title: Expression of FOXP3, CD68, and CD20 at diagnosis in the microenvironment of classical Hodgkin lymphoma is predictive of outcome.
abstract: OBJECTIVE
  The immune microenvironment is key to the pathophysiology of classical Hodgkin lymphoma (CHL). Twenty percent of patients experience failure of their initial treatment, and others receive excessively toxic treatment. Prognostic scores and biomarkers have yet to influence outcomes significantly. Previous biomarker studies have been limited by the extent of tissue analyzed, statistical inconsistencies, and failure to validate findings. We aimed to overcome these limitations by validating recently identified microenvironment biomarkers (CD68, FOXP3, and CD20) in a new patient cohort with a greater extent of tissue and by using rigorous statistical methodology.
  
  
  METHODS
  Diagnostic tissue from 122 patients with CHL was microarrayed and stained, and positive cells were counted across 10 to 20 high-powered fields per patient by using an automated system. Two statistical analyses were performed: a categorical analysis with test/validation set-defined cut points and Kaplan-Meier estimated outcome measures of 5-year overall survival (OS), disease-specific survival (DSS), and freedom from first-line treatment failure (FFTF) and an independent multivariate analysis of absolute uncategorized counts.
  
  
  RESULTS
  Increased CD20 expression confers superior OS. Increased FOXP3 expression confers superior OS, and increased CD68 confers inferior FFTF and OS. FOXP3 varies independently of CD68 expression and retains significance when analyzed as a continuous variable in multivariate analysis. A simple score combining FOXP3 and CD68 discriminates three groups: FFTF 93%, 62%, and 47% (P < .001), DSS 93%, 82%, and 63% (P = .03), and OS 93%, 82%, and 59% (P = .002).
  
  
  CONCLUSIONS
  We have independently validated CD68, FOXP3, and CD20 as prognostic biomarkers in CHL, and we demonstrate, to the best of our knowledge for the first time, that combining FOXP3 and CD68 may further improve prognostic stratification.
authors.affiliation: Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, United Kingdom. p.greaves@qmul.ac.uk
authors.forename: Paul
authors.initials: P
authors.lastname: Greaves
authors.forename: Andrew
authors.initials: A
authors.lastname: Clear
authors.forename: Rita
authors.initials: R
authors.lastname: Coutinho
authors.forename: Andrew
authors.initials: A
authors.lastname: Wilson
authors.forename: Janet
authors.initials: J
authors.lastname: Matthews
authors.forename: Andrew
authors.initials: A
authors.lastname: Owen
authors.forename: Milensu
authors.initials: M
authors.lastname: Shanyinde
authors.forename: T Andrew
authors.initials: TA
authors.lastname: Lister
authors.forename: Maria
authors.initials: M
authors.lastname: Calaminici
authors.forename: John G
authors.initials: JG
authors.lastname: Gribben
mesh_terms: D015703:Antigens, CD / Q000096:biosynthesis*; D018951:Antigens, CD20 / Q000096:biosynthesis*; D015214:Antigens, Differentiation, Myelomonocytic / Q000096:biosynthesis*; D014408:Biomarkers, Tumor / Q000096:biosynthesis; D005260:Female; D051858:Forkhead Transcription Factors / Q000096:biosynthesis*; D006689:Hodgkin Disease / Q000175:diagnosis / Q000188:drug therapy / Q000378:metabolism* / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016019:Survival Analysis; D016896:Treatment Outcome; D059016:Tumor Microenvironment; D000097382:CD68 Molecule
chemical_list: D015703:Antigens, CD; D018951:Antigens, CD20; D015214:Antigens, Differentiation, Myelomonocytic; D014408:Biomarkers, Tumor; D051858:Forkhead Transcription Factors; C067980:CD68 antigen, human; D000097382:CD68 Molecule; C418974:FOXP3 protein, human