Aggressive B cell Lymphomas

Aggressive B cell Lymphomas Raju K. Pillai City of Hope National Medical Center I have no disclosures Outline What is new in the WHO 2016 classification Insights from genomic studies Double Hit Lymphoma and High grade B cell lymphoma, NOS Prognostic and predictive factors in DLBCL EBV positive diffuse large B cell lymphoma Primary mediastinal large B cell lymphoma and related lesions WHO 2016 Classification Large B cell Lymphomas Burkitt lymphoma Burkitt like lymphoma with 11q aberration* High grade B cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements* High grade B cell lymphoma, NOS* NEW ENTITIES IN 2016 WHO CLASSIFICATION 1

11/2/2017 WHO 2016 Classification Large B cell Lymphomas WHO 2016 Classification Large B cell Lymphomas Primary DLBCL of the central nervous system Primary cutaneous DLBCL, leg type Intravascular large B cell lymphoma Primary effusion lymphoma DLBCL associated with chronic inflammation EBV+ DLBCL, NOS* EBV+ mucocutaneous ulcer* HHV8+ DLBCL, NOS* Lymphomatoid granulomatosis Plasmablastic lymphoma NEW ENTITIES IN 2016 WHO CLASSIFICATION WHO 2016 Classification Large B cell Lymphomas NEW ENTITIES IN 2016 WHO CLASSIFICATION WHO 2016 Classification Large B cell Lymphomas T cell/histiocyte rich large B cell lymphoma ALK+ large B cell lymphoma Large B cell lymphoma with IRF4 rearrangement* NEW ENTITIES IN 2016 WHO CLASSIFICATION Primary mediastinal (thymic) large B cell lymphoma B cell lymphoma, unclassifiable, intermediate between DLBCL and CHL NEW ENTITIES IN 2016 WHO CLASSIFICATION 2

WHO 2016 Classification Large B cell Lymphomas WHO 2016 Classification Large B cell Lymphomas Diffuse large B cell lymphoma (DLBCL), NOS Germinal center B cell type* Activated B cell type* NEW ENTITIES IN 2016 WHO CLASSIFICATION Diffuse large B cell lymphoma (DLBCL), NOS Germinal center B cell type* 90% Activated B cell type* Burkitt lymphoma Burkitt like lymphoma with 11q aberration* High grade B cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements* High grade B cell lymphoma, NOS* EBV+ DLBCL, NOS* EBV+ mucocutaneous ulcer* HHV8+ DLBCL, NOS* Lymphomatoid granulomatosis Plasmablastic lymphoma Primary DLBCL of the central nervous system Primary cutaneous DLBCL, leg type Intravascular large B cell lymphoma Pi Primary effusion lymphoma DLBCL associated with chronic inflammation T cell/histiocyte rich large B cell lymphoma ALK+ large B cell lymphoma Large B cell lymphoma with IRF4 rearrangement* Primary mediastinal (thymic) large B cell lymphoma B cell lymphoma, unclassifiable, intermediate between DLBCL and CHL NEW ENTITIES IN 2016 WHO CLASSIFICATION Diffuse Large B cell Lymphoma DLBCL Subtypes based on Gene Expression Profiling Neoplasm of medium to large B cells with nuclear size equal to macrophage nuclei or >2X lymphocyte nuclei HE + CD20 CD10, BCL6, MUM1, Ki 67 MYC, BCL2, CD19, CD30 BCL1, CD5, TdT (Blastoid) With R CHOP, 5 year PFS and OS is 60% and 65% Very high genetic and clinical heterogeneity 2 molecular subgroups defined by gene expression profiling Activated B cell type Germinal center type Small lymphocyte Histiocyte Burkitt Centroblastic Immunoblastic Anaplastic Alizadeh, Nature 2000 3

DLBCL A Very Heterogenous Disease ABC and GCB subtypes Drive Different Pathways GCB ABC Cell of origin Disease Biology Chromosomal rearrangements Mutation spectrum Gene expression patterns Infectious agents Site of involvement Transformation from low grade Clinical background Differences in gene expression, chromosomal alterations, mutations and pathways affected ABC GCB BCL2 translocation 5% 40% BCL6 / 3q27 GAIN 45% 15% EZH2, GNA13, TNFRSF14 Rare 25% CD79B, MYD88 25% 30% Rare Pathways NF kappab PI3/AKT, JAK/STAT Survival, PFS, 5 yrs 40 50% 70 80% Prognostic and Predictive factors in DLBCL Hans Algorithm for Cell of Origin Benefit from certain drugs is preferentially seen in the ABCsubtype ( bortezomib, lenalidomide and Ibrutinib with R CHOP) Determination of cell of origin subtype is now required in the WHO 2016 classification Methods: IHC: State algorithm used (Hans, Choi, Tally) Gene expression profiling from FFPE 4

Other IHC algorithms to Determine Cell of Origin Concordance with gene expression profiling Hans 86% Tally 93% Choi 87% Methods to Determine Cell of Origin Reproducibility of IHC algorithms Gene expression profiling from FFPE is technically difficult, but highly reproducible GEP Hans Meyer et al, JCO 2011 Read JA et al 2014 Clin Lymphoma Myeloma Leuk Gene Expression Profiling with Nanostring Technology Single molecule barcoding FFPE compatible Up to 800X multiplex Nanostring Technology 5

11/2/2017 Lymph2Cx Assay Mutation Landscape and Networks in DLBCL Gene expression profiling from 20 genes 8 ABC 7 GCB 5 controls 2% mis assignment, 5% unclassified B cell receptor signaling NF kappab Notch Toll like receptor PI3K JAK/STAT Apoptosis Cell Cycle Histone Methylation RNA Splicing MYC Immune Escape Scott DW 2015 Courtesy Sandeep Dave, Duke Cancer center. Reddy et al. Cell 2017: 171 Relevance in Clinical Practice Enhanced risk stratification Choice Ch i off targeted t t d therapy th Genomic risk model cell of origin BCL2 BCL2 and MYC expression targeted sequencing of a panel of DLBCL driver genes WHO 2016 Classification Large B cell Lymphomas Burkitt lymphoma Burkitt like lymphoma with 11q aberration* High grade B cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements* High grade B cell lymphoma, NOS* Reddy et al. Cell 2017: 171 6

Burkitt Lymphoma Burkitt Lymphoma Starry sky pattern Diffuse proliferation of small to medium sized monomorphous cells. Slight nuclear pleomorphism, nuclear membrane irregularities, or nucleolar prominence is acceptable, particularly in immunodeficiency associated cases, provided other key immunophenotypic and genetic criteria are met. Centroblast Phenotype: CD20, CD10, BCL6 strongly positive BCL2 negative (maybe weak +) Ki 67 > 95% Genetics: MYC translocation > 95% of cases Usually IGH or IGL partners Absence of BCL2 or BCL6 rearrangement Non complex karyotype Ki67 MYC Case 1 41 / male with complaints of fevers/chills, 20lb wt loss and night sweats and pancytopenia. Imaging shows extensive disease Splenomegaly Sacral mass ground glass opacities and pleural effusions of the lung extensive lymphadenopathy. 7

CD20 CD10 BCL6 BCL2 CD3 MUM1 Negative for CD5, BCL1, TdT, CD138, CD34 Negative for MYC, BCL2 and BCL6 translocations Ki67 Differential Diagnosis Burkitt lymphoma Burkitt like lymphoma with 11q aberration* y p q High grade B cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (Double Hit / Triple Hit lymphoma) High grade B cell lymphoma, NOS Diffuse large B cell lymphoma 8

Important to Distinguish Burkitt Lymphoma Distinguishing Burkitt lymphoma from other aggressive B cell lymphomas is important for therapeutic decisions and prognosis Undertreatment of BL leads to markedly inferior survival in a curable disease Overtreatment BL therapy in misdiagnosed DLBCL leads to unnecessary toxicity No single parameter morphology, phenotype or genetics can be used as a gold standard for diagnosis Reconsider a Diagnosis of Burkitt Lymphoma High degree of morphologic variability in terms of nuclear size, nuclear irregularity, or nucleolar prominence Strong BCL2 expression Ki 67 less than 95% Positivity for MUM 1/IRF4, or negativity for BCL6 or CD10 Presence of BCL2 or BCL6 rearrangement in addition to MYC Older age at diagnosis in absence of immunosuppression or a predominantly leukemic presentation. Is MYC Translocation specific to Burkitt lymphoma? Are there MYC translocation negative Burkitt lymphomas? BURKITT 90 100% PLASMABLASTIC LYMPHOMA 50% TRANSFORMED MYELOMAS 55% DLBCL, NOS 10 15% DOUBLE HIT LYMPHOMA 100% HIGH GRADE B, NOS 30 50% FL, CLL, MCL, B ALL RARE Morphology similar to Burkitt lymphoma but more pleomorphic More in immunodeficient patients Negative for MYC translocation Proximal gains and distal losses of 11q Gene expression profile similar to BL but with decreased MYC RNA and protein Clinical i l course similar il to BL Burkitt Like Lymphoma with 11q Aberrations (provisional category) 9

Molecular Pathogenesis of Burkitt Lymphoma High Grade B cell Lymphoma Schmitz R, Nature 2012; Campo E. Nat Genet. 2012; ID3 55% TCF3 20% CCND3 38% MYC 70% TP53 50% Revised definition in WHO 2016 Working category, not a new entity Aggressive mature B cell lymphomas with features intermediate between DLBCL and BL 2 categories: Doublehit / triplehitlymphoma: lymphoma: High grade grade B celllymphoma lymphoma with MYC and BCL2 and/or BCL6 rearrangements High grade B cell lymphoma, NOS Morphology of MYC/BCL2 or BCL6 Double Hit Lymphoma BL/DLBCL type starry sky pattern, but greater nuclear size variation, nuclear irregularity or nucleolar prominence than acceptable for BL Blastoid type small cells with dispersed chromatin and absent / inconspicuous nucleoli DLBCL type large cells resembling typical centroblasts or immunoblasts with high hdegree of nuclear size variability bl (50%) Exclusion Criteria for Double Hit Lymphoma May arise from antecedent follicular lymphoma in half of MYC/BCL2 double hit lymphomas Excludes follicular lymphoma with MYC and BCL2 rearrangements, blastoid mantle and B lymphoblastic leukemia Copy number alterations or somatic mutations of MYC and BCL2 do not qualify MYCand BCL2 proteinexpression expression donot correlate withdhl / THL but are useful for screening cases for FISH studies Ki 67 index does not correlate with DHL / THL (30 100%) 10

Overlap of High Grade B cell lymphoma, NOS with BL Medium sized or slightly larger cells Variation in cell, nuclear and nucleolar size Higher ih proportion of cases expressing BCL2 Upto 20% of BL show weak expression of BCL2 Lack of CD10 expression Rare BL cases can be CD10 negative <90% Ki 67 expression One third of cases with the molecular signature of BL has <95% Ki 67 MYC translocation with Non IgH/IgL partners Upto 10% are negative for MYC translocation Complex karyotype (>6 Abnormalities by SNP Array) Diagnostic Approach to Aggressive B cell Lymphomas Blastoid BL DLBCL/BL DLBCL Morphology B LBL BL HGBL NOS DHL / THL DLBCL NOS Diagnosis Exclude B ALL, Blastoid MCL Double Hit vs Double Expressor Lymphoma WHO 2016 Classification Large B cell Lymphomas Double expressors have an intermediate prognosis in some studies MYC IHC >40% BCL2 IHC > 50% MYC protein expression is not reliable for detecting MYC translocation Johnson NA 2012 JCO EBV+ DLBCL, NOS* EBV+ mucocutaneous ulcer* HHV8+ DLBCL, NOS* Lymphomatoid granulomatosis Plasmablastic lymphoma 90% 11

EBV positive large B cell lymphomas Can occur in younger patients No documented immunodeficiency Morphologic spectrum: T cell / Histiocyte rich large B cell like (polymorphic pattern) Hodgkin Reed Sternberg type cells DLBCL Geographicalnecrosisand and angioinvasion CD10, BCL6, MUM1+, CD30+, EBER+ (>80%) Adverse prognosis only in older patients (median OS = 2 y) Nicolae A et al. Blood (2015) 126:863 Mucocutaneous Ulcer Occurs in older adults with immune senescence, or with iatrogenic immunosuppression EBV positive Should be differentiated from EBV positive large B cell lymphoma Cutaneous or mucosal superficial ulcer Marked reactive T cell infiltrate at the base Large cells do not form clusters and sheets Lesions resolve withdecreased immunosuppression withor without rituximab. None of these patients are reported to have EBV DNA in their blood WHO 2016 Classification Large B cell Lymphomas Case 2 21 year old male with a history of progressive shortness of breath, 2 months duration Mediastinal mass biopsy Primary mediastinal (thymic) large B cell lymphoma B cell lymphoma, unclassifiable, intermediate between DLBCL and CHL 12

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CD30 CD20 Primary mediastinal large B cell lymphoma (PMBL) PMBL in seen in young adults, more in females Bulky mediastinal mass; rarely outside Prominent sclerosis, compartmentalizing fibrosis Diffuse infiltrate of large or medium sized lymphoma cells with abundant pale cytoplasm May resemble Reed Sternberg like cells. PMBL Immunophenotype PMBL Genetic Alterations B cell lineage antigens CD20, CD79a, PAX5, OCT2, BOB1 CD23 + in 70% CD30 + in 80% MAL + in 70% PDL1 and PDL2 in 70% Surface Ig negative in most cases BCL6 + in 60%, CD10 + in 25% EBV negative Twa et al. Leuk Lymphoma. 2015;56:2239 CIITA rearrangements (53%) Decreased HLA Class II PDL1 / PDL2 Translocations and copy number alterations Inactivates T cells 14

PMBL Genetic Alterations CIITA rearrangements (53%) Decreased HLA Class II PDL1 / PDL2 Translocations and copy number alterations Inactivates T cells NF kappab pathway activation JAK/STAT pathway activation Mediastinal Gray zone Lymphoma B cell lymphoma, unclassifiable, with features intermediate between DLBCL and CHL Mediastinal gray zone lymphoma Important to distinguish PMBL from BCLU DLBCL/CHL PMBL has good response to chemotherapy with high cure rates PMBL has more favorable survival than DLBCL Twa et al. Leuk Lymphoma. 2015;56:2239 Case 3 52 year old male Multiple enlargedretroperitonealretroperitoneal lymph nodesandleft supraclavicular lymphadenopathy. 15

CD20 OCT2 16

CD30 CD15 BCLU DLBCL/CHL AKA Mediastinal gray zone lymphoma (MGZL) Introduced as a provisional category in the 2008 WHO classification Most cases present as a mediastinal mass; male predominance Asynchrony between morphology and immunophenotype Morphology of Classical Hodgkin lymphoma, nodular sclerosis type PreservedB cell programcd20 CD20, CD79a, BOB1andOCT2 OCT2, variable BCL6, and common loss of CD15 Morphology of DLBCL / PMBL In addition to B cell marker expression, strong and homogeneous CD30 positivity and often CD15 positivity, or contain EBV. Classification of Lymphomas the last 50 years.. 17

Can we definitively classify every lymphoma? Role of Molecular Studies in Clinical Practice BL PMBCL DLBCL CHL Full impact of molecular studies will be reflected in the 5 th edition Unlikely to change current multiparametric classification Improvement of diagnostic accuracy Identification of prognostic and predictive markers Finding new therapeutic targets at the molecular level g p g Better understanding of disease mechanisms will support immunotherapy 18