Linfoma Hodgkin Clásico en el departamento de Anatomía Patológica del Hospital Nacional Edgardo Rebagliati Martins durante los años 2015 a 2019 / Classic Hodgkin Lymphoma at the Edgardo Rebagliati Martins National Hospital during 2015 to 2019

RESUMEN Introducción: Los Linfomas Hodgkin son neoplasias linfoides de células B, caracterizadas histológicamente por un contexto celular inflamatorio mixto mayoritario y escasas células neoplásicas de Hodgkin/ Reed- Sternberg. El Linfoma Hodgkin Clásico (LHC) representa el 10% de todos los casos de linfoma y el 85% de todos los Linfomas Hodgkin. De acuerdo con la vigente clasificación de la Organización Mundial de la Salud, el LHC se divide en 4 variantes: Esclerosis Nodular (EN), Celularidad Mixta (CM), Rico en Linfocitos (RL) y Depleción Linfocítica (DL). Objetivo: En este estudio revisamos todos los casos de Linfoma Hodgkin Clásico en el Departamento de Anatomía Patológica del Hospital Nacional Edgardo Rebagliati Martins durante los años 2015 a 2019, para determinar la variante más frecuente, la incidencia en cuanto a edad y sexo, características fenotípicas y relación con el Epstein Barr Virus (EBV). Materiales y Métodos: Se realizó un estudio descriptivo retrospectivo de la casuística de Linfoma Hodgkin Clásico en sus 4 variantes clínico - patológicas en el Departamento de Anatomía Patológica del Hospital Nacional Edgardo Rebagliati Martins durante los años 2015 a 2019. Se identificaron 72 pacientes con el diagnóstico de Linfoma Hodgkin Clásico, de los cuales únicamente se seleccionaron para el estudio 64. Los criterios de exclusión fueron la ausencia de pruebas de inmunohistoquímica confirmatoria y los casos de recidiva. Resultados: Se observó que la variante más frecuente correspondió a Esclerosis Nodular con 34 casos (53.12%) y la menos frecuente a la variante Rica en Linfocitos con 2 casos (3.12%). Así mismo se observó una predominancia en el sexo masculino con 42 casos, 20 de ellos con Esclerosis Nodular y 14 no clasificables, como las variantes más frecuentes, y una mayor incidencia entre los 41 y 50 años de edad, sin detectarse el pico bimodal referido en la literatura internacional. El perfil inmunohistoquímico más frecuente de las células Hodgkin/ Reed- Sternberg es CD15 y CD30 positivo, con CD45 negativo. El EBV estuvo presente en el 36% de los casos realizados y es más frecuente en las variedades Celularidad Mixta y Depleción Linfocítica. Conclusiones: El Linfoma Hodgkin Clásico es un grupo de neoplasias linfoides con características clínicas, histológicas y fenotípicas definidas. Es más frecuente en varones entre 41 y 50 años. Para un adecuado diagnóstico se requiere una completa información clínica y una buena biopsia, de preferencia excisional. La variante Esclerosis Nodular es la más frecuente y la Rica en Linfocitos la menos frecuente. Las células Hodgkin/ Reed- Sternberg suelen ser positivas para CD15 y CD30 y negativas para CD45. La positividad tenue del Pax-5 permite diferenciarlo de Linfomas no Hodgkin de Células B. El EBV es más frecuente en las variantes Celularidad Mixta y Depleción Linfocítica.

ABSTRACT Introduction: Hodgkin lymphomas are B-cell lymphoid neoplasms histologically characterized by a mixed inflammatory cellular component and few Hodgkin/Reed-Sternberg neoplastic cells. Classical Hodgkin Lymphoma (CHL) represents 10% of all lymphoma cases and 85% of all Hodgkin Lymphomas. According to the current World Health Organization classification, CHL is divided into 4 types: Nodular Sclerosing (NS), Mixed Cellularity (MC), Lymphocyte-Rich (LR), and Lymphocyte-Depleted (LD). Objective: We reviewed all cases of Classical Hodgkin Lymphoma in the Pathological Anatomy Department at Edgardo Rebagliati Martins National Hospital during 2015 to 2019, in order to determine the most frequent type, the incidence according to age and gender, phenotypical characteristics and relation to Epstein Barr Virus (EBV). Materials and Methods: We performed a retrospective descriptive case study of Classical Hodgkin Lymphoma and its 4 clinical-pathological types in the Pathological Anatomy Department at Edgardo Rebagliati Martins National Hospital during 2015 to 2019. 72 patients were identified with Classical Hodgkin Lymphoma diagnosis, of which only 64 were selected for the study. The exclusion criteria were the absence of confirmatory immunohistochemical tests and relapse cases. Results: The most frequent type observed was Nodular Sclerosing with 34 cases (53.12%) and the least frequent type was Lymphocyte-Rich with 2 cases (3.12%). Likewise, a predominance in the male gender was observed, with 42 cases, 20 of which were Nodular Sclerosing and 14 not classified, as the most frequent types, and a greater incidence among those 41 to 50 years of age, without detection of the bimodal peak referenced in international literature. The most frequent immunohistochemical profile of Hodgkin/ Reed- Sternberg was CD15 and CD30 positive, with CD45 negative. EBV was present in 36% of cases and is more frequent in the Mixed Cellularity and Lymphocyte-Depleted types. Conclusions: Classical Hodgkin Lymphoma is a group of lymphoid neoplasms with clinical, histological, and phenotypically defined characteristics. It is more frequent in men between 41 and 50 years of age. A complete clinical information and a good biopsy, preferably excisional, is required for an adequate diagnosis. The Nodular Sclerosing type is the most frequent and the Lymphocyte-Rich is the least frequent type. Hodgkin/ Reed- Sternberg cells are usually CD-15 and CD-30 positive and CD-45 negative. The Pax-5 mild positivity allows it to be differentiated from B-cell Non-Hodgkin Lymphomas. EBV is most frequent in Mixed Cellularity and Lymphocyte-Depleted types.

Cyclooxygenase-2 expression as a prognostic factor in pediatric classical Hodgkin lymphoma.

PURPOSE: Cyclooxygenase-2 (COX-2) is an inflammation-related enzyme that has been shown to have a role in tumor initiation, angiogenesis, and proliferation. It has been demonstrated that COX-2 expression is increased in many tumors and is a negative prognostic parameter. Our objective is to investigate the prognostic value of COX-2 expression in pediatric patients with classical Hodgkin lymphoma (CHL). METHODS: This was a retrospective analysis in pediatric patients (n = 127) diagnosed with CHL and treated at the pediatric oncology department, National Cancer Institute, Cairo University, January 2005-June 2013. We correlated COX-2 immunostaining in Reed-Sternberg (RS) cells with clinical variables and outcome. RESULTS: COX-2 was expressed on 38.6% of RS cells. The median follow-up time was 48.4 months (range 4-114 months). The 5-year OS and PFS, in COX-2(+ve) versus COX-2(-ve) was 85.3% versus 96.0% (p = 0.248) and 78.6% versus 84.3% (p = 0.354), respectively. A multivariate analysis showed that COX-2(+ve) was not significantly associated with the 5-year OS (HR = 2.9; 95% CI 0.7-12.4, p = 0.149) or with the 5-year PFS (HR = 1.4; 95% CI 0.6-3.2, p = 0.490). High-risk patients in the COX-2(+ve) group had a significantly lower 5-year OS (p = 0.021). The 5-year PFS was significantly lower in the COX-2(+ve) group with B symptoms (p = 0.023) and bulky disease (p = 0.028). Radiotherapy was given only to high-risk patients; survival was much better in radiation-treated children in both the Cox-2(+ve) and Cox-2(-ve) groups. The magnitude of the radiotherapy effect was also greater in the Cox-2(+ve) group, but this difference was not statistically significant. CONCLUSION: COX-2 expression showed a tendency to be a poor prognostic factor, but it failed to provide meaningful independent information. Further larger studies are needed to investigate COX-2 as a prognostic factor and potential therapeutic target.

Linfoma de la zona gris con características intermedias entre un linfoma difuso de células B grandes y un linfoma Hodgkin clásico. Reporte de un caso y revisión de la literatura / Grey zone lymphoma with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma. Case report and literature review

Resumen Entre los linfomas de la zona gris (LZG) encontramos neoplasias con características compartidas entre un linfoma difuso de células B grandes (LDCBG) y un linfoma de Hodgkin clásico (LHC). Lo poco habitual de la patología combinado con la heterogenicidad de la enfermedad, su reciente descripción como entidad específica que conlleva a dificultad y reto diagnóstico, así como la falta de suficiente experiencia terapéutica hacen de la enfermedad una entidad compleja de difícil diagnóstico y reto terapéutico que justifica su descripción continua. Se presenta una paciente con fiebre de un mes sin respuesta al manejo inicial, se estudió y realizó biopsia de ganglio inguinal izquierdo con resultado diagnóstico de LZG con características intermedias entre LDCBG y LHC. Aunque no existen guías establecidas para el manejo de esta entidad, la evidencia actual sugiere mejor respuesta en tratamientos dirigidos a LDCBG, misma terapia empleada en esta paciente con la cual se obtuvo respuesta favorable.

Abstract In the grey zone lymphomas (GZL), there are overlapping characteristics between diffuse large B-cell lymphoma (DLBCL) and classic Hodgkin lymphoma (CHL). The unusual nature of the pathology combined with the heterogeneity of the disease, its recent description as a specific entity, its diagnostic difficulty, and the lack of sufficient therapeutic experience justifies its continuous description. The case is presented of a patient with a fever of one month onset, with no response to initial management. A left inguinal lymph node biopsy reported a diagnosis of GZL with intermediate characteristics between DLBCL and CHL. Although there are no established guidelines for the management of this condition, the current evidence suggests a better response in treatments meant for diffuse large B-cell lymphoma. This same therapy was used in this patient, with a favourable clinical outcome.

Pathway-focused gene expression profiles and immunohistochemistry detection identify contrasting association of caspase 3 (CASP3) expression with prognosis in pediatric classical Hodgkin lymphoma.

The search for clinically relevant molecular markers in classical Hodgkin lymphoma (cHL) is hampered by the histopathological complexity of the disease, resulting from the admixture of a small number of neoplastic Hodgkin and Reed-Sternberg (H-RS) cells with an abundant and heterogeneous microenvironment. In this study, we evaluated gene expression profiles of 11 selected genes previously proposed as a molecular score for adult cHL, aiming to validate its application in the pediatric setting. Assays were performed by RT-qPCR from formalin-fixed paraffin-embedded (FFPE) lymph nodes in 80 patients with cHL. Selected genes were associated with cell cycle (CENPF, CDK1, CCNA2, CCNE2, and HMMR), apoptosis (BCL2, BCL2L1, and CASP3), and monocytes/macrophages (LYZ and STAT1). Despite using controlled preanalytical and analytical strategies, we were not able to validate the 11-gene score to be applied in pediatric cHL. Principal component analysis (PCA) disclosed 3 components that accounted for 65.7% of the total variability. The second PC included microenvironment and apoptosis genes, from which CASP3 expression was associated with a short time of progression-free survival, which impact was maintained in the unfavorable risk group, Epstein-Barr virus-negative cases, and multivariate analysis (P < .05). Because this is a counterintuitive association, CASP3 active expression was assessed at the protein level in H-RS cells by double immunohistochemistry. In contrast to the association of mRNA levels with a poor therapeutic response, a high number of cleaved CASP3+ cells were associated with longer progression-free survival (P = .03) and overall survival (P = .002). Our results demonstrate the feasibility of using FFPE samples as RNA source for molecular prognostication, but argue against the concept of direct and wide applicability of molecular scores in cHL. We reinforce the potential of CASP3 as an interesting target to be explored in adult and pediatric cHL, and alert for its dual biological role in H-RS cells and tumor microenvironment.

Quantificação das citocinas séricas Th1/Th2 por citometria de fluxo no linfoma de Hodgkin clássico / Measurement of Th1/Th2 serum cytokines by flow cytometry in classical Hodgkin lymphoma

O linfoma de Hodgkin clássico (LHC) é uma neoplasia com distúrbio na produção de citocinas. Estudos demonstram que o padrão anormal das citocinas no linfonodo acometido pela lesão contribui não somente com a proliferação das células malignas H-RS, como também com o característico infiltrado hiper-reativo que compõe o tecido no LHC. Esta disfunção pode ser observada tanto no quadro clínico dos pacientes, como nas características histopatológicas: sintomas B, deficiência na resposta imune celular, bandas de colágeno e eosinofilia. As concentrações séricas das citocinas Th1 (IL-2, TNF, INF-γ) e Th2 (IL-4, IL-5, IL-10) foram estudadas em 45 pacientes com LHC, ao diagnóstico, e em 34 doadores saudáveis, por citometria de fluxo (CBA - cytometric beads array). Houve aumento das concentrações das citocinas TNF (p<0,01), INF-γ (p<0,01), IL-4 (p=0,01), IL-5 (p<0,01) e IL-10 (p<0,01) dos pacientes quando comparados com o grupo controle. Não foi evidenciada diferença em relação a IL-2. Ao correlacionarmos as concentrações das citocinas Th1/Th2 com as variáveis clínico-laboratoriais dos pacientes, observou-se que níveis elevados da IL-10 (Th2) estão correlacionados com as variáveis que implicam em pior prognóstico: estádios III/IV (p=0,01), presença de sintomas B (p=0,04), hemoglobina < 10,5g/dL (p=0+,01), linfócitos <600 mm³ (p=0,01) e, de acordo com o IPI, os pacientes de alto risco (p=0,01). Por outro lado, níveis séricos elevados da IL-2 (Th1) foram encontrados em estádio I/II, quando comparados com III/IV (p=0,03), o que indica que a IL-2 diminui com a progressão da doença. Os resultados sugerem que a IL-10 possa estar regulando negativamente a resposta imune citotóxica (Th1) pela inibição da IL-2. Há uma possível associação entre progressão da doença e níveis elevados da IL-10. Esse estudo evidenciou que a utilização do CBA é factível na detecção das citocinas, e que as alterações encontradas podem estar envolvidas na biologia do LHC.

Classical Hodgkin lymphoma (CHL) is a malignancy with an abnormal or unbalanced secretion/production of cytokines, which might support the growth of H-RS cells, their surrounding reactive bystander cells and may be responsible for the typical clinical and histopathologic features of CHL: systemic B symptoms, an apparent defect in cell-mediated immune response, tumor fibrosis and eosinophilic infiltrate. Serum concentrations of IL-2, IL-4, IL5, IL-10, TNF and IFN-γ (Th1/Th2) were measured in 45 patients at diagnosis of classical Hodgkin lymphoma and in 34 healthy controls by cytometric beads array (CBA). Levels of TNF (p<0.01), INF-γ(p<0.01), IL-4 (p=0.01), IL-5 (p<0.01) e IL-10 (p<0.01) were significantly higher in patients compared to the control group. No difference was observed for IL-2 between the two groups. On correlating Th1/Th2 cytokine concentrations with clinical risk factors, elevated IL-10 (Th2) levels are associated with variables that suggest worse prognoses including III/IV stage (p=0.01), B-symptoms (p=0.04), hemoglobin < 10.5g/dL (p=0.01), lymphocytes < 600/mm³ (p=0.01) and according to the seven-factored international prognostic score (IPI), a subset of patients with a particularly high risk of failure (p=0.01). Furthermore, the serum levels of IL-2 (Th1) were significantly higher in a group of I/II stage patients compared to III/IV patients (p=0.03) which implies that, the levels of IL-2 might decrease with disease progression. The elevated IL-10 levels in a subset of patients with poor clinical risk factors might down regulate a Th1 immune response by inhibiting IL-2 production causing survival disadvantage by suppression of the cytotoxic immune response against the tumor. This suggests an association between progression of CHL and higher levels of the IL-10 cytokine. This study showed that measurement of serum cytokines using the CBA methodology is highly reproducible, and that changes in concentrations...

Influência do CD 20 na refratariedade do linfoma de Hodgkin clássico ao tratamento inicial com o esquema ABVD, no Ceará, Brasil / Influence of CD 20 antigen expression in the refractoriness of classical Hodgkin lymphoma in the first line treatment with ABVD protocol in Ceará state, Brazil

INTRODUÇÃO: A significância prognóstica do marcador imunológico CD 20 no linfoma de Hodgkin clássico (LHc) ainda é incerta, particularmente no que se refere à refratariedade ao tratamento inicial. OBJETIVOS: Avaliar a influência da positividade do marcador CD 20 na refratariedade do LHc ao tratamento poliquimioterápico inicial, com o esquema doxorubicina 25 mg/m², bleomicina 10 mg/m², vinblastina 6 mg/m² e dacarbazina 375 mg/m² (ABVD), no Ceará, Brasil. MATERIAL E MÉTODOS: Estudo analítico incluindo 97 pacientes com diagnóstico de LHc firmado entre janeiro de 2000 e dezembro de 2004. A análise foi realizada avaliando variáveis demográficas, clínicas e laboratoriais. RESULTADOS: Foi evidenciada uma positividade do CD 20 em 38,1 por cento dos pacientes. Na análise bivariada, CD 20 positivo (razão de chance [RC] = 4,02; intervalo de confiança [IC] = 1,09 - 8,54; p = 0,02), a presença de sintomas B (RC = 4,02; IC = 1,18-17,51; p = 0,01) e a elevação da desidrogenase lática (mediana não-refratários 248,5 [200,5 - 389,5]; mediana refratários 356 [208,5 - 545]; p = 0,03) apresentaram relação de pior prognóstico quanto à refratariedade. Na regressão logística, o CD 20 positivo (RC ajustada = 3,6; IC = 0,99 - 13,09; p = 0,05) e a presença de sintomas B (RC ajustada = 5,41; IC = 1,16 - 25,34; p = 0,03) continuaram apresentando pior prognóstico. DISCUSSÃO: Esses dados coincidem com a literatura, em que a positividade do marcador CD 20 está relacionada com pior resposta ao tratamento com ABVD. CONCLUSÃO: Os nossos dados indicam que o tratamento com ABVD não é completamente adequado para a abordagem terapêutica inicial deste subgrupo de pacientes e novas pesquisas precisam ser realizadas no sentido de aperfeiçoar o tratamento destes pacientes.

INTRODUCTION: The prognostic value of CD20 antigen expression in classical Hodgkin lymphoma (cHL) is uncertain, particularly regarding the refractoriness to first-line treatment. OBJECTIVES: To assess the influence of CD20 positiveness on the refractoriness of cHL to first-line chemotherapy with ABVD protocol in Ceará State, Brazil. MATERIAL AND METHODS: Analytical study including 97 patients diagnosed with cHL between January/2000 and December/2004. The analysis was performed evaluating demographic, clinical and laboratory variables. RESULTS: CD20 antigen expression was positive in 38.1 percent of the patients. In the bivariate analysis, CD20 antigen expression (OR = 4.02; CI = 1.09 - 8.54; p = 0.02), the presence of B-symptoms (OR = 4.02; CI = 1.18-17.51; p = 0.01) and an elevated lactate dehydrogenase level (median not refractory 248.5 [200.5 - 389.5]; median refractory 356 [208.5-545]; p = 0.03) showed worse prognosis as to refractoriness. In the logistic regression analysis, the presence of CD 20 (OR = 3.6; CI = 0.99-13.09; p = 0.05) and B-symptoms (OR = 5.41; CI = 1.16-25.34; p = 0.03) continued to show worse prognosis. DISCUSSION: These findings coincide with literature data indicating that CD 20 antigen expression is associated with low response to treatment with ABVD. CONCLUSION: Our data show that the treatment with ABVD is not totally appropriate for the initial therapeutic approach in this subgroup of patients and that further studies are required to optimize their treatment.