title: Molecular classification of tissue from a transformed non-Hogkin's lymphoma case with unexpected long-time remission.
abstract: BACKGROUND
  The concept of precision medicine in cancer includes individual molecular studies to predict clinical outcomes. In the present N = 1 case we retrospectively have analysed lymphoma tissue by exome sequencing and global gene expression in a patient with unexpected long-term remission following relaps. The goals were to phenotype the diagnostic and relapsed lymphoma tissue and evaluate its pattern. Furthermore, to identify mutations available for targeted therapy and expression of genes to predict specific drug effects by resistance gene signatures (REGS) for R-CHOP as described at http://www.hemaclass.org. We expected that such a study could generate therapeutic information and a frame for future individual evaluation of molecular resistance detected at clinical relapse.
  
  
  METHODS
  The patient was diagnosed with a transformed high-grade non-Hodgkin lymphoma stage III and treated with conventional R-CHOP [rituximab (R), cyclophosphamide (C), doxorubicin (H), vincristine (O) and prednisone (P)]. Unfortunately, she suffered from severe toxicity but recovered during the following 6 months' remission until biopsy-verified relapse. The patient refused second-line combination chemotherapy, but accepted 3 months' palliation with R and chlorambucil. Unexpectedly, she obtained continuous complete remission and is at present >9 years after primary diagnosis. Molecular studies and data evaluation by principal component analysis, mutation screening and copy number variations of the primary and relapsed tumor, identified a pattern of branched lymphoma evolution, most likely diverging from an in situ follicular lymphoma. Accordingly, the primary diagnosed transformed lymphoma was classified as a diffuse large B cell lymphoma (DLBCL) of the GCB/centrocytic subtype by "cell of origin BAGS" assignment and R sensitive and C, H, O and P resistant by "drug specific REGS" assignment. The relapsed DLBCL was classified as NC/memory subtype and R, C, H sensitive but O and P resistant.
  
  
  CONCLUSIONS
  Thorough analysis of the tumor DNA and RNA documented a branched evolution of the two clinical diagnosed tFL, most likely transformed from an unknown in situ lymphoma. Classification of the malignant tissue for drug-specific resistance did not explain the unexpected long-term remission and potential cure. However, it is tempting to consider the anti-CD20 immunotherapy as the curative intervention in the two independent tumors of this case.
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Julie Støve
authors.initials: JS
authors.lastname: Bødker
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Marianne Tang
authors.initials: MT
authors.lastname: Severinsen
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Tarec Christoffer
authors.initials: TC
authors.lastname: El-Galaly
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Rasmus Froberg
authors.initials: RF
authors.lastname: Brøndum
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Maria Bach
authors.initials: MB
authors.lastname: Laursen
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Steffen
authors.initials: S
authors.lastname: Falgreen
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Mette
authors.initials: M
authors.lastname: Nyegaard
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Alexander
authors.initials: A
authors.lastname: Schmitz
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Lasse Hjort
authors.initials: LH
authors.lastname: Jakobsen
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Anna Amanda
authors.initials: AA
authors.lastname: Schönherz
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Hanne
authors.initials: H
authors.lastname: Due
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Linn
authors.initials: L
authors.lastname: Reinholdt
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Martin
authors.initials: M
authors.lastname: Bøgsted
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Karen
authors.initials: K
authors.lastname: Dybkær
authors.affiliation: Department of Hematology, Aalborg University Hospital, Aalborg, Denmark ; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Hans Erik
authors.initials: HE
authors.lastname: Johnsen
keywords: Drug resistance prediction; Long-time remission; Molecular classification; Rituximab palliation; Transformed lymphoma