CASE REPORT

Unusual concurrent presentation of a double hit (MYC/BCL2)and follicular lymphoma in a young patient; case reportand review of key recent developments in double-hitlymphomas

Saurabh Malhotra & Norman B Levy & Prabhjot Kaur

Received: 25 June 2013 /Accepted: 19 July 2013# Springer-Verlag Berlin Heidelberg 2013

Abstract Double-hit lymphomas, usually refer to the MYC/BCL2 lymphomas, and are characterized by MYC 8qrearrangement and BCL2-IgH translocation in the same cells.They mainly comprise of a subset of the new entity “B celllymphomas unclassifiable with features intermediate betweendiffuse large B cell lymphomas (DLBCL) and Burkitt lym-phoma” included in the World Health Organization 2008classification. In addition, they also include a small subset ofother DLBCL. They have been reported to have worse prog-nosis than either Burkitt or DLBCL, with which they shareoverlapping morphological and immunophenotypical fea-tures. These cases usually present de novo and have beenreported in the older age group (Snuderl et al. in Am J SurgPathol 34(3):327–340, 2010; Le Gouill et al. in Haematologica92(10):1335–1342, 2007; Macpherson et al. in J Clin Oncol17(5):1558–1567, 1999; Johnson et al. in Blood 114(11):2273–2279, 2009; Bertrand et al. in Leuk Off J Leuk Soc Am LeukRes Fund UK 21(3):515–523, 2007). Here, we describe anunusual simultaneous presentation of MYC/BCL2 double-hitlymphoma with low-grade follicular lymphoma, occurring attwo different sites, in a young patient. This has not beenreported to the best of our knowledge.

Keywords Lymphoma .MYC/BCL2 . Double-hitlymphomas . Diffuse large B cell lymphomas

Introduction

Burkitt lymphomas (BL) are characterized by intermediatesized lymphocytes with high proliferative index and MYCrearrangement in approximately 90 % of cases [1]. Diffuselarge B cell lymphomas (DLBCL) have larger cells witha lower proliferative index and may harbor BCL2-IgHtranslocation (characteristic of follicular lymphoma) in20–30 % cases [1]. Lymphomas with morphological andimmunophenotypical features intermediate between Burkittand DLBCL have been known for some time and had beenpreviously referred to as Burkitt-like lymphomas, but nowaccording to the World Health Organization 2008 classifica-tion, have led to the formulation of a novel category, “B Celllymphoma unclassifiable, with features intermediate betweenDLBCL and Burkitt Lymphoma”. They are characterized byan overlapping pattern with some cells smaller than typicalDLBCL, NOS while some cells larger than typical BL, andhave a high proliferative fraction. A subset of cases within thiscategory harbor a double genetic abnormality with MYCrearrangement and BCL2 translocation in the same tumor cells,and have been found to have worse prognosis, requiring treat-ment withmore aggressive protocols [1, 2]. They are commonlyreferred to as double-hit lymphomas in literature; however, thisterm is vague and has also been used to denote other rare tumorscarrying BCL6/MYC, CCND1/MYC and even BCL2/BCL6/MYC triple-hit mutations [3]. For this reason, many prefer torefer these neoplasms as MYC/BCL2 lymphomas [4]. Most ofthese cases occur in middle aged to elderly individuals with amean age of 53 years at presentation [4]. Rarely have they beenreported presenting in patients with a prior history of follicularlymphoma where they are believed to evolve from the follicularlymphoma by acquiring further genetic abnormalities. In thesecases, prognosis is even more dismal [4]. Concurrent presenta-tion of a double-hit lymphoma with a low-grade follicular

S. Malhotra (*) :N. B. Levy : P. KaurDepartment of Pathology, Dartmouth Hitchock Medical Center,One Medical Center Dr, Lebanon, NH 03756, USAe-mail: saurabh.aastha@gmail.com

J HematopatholDOI 10.1007/s12308-013-0192-x

lymphoma occurring at the same point of time at two differentlocations in a young patient is very unusual and to best of ourknowledge has not been reported so far.

Report of a case

Clinicopathologic findings

A 27-year-old woman presented with lower abdominal pain,anorexia, fatigue, significant weight loss, and lower extremityweakness. CT scan revealed enlarged lymph nodes in retro-peritoneal, mesenteric, pelvic, right inguinal, porta hepatic,cervical regions, and lytic lesions in her thoracic, lumbar,and sacral spine. She was HIV negative. A biopsy from her5.8 cm right inguinal mass showed a necrotic tumor suspectedto be a high-grade lymphoma.

The cervical lymph node biopsy showed an effaced archi-tecture by irregular closely packed back-to-back follicles lack-ing polarization and with attenuated mantle zones. They werecomposed of small cleaved centrocytes, with rare centroblastand did not show tingible bodymacrophages. BCL-2 highlight-ed the neoplastic nature of the follicles/lymphocytes and Ki-67showed a low proliferative fraction. No large cell transforma-tion was seen. Based on these features, a diagnosis of follicular

lymphoma grades I–II was made (Fig. 1). The bone marrowbiopsy was negative for lymphoma.

A repeat biopsy from a right inguinal lymph node wasperformed for a more definitive diagnosis of aggressive lym-phoma. Sections were cut at 4–5 μm and slides were stainedwith eosin hematoxylin. CD20, CD3, CD10, BCL2, BCL6,MUM1, TDT, CYCLIN D1, and Ki-67 immunostains werealso performed using the avidin–biotin complex techniquewith appropriate controls.

The lymph node architecture was effaced by a diffusepopulation of medium- to large-sized monomorphous cellswith fine chromatin, small single nucleoli, and variableamount of cytoplasm. The cells exhibited squared off bordersof retracted cytoplasm. Numerous mitoses, prominent apopto-sis, and background sclerosis were also seen. The tumor cellswere diffusely positive for CD20, CD10, BCL2, and BCL6with a Ki-67 proliferative index of 95–100 %. CD3 highlight-ed reactive small T lymphocytes. The neoplastic lymphocyteswere negative for TDT, CyclinD1, and MUM1 (Fig. 1).

Interphase fluorescence in situ hybridization (FISH)performed on the inguinal lymph node with commercialMYC Dual Color Break Apart Rearrangement Probe (catalog#32-191096 from Abbott Molecular, Inc.) and BCL2 DualColor Break Apart Rearrangement Probe (catalog #32-231029 from Abbott Molecular, Inc.) revealed a signal patternconsistent with rearrangement of one MYC locus in 78 % of

Fig. 1 a Cervical lymph node, follicular lymphoma, low-grade (hema-toxylin-eosin; original magnification, ×100). b Original magnification,×400. c BCL2 immunostain; original magnification, ×100, ×40 (inset).d Inguinal lymph node, B cell lymphoma unclassifiable withfeatures intermediate between DLBCL and Burkitt lymphoma

(hematoxylin-eosin; original magnification, ×100). e CD20 (orig-inal magnification, ×100), BCL2 (inset; original magnification,×100). f Ki67 (original magnification, ×100), MYC dual colorbreak apart probe (upper inset), and BCL2 dual color break apartprobe (lower inset)

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200 nuclei scored and rearrangement of one BCL2 locus in69 % of 214 nuclei scored (Fig. 1). In addition, 15 % of214 nuclei scored revealed a variant signal pattern consistentwith rearrangement involving the BCL2 locus along withadditional changes.

The FISH diagnosis was:nuc ish(MYC×2)(5′MYC sep 3′MYC×1)[156/200],

(BCL2 × 2)(5 ′BCL2 sep3 ′BCL2 × 1)[147/214] / (5 ′BCL2 × 1,3 ′BCL2 × 2)(5 ′BCL2 sep3 ′BCL2 × 1)[33/214],(BCL6×2)[202]

Based on the morphology, immunohistochemistry, andFISH analysis, a diagnosis of double-hit (MYC/BCL2) Bcell lymphoma was made.

Discussion

The term “double-hit lymphomas” most commonly refersto rare tumors that harbor MYC rearrangements andBCL2-IgH translocations within the same cells and arecharacterized by an aggressive clinical course, resistanceto chemotherapy, increased relapse rate, and high mortality[1–9]. They present at a median age of 55 years [1];however, occasional cases have been reported in patientsas young as 2 years [10]. Most of these lymphomas presentalong with other poor prognostic parameters such as highlactate dehydrogenase (LDH), bone marrow, and centralnervous systyem (CNS) involvement and high InternationalPrognostic Index (IPI) score [2, 3]. Although (MYC/BCL-2)double-hit mutation most commonly occurs in “B cell lym-phoma unclassifiable with features intermediate betweenDLBCL and Burkitt lymphoma”; it is rarely found in lympho-mas with classical morphological features of Burkitt, DLBCLNOS, follicular (low and high grade), and lymphoblastic andplasmablastic lymphomas [1, 4, 11].

BCL2 and MYC are dominant oncogenes. The MYCrearrangement amplifies it by usually bringing it in closeproximity to either heavy chain gene IgH on chromosome14 or light chain genes IG kappa or IG lambda on chromo-some 2 and 22, respectively. The MYC gene has a role in cellproliferation and its amplification provides oncogenic poten-tial by increasing cell turn over [1]. On the other hand, BCL2is an antiapoptotic protein and its gene is located on chromo-some 18.When the BCL2 gene is translocated to chromosome14 (t14;18), it comes in close proximity to IgH heavy chaingene and gets amplified. Its overexpression provides onco-genic potential due to excessive antiapoptotic activity, therebyinhibiting regulated cell death [1]. These mechanisms areinvolved in pathogenesis of Burkitt and follicular lymphomasvia increasing cell turnover and inhibiting cell death, respec-tively. Rarely, these two genetic aberrations occur in the samecell; in such situations, MYC causes markedly increasedproliferative rate characterized by high Ki 67 index and at

the same time BCL2 exerts its enhanced antiapoptotic activity,thus producing these very aggressive “MYC/BCL2 double-hitlymphomas” that lead to rapid mortality. In such cases, am-plified BCL2 also leads to resistance to chemotherapy. It hasbeen reported that patients with MYC/BCL2 double-hit lym-phomas die within 1 year if treated with Burkitt or usualDLBCL-based chemotherapy regimens [12].

In some cases, extra copies of MYC are present in associ-ation with BCL2-IgH translocation or extra copies of BCL2are present in association with MYC-Ig rearrangement. Inboth these scenarios, a worse prognosis akin to cases withMYC/BCL-2 double-hit translocation has been reported [4].

The classical IPI (age, stage, LDH level, performancestatus, and more than 1 extranodal site) and subclassificationof DLBCL into germinal and post germinal subtypes wereusually good predictors of outcomes and useful guide inselection of appropriate therapy in the prerituximab era. How-ever, with the advent of rituximab-containing treatment pro-tocols, the outcomes of all DLBCL improved significantlyand the prognostic significance of classical IPI decreased anda revised IPI was instituted which used the same factors butclassified cases into only three categories: “very good, good,and poor”. This was found to be predictive of outcomes ofcases with fast-growing tumors being treated with rituximab-based therapies in the rituximab era [12]. However, a subset ofcases within the “poor” category of revised IPI has been foundto behave much worse than others in the same category evenwith rituximab-based regimens. This subset contains all MYC/BCL2 DHL cases along with some non DHL cases. Chemo-therapeutic regimen (R-CHOP) incorporating anti CD20 anti-body, rituximab has significantly improved survival of patientswith B cell lymphomas; however, it does not seem to be veryeffective against MYC/BCL2 double-hit lymphomas as CD20

Table 1 Review of major case series on DHL in literature

Studies Numberof DHLcases/totalstudy size(%)

Number of DHLcases with priorhistory of lowgrade follicularlymphoma n/N (%)

Median age(range)

Macpherson et al. [3, 7] 15/39 (38) 6/13 (46) 65*

Kanungo et al. [1, 3] 14/14 (100) None 55 (29–72)

Le Gouill et al. [3, 6] 16/16 (100) 4/16 (25) 61 (36–73)

Bertrand et al. [3, 9] 10/17 (59) 1/10 (10) 58 (45–81)

Johnson et al. [3, 8] 54/54 (100) 20/54 (46) 62 (24–93)

Niitsu et al. [2, 3] 19/19 (100) None 61 (29–79)

Tomita et al. [3, 11] 27/27 (100) 4/23 (17) 51 (36–79)

Snuderl et al. [3, 5] 20/20 (100) 3/20 (15) 64 (32–91)

Li et al. [4] 52/52 (100) 10/52 (19) 55 (18–76)

Total 227/258 48/221

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is expressed at much lower levels in these tumors [13].Therefore, recognizing these cases is of high importanceas they may need treatment with alternate regimens. Moreintensive chemotherapies such as R-CODOX-M/IVAC[combination of two chemotherapy regimens—rituximab,cyclophosphamide,vincristine, doxorubicin, and metho-trexate (R-CODOX-M) and rituximab, etoposide, ifosfamideand cytarabine (R-IVAC), given alternatively] may show bet-ter results; however, no supporting data for this exists so far.Novel therapeutic agents such as enzastaurin, bortezomib,bevacizumab, lenalidomide, bendamustine, mTor inhibitors,syk inhibitors, and acetone deacetylase inhibitors are beingtested and may have a future role in treatment of these aggres-sive tumors [14]. In a recent study, Leskov et al. [15]engineered MYC/BCL2 double-hit lymphomas in humanizedmouse models and reported good response of these tumorswith anti-CD52 antibody, alemtuzumab, at all sites exceptCNS. Alemtuzumab-containing regimens have not been triedfor MYC/BCL2 double-hit lymphomas in humans and mayrepresent good target for future trials despite their high toxic-ity. Considering the aggressive behavior and poor prognosisof these tumors, some centers use upfront autologous orallogeneic transplants and this approach has been mentionedto have shown better results by some people [14].

In most of the major case series on DHL in literature,presentation of both DHL and follicular lymphoma in thesame patient is either absent [1, 2] or only few cases of thisunusual event are reported [3–9] (Table 1). All of these pa-tients harboring both MYC/BCL2 DHL and follicular lym-phoma have been reported to have antecedent history offollicular lymphoma rather than concurrent presentation ofDHL and follicular lymphoma [1–9, 15]. Li et al. [4], in arecent case series, reported 52 cases of double-hitMYC/BCL2lymphomas with a small subset of these (n=10) havingantecedent/concurrent follicular lymphoma. Exact number ofcases where concurrent diagnosis of both lymphomas wasmade was not mentioned, neither was there a description ofclinical presentation of these unfamiliar cases.

Our patient is a young woman who had a concurrentpresentation of follicular lymphoma in her cervical lymphnode and MYC/BCL2 DHL with morphological and immu-nohistochemical features intermediate between BL andDLBCL in inguinal lymph node. Her IPI score was 3. Sheunderwent treatment with HyperCVAD (course A—cyclo-phosphamide, vincristine, doxorubicin; course B—methotrex-ate and cytarabine) from January 2011 till May 2011. Subse-quently, she had autologous stem cell transplant with CBV[Cytoxan (cyclophosphamide), BCNU (carmustine), and VP-16 (etoposide)] regimen in July 2011. Her last follow up wasin September 2012 at our hospital. Her PET scan 14 monthspost-autologous transplant was negative for recurrent lympho-ma. Cases with both DHL and follicular lymphoma have beenreported to havemedian survival of 6–8months (in comparison

to 48 months for de novo MYC/BCL2 double-hit lymphomas)[4] and relapse within 1 year. Our patient who presented withDHL and follicular lymphoma has done better than expected.Although it is too early to consider her cured, a good responseand disease-free status so far with survival more than themedian highlights the importance of recognizing these tumorsearly especially in young patients so that they can be treatedwith more intensive and alternative regimens other than R-CHOP.

In summary, the presence of follicular lymphoma concur-rently presenting at a different site than MYC/BCL2 DHLraises the possibility of missing a highly aggressive neoplasm,once the diagnosis of follicular lymphomas is established at onesite. A more intensive search for an associated high-gradelymphomamay be necessary in cases where clinical parametersare suggestive of a more aggressive neoplasm. Also, recogniz-ing the presence of follicular lymphoma in a case of MYC/BCL2 DHL lymphoma also appears to be of significance asthese tumors have been mentioned to have more dismal prog-nosis and may need a more intense treatment approach.

References

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