MYC-associated and Double Hit Lymphomas Lisa G Roth, MD Division of Hematology/Oncology Weill Cornell Medical College New York, NY Overview • How to define double hit lymphoma – FISH – IHC • Prognostic relevance of MYC and BLC2 aberrations • Management challenges What is a “double hit” lymphoma? • Recurrent oncogene rearrangements, one being MYC • MYC and BCL2 rearrangements most common • BCL6, CCND1 and BCL3 may also occur • Can also have “triple hit” Burkitt Lymphoma (BL) clinical variants Endemic BL Sporadic BL EBV pos children sub-Saharan Africa MYC/IG breakpoints (somatic hypermutation) EBV +/adults MYC/IgH locus 8q24 MYC rearrangement •14q32 (80%) •2p11 (15%) •22q11 (5%) Immunodeficiency-related BL EBV pos Cooperation with HIV? MYC translocation is not specific for Burkitt Lymphoma • Diffuse large B-cell lymphoma • B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma (BCL, U) • Follicular lymphoma Frequency of MYC-rearrangements in DLBCL Reference N Treatment MYC rearranged Outcome UK 245 R-CHOP 35/245 (14%) 2-yr OS 35% BCCA 135 R-CHOP 12/135 (9%) Japan 252 CHOP 28/252 (11%) 5-yr OS 44% France 161 R-CHOP, RCVP, R-FCM 28/161 (17%) NR Barrans JCO 28:3360-3365; Savage Blood. 2009;114: 3533-3537; Niitsu Ca Sci 2009; Cuccioni Blood 2010 5-yr OS 33% Outcome for MYC pos DLBCL 66% PFS 31% 72% OS 33% Savage Blood 2009 Outcome for MYC+ DLBCL • N=303 de novo DLBCL • All treated with R-CHOP • Med f/u 4 years Barrans J Clin Oncol 28:3360-3365, 2010 MYC rearrangement alone may not explain poor prognosis Frequency of MYC and BCL2-rearrangements in DLBCL Ref. N MYC rearr. MYC and BCL2 rearr. Barrans 245 35 (14%) 19 (7.7%) BCCA 135 12 (9%) 3 (2%) Japan 394 24 (6%) 19 (4.8%) MYC proliferation + BCL2 Antiapoptosis Barrans JCO 2010; Savage Blood 2009; Niitsu = Comments MYC as sole abnl was rare (2%) Only looked at pts with cytogenetic abnl “DOUBLE HIT LYMPHOMA” Overall Survival Double hit lymphoma: BCL2 expression associated with inferior prognosis Johnson Blood 2009 Johnson Blood 2009 Immunophenotype of Double hit Lymphoma • • • • DLBCL and BCL, U histology CD10+, GCB phenotype BCL2 + in 95% of cases High proliferative index – median 90% Ki67+ Aukema et al, Blood 2011 Clinical Characteristics of Double hit Lymphoma • • • • • • Higher IPI Worse PS Higher LDH Increased advanced stage disease Increased extranodal sites Increased CNS disease Petrich, Cancer 2014 How to detect MYC aberrations Routine karyotyping FISH breakapart Rearrangement Images courtesy of Dr. Gordana Raca, The University of Chicago Increased copy number NEW: Immunohistochemistry for MYC Images courtesy of Dr. Girish Venkataraman, The University of Chicago Hematopathology Relative frequency of MYC via IHC Ref. N Subtype MYC rearr Horn 2013 442 DLBCL (RICOVER) 8.8% Johnson 2012 167 DLBCL (training) 11% Johnson 2012 140 DLBCL (validation) 13% Hu 2013 466 DLBCL (training) NR MYC IHC 32% BCL2 rearr 13.5% (>40%) 29% BCL2 IHC 80% (>0%) 18% 44% 30% 62% NR 50% (>40%) 37% (>40%) 64% (>40%) Johnson JCO 2012; Horn Blood 2013; Hu Blood 2013 BCL2 and MYC IHC (>70%) 18% overall (vs. 5% with DHL) 34% (vs. 3% with DHL) IHC expression of BCL2 and MYC is associated with poor prognosis Overall survival Perry BJH 2014 EFS Prognosis of classic double hit lymphoma vs. MYC/BCL2 expressing lymphomas OS and PFS for classic DHL (MYC/BCL2 rearranged) OS and PFS for MYC/BCL2 expression Hu Blood 2013 75% 30% 73% 27% Clinicopathologic features lymphoma expressing MYC and Bcl2 Age, PS, B sx, stage IPI CR, COO, Ki67 Hu Blood 2013 Prognostic relevance of COO and MYC/Bcl2 protein expression Co-expression of BCL2 and MYC is 2-fold higher in ABC DLBCL Hu, et al., Blood. 2013;121(20):40214031 Co-expression of BCL2 and MYC drives the negative outcomes in ABC DLBCL How should we treat double hit lymphoma? • Questions: – R-CHOP vs. intensified treatment? • If intensified treatment – which regimen? – Upfront SCT? • Considerations: – All data to date is retrospective – All data to date is on DHL defined by FISH/cytogenetics not IHC Are more intensive regimens better? MDACC experience Oki BJH 2014 MDACC: SCT in patients achieving CR Oki BJH 2014 Are more intensive regimens better? Petrich et al, Blood 124 (15), 2014 What is the role of SCT in patients who achieve a CR? Petrich et al, Blood 124 (15), 2014 Treatment of double hit lymphoma in 2014: Many questions, no answers • What is the best initial treatment? • Should patients with DHL and IHC-DHL be approached similarly? • Should autologous stem cell transplant be offered as consolidation? • How should relapsed disease be treated? Ongoing trials and new agents • Phase II trial of DA-EPOCH-R (NCI) • Phase I/II trial of lenalidomide plus DA-EPOCH-R • New agents: – Bromodomain inhibitors – Direct inhibitors of BCL2 – Dasatinib Thank you!
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