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EDUCATION SESSION Non-Hodgkins Lymphoma
Clinical Impact of Gene Expression Profiling in
Aggressive Lymphoma Andreas Rosenwald,
M.D. Institute of Pathology, University of
Würzburg
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Diffuse Large B-Cell Lymphoma (DLBCL) Burkitts
Lymphoma (BL)
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Diffuse Large B-cell Cell Lymphoma GCB and ABC
DLBCL
Germinal center B cell-like (GCB)
Activated B cell-like (ABC)
Germinal center B cell
? Post-Germinal Center B cell
Cell of Origin

• t(1418) translocation of BCL-2
• Chr. 2p amplification of c-rel locus

Constitutive activation of NF-kB Gains in 3q, 18q
Oncogenic Mechanisms
Clinical Outcome
Favorable 60 5-yr survival
Poor 35 5-yr survival
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A
B
FFS Bcl-6-negative
1.0
0.8
R-CHOP, n21
CHOP, n68
0.6
Probability
Probability
0.4
p0.00007
R-CHOP, n86
0.2
CHOP, n24
p0.80
0.0
0
1
2
3
4
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C
D
OS Bcl-6-negative
OS Bcl-6-positive
1.0
R-CHOP, n21
CHOP, n68
0.8
0.6
p0.0003
R-CHOP, n86
Probability
Probability
0.4
CHOP, n24
0.2
p0.12
0.0
0
1
2
3
4
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Years from Induction Randomization
Winter et al., Blood 107(11), 2006
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Burkitts Lymphoma
Hummel et al. NEJM 354 (23), June 8, 2006 Dave et
al. NEJM 354 (23), June 8, 2006
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Burkitts Lymphoma (BL)
General 1-2 of NHL in Western Europe and
US 30-50 of childhood lymphoma Most common
malignancy in children in endemic areas 25-35 of
HIV-associated lymphomas Clinical
variants Endemic BL (equatorial Africa, 90
EBV) Sporadic BL (around the world, 10-30
EBV) Immunodeficiency associated BL (HIV, 25-40
EBV) Morphological variants Classical BL BL
with plasmacytoid differentiation Atypical BL,
BL-like
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Diagnostic Grey Zone
Classical Burkitts Lymphoma
Atypical Burkitts Lymphoma
Diffuse Large B-Cell Lymphoma (DLBCL) 50
agreement only among expert hematopathologists!
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Burkitts LymphomaGenetics
Rearrangement of c-Myc t(28)(p12q24),
t(814)(q2432) t(822)(q24q11)
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Deutsche Krebshilfe Network Project Molecular
Mechanisms in Malignant Lymphoma
Molecular characterisation of Burkitts/Aggressiv
e Lymphoma Hummel et al., NEJM 2006
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Molecular Mechanisms in Malignant Lymphomas
Population 254 Mature Aggressive B-cell
Lymphomas (gt70 Tumor Cells) Pathology
Panel review Expression Affymetrix
U133A FISH MYC, IGH-MYC, IGH-BCL2, BCL6,
IGH, IGK, IGL Array-CGH 2.8K
Chip Hypermutation IGVH, BCL6
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Definition of a molecular Burkitt lymphoma
Purpose Identification of a molecular Burkitt
lymphoma signature
Criteria Consensus panel diagnosis as classic or
atypical BL CD10 positive BCL-6
positive BCL-2 negative CD5 negative Ki-67
greater 95 IG-MYC-break

• Identification of a highly consistent expression
  pattern by a new bioinformatic core extention
  approach mBL signature

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Application of the mBL signature to a training
set of aggressive B-NHL cases (n110)
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Application of the mBL signature to the test set
of aggressive B-NHL cases (n110)
Test set
Training set
? Identification of 44 molecular Burkitt lymphoma
cases
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Correlation of the subgroups identified by the
mBL signature with morphology
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Correlation of the subgroups identified by the
mBL signature with immunophenotype
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Clinical significance of the molecular Burkitt
lymphoma signature
(n146 patients with aggressive B-NHL)
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Clinical significance of the MYC-break in non mBL
cases
(n115 patients lacking the mBL signature)
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Conclusions

• A molecular signature of BL could be identified
  among aggressive B-cell lymphoma
• The molecular Burkitt lymphoma (mBL) signature
  significantly sharpens and extends the current
  diagnostic criteria
• Non-mBL (DLBCL) cases with a MYC break represent
  a prognostically adverse group

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Collaborating Institutions University of
Nebraska Medical Center University of Würzburg,
Germany British Columbia Cancer Center,
Vancouver, Canada University of Barcelona,
Spain Southwest Oncology Group
(SWOG) Norwegian Radium Hospital, Oslo,
Norway St. Bartholomews Hospital, London,
GB National Cancer Institute, Center for Cancer
Research, USA
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Development of a Burkitt Lymphoma
PredictorMethods

• Lymphoma biopsy samples obtained from
• -71 patients with Burkitt lymphoma or
  Burkitt-like lymphoma
• -241 cases of DLBCL
• Median age of patients with Burkitt lymphoma
  23.7 years
• 52 adults 48 pediatric.
• Gene expression profiling performed on a custom
  oligonucleotide
• and U133 plus microarrays.
• Cases diagnosed as Burkitt lymphoma by an expert
  panel of 8 hematopathologists based on
• --c-myc translocation by FISH
• --Burkitt morphology
• --Immunophenotype CD10 or BCL-6 Ki67 gt 90

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Burkitt Lymphoma discrepant cases
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Effect of Treatment on Overall Survival in Adult
Patients with Burkitt Lymphoma
Classification of Treatments

• Intensive
• BFM
• CODOX-M/IVAC
• Any regimen requiring autologous stem cell rescue

• CHOP-Like
• CHOP
• CNOP

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Burkitt lymphoma cases potentially undertreated
by CHOP-like therapy
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Take Home Messages

• Burkitt lymphoma has a distinct gene expression
  profile.
• 2. 10-15 disagreement between current diagnosis
  of BL and the molecular diagnosis using gene
  expression profiling.
• 3. Potential over-/undertreatment in some
  patients with aggressive NHL.
• 4. Non-mBL (DLBCL) cases with a MYC break have
  poor outcome.

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Louis M. Staudt Metabolism Branch, CCR,
NCIGeorge Wright BRB, DCTD, NCISandeep
Dave Metabolism Branch, CCR, NCI John Chan,
Kai Fu Univ. of Nebraska Med. CenterJoseph M.
Connors British Columbia Cancer Center,
CanadaElias Campo University of Barcelona,
SpainRichard I. Fisher Southwest Oncology
GroupRandy Gascoyne British Columbia Cancer
Center, Canada H. Konrad Müller-Hermelink Univers
ity of Würzburg, GermanyErlend B.
Smeland Norwegian Radium HospitalPhilip
Kluin University of Groningen, Netherlands
Acknowledgements ILLMPP Leukemia and Lymphoma
Molecular Profiling Project
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Acknowledgements II
Molecular Mechanisms in Malignant Lymphomas
Network Project
Michael Hummel Stefan Bentink Rainer Spang Hilmar
Berger Wolfram Klapper Swen Wessendorf Christiane
Pott Carsten Schwänen
A.C. Feller M.L. Hansmann German Ott H.K.
Müller-Hermelink P. Möller H-H. Wacker R.
Parwaresch S.B. Cogliatti
M. Löffler L. Trümper H. Stein R. Siebert
et al.!!