title: B-cell lymphomas with concurrent IGH-BCL2 and MYC rearrangements are aggressive neoplasms with clinical and pathologic features distinct from Burkitt lymphoma and diffuse large B-cell lymphoma.
abstract: B-cell lymphomas with concurrent IGH-BCL2 and MYC rearrangements, also known as "double-hit" lymphomas (DHL), are rare neoplasms characterized by highly aggressive clinical behavior, complex karyotypes, and a spectrum of pathologic features overlapping with Burkitt lymphoma (BL), diffuse large B-cell lymphoma (DLBCL) and B-lymphoblastic lymphoma/leukemia (B-LBL). The clinical and pathologic spectrum of this rare entity, including comparison to other high-grade B-cell neoplasms, has not been well defined. We conducted a retrospective analysis of clinical and pathologic features of 20 cases of DHL seen at our institution during a 5-year period. In addition, we carried out case-control comparisons of DHL with BL and International Prognostic Index (IPI)-matched DLBCL. The 11 men and 9 women had a median age of 63.5 years (range 32 to 91). Six patients had a history of grade 1 to 2 follicular lymphoma; review of the prior biopsy specimens in 2 of 5 cases revealed blastoid morphology. Eighteen patients had Ann Arbor stage 3 or 4 disease and all had elevated serum lactate dehydrogenase (LDH) levels at presentation. Extranodal disease was present in 17/20 (85%), bone marrow involvement in 10/17 (59%) and central nervous system (CNS) disease in 5/11 (45%). Nineteen patients were treated with combination chemotherapy, of whom 18 received rituximab and 14 received CNS-directed therapy. Fourteen patients (70%) died within 8 months of diagnosis. Median overall survival in the DHL group (4.5 mo) was inferior to both BL (P=0.002) and IPI-matched DLBCL (P=0.04) control patients. Twelve DHL cases (60%) were classified as B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and BL, 7 cases (35%) as DLBCL, not otherwise specified, and 1 case as B-LBL. Distinguishing features from BL included expression of Bcl2 (P<0.0001), Mum1/IRF4 (P=0.006), Ki-67 <95% (P<0.0001), and absence of EBV-EBER (P=0.006). DHL commonly contained the t(8;22) rather than the t(8;14) seen in most BL controls (P=0.001), and exhibited a higher number of chromosomal aberrations (P=0.0009). DHL is a high-grade B-cell neoplasm with a poor prognosis, resistance to multiagent chemotherapy, and clinical and pathologic features distinct from other high-grade B-cell neoplasms. Familiarity with the morphologic and immunophenotypic spectrum of DHL is important in directing testing to detect concurrent IGH-BCL2 and MYC rearrangements when a karyotype is unavailable. The aggressive clinical behavior and combination of genetic abnormalities seen in these cases may warrant categorization as a separate entity in future classifications and call for novel therapeutic approaches.
authors.affiliation: Department of Pathology, James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Matija
authors.initials: M
authors.lastname: Snuderl
authors.forename: Olga K
authors.initials: OK
authors.lastname: Kolman
authors.forename: Yi-Bin
authors.initials: YB
authors.lastname: Chen
authors.forename: Jessie J
authors.initials: JJ
authors.lastname: Hsu
authors.forename: Adam M
authors.initials: AM
authors.lastname: Ackerman
authors.forename: Paola
authors.initials: P
authors.lastname: Dal Cin
authors.forename: Judith A
authors.initials: JA
authors.lastname: Ferry
authors.forename: Nancy Lee
authors.initials: NL
authors.lastname: Harris
authors.forename: Robert P
authors.initials: RP
authors.lastname: Hasserjian
authors.forename: Lawrence R
authors.initials: LR
authors.lastname: Zukerberg
authors.forename: Jeremy S
authors.initials: JS
authors.lastname: Abramson
authors.forename: Ephraim P
authors.initials: EP
authors.lastname: Hochberg
authors.forename: Hang
authors.initials: H
authors.lastname: Lee
authors.forename: Alfred I
authors.initials: AI
authors.lastname: Lee
authors.forename: Christiana E
authors.initials: CE
authors.lastname: Toomey
authors.forename: Aliyah R
authors.initials: AR
authors.lastname: Sohani
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols; D002051:Burkitt Lymphoma / Q000145:classification / Q000235:genetics* / Q000401:mortality / Q000473:pathology / Q000628:therapy; D002648:Child; D019008:Drug Resistance, Neoplasm; D005260:Female; D015972:Gene Expression Regulation, Neoplastic; D015326:Gene Rearrangement, B-Lymphocyte, Heavy Chain; D050438:Genes, Immunoglobulin Heavy Chain; D006801:Humans; D016130:Immunophenotyping; D017404:In Situ Hybridization, Fluorescence; D053208:Kaplan-Meier Estimate; D007621:Karyotyping; D016393:Lymphoma, B-Cell / Q000145:classification / Q000235:genetics* / Q000401:mortality / Q000473:pathology / Q000628:therapy; D016403:Lymphoma, Large B-Cell, Diffuse / Q000145:classification / Q000235:genetics* / Q000401:mortality / Q000473:pathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016133:Polymerase Chain Reaction; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D019253:Proto-Oncogene Proteins c-bcl-2 / Q000235:genetics*; D016271:Proto-Oncogene Proteins c-myc / Q000235:genetics*; D012189:Retrospective Studies; D018570:Risk Assessment; D009626:Terminology as Topic; D013997:Time Factors; D016896:Treatment Outcome; D014944:World Health Organization; D055815:Young Adult
chemical_list: C489427:MYC protein, human; D019253:Proto-Oncogene Proteins c-bcl-2; D016271:Proto-Oncogene Proteins c-myc