15th Milan Breast Cancer Conference
Adjunct therapy for lymphoma
Dr Giancarlo Pruneri - European Institute of Oncology, Milan, Italy
For lymphoma now we have quite a wide range of adjuncts, especially from the genomic point of view. Because we are able to identify very specific genomic lesions in the lymphomas, for example the classical translocation of the cyclin D1, and we can do that in formalin fixed paraffin embedded tissue so we do not need to have quite complex logistics with fresh tissue or biobanking of the tissue. But we are able to identify the specific lesions in very tiny pieces of the lymph node. So we decided to change quite dramatically the way we do the diagnosis of lymphoma. For the time being most of the hematopathologists prefer to have the surgical excision of the lymph node but that means that we need to have the patient operated. So, as you can imagine, this is a matter of anxiety for the patient and also a cost for the public health system. So we prefer to do a diagnosis of lymphoma by using lymph node biopsies. So we take a very small fragment of the lymph node and by using this small fragment of the lymph node we are able to identify all the morphological, phenotypical and genomic lesions of the lymphoma so we are able to render a diagnosis. We are very confident that this method is very useful for the patients because lymphoma is quite different from other kinds of tumour because, for example for some kinds of tumours, for the epithelial tumours, the operating theatre is a way by which the patient is cured. But for lymphoma this is completely different because we need to operate on the patient by using the old way just to have the diagnosis. The path of the patient starts when we render the diagnosis so the patient is operated and then we tell him or her now we can treat you. At the opposite, by using the biopsies of the lymph node we can do that in one or two days, one or two working days, the patient is not hospitalised and so we can start very quickly the treatment of the patient.
Of course this method has, as a matter, a number of downsides. For example, in our experience we have to re-operate a fraction of the patients because in some cases we are not able to discriminate between an inflammatory lesion or a lymphoma and so in this case the patient may be operated. But in most of the cases of the most common histotypes of lymphoma, diffuse large B-cell lymphoma, follicular lymphoma, Hodgkin’s lymphoma, we are quite confident that we can do the diagnosis just by using a small biopsy. This in my opinion is quite dramatically changing the clinical practice in this field.
Are there more subtypes of lymphoma to identify because of this?
We are able to render a diagnosis of lymphoma so we are able to discriminate between a tumoural process and an inflammatory process. Then we are able in most of the cases to distinguish between the different subtypes of lymphoma quite easily because it is quite different from the past because in the past we had just the light microscope. So we should have the lymph node just in order to evaluate all the morphological features of the lymph node. Now there are some hallmarks that are genomic hallmarks so we do not need to have that kind of precision in the morphological analysis of the lymph node. You can do just a quite quick, a quite fast, evaluation of the lymph node by a morphological point of view and then we can apply the new genomic tools just in order to pinpoint, to hallmark, the alteration. If I have just five cells, ten cells, one hundred cells, that is not the case because in our experience our radiologists are quite skilled so they are able to give us quite a sufficient amount of material. But even if we have quite a small biopsy, one hundred cells for example, whenever these cells carry the hallmark translocation, for example of the mantle cell lymphoma, to me it’s a mantle cell lymphoma. Then we can put together the clinical features, the histological features, the genomic features and we can just brainstorm and can decide together with the clinicians that the patient should be treated with a therapy.
This is very useful, in my opinion, for the aggressive lymphomas, especially for the lymphoma, for example, arising in the mediastinum where you should treat the patient with an operation just to have a diagnosis and these patients may be a problem for the oncologist because they may have some cardiac event. So it is very, very useful for them to have a diagnosis just by taking a piece of the tissue with a biopsy.
Are there any new or developing therapies?
New therapies for lymphoma, now in lymphomas because, you know, lymphoma was a pilot tumour in the past because we were able to identify new genomic lesions in the blood of the patients so we could have quite easily the samples in order to do all the analyses we need to do. So, for example, we find that imatinib, that is one of the first targeted therapies for patients with… this is not a lymphoma but it’s a chronic myeloid leukaemia, and so it was a completely new therapy in the field of oncology using targeted therapy instead of a chemotherapy. But then there were no news for some decades at least and now we are starting evaluating the drugs that are capable to block some specific pathways that are activated in lymphomas as happens, for example, in breast cancer where we are able to identify some specific genomic lesions and then treat them with specific targeted therapy. This is the beginning also in lymphoma with quite exciting clinical trials in difficult histotypes of lymphoma such as mantle cell lymphoma which still has a poor prognosis.