|Year : 2015 | Volume
| Issue : 4 | Page : 852-856
Immunological subtypes analysis of Uygur diffuse large B-cell lymphoma in Xinjiang and their prognostic significance
Cun-Dong Jia1, Li-Ping Liang2, Li-Li Yang2, Na Yue2, Feng Zhao2, Jing-Ping Bai3
1 Department of Medical Oncology, Affiliated Tumor Hospital, Xinjiang Medical University, Urumqi 830011, China
2 Department of Pathology, Affiliated Tumor Hospital, Xinjiang Medical University, Urumqi 830011, China
3 Department of Bone Oncology, Affiliated Tumor Hospital, Xinjiang Medical University, Urumqi 830011, China
|Date of Web Publication||15-Feb-2016|
Department of Bone Oncology Affiliated Tumor Hospital, Xinjiang Medical University, Urumqi 830011
Source of Support: None, Conflict of Interest: None
Objective: This study aims to explore the application of Choi's typing method in the immunological typing of diffuse large B-cell lymphoma (DLBCL) in Xinjiang Autonomous Region and its prognostic significance.
Materials and Methods: Seventy-eight cases of DLBCL tumor tissues from Xinjiang were collected to detect the expression of germinal center B (GCB) cell-expressed transcript-1, FOXP1, CD10, bcl-6, and MUM1 using an immunohistochemical method. Then, immunological typing was carried out using Choi's typing method, and the survival analysis was performed using Kaplan-Meier method. Cox proportional hazard model was used to analyze the prognostic factors.
Results: GCB-cell-like-DLBCL and non-GCB-DLBCL accounting for 29.5% (23/78) and 70.5% (55/78), respectively. The 3-year overall survival of GCB-DLBCL was 58%, significantly higher than that of non-GCB-DLBCL (39%, P < 0.05). Multivariate analysis showed that International Prognostic Index and immunological typing were two independent prognostic factors for Uygur patients with DLBCL.
Conclusion: Non-GCB-DLBCL is the main type of DLBCL in Xinjiang and Choi's typing method can be a helpful indicator to determine the prognosis of the Uygur DLBCL in Xinjiang.
Keywords: Diffuse large B-cell lymphoma, immunological typing, prognosis, Uygur
|How to cite this article:|
Jia CD, Liang LP, Yang LL, Yue N, Zhao F, Bai JP. Immunological subtypes analysis of Uygur diffuse large B-cell lymphoma in Xinjiang and their prognostic significance. J Can Res Ther 2015;11:852-6
|How to cite this URL:|
Jia CD, Liang LP, Yang LL, Yue N, Zhao F, Bai JP. Immunological subtypes analysis of Uygur diffuse large B-cell lymphoma in Xinjiang and their prognostic significance. J Can Res Ther [serial online] 2015 [cited 2020 Aug 4];11:852-6. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/852/144357
| > Introduction|| |
The diffuse large B-cell lymphoma (DLBCL) is one of the most common histologic subtypes of non-Hodgkin's lymphoma (NHL) in Xinjiang Uygur region.  Back in 2000, Alizadeh et al. firstly applied the DNA microarray technology into the DLBCL study, and found that DLBCL could be divided into two different subtypes with different gene expression patterns, among which the characteristic gene expressed by one subtype was similar to the germinal center B-cells (GCBs) of normal lymph nodes; thus, it was called as the GCB DLBCL; the characteristic gene expressed by another subtype was similar to the activated B-cell-like (ABC); thus, it was called as the non-GCB-DLBCL, or ABC-DLBCL. This classification method according to the different cell origins has attracted more and more attention, because the two different subtypes of DLBCL have significantly different prognosis and pathogenesis. ,,, The recent research has indicated that, the immunophenotype detection of different DLBCL tumor cells with the immunohistochemical method could also divide DLBCL into the GCB-DLBCL and non-GCB-DLBCL. , Because of such reasons as research means, cases choosing and immunohistochemical diagnostic criteria, although there have been a variety of immunohistochemical classification methods used toward DLBCL, there still exists the conflicting phenomenon of goodness of fit against the DLBCL gene expression profiling (GEP); thus, the immunohistochemical classification of DLBCL is still controversial in the clinical practice. , A recent research showed that the expression detection of germinal center B-cell-expressed transcript-1 (GCET1), FOXP1, CD10, bcl-6 and MUM1 with the Choi method could divide DLBCL into the GCB-DLBCL and non-GCB-DLBCL. The application of Choi method into the immunological classification of DLBCL could exhibit better goodness of fit with GEP, and would be beneficial toward the prognosis evaluation.  The studies have shown that the incidence of DLBCL did exist the geographic and racial differences.  DLBCL is one of the most common histologic subtypes in Xinjiang Uygur NHL, and DLBCL in Xinjiang Uygur has its unique clinical characteristic and prognosis; but, it is still not clear about the immunological subtype distributions of DLBCL and prognostic significance in Xinjiang Uygur region. Therefore, this study applied the immunohistochemical method to detect the expressions of GCET1 Uygur, FOXP1 CD10, bcl-6 and MUM1 in 78 DLBCL Uighur patients, and then performed the immunological classification and analyzed its significance with the Choi method, the study would promote the research toward the specific occurrence laws of Xinjiang Uygur DLBCL patients, thus exhibiting the great significance in realizing the individualized treatment toward the Uighur DLBCL disease.
| > Materials and Methods|| |
Seventy-eight cases of DLBCL tumor tissues were collected from the Department of Pathology of the Affiliated Tumor Hospital, Xinjiang Medical University. Specimens were obtained from Uygur patients who underwent biopsy examination for histologically confirmed DLBCL, according to the classification of lymphoma established by WHO (2008), between January 2007 and June 2013. The patients included 50 males and 28 females with a ratio of 1.79:1. The median age at the diagnosed time was 50 years (from 14 to 84 years). According to the Ann Arbor staging criteria, specimens were staged into Stage I in 5 cases, Stage II in 37 cases, Stage III in 22 cases and Stage IV in 14 cases. In terms of metastases, 42 cases with metastases limited in the lymph nodes (53.8%) and 36 cases with metastases involving extranodal lesions (46.2%) when they were finally diagnosed. The extranodal involvement included gastrointestinal tract (n = 11), muscles and soft tissues (n = 7), kidney (n = 4), thyroid (n = 3), testicular (n = 3), liver (n = 2), breast (n = 2), cervix (n = 2), ovarian (n = 1), and parotid gland (n = 1). The performance status (PS) of the subjects at the diagnosed time was assessed according to the determination criteria of Eastern Cooperative Oncology Group: 73 patients with PS score between 0 and 1 (93.6%) and five patients with PS score of 2 points (6.4%). There were 15 of 78 patients (19.2%) with lactate dehydrogenase (LDH) above the normal levels and 11 of 78 patients (14.1%) with B symptoms. As classified with the International Prognostic Index (IPI), there were 59 patients with low-risk (IPI = 0-1), 10 patients with low-medium risk (IPI = 2), six patients with medium-high risk (IPI = 3) and three patients with high-risk (IPI = 4-5). The clinicopathological features of 78 patients were shown in [Table 1]. As for the treatment of DLBCL, CHOP (cyclophosphamide [CTX], Adriamycin [ADM], vincristine [VCR], and prednisone [PDN]) or European Electronic Commerce for Hospital Procurement (ECHOP) (VP-16, CTX, ADM, VCR, and PDN) program was performed as a first-line treatment on 75 patients whose IPI showed the patients belong to low-and median-risk group, and RCHOP (Rituximab, CTX, ADM, VCR and PDN) was carried out on three patients as a first-line therapy whose IPI belong to the high-risk group. The second-line treatment regimens included CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), DHAP (DDP, Ara-C and dexamethasone [DXM]), DICE (DXM, ifosfamide [IFO], DDP and VP-16), ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin), ICE (VP-16, CBP and IFO) and gemcitabine and oxaliplatin programs.
Primary antibodies GCET1, FOXP1, CD10, bcl-6, MUM1, and secondary antibodies were all purchased from Beijing ZSGB Biotechnology Co., Limited, China.
Formalin ﬁxed and parafin embedded sections of tumor tissues were cut into 4 μm thickness and placed on silane coated slides. Then the slides were used to detect the expression of GCET1, FOXP1 CD10, bcl-6 and MUM1 using Envision two-step detection kit (Dako Corporation, Carpinteria, CA) according to the manufacturer's instructions.
Immunohistochemical typing of diffuse large B-cell lymphoma
Tumor tissues were classified into GCB DLBCL and non-GCB DLBCL following the typing method of Choi.  In brief, DLBCL with GCET1-positive and MUM1-negative was regarded as GCB-DLBCL, while DLBCL with GCET1-positive and MUM1-positive was regarded as non-GCB-DLBCL. Otherwise, if GCET1 is negative, DLBCL with CD10 + was determined as GCB-DLBCL. If both GCET1 and CD10 were negative, DLBCL with bcl-6 - was non-GCB-DLBCL. If GCET1- and CD10-negative were combined with bcl-6-positive, FOXP1 + could be used to determine non-GCB-DLBCL and FOXP1 - was GCB-DLBCL. ,
Outpatient follow-up and telephone follow-up were used in this study and ended at November 30, 2013. Overall survival time (OS) referred to the period from the date starting the treatment to the death date or the date of last follow-up or the end of follow-up time. The OS time was expressed in months.
Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) 16.0 software. Survival analysis was carried out using Kaplan-Meier method and comparison of the survival between groups was performed using Log-rank method. P < 0.05 was considered as statistically significant.
| > Results|| |
Immunological typing of diffuse large B-cell lymphoma by immunohistochemistry
The positive rates of CD10, bcl-6, MUM1, GCET1, FOXP1 were 19.2% (15/78), 24.4% (19/78), 62.8% (49/78), 30.8% (24/78) and 53.8% (42/78), respectively. The expression of CD10, bcl-6, MUM1, GCET1 and FOXP1 in Uygur DLBCL tumor tissues showed no correlation with the IPI of DLBCL [P > 0.05, [Figure 1]. GCB DLBCL and non-GCB DLBCL accounted for 29.5% (23/78) and 70.5% (55/78), respectively.
|Figure 1: The expression of CD10, bcl-6, MUM1, GCET1 and FOXP1 in Uygur diffuse large B-cell lymphoma tumor tissues (×200)|
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Survival and multivariate analysis
Since the patients of IPI low-risk and median-risk whose first-line therapy were CHOP and ECHOP without remission rate difference,  as well as the three patients of IPI high-risk whose first-line therapy was RCHOP.  When ANOVA was taken before the multivariate analysis to find if the chemotherapy regimens was one of the influence factors, but no statistical significance was found. At the end of the follow-up time, the median follow-up time was 26 months (from 5 to 85 months). Forty one patients died of disease progression or recurrence during the follow-up time. The median OS time was 28 months (95% confidence interval = 24.6-31.4 months) with a 3-year OS of 46%. The 3-year OS of GCB-DLBCL was 58%, showing statistically significant difference from that of non-GCB-DLBCL [39%, P < 0.05, [Figure 2]. Univariate analysis showed that IPI, LDH and Choi's immunological typing were correlated with the prognosis of Uygur patients with DLBCL [P < 0.05, [Table 2]. Multivariate analysis showed IPI and Choi's typing were two independent prognostic factors for patients with DLBCL (P < 0.01).
|Figure 2: Survival curves of Uygur patients with germinal center B-cell (GCB) -and non-GCB-diffuse large B-cell lymphoma|
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|Table 2: The relationship between clinical features and the prognosis of Uygur patients with DLBCL |
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| > Discussion|| |
The immunological phenotypes of DLBCL are distributed with race difference. Studies from Europe and America showed that, the proportion of GCB-DLBCL is slightly more than or roughly equal to the proportion of non-GCB-DLBCL. ,, Chen et al.  classified 124 patients with DLBCL using Choi's typing criteria and found that 27% of the patients are GCB-DLBCL and 73% of the patients belong to the non-GCB-DLBCL. Luo et al.  also analyzed a total of 500 patients with DLBCL. They found that non-GCB-DLBCL accounted for 68.5% of the unspecified DLBCL (219/320), while GCB-DLBCL only accounted for 28.4% (91/320). Korean scholars Oh et al.  analyzed 94 Korean patients with DLBCL using Hans' classification method and found that, GCB-DLBCL accounted for 19.1% (18/94) and non-GCB-DLBCL accounted for 80.9% (76/94). Another South Korean scholar Kim et al.  detected the expression of CD10, Bcl-6, Bcl-2 and MUM1 in 123 cases of DLBCL tissues and carried out an immunological typing on them. They found that patients with GCB-DLBCL accounted for 32.5% (40/123) and non-GCB-DLBCL patients accounted for 67.5% (83/123). Peh et al.  reported that 84 patients with newly diagnosed DLBCL in Malaysia were classified into GCB-DLBCL (39.3%) and non-GCB-DLBCL (60.7%) with the immunohistochemical detection of the expression of CD10, Bcl-6, Bcl-2 and MUM1. All the above results suggest that the distribution of the immunological subtypes of DLBCL is almost similar in Korea, Malaysia and China, but rather than the Western distribution. Our findings showed that the proportion of non-GCB-DLBCL was far more than that of GCB-DLBCL in Uygur, which is consistent with the reports in China,  but different from the foreign reports, suggesting that the distribution of the immunological subtypes of DLBCL in Uygur may be similar to Han people in China. Thus, we may conclude that the pathogenesis of these two groups of DLBCL was in common, but it should be confirmed by more control studies with a larger sample.
The prognostic factors of DLBCL are still the hot issues for researchers. Currently, the evaluation system for the prognosis of DLBCL is to classify the DLBCL patients into low-risk, low-medium risk, medium-high risk and high-risk, basing on the IPI. However, patients with the same IPI values can also present completely distinct prognosis, suggesting that there are other factors affecting the prognosis of patients with DLBCL. Previous studies showed that DLBCL originated from different cells can be classified into GCB-DLBCL and non-GCB-DLBCL using GEP classification method. However, due to the highly expensive cost, GEP cannot be widely used clinically. Recent studies have shown that the application of Choi's immunological typing method on DLBCL can get a comparable result with GEP. Thus, it can be used to determine the prognosis of DLBCL.  But some studies argued that the use of immunohistochemical methods in the classification of DLBCL cannot be comparable with GEP.  The application of relevant model with only immunological phenotypes of DLBCL in predicting the prognosis remains more controversial. , In this study, we classified Uygur DLBCL patients using Choi's methods and found that the 3-year OS of GCB- and non-GCB DLBCL were 66% and 39%, respectively, which can predict the prognosis of DLBCL well. But the expression of GCET1, FOXP1, CD10, bcl-6 and MUM1 were not correlated with the IPI of DLBCL patients, suggesting that only combined detection of GCET1, FOXP1, CD10, bcl-6 and MUM1 can predict the prognosis of patients with DLBCL better.
In the era of treating DLBCL with rituximab, rituximab can improve the survival and prognosis of patients with DLBCL. , Studies also reported that R-CHOP program can significantly improve the survival of patients with non-GCB-DLBCL to the level of GCB-DLBCL. Thus, some scholars believe that rituximab therapy can significantly reduce the prognostic role of immunological typing in DLBCL. ,, However, A meta-analysis of Fang et al.  on six control studies with 748 DLBCL patients showed that the rituximab combined with chemotherapy lead to a better prognosis of patients with GCB-DLBCL than patients with non-GCB-DLBCL, suggesting that the immunological typing still can be a predictor for the prognosis of DLBCL patients in the rituximab era. In this study, multivariate analysis showed that IPI and immunological typing were two independent prognostic factors for Uygur patients with DLBCL. Thus, Choi's classification is helpful to predict the prognosis of Uygur patients with DLBCL, despite the lower OS may be associated with the fact that most of the patients never received rituximab therapy. Therefore, the application of Choi's classification in the determination of Uygur patients with DLBCL in different treatment schema still needs the supports of more researches.
In summary, the detection of GCET1, FOXP1, CD10, bcl-6 and MUM1 using immunohistochemical methods and the immunological typing using Choi typing methods contribute to the diagnosis and typing of Uygur DLBCL. Non-GCB-DLBCL is the main type of DLBCL in Uygur patients, and Choi's typing methods can be helpful to the evaluation of the prognosis of Xinjiang Uygur patients with DLBCL.
| > Acknowledgements|| |
This study was supported by Natural Science Foundation of the Xinjiang Uygur Autonomous Region, China (No. 2012211A045).
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[Figure 1], [Figure 2]
[Table 1], [Table 2]