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Prognostic value of CD10, BCL-6, MUM-1, and CD138 in diffuse large B-cell lymphoma

Abd El-Maqsoud, Nehad M.R.*; Gayyed, Mariana F.*

Egyptian Journal of Pathology: July 2015 - Volume 35 - Issue 1 - p 95–104
doi: 10.1097/01.XEJ.0000465876.33342.db

Introduction Diffuse large B-cell lymphoma (DLBCL) encompass a heterogeneous group of aggressive tumors that are rapidly fatal if untreated. Two major groups of tumors with uneven survival outcomes, germinal center B-cell lymphomas (GCBs) and nongerminal center B-cell lymphomas (non-GCB), are described.

Aim We investigated the expression of CD10, B-cell CLL/lymphoma 6 (BCL-6), MUM-1, and CD138 to evaluate their prognostic value.

Materials and methods Paraffin-embedded tumor biopsies of 62 DLBCL patients were retrospectively analyzed by immunohistochemistry to investigate the expression of CD10, BCL-6, MUM-1, and CD138. We also studied the possible correlations of these markers with the clinical presentations and overall survival.

Results Positive expression of CD10, BCL-6, MUM-1 and CD138 were 45.2%, 64.5%, 45.2% and 14.5%, respectively. Thirty two out of sixty two (51.6%) patients were subgrouped as GCB and 30 of 62 (48.4%) of patients were subgrouped as non-GCB. Overall survival in the GCB and non GCB groups was 65.1% and 34.9%, respectively and the difference was highly significant statistically (P=0.001). CD10 being associated with better overall survival (P=0.006), whereas positive MUM-1 and CD138 was associated with poor overall survival (P=0.007 and P=0.001 respectively). Using a multivariate regression analysis, the expression of CD138 (P=0.011) was statistically significant as independently poor prognostic factors.

Conclusion CD138 may play an important role as a poor prognostic marker in DLBCL in the Egyptian population.

Department of Pathology, Faculty of Medicine, Minia University, Minia, Egypt

* Nehad M.R. Abd El-Maqsoud and Mariana F. Gayyed contributed equally to this work.

Correspondence to Nehad M.R. Abd El-Maqsoud, MD, Department of Pathology, Faculty of Medicine, Minia University, PO Box 61111, Minia, Egypt Tel: +20 100 496 4423; fax: +20 208 623 42813; e-mail:

Received November 20, 2014

Accepted December 22, 2014

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Non-Hodgkin lymphoma (NHL) represents the sixth most common cause of cancer death worldwide (McNally, 2011). In Egypt, it is the second most common cancer in adult Egyptian patients (Soliman and Boffetta, 2006). One of the major subtypes of NHL is diffuse large B-cell lymphoma (DLBCL) as it accounts for approximately more than 30% of NHL worldwide (Hunt and Reichard, 2008) and about 54.55% of NHL cases presenting at the Egyptian National Cancer Institute (Mokhtar et al., 2007).

DLBCL is a clinically, morphologically, and genetically heterogeneous disease; therefore, although some of the DLBCL patients are of the same age, sex, and stage, they respond differently to chemotherapy regimens. An attempt to standardize the clinical response to chemotherapy and to predict a long-term overall survival (OS) was devised using the International Prognostic Index (IPI) (Lossos and Morgensztern, 2006). The IPI includes age, tumor stage, serum lactate dehydrogenase (LDH) levels, patient performance status (PS), and nodal involvement (Lossos and Morgensztern, 2006; Magomedoua and Vorobev, 2008). However, there is still a significant proportion (20–40%) of patients who cannot achieve a cure with current chemotherapeutic regimens (Pfreundschuh et al., 2011; Récher et al., 2011).

Alizadeh et al. (2000) could classify 85% of DLBCL cases, by means of gene expression profiles, into two groups. The first group is one with a genetic expression profile similar to nodal germinal center B cells as it originates from germinal center B cells and is termed germinal center B-cell-like (GCB) DLBCL (GCB subtype). The second group is one with an expression profile subsequent to the activation of B cells at a further stage of differentiation and has been termed activated B-cell-like (ABC) DLBCL (non-GCB subtype). The GCB subgroup shows a better OS than the non-GCB subgroup (Alizadeh et al., 2000; Wright et al., 2003). Certain features of lymphomas are considered to derive from their nontransformed progenitor cells. Each of the currently identified types of B-cell lymphoma has been associated with a distinct step in normal B-cell differentiation (Lenz and Staudt, 2010), and this is useful for a general classification of the various lymphoma entities.

Several immunohistochemical algorithms using certain prognostic markers have been proposed to differentiate between the GCB subgroup and the non-GCB subgroup. The most commonly used algorithms are those described by Hans et al. (2004) and Chang et al. (2004). These prognostic markers are used to predict the clinical outcome of patients. The commonly used markers are CD10 and B-cell CLL/lymphoma 6 (BCL-6) as markers of the GCB subgroup and MUM-1 and CD138 as markers of the non-GCB subgroup (Chang et al., 2004; Hans et al., 2004; De Paepe and De Wolf-Peeters, 2007).

CD10 (common acute lymphoblastic leukemia antigen, CALLA), a neutral endopeptidase, is expressed only in the germinal center B cell and it represents a good prognostic factor (Dogan et al., 2000).

BCL-6, a zinc-finger transcription repressor factor, is a proto-oncogene at chromosome band 3q27. BCL-6 is present in normal germinal-center B cells and in some CD4-positive T cells, both in the germinal centers and in the interfollicular areas (Phan and Dalla-Favera, 2004). Chromosomal translocations of the BCL-6 are the most frequent cytogenetic abnormality in DLBCL, occurring in up to 35% of cases (Shustik et al., 2010). Mutations of BCL-6 have also been detected in about 10–15% of follicular lymphoma (Winter et al., 2006). The role of BCL-6 in lymphoid neoplasm formation is not obvious, but it acts as a good prognostic factor (Tibiletti et al., 2009).

MUM-1/IRF4 (multiple myeloma oncogene 1/interferon regulatory factor 4), a lymphoid-specific gene, is a transcription factor that plays an important role in the regulation of gene expression in response to interferon and other signaling cytokines. It is found mainly in plasma cells and to a lesser extent in nonproliferating germinal center B cells. It is also present in small number of perifollicular CD30+ T cells (Falini et al., 2000; Tsuboi et al., 2000). It is expressed in lymphoplasmacytic lymphoma, multiple myeloma, and Hodgkin lymphoma (Gaidano and Carbone, 2000). MUM-1 is strongly expressed in about 75% of DLBCL and is considered an unfavorable prognostic factor (Sjö et al., 2007).

CD138, also known as syndecan-1, is the main member of syndecans. It is a cell surface heparin sulfate proteoglycan. Normally, it plays a role in cell adhesion and growth control. It also maintains the cell morphology. CD138 is expressed mainly in epithelial cells and it is also present in the B-cell lineage. The expression of CD138 plays an important role in the classification of B-cell malignancy in addition to being a poor prognostic factor (Hoffmann et al., 2005; Oh and Park, 2006).

The aim of this study is the investigation of the value of CD10, BCL-6, MUM-1 and CD138 as prognostic markers in DLBCL patients through studying the immunohistochemical expression of these markers and their possible correlations with the clinicopathological data and the OS.

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Materials and methods

Study design

In this retrospective study, paraffin blocks of formalin-fixed tumor sections from 77 cases of DLBCL were retrieved randomly from the archives of the Pathology Department, Minia University Hospital, and Minia Oncology Center, Egypt, during the period from 2008 to 2012. From these 77 cases, only 62 cases had complete clinical information, follow-up data, and sufficient histological material. The follow-up period was counted from the day of diagnosis until death or the date of the last follow-up for living (censored) patients. The histopathological diagnosis and classification of all cases were confirmed by authors using hematoxylin and eosin-stained sections and strong membrane positivity for CD20 (Fig. 1a and b). This was done according to the WHO and the Revised European-American classification of Lymphomas (REAL) (Gatter and Warnke, 2001). In each case, we used both Hans et al. (2004) and Chang et al. (2004) immunohistochemistry systems to classify these cases into GCB and non-GCB types. The DLBCL cases were also classified clinically according to the site of presentation into primary nodal tumors with or without splenic involvement and extra-nodal tumors, including cases showed no nodal involvement or only a minor nodal involvement together with a clinically major extra-nodal component. The GCB and non-GCB groups were compared according to clinicopathological characteristics, namely, age, sex, nodal involvement, tumor size, LDH, staging, PS, IPI, and OS.

Fig. 1

Fig. 1

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Immunohistochemistry study

Formalin-fixed, paraffin-embedded tumor sections were examined for the expression of CD20, CD10, BCL-6, MUM-1, and CD138 using the avidin–biotin peroxidase complex method. Sections were cut into 3 μm thicknesses, deparaffinized in xylene, and rehydrated through descending grades of ethyl alcohol in distilled water. Endogenous peroxidase activity was blocked with 0.3% hydrogen peroxide for 15 min and subsequently, slides were washed with PBS. For antigen retrieval, the slides were microwave treated in 10-mmol/l citrate buffer (pH 6.0) for CD20 and CD138 and in 10-mmol/l Tris-EDTA (pH9.0) for CD10, BCL-6, and MUM-1. The sections were allowed to cool at room temperature for 30 min and then washed with PBS. The slides were incubated with the following mouse monoclonal antibodies: anti-CD20 (clone: L26, code M0755, 1 : 100), anti-CD10 (clone: 56C6, code M7308, 1 : 100), anti-Bcl-6 (clone: PG-B6p, code M7211, 1 : 20), anti-MUM-1 (MUM1p, code M7259, 1 : 200), and anti-CD138 (clone: MI15, code M7228, 1 : 100) from Dako (Glostrup, Denmark) for 60 min at 37°C in a humidity chamber. Following primary antibody incubation, sections were washed thoroughly with PBS and incubated with biotinylated rabbit anti-mouse antibody (Dako) for 30 min at room temperature in moist chamber. Subsequently, sections were washed with PBS and incubated with HRP-coupled avidin–biotin complex (Dako) for 30 min at room temperature in a humidity chamber. Following a final wash with PBS, immunoreactivity was visualized with 3,3-diaminobenzidine. Finally, sections were briefly counterstained with Mayer’s hematoxylin, dehydrated with ascending grades of ethyl alcohol, mounted with distyrene, plasticizer and xylene (DPX), and finally examined by light microscopy.

Negative control was performed by replacing the primary antibody with a normal IgG. Positive control consisted of samples of tonsils or lymph nodes with reactive hyperplasia. CD20 stain was performed to evaluate each case for the presence of tumor.

All specimens were analyzed semiquantitatively after a thorough examination of the whole immunostained slide. For CD20 immunostaining, cases with diffuse membranous staining were considered positive. At least 200 cells were scored for each slide. CD10, BCL-6, MUM-1, and CD138 were labeled as positive if at least more than 10% of cells were positive for the respective antibodies (Hans et al., 2004; Reber et al., 2013). CD20, CD10, and CD138 expression showed membrane staining in tumor cells, whereas in the case of BCL-6 and MUM-1expression, positivity was scored only when tumor cells showed nuclear staining.

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Immunophenotypic patterns

Using the algorithm of Hans et al. (2004), two immunophenotypic patterns of DLBCL were identified according to the immunohistochemical expression of two GCB-associated markers (CD10 and BCL-6) and two non-GCB-associated markers (MUM-1 and CD138). The GCB subgroup included all tumors with the CD10+ or CD10–/BCL-6+/MUM-1– immunophenotype. Other cases were classified into the non-GCB subgroup, including MUM-1+ tumors, irrespective of their BCL-6 status (CD10–/BCL-6+/MUM-1+ or CD10–/BCL-6–/MUM-1+) (Diagram 1a).

As described by Chang et al. (2004), three immunophenotypic patterns of DLBCL were found according to the immunohistochemical expression of CD10, BCL-6, MUM-1, and CD138. Cases were assigned to the GCB group if tumor was positive for CD10 and/or BCL-6, but negative for MUM-1 and CD138 (CD10/BCL-6+/+, pattern A); cases were assigned to the activated GCB group if positive for CD10 and/or BCL-6 and at least one of the non-GCB markers (CD10/BCL-6+/+ and MUM-1/CD138+/–, pattern B); cases were assigned to the activated non-GCB cell group if positive for at least one non-GCB-associated marker, but negative for GCB-associated markers (MUM-1/CD138+/+, pattern C) (Diagram 1b).

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Statistical analysis

Statistical analysis was carried out using the SPSS software (SPSS standard version 17.0; SPSS Inc., Chicago, Illinois, USA). Categorical data were compared using χ2 or Fisher’s exact tests. A P value of 0.05 or less was considered significant.

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Survival analysis

OS was calculated from the date of initial diagnosis until the last follow-up or death. Patients who were alive at last contact were treated as censored for OS analysis. Univariate and multivariate Cox proportional hazards regression analyses were carried out to estimate the impact of expression of each markers and IPI on OS in these patients. Survival curves were constructed using the Kaplan–Meier method. The log-rank test was used to compare the survival curves. The significance level used was P value less than 0.05.

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Clinical data

The study group included 34 (54.8%) men and 28 (45.2%) women. The age of the patients ranged from 20 to 77 years, with a mean±SD of 52.52±11.12 years and a median of 55 years. In our series, 46 (74.2%) patients had a primary nodal involvement (nodal subgroup), whereas 16 (25.8%) patients presented with two or more extranodal sites (extranodal subgroup). Advanced disease (stages III and IV) was reported in 59.7% of the patients. 40.3% of the patients had PS more than 1. LDH was above normal in 72.6% of the patients. The median follow-up of the surviving patients was 30 months (range 3–60 months). The 5-year OS for the entire group was 69.4%. A summary of the clinicopathological characteristics of all cases is shown in Table 1.

Table 1

Table 1

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Immunohistochemical expression

All cases showed positive immunohistochemical expression of CD20. The results of the immunohistochemical staining of markers for both GCB and non-GCB subgroups are summarized in Table 2. The positive expression of GCB markers including CD10 and BCL-6 was 45.2% (28/62) and 64.5% (40/62), respectively (Fig. 1c and d). In terms of the expression in the other two non-GCB markers, we found that immunostaining of MUM-1 was 45.2% (28/62) and that of CD138 was 14.5% (9/62) (Fig. 1e and f).

Table 2

Table 2

On the basis of the algorithm of Hans et al. (2004), 51.6% (32/62) of patients were subgrouped as GCB and 48.4% (30/62) of patients were subgrouped as non-GCB, as shown in Diagram 1a. For the GCB cases, 46.9% (15/32) expressed CD10 alone, 12.5% (4/32) expressed BCL-6 alone, and 40.6% expressed both CD10 and BCL-6 (13/32). MUM-1 expression was observed in 15.6% (5/32) of the GCB cases. In the non-GCB cases, 76.7% (23/30) expressed both MUM-1and BCL-6, 10% (3/30) expressed CD138 alone, 33.3% (6/30) expressed both CD138 and MUM-1, whereas 13.3% (4/30) were negative for both markers.

In addition, we used the classification system suggested by Chang et al. (2004) to further subgroup the cases. Accordingly, 11.3% (7/62) of patients were subclassified as pattern A, 82.3% (51/62) as pattern B, and 6.4% (4/62) as pattern C, as shown in Diagram 1b. Pattern A had a better clinical course than the remaining two patterns; however, this was not significant.

Significant associations were detected between the two subgroups and the expression of CD10 (P<0.001), BCL-6 (P=0.047), MUM-1 (P<0.001), and CD138 (P=0.001). CD10 immunostaining was present in the GCB group; however, CD138 positive expression was observed in the non-GCB group.

Studying the clinicopathological aspects of the cases on the basis of the Hans et al. (2004) algorithm, significant associations were observed between the two subgroups and the clinicopathological parameters including stage (P=0. 043), LDH (P=0.016), PS (P=0.011), and IPI risk (P=0.030). No significant associations were found between the two subgroups and other clinicopathological parameters, namely, age (P=0.062), sex (P=0.490), nodal involvement (P=0.054), and tumor size (P=0.239). A summary of the subgrouping data of the cases is shown in Table 3.

Table 3

Table 3

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Prognostic value and survival analysis

We investigated the OS of 62 cases of DLBCL patients. Variables analyzed were PS, risk of IPI, marker expression, and GCB/non-GCB classification shown in Fig. 2a–h. The time of OS ranged from 3 to 60 months, with a mean±SD of 31.21±17.046 months and a median survival time of 30 months. The OS was 69.4%. The OS rate in DLBCL patients with a high LDH level (P=0.021), stage (P=0.023), PS more than 1 (P=0.041) (Fig. 2a), and high risk of IPI (P=0.026) (Fig. 2b) were all associated with increased risk of mortality, whereas other clinicopathological parameters were not associated with any statistically significant difference in OS including age (P=0.778), sex (P=0.169), nodal involvement (P=0.171), and tumor size (P=0.957).

Fig. 2

Fig. 2

Fig. 2

Fig. 2

On subgrouping of cases into GCB and non-GCB, we found that patients in the GCB group had a mortality rate of 21.1% (4/19), whereas patients in the non-GCB group had a mortality rate of 78.9% (15/19) (P=0.001).

The patients in the GCB group had better OS compared with the patients in the non-GCB group (log rank χ2=7.729, P=0.005, Breslow’s χ2=5.967, P=0.014; Fig. 2c), whereas according to the Chang classification, there was no statistically significant difference in OS (P=0.556; Fig. 2d).

The positive expression of CD10 was associated with better OS (log rank χ2=7.495, P=0.006, Breslow’s χ2=6.668, P=0.010; Fig. 2e). The expression of BCL-6 was not associated with any difference in OS (log rank χ2=3.492, P=0.062, Breslow’s χ2=3.628, P=0.057; Fig. 2f). Positive expressions of MUM-1 (log rank χ2=7.181, P=0.007, Breslow’s χ2=5.635, P=0.018; Fig. 2g) and CD138 (log rank χ2=11.593, P=0.001, Breslow’s χ2=12.023, P=0.001; Fig. 2h) were found to be associated with a significantly poor OS.

On multivariate analysis, the expression of CD138 was found to be statistically significant as an independently poor prognostic factor (P=0.011, odds ratio 4.598, 95% confidence interval 1.415–14.948).

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DLBCL represents a heterogeneous group of B-cell lymphomas rather than a single clinicopathological entity (Sahai et al., 2011). Its heterogeneity includes a diverse spectrum of clinical presentation, morphology, immunophenotype, and genetic and molecular alterations (Xu et al., 2006). The prognosis of DLBCL was assessed using ancillary techniques including immunohistochemistry and cytogenetics (Hunt and Reichard, 2008). Many of the traditionally used prognostic markers should be re-evaluated now because of the differences in prognosis in race, genetics, and treatment options. The goal is that therapeutic regimens will become customized to specific subgroups; thus, longer remissions and potential cures of patients with DLBCL could be achieved (Hunt and Reichard, 2008).

On analyzing the data of the clinicopathological characteristics of DLBCL, we observed a slight male predominance, with a male to female ratio of 1.2 : 1. This finding is in agreement with the results reported by De Paepe et al. (2005) and Naz et al. (2011). Concerning patients’ age, we found that the mean age was 52.52±11.12 years compared with Naz et al. (2011), who reported early presentation of DLBCL in patients with a mean age of 44.1±15 years. In the present study, statistically significant differences were found in the clinical presentations including high LDH level (P=0.021), stage (P=0.023), PS more than 1 (P=0.041), and IPI high risk (P=0.026).

In the present study, we highlighted the distribution of immunophenotype patterns related to the germinal center and the nongerminal center in a cohort of 62 Egyptian patients with de novo DLBCLs using the immunohistochemistry technique to examine the expression of CD10, BCL-6, MUM-1, and CD138 and to evaluate the possible use of these markers as prognostic markers.

Different algorithms to identify GCB and non-GCB DLBCL have been identified (Colomo et al., 2003; Chang et al., 2004; Hans et al., 2004). The algorithm of Hans et al. (2004) still remains the easiest and the most commonly used, which is why we used it in this study as well. Hans et al. (2004) reported that on the basis of the combined expression of CD10, BCL-6, and MUM-1, DLBCL patients can be divided into GCB and non-GCB subgroups. The algorithm of Chang et al. (2004) proposed that the immunohistochemical expression patterns of CD10, BCL-6, MUM-1, and CD138 correlated with the prognosis of DLBCL patients. In contrast, the algorithm of Colomo et al. (2003) reported that the immunohistochemical profiles of CD10, BCL-6, MUM-1, and CD138 were not essential for predicting DLBCL patients’ outcome.

Compared with the studies of Hans et al. (2004) and Chang et al. (2004), our algorithm, using two GCB-associated markers CD10 and BCL-6 and two non-GCB-associated markers MUM-1 and CD138, could differentiate between the GCB phenotype (pattern A) and non-GCB phenotype (patterns B and C) easily. Moreover, it could predict the OS more accurately.

In agreement with the previous studies (Jabłońska et al., 2010; Huang et al., 2012; Reber et al., 2013), we found that the frequency of the GCB type (51.6%) was higher than that of the non-GCB type (48.4%). This distribution was also comparable with previously published data of Saad et al. (2010) (56% of the Egyptian DLBCL cases were the GCB cell type and 44% were the nongerminal center subtype). However, the results reported by Hans et al. (2004); De Jong et al. (2009); Song et al. (2010) showed a higher frequency of the non-GCB type. The proportions of the GCB type with the non-GCB type between western and Egyptian populations are still unclear and the discrepancy that was observed may reflect the distinct genetic behavior in addition to different sources of antibodies used and variable cut-off values for positive staining.

In our study, positive membranous expression of CD10 was scored in 45.2% of the cases using the 10% cut-off value. This result was similar to the study of Sjö et al. (2007), which showed 41% positive expression of CD10. Other studies including Oh and Park (2006), Borovecki et al. (2008), and De Jong et al. (2009) reported lower percentages of CD10 expression ranging from 19 to 30% of cases. However, studies carried out by Saad et al. (2010) and Bodoor et al. (2012) reported a high expression (61 and 65%, respectively). This high expression of CD10 was in agreement with our finding that the GCB cell type was more common than the non-GCB cell type. In this study, BCL-6 positive nuclear expression was scored in 64.5% of the cases using a 10% cut-off. This was similar to studies using the same cut-off value: 63% (Lossos et al., 2001) and 78% (Bodoor et al., 2012).

We emphasized that MUM-1 identified cases of the non-GCB phenotype when used in conjunction with CD10 and BCL-6. In terms of MUM-1 expression, we found that positive expression was shown in 45.2% of the cases studied using the 10% cut-off value. The same results were reported by Hans et al. (2004) and Sahai et al. (2011) (47 and 43%, respectively). However, other studies have reported MUM-1 expression in 50 to 77% of DLBCLs (Falini et al., 2000; Tsuboi et al., 2000; Li et al., 2010). In the present study, CD138 was shown to be expressed in 14.5% of the cases studied using a cut-off value of 10%. Some of the studies using the same cut-off reported lower positive expression: 5% (Sahai et al., 2011), whereas others showed a higher frequency of 39% (Bodoor et al., 2012).

Our study found that high levels of LDH, PS more than 1, and IPI were significantly associated with poor survival. This was the same as that reported by a previous study that was reported by Saad et al. (2010). For IPI, Bodoor et al. (2012) reported statistically significant differences between OS and IPI. In our study, no statistically significant differences were found in other clinical presentations and OS. Previous studies have reported similar results (Saad et al., 2010; Bodoor et al., 2012).

In this study, DLBCL patients with the GCB type had a better OS than those with the non-GCB type, which was in agreement with other reports (Chang et al., 2004; Hans et al., 2004; Jabłońska et al., 2010; Song et al., 2010; Reber et al., 2013). The 5-year OS for the GCB group was 65.1%, whereas that of the non-GCB group was 34.9%. According to Hans et al. (2004), the 5-year OS for the GCB group was 76%, whereas that of the non-GCB group was only 34%. On the basis of univariate analysis, we found that there were no significant associations between clinicopathological parameters and the two DLBCL subgroups: the GCB group and the non-GCB group, similar to previous reports published (Hans et al., 2004; Berglund et al., 2005; Oh and Park, 2006; Saad et al., 2010).

We also used the classification system suggested by Chang et al. (2004) to further divide the cases into three subgroups using a cut-off value of 10. Accordingly, 11.3% of patients were subclassified as pattern A, 82.3% as pattern B, and 6.4% as pattern C. There was no statistically significant correlation between the three groups as well as between the Chang groups and OS. Similar results were reported by Bodoor et al. (2012), with no significance difference between the three groups. However, we found that pattern A had a significantly better clinical course than the remaining two patterns, and these results were in agreement with those obtained by Chang et al. (2004).

In the present series, positive correlation between the expression of CD10 and OS was observed. The prognostic significance of CD10 positivity in DLBCL is controversial. Some studies have reported such correlation between CD10 expression and prognosis (Chang et al., 2004; Hans et al., 2004; Berglund et al., 2005; Sjö et al., 2007; Jabłońska et al., 2010; Li et al., 2010); while others had found no difference in outcome between CD10 positive and CD10 negative tumors (Colomo et al., 2003; Fabiani et al., 2004; Bodoor et al., 2012). The difference in results might be attributed to the use of different numbers of patients examined. The variability in prognostic data suggests that CD10 could not be used alone to predict the survival in DLBCL.

Our results showed that patients with BCL-6 expression tended to show better survival, but not at a statistically significant level. This result was in agreement with the results reported by others (Lossos et al., 2001; Chang et al., 2004; Hans et al., 2004; Berglund et al., 2005; Oh and Park, 2006; Sjö et al., 2007; Li et al., 2010; Bodoor et al., 2012), whereas other studies did not report any significant difference in OS between positive and negative BCL-6 expression in DLBCL patients in addition to having no impact on prognosis in their cohort of DLBCLs (Colomo et al., 2003; Liu et al., 2008). These findings suggested that using this antigen alone as a prognostic marker may yield divergent results. It may be more useful to associate BCL-6 with other markers and use the three-marker model proposed by Hans et al. (2004).

The prognostic significance of MUM-1 expression in DLBCL patients is not clear. We found that the expression of MUM-1 was associated with a significantly worse OS. Others have also reported MUM-1 as a predictor of worse OS (Chang et al., 2004; Hans et al., 2004; Li et al., 2010). The results of other studies were in contrast to ours as they provided no correlation between MUM-1 expression and OS (Colomo et al., 2003; Berglund et al., 2005; Oh and Park, 2006; Sjö et al., 2007; Bodoor et al., 2012).

We reported a significant decrease in OS in DLBCL patients with positive CD138 expression. This finding was in agreement with previous studies that examined the prognostic value of CD138 expression for DLBCL patients (Hoffmann et al., 2005; Oh and Park, 2006; Bodoor et al., 2012). Some of these studies used the same cut-off value 10% (Bodoor et al., 2012), but others set a scoring cut-off value of 30% (Oh and Park, 2006) and 50% (Hoffmann et al., 2005). Using a multivariate analysis, only the expression of CD138 alone was statistically significant as an independently poor prognostic factor. Similar results were reported by Oh and Park (2006) and Bodoor et al. (2012).

In conclusion, our results, besides the different results of many studies, showed that none of these markers alone could be considered a factor with statistically important prognostic value, but determination of all these markers together provides a useful tool in the identification of important subgroups of DLBCL. In addition, CD138 may play an important role as a poor prognostic marker. Further investigations examining CD138 expression that include more patients are necessary to reach more specific conclusions. The expressions of CD10, BCl-6, MUM-1, and CD138 are each predictive of survival in DLBCL and prognostically important subclassification of DLBCL patients. Thus, they could provide new research and treatment strategies for DLBCL treatment.

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Conflicts of interest

There are no conflicts of interest.

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