Primer diffüz büyük B hücreli lenfoma olgularında PD-1/ PD-L1 ekspresyonunun, tümör mikroçevresinin ve prognostik özelliklerinin değerlendirilmesi
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Tarih
2019
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Dergi Başlığı
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Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Diffüz büyük B hücreli lenfoma (DBBHL), Dünya Sağlık Örgütü (DSÖ) 2016 sınıflamasında matür B hücreli neoplaziler grubunda yer almaktadır. Gelişmiş ülkelerde non-Hodgkin lenfomaların % 25-35'ini oluşturmaktadır. Standart kemoterapi rejimleri ile 5 yıllık sağkalım oranları %60-70'e ulaşmaktadır. Non-Hodgkin lenfoma olgularında aynı tedavi uygulanan hastalar arasında prognoz, oldukça değişkenlik göstermektedir. Bu nedenle hem prognozu öngörmede, hem de hedefe yönelik tedaviler açısından biyobelirteçlere ihtiyaç duyulmaktadır. Tümörler, neoplastik hücreler yanı sıra inflamatuar hücreler, fibroblastlar, endotel hücreleri ve bu hücreler arasında salınan molekülleri içermektedir. Son dönemde yapılan çalışmalarda tümör mikroçevresinin kanser gelişimi ve progresyonunda önemli rol oynadığı gösterilmiştir. DBBHL'lerde de, tümör mikroçevresinde yer alan neoplastik olmayan hücrelerin ve ekstrasellüler matriks bileşenlerinin prognostik öneme sahip olduğu bildirilmiş, immün sistem hücrelerinin ve eksprese ettikleri reseptörlerin ya da ligandların oluşturduğu tümör mikroçevresinin moleküler ve hücresel yapısının tümör büyümesinde ve klinik progresyonda önemli olduğu ortaya konmuştur. Tümöre spesifik sitotoksik CD8 pozitif T lenfositlerin aktivasyonu anti-tümör immun yanıt oluştururken, CD4 pozitif ve bir transkripsiyon faktörü olan FOXP3 ile pozitif regülatuar T hücrelerin (Treg), myeloid-derive supresör hücrelerin ve immun kontrol noktasında etkili olan PD-1 ve PDL-1 gibi moleküllerin, CD8 pozitif T hücreler üzerinde inhibitör etkileri bulunmaktadır. CD68 pozitif tümör ilişkili makrofajların (TİM) büyüme faktörleri, sitokinler ve proteazlar üreterek tümör gelişimine ve progresyonuna katkıda bulunduğu bildirilmiştir. Solid tümörlerde PD-1 ve PD-L1 blokajı yapan immunoterapi ajanları ile yapılan çalışmalarda elde edilen uzun dönem klinik sonuçlar nedeniyle anti-tümör immunite önem kazanmaktadır. Çalışmamızda Ege Üniversitesi Tıp Fakültesi Hastanesi Tıbbi Patoloji Anabilim Dalı'nda, 2009-2016 yılları arasındaki arşiv kayıtlarına ait veriler değerlendirilerek, nodal ya da ekstranodal lokalizasyonlu "diffüz büyük B hücreli lenfoma, spesifiye edilemeyen (NOS)" tanısı almış, parafin blok ve preperatlarına ulaşılabilen toplam 163 olgu çalışmaya dahil edilmiştir. Olguların tamamı arşivimizde bulunan CD3, CD20, BCL-2, BCL-6, MUM1, CD10, MYC, Ki67 immunhistokimyasal belirteçlerine ait preperatları ve EBER-CISH yöntemi ile EBV enfeksiyonunun varlığı açısından yeniden değerlendirildi. Tümörde ve tümör mikroçevresinde ekspresyon durumlarını değerlendirmek amacıyla immunhistokimyasal yöntemle PD-L1, PD-1, FOXP3, CD4, CD8, CD68 ve CD163 incelemeleri uygulandı. Çalışmaya dahil edilen olguların tanı aldığı dönemdeki medyan yaşı 62 olup tanı yaşı aralıkları 13 ile 92 yaş arasında değişmektedir. Olguların 83'ü (%50,9) kadın, 80'i (%49,1) erkek olup, tümör lokalizasyonu açısından ele alındığında olguların 78'inde (%47,9) nodal tutulum, 85'inde (%52,1) ekstranodal tutulum saptandı. Olguların arşivimizde evreleme amacıyla yapılmış kemik iliği biyopsisi bulunan 114 olgunun (%69,9) 20'sinde (%17,5) DBBHL infiltrasyonu saptandı. Çalışmada olguların medyan izlem süresi 81 ay (min-maks: 1-143 ay) olarak belirlendi. Çalışmaya dahil edilen 163 olgunun 40'ının (%24,5) öldüğü, 29'unda (%17,8) biyopsi ya da PET/BT ile saptanan hastalık progresyonu olduğu belirlendi. Olguların genel sağkalım medyan değeri 115,7±4,2 ay; progresyonsuz sağkalım medyan değeri 103,8±3,4 ay olarak saptandı. Olguların bir yıllık genel sağkalım oranı %92,4; üç yıllık genel sağkalım oranı %84,6 ve beş yıllık genel sağkalım oranı %80 olarak hesaplandı. Olguların bir yıllık progresyonsuz sağkalım oranı %87,3; üç yıllık progresyonsuz sağkalım oranı %77 ve beş yıllık progresyonsuz sağkalım oranı %73,1 olarak hesaplandı. Tanı yaşının artışının, genel sağkalım açısından 1,066 kat artmış riske sahip olduğu bulundu (p<0,001), progresyonsuz sağkalım açısından ise 1,036 kat artmış riske sahip olduğu belirlendi (p=0,034). Hans algoritmasına göre olguların 101 tanesi (%62) non-GCB/ABC, 62 tanesi (%38) GCB fenotipinde değerlendirildi. Çalışmamızda hem prognostik farklılıkların öngörülmesinde, hem de immunmodülatör tedavilere uygun hastaların belirlenmesinde önemli rolü olan tümör mikroçevresini ve tümör hücrelerinde PD-1/PD-L1 ekspresyonunu değerlendirdik. Tümör hücrelerinde ve tümör mikroçevresinde PD-1/PD-L1 ekspresyonu ya da tümör mikroçevresini oluşturan hücreleri değerlendirmeye yönelik yaptığımız FOXP3, CD4, CD8, CD68 ve CD163 immunhistokimyasal belirteçleri ile sağkalım analizinde anlamlı ilişki saptamadık. Ancak prognostik öneme sahip olan Hans algoritması, kemik iliği tutulumu, serum LDH düzeyi, Ki67 proliferasyon indeksi gibi parametreler ile tümör hücrelerine ya da tümör mikroçevresine ait immunhistokimyasal özelliklere ait analizlerde istatistiksel anlamlı sonuçlar saptadık. Tümörde PD-L1 ekspresyonu saptanan hastaların %73,2'si Hans algoritmasına göre daha kötü prognostik olduğu bilinen ABC alt grubunda yer almaktaydı. Ayrıca tümörde PD-L1 ekspresyonu bulunan olgularda, prognostik olarak değerlendirilebilecek bir başka parametre olan Ki67 proliferasyon indeksi de anlamlı olarak daha yüksekti. İmmun kontrol noktası inhibitörlerinin hedefi olan PD-1, az sayıda olguda X tümörde pozitif saptanmış olmakla birlikte, boyanma oranının artışı ile progresyon oranı açısından 0,359 kat artan riske sahip olduğu belirlendi (p<0,001). PD-L1'in tümör mikroçevresinde pozitif saptandığı olgular ise anlamlı olarak daha sıklıkla GCB alt grubundaydı. DBBHL olgularında neoplastik hücrede PD-L1 ekspresyonu ile sağkalım analizleri arasında ilişki saptanmamış olmakla birlikte Ki67 proliferasyon indeksi ve ABC tipi ilişkisi nedeniyle tümörde PD-L1 ekspresyonunun kötü prognoz ile ilişkili olabileceği düşünülebilir. Tümör mikroçevresinin ve tümör hücresi ile etkileşimlerinin detaylı olarak ortaya konması, yeni tedavi açılımlarının belirlenmesi ve yeni terapötik ajanların geliştirilmesi için ışık tutacaktır. Tümör, tümör mikroçevresi ve prognostik özellikler ile ilişkisinin net olarak ortaya konması için geniş olgu serilerinde yapılacak çalışmalara ihtiyaç vardır.
Diffuse large B cell lymphoma (DLBCL), is classified in mature B cell neoplasms according to WHO classification of tumours of haematopoietic and lymphoid tissues. DLBCL, not otherwise specified (NOS), constitutes 25-35% of adult non-Hodgkin lymphomas in developed countries. The 5 year overall survival is approximately 60-70% with standard chemotherapy regimens. The prognosis of DLBCL patients varies even with the same treatment protocols. Therefore, biomarkers are needed for predicting prognosis and for targeted therapies. Tumors include neoplastic cells as well as inflammatory cells, fibroblasts, endothelial cells and molecules released between these cells. Recent studies have shown that tumor microenvironment plays an important role in cancer development and progression. Likewise in DLBCL, non-neoplastic cells and extracellular matrix components in the tumor microenvironment have been reported to have prognostic significance. The molecular and cellular structure of the immune system cells and the tumor microenvironment formed by the receptors or ligands they express have been shown to be important in tumor growth and clinical progression in DLBCL. Activation of tumor-specific cytotoxic CD8 positive T lymphocytes produces an anti-tumor immune response. CD4 positive and FOXP3 positive regulatory T cells (Treg), myeloid-derived suppressor cells and molecules such as PD-1 and PDL-1, which are effective at the immune control point, have positive inhibitory effects on CD8 positive T cells. CD68 positive tumor-associated macrophages (TAM) have been reported to contribute to tumor growth and progression by producing growth factors, cytokines, and proteases. Anti-tumor immunity gains importance due to the long-term clinical results obtained from studies with immunotherapy agents that block PD-1 and PD-L1 in solid tumors. In our study, the data of the archival records between the years of 2009-2016 were evaluated in the Department of Pathology, Ege University Faculty of Medicine Hospital. A total of 163 cases, diagnosed as diffuse large B cell lymphoma, NOS were included in the study. All of the cases were re-evaluated for the slides of CD3, CD20, BCL-2, BCL-6, MUM1, CD10, MYC, Ki67 immunohistochemical markers and presence of EBV infection by EBER-CISH method that were in our archive. Immunohistochemical stainings of PD-L1, PD- 1, FOXP3, CD4, CD8, CD68 and CD163 were performed to evaluate the expression status of tumor and tumor microenvironment. The median age of the subjects included in the study at the time of diagnosis was 62 years (minimum;13- maximum; 92). Eighty-three (50.9%) of the patients were female and 80 (49.1%) were male. Nodal involvement was found in 78 (47.9%) and extranodal involvement was found in 85 (52.1%) of the cases. DLBCL infiltration in bone marrow was detected in 20 (17.5%) of 114 cases (69.9%) who had bone marrow biopsy performed in our archive. The median follow-up period was 81 months (minimum;1- maximum; 143). Forty of them (24.5%) died and 29 of them (17.8%) had disease progression detected by biopsy or PET / CT. The median overall survival was 115.7 ± 4.2 months. The median value of progression-free survival was 103.8 ± 3.4 months. One-year overall survival rate was 92.4%; three-years overall survival rate was 84.6% and the five-years overall survival rate was 80%. One-year progression-free survival was 87.3%; three-years progression-free survival rate was 77% and the five-years progression-free survival rate was 73.1%. The increase in the age at the time of diagnosis was found to have a 1.066-fold increased risk for overall survival (p <0.001), and a 1.036-fold increased risk for progression-free survival (p = 0.034). According to Hans algorithm, 101 (62%) of the cases were evaluated in non-GCB / ABC and 62 (38%) were in GCB phenotype. In our study, we evaluated tumor microenvironment and PD-1 / PD-L1 expression in tumor cells, which play an important role both in predicting prognostic differences and in identifying patients suitable for immunomodulatory therapies. We did not find a significant correlation in the survival analysis with the FOXP3, CD4, CD8, CD68, CD163 and PD-1/PD-L1 expressions in tumor microenvironment cells or tumor cells. However, we found statistically significant results in the analysis of the prognostic significance of the Hans algorithm, bone marrow involvement, serum LDH level, Ki67 proliferation index, and immunohistochemical properties of tumor cells or tumor microenvironment. 73.2% of patients with PD-L1 expression in the tumor were in the ABC subgroup, which is known to have a worse prognosis than GCB subgroup. In addition, Ki67 proliferation index, another parameter that can be evaluated prognostically, was significantly higher in patients with PD-L1 expression in the tumor. Although PD-1, which is the target of immune control point inhibitors, was found to be positive in a small number of tumors, it was found that the risk of progression was increased by 0.359 times with increasing expression rate (p <0.001). Patients with PD-L1 positivity in the tumor microenvironment were significantly more often in the GCB subgroup. Although PD-L1 expression in neoplastic cells was not correlated with survival analysis in DLBCL cases, PD-L1 expression in neoplastic cells may be associated with poor prognosis due to Ki67 proliferation index and ABC type relationship. A detailed understanding of tumor microenvironment and tumor cell interactions will shed light on identifying new therapeutic expansions and developing new therapeutic agents. In order to establish the relationship between tumor, tumor microenvironment and prognostic features, studies in large case series are needed.
Diffuse large B cell lymphoma (DLBCL), is classified in mature B cell neoplasms according to WHO classification of tumours of haematopoietic and lymphoid tissues. DLBCL, not otherwise specified (NOS), constitutes 25-35% of adult non-Hodgkin lymphomas in developed countries. The 5 year overall survival is approximately 60-70% with standard chemotherapy regimens. The prognosis of DLBCL patients varies even with the same treatment protocols. Therefore, biomarkers are needed for predicting prognosis and for targeted therapies. Tumors include neoplastic cells as well as inflammatory cells, fibroblasts, endothelial cells and molecules released between these cells. Recent studies have shown that tumor microenvironment plays an important role in cancer development and progression. Likewise in DLBCL, non-neoplastic cells and extracellular matrix components in the tumor microenvironment have been reported to have prognostic significance. The molecular and cellular structure of the immune system cells and the tumor microenvironment formed by the receptors or ligands they express have been shown to be important in tumor growth and clinical progression in DLBCL. Activation of tumor-specific cytotoxic CD8 positive T lymphocytes produces an anti-tumor immune response. CD4 positive and FOXP3 positive regulatory T cells (Treg), myeloid-derived suppressor cells and molecules such as PD-1 and PDL-1, which are effective at the immune control point, have positive inhibitory effects on CD8 positive T cells. CD68 positive tumor-associated macrophages (TAM) have been reported to contribute to tumor growth and progression by producing growth factors, cytokines, and proteases. Anti-tumor immunity gains importance due to the long-term clinical results obtained from studies with immunotherapy agents that block PD-1 and PD-L1 in solid tumors. In our study, the data of the archival records between the years of 2009-2016 were evaluated in the Department of Pathology, Ege University Faculty of Medicine Hospital. A total of 163 cases, diagnosed as diffuse large B cell lymphoma, NOS were included in the study. All of the cases were re-evaluated for the slides of CD3, CD20, BCL-2, BCL-6, MUM1, CD10, MYC, Ki67 immunohistochemical markers and presence of EBV infection by EBER-CISH method that were in our archive. Immunohistochemical stainings of PD-L1, PD- 1, FOXP3, CD4, CD8, CD68 and CD163 were performed to evaluate the expression status of tumor and tumor microenvironment. The median age of the subjects included in the study at the time of diagnosis was 62 years (minimum;13- maximum; 92). Eighty-three (50.9%) of the patients were female and 80 (49.1%) were male. Nodal involvement was found in 78 (47.9%) and extranodal involvement was found in 85 (52.1%) of the cases. DLBCL infiltration in bone marrow was detected in 20 (17.5%) of 114 cases (69.9%) who had bone marrow biopsy performed in our archive. The median follow-up period was 81 months (minimum;1- maximum; 143). Forty of them (24.5%) died and 29 of them (17.8%) had disease progression detected by biopsy or PET / CT. The median overall survival was 115.7 ± 4.2 months. The median value of progression-free survival was 103.8 ± 3.4 months. One-year overall survival rate was 92.4%; three-years overall survival rate was 84.6% and the five-years overall survival rate was 80%. One-year progression-free survival was 87.3%; three-years progression-free survival rate was 77% and the five-years progression-free survival rate was 73.1%. The increase in the age at the time of diagnosis was found to have a 1.066-fold increased risk for overall survival (p <0.001), and a 1.036-fold increased risk for progression-free survival (p = 0.034). According to Hans algorithm, 101 (62%) of the cases were evaluated in non-GCB / ABC and 62 (38%) were in GCB phenotype. In our study, we evaluated tumor microenvironment and PD-1 / PD-L1 expression in tumor cells, which play an important role both in predicting prognostic differences and in identifying patients suitable for immunomodulatory therapies. We did not find a significant correlation in the survival analysis with the FOXP3, CD4, CD8, CD68, CD163 and PD-1/PD-L1 expressions in tumor microenvironment cells or tumor cells. However, we found statistically significant results in the analysis of the prognostic significance of the Hans algorithm, bone marrow involvement, serum LDH level, Ki67 proliferation index, and immunohistochemical properties of tumor cells or tumor microenvironment. 73.2% of patients with PD-L1 expression in the tumor were in the ABC subgroup, which is known to have a worse prognosis than GCB subgroup. In addition, Ki67 proliferation index, another parameter that can be evaluated prognostically, was significantly higher in patients with PD-L1 expression in the tumor. Although PD-1, which is the target of immune control point inhibitors, was found to be positive in a small number of tumors, it was found that the risk of progression was increased by 0.359 times with increasing expression rate (p <0.001). Patients with PD-L1 positivity in the tumor microenvironment were significantly more often in the GCB subgroup. Although PD-L1 expression in neoplastic cells was not correlated with survival analysis in DLBCL cases, PD-L1 expression in neoplastic cells may be associated with poor prognosis due to Ki67 proliferation index and ABC type relationship. A detailed understanding of tumor microenvironment and tumor cell interactions will shed light on identifying new therapeutic expansions and developing new therapeutic agents. In order to establish the relationship between tumor, tumor microenvironment and prognostic features, studies in large case series are needed.
Açıklama
Anahtar Kelimeler
PD-1, PD-L1, Diffüz Büyük B Hücreli Lenfoma, Tümör Mikroçevresi, Prognoz, Diffuse Large B Cell Lymphoma, Tumor Microenvironment, Prognosis
