"Tumor-Associated Macrophages and Survival in Classic Hodgkin's Lymphoma".

Christian Steidl, M.D., Tang Lee, M.Sc., Sohrab P. Shah, Ph.D., Pedro Farinha, M.D., Guangming Han, M.D., Tarun Nayar, M.Sc., Allen Delaney, Ph.D., Steven J. Jones, Ph.D., Javeed Iqbal, Ph.D., Dennis D. Weisenburger, M.D., Martin A. Bast, B.S., Andreas Rosenwald, M.D., Hans-Konrad Muller-Hermelink, M.D., Lisa M. Rimsza, M.D., Elias Campo, M.D., Ph.D., Jan Delabie, M.D., Ph.D., Rita M. Braziel, M.D., James R. Cook, M.D., Ray R. Tubbs, D.O., Elaine S. Jaffe, M.D., Georg Lenz, M.D., Joseph M. Connors, M.D., Louis M. Staudt, M.D., Ph.D., Wing C. Chan, M.D., and Randy D. Gascoyne, M.D.

The authors' affiliations:

ABSTRACT

Background:
Despite advances in treatments for Hodgkin's lymphoma, about 20% of patients still die from progressive disease. Current prognostic models predict the outcome of treatment with imperfect accuracy, and clinically relevant biomarkers have not been established to improve on the International Prognostic Score.

Methods:
Using gene-expression profiling, we analyzed 130 frozen samples obtained from patients with classic Hodgkin's lymphoma during diagnostic lymph-node biopsy to determine which cellular signatures were correlated with treatment outcome. We confirmed our findings in an independent cohort of 166 patients, using immunohistochemical analysis.

Results:
Gene-expression profiling identified a gene signature of tumor-associated macrophages that was significantly associated with primary treatment failure (P=0.02). In an independent cohort of patients, we found that an increased number of CD68+ macrophages was correlated with a shortened progression-free survival (P=0.03) and with an increased likelihood of relapse after autologous hematopoietic stem-cell transplantation (P=0.008), resulting in shortened disease-specific survival (P=0.003). In multivariate analysis, this adverse prognostic factor outperformed the International Prognostic Score for disease-specific survival (P=0.003 vs. P=0.03). The absence of an elevated number of CD68+ cells in patients with limited-stage disease defined a subgroup of patients with a long-term disease-specific survival of 100% with the use of current treatment strategies.

Conclusions:
An increased number of tumor-associated macrophages was strongly associated with shortened survival in patients with classic Hodgkin's lymphoma and provides a new biomarker for risk stratification.

Supplementary Appendix:

http://content.nejm.org/cgi/data/362/10/875/DC1/1
 

Address reprint requests to Dr. Gascoyne at the Department of Pathology and Advanced Therapeutics, British Columbia Cancer Agency, 675 W. 10th Ave., Rm. 5-113, Vancouver, BC V5Z 1L3, Canada, or at rgascoyn@bccancer.bc.ca

This article has been cited by other articles:

DeVita, V. T. Jr., Costa, J. (2010). Toward a Personalized Treatment of Hodgkin's Disease. NEJM 362: 942-943 [Full Text]

(2010). Predicting Cure in Patients with Hodgkin Lymphoma. JWatch Oncology and Hematology 2010: 1-1 [Full Text]

1. Masek MA, Rhoades DJ, and Frenster JH, "In-Vivo Macrophage Interactions with Lymphocytes in Hodgkin's Disease", Proc. Am. Assoc. Cancer Res. 14: 8 (1973).

2. Rowan RA, Masek MA, Thompson JM, and Frenster JH, "Electron Microscopic Localization of Acid Phosphatase Activity within Hodgkin's Disease Lymph Nodes", Proc. Am. Assoc. Cancer Res. 16: 10 (1975).

3. Frenster JH, "Phytohemagglutinin-Activated Autochthonous Lymphocytes for Systemic Immunotherapy of  Human Neoplasms", Ann. N.Y. Acad. Sci. 277: 45-51 (1976).

4. Frenster JH, Papalian MM, Masek MA and Frenster JA, "Electron Microscopic Analysis of Lymph Node Cellular Activity in Hodgkin's Disease", Journal of the National Cancer Institute, Vol. 63, pp. 331-335, Aug. 1979.

5. Frenster JH, "Single-Cell Analysis of DNase I-Sensitive Sites During Neoplastic Cell Differentiation within Hodgkin's Disease Lymph Nodes", Leukemia Reviews International, Rich MA, Editor, Volume 1, pp. 22-23, (Marcel Dekker, Inc. New York/1983).

6. Frenster JH, "Uni-Polar Clustering of Lymphocyte DNA Templates Toward Neoplastic Target Cells within Hodgkin's Disease Lymph Nodes", Proc. Am. Assoc. Cancer Res. vol. 43, p. 1134 (March, 2002).

7. Su C-C, Chiu H-H, Chang C-C, Chen J-C, and Hsu S-M, "CD30 is Involved in Inhibition of T-Cell Proliferation by Hodgkin's Reed-Sternberg Cells", Cancer Research, vol. 64, no. 6, pp. 2148-2152 (March 15, 2004).

8. Chen JJW, Lin Y-C, Yao P-L, Yuan A, Chen H-Y, Shun C-T, Tsai M-F, Chen C-H, Yang P-C, "Tumor-Associated Macrophages: The Double-Edged Sword in Cancer Progression", Journal of Clinical Oncology, vol. 23, no. 5, pp. 953-964 (February 10, 2005).

9. Janz M, Hummel M, Truss M, Wollert-Wulf B, Mathas S, Johrens K, Hagemeier C, Bommert K, Stein H, Dorken B, and Bargou RC, "Classical Hodgkin lymphoma is characterized by high constitutive expression of activating transcription factor 3 (ATF3) which promotes viability of Hodgkin/Reed-Sternberg cells", Blood, vol. 107, no. 6, pp. 2536-2539 (March 15, 2006).

10. Lewis CE, Pollard JW. Distinct role of macrophages in different tumor microenvironments. Cancer Res 2006;66:605-612.

"Toward a Personalized Treatment of Hodgkin's Disease".

Vincent T. DeVita, Jr., M.D., and José Costa, M.D.

From the Yale Cancer Center, Yale School of Medicine, New Haven, CT.

In this issue of the Journal, Steidl et al.1 provide a technically sound and important model for using molecular tools to better predict how various cancers will respond to currently effective treatments. One example of such cancers is Hodgkin's disease, which has been curable in its early stages with radiotherapy and in its advanced stages with combination chemotherapy for almost 40 years. However, until recently, Hodgkin's disease has trailed behind other cancers in the application of molecular analysis because of the rarity of the malignant Reed–Sternberg cell in the lesion and the complex composition of the tumor tissue. Despite an overall cure rate of about 80%, advances in treatment have stagnated for 20 years because we have lacked markers that can reliably predict the response to therapy. As a consequence, overtreatment with both radiotherapy and combination chemotherapy is the rule for most patients with Hodgkin's disease.2

Almost all patients with classic Hodgkin's disease have a remission after initial treatment, but about one third of patients with advanced disease and about 15% of those with early disease have a relapse after treatment. Early relapses in the advanced and localized forms of the disease define a drug-resistant subgroup of Hodgkin's lymphoma that is associated with a poor prognosis through all subsequent treatments.3 This important principle applies to all tumor types in which remission is possible.

If at the time of diagnosis we could identify patients who are destined to have a poor response to treatment, most patients could be spared a combination of therapies or radiotherapy with its attendant long-term toxic effects. Steidl et al. may have provided the necessary tool to do just that.

The key to this study was the availability of fresh-frozen tissue for gene profiling and additional paraffin-fixed material for follow-up immunohistochemical analysis of diagnostic biopsy samples from uniformly treated patients. Using biocomputational tools, the authors discovered a gene signature of tumor-associated macrophages and monocytes that correlated with clinical outcome, and remarkably, they validated the correlation in an independent cohort of patients with a single immunohistochemical marker of normal macrophages, CD68. Despite what appears to be a rather narrow range of immunohistochemical positivity that could be subject to observer error, the correlation between the number of CD68-positive macrophages in the tumor stroma and clinical outcome was strong. This work by Steidl et al. is a clear example of moving from a high-density data set to a single biomarker with promising clinical use.

In this study, all patients with limited disease in which the diagnostic biopsy was minimally positive for CD68 were alive and free of disease at the time of the report. The association between CD68 positivity and the rate of disease-specific death was strong in all subgroups. In patients with advanced disease, the correlation between the number of macrophages in the stroma and progression-free survival was statistically significant. Missing, however, are similar correlations between CD68-positive macrophages and relapse-free survival, which is a more reliable indicator of curability than progression-free survival.

The Reed–Sternberg cell is a crippled, preapoptotic, germinal center B cell that has lost its B-cell phenotype.4 It is unique among lymphoma cells in that it constitutively activates important signaling pathways, including those involving JAK–STAT, receptor tyrosine kinase, and nuclear factor-B.5,6 Moreover, this malignant cell appears to depend on signaling from the surrounding normal cells for its survival. The Reed–Sternberg cell also secretes numerous cytokines, including granulocyte–macrophage colony-stimulating factor, which may attract an assemblage of inflammatory cells to involved lymph nodes. For this reason, the Reed–Sternberg cell has been called the master regulator of the inflammatory response in the lymphoid tissue of Hodgkin's disease.4, 6

It was once thought that macrophages, which occur in many kinds of tumors, are a manifestation of an immune response against the tumor. Most of the evidence, however, now links the presence of tumor-associated macrophages with a poor prognosis.7 Termed trophic macrophages by Pollard 8 and Mantovani et al., 9 tumor-associated macrophages and the macrophages that are associated with cell migration in the embryo appear to have similar functions.10 Like embryonic macrophages, tumor-associated macrophages mediate blood-vessel formation by regulating the angiogenic switch through the secretion of vascular endothelial growth factor and hypoxia-inducing factor.11

The migration of macrophages to tumors appears to be a late event in Hodgkin's disease. It is not very difficult to imagine how an abundance of trophic macrophages can lead to tumor progression in light of the cytokine-rich microenvironment of the Reed–Sternberg cell. It is more difficult, however, to explain the association between the number of tumor-associated macrophages and a poor response to treatment, unless their abundance signals the deregulation of a critical pathway to apoptosis in Reed–Sternberg cells that inhibits cell death in response to cytotoxic agents.

Nonetheless, the data provided by Steidl et al. appear to be the breakthrough we have been looking for by enabling the selection of patients with a particularly poor prognosis (regardless of stage) for aggressive treatment, which can bring more logic to the treatment of this curable cancer.

Financial and other disclosures provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the Yale Cancer Center, Yale School of Medicine, New Haven, CT.

References

Steidl C, Lee T, Shah SP, et al. Tumor-associated macrophages and survival in classic Hodgkin's lymphoma. N Engl J Med 2010;362:875-885. [Free Full Text]

DeVita VT. A selective history of the therapy of Hodgkin's disease. Br J Haematol 2003;122:718-727. [CrossRef][Web of Science][Medline]

Fisher RI, DeVita VT, Hubbard SM, Simon R, Young RC. Prolonged disease-free survival in Hodgkin's disease with MOPP reinduction after first relapse. Ann Intern Med 1979;90:761-763. [Free Full Text]

Küppers R. The biology of Hodgkin's lymphoma. Nat Rev Cancer 2009;9:15-27. [CrossRef][Web of Science][Medline]

Aldinucci D, Lorenzon D, Cattaruzza L, et al. Expression of CCR5 receptors on Reed-Sternberg cells and Hodgkin lymphoma cell lines: involvement of CCL5/Rantes in tumor cell growth and microenvironmental interactions. Int J Cancer 2008;122:769-776. [CrossRef][Web of Science][Medline]

Emmerich F, Meiser M, Hummel M, et al. Overexpression of I Kappa B alpha without inhibition of NF-kappaB activity and mutations in the I kappa B alpha gene in Reed-Sternberg cells. Blood 1999;94:3129-3134. [Free Full Text]

Lewis CE, Pollard JW. Distinct role of macrophages in different tumor microenvironments. Cancer Res 2006;66:605-612. [Free Full Text]

Pollard JW. Trophic macrophages in development and disease. Nat Rev Immunol 2009;9:259-270. [CrossRef][Web of Science][Medline]

Mantovani A, Bottazzi B, Colotta R, Sozzani S, Ruco L. The origin and function of tumor-associated macrophages. Immunol Today 1992;13:265-270. [CrossRef][Web of Science][Medline]

Mantovani A, Schioppa T, Porta C, Allavena P, Sica A. Role of tumor-associated macrophages in tumor progression and invasion. Cancer Metastasis Rev 2006;25:315-322. [CrossRef][Web of Science][Medline]

Lin EY, Pollard JW. Tumor-associated macrophages press the angiogenic switch in breast cancer. Cancer Res 2007;67:5064-5066. [Free Full Text]

1. Each cell retains all of its embryonic genes for a lifetime.

2. Controls for embryonic genes are often absent in adults.

3. Uncontrolled embryonic genes can replicate wildly.

4.  Replicating genes participate in  intra-cellular competition.

5.  The basis for gene competition is selective transcription.

6.  MicroRNAs can reprogram embryomic transcription.

7.  Gene reprogramming can produce normal phenotypes.

8.  Normal phenotypes can by-pass chromosomal lesions.

9.  MicroRNA therapy may need to be permanent.

10. Transplantation of microRNAs could be preferred.

http://www.embryomas.net/

1. Pathways within cell genomes involve a flow of information.

2. Information can flow by direct contact or by third parties.

3. Direct contact within whole genomes is difficult to regulate.

4. DNA-DNA direct contects are influenced by agents.

5. Nuclear agents include hydrophilic ionic and hydrophobic conforming ligands.

6. Third parties within genomes involve RNAs and proteins.

7.  RNAs and proteins are easy to regulate or reverse.

8.  Information can be shared, lost, or transformed.

9. System information can be hidden during system isolation.

10.  Local information can be permanently lost during system entropy.

http://www.embryomas.net/

Links to Current Research in Euchromatin:
Links to Euchromatin Activator RNA Reviews:
Links to Euchromatin Activator RNA Research:
Links to Ultrastructural Probes of DNase I-Sensitive Sites:
Links to RNA as a Therapeutic Agent:
Links to Hodgkin Lymphoma Immuno-Pathology:
Links to Activated T-Lymphocyte Immunotherapy:
Links to Medical Systems Biology:
Links to Selective Gene Transcription:
Links to RNA-Induced Epigenetics:
Links to RNA-Induced Embryogenesis:
Links to RNA and Biological Causality:
Links to Reprogramming and Neoplasia:

A Brief History of Activator RNA:

"Ultrastructural Probes of Active DNA Sites, and the RNA Activators of DNA".
(PowerPoint Presentation).

Top of Page - Euchromatin Network -  Euchromatin Research -  Research in Quantitative Radiology

For Further Information and Feedback:

Jeannette A. Hovsepian, M.D.
E-mail: frensasc@ix.netcom.com
Phone:  +1 650 367 6483