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Clinical Cancer Research 14, 3002, May 15, 2008. Published Online First April 29, 2008;
doi: 10.1158/1078-0432.CCR-07-4946
© 2008 American Association for Cancer Research
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Imaging, Diagnosis, Prognosis

Translocations Involving the Immunoglobulin Heavy Chain Gene Locus Predict Better Survival in Gastric Diffuse Large B-Cell Lymphoma

Shotaro Nakamura1,2, Hongtao Ye1, Chris M. Bacon1, Alison Goatly1, Hongxiang Liu1, Lucy Kerr1, Alison H. Banham5, Berthold Streubel6, Takashi Yao3, Masazumi Tsuneyoshi3, Antonella Savio7, Morishige Takeshita4, Peggy Dartigues8, Agnès Ruskoné-Fourmestraux9, Takayuki Matsumoto2, Mitsuo Iida2 and Ming-Qing Du1

Authors' Affiliations: 1 Division of Molecular Histopathology, Department of Pathology, University of Cambridge, Cambridge, United Kingdom; Departments of 2 Medicine and Clinical Science; 3 Anatomic Pathology, Graduate School of Medical Sciences; and 4 Department of Pathology, School of Medicine, Fukuoka University, Fukuoka, Japan; 5 Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, United Kingdom; 6 Department of Pathology, Medical University of Vienna, Vienna, Austria; 7 Department of Histopathology, Ospedale S. Orsola FBF, Brescia, Italy; and GELD Departments of 8 Pathology and 9 Gastroenterology, AP-HP, Hôpital Saint Antoine, Paris, France

Requests for reprints: Shotaro Nakamura, Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582, Japan. Phone: 81-92-642-5261; Fax: 81-92-642-5273; E-mail: shonaka{at}intmed2.med.kyushu-u.ac.jp.


   Abstract
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Purpose: The pathogenesis and clinical heterogeneity of gastric diffuse large B-cell lymphoma (DLBCL) are poorly understood. We have comprehensively investigated the incidence and clinical significance of lymphoma-associated chromosomal translocations, particularly those involving the immunoglobulin heavy chain (IGH) gene locus, in a large series of gastric DLBCL.

Experimental Design: One hundred forty-one cases of primary gastric DLBCL [58 with mucosa-associated lymphoid tissue (MALT) lymphoma and 83 without MALT lymphoma] were enrolled. Translocations involving BCL6, c-MYC, FOXP1, MALT1, and IGH were investigated using interphase fluorescence in situ hybridization. In positive cases, additional fluorescence in situ hybridization was done with appropriate probes for potential partner genes. Cases were classified into germinal center B-cell–like (GCB) or non-GCB subgroups by immunophenotyping with CD10, BCL6, and MUM1.

Results: Translocations involving IGH were detected in 36 (32%) of 111 cases; their partner genes included BCL6 (n = 10), c-MYC (n = 5), and FOXP1 (n = 3) but remained unknown in the remaining 18 cases. t(14;18)/IGH-BCL2, t(14;18)/IGH-MALT1, and t(1;14)/BCL10-IGH were not detected in any case. t(11;18)/API2-MALT1 was detected in none of the cases, except for one case of DLBCL with MALT lymphoma, which showed positive signals only in MALT lymphoma cells. IGH-involved translocation was associated with younger age but not with any other clinicopathologic factors including GCB or non-GCB immunophenotypes. Cox multivariate analysis revealed that IGH-involved translocation, in addition to younger age and early stage, was an independent prognostic factor for better overall and EFSs.

Conclusion: IGH-involved translocations are frequent in gastric DLBCL and seem to identify cases with favorable prognosis.

Primary gastric lymphoma is the most common extranodal lymphoma (1). Histologically, the majority of gastric lymphoma comprises extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) and diffuse large B-cell lymphoma (DLBCL). In gastric MALT lymphoma, t(11;18)(q21;q21)/API2-MALT1, t(1;14)(p22;q32)/BCL10-IGH, t(14;18)(q32;q21)/IGH-MALT1, and t(3;14)(p14;q32)/FOXP1-IGH have been identified at variable frequencies, and the clinical effect of t(11;18)(q21;q21) is well-characterized (1, 2). In contrast, the molecular pathogenesis of gastric DLBCL is poorly understood, although it is generally believed that many cases arise by transformation of MALT lymphoma.

Across all sites, DLBCL is the most common type of non–Hodgkin lymphoma. Importantly, DLBCL shows marked heterogeneity in morphology, genetics, and clinical features (3). Translocations involving the immunoglobulin heavy chain gene (IGH) locus are frequent in DLBCL and are most commonly t(3;14)(q27;q32), t(14;18)(q32;q21), and t(8;14)(q24;q32), which result in dysregulation of the BCL6, BCL2, and c-MYC proto-oncogenes, respectively (4). In addition, BCL6 is often translocated to nonimmunoglobulin (Ig) gene loci (5). Several studies have suggested the presence of these translocations to be of prognostic value. However, most of these studies were predominantly based on nodal disease, and the incidence and significance of translocations in gastric DLBCL have been examined in only a few small series (6, 7).

Recently, gene expression profiling revealed that DLBCL can be subdivided into prognostically different subsets, the germinal center B-cell–like (GCB) and the activated B-cell–like groups (8, 9). Remarkably, these subsets differ in several genetic features (10). Hans et al. (11) subsequently showed that an immunohistochemical panel of CD10, BCL6, and MUM1 was able to classify DLBCL into GCB and non-GCB subgroups, with prognostic significance equivalent to that of gene expression profiling. However, several studies failed to confirm the prognostic value of this immunophenotyping (12–15). In gastric DLBCL, the prognostic effect of immunophenotyping into GCB/non-GCB subgroups remains unclear.

The aims of this study were to investigate in a large number of well-characterized gastric DLBCL the incidence of chromosome translocations involving the BCL6, c-MYC, FOXP1, MALT1, and IGH loci, and to determine whether such genetic abnormalities and phenotyping into GCB/non-GCB subgroups are of prognostic value.


   Materials and Methods
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Subjects. Patients (141) with primary gastric DLBCL, for whom formalin-fixed paraffin-embedded tissues were available, were retrospectively identified from Japan (n = 122), Italy (n = 12), and France (n = 7). The histologic diagnosis of each case was reviewed according to the criteria by the WHO classification (3). Solid or sheet-like proliferations of transformed blasts were present in each case. When areas of typical MALT lymphoma were observed, a diagnosis of DLBCL with MALT lymphoma was made, regardless of which component was dominant in the material studied (1). Fifty-eight cases were diagnosed as DLBCL with MALT lymphoma and 83 as DLBCL without MALT lymphoma. Some patients were included in previous studies (16–18).

Patients consisted of 84 men and 57 women, ages from 13 to 91 y (mean, 59.5 y). Depth of tumor invasion was determined by histologic examination of the resected specimens or by endosonography (17). Clinical staging was based on the Lugano International Conference classification (19). Helicobacter pylori infection was considered positive if one of any tests for H. pylori including serology and histology showed a positive result. One hundred patients (71%) were initially treated by gastrectomy with (n = 41) or without (n = 59) chemotherapy using a cyclophosphamide-Adriamycin-vincristine-prednisone–based regimen, with (n = 3) or without (n = 56) rituximab. Thirty (21%) patients underwent H. pylori eradication with a proton pump inhibitor (omeprazole, lansoprazole, or rabeprazole) plus a combination of antibiotics (amoxicillin, clarithromycin, and/or metronidazole). Six of the 30 patients underwent eradication therapy alone, whereas 24 nonresponsive patients were subsequently treated by cyclophosphamide-Adriamycin-vincristine-prednisone–based chemotherapy (n = 16) with (n = 2) or without (n = 14) rituximab, radiotherapy (n = 4), or gastrectomy (n = 4). Seven patients (5%) were treated by chemotherapy alone, with (n = 3) or without (n = 4) rituximab, and 1 patient (0.7%) underwent chemotherapy plus radiotherapy. One patient (0.7%) did not receive any treatment. In the remaining 2 patients (1.4%), information regarding treatment was not available.

The clinicopathologic features are summarized in Table 1 . Compared with DLBCL with MALT lymphoma, DLBCL without MALT lymphoma more frequently was of mass-forming type, involved the serosa, and was of advanced stage. Complete remissions (CR) after H. pylori eradication and after all treatments were each less frequent among cases without MALT lymphoma. CR was defined as complete disappearance of clinical and histologic evidence of lymphoma. Other factors were not different between the two groups.


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  		Table 1. Clinical features of DLBCL with and without MALT lymphoma

 
Interphase fluorescence in situ hybridization. Chromosome translocations were investigated by interphase fluorescence in situ hybridization (FISH) on formalin-fixed paraffin-embedded tissues as described previously (20). In each case, the hybridization signals for each probe were evaluated in at least 100 nuclei. The threshold for positivity was the mean percentage of cells with false-positive signals plus 3SD, as assessed on sections of 8 to 10 reactive tonsils (20). Initially, translocations were screened by FISH with dual-color break-apart probes for BCL6, c-MYC, MALT1, IGH (Vysis/Abbott), and FOXP1 (in house; ref. 21). In cases positive for a MALT1 gene break, additional FISH with an API2/MALT1 dual-color dual-fusion translocation probe (Vysis/Abbott) was done, whereas in those positive for an IGH breakage and negative for both BCL6 and c-MYC breakage, further FISH was carried out with dual-color break-apart probes for the BCL2, cyclin (CCN) D1 (Vysis/Abbott), and BCL10 loci (provided by Prof. Reiner Siebert, Institute of Human Genetics, University Hospital Schleswig, Holstern, Kiel, Germany). Cases with both IGH breakage and either c-MYC or FOXP1 breakage were further assessed using c-MYC/IGH (Vysis/Abbott) or FOXP1/IGH (in house) dual-fusion probes, respectively. Numerical changes at chromosome 18q21, 3p14, 3q27, and 8q24 were investigated by FISH with MALT1 and/or BCL2, FOXP1, BCL6, and c-MYC break-apart probes, respectively.

Immunohistochemistry. Immunohistochemical staining was done on formalin-fixed paraffin-embedded tissues by the streptavidin-biotin complex method using mouse monoclonal antibodies. Classification of DLBCL into GCB/non-GCB subgroups was based on the algorithm of Hans et al. (11) using an immunohistochemical panel including CD10 (Novocastra), BCL6, and MUM1 (Dako United Kingdom). Immunohistochemical staining for FOXP1 was carried out using JC12 (22). For each antibody, cases were considered positive if 30% of DLBCL cells showed positive staining, and were excluded if neither tumor cells nor internal control cells were positive.

Prognosis and statistical analysis. Overall survival (OS) was measured from the date of diagnosis to death from any cause. Event-free survival (EFS) was measured from the date of diagnosis to disease progression, relapse, or death from any cause. Probabilities of OS and EFS were calculated by the Kaplan-Meier method, and the value was compared using the log-rank test. All variables with a P value of <0.1 were included in a multivariate analysis using the Cox proportional hazards regression model. Model selection for identifying the subset of significant variables was based on a forward stepwise procedure using the maximum likelihood ratio test. Other differences were evaluated by the Fisher's exact test, the {chi}2 test, or the Mann-Whitney U test. Probabilities of <0.05 were regarded as statistically significant.


   Results
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Incidence of genetic aberrations. Table 2 summarizes the FISH results. FISH with the BCL6 break-apart probe was successful in 82 (58%) of 141 cases. Evidence of BCL6 breakage was detected in 16 (20%) of 82 cases, more frequently in DLBCL with MALT lymphoma (28%) than in DLBCL without MALT lymphoma (12%; P = 0.053). Of the 16 cases positive for BCL6 breakage, 10 cases also showed a breakage of IGH, suggesting the presence of t(3;14)/BCL6-IGH. FISH with the c-MYC break-apart probe was successful in 73 (52%) of 141 cases. Evidence of c-MYC breakage was found in 7 (10%) of 73 cases; the frequency was not different between DLBCLs with MALT lymphoma (9%) and those without MALT lymphoma (10%). An IGH breakage was observed in 5 of the 7 cases with c-MYC breakage, and t(8;14)/c-MYC-IGH was confirmed by FISH with c-MYC/IGH dual-fusion probes in all the 5 cases. FISH with the FOXP1 break-apart probe was successful in 97 (69%) of 141 cases. FOXP1 breakage was observed in 4 (4%) of 97 cases, and t(3;14)/FOXP1-IGH was confirmed in 3 by FISH with FOXP1/IGH dual-fusion probes. Translocations involving BCL6, c-MYC, and FOXP1 were mutually exclusive in this series.


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  		Table 2. Genetic aberrations and immunohistochemical results

 
FISH with the MALT1 break-apart probe was successful in 105 (74%) of 141 cases. No MALT1 breakage was detected in DLBCL cells in any of the cases examined. In one case of DLBCL with MALT lymphoma, however, a MALT1 breakage was found only in MALT lymphoma cells; in this case, the presence of t(11;18)/API2-MALT1 was shown by FISH with the API2-MALT1 dual fusion probe.

FISH with the IGH break-apart probe was successful in 112 (79%) of 141 cases. IGH breakage was found in 36 (32%) of 112 cases; 14 (27%) of 51 DLBCLs with MALT lymphoma, and 22 (36%) of 61 DLBCLs without MALT lymphoma. As described above, the partner gene for IGH was identified in 18 of these 36 cases: BCL6 (n = 10), c-MYC (n = 5), and FOXP1 (n = 3). The partner gene remained unidentified in the remaining 18 cases with IGH breakage; 10 cases showed no evidence of signal-split with dual-color break-apart probes for MALT1, FOXP1, BCL6, c-MYC, BCL2, CCND1, and BCL10, whereas in the other 8 cases, FISH with some of these probes failed to provide adequate signals. IGH-involved translocations with unidentified partner genes were more frequent in DLBCL without MALT lymphoma (14 of 61; 23%) than in DLBCL with MALT lymphoma (4 of 50; 8%; P < 0.05).

The presence of extra copies of BCL2 and/orMALT1, suggesting partial or complete trisomy 18, was detected in 25 (24%) of 106 cases; 29% of DLBCL without MALT lymphoma and 18% of DLBCL with MALT lymphoma. Extra copies of FOXP1 and/or BCL6 suggesting partial or complete trisomy 3 were detected in 21 (21%) of 101 cases, more frequently in DLBCL without MALT lymphoma (32%) than in DLBCL with MALT lymphoma (7%; P < 0.005). Concurrent gain of extra copies of both MALT1/BCL2 and FOXP1/BCL6 was observed in 12 (13%) of 94 cases in which FISH with the corresponding probes was successful; the frequency was significantly higher in DLBCL without MALT lymphoma (10 of 49; 20%) than in those with MALT lymphoma (2 of 45; 4%; P < 0.05). Extra copies of c-MYC suggesting partial or complete trisomy 8 was detected in 7 (10%) of 73 cases, more frequent in DLBCL without MALT lymphoma (15%) than in DLBCL with MALT lymphoma (3%). In 37 (32%) of 114 cases, at least one of these copy number changes was observed. In total, 67 (55%) of 121 cases had structural or numerical genetic aberrations. Among them, 15 cases had both a translocation and a numerical abnormality. There was no significant difference in the incidence of the genetic aberration studied between cases assigned to GCB or non-GCB subgroups (see below).

Immunohistochemical results. Reliable evaluation of CD10, BCL6, and MUM1 immunostaining was possible in all 141 cases (Table 2). Expression of CD10, BCL6, and MUM1 by DLBCL cells was observed in 56 (40%), 74 (52%), and 82 (58%) cases, respectively. Using the algorithm of Hans et al. (11), 72 (51%) cases were classified as GCB and 69 (49%) as non-GCB phenotypes. MUM1 was expressed by 23 (32%) of GCB cases, all of which expressed CD10. No difference in the expression of CD10, BCL6, MUM1, or in classification into GCB/non-GCB subgroups was observed between DLBCL cases with MALT lymphoma and those without MALT lymphoma. Immunostaining for FOXP1 was successful in 82 cases. DLBCL cells showed positive nuclear expression of FOXP1 (in at least 30% DLBCL cells) in 31 (38%) of 82 cases. Expression of FOXP1 was more frequent in DLBCL with MALT lymphoma (53%) than DLBCL without MALT lymphoma (29%; P < 0.05).

Translocations involving IGH predict better survival in gastric DLBCL. Follow-up data were available for 138 patients: the period after diagnosis ranged from 1 to 247 months (mean, 66 months). The OS and EFS after 5 years were 76% and 68%, respectively. Table 3 summarizes the results of the univariate analysis of prognostic variables. Patients of younger age showed significantly better OS and EFS (both, P < 0.001). Deep invasion of the gastric wall was significantly associated with worse OS (P < 0.05), but it did not correlate with EFS. Cases with early stage showed significantly better OS (P < 0.005) and EFS (P < 0.05). Cases with IGH translocations showed significantly better OS (P < 0.01) and EFS (P < 0.05) than those without IGH translocations (Fig. 1 ). Other factors, including histologic type; translocations involving BCL6, c-MYC, or FOXP1; extra copies of MALT1/BCL2 or FOXP1/BCL6; immunoexpression of CD10, BCL6, MUM1, FOXP1, and classification into GCB/non-GCB phenotypes did not affect OS or EFS. In addition, neither OS nor EFS differed between patients treated with chemotherapy and those without chemotherapy. We also analyzed the above variables separately in the groups of DLBCL with and without MALT lymphoma. The number of cases of DLBCL with MALT lymphoma is small and proved insufficient for such analysis. The subset of DLBCL without MALT lymphoma showed very similar results to those of all cases combined, with the sole additional finding that BCL6 protein expression was associated with better OS (P < 0.05).


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  		Table 3. Results of univariate analysis for prognosis evaluated by the Kaplan-Meier method

 

Figure 1
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  		Fig. 1. Survival curves of patients with gastric DLBCL with (solid line; n = 35) and without (dotted line; n = 74) IGH-involved translocation. A, OS (P = 0.007). B, EFS (P = 0.025).

 
Multivariate analysis revealed that younger age, early stage, and translocations involving IGH were significant independent prognostic factors for both better OS and better EFS (Table 4 ).


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  		Table 4. Independent prognostic factors determined by multivariate analysis

 
Relationship between IGH-involved translocation and clinicopathologic and immunohistochemical features. Table 5 compares the clinicopathologic and immunohistochemical findings of cases with and without IGH-involved translocations. Patients with IGH-involved translocations were younger than those without the translocation (P < 0.05). Translocations involving BCL6 or c-MYC were more frequently observed in cases with IGH-involved translocations than in those without IGH-translocations (both, P < 0.05). Cases with IGH-involved translocations tended to be of more advanced stage than those without IGH-involved translocations (P < 0.1). No differences were observed in the other factors studied including GCB/non-GCB phenotypes.


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  		Table 5. Relationship between IGH-involved translocation and clinicopathologic and immunohistochemical features

 

   Discussion
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In our study, translocations involving BCL6 and c-MYC were detected in 20% and 10% of cases, respectively, similar to results from series of DLBCL published previously (4, 14, 23–29). The prognostic effect of these translocations in DLBCL is controversial. The BCL6 translocation has been associated with favorable outcome (23), poor survival (26, 27), or no effect (4, 7, 24, 25), whereas c-MYC translocations have been associated with a poor prognosis in some studies (25, 28) but not all (4). In gastric DLBCL, Chen et al. (7) found no prognostic effect for BCL6 translocation, whereas c-MYC translocations were associated with low stage and better outcome in one study (4) but with aggressive disease in another (28). Such differences are probably due to the small numbers of translocation-positive cases identified, the different patient populations studied, and their heterogeneous treatments. In our study, neither OS nor EFS was influenced by BCL6 or c-MYC–involved translocations. The fact that most cases (20 of 23; 87%) with BCL6 or c-MYC–translocations in our study had stage I/II disease might be associated with their relatively good clinical course.

FOXP1-involved translocations have been detected in a small proportion of MALT lymphomas and extranodal DLBCL (21, 30, 31). In cases of gastric MALT lymphoma without DLBCL, this translocation has been rarely observed (21, 30, 32). In the present study, we detected FOXP1-translocations predominantly in DLBCL with MALT lymphoma (7%) rather than in DLBCL without MALT lymphoma (2%). In addition, overexpression of FOXP1 protein was more frequent in DLBCL with MALT lymphoma than DLBCL without MALT lymphoma. These and other observations suggest that FOXP1 expression and/or FOXP1 translocations may be associated with the transformation of gastric MALT lymphoma to DLBCL (33). Although several studies have shown that overexpression of FOXP1 is associated with inferior survival in DLBCL and MALT lymphoma (23, 33, 34), such an association was not found in our present study. In one study (34), the poor prognostic effect of FOXP1 expression in DLBCL was seen only in cases with strong diffuse FOXP1 staining. Analysis of our data using similar criteria did not reveal an effect on outcome (data not shown).

t(11;18)/API2-MALT1, specific for MALT lymphoma, has been rarely found in cases of gastric DLBCL with or without MALT lymphoma (35, 36). We detected t(11;18)/API2-MALT1 only in MALT lymphoma cells in one case of DLBCL with MALT lymphoma. In this case, the translocation signals were not observed in DLBCL cells. Chuang et al. (36) described two cases of gastric DLBCL with MALT lymphoma with t(11;18)/API2-MALT1; in one of the cases, the translocation was detected only in the MALT lymphoma, as seen in our present case. In such cases, DLBCL is unlikely to have arisen from the MALT lymphoma, and the two lymphomas are likely to have developed independently. Conversely, the other translocation-positive case in their study showed t(11;18)/API2-MALT1 not only in the MALT lymphoma but also in the DLBCL (36). Remstein et al. (35) described a similar case with t(11;18)/API2-MALT1 in both the original MALT lymphoma and the subsequent DLBCL. In these cases, the DLBCL probably arose by transformation from a preexisting MALT lymphoma. Thus, two different pathways are possible for the development of DLBCL in patients with t(11;18)/API2-MALT1–positive MALT lymphoma.

The incidence of IGH-involved translocations among gastric DLBCL cases has not previously been determined. We identified IGH-involved translocations in 32% of cases of DLBCL with or without MALT lymphoma. In our series, the most frequent partner gene for IGH was BCL6, followed by c-MYC. None of our cases carried t(14;18)/IGH-BCL2, although this translocation has been observed in 4% to 21% of DLBCL at other sites (4, 13, 23, 28, 29). We could not identify the partner genes in 18 of 36 (50%) cases with an IGH-involved translocation. Ten of these 18 cases were negative by FISH for most known major partner genes. In such cases, IGH-involved translocations may involve rare partner genes such as CCND3 (37) or PAX5 (38), or others as yet undiscovered.

Extra copies of MALT1/BCL2, FOXP1/BCL6, and c-MYC genes, most likely reflecting partial or complete trisomies 18, 3, and 8, were identified in 24%, 21%, and 10% of cases, respectively. Aneuploidy, most commonly trisomy 18 and trisomy 3 or both, is frequently observed in DLBCL and t(11;18)/API2-MALT1–negative MALT lymphomas, and several authors suggested that these numerical gains are associated with transformation of MALT lymphoma to DLBCL (35). Our recent study revealed that the presence of extra copies of MALT1 was associated with worse EFS in gastric MALT lymphoma (32). Another study showed that the presence of extra copies of MALT1 was associated with worse disease-specific survival in gastrointestinal DLBCL (39). In our current study, however, extra copies of MALT1/BCL2, FOXP1/BCL6, or c-MYC failed to influence OS or EFS in gastric DLBCL.

The prognostic effect of immunophenotyping of DLBCL into GCB/non-GCB subgroups has been controversial. Although a number of publications have shown its usefulness for predicting OS (7, 11, 29, 40), the significance of this subclassification has only been proven by multivariate analysis in two studies (11, 29). Most of these studies were dominated by patients with nodal disease and included 50% to 100% of cases with Ann-Arbor stage III/IV disease. In contrast, several other studies showed that this phenotyping did not correlate with prognosis (12–14). These differences may reflect differences in both the patient populations under investigation and their treatments (14, 15). The incomplete concordance between the immunophenotyping and gene expression-based subclassification (70-80%) might be another reason for such variation (11). Several studies have reported that expression of single antigens, such as CD10 (12, 29, 40–42) or BCL2 (12, 40, 42) proteins, may also be useful for predicting the favorable or unfavorable survival of patients with DLBCL. It is unclear how these studies apply to the assessment of gastric DLBCL, which shows much better prognosis than nodal disease, perhaps because most cases are of early stage (I/II). In gastric DLBCL, only three studies have shown the prognostic value of immunoexpression of CD10 (41, 42), BCL6 (7, 41), or GCB/non-GCB phenotyping (7) in a relatively small number of cases. In our large study, classification of all cases by GCB/non-GCB subgroup or by expression of CD10, BCL6, or MUM1 did not correlate with OS or EFS. However, the fact that our series comprised a mix of de novo and transformed cases might have affected the interpretation of these data.

The most striking finding in the present study was that a translocation involving IGH was an independent prognostic factor for better OS and EFS in gastric DLBCL. Although patients with an IGH translocation were, on average, of a younger age, multivariate analysis revealed these two factors to be independent. The mechanism for the beneficial prognostic effect of IGH translocations remains obscure, particularly given the range of translocation partners recognized for IGH. Nevertheless, there is precedence for such an effect; Akasaka et al. (27) reported that fusion of BCL6 and non-Ig genes resulted in a worse prognosis than BCL6-Ig (IGH, Ig {kappa}, or {lambda}) fusions. In our study, 17 of 18 cases with translocations involving IGH and either BCL6, c-MYC, or FOXP1 were alive at the last time of follow-up, but the remaining 18 cases with translocations involving IGH and unknown partners also had favorable clinical course. There were too few cases with each translocation partner for the prognostic effect of each to be analyzed separately. It is possible that the presence or absence of an IGH translocation is a marker for underlying differences in the cell of origin, differentiation state, or genomic stability of the lymphoma, and that it is these latter differences that are of primary prognostic importance. It is interesting to note that there is a cluster of 41 microRNAs ~5 Mb centromeric to the IGH locus, which may be the target of 14q32 deletions seen recurrently in several B-cell malignancies (43). As microRNA can act as a tumor suppressors, it is pertinent to investigate whether deletion of these microRNAs occur in gastric DLBCL in association with IGH translocation. Whatever the underlying mechanism, we believe that the detection of an IGH-involved translocation, regardless of the partner gene, may be useful for predicting a favorable clinical outcome in patients with gastric DLBCL. However, the present study was retrospective in nature, based on cases accrued over long periods and treated by heterogeneous modalities. Therefore, further prospective studies are needed to confirm whether these translocations indeed influence the prognosis of gastric DLBCL.


   Disclosure of Potential Conflicts of Interest
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A. H. Bantham is the inventor on a patent for the FOXP1 gene.


   Acknowledgments
 
We thank Prof. Reiner Siebert, Institute of Human Genetics, University Hospital Schleswig-Holstein, Kiel, Germany for providing the BCL10 FISH probe; and Dr. A. Paterlini, Dr. G. Viviani, and Dr. B. Kildani, Ospedale S. Orsola FBF, Brescia, Italy for their contribution of clinical follow-up data in some of the cases enrolled in this study.


   Footnotes
 
Grant support: Research grants from Leukaemia Research Fund, United Kingdom and the Wellcom Trust, United Kingdom (M.Q. Du), and a Senior Clinician Scientist Fellowship from The Health Foundation, The Royal College of Pathologists, and The Pathological Society of Great Britain and Ireland (C.M. Bacon).

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received 11/22/07; revised 2/25/08; accepted 2/26/08.


   References
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