MIB-1 labeling index as a prognostic factor for patients with follicular lymphoma treated with rituximab plus CHOP therapy

Ki67 proliferation index in follicular lymphoma is associated with favorable outcome in patients treated with R-CHOP

Follicular lymphoma (FL) is a common, indolent small B-cell lymphoma. While the Follicular Lymphoma International Prognostic Index is widely used, reliable prognostic and predictive biomarkers are needed. A recent study suggested that architectural patterns of CD10, BCL6, and Ki67 expression may correlate with progression-free survival (PFS) in FL patients treated with chemotherapy-free regimens. We examined the prognostic and predictive utility of architectural patterns of CD10, BCL6, Ki67, and FOXP1 in 90 patients treated with immunochemotherapy (bendamustine-rituximab [BR] and R-cyclophosphamide, doxorubicin, vincristine, prednisone [CHOP]). We found that high follicular Ki67 (≥30%) was associated with longer PFS in the subgroup of patients treated with R-CHOP but not among those treated with BR. Validation of this biomarker may support routine use of Ki67 as a predictive marker in FL.

Risk factors for POD24 in patients with previously untreated follicular lymphoma: a systematic review and meta-analysis

Progression of disease within 24 months (POD24) is strongly associated with a poor outcome in patients with follicular lymphoma (FL). Our study aimed to identify the potential risk factors for POD24 in patients with FL. Medline, EMBASE and the Cochrane Library were systematically searched from the earliest record to September 2020. Studies investigating the prognostic factors for POD24 in patients with newly diagnosed grade 1-3a FL were included. Among 10,014 pieces of literature, a total of 90 studies investigating 82 risk factors were included for qualitative analysis. Meta-analyses were performed in 31 studies with 11 factors. Results showed that elevated sIL-2R, β2m and LDH, total metabolic tumour volume > 510 cm³, vitamin D < 20 ng/mL, grade 3a and lymphoma-associated macrophages/high-power field ≥ 15 were significantly associated with an increased risk of POD24. No significant association was found between POD24 and the ALC/AMC ratio, sex, T effector signature or EZH2 genetic alteration. Additionally, minimal residual disease, Ki-67, PD-1 and TP53 were analysed narratively. Overall, this is the first study that comprehensively analysed the prognostic factors associated with POD24 in FL patients. We have confirmed the significance value of several common prognostic factors as well as others not commonly included in clinical study, helping to construct an integrated and more efficient model.

Improving the prognostic ability of PET/CT SUVmax to identify follicular lymphoma with early treatment failure

Follicular lymphoma (FL) has a high degree of heterogeneity both clinically and molecularly. Early treatment failure (ETF), progression or relapse within 24 months of frontline immunochemotherapy is associated with a poor prognosis in FL. However, the clinical utility of ETF at diagnosis is limited. The maximum standardized uptake value (SUVmax) is a metabolic parameter for positron emission tomography/computed tomography (PET/CT); nevertheless, the relationship between SUVmax and ETF remains unclear. Thus, identifying early biomarkers that incorporate SUVmax and other clinical correlative variables could be helpful in identifying patients at high risk of ETF. A nomogram consisted of three independent variables, including SUVmax ≥ 12, beta-2 microglobulin > 3 mg/L, and Ki67 > 40%, was established to predict ETF in 127 patients with grade 1, 2, or 3a FL from the First Hospital of Jilin University (training cohort) and was validated using data from the Duke University Medical Center (validation cohort, n=95). The nomogram demonstrated prognostic accuracy in predicting ETF (sensitivity 70.8% and specificity 83.5% in the training cohort; sensitivity 84.2% and specificity 68.4% in the validation cohort). The patients were stratified into three groups: low-, intermediate-, and high-risk. In the training cohort, the corresponding 5-year progression-free survival (PFS) rates were 81.7%, 73.4%, and 34.9%, and the 5-year overall survival (OS) rates were 97.4%, 87.4%, and 62.3%, respectively. In the validation cohort, the 5-year PFS rates were 77.7%, 52.9%, and 34.8%, and the 5-year OS rates were 96.4%, 94.1%, and 73.7%, respectively. This was the first study to use a nomogram with SUVmax to predict ETF in FL to identify a subset of patients who might benefit from individualized targeted therapy.

Clinicopathological analysis of follicular lymphoma with BCL2, BCL6, and MYC rearrangements

Most follicular lymphomas (FL) show t(14;18)/IGH-BCL2 translocation, but rearrangement (R) negative cases exist. A series of 140 FL patients with a BCL2, BCL6, and MYC gene status examined by fluorescence in situ hybridization (FISH) were classified into five groups: (a) BCL2-R group (BCL2-R/BCL6-G/MYC-G) (G, germline), 77 cases; (b) BCL2/BCL6 double-R group (BCL2-R/BCL6-R/MYC-G), 16 cases; (c) BCL6-R group (BCL2-G/BCL6-R/MYC-G), 16 cases; (d) MYC-R group (BCL2-R or G/BCL6-R or G/MYC-R), three cases; (e) Triple-G group (BCL2-G/BCL6-G/MYC-G), 28 cases. The BCL6-R group had different clinicopathological characteristics. It showed lower rates of an advanced clinical stage and bone marrow invasion, less disease progression (p = 0.036), and a 'trend' toward a favorable progression-free survival (PFS) (p = 0.06). It also showed higher rates of grade 3A and MUM1-expression, and when analyzing the interfollicular spread pattern of CD20-positive cells, had fewer cases showing the IF3+ pattern (high interfollicular spread). Moreover, cases with BCL6-R and/or BCL6 gain (with cases of BCL2 rearrangement and/or of copy number gain excluded) correlated with favorable PFS (p = 0.014) and less IF3+ pattern (p = 0.007). We demonstrated that BCL6-R FLs showed unique clinicopathological findings, and FISH of BCL2, BCL6, and MYC is useful for FL diagnosis and clinical management.

Identification and Analysis of Potential Autophagy-Related Biomarkers in Endometriosis by WGCNA

Background: Endometriosis is a serious gynecological disorder characterized by debilitating pain, infertility and the establishment of innervated endometriosis lesions outside the uterus. Early detection and accurate diagnosis are pivotal in endometriosis. The work screened autophagy-related genes (ATGs) as potential biomarkers to reveal new molecular subgroups for the early diagnosis of endometriosis.

Materials and Methods: The gene lists of ATGs from five databases were integrated. Then, weighted gene co-expression network analysis (WGCNA) was used to map the genes to the gene profile of endometriosis samples in GSE51981 to obtain functional modules. GO and KEGG analyses were performed on the ATGs from the key modules. Differentially expressed ATGs were identified by the limma R package and further validated in the external datasets of GSE7305 and GSE135485. The DESeq2 R package was utilized to establish multifactorial network. Subsequently, one-way analysis of variance (ANOVA) was performed to identify new molecular subgroups. Real-time quantitative polymerase chain reaction (RT-qPCR) and Western blotting were used to confirm the differential expression of hub ATGs, and the receiver operating characteristic (ROC) curve analysis and Spearman correlation analysis were applied to assess the diagnostic value of hub ATGs in 40 clinical samples and human primary endometrial stromal cells (ESCs).

Results: We screened 4 key modules and 12 hub ATGs and found the key genes to be strongly correlated with endometriosis. The pathways of ATGs were mainly enriched in autophagy, apoptosis, ubiquitin-protein ligase binding, and MAPK signaling pathway. The expression levels of EZH2 (Enhancer of Zeste homolog 2) and RND3 (also known as RhoE) had statistically significant changes with higher values in the endometriosis group compared with the controls, both in the tissue samples and primary ESCs. Besides, they also showed higher specificity and sensitivity by the receiver operating characteristic analysis and Spearman correlation analysis for the diagnosis of endometriosis. The TF-mRNA-miRNA-lncRNA multifactorial network was successfully constructed. Four new molecular subgroups were identified, and we preliminarily showed the ability of IQCG to independently differentiate subgroups.

Conclusion: EZH2 and RND3 could be candidate biomarkers for endometriosis, which would contribute to the early diagnosis and intervention in endometriosis.

Low-Grade Primary Splenic CD10-Positive Small B-Cell Lymphoma/Follicular Lymphoma

Primary splenic lymphoma (PSL) is a rare malignancy representing about 1% of all lymphoproliferative disorders, when using a strict definition that allows only involvement of spleen and hilar lymph nodes. In contrast, secondary low-grade B-cell lymphomas in the spleen, such as follicular lymphomas (FL), lymphoplasmacytic lymphoma and chronic lymphocytic leukemia/ small lymphocytic lymphoma, particularly as part of advanced stage disease, are more common. Indolent B cell lymphomas expressing CD10 almost always represent FL, which in its primary splenic form is the focus of this review. Primary splenic follicular lymphoma (PSFL) is exceedingly infrequent. This type of lymphoproliferative disorder is understudied and, in most cases, clinically characterized by splenomegaly or cytopenias related to hypersplenism. The diagnosis requires correlation of histopathology of spleen, blood and/or bone marrow with the correct immunophenotype (determined by flow cytometry and/or immunohistochemistry) and if necessary, additional molecular profiling. Management of this incurable disease is evolving, and splenectomy remains the mainstream treatment for stage I PSFL.

Clinicopathological factors and tumor microenvironment markers predicting watch-and-wait discontinuation in 82 patients with follicular lymphoma

OBJECTIVES

In this study, we aimed to determine the clinicopathological factors influencing the treatment-free period in patients with follicular lymphoma (FL) using a watch-and-wait (WW) strategy.

METHODS

We retrospectively assessed histopathological parameters of 82 patients with FL.

RESULTS

The median time from diagnosis to WW discontinuation was 62 months (range, 3-138), and median follow-up was 86 months (range, 3-183). Intermediate or high-risk Follicular Lymphoma International Prognostic Index score (P = .012), non-duodenal-type (P = .011), higher numbers of interfollicular CD4⁺ (P = .038) and intrafollicular FOXP3⁺ cells (P = .024) in the tumor microenvironment, and Ki-67 index ≥10% (P = .031) were significant adverse factors for WW discontinuation in univariate analyses.

CONCLUSION

Patients with adverse factors for WW discontinuation should be carefully observed during follow-up.

Prognostic significance of histologic grade and Ki-67 proliferation index in follicular lymphoma

The prognostic value of histologic grading and the Ki-67 proliferation index in follicular lymphoma (FL) is controversial. This study investigated the clinical usefulness of these two factors in Asian FL patients. Four hundred and thirty-three patients diagnosed with FL were retrospectively reviewed with a median follow-up time of 47.0 months (range, 24.0-168.0). The 10-year overall survival (OS) rate and progression-free survival (PFS) rate were 91.0% and 47.1%, respectively. Grade 3B and grade 3B with diffuse large B cell lymphoma (DLBCL) showed a better PFS than grade 1-3A (P < 0.001), and similar findings were noted in patients who received rituximab-containing regimens (P = 0.002). In contrast, no significant differences in terms of OS or PFS were observed between grades 1-2 and 3A. In addition, patients with Ki-67 ≥ 30% had a significantly better PFS than patients with Ki-67 < 30% (P = 0.014), although the difference was eliminated in the multivariate analysis. Both grade and Ki-67 index had no impact on prognosis in patients who did not receive rituximab treatment. In conclusion, grade 3A is closely related to grade 1-2, as reflected by a similar indolent clinical course and a lower PFS rate than grade 3B/3B + DLBCL. In addition, a higher Ki-67 index seems to have a positive effect on PFS in FL patients.

Ki-67 expression of immunohistochemistry using computerized image analysis is a useful prognostic marker in follicular lymphomas

Ki-67 is a useful proliferation marker in various tumors including lymphoma. In general, the number of Ki-67 positive cells in immunohistochemistry (IHC) is counted manually for routine pathological diagnosis. However, a manual count is subjective and time consuming. Currently, image analysis is often used for the quantification of positive cells in tissue in IHC. Thus, to determine the pathological prognostic factors for follicular lymphoma (FL), we studied the relationship between Ki-67 expression in IHC and the treatment effect and prognosis using image analysis software. We analyzed 82 newly-diagnosed patients with FL. All patients were treated with rituximab-containing regimens. The median Ki-67 expression was 17.0%. A high expression of Ki-67 tended to be associated with short overall survival (P = 0.058). Moreover, Ki-67 expression was significantly lower in patients with FL grade 1-2 than in those with FL grade 3a. This study suggests that image analysis provides an accurate, reproducible, and easy method of measuring Ki-67 expression in IHC in FL, and is possibly a useful marker for treatment selection or prognosis prediction in FL.

Extrafollicular PD1 and Intrafollicular CD3 Expression Are Associated With Survival in Follicular Lymphoma

INTRODUCTION

Both microenvironment and tumor biomarkers impact outcome in follicular lymphoma (FL). We aimed to study the effect of Ki-67, CD3, CD68, and PD1 expression on outcome of FL.

MATERIALS AND METHODS

Forty-eight patients were included. Stained slides were visually assessed and marker expression was correlated with outcome. Both intra- and extrafollicular expression of Ki-67, CD68, and PD1 were evaluated. CD3 was evaluated only in the intrafollicular area. The median values of expression served as a cutoff point for low- and high-expression groups.

RESULTS

High extrafollicular PD1 expression predicted superior FFTF (freedom from treatment failure) compared with low expression (5-year 52% vs. 44%, P = .04). Five-year FFTF markedly increased from 37% to 67% (P = .057) in patients with low intrafollicular CD3 expression.

CONCLUSION

Our study supports the hypothesis that survival in FL depends on the immunologic cross talk between malignant cells and microenvironment; however, the specific types of cells that influence the clinical behavior of FL are still unknown.

Total peroxiredoxin expression is associated with survival in patients with follicular lymphoma

Redox state-regulating enzymes may have roles in chemoresistance and also in lymphomagenesis, but there have been only a limited number of studies on this topic in lymphomas. Our aim was to assess expression of the redox state-regulating enzymes peroxiredoxins (Prxs) I-VI and thioredoxin (Trx) and the oxidative stress marker nitrotyrosine in follicular lymphomas (FLs). We immunohistochemically assessed Prxs I-VI, Trx and nitrotyrosine in a cohort of 76 histologically confirmed, untreated FLs. We also studied the localisation of Prxs I, II, III, V and VI by means of immunoelectron microscopy (IEM). Immunohistochemistry results were correlated with disease-specific survival (DSS), progression-free survival (PFS), overall survival (OS) and clinical prognostic factors. When all Prx expression intensities were grouped as a single variable, we discovered that high total Prx intensity correlated with favourable DSS (p = 0.024) and OS (p = 0.035) but not with PFS. No deaths due to lymphoma were recorded amongst patients with high total Prx expression during the median follow-up period of 7.6 years. IEM results were in line with earlier ones demonstrating wide subcellular localisation of Prx isoenzymes. In conclusion, our results demonstrate an association between high total Prx expression and prolonged survival and suggest that Prxs may have a protective role in FL that cannot be compensated by other antioxidant mechanisms.

Grading of follicular lymphoma in cytological samples

OBJECTIVE

The treatment of follicular lymphoma (FL) depends on its grade. The current World Health Organization (WHO) 2008 Classification of Tumours of Haematopoietic and Lymphoid Tissues recommends the grading of FL on histological samples according to the Mann and Berard method, taking into consideration the number of centroblasts. There is no generally accepted method for the grading of FL in fine needle aspiration biopsy (FNAB) samples. The aim of the present study was to devise a grading system for FL in cytological samples.

METHODS

Flow cytometry (FC) was performed on 60 FNAB samples of patients with primary FL. We assumed that FL cells larger than reactive T lymphocytes on FC histograms corresponded to centroblasts. The percentage of large cells was calculated and compared with histological grade, proliferative activity and number of centroblasts per high-power field (HPF) on histological slides, and with survival.

RESULTS

The histological analysis of lymph nodes revealed 20 patients with high-grade and 40 patients with low-grade FL. The percentage of large cells in FNAB samples correlated significantly with histological grade (P = 0.02), MIB1 status (P < 0.001) and the number of centroblasts per HPF (P < 0.001). An age over 60 years and a percentage of large cells over 50% in FNAB samples were found to have a statistically significant impact on survival by univariate analysis (P = 0.001 and P = 0.006, respectively).

CONCLUSIONS

The percentage of large lymphoma cells in FNAB samples of FL determined by FC can be used as a reliable method for FL grading, as it is comparable with the histological grading system.

MIB-1 labeling index as a prognostic factor for patients with follicular lymphoma treated with rituximab plus CHOP therapy

The MIB-1 labeling index, which is based on Ki67 immunostaining, is widely used to evaluate the proliferation of tumor cells in lymphoma. However, its clinical significance has not been fully assessed. We retrospectively evaluated the prognostic impact of the MIB-1 labeling index at the time of diagnosis, in 98 patients with follicular lymphoma (FL) grade 1-3b who were treated uniformly with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) therapy. The 5-year progression-free survival (PFS) for an MIB-1 labeling index of ≥10% (n = 60) and <10% (n = 38) was 35% and 61%, respectively (P = 0.015). The 5-year overall survival (OS) for an MIB-1 labeling index of ≥10% and <10% was 77% and 92%, respectively (P = 0.025). Pathological grading was not correlated with PFS or OS. In multivariate analysis, an MIB-1 labeling index of ≥10% was independently associated with poor PFS and OS. In conclusion, an MIB-1 labeling index of 10% is a useful cut-off level for predicting the prognosis of patients with FL.