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Hodgkin Lymphomas: An Updatep

Roberto N. Miranda, M.D.Professor

UT MD Anderson Cancer Center

Huntington Beach, CaliforniaNovember 2nd, 2017

UT MD Anderson Cancer Center

Disclosures

• No conflict of interest: Nothing to disclose

• 2017 Revised 4th Edition WHO compatible

Hodgkin Lymphomas

• Classical Hodgkin Lymphoma (CHL): 90%– Nodular sclerosis– Mixed cellularity– Lymphocyte rich– Lymphocyte depleted

• Nodular Lymphocyte Predominant• Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL): 10%– A & B: Typical– C – F: Variants

Outline CHL• Clinical, histopathology, immunophenotype• Therapy

P th i• Pathogenesis– Cell of origin– Cell biology and molecular targets

• Loss of B-cell antigens• Proliferative advantage• Microenvironment• Microenvironment

• HL and immunodeficiency

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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 fibroblastshistiocytes, plasma cells, and fibroblasts

WHO 2008Revised WHO 2017

CHL: Neoplastic Cells

Mononuclear: Hodgkin cell

Rare neoplastic cells: 0.1 – 10 %

Multilobated: Reed-Sternberg cell

Immunophenotype

CD30+ PAX5+

CD15+ CD45-

Other Useful Markers

EBER+ MUM1+EBER+ MUM1+

CD79- OCT2-

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Background Cells

CD4

Subtypes

• Nodular sclerosis (NS) 66%• Mixed cellularity (MC) 27%• 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

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Nodular Sclerosis HL:Syncytial Variant

CD30CD30

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• Male predominance• Stage III or IV•B-symptoms more frequent than in NS

•Mediastinal LNs uncommon•EBV+ ~70%

Mixed Cellularity HL

LMP1EBER

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Lymphocyte-rich HLNodular >> Diffuse Lymphocyte-Rich HL

Nodular pattern

CD30CD20

Lymphocyte-Depleted HL

• Advanced age• B-symptoms (80%)• Stage III or IV disease

– Extensive subdiaphragmatic disease– Abdominal LNs

M t i f f HL• Most aggressive form of HL• Very rare

Lymphocyte Depleted HL

• Diffuse fibrosis: Fibroblastic proliferation• Reticular: Abundant HRS cells

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HL: Therapy

• Chemotherapy (ABVD or BEACOPP) + R di ti St d d f i USARadiation: 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 th j it fthe majority of cases

• Histologic subtype is currently less relevant for prognosis

• Combined pathologic, laboratory, clinical stage appear more important thanstage 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: 62Advanced 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 d i k freduce risks of

• Second cancers• Cardiovascular toxicity

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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-CD30Auristatin 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+ ylymphomas of B- or T-cell lineage

Exp Op Inv Drugs 2011; 20: 141Berger et al. Crit Rev Oncol/Hem 2017Viviani 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

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Clonality Studies in CHL

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

Single Cell Analysis in CHL

Antigen receptor-genesHRS ll h l l I• HRS cells show clonal Ig gene rearrangements

Somatic mutations of VH immunoglobulin genes

• The rearranged Ig genes harbor a high• The rearranged Ig genes harbor a high load of somatic mutations

HRS Cells are GC B-Cells

HRS CellSomatic Mutations YesOngoing Mutations NoIg mRNA NomRNA crippling mutations 25%OCT-2 & BOB.1 NoFunctional Rearrangement NoFunctional Rearrangement No

HRS Cell: Pre-apoptotic GC cell

HRS are GC B-cells

Somatic Favorable PC or SomaticHypermutation

FavorableMemory B-Cell

Apoptotic CellNaïveB-cell

Unfavorable

Apoptotic Cell

HRS Cell

GC

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What is the cause of B-cell Downregulation in CHL?

Leukemia 2008; 22: 1587Nat Immunol 2006; 7:207

CD20 (-) Pax-5 dim (+)

Downregulation of B-cell genes CD19, CD20 and CD79a

• Aberrant expression of Id2 and ABF1Aberrant expression of Id2 and ABF1– Inactivate E2A (Early B factor)

• Notch-1 antagonizes B-cell transcription factors E2A and EBF(early B-cell factor)(early B cell factor)

Leukemia 2008; 22: 1587Nat Immunol 2006; 7:207

B-cell Downregulation in HL

ABF1

PAX5 OCT-2

PU.1

E2A

E2A

E2AABF1

Id2

NOTCH1

B-CELL GENES

Ann Rev Pathol Mech Dis 2009; 4: 151

BOB.1

NOTCH1

EBF

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

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Methylation: Epigenetic Silencing

• Loss of function as a mechanism of carcinogenesis, but without changing DNA sequence

• Results from aberrant methylation of promotersof genes in regions rich with CpG (Cytidine Guanidine dinucleotide)Guanidine dinucleotide)

Epigenetics in HL• Downregulation of B-cell transcription factors

BCMA– BCMA– LCK– SYK– TCL1

• Downregulation of B-cell genesCD19– 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

Hi t d t l i hibit• Histone deacetylases inhibitors– Panobinostat: 86% response rate in ASCT

failures

Blood 2012; 119: 4017Am J Hematol 2012; 87: 277Exp Op Inv Drugs 2011; 20: 141

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Consequences of Apoptosis and B-Cell Downregulation

• Cell death• However HRS cells survive

– Antiapoptosis• Extrinsic Pathway• Intrinsic Pathway

– Proliferation signals• NFkB

Canonical pathwayAlternative pathway

Hum Pathol 2007; 38:103

Proliferative advantage in CHL: Activation of NFκB pathway

• NFkB pathway may be a transformingNFkB 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 compo nds– Arsenic-containing compounds• Target IKK and downregulate NFkB pathway

– Bortezomib: May be useful in combination

Blood 2012; 119: 4017Am J Hematol 2012; 87: 277Exp Op Inv Drugs 2011; 20: 141

The Microenvironment in HL

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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

cellscells– 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, b t i hibit d th h PDL 1/2 b APC llbut 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• Tumor cells overexpress PDL-1 to evade immune response

Viviani et al. Tumori 2017; 103: 101Ok & 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: 1611Ok & Young; J Hem Oncol 2017; 10: 103Jelinek T et al. Immunology 2017; 1

Role of EBV

LMP-1 EBV encoded RNA(EBER)

(Most sensitive test)

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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)– LMP2A: Rescue from apoptosis (~BCR)

J Clin Pathol 2007; 60: 1342

Targeted Therapy for EBV• EBV

LMP2A specific c toto ic l mphoc tes– 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 MechanismB-cell Neoplasm Monoclonal IGH GRHRS Cell GC cell rescued from apoptosisCD45 (-) Inactivation of b2MAbsent Ig Absent OCT2, BOB.1, PU.1B-cell Downregulation NOTCH1, ID2Antiapoptosis c-FLIP, XIAP, LMP2AIncreased proliferation NFkBActivation: CD40 LMP1

Evolving ConceptEvolving Concept

HL and Immunodeficiency

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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:y g– 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-symptomsy p p y y p

CD30 CD15

CD45EBER

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• Other iatrogenic immunodeficiency-i t d LPD

WHO Entity:

associated LPD– Immunosuppression other than in transplant– MTX– Immunomodulators: Anti-TNFα

• Polymorphic to full-blown NHL or HLPolymorphic to full blown NHL or HL• 40% extranodal: GI, skin, liver, spleen

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 (-)CD15 ( ) / CD30 ( )

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Histopathology

Nodules are larger than follicles of follicular lymphoma or follicular hyperplasia

Histopathology

LP cells surrounded by small lymphocytes

CD20 CD20

Nodules are composed mainly of B cells

LP cells are CD20+

CD57 CD21

Rossettes Meshwork

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OCT-2 and BOB.1

• OCT-2 is a transcription factor that i d I th i b ti ti thinduces 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-Stronger in LP cells surrounding small B

cells• (+) 20 % in CHL

Blood 2001; 97: 496Eur J Haematol 2000; 30: 458 - 469

NLPHL: Variant Patterns• 137 biopsies

U d H&E CD3 CD20 d CD21• Used H&E, CD3, CD20 and CD21• 6 immunoarchitectural patterns

A. Nodular B-cell richB. SerpiginousC. Nodular with prominent extranodular LP cellsD. Nodular T-cell richE. Diffuse with increased T-cells: THRBCL-likeF. 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“Popcorn” cells

CD21 MeshworkInterfollicular T-cells

67 % of all cases

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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

CD3

12 % of all cases

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E. Diffuse T-Cell Rich (THRBCL-like)

12 % of all casesMore 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 inThe 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, 2016Blood 2000; 96: 1889 – 1899

F. Diffuse B-Cell Rich

1 % of all casesCD21 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 %

G d i if l li d– Good prognosis if localized

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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 ll P t ti ll• 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 ll A l d B ll• NLPHL cell: Ag selected B-cell– Produces Ig and has a full set of B cell functioning

genes– Predictive value of variants