Impact of Cell-of-Origin and MYC/BCL2 Status on the Risk of Central Nervous System Relapse in Primary Breast Diffuse Large B-Cell Lymphoma

Chang-Hoon Lee; Ga-Young Song; Ho-Young Yhim; Dok Hyun Yoon; Kyu Yun Jang; Sang Eun Yoon; Jin Seok Kim; Jeong-Ok Lee; Hyeon-Seok Eom; Hyewon Lee; Kyoung Ha Kim; Ka-Won Kang; Young Rok Do; Soon Il Lee; Han Sang Lee; Hyo Jung Kim; Ae Ri Ahn; Deok-Hwan Yang; Won Seog Kim; Jae-Yong Kwak

doi:10.4143/crt.2025.836

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Original Article Impact of Cell-of-Origin and MYC/BCL2 Status on the Risk of Central Nervous System Relapse in Primary Breast Diffuse Large B-Cell Lymphoma: Chang-Hoon Lee^1,2, Ga-Young Song³, Ho-Young Yhim^1,2, Dok Hyun Yoon⁴, Kyu Yun Jang⁵, Sang Eun Yoon⁶, Jin Seok Kim⁷, Jeong-Ok Lee⁸, Hyeon-Seok Eom⁹, Hyewon Lee⁹, Kyoung Ha Kim¹⁰, Ka-Won Kang¹¹, Young Rok Do¹², Soon Il Lee¹³, Han Sang Lee¹³, Hyo Jung Kim¹⁴, Ae Ri Ahn⁵, Deok-Hwan Yang³, Won Seog Kim⁶, Jae-Yong Kwak^1,2; DOI: https://doi.org/10.4143/crt.2025.836
Published online: November 5, 2025

¹Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Korea

²Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea

³Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea

⁴Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

⁵Department of Pathology, Jeonbuk National University Medical School, Jeonju, Korea

⁶Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

⁷Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea

⁸Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

⁹Department of Internal Medicine, Center for Hematologic Malignancies, National Cancer Center, Goyang, Korea

¹⁰Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea

¹¹Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea

¹²Department of Internal Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea

¹³Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea

¹⁴Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea

Correspondence: Ho-Young Yhim, Department of Internal Medicine, Jeonbuk National University Medical School, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea
Tel: 82-63-250-2523 E-mail: yhimhy@jbnu.ac.kr

*Chang-Hoon Lee and Ga-Young Song contributed equally to this work.
*This study was presented in part as an abstract for the 64th American Society of Hematology Annual Meeting, New Orleans, LA, December 10-13, 2022.

• Received: August 5, 2025 • Accepted: November 3, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

Purpose
Primary breast diffuse large B-cell lymphoma (DLBCL) is a rare entity with a distinct relapse pattern involving the central nervous system (CNS). However, data regarding predictors of CNS relapse in this population remain limited.
Materials and Methods
CNS relapse was retrospectively analyzed in two multicenter cohorts comprising 53 patients with newly diagnosed primary breast DLBCL, including a prospective trial and real-world cohort, all treated with rituximab-based immunochemotherapy. The impact of baseline clinical parameters, cell-of-origin, and MYC/BCL2 dual expression (DE) status on CNS relapse was assessed using a multivariate Cox regression model, separately conducted for the overall study set (n=53) and the immunohistochemical study set (n=36).
Results
By the CNS-International Prognostic Index (CNS-IPI), most patients were classified as low or intermediate risk; no patients were classified as high risk. With a median follow-up of 58.8 months, the 4-year risk of CNS relapse was 15.6% in the overall study set and 14.2% in the immunohistochemical set. MYC/BCL2 DE was identified in 14 patients (38.9%) and was significantly associated with increased risk of CNS relapse (4-year risk, 30.7% vs. 0%, p=0.001). Patients with non-germinal center B-cell–like subtype had a numerically higher risk of CNS relapse. However, in multivariate analysis, only MYC/BCL2 DE status was associated with CNS relapse. Synchronous bilateral involvement was also an independent predictor of CNS relapse in both study sets. CNS-IPI was not discriminatory for CNS relapse.
Conclusion
MYC/BCL2 DE and synchronous bilateral breast involvement may help identify patients at higher risk for CNS relapse. Further studies are warranted.
Key words: Primary breast diffuse large B-cell lymphoma, Central nervous system, Recurrence, Immunohistochemistry, MYC/BCL2 dual expression, Cell-of-origin

Introduction

Primary breast diffuse large B-cell lymphoma (DLBCL) is a rare extranodal subtype of non-Hodgkin lymphoma, accounting for less than 3% of all extranodal lymphomas [1,2]. It predominantly affects middle-aged to elderly women and presents most commonly as a unilateral breast mass [3-9]. Although it usually manifests as localized stage disease, primary breast DLBCL has been associated with less favorable clinical outcomes compared to nodal DLBCL [4,6,7]. In addition, this entity exhibits a distinct treatment failure pattern, with disease relapse frequently occurring at extranodal sites such as the ipsilateral or contralateral breast or the central nervous system (CNS), highlighting its characteristic tendency for extranodal dissemination [3-10].

CNS relapse remains a rare but devastating complication in DLBCL [11,12]. Numerous studies have explored the incidence and associated risk factors for CNS relapse, including clinical features such as extranodal involvement > 1 site [13], elevated lactate dehydrogenase (LDH) levels [14], Eastern Cooperative Oncology Group performance status ≥ 2 [14], and specific extranodal involvements [15,16]. These clinical parameters have been collectively incorporated into the CNS–International Prognostic Index (CNS-IPI), a scoring system proposed to predict the risk of CNS relapse [11]. Moreover, non-germinal center B-cell–like (non-GCB)/activated B-cell–like (ABC) cell-of-origin (COO) subtypes [17,18] and biological aberrations such as MYC and BCL2 protein dual expression (DE) [17] or rearrangements [19] have been associated with a heightened risk of CNS relapse in nodal DLBCL. However, the CNS-IPI has limited utility in primary breast DLBCL [3], and reliable biologic predictors for CNS relapse are lacking. To date, no biologic correlative study has specifically addressed the risk of CNS relapse in primary breast DLBCL, a distinct clinicopathologic entity with a proclivity toward CNS involvement.

Herein, we investigated the incidence and risk factors for CNS relapse in patients with newly diagnosed primary breast DLBCL using data from prospective trial and real-world practice. We aimed to identify clinical and immunohistochemical (IHC) predictors of CNS relapse in our dataset, with particular focus on COO classification and MYC/BCL2 DE.

Materials and Methods

1. Study design and patients

Two independent cohorts were screened for eligibility to construct two distinct datasets for analysis. Cohort 1 included patients with newly diagnosed primary breast DLBCL who were enrolled in a multicenter, single-arm, phase 2 clinical trial (NCT01448096) conducted by the Consortium for Improving Survival of Lymphoma (CISL) between January 2012 and July 2017. This trial design was described in full elsewhere [3]. Briefly, patients received six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) combined with four doses of prophylactic intrathecal methotrexate. Eligibility criteria for this trial included histologically confirmed primary breast DLBCL, defined as lymphoma involving the breast as the major extranodal site with or without nodal involvement [20], and age between 20 and 75 years. Patients with baseline CNS involvement or evidence of disseminated extranodal disease were excluded. Cohort 2 included patients with histologically confirmed primary breast DLBCL, diagnosed between January 2012 and December 2020, who were treated with R-CHOP or similar immunochemotherapy at institutions participating in the CISL network outside of clinical trials. Except for the absence of an age restriction in cohort 2, the inclusion and exclusion criteria for this retrospective cohort were consistent with those of the phase 2 trial. Based on these two cohorts, we defined the overall study set as patients with available clinical data and the IHC study set as patients for whom formalin-fixed paraffin-embedded (FFPE) tumor specimens, obtained at initial diagnosis, were available for IHC assessment of COO and MYC/BCL2 protein expression status.

2. Treatment and assessment

Patients in cohort 1 received six 21-day cycles of standard R-CHOP, with methotrexate (12 mg) administered intrathecally on day 1 or 2 of the first four cycles as CNS prophylaxis. Radiotherapy was not routinely administered and was reserved for patients with bulky disease or residual lesions on end-of-treatment imaging. Treatment protocols in cohort 2 followed institutional standards and were based on R-CHOP or similar regimens, without predefined protocols for CNS prophylaxis or radiotherapy. Data regarding the administration of prophylactic methotrexate, use of radiotherapy, treatments, and clinical outcomes were retrospectively collected using a study-specific case report form for cohort 2.

Pretreatment evaluations included complete blood count, serum biochemistry, LDH levels, computed tomography (CT) of the chest, abdomen, and pelvis, fluorodeoxyglucose–positron emission tomography (PET), and bone marrow aspiration and biopsy. CNS involvement at baseline was excluded through clinical evaluation, cerebrospinal fluid cytology, and, where indicated, neuroimaging. The IPI and CNS-IPI [11] were calculated to determine prognosis and the risk of CNS relapse. Tumor response was assessed according to the Lugano 2014 criteria [21]. In cohort 1, PET-CT was performed at baseline, after three cycles, and at the end of treatment, whereas cohort 2 assessments followed local practice standards. CNS relapse was defined as imaging and/or cytological confirmation of CNS involvement in patients with clinical suspicion.

3. COO, immunohistochemistry and fluorescence in situ hybridization analyses

Diagnostic histology for all cases included in this study was reviewed and confirmed by two experienced hematopathologists (K.Y.J. and A.R.A.). All IHC analyses were centrally performed on diagnostic FFPE tissue sections using standard protocols [22]. The IHC slides were reviewed independently by two hematopathologists who were blinded to patients’ clinical outcomes. Each reviewer semiquantitatively scored the percentage of positively stained tumor cells in 5% increments. Any discrepancies between the reviewers were resolved through joint review and consensus on a multiheaded microscope. The COO subtype was determined according to the Hans algorithm [23], based on CD10 (clone 56C6, Novocastra), BCL6 (LN22, Novocastra), and MUM1 (MUM1p, Dako) expression. DE was defined by concurrent MYC (Y69, Ventana Medical Systems) and BCL2 (124, Ventana Medical Systems) protein overexpression, using ≥ 40% positivity for MYC and ≥ 50% for BCL2 as cutoff values [17]. Interphase fluorescence in situ hybridization (FISH) analysis for MYC gene rearrangement was centrally performed using the Vysis LSI MYC Dual Color Break Apart Rearrangement Probe (Abbott Molecular) in cases where sufficient FFPE tissues were available. At least 100 nuclei were evaluated, and MYC rearrangement was defined as the break-apart signals in ≥ 10%. In cases with MYC rearrangement, additional FISH testing to detect BCL2 and BCL6 rearrangement was performed using Vysis LSI BCL2 and BCL6 Dual Color Break Apart Rearrangement Probes (Abbott Molecular). Double-hit or triple-hit lymphoma was defined as concurrent rearrangement of MYC and BCL2 and/or BCL6.

4. Statistical analyses

The primary endpoint of this study was the cumulative rate of CNS relapse, defined as the time from diagnosis to the documentation of CNS involvement. Secondary endpoints included progression-free survival (PFS) and overall survival (OS). Time-to-event outcomes, including cumulative rate of CNS relapse, PFS, and OS, were estimated using the Kaplan-Meier method, and comparisons between groups were performed using the log-rank test. To identify potential risk factors for CNS relapse, univariate and multivariate Cox proportional hazards regression analyses were conducted separately in the overall and IHC study sets. Variables with p < 0.10 in the univariate analysis were included in the multivariate model. Descriptive statistics were presented as percentages for categorical variables and as medians with interquartile ranges (IQRs) for continuous variables. All statistical analyses were performed using R ver. 4.2.0. (R Foundation for Statistical Computing; http://www.r-project.org).

Results

1. Patient characteristics

A total of 53 patients with primary breast DLBCL were identified across two cohorts and included in the overall study set (Fig. 1). Of these, 33 patients were enrolled in a prospective phase 2 trial (cohort 1), and 20 were retrospectively identified from seven institutions (cohort 2). Among them, diagnostic FFPE tissue sufficient for histopathologic analysis was available for 36 patients, comprising the IHC study set. The primary reasons for exclusion from the IHC study set included lack of tumor material (n=8), institutional administrative restrictions (n=7), and patients’ refusal to provide archival tissue for additional testing (n=2).

Baseline clinical characteristics of the overall and IHC study sets are summarized in Table 1. The baseline characteristics and outcomes of patients included versus excluded from the IHC study set were generally comparable, suggesting that the IHC study set was reasonably representative of the overall population (S1 Table). The median age was 55 years in the overall study set and 57 years in the IHC study set, with all patients being female. Most patients presented with localized stage disease, unilateral breast involvement, and good performance status. Elevated serum LDH level was observed in approximately one-quarter of patients, and the majority had low or intermediate risk by CNS-IPI. Synchronous bilateral breast involvement was found in three patients (5.7%) of overall set and in two patients (5.6%) in IHC study set. Nearly all patients received CNS prophylaxis, predominantly with intrathecal methotrexate (12-15 mg, 4-6 doses), while a small subset received intravenous high-dose methotrexate (2.5-3 g/m²) twice—after cycle 2 and at the end of R-CHOP. The median follow-up duration was 58.8 months (IQR, 30.3 to 72.9) for the overall study set and 54.4 months (IQR, 20.5 to 71.7) for the IHC study set. The 4-year PFS and OS rates in the overall set were 78.2% (95% confidence interval [CI], 63.0 to 87.7) and 85.5% (95% CI, 70.1 to 93.3), respectively. In the IHC study set, the 4-year PFS and OS rates were 83.6% (95% CI, 64.7 to 92.9) and 89.8% (95% CI, 71.4 to 96.6), respectively.

2. Incidence and patterns of CNS relapse

CNS relapse occurred in seven patients in the overall study set and in four patients in the IHC study set. The 4-year cumulative incidence of CNS relapse was 15.6% (95% CI, 6.7 to 27.9) in the overall set and 14.2% (95% CI, 0.4 to 26.3) in the IHC study set (Fig. 2A and B). The median time to CNS relapse was 19.2 months (range, 6.6 to 39.3 months) in the overall set and 18.2 months (range, 6.6 to 39.3 months) in the IHC study set. All but one CNS relapse occurred within the first two years of initial diagnosis. Approximately half of the CNS relapses occurred as isolated CNS events, while the remaining CNS relapses were accompanied by concurrent systemic progression. The distribution of CNS involvement sites is described in Table 2. These findings suggest a continued risk of CNS relapse in patients with primary breast DLBCL, even with the use of traditional intrathecal or systemic methotrexate prophylaxis.

3. COO, MYC/BCL2 DE status, and CNS relapse risk

Among the 36 patients in the IHC study set, the majority (n=30, 83.3%) were classified as the non-GCB subtype according to the Hans algorithm, while six patients (16.7%) were categorized as GCB. MYC/BCL2 DE was identified in 14 patients (38.9%), of whom 13 were non-GCB. All four CNS relapse events occurred exclusively in patients with MYC/BCL2 DE and the non-GCB subtype (Fig. 2C). However, there was no statistically significant difference in the cumulative incidence of CNS relapse according to COO classification (non-GCB vs. GCB; 17.4% [95% CI, 0 to 31.9] vs. 0%; hazard ratio [HR], 28.11 [95% CI, not applicable], p=0.105) (Table 3). In contrast, a significant difference in the 4-year cumulative incidence of CNS relapse was observed based on DE status (DE vs. non-DE, 30.7% [95% CI, 1.17 to 52.0] vs. 0%; HR 90.60 [95% CI, not applicable], p=0.001) (Table 3, Fig. 2D).

FISH analysis was performed in 20 patients with sufficient FFPE material. Only one patient harbored a MYC rearrangement, without concurrent BCL2 or BCL6 rearrangements, and thus none of the patients was classified as double-hit or triple-hit lymphoma. Notably, the patients with MYC rearrangement did not experience CNS relapse during follow-up.

Univariate analysis of CNS relapse was conducted separately for the overall and IHC study sets, including key baseline variables (Table 3). In the overall set, synchronous bilateral breast involvement was significantly associated with increased risk of CNS relapse, while the presence of B symptoms showed a trend toward heightened risk. In the IHC study set, synchronous bilateral breast involvement, bulky (> 10 cm) mass, intermediate-risk CNS-IPI, and MYC/BCL2 DE were significant variables associated with CNS relapse. To identify independent prognostic factors for predicting CNS relapse, multivariate Cox regression analysis were performed for each dataset, including variables with p < 0.10 in the univariate analysis. In the overall study set, synchronous bilateral breast involvement (HR, 3.37; 95% CI, 1.39 to 8.15) was an independent factor for predicting CNS relapse (Table 4). In the IHC study set, bilateral breast involvement (HR, 3.73; 95% CI, 1.28 to 10.86) and MYC/BCL2 DE (HR, 2.42×104; 95% CI, not applicable) were identified as independent predictors of CNS relapse (Table 4).

Discussion

In the present analysis, we investigated CNS relapse risk in patients with newly diagnosed primary breast DLBCL using both prospective trial and real-world cohorts, all treated with rituximab-based immunochemotherapy and predominantly receiving prophylactic intrathecal or systemic methotrexate. Although most patients received conventional CNS prophylaxis using intrathecal or systemic methotrexate, CNS relapse still occurred in approximately 15% of cases, with the majority of events developing within two years of diagnosis, consistent with previous reports [3-9]. Notably, CNS relapse occurred even in patients classified as low risk by CNS-IPI, and no patients in our dataset were classified as high risk, demonstrating the limitations of existing prognostic tools in this unique subset. Importantly, although validation studies are needed, we identified for the first time, to our knowledge, that MYC/BCL2 DE is an independent predictor of CNS relapse, while no cases of double-hit lymphoma were detected. These findings suggest the urgent need for studies on biologically informed risk stratification and the development of appropriate prophylactic strategies to improve CNS outcomes in high-risk patients with primary breast DLBCL.

Previous studies in nodal DLBCL have identified several biological features that may contribute to the risk of CNS relapse, including the COO [18], MYC/BCL2 DE [17], double-hit status [19], and dark zone lymphoma [24]. In the present study, MYC/BCL2 DE was identified as an independent predictor of CNS relapse. This finding is consistent with a report by Savage et al. [17], in which MYC and BCL2 co-expression by IHC was significantly associated with an increased risk of CNS relapse among patients treated with R-CHOP, independent of CNS-IPI and COO classification. These results suggest that MYC/BCL2 DE may serve as a biomarker for identifying patients at higher risk of CNS relapse in primary breast DLBCL.

Thirteen of the 14 DE patients were classified as non-GCB by IHC, consistent with previous reports that DE status is frequently associated with the non-GCB/ABC subtype [24-26]. Considering the frequent association between the non-GCB subtype and MYC/BCL2 co-expression, we explored whether the increased risk of CNS relapse might be related to the IHC-defined non-GCB subtype. Although the number of CNS relapses was numerically higher in patients with non-GCB subtype, we did not find a statistically significant difference in CNS relapse risk on multivariate analysis. This result should be interpreted with caution, as the small number of GCB cases (n=6) and absence of CNS relapse events in this group may have limited the statistical power to detect meaningful differences. Furthermore, the markedly high prevalence of the non-GCB subtype (83.3%) in our dataset, which is higher than that generally observed in other nodal DLBCL studies [17,18,27], may also have contributed to this finding. One possible explanation for this predominance is the genetic similarity of primary breast DLBCL to DLBCL of immune-privileged sites, where mutations such as MYD88 and CD79B are frequently observed [28]. Based on molecular classification of DLBCL, these alterations are enriched in the MCD/C5 genetic subtype, which is mostly classified as ABC or non-GCB [29,30]. Therefore, our dataset may inherently harbor a high proportion of CNS relapse-prone patients who are classified as non-GCB phenotype. Given that Bruton’s tyrosine kinase inhibitors have shown clinical activity in MCD-subtype DLBCL [31] and demonstrate adequate CNS penetration [32], these agents could be explored as potential preventive and therapeutic options for CNS relapse in this biologically defined subset of patients.

Double-hit or triple-hit lymphomas were identified in approximately 5% to 10% of nodal DLBCL cases [33]. However, data regarding their prevalence in primary breast DLBCL remain scarce. In our study, FISH analysis was conducted in 20 patients, and no cases of double-hit or triple-hit lymphoma were identified. Nevertheless, the small number of patients with sufficient tissue available for FISH testing limited the assessment of the incidence of double-hit or triple-hit lymphoma and their impact on the risk of CNS relapse.

Few clinical parameters have been associated with CNS relapse in primary breast DLBCL. Clinical parameters such as stage-modified IPI [5] and bulky disease [8] have been reported as potential risk predictors. However, these parameters have not been consistently validated across studies, and their predictive value remains uncertain. In contrast, our study demonstrated that synchronous bilateral breast disease appears to confer a higher risk of CNS relapse, which is in line with previous report [6]. This finding may suggest that bilateral breast disease at presentation indicates a more extensive burden of extranodal involvement, which may facilitate hematogenous dissemination to the CNS. Larger studies are needed to validate this observation and provide further insight.

Our study has several limitations. First, it was a retrospective analysis involving a relatively small number of patients, which may introduce unexpected selection bias and limit generalizability of the findings. Moreover, because of the small sample size, the number of patients who experienced CNS relapse events was also limited, with no events observed in the non-DE subgroup. This small number of CNS events might influence our results, as evidenced by the large HR estimates and wide range of CIs. Therefore, the findings should be interpreted with caution and considered exploratory rather than definitive. To address these limitations, future studies should focus on enrolling a larger patient population in a prospective manner, with systematic procurement of diagnostic tissue suitable for biomarker analysis. However, given the rarity of primary breast DLBCL, such studies may necessitate international collaboration, as conducting them within a single institution or an individual study group would be impractical. Second, our analysis focused specifically on the impact of DE status, COO, and double-hit status on the risk of CNS relapse. As a result, we were unable to conduct additional comprehensive genomic analyses. Recent genomic studies have shown that the MCD/C5 subtype, including rare extranodal DLBCL such as primary breast and testicular DLBCL, harbors a MYD88 mutation [29,30,34,35]. In addition, a recent study from the British Columbia group suggested that the presence of BCL6 and/or PDL rearrangements is associated with an increased risk of CNS relapse in testicular DLBCL, a well-known extranodal DLBCL with a high risk of CNS relapse [34]. Thus, comprehensive genomic analyses to identify genomic biomarkers in primary breast DLBCL are warranted to refine risk stratification. Nevertheless, given the limitations of current clinical risk models for predicting CNS relapse in primary breast DLBCL, our study is, to our knowledge, the first to demonstrate that MYC/BCL2 DE is a significant predictor of CNS relapse in this unique patient population.

In conclusion, CNS relapse occurred in a substantial proportion of patients who had received intrathecal or systemic methotrexate prophylaxis, with most events occurring within two years of diagnosis. While traditional clinical risk models, such as CNS-IPI, were not discriminatory in this unique subtype, our findings identify MYC/BCL2 DE as an independent predictor associated with an increased risk of CNS relapse. Furthermore, bilateral breast involvement at initial presentation was also associated with higher risk of CNS progression. Therefore, future studies with larger cohorts and comprehensive genomic profiling are warranted to refine predictive models and guide CNS-directed preventive strategies in patients with primary breast DLBCL.

Electronic Supplementary Material

Supplementary materials are available at Cancer Research and Treatment website (https://www.e-crt.org).

CRT_25-836_S1_Table.pdf

NOTES

Ethical Statement

The study was approved by the institutional review board at each institution and conducted in accordance with the Declaration of Helsinki. All patients provided written informed consent.

Author Contributions

Conceived and designed the analysis: Lee CH, Song GY, Yhim HY.

Collected the data: Yoon DH, Yoon SE, Kim JS, Lee JO, Eom HS, Lee H, Kim KH, Kang KW, Do YR, Lee SI, Lee HS, Kim HJ, Yang DH, Kim WS, Kwak JY.

Contributed data or analysis tools: Jang KY, Ahn AR.

Performed the analysis: Lee CH, Song GY, Yhim HY.

Wrote the paper: Lee CH, Song GY, Yhim HY.

Critically revised manuscript and approved final version: Lee CH, Song GY, Yhim HY, Yoon DH, Jang KY, Yoon SE, Kim JS, Lee JO, Eom HS, Lee H, Kim KH, Kang KW, Do YR, Lee SI, Lee HS, Kim HJ, Ahn AR, Yang DH, Kim WS, Kwak JY.

Conflicts of Interest

Conflict of interest relevant to this article was not reported.

Funding

This paper was supported by Fund of Biomedical Research Institute, Jeonbuk National University Hospital.

Fig. 1.

Study flow. COO, cell-of-origin; DLBCL, diffuse large B-cell lymphoma.

Fig. 2.

Cumulative risk of central nervous system relapse and its association with immunohistochemical features. Cumulative risk of central nervous system (CNS) relapse in the (A) overall study set and the (B) immunohistochemical study set. (C) Distribution of CNS relapse events according to MYC/BCL2 dual expression status and cell-of-origin subtype among patients in the immunohistochemical study set. (D) Comparison of the CNS relapse risk by MYC/BCL2 dual expression status. CI, confidence interval; DE, dual expression; GCB, germinal center B-cell–like.

Table 1.

Clinical characteristics

	Overall study set (n=53)	IHC study set (n=36)
Age (yr)
Median (range)	55 (29-78)	57 (29-78)
> 60	19 (35.8)	15 (41.7)
Sex
Female	53 (100)	36 (100)
Ann Arbor stage
IE	24 (45.3)	14 (38.9)
IIE	24 (45.3)	18 (50.0)
IIIE	2 (3.8)	2 (5.6)
IV	3 (5.7)	2 (5.6)
Primary site
Unilateral	50 (94.3)	34 (94.4)
Right	28	19
Left	22	15
Bilateral	3 (5.7)	2 (5.6)
Lymph node involvement
Not involved	24 (45.3)	14 (38.9)
Involved	29 (54.7)	22 (61.1)
Regional LN	27	20
Distant LN	2	2
ECOG PS
0-1	51 (96.2)	34 (94.4)
2-4	2 (3.8)	2 (5.6)
Serum LDH level
Normal	39 (73.6)	28 (77.8)
Elevated	14 (26.4)	8 (22.2)
B symptoms
Absence	51 (96.2)	36 (100)
Presence	2 (3.8)	0
Bulky (> 10 cm) mass
No	50 (94.3)	34 (94.4)
Yes	3 (5.7)	2 (5.6)
IPI
Low	45 (84.9)	31 (86.1)
Low-intermediate	4 (7.5)	2 (5.6)
High-intermediate	4 (7.5)	3 (8.3)
High	0	0
CNS-IPI
Low	45 (84.9)	31 (86.1)
Intermediate	8 (15.1)	5 (13.9)
High	0	0
CNS prophylaxis
Not performed	3 (5.7)	2 (5.6)
Performed	50 (94.3)	34 (94.4)
Intrathecal methotrexate	47	31
Intravenous methotrexate	3	3
Follow-up duration
Median (IQR, mo)	58.8 (30.3-72.9)	54.4 (20.5-71.7)

CNS, central nervous system; ECOG PS, Eastern Cooperative Oncology Group performance status; IHC, immunohistochemistry; IPI, International Prognostic Index; IQR, interquartile range; LDH, lactate dehydrogenase; LN, lymph node.

Table 2.

Distribution of CNS relapse

	Overall set (n=53)	IHC study set (n=36)
CNS relapse	7 (100)	4 (100)
Isolated CNS relapse	4 (57)	2 (50)
Leptomeningeal	1	1
Parenchymal	3	1
Leptomeningeal+parenchymal	0	0
CNS relapse with concurrent systemic progression	3 (43)	2 (50)
Leptomeningeal	1	0
Parenchymal	1	1
Leptomeningeal+parenchymal	1	1

Values are presented as number (%). CNS, central nervous system; IHC, immunohistochemistry.

Table 3.

Univariate analysis for CNS relapse in the overall set and immunohistochemical study set

Variable	Overall set			Immunohistochemical study set
Variable	No. (%) (n=53)	HR (95% CI)	p-value	No. (%) (n=36)	HR (95% CI)	p-value
Age > 60 yr	19 (35.8)	0.85 (0.15-4.43)	0.848	15 (41.7)	0.58 (0.06-5.67)	0.640
Elevated serum LDH level	14 (26.4)	2.34 (0.52-10.47)	0.265	8 (22.2)	2.79 (0.28-27.07)	0.375
Synchronous bilateral breast involvement	3 (5.7)	3.06 (1.30-7.22)	0.010	2 (5.6)	35.33 (3.15-395.33)	0.004
Lymph node involvement	29 (54.7)	1.43 (0.31-6.40)	0.639	22 (61.1)	2.79 (0.28-27.01)	0.375
Bulky (> 10 cm) mass	3 (5.7)	5.38 (0.61-47.02)	0.122	2 (5.6)	21.54 (1.30-355.10)	0.032
Presence of B symptoms	2 (3.8)	6.09 (0.72-50.93)	0.095	0
CNS-IPI intermediate-risk	8 (15.1)	1.91 (0.84-4.36)	0.121	5 (13.9)	16.24 (2.23-118.30)	0.006
CNS prophylaxis using IT/IV MTX	50 (94.3)	0.20 (0.02-1.69)	0.140	34 (94.2)	0.18 (0.01-1.88)	0.180
Cell-of-origin non-GCB subtype	-	-	-	30 (83.3)	28.11 (not applicable)^a)	0.105
MYC/BCL2 double expression	-	-	-	14 (38.9)	90.60 (not applicable)^a)	0.001

CI, confidence interval; CNS, central nervous system; GCB, germinal center B-cell-like; HR, hazard ratio; IPI, International Prognostic Index; IT/IV MTX, intrathecal or intravenous methotrexate; LDH, lactate dehydrogenase.

^a) 95% CI cannot be calculated because there were no events in the reference groups (i.e., GCB subtype and MYC/BCL2 non-double expression).

Table 4.

Multivariate Cox regression analysis for predicting CNS relapse in the overall set and immunohistochemical study set

Variable	Overall set			Immunohistochemical study set
Variable	No. (%) (n=53)	HR (95% CI)	p-value	No. (%) (n=36)	HR (95% CI)	p-value
Primary site
Unilateral breast involvement	50 (94.3)	1	0.007	34 (94.4)	1	0.015
Bilateral breast involvement	3 (5.7)	3.37 (1.39-8.15)		2 (5.6)	3.73 (1.28-10.86)
MYC/BCL2 dual expression status
MYC/BCL2 non-dual expression				22 (61.1)	1
MYC/BCL2 dual expression				14 (38.9)	2.42×10⁴ (not applicable)^a)	0.001

CI, confidence interval; CNS, central nervous system; HR, hazard ratio.

^a) 95% CI is not calculated because there was no event in the MYC/BCL2 non-dual expression (reference) group.

REFERENCES

1. Validire P, Capovilla M, Asselain B, Kirova Y, Goudefroye R, Plancher C, et al. Primary breast non-Hodgkin’s lymphoma: a large single center study of initial characteristics, natural history, and prognostic factors. Am J Hematol. 2009;84:133–9. Article PubMed
2. Thomas A, Link BK, Altekruse S, Romitti PA, Schroeder MC. Primary breast lymphoma in the United States: 1975-2013. J Natl Cancer Inst. 2017;109:djw294.Article PubMed PMC
3. Yhim HY, Yoon DH, Kim SJ, Yang DH, Eom HS, Kim KH, et al. First-line treatment for primary breast diffuse large B-cell lymphoma using immunochemotherapy and central nervous system prophylaxis: a multicenter phase 2 trial. Cancers (Basel). 2020;12:2192.Article PubMed PMC
4. Yhim HY, Kim JS, Kang HJ, Kim SJ, Kim WS, Choi CW, et al. Matched-pair analysis comparing the outcomes of primary breast and nodal diffuse large B-cell lymphoma in patients treated with rituximab plus chemotherapy. Int J Cancer. 2012;131:235–43. Article PubMed
5. Hosein PJ, Maragulia JC, Salzberg MP, Press OW, Habermann TM, Vose JM, et al. A multicentre study of primary breast diffuse large B-cell lymphoma in the rituximab era. Br J Haematol. 2014;165:358–63. Article PubMed PMC
6. Hu S, Song Y, Sun X, Su L, Zhang W, Jia J, et al. Primary breast diffuse large B-cell lymphoma in the rituximab era: therapeutic strategies and patterns of failure. Cancer Sci. 2018;109:3943–52. Article PubMed PMC PDF
7. Ryan G, Martinelli G, Kuper-Hommel M, Tsang R, Pruneri G, Yuen K, et al. Primary diffuse large B-cell lymphoma of the breast: prognostic factors and outcomes of a study by the International Extranodal Lymphoma Study Group. Ann Oncol. 2008;19:233–41. Article PubMed
8. Fukuhara S, Watanabe T, Munakata W, Mori M, Maruyama D, Kim SW, et al. Bulky disease has an impact on outcomes in primary diffuse large B-cell lymphoma of the breast: a retrospective analysis at a single institution. Eur J Haematol. 2011;87:434–40. Article PubMed
9. Weng H, Shrestha PR, Hong H, Chen Z, Yu L, Yao Y, et al. Primary breast diffuse large B-cell lymphoma in the rituximab era: a retrospective study of the Chinese Southwest Oncology Group. Cancer Med. 2023;12:21188–98. Article PubMed PMC
10. Demirci U, Yuksel MK, Kirkizlar HO, Atesoglu EB, Mehtap O, Salim O, et al. A survey evaluating hematology physicians’ perspectives on central nervous system prophylaxis. Blood Res. 2023;58:99–104. Article PubMed PMC
11. Schmitz N, Zeynalova S, Nickelsen M, Kansara R, Villa D, Sehn LH, et al. CNS International Prognostic Index: a risk model for CNS relapse in patients with diffuse large B-cell lymphoma treated with R-CHOP. J Clin Oncol. 2016;34:3150–6. Article PubMed
12. Boehme V, Schmitz N, Zeynalova S, Loeffler M, Pfreundschuh M. CNS events in elderly patients with aggressive lymphoma treated with modern chemotherapy (CHOP-14) with or without rituximab: an analysis of patients treated in the RICOVER-60 trial of the German High-Grade Non-Hodgkin Lymphoma Study Group (DSHNHL). Blood. 2009;113:3896–902. Article PubMed PDF
13. El-Galaly TC, Villa D, Michaelsen TY, Hutchings M, Mikhaeel NG, Savage KJ, et al. The number of extranodal sites assessed by PET/CT scan is a powerful predictor of CNS relapse for patients with diffuse large B-cell lymphoma: an international multicenter study of 1532 patients treated with chemoimmunotherapy. Eur J Cancer. 2017;75:195–203. Article PubMed
14. Kim SJ, Hong JS, Chang MH, Kim JA, Kwak JY, Kim JS, et al. Highly elevated serum lactate dehydrogenase is associated with central nervous system relapse in patients with diffuse large B-cell lymphoma: results of a multicenter prospective cohort study. Oncotarget. 2016;7:72033–43. Article PubMed PMC
15. Ferreri AJ. Risk of CNS dissemination in extranodal lymphomas. Lancet Oncol. 2014;15:e159Article PubMed
16. Tomita N, Yokoyama M, Yamamoto W, Watanabe R, Shimazu Y, Masaki Y, et al. Central nervous system event in patients with diffuse large B-cell lymphoma in the rituximab era. Cancer Sci. 2012;103:245–51. Article PubMed
17. Savage KJ, Slack GW, Mottok A, Sehn LH, Villa D, Kansara R, et al. Impact of dual expression of MYC and BCL2 by immunohistochemistry on the risk of CNS relapse in DLBCL. Blood. 2016;127:2182–8. Article PubMed PDF
18. Klanova M, Sehn LH, Bence-Bruckler I, Cavallo F, Jin J, Martelli M, et al. Integration of cell of origin into the clinical CNS International Prognostic Index improves CNS relapse prediction in DLBCL. Blood. 2019;133:919–26. Article PubMed PMC PDF
19. Oki Y, Noorani M, Lin P, Davis RE, Neelapu SS, Ma L, et al. Double hit lymphoma: the MD Anderson Cancer Center clinical experience. Br J Haematol. 2014;166:891–901. Article PubMed
20. Yhim HY, Kang HJ, Choi YH, Kim SJ, Kim WS, Chae YS, et al. Clinical outcomes and prognostic factors in patients with breast diffuse large B cell lymphoma: Consortium for Improving Survival of Lymphoma (CISL) study. BMC Cancer. 2010;10:321.Article PubMed PMC PDF
21. Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32:3059–68. Article PubMed PMC
22. Cho I, Yoon N, Hyeon J, Sim J, Yoo HY, Kim SJ, et al. Comparison of the Lymph2Cx assay and Hans algorithm in determining the cell-of-origin of diffuse large B-cell lymphomas, not otherwise specified. Appl Immunohistochem Mol Morphol. 2020;28:731–40. Article PubMed
23. Hans CP, Weisenburger DD, Greiner TC, Gascoyne RD, Delabie J, Ott G, et al. Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray. Blood. 2004;103:275–82. Article PubMed
24. Alduaij W, Collinge B, Ben-Neriah S, Jiang A, Hilton LK, Boyle M, et al. Molecular determinants of clinical outcomes in a real-world diffuse large B-cell lymphoma population. Blood. 2023;141:2493–507. Article PubMed PDF
25. Scott DW, Mottok A, Ennishi D, Wright GW, Farinha P, Ben-Neriah S, et al. Prognostic significance of diffuse large B-cell lymphoma cell of origin determined by digital gene expression in formalin-fixed paraffin-embedded tissue biopsies. J Clin Oncol. 2015;33:2848–56. Article PubMed PMC
26. Staiger AM, Ziepert M, Horn H, Scott DW, Barth TF, Bernd HW, et al. Clinical impact of the cell-of-origin classification and the MYC/BCL2 dual expresser status in diffuse large B-cell lymphoma treated within prospective clinical trials of the German High-Grade Non-Hodgkin’s Lymphoma Study Group. J Clin Oncol. 2017;35:2515–26. Article PubMed
27. Warnnissorn N, Kanitsap N, Niparuck P, Boonsakan P, Kulalert P, Limvorapitak W, et al. Adding MYC/BCL2 double expression to NCCN-IPI may not improve prognostic value to an acceptable level. Blood Res. 2024;59:2.Article PubMed PMC PDF
28. Koh HH, Yoon SE, Kim SJ, Kim WS, Cho J. Differences in mutational signature of diffuse large B-cell lymphomas according to the primary organ. Cancer Med. 2023;12:19732–43. Article PubMed PMC
29. Schmitz R, Wright GW, Huang DW, Johnson CA, Phelan JD, Wang JQ, et al. Genetics and pathogenesis of diffuse large B-cell lymphoma. N Engl J Med. 2018;378:1396–407. PubMed PMC
30. Chapuy B, Stewart C, Dunford AJ, Kim J, Kamburov A, Redd RA, et al. Molecular subtypes of diffuse large B cell lymphoma are associated with distinct pathogenic mechanisms and outcomes. Nat Med. 2018;24:679–90. PubMed PMC
31. Wilson WH, Wright GW, Huang DW, Hodkinson B, Balasubramanian S, Fan Y, et al. Effect of ibrutinib with R-CHOP chemotherapy in genetic subtypes of DLBCL. Cancer Cell. 2021;39:1643–53. Article PubMed PMC
32. Grommes C, Pastore A, Palaskas N, Tang SS, Campos C, Schartz D, et al. Ibrutinib unmasks critical role of Bruton tyrosine kinase in primary CNS lymphoma. Cancer Discov. 2017;7:1018–29. Article PubMed PMC PDF
33. Petrich AM, Nabhan C, Smith SM. MYC-associated and double-hit lymphomas: a review of pathobiology, prognosis, and therapeutic approaches. Cancer. 2014;120:3884–95. Article PubMed
34. Twa DD, Lee DG, Tan KL, Slack GW, Ben-Neriah S, Villa D, et al. Genomic predictors of central nervous system relapse in primary testicular diffuse large B-cell lymphoma. Blood. 2021;137:1256–9. Article PubMed PDF
35. Jiang S, Zhang Q, Jin J, Zhang W. Genomic risk factors for central nervous system relapse in patients with diffuse large B-cell lymphoma. Blood Res. 2025;60:36.Article PubMed PMC PDF

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Impact of Cell-of-Origin and MYC/BCL2 Status on the Risk of Central Nervous System Relapse in Primary Breast Diffuse Large B-Cell Lymphoma

DOI: https://doi.org/10.4143/crt.2025.836

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Abstract
Introduction
Materials and Methods
Results
Discussion
Electronic Supplementary Material
NOTES
REFERENCES

Impact of Cell-of-Origin and MYC/BCL2 Status on the Risk of Central Nervous System Relapse in Primary Breast Diffuse Large B-Cell Lymphoma

Fig. 1. Study flow. COO, cell-of-origin; DLBCL, diffuse large B-cell lymphoma.

Fig. 2. Cumulative risk of central nervous system relapse and its association with immunohistochemical features. Cumulative risk of central nervous system (CNS) relapse in the (A) overall study set and the (B) immunohistochemical study set. (C) Distribution of CNS relapse events according to MYC/BCL2 dual expression status and cell-of-origin subtype among patients in the immunohistochemical study set. (D) Comparison of the CNS relapse risk by MYC/BCL2 dual expression status. CI, confidence interval; DE, dual expression; GCB, germinal center B-cell–like.

Fig. 1.

Fig. 2.

Impact of Cell-of-Origin and MYC/BCL2 Status on the Risk of Central Nervous System Relapse in Primary Breast Diffuse Large B-Cell Lymphoma

	Overall study set (n=53)	IHC study set (n=36)
Age (yr)
Median (range)	55 (29-78)	57 (29-78)
> 60	19 (35.8)	15 (41.7)
Sex
Female	53 (100)	36 (100)
Ann Arbor stage
IE	24 (45.3)	14 (38.9)
IIE	24 (45.3)	18 (50.0)
IIIE	2 (3.8)	2 (5.6)
IV	3 (5.7)	2 (5.6)
Primary site
Unilateral	50 (94.3)	34 (94.4)
Right	28	19
Left	22	15
Bilateral	3 (5.7)	2 (5.6)
Lymph node involvement
Not involved	24 (45.3)	14 (38.9)
Involved	29 (54.7)	22 (61.1)
Regional LN	27	20
Distant LN	2	2
ECOG PS
0-1	51 (96.2)	34 (94.4)
2-4	2 (3.8)	2 (5.6)
Serum LDH level
Normal	39 (73.6)	28 (77.8)
Elevated	14 (26.4)	8 (22.2)
B symptoms
Absence	51 (96.2)	36 (100)
Presence	2 (3.8)	0
Bulky (> 10 cm) mass
No	50 (94.3)	34 (94.4)
Yes	3 (5.7)	2 (5.6)
IPI
Low	45 (84.9)	31 (86.1)
Low-intermediate	4 (7.5)	2 (5.6)
High-intermediate	4 (7.5)	3 (8.3)
High	0	0
CNS-IPI
Low	45 (84.9)	31 (86.1)
Intermediate	8 (15.1)	5 (13.9)
High	0	0
CNS prophylaxis
Not performed	3 (5.7)	2 (5.6)
Performed	50 (94.3)	34 (94.4)
Intrathecal methotrexate	47	31
Intravenous methotrexate	3	3
Follow-up duration
Median (IQR, mo)	58.8 (30.3-72.9)	54.4 (20.5-71.7)

	Overall set (n=53)	IHC study set (n=36)
CNS relapse	7 (100)	4 (100)
Isolated CNS relapse	4 (57)	2 (50)
Leptomeningeal	1	1
Parenchymal	3	1
Leptomeningeal+parenchymal	0	0
CNS relapse with concurrent systemic progression	3 (43)	2 (50)
Leptomeningeal	1	0
Parenchymal	1	1
Leptomeningeal+parenchymal	1	1

Variable	Overall set			Immunohistochemical study set
Variable	No. (%) (n=53)	HR (95% CI)	p-value	No. (%) (n=36)	HR (95% CI)	p-value
Age > 60 yr	19 (35.8)	0.85 (0.15-4.43)	0.848	15 (41.7)	0.58 (0.06-5.67)	0.640
Elevated serum LDH level	14 (26.4)	2.34 (0.52-10.47)	0.265	8 (22.2)	2.79 (0.28-27.07)	0.375
Synchronous bilateral breast involvement	3 (5.7)	3.06 (1.30-7.22)	0.010	2 (5.6)	35.33 (3.15-395.33)	0.004
Lymph node involvement	29 (54.7)	1.43 (0.31-6.40)	0.639	22 (61.1)	2.79 (0.28-27.01)	0.375
Bulky (> 10 cm) mass	3 (5.7)	5.38 (0.61-47.02)	0.122	2 (5.6)	21.54 (1.30-355.10)	0.032
Presence of B symptoms	2 (3.8)	6.09 (0.72-50.93)	0.095	0
CNS-IPI intermediate-risk	8 (15.1)	1.91 (0.84-4.36)	0.121	5 (13.9)	16.24 (2.23-118.30)	0.006
CNS prophylaxis using IT/IV MTX	50 (94.3)	0.20 (0.02-1.69)	0.140	34 (94.2)	0.18 (0.01-1.88)	0.180
Cell-of-origin non-GCB subtype	-	-	-	30 (83.3)	28.11 (not applicable)^a)	0.105
MYC/BCL2 double expression	-	-	-	14 (38.9)	90.60 (not applicable)^a)	0.001

Variable	Overall set			Immunohistochemical study set
Variable	No. (%) (n=53)	HR (95% CI)	p-value	No. (%) (n=36)	HR (95% CI)	p-value
Primary site
Unilateral breast involvement	50 (94.3)	1	0.007	34 (94.4)	1	0.015
Bilateral breast involvement	3 (5.7)	3.37 (1.39-8.15)		2 (5.6)	3.73 (1.28-10.86)
MYC/BCL2 dual expression status
MYC/BCL2 non-dual expression				22 (61.1)	1
MYC/BCL2 dual expression				14 (38.9)	2.42×10⁴ (not applicable)^a)	0.001

Table 1. Clinical characteristics

Table 2. Distribution of CNS relapse

Values are presented as number (%). CNS, central nervous system; IHC, immunohistochemistry.

Table 3. Univariate analysis for CNS relapse in the overall set and immunohistochemical study set

95% CI cannot be calculated because there were no events in the reference groups (i.e., GCB subtype and MYC/BCL2 non-double expression).

Table 4. Multivariate Cox regression analysis for predicting CNS relapse in the overall set and immunohistochemical study set

CI, confidence interval; CNS, central nervous system; HR, hazard ratio.

95% CI is not calculated because there was no event in the MYC/BCL2 non-dual expression (reference) group.