Originally published as JCO Early Release 10.1200/JCO.2007.15.9277 on July 28 2008

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fu, K. Articles by Vose, J. M. Search for Related Content PubMed PubMed Citation Articles by Fu, K. Articles by Vose, J. M. Social Bookmarking                            What's this?

Addition of Rituximab to Standard Chemotherapy Improves the Survival of Both the Germinal Center B-Cell–Like and Non–Germinal Center B-Cell–Like Subtypes of Diffuse Large B-Cell Lymphoma

Kai Fu, Dennis D. Weisenburger, William W.L. Choi, Kyle D. Perry, Lynette M. Smith, Xinlan Shi, Christine P. Hans, Timothy C. Greiner, Philip J. Bierman, R. Gregory Bociek, James O. Armitage, Wing C. Chan, Julie M. Vose

From the Departments of Pathology and Microbiology; Biostatistics; and Internal Medicine, University of Nebraska Medical Center, Omaha, NE

Corresponding author: Julie M. Vose, MD, Department of Internal Medicine, University of Nebraska Medical Center, 98760 Nebraska Medical Center, Omaha, NE 68198-7680; e-mail: jmvose{at}unmc.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Purpose Diffuse large B-cell lymphoma (DLBCL) includes at least two prognostically important subtypes (ie, germinal center B-cell–like [GCB] and activated B-cell–like [ABC] DLBCL), which initially were characterized by gene expression profiling and subsequently were confirmed by immunostaining. However, with the addition of rituximab to standard chemotherapy, the prognostic significance of this subclassification of DLBCL is unclear.

Patients and Methods We studied 243 patient cases of de novo DLBCL, which included 131 patient cases treated with rituximab plus standard chemotherapy (rituximab group) and 112 patient cases treated with only standard chemotherapy (control group). The cases were assigned to GCB or non-GCB subgroups (the latter of which included both ABC DLBCL and unclassifiable DLBCL) on the basis of immunophenotype by using the Hans method. Clinical characteristics and survival outcomes of the two patient groups were compared.

Results The clinical characteristics of the patients in the rituximab and the control groups were similar. Compared with the control group, addition of rituximab improved the 3-year overall survival (OS; 42% v 77%; P < .001) of patients with DLBCL. Rituximab-treated patients in either the GCB or the non-GCB subgroups also had a significantly improved 3-year OS compared with their respective subgroups in the control group (P < .001). In the rituximab group, the GCB subgroup had a significantly better 3-year OS than the non-GCB subgroup (85% v 69%; P = .032). Multivariate analyses confirmed that rituximab treatment was predictive for survival in both the GCB and the non-GCB subgroups.

Conclusion In this retrospective study, we have shown that the subclassification of DLBCL on the basis of the cell of origin continues to have prognostic importance in the rituximab era.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy, as it accounts for approximately one third of all patient cases of non-Hodgkin's lymphoma (NHL) diagnosed each year.¹ DLBCL is an aggressive disease, and more than one half of the patients will eventually die of the disease after standard cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like chemotherapy. During the past few years, studies have shown that the addition of rituximab to CHOP-like chemotherapy significantly improves the clinical outcome of patients with DLBCL.^2-5

From both biologic and clinical perspectives, DLBCL is a heterogeneous disease that includes at least three major, prognostically important subtypes (ie, germinal center B-cell–like [GCB] DLBCL, activated B-cell–like [ABC] DLBCL, and primary mediastinal large B-cell lymphoma [PMBL]), as defined by gene expression profiling studies.^6-11 Some patient cases do not fit into any of these categories and have been designated as unclassifiable DLBCL.^7,11 Subsequent studies have demonstrated that GCB and ABC DLBCL differ in the presumptive cell of origin,¹² pathogenetic mechanisms,^13-16 and survival.^7,9 This classification of DLBCL has also been shown to be clinically applicable by using an immunostaining approach.¹⁷DLBCL can be subclassified on the basis of the differential expression of CD10, BCL-6, and MUM-1 into either GCB or non-GCB subgroups. The GCB subgroup includes both GCB DLBCL and PMBL, and the non-GCB subgroup includes both ABC DLBCL and unclassifiable DLBCL, as defined by gene expression profiling. Various studies have shown that this classification on the basis of the cell of origin is an important independent prognostic factor for patients who are treated with CHOP or CHOP-like chemotherapy.^17-19

Expression of individual biomarkers by the tumor cells, such as BCL-2, also may provide important prognostic information in DLBCL.^20-23 However, different studies have yielded conflicting and inconclusive results, which probably reflects the heterogeneity of the disease and the various methods used. For example, overexpression of BCL-2 has been associated with an adverse outcome in patients with DLBCL who were treated with CHOP-like chemotherapy in some studies,^20-23 but it has not been associated in others.^24,25 However, by using a classification on the basis of the cell of origin, the significance of some biomarkers has been clarified. Specifically, we have recently shown that BCL-2 overexpression is a significant prognostic factor in ABC DLBCL but not in GCB DLBCL.²⁶

Because nearly all studies of prognostic indicators in DLBCL have used survival outcomes after treatment with CHOP-like regimens, it is unclear whether these prognostic indicators continue to be relevant for patients with DLBCL who were treated with rituximab plus CHOP-like chemotherapy. Recently, Nyman et al²⁷ found that the addition of rituximab to standard chemotherapy appeared to eliminate the prognostic value of the immunohistochemically defined GCB and non-GCB subtypes of DLBCL. This finding suggests that prognostic markers need to be re-evaluated in the rituximab era. Several reports have also shown that the addition of rituximab to standard chemotherapy eliminates the prognostic significance of BCL-2 overexpression in DLBCL.^28-30

Therefore, we decided to perform a retrospective analysis of the outcome of our patients with DLBCL who were treated with rituximab plus standard chemotherapy versus those who were treated with standard, CHOP-like, chemotherapy alone. We found that the addition of rituximab to standard chemotherapy improved the survival of patients in both the GCB- and non-GCB subgroups of DLBCL. In our study, immunohistochemical subclassification on the basis of the cell of origin¹⁷ continues to be a prognostic marker in patients with DLBCL who were treated with rituximab plus standard chemotherapy.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Patients
The study population consisted of 243 patients with de novo DLBCL who were treated by the Nebraska Lymphoma Study Group between 1987 and 2005. One hundred thirty-one patients received rituximab plus standard CHOP or CHOP-like chemotherapy (rituximab group), whereas 112 patients were treated with CHOP or CHOP-like chemotherapy alone (control group). The chemotherapy regimens used were all anthracycline-based and included CHOP; cyclophosphamide, mitoxantrone, vincristine, and prednisone (CNOP); or cyclophosphamide, doxorubicin, procarbazine, bleomycin, vincristine, prednisone (CAPBOP). All patients in the rituximab group were treated with CHOP or CNOP regimens plus rituximab; in the control group, 97 patients (87%) were treated with CHOP or CNOP regimens, and 15 patients (13%) were treated with the CAPBOP regimen. The median follow-up for the control and the rituximab-treated patients were 6.4 years (range, 1.4 to 12.3 years) and 3.2 years (range, 0.5 to 7.9 years), respectively. This study was approved by the institutional review board of the University of Nebraska Medical Center.

Tissue Microarray Immunohistochemistry
All tissue biopsies were fixed in 10% buffered formalin and were routinely processed and embedded in paraffin, and 4-µm sections were cut and stained with hematoxylin and eosin (H&E). The H&E-stained slides from each tumor block were reviewed, and representative areas with the highest percentage of tumor cells were selected for tissue microarray (TMA) construction. TMA blocks were constructed with a tissue microarrayer (Beecher Instruments, Sun Prairie, WI). For each patient case, three tissue cores that measured 1 mm in diameter were arrayed into a recipient block. Immunohistochemistry was performed on 4-µm TMA sections by using a streptavidin-biotin complex technique, and antibodies against the following antigens were utilized: CD20, CD3, CD10, BCL-2, BCL-6, and MUM-1 (Appendix Table A1, online only). Immunoreactivity was determined without any knowledge of the survival or other clinical data. Antigen expression was evaluated by assessing the percentage of immunoreactive tumor cells in 10% increments. The cases were then subclassified by using the algorithm described by Hans et al¹⁷ For evaluation of CD10, BCL-2, BCL-6, and MUM-1, the staining was interpreted as positive if 30% or more of the tumor cells showed expression.¹⁷ Internal positive controls for each core were required for interpretation.³¹ The samples were analyzed independently by two hematopathologists (K.F. and W.W.L.C.), and disagreements were resolved by joint review on a multiheaded microscope.

Statistical Analysis
Characteristics of the two treatment groups were compared with the ² test, and mean age was compared with the t test. The Kaplan-Meier method was used to estimate the overall and event-free survival distributions. Overall survival (OS) was defined as the time from initial diagnosis to the date of death or last contact. Event-free survival (EFS) was defined as the time from initial diagnosis to the date of progression, relapse, death, or last contact. The log-rank test was used to compare the survival distributions. Cox regression was used to compare OS and EFS survival distributions in multivariate analysis, and the backwards selection method was used to select variables with independent predictive significance.³² All statistical tests were two-sided, and P values less than .05 were considered statistically significant. The analysis was conducted with SAS software (SAS Institute Inc, Cary, NC).

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Patient Characteristics
There were 243 patients in the study; the median age was 68 years (range, 20 to 94 years); and there were 125 men (51%) and 118 women (49%). At the time of analysis, 98 patients (40%) had died, and 145 (60%) were alive at last contact. The median follow-up of the surviving patients was 3.8 years (range, 0.5 to 12.3 years). Of the 243 patients, the rituximab group consisted of 131 patients, and 112 patients were in the control group. The median age of the rituximab group (63 years; range, 20 to 89 years) was lower than that of the control group (70 years; range, 20 to 94 years; P = .05). Otherwise, the clinical features were not significantly different between the rituximab and control groups. The distribution of immunohistochemically defined GCB and non-GCB phenotypes was also similar between the two groups (P = .48; Appendix Table A2, online only).

Addition of Rituximab to Standard Chemotherapy Improved the Survival of Patients With DLBCL
First, we compared the survival outcomes of the rituximab group and the control group. A significant difference in both OS and EFS was observed between the two groups (Figs 1A and 1B). Specifically, the 3-year OS was 77% in the rituximab group and was only 42% in the control group (P < .001). Similarly, the 3-year EFS was 59% and 37% for the rituximab and control groups, respectively (P < .001). When patients who were treated with CAPBOP regimen were excluded from the analyses, the differences in OS and EFS remained similar (3-year OS, 77% v 37%, P < .001; 3-year EFS, 59% v 33%, P < .001). These differences were more pronounced in older patients ( 60 years) than in younger patients (< 60 years; Appendix Figs A1A and A1B, online only). These differences also were seen in the low (0 to 2) and high (3 to 5) International Prognostic Index (IPI) subgroups (Appendix Figs A1C and A1D). Our study confirms previous clinical studies that showed that the addition of rituximab to standard chemotherapy results in a significant improvement in survival for patients with DLBCL who are of all ages and risk groups.^2-5

View larger version (12K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1. Addition of rituximab to standard chemotherapy improved the (A) overall and (B) event-free survival of patients with diffuse large B-cell lymphoma.

Patients in the GCB subgroup who received rituximab plus standard chemotherapy had a significantly better survival than those treated with standard chemotherapy alone (3-year OS, 85% v 52%, P < .001; 3-year EFS, 67% v 47%, P = .005; Figs 2A and 2B). The results of Cox multivariate proportional hazards analysis confirmed the prognostic effect of rituximab in the GCB subgroup (P = .0043). The IPI score and rituximab treatment were the only independent prognostic factors for OS in patients with GCB DLBCL, and rituximab treatment was also an independent prognostic factor for EFS in patients with GCB DLBCL (Table 1).

View larger version (16K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 2. Addition of rituximab to standard chemotherapy improved the overall and event-free survival of patients in both the (A, B, respectively) germinal center B-cell–like and the (C, D, respectively) non–germinal center B-cell–like subgroups of diffuse large B-cell lymphoma.

Subclassification on the Basis of the Cell of Origin Is Predictive of Survival in Patients With DLBCL Who Were Treated With Rituximab
The survival outcome according to the cell of origin (ie, GCB and non-GCB subtypes) in patients who were treated with rituximab also was examined. The clinical features were not significantly different between the GCB and non-GCB subgroups within the rituximab group (Table 2). Rituximab-treated patients in the GCB subgroup had significantly better OS than those in the non-GCB subgroup (3-year OS, 85% v 69%, P = .032; Fig 3A). Patients in the GCB subgroup also had a better 3-year EFS than those in the non-GCB subgroup (67% v 52%; P = .11; Fig 3B). To further investigate the prognostic impact of the subclassification on the basis of the cell of origin in patients who were treated with rituximab, multivariate analysis was performed. As listed in Table 3, the IPI was a significant predictor of OS (P = .0094), and the classification on the basis of the cell of origin was a less significant predictor of OS (P = .089), but neither were significant predictors of EFS (Table 3). We also performed multivariate analysis by using the individual components of IPI. In that analysis, classification on the basis of the cell of origin was a significant predictor of OS (P = .041) but not of EFS, whereas the serum lactate dehydrogenase (LDH) level was a significant predictor of both OS and EFS in patients who were treated with rituximab (Table 3).

View larger version (11K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 3. Subclassification on the basis of the cell of origin was predictive of (A) overall and (B) event-free survival in patients with diffuse large B-cell lymphoma who were treated with rituximab plus standard chemotherapy. GBC, germinal center B-cell–like.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Given the heterogeneity of DLBCL, reliable and clinically applicable tools are needed to predict prognosis and to optimize patient care. The aim of our study was to determine whether previously recognized prognostic factors, including the classification of DLBCL on the basis of the cell of origin, continue to have prognostic importance in the rituximab era. In accordance with previous retrospective analyses,^2-5,27,33,34 our study confirms that the addition of rituximab to standard anthracycline-based chemotherapeutic regimens improves the survival of patients with DLBCL. More importantly, we have demonstrated that the addition of rituximab to standard chemotherapy significantly improved the OS and EFS of patients with both the GCB and non-GCB subtypes. Multivariate analyses confirmed that rituximab was one of the independent prognostic factors for survival in both the GCB and the non-GCB subgroups. Our study also supports the notion that the classification of DLBCL on the basis of the cell of origin continues to be important for predicting the outcome of patients who are treated with rituximab plus standard chemotherapy. Multivariate analyses with the IPI or individual components of the IPI confirmed that the classification of DLBCL on the basis of the cell of origin was an independent prognostic factor for OS in patients who were treated with rituximab.

Our findings are in agreement with a recent study, which was just published in abstract form, from the Leukemia and Lymphoma Molecular Profiling Project (LLMPP).³⁵ In that study, gene expression profiling of 156 samples from previously untreated patients with DLBCL was performed by using Affymetrix U133 plus arrays. Addition of rituximab to standard chemotherapy improved the OS for both GCB and ABC DLBCL compared with historical control patients who were treated with CHOP-like chemotherapy alone. After a median follow-up of 2.3 years, rituximab-treated patients with GCB DLBCL also had a more favorable OS than those with ABC DLBCL; 3-year OS rates were 86% and 68%, respectively (P = .014).³⁵

Our findings are, however, different from those reported in a recent study by Nyman et al.²⁷ They found that the additional benefit of rituximab extended only to patients with immunohistochemistry (IHC)-defined non-GCB DLBCL but not to those with GCB DLBCL. In addition, Nyman et al²⁷ did not find a difference in survival between GCB and non-GCB subgroups in the post-rituximab era, which implies that the addition of rituximab eliminates the prognostic significance of the classification of DLBCL on the basis of the cell of origin. Several other studies with similar results, including a recent report from the GELA LNH 98-5 trial, have also been reported in brief abstract form.^36-38 The differences between our study and these studies could result from multiple factors. The current IHC algorithm derived by Hans et al¹⁷ to assign DLBCL to GCB and non-GCB subgroups is considered imperfect and has a misclassification rate of 19.7% when compared with gene expression profiling data. As Nyman et al²⁷ pointed out in their article, this misclassification could potentially confound the analysis in some studies. In addition, these differences may be secondary to the technical challenges of performing and interpreting immunohistochemical stains, such as differences in laboratory techniques, scoring definitions, and interobserver variation.³¹ Furthermore, although anthracycline-based regimens were used in these studies, the differences in the proportions of patients treated with various regimens could have contributed to the differences observed. Therefore, a prospective study of patients treated with the same chemotherapeutic regimen is warranted to eliminate these potential confounding variables.

BCL-2 is a member of the family of proteins that regulate programmed cell death. Overexpression of BCL-2 protein in B-cell NHL is thought to result in chemotherapy resistance of the lymphoma cells both in vitro and in vivo.^20,21,39 As a consequence, BCL-2 protein overexpression generally is associated with poor survival in patients with DLBCL who are treated with standard chemotherapy.^{18,20-23,39-42} This effect is most evident in non-GCB DLBCL.²⁶ Addition of rituximab to standard chemotherapy, as we show in the current study and in agreement with several previous studies,^28-30 eliminates the negative effect of BCL-2 protein overexpression in patients with DLBCL. More specifically, we have shown that rituximab overcame the adverse influence of BCL-2 overexpression on survival in non-GCB DLBCL.

Despite the widespread use of rituximab in the treatment of B-cell NHL, the mechanisms by which rituximab exerts its antilymphoma effect are still not fully understood. Evidence from in vitro studies that used lymphoma cell lines or fresh tumor cells, and from in vivo animal studies, suggest that rituximab acts through three different mechanisms: complement-dependent cytotoxicity,^43-51 antibody-dependent cell-mediated cytotoxicity,^43,44,52,53 and induction of apoptosis.^54-56 Among these, induction of apoptosis may be particularly important for a chemotherapy-sensitization effect of rituximab.^54-56 Rituximab appears to induce apoptosis through multiple signaling pathways that inhibit at least two antiapoptotic proteins, namely BCL-2 and BCL-xL.⁵⁷ Studies of the Adult immunodeficiency virus–related DLBCL cell line 2F7 (Epstein-Barr virus–positive) have shown that rituximab treatment leads to inhibition of p38/MAPK activity, which in turn disrupts an interleukin-10 (IL-10) autocrine loop.^58,59 In addition, it has been shown that rituximab can synergize with chemotherapeutic agents, including doxorubicin, in the killing of these cells. This synergism is mediated, at least in part, by downregulation of IL-10.⁵⁹ The resultant decrease in IL-10 binding to its receptor decreases phosphorylated STAT3 and, hence, decreases the expression of BCL-2 protein.⁶⁰ In accordance with these findings, our study showed that the addition of rituximab to standard therapy significantly improved the survival of patients with DLBCL who were overexpressing BCL-2 protein. Conversely, we also showed that the addition of rituximab to standard therapy significantly improved the survival of patients with DLBCL who did not overexpress BCL-2 protein. Whether this was caused by the suppression of BCL-xL or by some other mechanisms remains to be investigated. Studies of two Epstein-Barr virus–positive Burkitt lymphoma cell lines (Ramos and Daudi) have shown that the binding of rituximab to CD20 inhibits both the NF-B and the ERK1/2 pathways via an increase in Raf-1 kinase inhibitor, which results in decreased expression of BCL-xL.^57,61-64

In summary, we have confirmed that rituximab therapy results in a significant survival advantage for patients with DLBCL when added to an anthracycline-based chemotherapeutic regimen. This survival advantage remains when DLBCL patient cases are segregated into GCB or non-GCB subgroups on the basis of the IHC algorithm of Hans et al.¹⁷ Our study has also shown that the survival of patients with GCB DLBCL is still superior to that of their non-GCB counterparts in the rituximab era. However, because our study is retrospective, prospective studies with a larger number of patients who are treated with rituximab plus standard chemotherapy are needed to confirm our findings.

	AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Employment or Leadership Position: None Consultant or Advisory Role: Kai Fu, Cephalon (C); Dennis D. Weisenburger, Astellas (C); James O. Armitage, Roche (C), Genentech (C), Biogen Idec (C) Stock Ownership: None Honoraria: James O. Armitage, Roche, Genentech, Biogen Idec Research Funding: Wing C. Chan, Roche; Julie M. Vose, Genentech, Biogen Idec Expert Testimony: None Other Remuneration: None

	AUTHOR CONTRIBUTIONS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
Conception and design: Kai Fu, Dennis D. Weisenburger, James O. Armitage, Wing C. Chan, Julie M. Vose

Financial support: Kai Fu, Dennis D. Weisenburger, James O. Armitage, Julie M. Vose

Administrative support: Kai Fu, Dennis D. Weisenburger

Provision of study materials or patients: Kai Fu, Dennis D. Weisenburger, Christine P. Hans, Timothy C. Greiner, Philip J. Bierman, R. Gregory Bociek, James O. Armitage, Wing C. Chan, Julie M. Vose

Collection and assembly of data: Kai Fu, William W.L. Choi, Kyle D. Perry, Xinlan Shi

Data analysis and interpretation: Kai Fu, Dennis D. Weisenburger, William W.L. Choi, Kyle D. Perry, Lynette M. Smith, Xinlan Shi, Christine P. Hans, Timothy C. Greiner, James O. Armitage, Wing C. Chan, Julie M. Vose

Manuscript writing: Kai Fu, Dennis D. Weisenburger, William W.L. Choi, Lynette M. Smith

Final approval of manuscript: Kai Fu, Dennis D. Weisenburger, William W.L. Choi, Kyle D. Perry, Lynette M. Smith, Xinlan Shi, Christine P. Hans, Timothy C. Greiner, Philip J. Bierman, R. Gregory Bociek, James O. Armitage, Wing C. Chan, Julie M. Vose

	Appendix

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 

View larger version (16K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig A1. Addition of rituximab to standard chemotherapy improved the overall survival of patients with diffuse large B-cell lymphoma. The improvement was seen in both (A, B, respectively) age and (C, D, respectively) International Prognostic Index risk groups.

View larger version (10K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig A2. BCL-2 overexpression was not predictive of overall survival in either the (A) germinal center B-cell–like or (B) non–germinal center B-cell–like subgroups of patients with diffuse large B-cell lymphoma who were treated with rituximab.

View larger version (12K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig A3. Addition of rituximab to standard chemotherapy improved the overall survival of patients with diffuse large B-cell lymphoma in both the (A) BCL-2–positive and (B) BCL-2–negative subgroups.

	NOTES

 
published online ahead of print at www.jco.org on July 28, 2008.

Supported in part by research Grant (Protocol) No. U3130S (J.M.V.) awarded by Genentech Inc.

Presented in part at the 43rd Annual Meeting of the American Society of Clinical Oncology, June 1-5, 2007, Chicago, IL.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS Appendix REFERENCES

 
1. Anderson JR, Armitage JO, Weisenburger DD: Epidemiology of the non-Hodgkin's lymphomas: Distributions of the major subtypes differ by geographic locations. Non-Hodgkin's Lymphoma Classification Project. Ann Oncol 9:717-720, 1998[Abstract/Free Full Text]

2. Coiffier B, Lepage E, Briere J, et al: CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med 346:235-242, 2002[Abstract/Free Full Text]

3. Habermann TM, Weller EA, Morrison VA, et al: Rituximab-CHOP versus CHOP alone or with maintenance rituximab in older patients with diffuse large B-cell lymphoma. J Clin Oncol 24:3121-3127, 2006[Abstract/Free Full Text]

4. Pfreundschuh M, Trumper L, Osterborg A, et al: CHOP-like chemotherapy plus rituximab versus CHOP-like chemotherapy alone in young patients with good-prognosis diffuse large-B-cell lymphoma: A randomised controlled trial by the MabThera International Trial (MInT) Group. Lancet Oncol 7:379-391, 2006[CrossRef][Medline]

5. Sehn LH, Donaldson J, Chhanabhai M, et al: Introduction of combined CHOP plus rituximab therapy dramatically improved outcome of diffuse large B-cell lymphoma in British Columbia. J Clin Oncol 23:5027-5033, 2005[Abstract/Free Full Text]

6. Alizadeh AA, Eisen MB, Davis RE, et al: Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling. Nature 403:503-511, 2000[CrossRef][Medline]

7. Rosenwald A, Wright G, Chan WC, et al: The use of molecular profiling to predict survival after chemotherapy for diffuse large-B-cell lymphoma. N Engl J Med 346:1937-1947, 2002[Abstract/Free Full Text]

8. Rosenwald A, Wright G, Leroy K, et al: Molecular diagnosis of primary mediastinal B cell lymphoma identifies a clinically favorable subgroup of diffuse large B cell lymphoma related to Hodgkin lymphoma. J Exp Med 198:851-862, 2003[Abstract/Free Full Text]

9. Shipp MA, Ross KN, Tamayo P, et al: Diffuse large B-cell lymphoma outcome prediction by gene-expression profiling and supervised machine learning. Nat Med 8:68-74, 2002[CrossRef][Medline]

10. Savage KJ, Monti S, Kutok JL, et al: The molecular signature of mediastinal large B-cell lymphoma differs from that of other diffuse large B-cell lymphomas and shares features with classical Hodgkin lymphoma. Blood 102:3871-3879, 2003[Abstract/Free Full Text]

11. Wright G, Tan B, Rosenwald A, et al: A gene expression-based method to diagnose clinically distinct subgroups of diffuse large B cell lymphoma. Proc Natl Acad Sci U S A 100:9991-9996, 2003[Abstract/Free Full Text]

12. Lossos IS, Alizadeh AA, Eisen MB, et al: Ongoing immunoglobulin somatic mutation in germinal center B cell-like but not in activated B cell-like diffuse large cell lymphomas. Proc Natl Acad Sci U S A 97:10209-10213, 2000[Abstract/Free Full Text]

13. Huang JZ, Sanger WG, Greiner TC, et al: The t(14;18) defines a unique subset of diffuse large B-cell lymphoma with a germinal center B-cell gene expression profile. Blood 99:2285-2290, 2002[Abstract/Free Full Text]

14. Tam W, Gomez M, Chadburn A, et al: Mutational analysis of PRDM1 indicates a tumor-suppressor role in diffuse large B-cell lymphomas. Blood 107:4090-4100, 2006[Abstract/Free Full Text]

15. Davis RE, Brown KD, Siebenlist U, et al: Constitutive nuclear factor kappaB activity is required for survival of activated B cell-like diffuse large B cell lymphoma cells. J Exp Med 194:1861-1874, 2001[Abstract/Free Full Text]

16. Pasqualucci L, Compagno M, Houldsworth J, et al: Inactivation of the PRDM1/BLIMP1 gene in diffuse large B cell lymphoma. J Exp Med 203:311-317, 2006[Abstract/Free Full Text]

17. Hans CP, Weisenburger DD, Greiner TC, et al: Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray. Blood 103:275-282, 2004[Abstract/Free Full Text]

18. Berglund M, Thunberg U, Amini RM, et al: Evaluation of immunophenotype in diffuse large B-cell lymphoma and its impact on prognosis. Mod Pathol 18:1113-1120, 2005[CrossRef][Medline]

19. van Imhoff GW, Boerma EJ, van der Holt B, et al: Prognostic impact of germinal center-associated proteins and chromosomal breakpoints in poor-risk diffuse large B-cell lymphoma. J Clin Oncol 24:4135-4142, 2006[Abstract/Free Full Text]

20. Hermine O, Haioun C, Lepage E, et al: Prognostic significance of bcl-2 protein expression in aggressive non-Hodgkin's lymphoma: Groupe d'Etude des Lymphomes de l'Adulte (GELA). Blood 87:265-272, 1996[Abstract/Free Full Text]

21. Kramer MH, Hermans J, Wijburg E, et al: Clinical relevance of BCL2, BCL6, and MYC rearrangements in diffuse large B-cell lymphoma. Blood 92:3152-3162, 1998[Abstract/Free Full Text]

22. Hill ME, MacLennan KA, Cunningham DC, et al: Prognostic significance of BCL-2 expression and bcl-2 major breakpoint region rearrangement in diffuse large cell non-Hodgkin's lymphoma: A British National Lymphoma Investigation Study. Blood 88:1046-1051, 1996[Abstract/Free Full Text]

23. Gascoyne RD, Adomat SA, Krajewski S, et al: Prognostic significance of Bcl-2 protein expression and Bcl-2 gene rearrangement in diffuse aggressive non-Hodgkin's lymphoma. Blood 90:244-251, 1997[Abstract/Free Full Text]

24. Piris MA, Pezzella F, Martinez-Montero JC, et al: p53 and bcl-2 expression in high-grade B-cell lymphomas: Correlation with survival time. Br J Cancer 69:337-341, 1994[Medline]

25. Wilson WH, Teruya-Feldstein J, Fest T, et al: Relationship of p53, bcl-2, and tumor proliferation to clinical drug resistance in non-Hodgkin's lymphomas. Blood 89:601-609, 1997[Abstract/Free Full Text]

26. Iqbal J, Neppalli VT, Wright G, et al: BCL2 expression is a prognostic marker for the activated B-cell-like type of diffuse large B-cell lymphoma. J Clin Oncol 24:961-968, 2006[Abstract/Free Full Text]

27. Nyman H, Adde M, Karjalainen-Lindsberg ML, et al: Prognostic impact of immunohistochemically defined germinal center phenotype in diffuse large B-cell lymphoma patients treated with immunochemotherapy. Blood 109:4930-4935, 2007[Abstract/Free Full Text]

28. Mounier N, Briere J, Gisselbrecht C, et al: Rituximab plus CHOP (R-CHOP) overcomes bcl-2–associated resistance to chemotherapy in elderly patients with diffuse large B-cell lymphoma (DLBCL). Blood 101:4279-4284, 2003[Abstract/Free Full Text]

29. Shivakumar L, Armitage JO: Bcl-2 gene expression as a predictor of outcome in diffuse large B-cell lymphoma. Clin Lymphoma Myeloma 6:455-457, 2006[Medline]

30. Wilson KS, Sehn LH, Berry B, et al: CHOP-R therapy overcomes the adverse prognostic influence of BCL-2 expression in diffuse large B-cell lymphoma. Leuk Lymphoma 48:1102-1109, 2007[CrossRef][Medline]

31. de Jong D, Rosenwald A, Chhanabhai M, et al: Immunohistochemical prognostic markers in diffuse large B-cell lymphoma: Validation of tissue microarray as a prerequisite for broad clinical applications—A study from the Lunenburg Lymphoma Biomarker Consortium. J Clin Oncol 25:805-812, 2007[Abstract/Free Full Text]

32. Hosmer DW, Lemeshow S: Applied Survival Analysis: Regression Modeling of Time to Event Data. New York, NY, John Wiley and Sons Inc, 1999

33. Feugier P, Van Hoof A, Sebban C, et al: Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: A study by the Groupe d'Etude des Lymphomes de l'Adulte. J Clin Oncol 23:4117-4126, 2005[Abstract/Free Full Text]

34. Park YH, Lee JJ, Ryu MH, et al: Improved therapeutic outcomes of DLBCL after introduction of rituximab in Korean patients. Ann Hematol 85:257-262, 2006[CrossRef][Medline]

35. Lenz G, Wright, G., Dave, S., et al: Gene expression signatures predict overall survival in diffuse large b cell lymphoma treated with rituximab and chop-like chemotherapy. Blood 110:209a, 2007 (abstr 348)

36. Molina T, Gaulard P, Jais JP, et al: Germinal center phenotype determined by immunohistochemistry on tissue microarray does not correlate with outcome in diffuse large b-cell lymphoma patients treated with immunochemotherapy in the randomized trial LNNH98-5. Blood 110:51a, 2007 (abstr 51)

37. Farinha P, Sehn LH, Skinnider B, et al: Addition of Rituximab (R) to CHOP Improves Survival in the Non-GCB Subtype of Diffuse Large B Cell Lymphoma (DLBCL). Blood 108:245a, 2006 (abstr 816)

38. Saito B, Shiozawa E, Usui T, et al: Treatment effect of rituximab plus chemotherapy is obtained by improving survival from non-germinal center-type untreated diffuse large B-cell lymphoma. Blood 108:575a, 2006 (abstr 2032)[CrossRef]

39. Barrans SL, Carter I, Owen RG, et al: Germinal center phenotype and bcl-2 expression combined with the International Prognostic Index improves patient risk stratification in diffuse large B-cell lymphoma. Blood 99:1136-1143, 2002[Abstract/Free Full Text]

40. Veelken H, Vik Dannheim S, Schulte Moenting J, et al: Immunophenotype as prognostic factor for diffuse large B-cell lymphoma in patients undergoing clinical risk-adapted therapy. Ann Oncol 18:931-939, 2007[Abstract/Free Full Text]

41. Muris JJ, Meijer CJ, Vos W, et al: Immunohistochemical profiling based on Bcl-2, CD10 and MUM1 expression improves risk stratification in patients with primary nodal diffuse large B cell lymphoma. J Pathol 208:714-723, 2006[CrossRef][Medline]

42. Biasoli I, Morais JC, Scheliga A, et al: CD10 and Bcl-2 expression combined with the International Prognostic Index can identify subgroups of patients with diffuse large-cell lymphoma with very good or very poor prognoses. Histopathology 46:328-333, 2005[CrossRef][Medline]

43. Reff ME, Carner K, Chambers KS, et al: Depletion of B cells in vivo by a chimeric mouse human monoclonal antibody to CD20. Blood 83:435-445, 1994[Abstract/Free Full Text]

44. Flieger D, Renoth S, Beier I, et al: Mechanism of cytotoxicity induced by chimeric mouse human monoclonal antibody IDEC-C2B8 in CD20-expressing lymphoma cell lines. Cell Immunol 204:55-63, 2000[CrossRef][Medline]

45. Harjunpaa A, Junnikkala S, Meri S: Rituximab (anti-CD20) therapy of B-cell lymphomas: Direct complement killing is superior to cellular effector mechanisms. Scand J Immunol 51:634-641, 2000[CrossRef][Medline]

46. Golay J, Lazzari M, Facchinetti V, et al: CD20 levels determine the in vitro susceptibility to rituximab and complement of B-cell chronic lymphocytic leukemia: Further regulation by CD55 and CD59. Blood 98:3383-3389, 2001[Abstract/Free Full Text]

47. Bellosillo B, Villamor N, Lopez-Guillermo A, et al: Complement-mediated cell death induced by rituximab in B-cell lymphoproliferative disorders is mediated in vitro by a caspase-independent mechanism involving the generation of reactive oxygen species. Blood 98:2771-2777, 2001[Abstract/Free Full Text]

48. Weng WK, Levy R: Expression of complement inhibitors CD46, CD55, and CD59 on tumor cells does not predict clinical outcome after rituximab treatment in follicular non-Hodgkin lymphoma. Blood 98:1352-1357, 2001[Abstract/Free Full Text]

49. Golay J, Gramigna R, Facchinetti V, et al: Acquired immunodeficiency syndrome-associated lymphomas are efficiently lysed through complement-dependent cytotoxicity and antibody-dependent cellular cytotoxicity by rituximab. Br J Haematol 119:923-929, 2002[CrossRef][Medline]

50. Manches O, Lui G, Chaperot L, et al: In vitro mechanisms of action of rituximab on primary non-Hodgkin lymphomas. Blood 101:949-954, 2003[Abstract/Free Full Text]

51. Kennedy AD, Solga MD, Schuman TA, et al: An anti-C3b(i) mAb enhances complement activation, C3b(i) deposition, and killing of CD20+ cells by rituximab. Blood 101:1071-1079, 2003[Abstract/Free Full Text]

52. Funakoshi S, Longo DL, Murphy WJ: Differential in vitro and in vivo antitumor effects mediated by anti-CD40 and anti-CD20 monoclonal antibodies against human B-cell lymphomas. J Immunother Emphasis Tumor Immunol 19:93-101, 1996[Medline]

53. Clynes RA, Towers TL, Presta LG, et al: Inhibitory Fc receptors modulate in vivo cytoxicity against tumor targets. Nat Med 6:443-446, 2000[CrossRef][Medline]

54. Demidem A, Lam T, Alas S, et al: Chimeric anti-CD20 (IDEC-C2B8) monoclonal antibody sensitizes a B cell lymphoma cell line to cell killing by cytotoxic drugs. Cancer Biother Radiopharm 12:177-186, 1997[Medline]

55. Ghetie MA, Podar EM, Ilgen A, et al: Homodimerization of tumor-reactive monoclonal antibodies markedly increases their ability to induce growth arrest or apoptosis of tumor cells. Proc Natl Acad Sci USA 94:7509-7514, 1997[Abstract/Free Full Text]

56. Ghetie MA, Bright H, Vitetta ES: Homodimers but not monomers of Rituxan (chimeric anti-CD20) induce apoptosis in human B-lymphoma cells and synergize with a chemotherapeutic agent and an immunotoxin. Blood 97:1392-1398, 2001[Abstract/Free Full Text]

57. Jazirehi AR, Bonavida B: Cellular and molecular signal transduction pathways modulated by rituximab (rituxan, anti-CD20 mAb) in non-Hodgkin's lymphoma: Implications in chemosensitization and therapeutic intervention. Oncogene 24:2121-2143, 2005[CrossRef][Medline]

58. Alas S, Emmanouilides C, Bonavida B: Inhibition of interleukin 10 by rituximab results in down-regulation of bcl-2 and sensitization of B-cell non-Hodgkin's lymphoma to apoptosis. Clin Cancer Res 7:709-723, 2001[Abstract/Free Full Text]

59. Vega MI, Huerta-Yepaz S, Garban H, et al: Rituximab inhibits p38 MAPK activity in 2F7 B NHL and decreases IL-10 transcription: Pivotal role of p38 MAPK in drug resistance. Oncogene 23:3530-3540, 2004[CrossRef][Medline]

60. Alas S, Bonavida B: Rituximab inactivates signal transducer and activation of transcription 3 (STAT3) activity in B-non-Hodgkin's lymphoma through inhibition of the interleukin 10 autocrine/paracrine loop and results in down-regulation of Bcl-2 and sensitization to cytotoxic drugs. Cancer Res 61:5137-5144, 2001[Abstract/Free Full Text]

61. Yeung K, Seitz T, Li S, et al: Suppression of Raf-1 kinase activity and MAP kinase signalling by RKIP. Nature 401:173-177, 1999[CrossRef][Medline]

62. Yeung K, Janosch P, McFerran B, et al: Mechanism of suppression of the Raf/MEK/extracellular signal-regulated kinase pathway by the raf kinase inhibitor protein. Mol Cell Biol 20:3079-3085, 2000[Abstract/Free Full Text]

63. Yeung KC, Rose DW, Dhillon AS, et al: Raf kinase inhibitor protein interacts with NF-kappaB-inducing kinase and TAK1 and inhibits NF-kappaB activation. Mol Cell Biol 21:7207-7217, 2001[Abstract/Free Full Text]

64. Odabaei G, Chatterjee D, Jazirehi AR, et al: Raf-1 kinase inhibitor protein: Structure, function, regulation of cell signaling, and pivotal role in apoptosis. Adv Cancer Res 91:169-200, 2004[Medline]

Submitted December 21, 2007; accepted April 4, 2008.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				M.-K. Song, J.-S. Chung, Y.-M. Seol, S.-G. Kim, H.-J. Shin, Y.-J. Choi, G.-J. Cho, and D.-H. Shin Influence of low absolute lymphocyte count of patients with nongerminal center type diffuse large B-cell lymphoma with R-CHOP therapy Ann. Onc., November 3, 2009; (2009) mdp505v1. [Abstract] [Full Text] [PDF]

				F. Bosch, P. Abrisqueta, N. Villamor, M. J. Terol, E. Gonzalez-Barca, C. Ferra, M. Gonzalez Diaz, E. Abella, J. Delgado, F. Carbonell, et al. Rituximab, Fludarabine, Cyclophosphamide, and Mitoxantrone: A New, Highly Active Chemoimmunotherapy Regimen for Chronic Lymphocytic Leukemia J. Clin. Oncol., September 20, 2009; 27(27): 4578 - 4584. [Abstract] [Full Text] [PDF]

				W. W.L. Choi, D. D. Weisenburger, T. C. Greiner, M. A. Piris, A. H. Banham, J. Delabie, R. M. Braziel, H. Geng, J. Iqbal, G. Lenz, et al. A New Immunostain Algorithm Classifies Diffuse Large B-Cell Lymphoma into Molecular Subtypes with High Accuracy Clin. Cancer Res., September 1, 2009; 15(17): 5494 - 5502. [Abstract] [Full Text] [PDF]

				K. R. Carson, A. M. Evens, E. A. Richey, T. M. Habermann, D. Focosi, J. F. Seymour, J. Laubach, S. D. Bawn, L. I. Gordon, J. N. Winter, et al. Progressive multifocal leukoencephalopathy after rituximab therapy in HIV-negative patients: a report of 57 cases from the Research on Adverse Drug Events and Reports project Blood, May 14, 2009; 113(20): 4834 - 4840. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fu, K. Articles by Vose, J. M. Search for Related Content PubMed PubMed Citation Articles by Fu, K. Articles by Vose, J. M. Social Bookmarking                            What's this?