2 with MYC levels,
GCB vs ABC,
HIF1, EBV, CD5, loss of
HLA-DR, p53 mutations,
p16 loss, IBL
morphology
Stomal-1, stromal-2,
MVD, macrophages
Clinical Factors
Non-neoplastic
cells in the
microenvironment
Host (germline)
genetics (SNPs)
IL10, IL8RB, IL4R
IL1A, TNF

GCB vs Non-GCB DLBCL by
Immunohistochemistry
+
GCB
-
GCB
CD10
-
BCL6
MUM1
+ +
-
Non-GCB
Non-GCB
Hans CP, et al. Blood. 2004;103:275-282.

Develop New and Improved Immunohistochemistry Profiles
93%
81%

Cell-of-Origin Phenotype: GCB
CD10
FOXP1
GCET1
BCL6
MUM1
Choi WW, et al. Clin Cancer Res. 2009;15:5494-4402.

Cell of Origin Phenotype: Non-GCB
CD10
FOXP1
GCET1
BCL6
MUM1
Choi WW, et al. Clin Cancer Res. 2009;15:5494-4402.

A Bayesian Classifier to Estimate the
Probability That a
Lymphoma is ABC vs GCB DLBCL
15-20% unclassified
Non-GCB
GCB
Wright G, et al. Proc Natl Acad Sci USA. 2003;100:9991-9996.

The Hans Classifier – Controversies in
the CHOP and R-CHOP Era
Hans, et al. Blood 2003
Berglund, et al. Mod Pathol 2005
Haarer, et al. Arch Pathol Lab Med 2006
Muris, et al. J Pathol 2006
Sjo, et al. Eur J Haematol 2007
van Imhoff, et al. J Clin Oncol 2007
Nyman, et al. Blood 2007
Amara, et al. Mod Pathol 2008
Fu, et al. J Clin Oncol, 2008 (R-CHOP)
Colomo, et al. Blood 2003
Nyman, et al. Blood 2007 (R-CHOP)
De Paepe, et al. J Clin Oncol 2005
Dupuis, et al. Haematologica 2007
Natkunam, et al. J Clin Oncol 2008 (R-CHOP)
Veelken, et al. Ann Oncol 2007
Amen, et al. Histopathology 2007
Wilson, et al. J Clin Oncol 2008 (DA-EPOCH-R)
Ott, et al. Blood (epub 2010) (R-CHOP)
Survival association
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
no

We Studied 135 Patients With de novo DLBCL
Treated With R-CHOP Using a TMA and
Performed MYC FISH With a Breakapart Probe
Normal MYC signal
MYC translocated
Savage KJ, et al. Blood. 2009;114:3533-3537.

Cumulative Survival
MYC Translocations in de novo DLBCL
Affect PFS/OS in Patients Treated With R-CHOP
1.0
1.0
.9
.8
MYC Translocation – (n = 123)
.8
MYC Translocation – (n = 123)
.7
.6
.6
MYC Translocation + (n = 12)
.5
.4
.4
.3
.2
MYC Translocation + (n = 12)
.2
.1
0.0
0.0
0
2
4
6
8
10
0
2
4
6
8
10
Progression free survival (y)
Overall survival (y)
Savage KJ, et al. Blood. 2009;114:3533-3537;
Barrans S, et al. J Clin Oncol. 2010;28:3360-3365.

Patterns of BM Involvement in DLBCL
LN
CD20
Concordant
Discordant
CD20
CD20

Overall Survival for 795 Patients
With DLBCL Treated With R-CHOP
Negative BM (n = 670)
Discordant BM (n = 58)
Concordant BM (n = 67)
Sehn LH, et al. Submitted (2010).

Progression-Free Survival for 795 Patients
With DLBCL Treated With R-CHOP
Negative BM (n = 670)
Discordant BM (n = 58)
Concordant BM (n = 67)
Sehn LH, et al. Submitted (2010).

The Future in DLBCL
• Cell-of-origin distinctions are important in R-
CHOP treated patients and are beginning to be
used to stratify patients in phase III clinical trials
testing novel agents
• MYC translocations and concordant BM
involvement are reliable predictors of treatment
failure in de novo DLBCL
• Next-generation sequencing will add texture to
this list and identify those patients needing
targeted approaches based on their mutational
profile at diagnosis

Conclusions
• There are reliable biomarkers predictive of
decreased survival and risk of transformation in FL,
but these need to be studied in the current era of
treatment with R-chemo
• Beyond the proliferative rate, MCL is in desperate
need of novel biomarker discovery
• Cell-of-origin distinctions, MYC, and concordant BM
involvement appear to be clinically relevant in
DLBCL; further meaningful progress must await the
publication of the mutational landscape of this
tumor