title: Apoptosis and the Bcl-2 gene family -- patterns of expression and prognostic value in stage I and II follicular center lymphoma.
abstract: OBJECTIVE
  The prognostic significance of spontaneous levels of apoptosis and Bcl-2, Bax, and Bcl-x protein expression in follicular center lymphoma (FCL) is unknown. The objectives of this retrospective study were (1) to investigate the relationship between pretreatment apoptosis levels and long-term treatment outcome in patients with Stage I and II FCL; (2) to define the incidence and patterns of Bax and Bcl-x protein expression in human FC; and (3) to determine the relationship of Bcl-2, Bax, and Bcl-x expression with spontaneous apoptosis levels and clinical outcome in localized FCL.
  
  
  METHODS
  Between 1974 and 1988, 144 patients with Stage I or II FCL were treated. Hematoxylin and eosin (H & E) stained tissue sections of pretreatment specimens were retrieved for 96 patients. Treatment consisted of regional radiation therapy (XRT) for 25 patients, combined modality therapy (CMT) consisting of combination chemotherapy and XRT for 57 patients, and other treatments for 14 patients. Median follow-up for living patients was nearly 12 years. The apoptotic index (AI) was calculated by dividing the number of apoptotic cells by the total number of cells counted and multiplying by 100. Expression of Bcl-2, Bax, and Bcl-x proteins was assessed using immunohistochemistry.
  
  
  RESULTS
  The mean and median AI values for the entire group were 0.53 and 0.4, respectively (range: 0-5.2). The AI strongly correlated with cytologic grade, with mean AI values of 0.25 for grade 1, 0.56 for grade 2, and 0.84 for grade 3 (p < 0.0005; Kendall correlation). A positive correlation was present between grouped AI and grouped mitotic index (MI) (p = 0.014). For patients treated with CMT, an AI < 0.4 correlated with improved freedom from relapse (FFR) p = 0.0145) and overall survival (OS) (p = 0.0081). An AI < 0.4 did not correlate with clinical outcome for the entire cohort or for patients receiving XRT only. Staining of tumor follicles for the Bcl-2 protein was positive, variable, and negative in 73%, 15%, and 12% of cases, respectively. Positive staining of tumor follicles was observed in 96% of cases for both the Bax and Bcl-x proteins. Expression of Bcl-2, Bax, or Bcl-x did not correlate with AI or clinical outcome.
  
  
  CONCLUSIONS
  The level of spontaneous apoptosis in pretreatment specimens correlates with cytologic grade of FCL and is a significant predictor of FFR and OS for patients with localized FCL receiving CMT.
authors.affiliation: Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Logsdon
authors.forename: R E
authors.initials: RE
authors.lastname: Meyn
authors.forename: P C
authors.initials: PC
authors.lastname: Besa
authors.forename: W C
authors.initials: WC
authors.lastname: Pugh
authors.forename: L C
authors.initials: LC
authors.lastname: Stephens
authors.forename: L J
authors.initials: LJ
authors.lastname: Peters
authors.forename: L
authors.initials: L
authors.lastname: Milas
authors.forename: J D
authors.initials: JD
authors.lastname: Cox
authors.forename: F
authors.initials: F
authors.lastname: Cabanillas
authors.forename: S
authors.initials: S
authors.lastname: Brisbay
authors.forename: M
authors.initials: M
authors.lastname: Andersen
authors.forename: T J
authors.initials: TJ
authors.lastname: McDonnell
mesh_terms: D000704:Analysis of Variance; D017209:Apoptosis; D015331:Cohort Studies; D005260:Female; D015870:Gene Expression; D019254:Genes, bcl-2; D006801:Humans; D008224:Lymphoma, Follicular / Q000235:genetics / Q000378:metabolism / Q000473:pathology / Q000503:physiopathology / Q000532:radiotherapy; D008297:Male; D008875:Middle Aged; D008940:Mitotic Index; D009363:Neoplasm Proteins / Q000378:metabolism; D009367:Neoplasm Staging; D011379:Prognosis; D011518:Proto-Oncogene Proteins / Q000378:metabolism; D019253:Proto-Oncogene Proteins c-bcl-2 / Q000378:metabolism; D012189:Retrospective Studies; D016896:Treatment Outcome; D051028:bcl-2-Associated X Protein; D051020:bcl-X Protein
chemical_list: C494826:BAX protein, human; C494811:BCL2L1 protein, human; D009363:Neoplasm Proteins; D011518:Proto-Oncogene Proteins; D019253:Proto-Oncogene Proteins c-bcl-2; D051028:bcl-2-Associated X Protein; D051020:bcl-X Protein