【作者】 周军；

【导师】 马捷； 周晓军；

【作者基本信息】 南京大学 ， 病理与病理生理学， 2013， 硕士

【摘要】 目的：研究胃肠道侵袭性B细胞淋巴瘤的组织学特点、诊断与鉴别诊断,探讨临床病理参数、免疫组织分型与预后的相关性。重点观察c-MYC抗体在胃道侵袭性B细胞淋巴瘤中的表达特点,与临床预后的关系及预测其基因易位的价值和现实意义。方法：回顾性收集南京军区南京总医院2000年-2011年具有完整临床及病理资料的胃肠道侵袭性B细胞淋巴瘤共54例,包括弥漫大B细胞性淋巴瘤(DLBCL)49例,特征介于DLBCL和BL之间不能分类型的B细胞淋巴瘤(DLBCL/BL)4例、伯基特淋巴细瘤(BL)1例。复习临床病理资料及病理切片并随访。免疫组织化学染色采用En Vision法,应用免疫指标CD10、Bcl-6、Mum-1、CD5对49例DLBCL进行分型；同时使用c-MYC、Tcl-1、CD38评估54例淋巴瘤c-myc基因状态,并选择8例胃肠道外BL作为对照；其余抗体包括CD20、CD79α、 CD5、CD3、CD43、Bcl-2、CD4、CD30、Ki-67。运用SPSS16.0分析软件,采用χ2检验或Fisher精确概率法检验相关免疫指标与临床病理参数及预后的关系,Kaplan-Meier法进行单因素生存分析,并使用log-rank法进行检验,Cox模型运用正向逐步回法进行多因素分析。对免疫组化c-MYC阳性的病例及8例胃肠道外BL进行FISH检测,运用c-myc基因断裂重组探针检测c-myc的基因状态,运用ROC曲线检验免疫组化法检测c-myc易位的准确性。进一步对c-MYC阳性和BCL-2强阳性(+++)的病例进行FISH检测bcl-2的基因状态。结果：(1)临床资料：54例胃肠道侵袭性B细胞淋巴瘤患者,男性33例,女性21例,平均年龄52岁,中位年龄56岁。包括胃DLBCL12例,DLBCL/BL1例；肠道DLBCL35例,DLBCL/BL3例,BL1例；胃和肠同时受累DLBCL2例。临床症状主要表现为胃肠道占位,可出现腹部不适或疼痛,伴或不伴有发热、盗汗、体重下降等消耗性症状,部分病人因肠穿孔等急腹症收治入院。(2)随访资料：54例患者均获得随访结果,随访时间2-150个月(中位随访时间45个月)。治疗以CHOP方案为主,部分病人加用靶向治疗药物美罗华。54例中有11例(DLBCL9例,DLBCL/BL1例,BLl例)在97个月内死亡,中位生存期为42个月,其余病人病情相对稳定。(3)组织学特点：54例肿瘤瘤细胞弥漫浸润肠壁全层,以中心母细胞、免疫母细胞为主,伴有或不伴有浆样分化；部分病例瘤细胞呈巨核或多分叶核。其中17例出现明显的巨噬细胞吞噬核碎片,即“星空”现象。间质可出现纤维性硬化及血管增生。(4)免疫组织化学：54例包括11例GCB型DLBCL、38例ABC型DLBCL、4例DLBCL/BL(CD20、CD10、Bcl-6、Bcl-2阳性)、1例BL(CD20、CD10、Bcl-6阳性、Bcl-2阴性)。7例DLBCL瘤细胞CD5阳性。19例c-MYC抗体阳性包括14例DLBCL、4例DLBCL/BL、1例BL。所有病例CD30阴性,除反应性的B或T淋巴细胞阳性外,CD4、CD20、CD79Q均阴性。Ki67指数40-100%,中位值为80%。(5)FISH检测显示1例DLBCL、2例DLBCL/BL、1例BL及8例胃肠道外BL存在c-myc易位,其c-MYC抗体染色均阳性,阳性百分数为80-100%;对4例c-myc异位及免疫组化Bcl-2阳性率>50%的病例进行FISH检测显示仅1例出现bcl-2／IgH融合。(6)统计分析：χ2检验(或Fisher精确概率法)显示c-MYC抗体阳性与核碎裂及“星空”现象、免疫指标Tcl-1、Ki-67指数之间存在显著性差异(P<0.05)；相关性分析显示c-MYC阳性百分数与Ki-67阳性百分数直线相关(P=-0.001)；Kaplan-Meier单因素生存分析显示B症状、高血清乳酸脱氢酶(LDH)值、差的行为状态(高ECGO评分)、远处转移、高IPI指数、高临床分期是影响病人生存率的不利病理参数,CD5阳性的DLBCL患者预后不良,Log-rank分析具有显著性差异(P<0.05)。COX多因素分析显示c-myc易位、远处转移、高LDH是影响生存率的独立不良预后因素。ROC曲线显示c-MYC抗体阳性百分数有助于预测c-myc基因状态,最佳阈值为75%。结论：(1)DLBCL、DLBCL/BL、BL是一组侵袭性的成熟B细胞淋巴瘤,胃肠道是其结外最常发生的部位之一。它们的诊断需结合临床资料及免疫组化,并排除其胃肠道的恶性圆细胞肿瘤综合判断。(2)患者预后受多方面临床病理因素影响,包括B症状、LDH值、行为状态、远处转移、IPI指数、临床分期、免疫表型CD5及c-myc基因状态等等。(3)DLBCL(多为GCB型)、DLBCL/BL可出现c-myc易位。该类病例组织学上常表现为“伯基特样”或“非典型伯基特”形态,即明显的核碎裂及“星空”现象,但瘤细胞及其胞核大小、形态更具异型,缺乏一致性。Ki-67常常极高表达,甚至接近100%。c-myc易位是影响病人预后的独立影响因素,其检测对于病人的治疗和预后的判断均有重要意义。(4)较高的C-MYC抗体染色阳性百分数,并联合Tcl-1、CD38等抗体有助于预测c-myc易位,可以为临床预测其易位和初筛的提供廉价、快捷的潜在检测方法,但能否普及,仍需更多的实验病例确证。Bcl-2抗体阳性的病例并非均伴有bcl-2基因的易位,但对于强阳性的患者,实际工作中仍应建议作bcl-2基因检测。更多还原

【Abstract】 Objective:To study the histological features, diagnosis, differential diagnosis and investigate the correlation between prognosis and clinicopathological parameters or immunophenotyping of the aggressive B cell lymphoma in gastrointestinal tact. And obversation was focused on the antibody against c-MYC with regard to its expression characteristic and influence in the prognosis and the value and practical significance in predicting the status of c-myc gene.Methods:54cases of aggressive B cell lymphomas in gastrointestinal tract with complete clinical and pathologic information were retrospectively collected including49cases of DLBCL,4cases of DLBCL/BL,1cases of BL. All the cases were reviewed and followed up. Then immunophenotyping for the49cases of DLBCL was detected by the antibodies CD10, Bcl-6, Mum-1and CD5using En Vision method. Meanwhile, the c-myc status was estimated in contrast with8cases of BL outside gastrointestinal tract. Other detection antibodies included CD20, CD79a, CD5, CD3, CD43, Bcl-2, CD4, CD30, Ki-67. Using chi-square test or Fisher’s exact probabilities investigated the correlation between the immune markers and clinicopathological parameters or prognosis, Kaplan-Meier explored the considerable factors of prognosis by univariate analysis, and Cox Regression studied the independent negative factors of prognosis by means of SPSS16.0analysis software.FISH were applied to examine the c-myc status in the54cases and8cases of BL outside gastrointestinal tract as control by virtue of c-myc dual-color break-apart commercial probe, and furthermore, ROC curves confirmed the accuracy to take advantage of c-MYC immunostaining. In addition, cases positive for c-MYC and strongly positive for Bcl-2immuochemistry were detected their bcl-2status.Results:(1) Clinical data54cases aggressive B cell lymphomas in gastrointestinal tract were comprised of33males and21females with average age52and median age56, including12cases of DLBCL,1case of DLBCL/BL in stomach,35cases of DLBCL,3cases of DLBCL/BL,1case of BL in intestinal tract, and2cases of DLBCL in both. Patients often presented with gastrointestinal masses emerging the symptom of abdominal discomfort or pain, sometimes coupled with constitutional symptoms such as fever, night sweating and cachexia. A share of the patients were hospitalized due to an acute abdomen as gastrointestinal perforation.(2) Follow-up data All the follow-up data of the54cases were acquired, with the duration ranging from2～150months(median follow-up time45months). Patients were mainly treated by CHOP regimen, part of which added rituximab.11(9DLBCL,1DLBCL/BL,1BL) out of54patients had died within97months, with median survival time42months, and others had been undergoing a relatively stable situation.(3) Histologic characteristics Lymphoma cells, mainly composed of centroblasts and centrocytes with or without plasmocytoid differentiation and multinucleated gaint cells, showed full-thickness infiltration of the gastrointestinal wall.17cases presented evident phagocytosis of karyorrhexis by macrophages("starry sky"). Interstitial fibrosis and vessel growth sometimes would be encountered.(4) Immunohistochemisty characteristics54cases consisted of11cases of GCB DLBCL,38cases of ABC DLBCL,4cases of DLBCL/BL(positive for CD20, CD10, Bcl-6, Bcl-2),1case of BL(positive for CD20, CD10, Bcl-6but Bcl-2). The tumor cells of7cases of DLBCL expressed CD5.19cases were positive for c-MYC including14cases of DLBCL,4cases of DLBCL/BL,1cases of BL. All the cases were negative for CD30, and also for CD4, CD3except positive for some reactive lymphoma cells. And proliferation index Ki-67was40-100%, median80%.(5) FISH detection results1case of DLBCL,2cases of DLBCL/BL,1case of BL and8BL outside gastrointestinal tract as control emerged c-myc translocation, all of which were positive for c-MYC by immunostaining, with percentage of positive cells varying from80%to100%. In addition,4c-myc-translocated cases and cases positive for Bcl-2exceeding50%positive cells were detected by FISH, in which1case presented fusion gene bcl-2/IgH. (6) Statistic analysis Chi-square test or Fisher’s exact probabilities showed cases positive for c-MYC and the index as karyorrhexis, Tcl-1, Ki-67had significant differences(P<0.05). Correlation analysis revealed there existed linear correlation between c-MYC percentage of positive cells and Ki-67labeling index. Kaplan-Meier displayed B symptoms, high LDH, high ECGO, distant metastasis, high IPI index and high clinical stage were negative factor for the patients’survival rate, and in addition, cases positive for CD5had unfavorable prognosis, all of which showed significant differences by Log-rank analysis(P<0.05). Cox regression analysis showed translocation of c-myc, distant metastasis and high LDH were independent unfavorable prognosis factors. ROC curve revealed the positive percentage for c-MYC would contribute to forecast the c-myc status, with75%as the optimal threshold.Conclusion:(1) DLBCL, DLBCL/BL, BL are a group of aggressive B cell lymphomas, and gastrointestinal tract is one of the most predilection sites. A correct diagnosis needs the comprehensive evaluation including clinical data and immunohistochemistry, and the exclusion of other round cell tumors developing in gastrointestinal tract.(2) Various clinicopathologic factors such as B symptom, LDH, performance, distant metastasis, IPI index, clinical stage, CD5and c-myc status are relevant with prognosis.(3) DLBCL and DLBCL/BL could possess translocation of c-myc. Theses types tend to be Burkitt-like or atypia Burkitt lymphoma(BL/aBL), which present with obvious karyorrhexis and "starry sky", but celluar size and morphology, lacking of uniformity, usually behave more atypia and always display significantly high proliferation index even close to100%. As independent factors influencing prognosis, detection of c-myc will contribute to assess the patientts’ curative effect and prognosis.(4) High c-MYC positive percentage of tumor cells combined with Tcl-1and CD38will contribute to predict the translocation of c-myc. That method using immunohistochemistry would provide a new and potential approach with cheap and fast characteristics as preliminary screening, however, more comfirmation is needed to popularize this method. Cases strong positive for Bcl-2were not always of translocation, but FISH detection still be recommended in practical.更多还原