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PII: S0037-1963(16)30044-0
DOI: http://dx.doi.org/10.1053/j.seminhematol.2016.05.007
Reference: YSHEM50884
To appear in: Seminars in Hematology
Cite this article as: Stephan Mathas, Sylvia Hartmann and Ralf Küppers,
Hodgkin lymphoma: Pathology and Biology, Seminars in Hematology,
http://dx.doi.org/10.1053/j.seminhematol.2016.05.007
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Hodgkin lymphoma: Pathology and Biology
a
Max-Delbrück-Center for Molecular Medicine, and Hematology, Oncology, and Tumor
Frankfurt/Main, Germany.
c
Institute of Cell Biology (Cancer Research), Medical Faculty, University of Duisburg-Essen,
Essen, Germany.
Address correspondence to Ralf Küppers, PhD, Institute of Cell Biology (Cancer Research),
Own work discussed in this review was supported by the Wilhelm Sander-Stiftung, the
Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the
1
Abstract
The Hodgkin and Reed-Sternberg (HRS) tumor cells of classical Hodgkin lymphoma (HL), as
(NLPHL) are derived from mature B cells. However, HRS cells have largely lost their B cell
phenotype and show a very unusual expression of many markers of other hematopoietic cell
lineages, which aids in the differential diagnosis between classical HL (cHL) and NLPHL and
distinguishes cHL from all other hematopoietic malignancies. The bi- or multinucleated Reed-
Sternberg cells most likely derive from the mononuclear Hodgkin cells through a process of
contributes to the pathogenesis of cHL. Recurrent genetic lesions in HRS cells identified so
far often involve members of the NF- B and JAK/STAT pathways and genes involved in
likely remain to be identified. We here discuss the current knowledge on HL pathology and
biology.
2
INTRODUCTION
More than 170 years ago, Thomas Hodgkin first described the disease named after him.1 For
several reasons, Hodgkin lymphoma (HL) is, despite recent progress, still one of the most
technical challenge and impedes rapid advances with respect to its pathogenesis. For a long
time, these technical challenges also prevented the identification of the cellular origin of the
not known. Despite these obstacles, the cellular origin of HL tumor cells has been clarified,
and various molecular and genomic defects were identified which allowed the development of
a concept for HL pathogenesis. In this article, we discuss current concepts on pathology, the
cellular origin, known molecular and genomic defects and the interaction between tumor and
PATHOLOGY
The main histological feature of HL is the abundance of reactive bystander cells and the
paucity of tumor cells in affected lymph nodes. Four classical HL (cHL) subtypes and nodular
Reed/Sternberg (HRS) cells in classical subtypes show expression of CD30 (Figure 1a),
MUM1, variable expression of CD15 (Figure 1b) and a typically weak expression of PAX5
(Figure 1c). HRS cells have usually downregulated B cell markers (Figure 1d). In contrast,
tumor cells of NLPHL - the lymphocyte predominant (LP) cells - resemble germinal center
3
Nodular sclerosing HL (NSHL)
This is the most frequent subtype in Western countries (around 80% of cases) mainly
Histologically, fibrotic bands confine nodular compartments containing the typical infiltrate
consisting of HRS cells, epithelioid cells, T cells and variable numbers of neutrophils and
eosinophils (Figure 2a). Due to shrinking artifacts the HRS cells can be located in lacunar-like
spaces and are then called lacunar cells (Figure 2b). In NSHL, HRS cells are usually Epstein-
patients. HRS cells tend to be frequently EBV-infected.2 The affected lymph node presents a
completely effaced architecture with diffuse infiltrates containing histiocytes and eosinophils.
In EBV-negative cases, the histiocytes rather present as epithelioid cells (Figure 2c), whereas
2d).3,4
This subtype has become exceedingly rare, since with better reagents for PAX5 staining,
PAX5-positive LDHL can now be better distinguished from PAX5-negative (and ALK-
negative) anaplastic large cell lymphoma. In LDHL, HRS cells can be relatively abundant
(reticular variant). Other cases of LDHL represent a diffuse fibrosis in which scattered HRS
(human immunodeficiency virus (HIV)-positive), and HRS cells are frequently EBV-infected.
4
Lymphocyte rich cHL (LRCHL)
This is another rare subtype of HL which usually occurs in adults and shows a prevalence for
cervical lymph nodes and the Waldeyer lymphatic tissue. LRCHL frequently presents with
early stages.5 HRS cells are EBV-infected in 30-50% of the cases.5,6 Histology shows a rather
monomorphic picture with small and often confluent nodules of mantle zone B cells,
frequently containing GCs. HRS cells are embedded in these nodules (Figure 2e). A helpful
diagnostic feature is the presence of rosetting PD1-positive T cells.6 In LRCHL, HRS cells
more frequently express B cell transcription factors (TFs) and CD20 than HRS cells in the
NLPHL most closely resembles LRCHL. However, there are several striking differences in
clinical presentation and morphology. NLPHL shows a strong predominance of the male
gender and more frequent relapses than LRCHL.5,7 The most important difference to LRCHL
are the LP tumor cells, which have a GC B cell phenotype and are usually negative for CD30
and CD15. Morphologically, typical and variant patterns can be distinguished.8 In the typical
pattern, LP cells are located in large nodules of naive B cells and are surrounded by follicular
T helper (TFH) cells (Figure 1e and 2f).9,10 In contrast, the follicular microenvironment is
usually lost in the diffuse NLPHL variants, which show considerable morphologic and
Differential diagnoses
Whereas NSHL in young patients usually represents a clear cut diagnosis, MCHL and
5
When HRS cells are PAX5-negative, a CD30-positive T cell lymphoma has to be excluded.
negative HL when involving lymph nodes.12 In most cases this differential diagnosis can be
molecules or HRS-related markers like CD83 (Figure 1f), CCL22, TUBB2B or STAT3 or a
Even when HRS cells are PAX5-positive, T cell lymphomas remain the main
lymphomas and in peripheral T cell lymphomas of the NOS (not other specified) type the
necessary, when HRS-like cells are EBV-infected and express B cell markers.
GCs. Rosetting of TFH cells is the feature that helps most in distuingishing NLPHL from
CELLULAR ORIGIN
As HRS cells show a very unusual immunophenotype with frequent coexpression of markers
of distinct cell types of the immune system,18 their cellular origin was enigmatic for a long
time. The detection of rearranged immunoglobulin (Ig) genes in isolated HRS cells finally
revealed their B cell origin in the vast majority of cases.19,20 This is because Ig heavy and light
chain gene rearrangements are highly specific for B cells and thus represent a genetic marker
for their origin. The finding of the same rearrangements in all HRS cells of a given case also
demonstrated monoclonality of HRS cells and thus settled a controversial discussion about
their clonality.19,20 Importantly, IgV genes of HRS cells in nearly all cases carried a high load
6
of somatic mutations, and in about 25% of cases, destructive mutations rendered originally
causes apoptotic death of the B cells. Thus, HRS cells frequently or as a rule derive from GC
B cells that acquired disadvantagous mutations and normally would have undergone
apoptosis. Further support for a B cell derivation of HRS cells is that these cells frequently
composite lymphomas of a cHL and a mature B cell non-Hodgkin lymphoma (NHL) these
lymphomas are frequently clonally related and hence stem from the same mature B cell.25
There are also a few lymphomas diagnosed as cHL that carry T cell receptor gene
rearrangements and hence derive from T cells.21 This may indicate that a very small subset of
cases of cHL has a T cell origin, or that T cell lymphomas exist that are histopathologically
and immunophenotypically indistinguishable from cHL. This holds particularly true for
cutaneous T cell lymphomas which can frequently drain to local lymph nodes and evoke
The GC B cell phenotype of LP cells in NLPHL already indicated their B cell origin.18
This was validated by IgV gene studies of isolated LP cells. The rearrangements lack
rearrangements, which indicates low level active somatic hypermutation during clonal
expansion.26,27 These features, together with the expression of typical markers of GC B cells,
the follicular growth pattern, and the global gene expression pattern of LP cells, strongly
7
GENERATION OF REED-STERNBERG CELLS, HRS PRECURSOR CELLS, AND
A hallmark of cHL is the presence of mononuclear Hodgkin and bi- or multinuclear Reed-
Sternberg cells. The relationship between these two forms of tumor cells has been unclear for
a long time. Recent time-lapse microscopy studies of HL cell lines showed that Hodgkin cells
frequently undergo incomplete cytokinesis and that Reed-Sternberg cells are generated by re-
fusion of two sister cells that are still connected by microtubuli bonds.29,30 Thus, it appears
that a defect to complete an advanced cytokinesis is the main reason for the generation of
Reed-Sternberg cells from Hodgkin cells. These experiments as well as earlier studies also
revealed that Reed-Sternberg cells have little proliferative capacity, and that Hodgkin cells are
the main proliferative compartment of the HRS tumor clone.29-31 However, perhaps not all
Hodgkin cells have the same proliferative capacity. Based on studies with HL cell lines, there
is indication that a small subset of Hodgkin cells, so-called side population cells that express
ABC transporters and can therefore expell Hochst dye 33342, have features of tumor stem
cells and can reestablish the HRS cell clone in subcloning experiments.32,33 However, as side
population cells were not seen in all HL cell lines, the general role of these cells for HL
remains unclear.
Another interesting issue is whether the tumor clone in HL also encompasses members
that are not identifiable as CD30+ cells with the typical morphology and phenotype of HRS
cells, and whether HRS cell clone members can be found in the peripheral blood. In an
analysis of two HL patients with advanced disease, IgV gene rearrangements of the HRS cells
were detected in multiple tissues, but even with a highly sensitive approach not in the
peripheral blood.34 Another study reported about the presence of CD20- and BCR-positive,
but CD30-negative HRS clone members in the peripheral blood,35 but the validity of that
study was critizised based on technical concerns.36 In a further recent study, IgV gene
8
rearrangements thought to stem from the HRS cells were detected in a few of the tested
samples in peripheral blood mononuclear cells, but much more frequently in serum.37
Because of the presence of HRS cell DNA in the serum, it needs to be clarified whether the
rearrangements detected in the cell fraction are really derived from circulating HRS cells, or
from contaminating HRS cell DNA in the serum. Further indication for the presence of HRS
cell-derived DNA in circulating cell-free DNA stems from a deep sequence analysis for
genomic imbalances detected in the HRS cells in the lymph node tissue.38 Thus, it appears
that DNA from HRS cells can frequently be detected in cell-free blood serum. It is
worthwhile to study whether this can be used for minimal residual disease detection and serve
as a prognostic biomarker.
PATHWAYS
HRS cells are characterized by a complex network of deregulated TFs, which interfere with
cellular differentiation, reflect their activated phenotype, and coordinate their growth and
survival. The loss of B cell phenotype is mediated by epigenetic silencing of key regulators of
as demonstrated for the E2A blockade by ABF-1 and ID2, or Pax5 inhibition by NOTCH1.40-
42
Whereas one group of B-cell TFs (e.g. OCT2, PU.1, BOB.1, FOXO1, ETS)43-46 is nearly
some instances even at high-level expression (e.g. E2A, IRF4).41,48 Although genetic
alterations for some TFs were described,46,49 a rather functional disruption of B cell-specific
cell/plasma cell gene expression (e.g. CD20, BCL6, BLIMP1) in a subfraction of HL cases, 50-
52
and ii) reactivation of B cell genes following e.g. FOXO1, EBF1 or CD99
9
reconstitution49,53,54 or NOTCH1 inhibition.40 Furthermore, reconstitution of KLF4 down-
regulated the E2A antagonist ABF-1.55 The role of altered epigenetic regulators such as PcG
unclear.56,57 Finally, transient hypoxic conditions in early stages of cHL pathogenesis might
HL was among the first malignancies for which an oncogenic role of NF- B was
recognized. Initially referred to classical NF- B-p65 (RELA),59 it became evident that
combinatorial activities of various NF- B components, including REL, RELB and p52,60-63
mediate its key functions in HRS cells, which reflects the concomitant activation of canonical
constitutive I B kinase (IKK) complex and NF- B inducing kinase (NIK) activation
contributes to NF- B activity in HRS cells and argues for ongoing upstream signaling.21,60
The JAK/STAT signaling pathway represents a second key pathway in HL. STAT3, STAT5
and STAT6 are activated and (for some factors) expressed at high level in HL (Figure 3).64,65
or pharmacological intervention led to growth inhibition and cell death. The high frequency of
genomic alterations as observed for the NF- B pathway (see below) and induction of HRS-
like cells by STAT5 suggest the JAK/STAT pathway as further key driver in HL
pathogenesis.65-68
JUN, JUNB and ATF3 are highly upregulated in HRS cells, contribute to growth and
survival, and regulate HL-specific genes (Figure 3).69,70 At least in the context of the
microenvironment, MAP kinases contribute to their activation.71 Furthermore, IRF TFs are
centrally involved in HL pathogenesis.48,72 IRF4 and IRF5 are consistently expressed in HRS
10
cells and drive their growth and survival; IRF5 orchestrates, together with NF- B, the HL-
specific gene expression pattern.73 There is increasing evidence for an extensive cross-talk
between these TFs. For example, NF- B maintains high-level expression of STAT5, JUNB
Finally, HRS cells express a unique pattern of TFs asssociated with hematopoietic stem or
precursor cells of other lineages such as GATA2 or HOXB9,75,76 which might be linked to
approaches are required to judge about the importance of individual TF activites and to
further dissect their hierarchical organization, in order to identify the hub TFs required for HL
Much less is known about signaling pathways and TF alterations in NLPHL. NLPHL
shares signaling pathways with cHL, as demonstrated for NF- B, STAT6 or JAK2 activation,
but is also clearly distinct from cHL.28 For example, AP-1 activation and target gene
expression is absent in most cases,70,77 and the loss of B cell phenotype is much less
pronounced.28,45,52
GENETIC LESIONS
A number of oncogene and tumor suppressor genes were studied in HRS cells for mutations.
pathway (Table 1). HRS cells recurrently harbor genomic gains of the NF- B factor REL,78,79
and of MAP3K14 (NIK),80,81 a major positive regulator of the alternative NF- B pathway.
The NF- B inhibitors NFKBIA, NFKBIE, and TNFAIP3 are frequently inactivated by point
and TRAF3, were also found to be mutated at low frequency.21 Another signaling pathway
with frequent genetic lesions in several of its components is the JAK/STAT pathway. The
11
JAK2 gene is frequently affected by genomic gains, and rarely by translocations.81,88-90 SOCS1
and PTPN1, encoding main negative regulators of JAK/STAT signaling, are recurrently
Another group of genetic lesions in HRS cells affects MHC expression and interaction
with T cells. The gene of the MHC class II transactivator (CIITA) is recurrently involved in
chromosomal translocations, which appear to inactivate the gene, causing reduced MHC class
II expression.93 The gene for 2-microglobulin (B2M), a component of the MHC class I
complex, carries inactivating mutations in a fraction of cases.94 In line with this, HRS cells
frequently lack detectable MHC class I expression. Furthermore, the chromosomal gains on
9p24.1 affecting the JAK2 gene also involve the PDL1 and PDL2 genes (and in addition
JMJD2C, encoding an epigenetic regulator).66,95 These ligands inhibit cytotoxic T cells when
binding to PD1, which is expressed by activated T cells. Interestingly, in contrast to its unique
morphological appearance, no genomic alteration unique to HL has been reported so far and a
lead genetic alteration, characteristic for many other hematologic malignancies, is still
lacking.
Only little is known about genetic lesions in the LP cells of NLPHL. Translocations of
the proto-oncogene BCL6 are detectable in about 30% of cases, and SOCS1 is mutated in
about half of the cases.18 Similar to other GC-derived B cell lymphomas and cHL, LP cells
frequently show gains of 2p16 (REL locus).11 A recent study revealed three further highly
recurrent genetic lesions in LP cells, each present in about 50% of NLPHL, namely mutations
in the genes for the phosphatase DUSP2, the serine/threonine kinase SGK1, and in JUNB.96
The high number of stop mutations in JUNB correlates well with the absence of AP-1
12
In about 30-40% of cases of cHL in Europe and North America, the HRS cells are latently
infected by EBV, a herpes virus.97 The infection rate is even higher in childhood cases in
Central and Southern America, where about 80% of cases show an EBV infection of HRS
cells. In EBV-positive cases, usually all HRS cells are positive, indicating that the infection
was an early event in lymphoma development. The EBV+ HRS cells typically show an EBV
latency II gene expression profile, meaning expression of the viral proteins EBV nuclear
antigen 1 (EBNA1) and latent membrane proteins 1 and 2a (LMP1 and LMP2a).97 EBNA1 is
essential for replication of the episomal viral genome in proliferating cells. LMP1 mimics an
active CD40 receptor and hence stimulates NF- B and PI3K/AKT activity.98 LMP2a has a
cytoplasmic motif that resembles the ITAM motif of the BCR. It can therefore mimic an
active BCR.99 As BCR and CD40 signalling are main survival signals for GC B cells, EBV
infection of GC B cells may be a way how GC B cells with destructive mutations survive and
become HRS precursor cells.100 Indeed, in vitro, EBV can rescue crippled GC B cell from
apoptosis,99,101 and all cHL cases with destructive mutations that prevent BCR expression
been reported to be associated with an increased risk of HL.102 These findings indicate a
MICROENVIRONMENTAL INTERACTIONS
eosinophils and others. Due to space limitations, here we can only focus on some aspects of
interactions between HRS and surrounding cells. It is assumed that i) cells of the
microenvironment take part in complex interactions with HRS cells and support their growth
and survival, and ii) the other way around, HRS cells actively influence and modify the
13
composition of the surrounding infiltrate, although experimental evidence for these
assumptions is rather weak and most data are correlative. Interactions might be direct, for
example by CD30, CD40, RANK or CD95 interactions, which contribute to e.g. NF- B
activation in HRS cells and to their immune escape.21 A plethora of interactions act indirectly,
for example the attraction and polarization of T cells by secretion of RANTES, TARC,
Furthermore, also fibroblasts have most likely impact on the microenvironmental composition
and establishment of the respective HL-subtype and contribute to the attraction of infiltrating
Apart from effects of bystander cells on HRS cell growth and survival, the lymphoma
with the functional activity of T cells, or a shift of T cell polarization towards a regulatory
phenotype.95,105,106 It is assumed that the impressive clinical results of patients treated with
immune response against HRS cells by reversion of the inhibited T cell effector functions. 105
However, serial biopsies in the course of PD-1/PDL1 antibody treatment are still lacking, and
redirection of T cells towards HRS cells following such treatment has not formally been
demonstrated. It could also be speculated that clinical responses following such immune-
checkpoint interference are mainly due to „simple“ disruption of the growth- and survival-
promoting interaction between HRS and surrounding T cells. HRS cells secrete substances,
such as IL-13 or galectin-1, which primarily act on and polarize specific T cell subsets or
14
Important lessons can be learned from HL in patients suffering from HIV infection.
Before the era of antiretroviral therapy (ART), when CD4+ T cell counts were usually very
low, a strong increase of aggressive NHL, but not HL, was documented in HIV-patients.108
This changed with the implementation of ART and an increase of CD4+ T cell numbers and
thus an improved immunity. Whereas the incidence of aggressive NHL dropped, the
incidence of HL increased.109 This might be the best in vivo evidence for the importance of
the HRS – T cell interaction in HL. Similarly, despite the high rate of EBV-reactivation and
setting.110
Apart from T cells, infiltrating macrophages might support the growth of HRS cells
and prevent an effective immune response towards HRS cells.3,103 HRS cells express at high
level cytokines and chemokines which act on macrophages, and the density of macrophage-
understand the complexity of interactions between HRS cells and their microenvironment and
their functional role during transformation, the impressive clinical results following disruption
of such interactions indicate its importance for both, to reveal pathogenic mechanisms and to
ACKNOWLEDGEMENTS
We thank Martin-Leo Hansmann for support and many stimulating discussions. We apologize
to all those colleagues whose work we could not cite due to length restrictions.
15
REFERENCES
1. Hodgkin T. On some morbid appearances of the absorbent glands and spleen. Med
Haematopoietic and Lymphoid Tissues. 4th ed. Lyon: IARC Press; 2008.
Pathol. 2013;26:648-657.
lymphoma and T cell/histiocyte rich large B cell lymphoma. Pathol Res Pract.
6. Nam-Cha SH, Montes-Moreno S, Salcedo MT, Sanjuan J, Garcia JF, Piris MA.
16
9. Hartmann S, Döring C, Jakobus C, et al. Nodular lymphocyte predominant Hodgkin
12. Eberle FC, Song JY, Xi L, et al. Nodal involvement by cutaneous CD30-positive T-
2012;36:716-725.
13. Sorg UR, Morse TM, Patton WN, et al. Hodgkin's cells express CD83, a dendritic cell
2012;36:1636-1646.
16. Quintanilla-Martinez L, Fend F, Moguel LR, et al. Peripheral T-cell lymphoma with
17
17. Hartmann S, Winkelmann R, Metcalf RA, et al. Immunoarchitectural patterns of
cells in Hodgkin's disease represent the outgrowth of a dominant tumor clone derived
20. Küppers R, Rajewsky K, Zhao M, et al. Hodgkin disease: Hodgkin and Reed-
Sternberg cells picked from histological sections show clonal immunoglobulin gene
2012;122:3439-3447.
human germinal centres by molecular analysis of single cells picked from histological
18
26. Braeuninger A, Küppers R, Strickler JG, Wacker HH, Rajewsky K, Hansmann ML.
represent clonal populations of germinal center-derived tumor B cells. Proc Natl Acad
28. Brune V, Tiacci E, Pfeil I, et al. Origin and pathogenesis of nodular lymphocyte-
30. Xavier de Carvalho A, Maiato H, Maia AF, et al. Reed-Sternberg cells form by
2015;10:e0124629.
31. Ikeda J, Mamat S, Tian T, et al. Tumorigenic potential of mononucleated small cells
Hodgkin and Reed-Sternberg cells and a target for nuclear factor-kappaB inhibitors in
33. Shafer JA, Cruz CR, Leen AM, et al. Antigen-specific cytotoxic T lymphocytes can
Lymphoma. 2010;51:870-880.
19
34. Vockerodt M, Soares M, Kanzler H, et al. Detection of clonal Hodgkin and Reed-
35. Jones RJ, Gocke CD, Kasamon YL, et al. Circulating clonotypic B cells in classic
3971.
37. Oki Y, Neelapu SS, Fanale M, et al. Detection of classical Hodgkin lymphoma
J Haematol. 2015;169:689-693.
39. Ushmorov A, Leithäuser F, Sakk O, et al. Epigenetic processes play a major role in B-
2500.
40. Jundt F, Acikgoz O, Kwon SH, et al. Aberrant expression of Notch1 interferes with
Leukemia. 2008;22:1587-1594.
41. Mathas S, Janz M, Hummel F, et al. Intrinsic inhibition of transcription factor E2A by
20
42. Renné C, Martin-Subero JI, Eickernjager M, et al. Aberrant expression of ID2, a
2006;169:655-664.
43. Hertel CB, Zhou XG, Hamilton-Dutoit SJ, Junker S. Loss of B cell identity correlates
44. Re D, Müschen M, Ahmadi T, et al. Oct-2 and Bob-1 deficiency in Hodgkin and Reed
2012;97:1612-1614.
47. Foss HD, Reusch R, Demel G, et al. Frequent expression of the B-cell-specific
49. Bohle V, Döring C, Hansmann ML, Küppers R. Role of early B-cell factor 1 (EBF1)
21
51. Watanabe K, Yamashita Y, Nakayama A, et al. Varied B-cell immunophenotypes of
361.
52. Falini B, Bigerna B, Pasqualucci L, et al. Distinctive expression pattern of the BCL-6
471.
Cancer. 2012;131:E382-394.
54. Vogel MJ, Xie L, Guan H, et al. FOXO1 repression contributes to block of plasma cell
55. Guan H, Xie L, Leithäuser F, et al. KLF4 is a tumor suppressor in B-cell non-Hodgkin
56. Sanchez-Beato M, Sanchez E, Garcia JF, et al. Abnormal PcG protein expression in
Pathol. 2004;204:528-537.
58. Wein F, Otto T, Lambertz P, Fandrey J, Hansmann ML, Küppers R. Potential role of
2015;100:1320-1326.
RelA activation is required for proliferation and survival of Hodgkin's disease tumor
22
60. Krappmann D, Emmerich F, Kordes U, Scharschmidt E, Dörken B, Scheidereit C.
61. Barth TF, Martin-Subero JI, Joos S, et al. Gains of 2p involving the REL locus
63. Ranuncolo SM, Pittaluga S, Evbuomwan MO, Jaffe ES, Lewis BA. Hodgkin
lymphoma requires stabilized NIK and constitutive RelB expression for survival.
Blood. 2012;120:3756-3763.
Med. 2002;196:605-617.
65. Skinnider BF, Elia AJ, Gascoyne RD, et al. Signal transducer and activator of
66. Rui L, Emre NC, Kruhlak MJ, et al. Cooperative epigenetic modulation by cancer
67. Scheeren FA, Diehl SA, Smit LA, et al. IL-21 is expressed in Hodgkin lymphoma and
23
68. Hao Y, Chapuy B, Monti S, Sun HH, Rodig SJ, Shipp MA. Selective JAK2 inhibition
70. Mathas S, Hinz M, Anagnostopoulos I, et al. Aberrantly expressed c-Jun and JunB are
activates the CD30 promoter in anaplastic large cell lymphoma and reed-sternberg
Haematol. 2011;152:182-190.
73. Kreher S, Bouhlel MA, Cauchy P, et al. Mapping of transcription factor motifs in
expression in classical Hodgkin lymphoma and its consequences for the cytokine
75. Schneider EM, Torlakovic E, Stuhler A, Diehl V, Tesch H, Giebel B. The early
2004;204:538-545.
24
76. Nagel S, Burek C, Venturini L, et al. Comprehensive analysis of homeobox genes in
2007;110:3387-3390.
78. Joos S, Menz CK, Wrobel G, et al. Classical Hodgkin lymphoma is characterized by
recurrent copy number gains of the short arm of chromosome 2. Blood. 2002;99:1381-
1387.
79. Martin-Subero JI, Gesk S, Harder L, et al. Recurrent involvement of the REL and
80. Otto C, Giefing M, Massow A, et al. Genetic lesions of the TRAF3 and MAP3K14
81. Steidl C, Telenius A, Shah SP, et al. Genome-wide copy number analysis of Hodgkin
82. Cabannes E, Khan G, Aillet F, Jarrett RF, Hay RT. Mutations in the I B gene in
1999;18:3063-3070.
the IkBa gene in the malignant cells in Hodgkin's disease. J Exp Med. 2000;191:395-
401.
25
85. Kato M, Sanada M, Kato I, et al. Frequent inactivation of A20 in B-cell lymphomas.
Nature. 2009;459:712-716.
86. Schmitz R, Hansmann ML, Bohle V, et al. TNFAIP3 (A20) is a tumor suppressor
gene in Hodgkin lymphoma and primary mediastinal B cell lymphoma. J Exp Med.
2009;206:981-989.
87. Nomoto J, Hiramoto N, Kato M, et al. Deletion of the TNFAIP3/A20 gene detected by
88. Joos S, Küpper M, Ohl S, et al. Genomic imbalances including amplification of the
tyrosine kinase gene JAK2 in CD30+ Hodgkin cells. Cancer Res. 2000;60:549-552.
89. Van Roosbroeck K, Cox L, Tousseyn T, et al. JAK2 rearrangements, including the
2011;117:4056-4064.
1326.
91. Gunawardana J, Chan FC, Telenius A, et al. Recurrent somatic mutations of PTPN1 in
2014;46:329-335.
92. Weniger MA, Melzner I, Menz CK, et al. Mutations of the tumor suppressor gene
SOCS-1 in classical Hodgkin lymphoma are frequent and associated with nuclear
93. Steidl C, Shah SP, Woolcock BW, et al. MHC class II transactivator CIITA is a
26
94. Reichel J, Chadburn A, Rubinstein PG, et al. Flow-sorting and exome sequencing
2015;125:1061-1072.
95. Green MR, Monti S, Rodig SJ, et al. Integrative analysis reveals selective 9p24.1
amplification, increased PD-1 ligand expression, and further induction via JAK2 in
97. Kapatai G, Murray P. Contribution of the Epstein Barr virus to the molecular
Epstein-Barr virus transforming protein LMP1 engages signaling proteins for the
cell receptor mimic and essential for B-cell survival. Blood. 2007;110:3715-3721.
Cancer. 2006;118:1853-1861.
center B cells by EBV supports a major role of the virus in the pathogenesis of
27
103. Steidl C, Connors JM, Gascoyne RD. Molecular pathogenesis of Hodgkin's
Oncol. 2011;29:1812-1826.
Blood. 1999;94:2065-2071.
105. Ansell SM, Lesokhin AM, Borrello I, et al. PD-1 blockade with Nivolumab in
107. Skinnider BF, Elia AJ, Gascoyne RD, et al. Interleukin 13 and interleukin 13 receptor
Blood. 2001;97:250-255.
109. Biggar RJ, Jaffe ES, Goedert JJ, Chaturvedi A, Pfeiffer R, Engels EA. Hodgkin
3791.
111. Steidl C, Lee T, Shah SP, et al. Tumor-associated macrophages and survival in classic
inhibition of NF-kappaB activity and mutations in the I kappa B alpha gene in Reed-
28
113. Schneider M, Schneider S, Zühlke-Jenisch R, et al. Alterations of the CD58 gene in
114. Küpper M, Joos S, Von Bonin F, et al. MDM2 gene amplification and lack of p53
2001;112:768-775.
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Figure legends
a. Expression of CD30 in HRS cells (arrows, membrane bound and golgi field, NSHL,
CD30-immunostaining, 400x).
immunostaining, 400x).
c. Typical weak PAX5 expression in a HRS cell in LRCHL (arrow). Surrounding mantle
zone B cells show a more prominent PAX5 expression (arrow heads, PAX5-
immunostaining, 400x)
d. Weak CD20 expression in an HRS cell, as it is observed in some cases (arrow). The few B
cells in the reactive infiltrate present a strong CD20 expression (arrow heads, CD20-
immunostaining, 400x).
immunostaining, 200x)
a. Typical nodule of NSHL confined by a sclerotic band (arrow heads) and containing HRS
c. MCHL with a typical mixed reactive infiltrate consisting of epithelioid cells, lymphocytes
and eosinophils (HE, 400x). HRS cells are marked with arrows.
(arrow heads, HE, 200x) HRS cells are marked with arrows.
30
e. HRS cells surrounded by small B cells in LRCHL (HE, 400x). HRS cells are marked with
arrows.
f. LP cells (arrows) in a mixed inflammatory infiltrate containing B cells, TFH cells and
Scheme of the main signaling pathways involved in cHL pathogenesis. In part by activation
of various cell surface receptors, as indicated, or the EBV protein LMP1, the canonical and
transcriptional activity of various NF- B members including p50/p65, p52, RELB or BCL3.
A second major pathway is the JAK/STAT signaling pathway, as documented for high-level
STAT3, STAT5 and STAT6 activation in HRS cells in at least a fraction of cHL cases.
Further key players in the TF landscape of HRS cells are IRF4 and IRF5, the activation
mechanism and composite binding site partners (marked by „X“) of which are not yet
clarified and which coordinates the HL-specific gene expression program, high-level
activation of various AP-1/CREB members (JUN, JUNB, ATF3) and NOTCH1. Known
TFs, are indicated by green arrows. Known genomic lesions of HRS cells include various
31
Table 1. Recurrent genetic lesions in HRS cells
cases analyzed
(%)
NF- B pathway
82,84,112
NFKBIA SNVs, deletions 5/23 (22)
83
NFKBIE SNVs, deletions 1/6
about 70%
78,79
REL gains 33/71 (46)
80,81
MAP3K14 gains 18/69 (26)
JAK/STAT pathway
92
SOCS1 SNVs, deletions 8/19 (42)
91
PTPN1 SNVs, deletions 6/30 (20)
81,88,90
JAK2 gains 30/77 (39) JAK2 gains also involve the
Antigen presentation
93
CIITA translocations 8/55 (14)
94
B2M SNVs, deletions 7/10 (70)
113
CD58 deletions 3/13 (23)*
Others
18
TP53 SNVs, deletions 3/39 (8)
18
FAS SNVs, deletions 2/30 (7)
32
114
MDM2 gains 4/6 (67)
SNVs, single nucleotide variants; *plus inactivating mutations in three of seven HL cell lines
33
34
Figure 3
35