JCO-2011-Steidl-JCO 2010 32 8401

Published Ahead of Print on April 11, 2011 as 10.1200/JCO.2010.32.8401 The latest version is at http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2010.32.
8401
JOURNAL OF CLINICAL ONCOLOGY
R E V I E W
A R T I C L E
Molecular Pathogenesis of Hodgkins Lymphoma: Increasing Evidence of the Importance of the Microenvironment
Christian Steidl, Joseph M. Connors, and Randy D. Gascoyne
From the British Columbia Cancer Agency, University of British Columbia, Vancouver, British Columbia, Canada. Submitted September 19, 2010; accepted January 4, 2011; published online ahead of print at www.jco.org on April 11, 2011. Supported in part by the Michael Smith Foundation for Health Research, the Lymphoma Research Foundation, and a postdoctoral fellowship from the Cancer Research Society (Steven E. Drabin fund; C.S.); Project Grant No. 019001 from the Terry Fox Foundation New Frontiers Program (J.M.C., R.D.G.); and Grant No. 178536 from the Canadian Institutes for Health Research (R.D.G.). Authors disclosures of potential conicts of interest and author contributions are found at the end of this article. Corresponding author: Randy Gascoyne, MD, Department of Pathology and Experimental Therapeutics, British Columbia Cancer Agency, 675 West 10th Ave, Room 5-113, Vancouver, BC V5Z 1L3, Canada; e-mail: rgascoyn@bccancer.bc.ca. 2011 by American Society of Clinical Oncology 0732-183X/11/2999-1/$20.00 DOI: 10.1200/JCO.2010.32.8401
Hodgkins lymphoma (HL) represents the most common subtype of malignant lymphoma in young people in the Western world. Most patients can be cured with modern treatment strategies, although approximately 20% will die after relapse or progressive disease. The histologic hallmark of the disease is the presence of the characteristic Hodgkin Reed-Sternberg (HRS) cells in classical HL and so-called lymphocyte-predominant (LP) cells in nodular lymphocyte-predominant HL. HL is unique among all cancers because malignant cells are greatly outnumbered by reactive cells in the tumor microenvironment and make up only approximately 1% of the tumor. Expression of a variety of cytokines and chemokines by the HRS and LP cells is believed to be the driving force for an abnormal immune response, perpetuated by additional factors secreted by reactive cells in the microenvironment that help maintain the inammatory milieu. The malignant HRS and LP cells manipulate the microenvironment, permitting them to develop their malignant phenotype fully and evade host immune attack. Gene expression signatures derived from non-neoplastic cells correlate well with response to initial and subsequent therapies, reecting their functional relevance. Recent biomarker studies have added texture to clinical outcome predictors, and their incorporation into prognostic models may improve our understanding of the biologic correlates of treatment failure. Moreover, recent preclinical and clinical studies have demonstrated that the tumor microenvironment represents a promising therapeutic target, raising hope that novel treatment strategies focused on the interface between malignant and reactive cells will soon emerge. J Clin Oncol 29. 2011 by American Society of Clinical Oncology
INTRODUCTION
Hodgkins lymphoma (HL) accounts for approximately 11% of all malignant lymphomas.1 The morphologic hallmarks of this unique lymphoma were initially described more than 100 years ago; it is characterized by the presence of Hodgkin ReedSternberg (HRS) cells in classical HL (cHL) and socalled lymphocyte-predominant (LP) cells in nodular lymphocyte-predominant HL (NLPHL).2 Typically, malignant cells are greatly outnumbered by reactive cells in a microenvironment that includes lymphocytes, macrophages, eosinophils, mast cells, plasma cells, stromal cells, broblasts, and other cells.3 Specically in cHL, the frequencies of all these cellular components, including the HRS cells, vary considerably between cHL subtypes; lymphocyte rich, lymphocyte depleted, mixed cellularity (MC), and nodular sclerosis (NS). Independent of advances in understanding the etiology and molecular biology of HL, the introduction of polychemotherapy has reduced the number of patients who succumb to the disease by more than
60% since the early 1970s.4 Consequently, most patients are cured by modern treatment strategies. Important milestones in our understanding of HL include rst, separation of HL into cHL versus NLPHL; second, development of distinct treatment strategies for limited versus advanced disease; and third, validation of the International Prognostic Score for advanced disease.5,6 Since its introduction in 1998, the International Prognostic Score has become the gold standard for risk assessment and stratication and been used to guide treatment decisions in advanced cHL. However, it can be anticipated that progress, especially among those 20% of patients who are still destined to die after relapse or progressive disease, will be tightly linked to novel biomarker discovery and targeted therapies for relapsed disease.7 In this review, we will rst focus on the crosstalk between malignant and reactive cells in the microenvironment mediated by cytokines and chemokines expressed in HL tissue. These soluble factors mediate the specic cellular composition of
2011 by American Society of Clinical Oncology
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Steidl, Connors, and Gascoyne
the reactive inltrate, promote receptor-mediated signaling, and cultivate immune privilege for malignant cells. We will then review the prognostic implications of the tumor microenvironment and nally discuss novel therapeutic approaches targeting the microenvironment or microenvironment-dependent receptor signaling.
CROSSTALK BETWEEN CELLS: THE IMPORTANCE OF CYTOKINES AND CHEMOKINES IN HL
Cytokines and chemokines are lowmolecular weight proteins with a wide variety of functions that work either in a paracrine manner to
modulate the activity of surrounding cells or in an autocrine fashion to directly affect the cells that produce them. Specically, these autocrine and paracrine interactions lead to the particular cellular composition found in HL and contribute to the proliferation and antiapoptotic phenotype of HRS cells (Fig 1). Although the cytokine and chemokine milieu in HL tissues is complex and interactive, a clear understanding of this biology will be clinically relevant in the future as therapies are developed that disrupt the crosstalk between malignant cells and the microenvironment. Hence, improved insight into the biology will be critical to introducing these novel biologic treatments into clinical practice. This section focuses on the involvement of cytokines in the
Fibroblast Fibroblast Mast cell CCL11/ Eotaxin Eosinophil

CCR3
IL8
CXCR1/2
B cell
FGF1/2 IL-13
CD30L IL-13R
CD30L
BLC CCL5 IL-4
TNF- LT- TGF- APRIL BAFF

CD95
Neutrophil
CD30
FASL
TNFR family
CCR3
HRS cell IL-5 MEC

CD30
HLA-G
CCR10 CD40
T cell (Treg /TH2)

CCR4
Cytotoxic T cell
CXCL16
CCR3/ CCR10
CD74
TARC MDC CD40L CCL20 IFN

CD7
Gal-1
MIF
PDL1 CX3CL1 CSF1
IL-10 TGF
CX3CR1 CSF1R
Macrophage
IFN
PD-1
IL-2R
IL-2 Plasma cell IL8 T cell (TH1)
NK cell
Fig 1. Schematic of the crosstalk between malignant Hodgkin Reed-Sternberg (HRS) cells and the tumor microenvironment in classical Hodgkins lymphoma. In the center, a bi-nucleated HRS cell is shown expressing characteristic surface molecules as well as secreted cytokines and chemokines. Surrounding the HRS cells are cell types representative of the non-neoplastic cells attracted and activated by these molecules. The cells in the microenvironment themselves express a variety of chemokines and cytokines that further shape the reactive inltrate and provide signaling for HRS cells. Only the main activating and inhibitory functions (arrows) of predominantly membrane-bound (purple triangles) and secreted molecules mediated by surface receptors (pink) are illustrated; other interactions exist. IL, interleukin; FGF, broblast growth factor; TNF-, tumor necrosis factor ; LT-, lymphotoxin ; TGF-, transforming growth factor ; BAFF, B-cell activating factor; APRIL, a proliferation-inducing ligand; BLC, B lymphocyte chemoattractant; TNFR, tumor necrosis factor receptor; FASL, Fas ligand; MEC, mucosae-associated epithelial chemokine; Treg, T regulatory cell; TH, T helper cell; TARC, thymus and activation-related chemokine; MDC, macrophage-derived chemokine; Gal-1, galectin-1; PDL, programmed cell death 1 ligand; IFN-, interferon gamma; NK, natural killer. 2
2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY
Microenvironment in Hodgkins Lymphoma
formation of the microenvironment and highlights how, in return, HRS cells receive signals from the microenvironment through surface receptors. The clinical and pathologic features of HL reect an abnormal immune response that is thought to be the result of expression of a variety of cytokines and chemokines by the HRS cells, altering the composition and function of the cells in the surrounding microenvironment and shaping the specic histopathologic appearance of the lymph node.8,9 Moreover, the reactive cells in the microenvironment produce specic cytokines and chemokines that help maintain and even amplify the intense inammatory reaction.10 Table 1 summarizes the most commonly described cytokines and chemokines in HL and their main functions. Of note, most of the studies in HL have focused on NSHL and MCHL, because NLPHL, lymphocyte-rich and lymphocyte-depleted cHL account for only a minority of cases.2 In addition to the variability of cytokine expression in the different HL subtypes, Epstein-Barr virus (EBV) positivity also inuences the relative expression of certain cytokines (eg, CXCL10, CXCL9, CCL5, and CCL3).9
B cells of various maturational stages are part of the normal cellular composition of lymph nodes, but in HL, this architecture is disturbed to varying degrees. Therefore, it remains an open question if and how reactive B cells are specically attracted into the microenvironment of HL, or whether they represent remnants not displaced by HL. However, as part of the general inammatory reaction, various cytokines, including TNF- and lymphotoxin , with effects on B-cell differentiation, proliferation, and chemotaxis have been shown to be expressed, which play critical roles in the initiation of germinal center reactions.21,33,66 In NLPHL, expression of B cellattracting chemokine 1 (CXCL13) has been demonstrated in a subset of cases.67
AUTOCRINE AND PARACRINE RECEPTOR SIGNALING BY HRS CELLS
COMPOSITION OF THE MICROENVIRONMENT
The most abundant cells found in HL are inltrating CD4 T cells.58 Several studies have revealed that the main subset of these cells displays a phenotype of T helper 2 (TH2) and T regulatory (Treg) cells, particularly those in the direct vicinity of HRS cells.13,59 HRS cells secrete regulated upon activation, normal T cell expressed and secreted (CCL5), thymus and activation-related chemokine (CCL17), and macrophage-derived chemokine (CCL22), potent chemokines that have all been shown to attract CCR4-expressing TH2 and Treg cells in HL.32,46,47,49-52 CCL5 has also been shown to attract mast cells commonly found in HL.46 Together with T helper 1 (TH1) cells, HRS cells themselves produce interferon gamma,11,15,16 an important enhancer of macrophage function. HRS cells also produce granulocyte colonystimulating factor (CSF1) and fractalkine (CX3CL1), chemokines and differentiation factors of monocytes and their progenitors explaining variable inltration by macrophages.40,43,60,61 In general, macrophages have been shown to be critical enhancers of tumor progression, to promote cell migration, and to suppress antitumor immunity in many cancers, including lymphoma.62 Particularly in HL, secretion of macrophage migration inhibitory factor (MIF) may contribute to the proliferation of HRS cells, which frequently express the CD74 receptor on their surface20,63; CD74 has been previously implicated in signaling and accessory functions for immune cell activation.64 Interleukin (IL) -8 expression by macrophages might also contribute to neutrophil inltration, which has been frequently described, most commonly in NSHL.53,54 Expression of IL-13, tumor necrosis factor (TNF) , and broblast growth factors by HRS cells has been well described,18,27,41 and this leads to the activation and proliferation of broblasts, most prominently seen in NSHL.48,65 Fibroblasts themselves can attract eosinophils and TH2 cells through secretion of eotaxin (CCL11).48 Furthermore, IL-5 and mucosae-associated epithelial chemokine (CCL28) expression of HRS might contribute to tissue eosinophilia.19,39 CCL28 and CXCL16 have been described as correlated with plasma cell inltration, a variable feature in cHL.39
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Although the malignant HRS cells gain a survival advantage by deregulated transcription factor networks and genetic lesions altering intrinsic signaling, the fully developed proliferation and antiapoptotic phenotype of HRS cells are critically dependent on their interaction with the microenvironment.68 In HL, the cooperation of direct genetic hits in signaling pathways with microenvironment-dependent signaling is most evident in the activation of nuclear factor kappa B (NFB) and Janus kinasesignal transducer and activator of transcription signaling (JAK-STAT; Fig 2). Many mutations and structural alterations in the genes involved in these pathways leading to constitutive activity, including chromosomal gains, overexpression of pathway genes,69-74 and inactivating mutations of tumor suppressor genes have been described.75-82 Moreover, the microenvironment provides signaling via surface receptors, namely IL receptors,83 members of the TNF receptor (TNFR) family,84 and receptor tyrosine kinases.85 Prominent receptor family members involved in activation of the canonical NFB pathway, including CD30 (TNFR superfamily [SF], member 8), CD40 (TNFRSF5), receptor activator of NFB (TNFRSF11A), and TNFR1 (TNFRSF1A), have been shown to be expressed on the surface of HRS cells.29,45,86,87 These receptors can be activated by membrane-bound or secreted ligands such as receptor activator of NFB ligand (TNFSF11, autocrine29), CD30L (TNFSF8, mast cells,30 eosinophils31), CD40L (TNFSF5, TH2/Treg86), TNF- (autocrine, macrophages and lymphocytes33,34), and lymphotoxin (autocrine21). Furthermore, in EBV-positive HL, the expression of viral oncogene LMP1 leads to protein aggregates in the cellular membrane mimicking an active CD40 receptor that similarly activates NFB signaling.88 Alternative activation (so-called noncanonical activation) of the NFB pathway can be achieved via the receptors transmembrane activator and calcium modulator and cyclophilin ligand interactor (TNFRSF13B) and B-cell maturation antigen (TNFRSF17) after engagement by their ligands a proliferation-inducing ligand (TNFSF13) and B-cell activating factor (TNFSF13B).28,89 Notably, these ligands are expressed not only by HRS cells but also by a variety of cells in the microenvironment, including macrophages, neutrophils, mast cells, and plasma cells, suggesting a prominent paracrine network.28 The constitutive activity of the Janus kinaseSTAT pathway is exemplied by autocrine and paracrine signaling of IL-13, which engages the IL-13 receptor and leads to HRS cell proliferation and survival by phosphorylated STAT6.18,90 Additionally, STAT3 activation through IL-21 and STAT5 activation have been described in HL.91,92 Overall, expression of a large number of ILs that display
Table 1. Cytokines and Chemokines Involved in the Pathogenesis of Hodgkins Lymphoma Name TH1 cytokines IL-2 IL-12 IFN- TH2 cytokines IL-4 IL-5 IL-6 IL-9 IL-10 IL-13 TNF receptor ligands TNFSF13B TNFSF11 TNFSF13 TNFSF8 CD40LG LTA TNF- Other cytokines IL-1A IL-1B TGF- IL-3 IL-7 MIF VEGF CSF1 CSF2 Chemokines CC chemokines (-chemokines) CCL1 CCL2 CCL5 CCL11 CCL13 CCL17 CCL19 CCL20 CCL22 CCL28 CXC chemokines (-chemokines) CXCL8 CXCL9 CXCL10 CXCL12 CXCL13 CXCL16 CX3C chemokines CX3CL1 Alternative Name Lymphokine BCGF1 EDF IFNB2 P40 CSIF Biological Function/Function in Hodgkins Lymphoma T-cell growth factor Growth factor for activated T and NK cells Macrophage activation, CXCL10 induction B-cell activation Eosinophil differentiation B- and plasma cell activation and maturation Mast cell activation Negative regulation of TH1 cytokines B-cell maturation and activation, broblast stimulation, CCL17 and CCL22 induction B- and HRS cell proliferation and differentiation Augmentation of T-cell activation by dendritic cells, HRS cell stimulation B- and HRS cell proliferation and differentiation T-cell stimulation B- and HRS cell proliferation B-cell growth factor, collagen synthesis CCL11 production enhancement through broblasts, collagen synthesis Proinammatory cytokine, brosis and sclerosis induction Fibrosis and sclerosis induction B- and T-cell suppression, broblast proliferation, associated with nodular sclerosis subtype Growth factor for HRS cells Growth factor for B and T cells Blocks cytotoxic T lymphocyte response Endothelial cell growth, angiogenesis Monocyte growth and differentiation Granulocyte, macrophage, and eosinophil differentiation Reference No. 11, 12 13, 14 11, 15-17 12, 16 12, 18, 19 12, 20-22 23, 24 16, 25, 26 18, 27
BAFF RANKL APRIL CD30L TNFSF5 TNFSF1 TNFSF2 IL-1 IL-1 Multi-CSF M-CSF GM-CSF
28 29 19 30, 31 32 21 33, 34 33, 35 33, 35 26, 36 37, 38 39 40 41, 42 20, 43, 44 12, 22, 45
I-309 MCP-1 RANTES Eotaxin MCP-4 TARC MIP-3 MIP-3 MDC MEC IL-8 MIG IP-10 SDF1 BLC SRPSOX Fractalkine
Monocyte chemotaxis Monocyte and basophil chemotaxis T-cell, eosinophil, and mast cell recruitment Eosinophil accumulation, produced by broblasts (TNF- induced) Monocyte chemotactic protein Induction of TH2 response and regulatory T cells Promotes B- and T-cell migration Lymphocyte recruitment TH2 response and regulatory T cell induction Plasma cell and eosinophil recruitment Neutrophil recruitment Reactive inltrate in EBV-positive disease Reactive inltrate in EBV-positive disease Monocyte migration stimulation B lymphocyte migration Recruitment of plasma cells Chemotactic for T cells, NK cells and monocytes
32, 39 33 16, 46, 47 16, 39, 48 14 32 49-51 32 32 16, 32, 39, 52 39 53-56 9, 16 16, 32, 40, 50 57 32, 57 39 40
Abbreviations: TH, T helper cell; IL, interleukin; NK, natural killer; IFN-, interferon gamma; TNF, tumor necrosis factor; TNFSF, TNF superfamily; BAFF, B-cell activating factor; HRS, Hodgkin Reed-Sternberg; RANKL, receptor activator of nuclear factor kappa B ligand; APRIL, a proliferation-inducing ligand; LTA, lymphotoxin alpha; GM-CSF, granulocyte macrophage colony-stimulating factor; MIF, macrophage migration inhibitory factor; VEGF, vascular endothelial growth factor; MCP, monocyte chemotactic protein; TARC, thymus and activation-related chemokine; MDC, macrophage-derived chemokine; MEC, mucosae-associated epithelial chemokine; MIG, monokine induced by gamma interferon; EBV, Epstein-Barr virus; IP-10, 10KDa interferon gamma-induced protein; SDF, stromal cell derived factor; BLC, B lymphocyte chemoattractant; SRPSOX, scavenger receptor for phospatidylserine and oxidised low-density lipoprotein.
JAK-STAT signaling
IL-4, IL13 IL-6, IL-10 IL-2, IL-7, IL-9, IL-15 IL-3, IL-5, GM-CSF
Canonical NFB
RANKL CD30L CD40L TNF- LT-
Alternative NFB
Tyrosine receptor kinases
APRIL BAFF
HGF NGF collagen type I
IL-2R IL-3R IL-6R IL-7R I IL-13R
CD40 TNFR1/2 RANK CD30
TACI BCMA
c M c-MET TRKA DDR2
STAT JAK1 JAK2 JAK3 TYK2

P P
STAT
P
RIP TRAF
P
TRAF
MAP3K14
Janus kinase
SHP2 GAB1 GRB2 SOS PI3K
STAT
STAT
NEMO IKK IKK
IKK complex
IKK IKK
p100 RELB
RAS
PDK
STAT-3 STAT-5 STAT-6
STAT STAT
STAT dimers/ oligomers
IB complex IB IB p50 RELA NFB complex Proteasomal degradation
RAF
AKT
p52 RELB
MEK
BAD MDM2 mTOR p21
ERK
Transcriptional regulation: - Inflammation - Survival - Cell proliferation - Differentiation
Apoptosis, cell cycle control, protein synthesis, DNA damage repair
Fig 2. Pathway activation in Hodgkin Reed-Sternberg cells through signaling from the microenvironment. Soluble and membrane-bound signaling molecules produced by reactive cells (paracrine activation) activate the Janus kinasesignal transducer and activator of transcription signaling (JAK-STAT) and canonical and alternative nuclear factor kappa B (NFB) pathways and receptor tyrosine kinases. For the JAK-STAT signaling pathway, the most commonly expressed interleukins (ILs), IL receptors, and activated STATs are shown. For the NFB pathway, only the principal activation cascades are shown, and inhibitor of kinase (IK) complex activation by other kinases are described. Downstream signaling of receptor tyrosine kinases is shown using the example of tyrosine kinase receptor A (TRKA) and illustrating the Ras and Akt pathways; other signal transduction pathways exist. GM-CSF, granulocyte macrophage colony-stimulating factor; RANKL, receptor activator of NFB ligand; TNF-, tumor necrosis factor ; LT-, lymphotoxin ; APRIL, a proliferation-inducing ligand; BAFF, B-cell activating factor; HGF, hepatocyte growth factor; NGF, nerve growth factor; TACI, transmembrane activator and CAML interactor; BCMA, B-cell maturation antigen; c-MET, mesenchymal-epithelial transition factor; DDR, discoidin domain receptor tyrosine kinase; TYK2, tyrosine kinase 2; RIP, receptor-interacting protein; TRAF, TNF receptorassociated factor 1; MAP3K, mitogenactivated protein 3 kinase; SHP2, Src homology 2 domain containing tyrosine phosphatase; SOS, son of sevenless homolog 1 (Drosophila); GRB2, growth factor receptor bound protein 2; PI3K, phosphoinositide 3-kinase; ERK, extracellular signal-regulated kinase; MEK, MAP-ERK kinase; PDK, 3-phosphoinositide dependant protein kinase; BAD, BCL2-associated agonist of cell death; MDM, mouse double minute; mTOR, mechanistic target of rapamycin.
receptor-specic binding similar to that seen with IL-13 has been reported in HL8,93 (Table 1), including ligands binding to IL-2 receptor complexes94,95 and the IL-3,37,38 IL-6,12,96 and IL-7 receptors.97 Recently, receptor tyrosine kinase signaling has been reported to play an important role in the pathogenesis of HL. In particular, the
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surface receptors mesenchymal-epithelial transition factor (c-MET), tyrosine receptor kinase A (TRKA), and discoidin domain receptor tyrosine kinase 2 (DDR2) are expressed and mediate survival signaling in HRS cells through paracrine signaling.98-102 The respective ligands of these receptors are thought to be produced by cells of the
microenvironment. Hepatocyte growth factor (HGF), a specic ligand of c-MET, is expressed by CD21 follicular dendritic cells.99 Collagen type I, the high-afnity ligand of TRKA, is expressed by broblasts, and nerve growth factor (NGF) producing granulocytes were found abundantly in the direct vicinity of HRS cells.100 Furthermore, autocrine activation loops have been suggested for the plateletderived growth factor receptor (PDGFRA) and EPH receptor B1 (EPHB1). In summary, cytokine and chemokine expression have been extensively studied in HL, and specic ligand-receptor interactions help explain the composition of the tumor environment and downstream receptor signaling critically inuencing the phenotype of malignant cells.
IMMUNE ESCAPE BY HRS CELLS
As discussed, HRS cells are dependent on the extensive inammatory microenvironment and use receptor signaling pathways to maintain their high proliferative capacity and antiapoptotic phenotype. However, HRS cells also appear to orchestrate their microenvironment in many ways to evade host immune attack. As evidenced in HIVassociated HL, malignant cells can thrive in an environment in which host immunity is globally impaired.103 Moreover, in recent years, specic mechanisms have been uncovered detailing how HRS cells induce a favorable microenvironment with suppressed antitumor immune activity. Major advances have been made that characterize the phenotypes and functions of specic T-cell subsets,104 including immunosuppressive Treg cells, which are abundant in tissue biopsies of HL.105,106 Specically, it has been shown that HRS cells produce chemokines such as CCL5, CCL17, and CCL22, which attract TH2 and Treg cells49,52,107 and secrete IL-7, an IL capable of inducing differentiation of CD4 naive T cells toward FOXP3 Treg cells.97,108 Treg and HRS cells themselves produce IL-10 and transforming growth factor (TGF-), which exert inhibitory effects on T-cell effector functions, especially on cytotoxic T lymphocytes (CTLs).8,25,105,109 In addition, prostaglandin E2 (PGE2) has been implicated as a contributor to immunosuppression and pathogenesis of HL110,111 similar to cancer progression of solid tumors.112 PGE2 leads to decreased CD4 T-cell activation through inhibition of leukocytespecic protein tyrosine kinase (LCK),113 suggesting that PGE2 contributes to the CD4 T-cell impairment observed in HL. The cells producing PGE2 have yet to be determined. Another important mechanism by which HRS cells evade host immune response is by overexpression of surface molecules maintaining peripheral tolerance. For example, the overexpression of Fas ligand (CD95L) that has been described in virtually all HRS cells of NS and MC subtypes114-116 induces apoptosis in tumor-specic CTLs.117 Similarly, galectin-1 (LGLAS1) was found to be overexpressed on the surface of HRS cells in HL, correlating with a reduced CD8 inltration at the tumor site.118 In cocultures of activated T cells with HL cell lines, galectin-1 induced secretion of TH2 cytokines and expansion of Treg cells, whereas knockdown of galectin-1 increased overall T-cell viability and restored the TH1/TH2 balance.119 Furthermore, overexpression of ligands of the receptor molecule programmed cell death 1 (PD1), PD1 ligand 1 (PDL1; CD274) itself, and PDL2 (CD273) has been described in HL.120,121 PD1 belongs to the CD28 costimulatory receptor superfamily expressed on CTLs and can modify T-cell activ6
ity by providing a second signal to T cells via the PD1 receptor, in conjunction with signaling through the T-cell receptor.122 In the setting of HL, PD1 ligand overexpression has been shown to contribute to the T-cell exhaustion observed in inltrating T cells. A recent study established a link between copy number gains of chromosome 9p where PDL1 and PDL2 reside and overexpression of these molecules in NSHL.121 Loss of HLA class I and II molecules on the surface of HRS cells occurs in a substantial proportion of cases and is correlated with latent EBV infection. HRS cell escape from immune surveillance has been suggested as a functional consequence of this nding,123-125 because the reduced immunogenicity of HRS cells could impair activation of CTLs (major histocompatibility complex [MHC] class I recognition) and CD4 T cells (MHC class II recognition). However, the underlying causes for this downregulation of HLA molecules and the exact functional consequences are largely unexplored in HL. In particular, no correlation between chromosomal loss and underexpression of HLA molecules has been found in two HL cell lines.126 Interestingly, certain HLA types are correlated with genetic susceptibility to HL EBV-positive HL cases in particularsuggesting that certain polymorphisms might effect antigen presentation to CTLs.127-129 Furthermore, expression of the nonclassical MHC class I gene HLA-G, the ligand for inhibitory receptors found on natural killer (NK) cells, subsets of T cells, and other immune cells may lead to evasion of NK-cell and CTL-mediated immune responses and has been implicated in the pathogenesis of HL.130 Such surface expression has been identied by immunohistochemistry (IHC) in more than half of cHL cases, and a strong correlation with absence of classical MHC class I molecule expression and EBV-negative status has been seen. In summary, it is now well established that the phenotypic changes that characterize HRS cells allow for efcient escape from the host immune attack through various mechanisms, including release of chemokines shaping an immunosuppressive microenvironment as well as the expression of surface molecules gaining immune privilege through the reduction of HRS cell immunogenicity. However, most of the underlying genetic mechanisms remain to be discovered.
BIOMARKERS IN HL: CORRELATIONS TO TREATMENT OUTCOME
As the impact of the microenvironment on the specic pathobiology of HL becomes increasingly clear, more and more work is focused on correlation of biomarkers with treatment outcome. Although treatment regimens have been remarkably stable in the last two decades, specic aspects of patient selection, varying histologies, and treatments might inuence cross-comparability and in part explain differing conclusions from these studies. In general, although a plethora of biomarkers associated with clinical outcome have been described, none of these factors has inuenced clinical practice to date. The main reason for this unsuccessful clinical translation lies in the lack of reproducibility between independent patient cohorts and prognostic implications that are not of signicant magnitude to justify a change in clinical management. For individual biomarkers, reproducibility of IHC scoring has been suggested as a reason for inconclusive results, and thus more robust multigene predictors have been reported based on expression proling.131,132 Table 2 summarizes some of the biomarkers for which outcome correlations have been described, separated into studies using IHC and gene expression proling. The focus
Table 2. Biomarkers With Outcome Correlations Described in the Literature Immunohistochemistry Marker/Signature Granzyme B TIA-1 FOXP3 CD20 BCL11A HLA-DR CD68, PNA ALDH1A1 STAT1 EBV-encoded small RNAs Expressed on/Staining Pattern Cytotoxic T cells Cytotoxic T cells Regulatory T cells Background B cells Background B cells, plasmacytoid dendritic cells HRS cells Macrophages Macrophages Macrophages HRS cells Function Target cell lysis Target cell lysis Transcriptional regulation B-cell differentiation Transcriptional regulation Antigen presentation Scavenger receptor Oxidative pathway/metabolism Transcriptional activation Activation of NFB Outcome Correlation Adverse (PFS, OS) Adverse (EFS, OS) Favorable (EFS) Favorable (OS, EFS) Favorable (OS, EFS) Reference No. 133-137 136,138 137-139 132,140 140
Favorable (FFS) Adverse (PFS, DSS) Adverse (DSS) Adverse in elderly patients, favorable in young patients (FFS, OS) Adverse (PFS)
123 132,141 142 143-147
MMP11
HRS cells, macrophages, endothelial cells, extracellular
Tissue remodeling Gene Expression Proling
132
Main Gene Components Angiogenic signature Adipocyte signature Fibroblast function/extracellular matrix remodeling ADH1B, CD93, SRPX, PLA2G2A, GPR126 GLUL, MGST1, COL1A2, FABP4 Adverse: MMP2, MMP3, TIMP1, COL1A1, COL4A1, COL4A2, COL5A1, COL18A1, COL16A1, MFAP2, THBS1/2, FN1, EDNRA, ITGB5, LAMA4; favorable: TIMP4, SPON1, LAMB1, TACR1, CCL26 BCL11A, BANK1, STAP1, BLNK, FCER2, CD24, CCL21 CD3D, CD8B1, CTSL, CD26, SH2D1A, IFI16, RGS13, CR2, ELL3, CCDC23, PPM1L, TRA@, PIK3CA ITM2A, SRPX, CTSB, APP ALDH1A1, LYZ, STAT1, ITGA4, CCL13, MS4A4A, CCL23, VCAN, HSP90AB3P, HSP90AB1, CTSB, CFL1, JMJD6, MAPK7, IKBKG, RAB7A, RXRA, MAPK13
Outcome Correlation Adverse (primary treatment failure) Adverse (primary treatment failure) Discordant: adverse/favorable (primary treatment outcome)
Reference No. 132 132 142,148
B-cell signature Cytotoxic T-cell signature
Favorable (primary treatment outcome) Adverse (primary treatment outcome) Adverse (primary treatment outcome) Adverse (primary treatment outcome)
132,140 131,132,142
Plasmacytoid dendritic cells Macrophage signature
132 131,132,142
Abbreviations: PFS, progression-free survival; OS, overall survival; TIA-1, T-cellrestricted intracellular antigen 1; EFS, event-free survival; FOXP3, forkhead box protein 3; BCL11A, B-cell lymphoma/leukemia 11A; HRS, Hodgkin Reed-Sternberg; FFS, failure-free survival; PNA, peanut agglutinin; DSS, disease-specic survival; ALDH1A1, aldehyde dehydrogenase 1A1; STAT, signal transducer and activator of transcription signaling; EBV, Epstein-Barr virus; NFB, nuclear factor kappa B; MMP11, matrix metalloproteinase 11.
of these studies has been cHL, because there are no biologic markers yet identied that can predict treatment outcome or transformation to an aggressive lymphoma in patients with NLPHL.
HISTOPATHOLOGY
The rst biomarker studies in cHL used classical histopathologic approaches to describe the specic cellular composition of subtypes and investigate correlations with treatment outcome. Although in initial reports, the rare lymphocyte-depleted subtype and grade 2 nodular sclerosis were reported to be associated with poor response to initial therapy and decreased survival,149 there is now overwhelming evidence that none of the cHL subtypes are correlated with survival using modern treatment modalities.133,150-152 Similarly, the number of HRS cells is not prognostically relevant. Tissue eosinophilia is still a subject of debate; a large study investigating diagnostic biopsies found a strong
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correlation between the presence of eosinophils and freedom from treatment failure and overall survival (OS),31 in agreement with a report showing prolonged disease-free survival in patients with heavy eosinophilic inltration in NSHL.153 However, several other studies could not conrm this nding.150,154,155 Mast cell inltration has also been linked to poor prognosis in cHL,156 and a recent study using c-kit/CD117 IHC was able to link the number of mast cells to unfavorable outcome after primary therapy157; however, these data have yet to be validated. These factors affecting HRS cells and the microenvironment as assessed by routine histopathology are of interest. However, none has yet had an impact on clinical practice.
MACROPHAGES
Some of the rst biomarker studies in the modern treatment era were conducted in the 1980s and suggested that increased numbers of
macrophages, as measured using peanut agglutinin binding cells, were associated with more frequent constitutional symptoms and relapse.141,158 The association of macrophages with adverse treatment outcome has now been conrmed in an increasing number of patient cohorts. In a gene expression proling study investigating the microenvironment, the authors found several genes expressed by macrophages, including STAT1 and ALDH1A1, to be signicantly correlated with disease-specic survival when investigated by IHC.142 The importance of these markers was also conrmed in an independent patient cohort using quantitative reverse-transcriptase polymerase chain reaction from archival parafn material.131 However, it was not conrmed in a second study by the same group, in which the authors found a correlation of the macrophage activation genes LYZ and STAT1 with favorable outcome.159 Most recently, tumor tissue signatures of monocytes and tumor-associated macrophages were found by gene expression proling in patients with therapy-refractory disease or relapse when compared with patients who sustained longterm remissions.132 Most importantly, in independent validation experiments, the authors demonstrated that the enumeration of CD68 macrophages in lymph node biopsies was a strong and independent predictor of disease-specic survival. These data are encouraging; in this study, it could be demonstrated that the number of CD68 macrophages was also signicantly associated with the outcome of secondary treatments such as autologous stem-cell transplantation. Overall, the adverse prognostic impact of tumor-associated macrophages in cHL biopsies can now be considered as rmly established in patients treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) or ABVD-like chemotherapy regimens. The correlation of tumor-associated macrophages with adverse clinical course and tumor progression has also been reported in follicular lymphoma160 and many other solid tumors in which macrophages stimulate tumor growth, angiogenesis, tumor cell migration, and invasion.62
T-CELL SUBSETS
nosis. Accordingly, high ratios of FOXP3/TIA-1 T cells138 were associated with favorable event- and disease-free survival and OS, whereas high ratios of FOXP3/GrB cells137 were shown to be associated with favorable failure-free survival and OS. The correlation of high numbers of intratumoral FOXP3 regulatory cells with OS and failure-free survival was validated in a subsequent study.139 In contrast, high numbers of regulatory T cells have mostly been reported to be associated with unfavorable outcome in various solid tumors.162 The reason for these unexpected ndings remains unclear. In an attempt to link T-cell inltration to the specic biology of HRS cells, the prognostically favorable low number of cytotoxic cells (CD8 T lymphocytes, CD57 NK cells, and GrB cells) was linked to overexpression of antiapoptotic proteins in HRS cells.163 Interestingly, recent work has shown that lack of HLA class II cell-surface expression on HRS cells was frequently observed, and this nding was associated with EBV-negative disease status, HLA class I loss, and adverse outcome in multivariate analysis.123 However, because loss of HLA class II likely leads to diminished activation of TH1 cells and thereby a reduced cytotoxic antitumor response, the exact functional mechanisms remain to be claried linking increased numbers of intratumoral CTLs with unfavorable outcome. Furthermore, signatures of cytotoxic T cells have been identied using gene expression proling, suggesting that overexpression of certain T-cell activation genes such as CD8B1, CD3D, CTSL, CD26, and SH2D1A might be correlated with inferior outcome.131,132,142 Additional biomarker studies investigating the prognostic impact of T-cell subsets together with tumor-associated macrophages are anticipated to address the question of whether combinations of IHC markers with well-established clinical risk factors might further improve the predictive value of a single biomarker alone.
BACKGROUND B CELLS
Another biomarker in the microenvironment of HL was described by Oudejans et al,134 who found that an increased number of activated CTLs in tissue biopsies of patients was associated with unfavorable clinical outcome. The authors used granzyme B (GrB) as an IHC marker and found GrB-expressing cells in the vast majority of patients, but they showed that patients with more than 15% GrB cells had signicantly shorter progression-free survival and OS. In a subsequent study of 83 patients with cHL using GrB IHC, this same factor was found to correlate with OS and to be independent of both age and stage in multivariate analysis.135 Several subsequent studies by independent groups validated these initial studies of CTLs as useful predictors of prognosis in cHL but also identied other T-cell subsets associated with treatment outcome.133,135-138,157,161 Despite this earlier work, the most useful T-cell marker combination for determining prognosis using IHC is still a subject of debate. In a large series of 257 patients with cHL represented on a tissue microarray, the number of FOXP3 Treg cells correlated with prolonged event- and disease-free survival, and the authors were able to validate the negative prognostic impact of CTLs.138 However, in this study, TIA-1another cytotoxic granule markerwas used to enumerate CTLs, and the number of GrB-activated CTLs was not signicantly associated with poor prog8
Recently, the number of CD20 background B cells was reported to be signicantly associated with treatment outcome in two independent studies.132,140 Both studies found an overrepresentation of signatures of benign B cells in diagnostic biopsies of patients whose primary treatments were successful and were able to demonstrate using CD20 IHC signicant correlations with OS and disease-specic survival, respectively. Although in one study the prognostic impact of the number of CD20 background B cells on OS was independent of clinical parameters,140 the second study found a strong correlation of CD20 cells with clinical stage.72 Interestingly, another marker expressed on B cellsBCL11Awas an even better predictor for OS, possibly because of an association of BCL11A plasmacytoid dendritic cells with favorable outcome.
FOLLICULAR DENDRITIC CELLS
The presence and distribution of follicular dendritic cells (FDCs) have been studied in both cHL and NLPHL using IHC.164,165 These studies reveal the close spatial relationship of HRS and LP cells with the FDC network. In one study of cHL, the authors reported a correlation between the absence of FDCs and unfavorable outcome.166 In a follow-up study, the association with outcome was validated, but only in the context of certain patterns of CD21 FDC staining.167 The
longest OS was observed in patients with well-dened follicle-like structures compared with visible but largely destroyed FDC meshworks (intermediate survival) and absence of FDCs (poor survival). These data suggest that not only the number of FDCs but also the level of destruction of normal lymph node architecture might be an important variable for outcome prediction.
EBV ASSOCIATION
EBV infection of HRS cells occurs in up to 60% of patients in some studies but varies with geographic location, age, sex, clinical stage, and histologic type.168 Recent gene expression proling data have shed more light on immune-related cells in EBV-positive versus EBV-negative disease, specically identifying a TH1/antiviral response in EBV-positive patients.140 Furthermore, an increased number of cytotoxic T cells has been linked to EBV positivity.134 The impact of EBV infection on outcome is controversial, with some studies showing no impact150,169 and others favorable143,170 or unfavorable outcomes.144,145 These discrepancies might result in part from patient selection and confounding differences in demographic factors, because there is an increasing body of work supporting an association between EBV positivity and adverse outcome in older adult patients144-146 and a favorable effect in younger, specically pediatric, patients.143,144,147 Additional studies might clarify the clinical value of these ndings; the apparent age dependence has hampered the translation of EBV status into a widely used biomarker.
SERUM MARKERS
IHC, including tissue-associated macrophages, background reactive B cells, and CTLs132,140,142; however, conrmation is still needed for others (Table 2). Of note, the prognostic implications of angiogenesis, adipoctyes, and dendritic cells have been studied in other lymphomas.179-181 Proteomic studies have recently been performed in HL. Two approaches have been chosen thus far, one using total cell lysates, the other studying the secretome of HRS cells.40,182,183 These studies have demonstrated the potential value for developing novel diagnostic tools by identifying specic proles linked to certain lymphoma entities and have helped to characterize secreted proteins that are critically involved in the crosstalk of HRS cells with their microenvironment.40 However, no outcome correlations have been described to date. Only one study has investigated correlations of a micro-RNA prole, which was previously found in HL,184 with outcome. The authors found that miR-135a expression was associated with a higher probability of relapse and shorter disease-free survival.185
THERAPEUTIC APPROACHES TARGETING THE TUMOR MICROENVIRONMENT
It has been shown that certain cytokines, chemokines, and other soluble factors are detectable in the sera of patients with HL, and multiple studies have focused on the negative prognostic impact of these molecules.17,171,172 In general, increased levels of these serum markers can be interpreted as surrogates for active crosstalk between HRS cells and their microenvironment. Characteristically, many of those markers, including sCD30, serum IL-2 receptor, soluble intercellular adhesion molecule (sCD54), and vascular cell adhesion molecule 1 (sCD106), have shown correlations to one another, and elevated levels have been reported to be associated with advanced tumor stage and unfavorable prognosis.173-176 Although all these markers have shown prognostic signicance, their independent value in comparison with the established clinical surrogate markers for tumor burden and disease activity has not been convincingly demonstrated.
GENOME-WIDE STUDIES
Gene expression proling studies have contributed substantially to improved understanding of the disease with respect to the inherent phenotypic features of malignant HRS cells177,178 and the specic composition of the microenvironment.132,140,142,148 Using the unbiased approach of transcriptome-wide gene expression proling, gene signatures have been identied that correlate with failure or success after primary treatments. Many of these signatures can be related to cellular compartments represented in whole-tissue biopsies. Some of these signatures have been subsequently validated by
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Although HL is overall a successfully treated disease, treatment failure in a substantial proportion of patients and treatment-related early and late sequelae of chemotherapy and radiotherapy underscore the need for novel therapeutic approaches, especially for relapsed HL. No new drugs have been approved for HL in the past two decades186; however, many agents are being tested in preclinical studies and currently enrolling active trials. Table 3 lists a selection of novel therapeutic agents in HL that are thought to target reactive cells in the microenvironment or surface receptors on the malignant cells or to interfere with downstream receptor signaling. The concept that the tumor microenvironment might be a promising therapeutic target has been reinforced by reports in relapsed HL about the efcacy of the pyrimidine analog gemcitabine,210 a cytotoxic agent that has been reported to specically target Treg cells.211 Furthermore, the results of a study combining the anti-CD20 monoclonal antibody rituximab with gemcitabine in relapsed HL are encouraging and suggest that a combined treatment targeting reactive B and T cells in the microenvironment might be an effective approach.188 Trials targeting CD20 B cells using radioimmunoconjugates have been initiated.191 However, it remains controversial if the efcacy of anti-CD20 immunotherapy results from the direct killing of HRS cells that do occasionally express CD20212 or from the depletion of HRS cellsupporting reactive B cells in the microenvironment.187 Of note, two gene expression proling studies have observed a correlation between increased numbers of background B cells and favorable prognosis, a nding that needs further clarication in the context of rituximab treatment.132,140 Support for a direct effect on HRS cells also comes from a recent study suggesting that HRS progenitor cells might express CD20 on their surface and could be eradicated by rituximab.213 Unequivocally, treatment effects in NLPHL have been attributed to a direct effect on the CD20-expressing LP cells.189,190 Other antibodies with a predominant effect on the microenvironment that are currently being tested in clinical trials including patients with HL are represented by alemtuzumab (anti CD52)193 and galiximab (antiCD80).192 Furthermore, immunotherapy with EBV-specic cytotoxic
Table 3. Selected Therapeutic Agents in Hodgkins Lymphoma and Their Presumed Targets Drug Cellular targets in microenvironment Rituximab
131
Main Target CD20 CD20 CD20 CD20 CD20 CD20 CD80 B cells HRS cells (LP cells) B cells HRS cells (LP cells) B cells HRS cells (LP cells) B cells, follicular dendritic cells, HRS cells
Reference No./Clinical Trial No. 187-190 NCT00484874 191 192 NCT00516217 193 NCT01030900 194 NCT00284804 195,196 NCT00947856, NCT01100502, NCT01060904 197 NCT00791011 198 NCT00670592 199 NCT00967044 200-202 NCT00439361 203,204 205 NCT00742027 206,207 NCT00540007 208,209
Itositumomab
90
Yibritumomab tiuxetan
Galiximab Alemtuzumab Receptor signaling on HRS cells MDX-060 SGN-35 AMG655 HCD122 Downstream signaling Everolimus Bortezomib Vorinostat Panobinostat Other Lenalidomide Cytotoxic T lymphocytes
CD52 cells in microenvironment
CD30 HRS cells CD30 HRS cells TNFRSF10B (TRAIL-R2) on HRS cells CD40 HRS cells, TH2/Treg signaling
TNFR signaling: PI3K, mTOR NFB signaling: inhibition of degradation of IB Histone modication, JAK-STAT signaling (pSTAT6) Histone modication
Immunomodulation, anti-angiogenic EBV-positive disease: viral LMP2
NOTE. US Food and Drug Administration clinical trail numbers according to http://clinicaltrials.gov. Abbreviations: HRS, Hodgkin Reed-Sternberg; LP, lymphocyte predominant; TNFRSF, tumor necrosis factor receptor superfamily; TH, T helper cell; Treg, T regulatory cell; PI3K, phosphoinositide 3-kinase; mTOR, mechanistic target of rapamycin; NFB, nuclear factor kappa B; IB, inhibitory kappa B; JAK-STAT, Janus kinasesignal transducer and activator of transcription signaling; EBV, Epstein-Barr virus; LMP2, latent membrane protein 2.
effector cells has shown promising results, providing proof of principle for adoptive immunotherapy with ex vivo expanded viral antigenspecic T cells.208 Remarkably, in a subsequent study, ve of six patients with relapsed HL had a tumor response; of these ve, four achieved complete remissions that were sustained for more than 9 months.209 Because of the increased expression of members of the TNF receptor family and the dependence of malignant cells on TNF receptor downstream signaling, these molecules are considered ideal targets for specic agents in HL. TNFRSF8 (CD30) in particular has been the target of a number of preclinical and clinical studies, of which the anti-CD30 compounds SGN-30 and MDX060 can be considered representative but disappointing in phase I/II clinical trials194,214 because of limited efcacy in relapsed disease. However, using an alternative strategy of conjugating an anti-CD30 antibody with the cytotoxic antimicrotubule agent monomethyl auristatin E (ie, SGN-35 or brentuximab vedotin),195 much higher partial and complete remission rates were achieved.196 It is noteworthy that in a heavily pretreated patient cohort, tumor reductions were documented in more than 80% of patients. As a result, additional clinical trials with brentuximab vedotin as a
10
single agent and in combination with ABVD are currently recruiting. An anti-CD40 (TNFRSF5) antibody (HCD122198) trial and a study of the combination bortezomib with agonistic antiTNFrelated apoptosis-inducing ligand receptor 2 (TNFRSF10B) compound AMG655197 are enrolling patients with HL; however, results are still pending. A number of novel drugs have downstream receptor signaling as their primary targets, of which everolimus (mammalian target of rapamycin, phosphoinositide 3-kinase pathway),199 bortezomib (TNFR signaling, NFB pathway),200 and vorinostat (STAT6, IL signaling)204 have shown promising preclinical results. Of these, however, bortezomib as a single agent in relapsed HL had low clinical efcacy.202 Combination therapies are now being tested. In summary, therapies targeting cells in the microenvironment or disrupting microenvironment-dependent signaling in the malignant cells seem to be effective and show promise in patients with relapsed HL. Current clinical trials are also focusing on combination therapies with classical chemotherapy agents. Randomized trials comparing these novel agents with the current standard of care for rstand second-line therapies will ultimately determine their signicance in the overall landscape of HL treatment.
AUTHORS DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conicts of interest.
AUTHOR CONTRIBUTIONS
Manuscript writing: All authors Final approval of manuscript: All authors
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Acknowledgment We thank Sibrand Poppema, MD, PhD, for his many contributions to the eld and for reviewing this manuscript prior to submission.
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Published Ahead of Print on April 11, 2011 as 10.1200/JCO.2010.32.8401 The latest version is at http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2010.32.

JOURNAL OF CLINICAL ONCOLOGY

Copyright 2011 by American Society of Clinical Oncology

Steidl, Connors, and Gascoyne

Fibroblast Fibroblast Mast cell CCL11/ Eotaxin Eosinophil

BLC CCL5 IL-4

TNF- LT- TGF- APRIL BAFF

HRS cell IL-5 MEC

T cell (Treg /TH2)

TARC MDC CD40L CCL20 IFN

PDL1 CX3CL1 CSF1

IL-2 Plasma cell IL8 T cell (TH1)

Microenvironment in Hodgkins Lymphoma

AUTOCRINE AND PARACRINE RECEPTOR SIGNALING BY HRS CELLS

COMPOSITION OF THE MICROENVIRONMENT

Steidl, Connors, and Gascoyne

2011 by American Society of Clinical Oncology

JOURNAL OF CLINICAL ONCOLOGY

Microenvironment in Hodgkins Lymphoma

Tyrosine receptor kinases

HGF NGF collagen type I

IL-2R IL-3R IL-6R IL-7R I IL-13R

CD40 TNFR1/2 RANK CD30

c M c-MET TRKA DDR2

STAT JAK1 JAK2 JAK3 TYK2

SHP2 GAB1 GRB2 SOS PI3K

NEMO IKK IKK

STAT-3 STAT-5 STAT-6

STAT dimers/ oligomers

IB complex IB IB p50 RELA NFB complex Proteasomal degradation

Transcriptional regulation: - Inflammation - Survival - Cell proliferation - Differentiation

Apoptosis, cell cycle control, protein synthesis, DNA damage repair

Steidl, Connors, and Gascoyne

Microenvironment in Hodgkins Lymphoma

123 132,141 142 143-147

HRS cells, macrophages, endothelial cells, extracellular

Tissue remodeling Gene Expression Proling

Reference No. 132 132 142,148

B-cell signature Cytotoxic T-cell signature

Plasmacytoid dendritic cells Macrophage signature

Steidl, Connors, and Gascoyne

Microenvironment in Hodgkins Lymphoma

THERAPEUTIC APPROACHES TARGETING THE TUMOR MICROENVIRONMENT

Steidl, Connors, and Gascoyne

CD52 cells in microenvironment

Immunomodulation, anti-angiogenic EBV-positive disease: viral LMP2

Microenvironment in Hodgkins Lymphoma

AUTHORS DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

2011 by American Society of Clinical Oncology

Steidl, Connors, and Gascoyne

2011 by American Society of Clinical Oncology

Microenvironment in Hodgkins Lymphoma

Steidl, Connors, and Gascoyne

2011 by American Society of Clinical Oncology

Microenvironment in Hodgkins Lymphoma

2011 by American Society of Clinical Oncology

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