Hodgkin Lymphomas:

An Update

November 10th, 2018

Roberto N. Miranda, M.D.

Professor

UT MD Anderson Cancer Center

Disclosures

• Scientific Advisory Board, Allergan Inc,

2018

Hodgkin Lymphomas

• Classical Hodgkin Lymphoma (CHL): 90%

– Nodular sclerosis

– Mixed cellularity

– Lymphocyte rich

– Lymphocyte depleted

• Nodular Lymphocyte Predominant

Hodgkin Lymphoma (NLPHL): 10%

– A & B: Typical

– C – F: Variants

Outline CHL • Clinical, histopathology, immunophenotype

• Therapy

• Pathogenesis

– Cell of origin

– Cell biology and molecular targets • Loss of B-cell antigens

• Proliferative advantage

• Microenvironment

• HL and immunodeficiency

CHL: Definition

• Nodal disease

• Neoplastic cells are a minority in the

infiltrate (< 10%)

• Majority of the cells in infiltrate are reactive

– Small lymphocytes, eosinophils, neutrophils,

histiocytes, plasma cells, and fibroblasts

WHO 2008

Revised WHO 2017

Mononuclear:

Hodgkin cell

Rare neoplastic cells: 0.1 – 10 %

Multilobated:

Reed-Sternberg cell

CHL: Neoplastic Cells

Immunophenotype

CD30+

CD15+ CD45-

PAX5+

Other Useful Markers

EBER+ MUM1+

CD79- OCT2-

Background Cells

CD4

Subtypes

• Nodular sclerosis (NS) 66%

• Mixed cellularity (MC) 27%

• Lymphocyte-rich (LR) 6%

• Lymphocyte-depleted (LD) 1%

Differences:

• Clinical features

• Histopathology

• EBV association

Nodular Sclerosis HL

• Median age, 28 years

• No male predominance

• Stage II disease in most patients

– Mediastinal involvement in 80%

• B-symptoms in 40%

Nodular Sclerosis HL

Nodular Sclerosis HL:

Syncytial Variant

CD30

Syncytial Variant

• Compared with typical NSHL

• Lower complete response rate to ABVD

– 74% vs 87%

• Higher Progression free survival

– 17 months vs not reached

Sethi T et al. Ther Adv Hematol 2017; 8: 13

Mixed Cellularity HL

• Median age, 37 years

• Male predominance

• Stage III or IV

•B-symptoms more frequent than in NS

•Mediastinal LNs uncommon

•EBV+ ~70%

Mixed Cellularity HL

LMP1 EBER

Lymphocyte-rich HL Nodular >> Diffuse

Lymphocyte-Rich HL Nodular pattern

CD30 CD20

Lymphocyte-Depleted HL

• Advanced age

• B-symptoms (80%)

• Stage III or IV disease

– Extensive subdiaphragmatic disease

– Abdominal LNs

• Most aggressive form of HL

• Very rare

• Diffuse fibrosis: Fibroblastic proliferation

• Reticular: Abundant HRS cells

Lymphocyte Depleted HL

HL: Therapy

• Chemotherapy (ABVD or BEACOPP) +

Radiation: Standard of care in USA

– 90% 5-y OS

– 60% 5-y FFS

• Chemotherapy alone for early stage HL

Nat Oncol 2008; 5:543

CHL: Prognosis

• Current therapy has made HL curable in

the majority of cases

• Histologic subtype is currently less

relevant for prognosis

• Combined pathologic, laboratory, clinical

stage appear more important than

histologic subtype, and determine mode of

therapy

Secondary MDS/AML in German

GHSG Trials

• N= 11,805

• 86 (0.72% developed MDS/AML)

– Early stages: 6

• < 4 cycles

– Intermediate stage: 18

– Advanced stage: 62

• > 4 cycles

Eichenauer, Blood 2010

CHL Therapy

• Stanford V

– Lower cumulative doses of chemotherapy

(adriamycin or bleomycin) to reduce risks of

• Acute leukemia, MDS

• Cardiopulmonary toxicity

– Lessen volume and dose of Radiation to

reduce risks of

• Second cancers

• Cardiovascular toxicity

CHL Therapy

• Challenges for the future

– Risk assessment to decrease secondary

toxicity

– Hope in targeted therapy

Targeted Therapy:

Vedotin Brentuximab (Anti-CD30)

• Auristatin is bound to anti-CD30 • Potent anti-tubulin (vincristine like) arrests G2-M

phase and triggers apoptosis

• FDA-approved for relapsed and refractory CHL

• Studies underway for other CD30+ lymphomas of B- or T-cell lineage

Exp Op Inv Drugs 2011; 20: 141

Berger et al. Crit Rev Oncol/Hem 2017

Viviani et al. Tumori 2017; 103: 101

Pathogenesis of HL

• Nature of the malignant cell

– B-cell, very abnormal, pre-apoptotic

• Many reactive cells

– HRS cells secrete cytokines that attract

inflammatory cells: IL-4, IL-5, TNF-α,

GM-CSF

Cell Biology of HRS Cells

Clonality Studies in CHL

J Exp Med 1996; 184: 1495 Single cell PCR analysis

Single Cell Analysis in CHL

Antigen receptor-genes

• HRS cells show clonal Ig gene

rearrangements

Somatic mutations of VH immunoglobulin

genes

• The rearranged Ig genes harbor a high

load of somatic mutations

HRS Cells are GC B-Cells

HRS Cell

Somatic Mutations Yes

Ongoing Mutations No

Ig mRNA No

mRNA crippling mutations 25%

OCT-2 & BOB.1 No

Functional Rearrangement No

HRS Cell: Pre-apoptotic GC cell

HRS are GC B-cells

Naïve

B-cell

Somatic

Hypermutation Favorable

Unfavorable

PC or

Memory B-Cell

Apoptotic Cell

HRS Cell

GC

What is the cause of

B-cell Downregulation in CHL?

Leukemia 2008; 22: 1587

Nat Immunol 2006; 7:207

CD20 (-) Pax-5 dim (+)

Downregulation of B-cell genes

CD19, CD20 and CD79a

• Aberrant expression of Id2 and ABF1

– Inactivate E2A (Early B factor)

• Notch-1 antagonizes B-cell

transcription factors E2A and EBF

(early B-cell factor)

Leukemia 2008; 22: 1587

Nat Immunol 2006; 7:207

B-cell Downregulation in HL

Ann Rev Pathol Mech Dis 2009; 4: 151

PAX5

BOB.1

OCT-2

PU.1

NOTCH1

E2A

E2A

E2A

ABF1

EBF

Id2

NOTCH1

B-CELL GENES

Does Reconstitution of BOB.1 and

OCT-2 lead to Ig production?

• No

• This finding suggests the presence of

other mechanisms such as:

– Epigenetic changes: Inactive chromatin

– Inhibition of transcription

Blood 2004; 104: 3326

Methylation: Epigenetic Silencing

• Loss of function as a mechanism of

carcinogenesis, but without changing DNA

sequence

• Results from aberrant methylation of promoters

of genes in regions rich with CpG (Cytidine

Guanidine dinucleotide)

Epigenetics in HL

• Downregulation of B-cell transcription factors

– BCMA

– LCK

– SYK

– TCL1

• Downregulation of B-cell genes

– CD19

– CD79a

– Ig

Leukemia 2008; 22: 835

Hypomethylation in CHL

• In refractory CHL

– Heavily treated

• Partial response to azacytidine

(Hypomethylating agent)

Falchi et al. J Hematol Oncol 2016; 30: 132

Targeted Therapy in HL

• Histone deacetylases inhibitors

– Panobinostat: 86% response rate in ASCT failures

Blood 2012; 119: 4017

Am J Hematol 2012; 87: 277

Exp Op Inv Drugs 2011; 20: 141

Consequences of Apoptosis and

B-Cell Downregulation

• Cell death

• However HRS cells survive

– Antiapoptosis • Extrinsic Pathway

• Intrinsic Pathway

– Proliferation signals • NFkB

Canonical pathway

Alternative pathway

Hum Pathol 2007; 38:103

Proliferative advantage in CHL:

Activation of NFκB pathway

• NFkB pathway may be a transforming master in CHL

– NFkB is a family of transcription factors involved in activation and survival of immune cells

– Abnormally activated in HL

• Other factors: JAK/STATs and AP1

Targeted Therapy in HL

• NFkB Pathway

– Arsenic-containing compounds • Target IKK and downregulate NFkB pathway

– Bortezomib: May be useful in combination

Blood 2012; 119: 4017

Am J Hematol 2012; 87: 277

Exp Op Inv Drugs 2011; 20: 141

The Microenvironment in HL

Role of the Microenvironment in HL

• Reactive cellular infiltrate

– Favors neoplastic proliferation

• Cytokines, chemokines and members of

the TNF receptor family

– Foster a favorable environment around HRS

cells

– Inhibit CD8 function

J Clin Oncol 2005; 23: 6379

PD1, PDL-1 and the Immune

Checkpoint Inhibitors in CHL • PD1 is normally expressed in effector T cells,

but inhibited through PDL-1/2 by APC cells

• HRS cells express

– PDL-1/CD274, PDL-2/CD273

– JAK2 (JAK/STAT)

• Tumor cells overexpress PDL-1 to evade

immune response

Viviani et al. Tumori 2017; 103: 101

Ok & Young; J Hem Oncol 2017; 10: 103

Immune Checkpoint Inhibitors in HL

• PDL-1 or PDL-2 increase due to gains and

amplification of 9p24.1

• EBV can induce PDL-1 expression

• Immune checkpoint inhibitors nivolumab and

pembrolizumab restore immune response

– Block interaction of PD1 with PDL-1

– FDA approved in 2016 for refractory HL

Green et al. Clin Cancer Res 2012; 18: 1611

Ok & Young; J Hem Oncol 2017; 10: 103

Jelinek T et al. Immunology 2017; 1

Role of EBV

LMP-1 EBV encoded RNA

(EBER)

(Most sensitive test)

CHL: EBV

• 70% in MC and LD CHL

• 20% in NS CHL

• EBV infected HRS

– Are monoclonal: Infection occurred before

clonal expansion

– LMP1: Activation (~CD40)

– LMP2A: Rescue from apoptosis (~BCR)

J Clin Pathol 2007; 60: 1342

Targeted Therapy for EBV

• EBV

– LMP2A-specific cytotoxic lymphocytes • Useful in relapsed EBV+ cases

• Microenvironment

– Immunomodulators: Thalidomide, lenalidomide

Exp Op Inv Drugs 2011; 20: 141

Cellular Changes and Possible

Mechanisms

Feature Mechanism

B-cell Neoplasm Monoclonal IGH GR

HRS Cell GC cell rescued from apoptosis

CD45 (-) Inactivation of b2M

Absent Ig Absent OCT2, BOB.1, PU.1

B-cell Downregulation NOTCH1, ID2

Antiapoptosis c-FLIP, XIAP, LMP2A

Increased proliferation NFkB

Activation: CD40 LMP1

Evolving Concept

HL and Immunodeficiency

HL and Immunodeficiency

• CHL is variable

– Immunocompetent: NS > MC

– Immunosuppressed: MC > NS

– HIV: If CD4+: 0.2 x 109/L: HL

<0.05 x 109/L: BL or DLBCL

• HL may regress in:

– Patients with autoimmune diseases receiving

MTX, anti-TNF

– Post-transplant LPD

• Decrease with reduction of immunosuppression

Case Discussion

• Adult patient with a history of

rheumatoid arthritis

• Therapy with methotrexate and

etanercept (anti-TNFα)

• Lymphadenopathy with B-symptoms

CD45 EBER

CD30 CD15

• Other iatrogenic immunodeficiency-

associated LPD

– Immunosuppression other than in transplant

– MTX

– Immunomodulators: Anti-TNFα

• Polymorphic to full-blown NHL or HL

• 40% extranodal: GI, skin, liver, spleen

WHO Entity:

Nodular Lymphocyte Predominant

Hodgkin Lymphoma

(NLPHL)

NLPHL

• Sites: Cervical, axillary, inguinal nodes

• Mostly males in 4th and 5th decades

• Rare in mediastinum, spleen and BM

• Most patients present in stage I or II

• 5 – 20 % present with stage III or IV

• Natural history:

– Slow development

– Frequent relapses, but rarely fatal

WHO, 2008

NLPHL • Nodular or nodular and diffuse pattern

• Large cells: LP or “popcorn” cells

• Contained within large nodular meshworks of

dendritic cells

• LP cell is a B cell, CD20 in 100% of cases

• Reactive background: mainly B lymphocytes

• CD15 (-) / CD30 (-)

Histopathology

Nodules are larger than follicles of

follicular lymphoma or follicular hyperplasia

Histopathology

LP cells surrounded by small lymphocytes

Nodules are composed

mainly of B cells

LP cells are CD20+

CD20 CD20

Rossettes Meshwork

CD57 CD21

OCT-2 and BOB.1

• OCT-2 is a transcription factor that

induces Ig synthesis by activating the

promoter of the Ig genes in conjunction

with BOB.1

• (+) 100 % in NLPHL

– Stronger in LP cells > surrounding small B-

cells

• (+) 20 % in CHL Blood 2001; 97: 496

Eur J Haematol 2000; 30: 458 - 469

NLPHL: Variant Patterns

• 137 biopsies

• Used H&E, CD3, CD20 and CD21

• 6 immunoarchitectural patterns

A. Nodular B-cell rich

B. Serpiginous

C. Nodular with prominent extranodular LP cells

D. Nodular T-cell rich

E. Diffuse with increased T-cells: THRBCL-like

F. Diffuse with B-cell rich pattern

Fan et al, Am J Surg Pathol 2003: 27: 1346

A. Typical Nodular Pattern

A. Typical Nodular B-cell Rich

B-cell nodules

CD21 Meshwork

“Popcorn” cells

Interfollicular T-cells

67 % of all cases

A. Typical Nodular B-cell Rich

CD20

B. “Serpiginous”:

Interconnected Nodular

6 % of all cases

CD20

C. Nodular with prominent

extranodular L&H cells

7 % of all cases

CD20

D. Nodular T-Cell Rich

12 % of all cases

CD3

E. Diffuse T-Cell Rich

(THRBCL-like)

12 % of all cases

More common in patients with recurrent disease (p<.003)

CD20

E. Diffuse T-Cell Rich-like vs

THRBCL

• The detection of one nodule typical of NLPHL in an otherwise diffuse THRBCL excludes the diagnosis of THRBCL

• Reactive lymphocytes are – CD8 (+), TIA-1 (+) in TCRBCL vs

– CD4 (+), CD57 (+) in NLPHL

WHO 2008, 2016

Blood 2000; 96: 1889 – 1899

F. Diffuse B-Cell Rich

1 % of all cases CD21 meshworks are detected

“mottled” pattern

NLPHL: Prognosis

• Stage I and II: > 90 % survival at 10 years

• Not established if immediate therapy is

required for stage I disease in children

• Stage III or IV: Unfavorable prognosis

• Progression to DLBCL: 3 – 5 %

– Good prognosis if localized

Prognosis of NLPHL:

Typical vs Variants • German Hodgkin Study Group, 423 pts

• Typical NLPHL: Patterns A and B (n= 308)

• Variants: Patterns C, D, E and F (n= 105)

• Adverse prognosis in variants

– > Advanced disease: 29.5% vs 14.6%

– > Relapse rate: 18.1% vs 6%

Hartmann S et al. Blood 2013; 122: 4246

LRHL vs NLPHL

Overall Survival Failure-free Survival

Summary

• HLs are heterogeneous B-cell neoplasms

• HRS cell: Pre-apoptotic cell

– Does not produce Ig and lacks many B cell genes

– Rescued with anti-apoptotic mechanisms

– Important role of targeted therapy

• NLPHL cell: Ag selected B-cell

– Produces Ig and has a full set of B cell functioning

genes

– Predictive value of variants