Dysfunctional endothelial progenitor cells in patients with Hodgkin's lymphoma in complete remission

18F-FDG PET/CT metabolic parameter changes to assess vascular inflammatory response in patients with diffuse large B-cell lymphoma

OBJECTIVE

To study the changes in positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) aortic target-to-background ratio (TBR) and aortic calcification scores before and after 6 cycles of chemotherapy with the rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen in patients with diffuse large B-cell lymphoma (DLBCL).

PATIENTS AND METHODS

We selected 161 patients with DLBCL who received 6 cycles of R-CHOP standard chemotherapy and underwent baseline and 6-cycle efficacy evaluations using 18F-FDG PET/CT examinations at the Second Hospital of Dalian Medical University from July 2017 to June 2023. Additionally, 125 patients who underwent 18F-FDG PET/CT for physical examination during the same period, without active malignancy or systemic inflammatory disease, were chosen as the control group. We measured metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of systemic lymphoma lesions in tumor patients. Aortic wall FDG uptake was semi quantitatively analyzed as TBR (target-to-blood pool ratio) in five different vascular regions using oncological 18F-FDG PET/CT. The aortic TBR difference (ΔTBR) was the difference between the post- and pre-chemotherapy TBR values. The degree of arterial segmental wall calcification was assessed using the CT semiquantitative method.

RESULTS

Comparison of the pre-treatment group of DLBCL with the control group showed that aortic TBR (1.28 ± 0.17 vs. 1.22 ± 0.18, P < 0.05) were higher in the former group. Additionally, comparing different stage groups of patients with DLBCL revealed that aortic TBR (1.30 ± 0.18 vs. 1.22 ± 0.15, P < 0.05) were higher in the Stage III/IV group compared to the Stage I/II group. Aortic TBR was positively correlated with TLG (P = 0.016, R = 0.19) and MTV (P = 0.032, R = 0.17). Analysis of changes in aortic 18F-FDG uptake in patients with DLBCL after 6 cycles of treatment revealed that aortic TBR levels were significantly higher post-treatment compared to pre-treatment(P < 0.05). The aortic ΔTBR value was significantly higher in the progression group than in the complete remission group(P < 0.05).

CONCLUSION

Aortic wall 18F-FDG uptake is related to disease severity and prognosis, indicating a possible vascular effect of lymphoma and its therapeutic interventions. This work highlights an additional potential role of PET/CT in imaging oncology for evaluating disease severity and its consequences on the vasculature.

Angiogenesis in Lymph Nodes Is a Critical Regulator of Immune Response and Lymphoma Growth

Tumor-induced remodeling of the microenvironment in lymph nodes (LNs) includes the formation of blood vessels, which goes beyond the regulation of metabolism, and shaping a survival niche for tumor cells. In contrast to solid tumors, which primarily rely on neo-angiogenesis, hematopoietic malignancies usually grow within pre-vascularized autochthonous niches in secondary lymphatic organs or the bone marrow. The mechanisms of vascular remodeling in expanding LNs during infection-induced responses have been studied in more detail; in contrast, insights into the conditions of lymphoma growth and lodging remain enigmatic. Based on previous murine studies and clinical trials in human, we conclude that there is not a universal LN-specific angiogenic program applicable. Instead, signaling pathways that are tightly connected to autochthonous and infiltrating cell types contribute variably to LN vascular expansion. Inflammation related angiogenesis within LNs relies on dendritic cell derived pro-inflammatory cytokines stimulating vascular endothelial growth factor-A (VEGF-A) expression in fibroblastic reticular cells, which in turn triggers vessel growth. In high-grade B cell lymphoma, angiogenesis correlates with poor prognosis. Lymphoma cells immigrate and grow in LNs and provide pro-angiogenic growth factors themselves. In contrast to infectious stimuli that impact on LN vasculature, they do not trigger the typical inflammatory and hypoxia-related stroma-remodeling cascade. Blood vessels in LNs are unique in selective recruitment of lymphocytes via high endothelial venules (HEVs). The dissemination routes of neoplastic lymphocytes are usually disease stage dependent. Early seeding via the blood stream requires the expression of the homeostatic chemokine receptor CCR7 and of L-selectin, both cooperate to facilitate transmigration of tumor and also of protective tumor-reactive lymphocytes via HEV structures. In this view, the HEV route is not only relevant for lymphoma cell homing, but also for a continuous immunosurveillance. We envision that HEV functional and structural alterations during lymphomagenesis are not only key to vascular remodeling, but also impact on tumor cell accessibility when targeted by T cell-mediated immunotherapies.

FDG PET/CT for evaluating systemic arterial inflammation induced by anthracycline-based chemotherapy of Hodgkin lymphoma: A retrospective cohort study

To evaluate arterial fluorodeoxyglucose (FDG) uptake as a marker of arterial inflammation in multiple vascular beds in patients treated with anthracycline-based chemotherapy for Hodgkin lymphoma (HL).We used maximum standardized uptake value (SUVmax) and target-to-background ratio (TBR) to quantify arterial FDG uptake in the carotid artery, ascending aorta, abdominal aorta, and femoral artery obtained on positron emission tomography/computed tomography (PET/CT) imaging performed at baseline before chemotherapy and after completion of chemotherapy in patients with HL treated with an anthracycline-containing regimen. We compared the SUVmax and TBR obtained at baseline with that obtained post-chemotherapy for each arterial bed to evaluate the effect of anthracycline-based chemotherapy. We evaluated the effect of cardiovascular risk factors such as human immunodeficiency virus (HIV) infection, smoking, hypertension, and diabetes on the changes in SUVmax and TBR seen in the different arterial beds after anthracycline-based chemotherapy.Fifty-two patients were included with a mean age of 34.56 ± 10.19 years. There were 33 males, and 18 patients were HIV-infected. The mean interval between completion of chemotherapy and follow-up flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan was 65 weeks. We found no significant difference in arterial FDG uptake measured by SUVmax and TBR in all arterial beds between the pre- and post-chemotherapy FDG PET/CT. There was no significant impact of HIV infection, smoking, and hypertension on the changes in arterial FDG uptake following treatment with anthracycline-based chemotherapy.In patients with HL who were treated with anthracycline-based chemotherapy, we found no significant increase in arterial inflammation measured by FDG PET/CT after an average follow-up period of about 65 weeks since completion of chemotherapy.

Dysfunctional endothelial progenitor cells in patients with Hodgkin's lymphoma in complete remission

Background

Patients with a history of Hodgkin's lymphoma (HL) are at increased long‐term risk of cardiovascular morbidity and mortality. Studies report an association between the pathophysiology of coronary artery disease (CAD) and levels of circulating endothelial progenitor cells (EPC), which play an essential role in vascular injury repair. The aim of the present study was to investigate the potential involvement of abnormal EPC level or function in the CAD risk of survivors of HL in remission.

Methods

EPCs were isolated from peripheral blood samples drawn from 4 groups of patients aged 20‐50 years with no history of CAD: 17 patients with HL who had been in complete remission for at least 2 years, four newly diagnosed patients with HL before treatment, 28 patients with diabetes all attending a tertiary medical center, and 16 healthy individuals. Levels of EPC surface markers were measured by flow cytometry, and EPC function was evaluated by the number of colony‐forming units (CFUs) and MTT assay.

Results

Levels of circulating CD34(+)/VEGFR2(+) and CD133(+)/VEGFR2(+) were significantly higher in the newly diagnosed untreated patients with HL compared to the patients with HL in remission (P = 0.03 and P = 0.005, respectively), in the patients in remission compared to the patients with diabetes (P = 0.011 and P < 0.001, respectively), and in the patients in remission compared to the healthy individuals (P = 0.08 and P = 0.003, respectively). The analysis of cell viability and the number of colony‐forming units in the patients with HL in remission yielded significant differences from the healthy group (P = 0.005 and P < 0.001, respectively) but not from either the newly diagnosed patients with HL or the diabetic patients.

Conclusions

These results suggest that patients in complete remission of HL for at least 2 years have an abnormal EPC profile characterized by high circulating levels but attenuated function.