Aggressive B cell Lymphomas I have nothing to disclose. Disclosures Raju K. Pillai City of Hope National Medical Center Outline WHO 2016 Classification Large B cell Lymphomas New entities and changes in WHO 2016 classification Double Hit Lymphoma and High grade B cell lymphoma, NOS Prognostic and predictive factors in DLBCL EBV positive diffuse large B cell lymphoma Primarymediastinal mediastinal large B cell lymphoma and related lesions Insights from genomic studies 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 1
Prognostic and Predictive factors in DLBCL 5 year PFS and OS with R CHOP is 60% and 65% respectively Very high genetic and clinical heterogeneity 2 molecular subgroups defined by gene expression profiling ABC and GCB Cell of Origin in DLBCL Alizadeh, Nature 2000 ABC and GCB subtypes Drive Different Pathways Prognostic and Predictive factors in DLBCL 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% Benefit from certain drugs is preferentially seen in the ABCsubtype ( bortezomib, lenalidomide and Ibrutinib with R CHOP) Determination of cell of origin subtype is required in the WHO 2016 classification Methods: IHC: State algorithm used (Hans, Choi, Tally) Gene expression profiling 2
Hans Algorithm for Cell of Origin Other Methods to Determine Cell of Origin Concordance with gene expression profiling Hans 86% Tally 93% Choi 87% Meyer et al, JCO 2011 Gene Expression Profiling with Nanostring Technology Nanostring Technology Single molecule barcoding, FFPE compatible Upto 800X multiplex 3
11/1/2017 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 Scott DW 2015 Courtesy Sandeep Dave, Duke Cancer center. Reddy et al. Cell 2017: 171 Mutation Landscape and Networks in DLBCL More comprehensive risk stratification Choice of targeted therapy Genomic risk model can be applied clinically using existing assays, through the measurement of cell of origin, BCL2 and MYC expression, and 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* 4
Burkitt Lymphoma Burkitt Lymphoma Diffuse proliferation of small to medium sized monomorphous cells. Starry sky pattern Slight nuclear pleomorphism, nuclear membrane irregularities, or nucleolar prominence is acceptable, particularly in immunodeficiency i associated itd 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 Differential Diagnosis Burkitt lymphoma Burkitt like lymphoma with 11q aberration* 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 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 5
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? 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 Are there MYC translocation negative Burkitt lymphomas? Molecular Pathogenesis of Burkitt Lymphoma 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) Schmitz R, Nature 2012; Campo E. Nat Genet. 2012; ID3 55% TCF3 20% CCND3 38% MYC 70% TP53 50% 6
High Grade B cell Lymphoma Revised definition in WHO 2016 Aggressive mature B cell lymphomas with features intermediate between DLBCL and BL 2 categories: Double hit / triple hit lymphoma: High grade B cell lymphoma with MYC andbcl2 and/orbcl6 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%) 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) 7
Diagnostic Approach to Aggressive B cell Lymphomas WHO 2016 Classification Large B cell Lymphomas Blastoid BL DLBCL/BL DLBCL MYC R+ DHL / THL 90% B LBL BL HGBL NOS DHL / THL DLBCL NOS Exclude B ALL, FL, Blastoid MCL, Plasmablastic Lymphoma EBV+ DLBCL, NOS* EBV+ mucocutaneous ulcer* HHV8+ DLBCL, NOS* Lymphomatoid granulomatosis Plasmablastic lymphoma EBV positive large B cell lymphomas Can occur in younger immunocompetent patients Morphologic spectrum: T cell / Histiocyte rich large B cell like Classical Hodgkin like DLBCL Nodal disease, 11% had extracellular involvement Adverse prognosis only in older patients Immune modulation tolerogenic microenvironment Mucocutaneous Ulcer Occurs in older adults with immune senescence, or with iatrogenic immunosuppression Cutaneous or mucosal Superficial ulcer with a marked reactive lymphoid infiltrate at the base. EBV positive in all cases Should be differentiated from EBV positive large B cell lymphoma Lesions resolve withdecreased immunosuppression withor without rituximab. None of these patients are reported to have EBV DNA in their blood Nicolae A et al. Blood (2015) 126:863 8
11/1/2017 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 9
CD30 CD20 Primary mediastinal large B cell lymphoma Young adults, more in females Bulky mediastinal mass; rarely outside Bulky mediastinal mass; rarely outside Prominent sclerosis, compartmentalizing fibrosis Diffuse infiltrate of large or mediumsized lymphoma cells with abundant pale cytoplasm May resemble Reed Sternberg like cells. 10
PMBL Immunophenotype 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 PMBL Genetic Alterations CIITA rearrangements (53%) Decreased HLA Class II PDL1 / PDL2 Translocations and copy number alterations Inactivates T cells Twa et al. Leuk Lymphoma. 2015;56:2239 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 PMBL vs Mediastinal Gray zone Lymphoma Important to distinguish PMBL from BCLU DLBCL/CHL B cell lymphoma, unclassifiable DLBCL/CHL y p, / 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 11
Case 3 52 year old male Multiple enlargedretroperitonealretroperitoneal lymph nodesandleft supraclavicular lymphadenopathy. 12
CD20 OCT2 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 BCLU DLBCL/CHL usually shows asynchrony between morphology and immunophenotype Morphology of Classical Hodgkin lymphoma, nodular sclerosis type Preserved B cell program CD20, CD79a, BOB1 and 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. 13