- Open Access
Prognostic values and clinical implications of programmed cell death-ligand 1 (PD-L1), fork head transcription factor P-1 (FOXP-1) and signal transducer and activator of transcription-3 (STAT-3) expression in diffuse large B-cell lymphoma (DLBCL); an immunohistochemical study
Surgical and Experimental Pathology volume 2, Article number: 15 (2019)
PD-L1 is an inhibitory ligand that functions as an essential immune checkpoint. FOXP-1 is a member of the FOXP family. STAT-3 plays a critical role in regulation of cell proliferation and survival. The detailed expression of the three markers together in DLBCL tissues and their prognostic value in patients with DLBCL were not fully investigated.
Aim was to assess the expression of PD-L1, FOXP-1 and STAT-3 in diffuse large B-cell lymphoma (DLBCL) and to correlate their expression with the pathological findings, prognostic parameters and clinical implications of patients.
PD-L1, FOXP-1 and STAT-3 were assessed in DLBCL tissues derived from 50 patients using immunohistochemistry. Patients were followed up for 3 years for response to therapy progression, recurrence and survival.
High PD-L1 expression was associated with bone marrow involvement (p = 0.004), extra-nodal involvement (p = 0.006) and advanced stage (p = 0.003). High FOXP-1 expression was associated with presence of bone marrow involvement and high risk group (p < 0.001). High STAT-3 expression was associated with older age of the patient (p < 0.001), presence of bone marrow involvement (p = 0.002), extra-nodal involvement (p = 0.009), and high risk group (p = 0.005). High expression of PD-L1, FOXP-1 and STAT-3 was related to poor response to therapy, poor OS rate and RFS rates (p < 0.001).
High expression of PD-L1, FOXP-1 and STAT-3 was related poor prognosis in DLBCL patients.
Detection of prognostic values PD-L1, FOXP-1 and STAT-3 expression in DLBCL.
Diffuse large B-cell lymphoma (DLBCL) is the commonest histological sub-type of non-Hodgkin lymphomas (NHLs) which occur in adults (Liu et al. 2018). The World Health Organization (WHO) classification identified DLBCL as a lymphoid malignancy which is clinically and genetically heterogeneous that is classified into two major molecular subtypes based on gene expression pattern; germinal center B-cell-like and specifically activated B-cell-like (Sun et al. 2017). DBCL accounts for about 80 % of aggressive lymphomas (ZL et al. 2011). International Prognostic Index (IPI) is used to for prediction of its prognosis (Sehn et al. 2007), but its role is still limited (Talaulikar et al. 2009). The currently used standard chemotherapy regimen for management of DLCBL patients enhances response rates and can prolong the survival of patients but 43% of patients still fail to respond or show disease relapse or chemo-resistance. Therefore, the development of novel prognostic biomarkers which could be effectively applied to improve the classification and categorization of DLBCL patients according to severity and prognosis is considered an essential need (Liu et al. 2018). Programmed cell death-ligand 1 (PD-L1) which is a B7 family member (also known as B7-H1), is an inhibitory ligand that functions as an essential immune checkpoint which plays a role in the regulation of cellular, humoral and adaptive immune responses (LY et al. 2017). Aberrant PD-L1 expression was reported to be associated with adverse prognosis of many types of cancers (LY et al. 2017; Gao et al. 2017). Several previous studies have reported the expression of PD-L1 in lymphoma and described its relationship with DLBCL prognosis (Kiyasu et al. 2015; Westin et al. 2014). However, the prognostic role of PD-L1 expression in DLBCL is still uncertain. Fork-head box protein P-1 (FOXP-1), which is found to be a winged helix transcription factor, a FOXP family member and it belongs to the fork head transcription factor family. FOXP-1 plays an important role in many biological processes, Moreover; it is considered a potential oncogene in pancreatic cancer, carcinoma of the liver, and various subtypes of B-cell non-Hodgkin lymphomas (van Keimpema et al. 2017). Several studies have evaluated the expression patterns of FOXP1 in DLBCL.
A few researchers assessed the correlations between expression of FOXP-1 and the survival rates; however, the results remain conflicting (Yu et al. 2011). Members of Signal Transducer and Activators of Transcription (STAT) family play essential role in regulation of transcription signal transduction. Signal transducer and activator of transcription-3 (STAT-3) plays a critical role in regulation of cell proliferation and survival and transcription activation of angiogenesis (ZL et al. 2011). STAT-3 is a transcription factor and an oncogene involved in cytokine growth signaling and cellular survival pathways (Silva 2004). However, the STAT-3 expression in DLBCL tissues and its prognostic value in patients with DLBCL were not fully investigated. Previous studies have assessed the expression and prognostic values of each marker alone in DLBCL but our current study was the first one to assess the prognostic values of PD-L1, FOXP-1 and STAT-3 expression together in tumor cells of DLBCL patients.
The aims of this study; were to assess the expression of PD-L1, FOXP-1 and STAT-3 in diffuse large B-cell lymphoma (DLBCL) and to correlate their expression with the pathological findings, prognostic parameters and clinical implications of patients.
Patients and methods
For this prospective cohort study, we have included 50 patients diagnosed with DLBCL, which were surgically operated at the General Surgery Department, Oncology unit, Faculty of Medicine, Zagazig University, sent to Pathology department Faculty of Medicine, Zagazig University for processing, diagnosis, grading and staging. Patients were followed up till death or their most recent medical examination for survival, progression and recurrence of the disease after successful therapy in Clinical Oncology and Nuclear Medicine Department, in Medical Oncology Department, Faculty of Medicine, Zagazig University and in Internal Medicine Department, Hematology unit, Faculty of Medicine, Zagazig University for 3 years, from October 2015 to October 2018. Formalin fixed paraffin embedded tissue blocks of the 50 patients were retrieved from the Department of Pathology for immunohistochemical analyses. We have included all cases of DLBCL and excluded other types of lymphomas, as identified by a full panel of immunohistochemical markers. Among the excluded cases were the mediastinal large B-cell lymphomas (Med LBCL), and the EBV-positive diffuse large B-cell lymphomas (EBV-positive DLBCL), as they tend to display variable PD-L1 expression patterns and represent a different tumor type. All laboratory investigation were done at Clinical Pathology Department, Faculty of Medicine, Zagazig University.
The Lugano modification of the Ann Arbor staging system was used for pathologic staging (Cheson et al. 2014), and the World Health Organization classification was used for pathologic grading.
Technique of immunohistochemical staining
For immunohistochemistry (IHC) analysis, 3-mm-thick formalin fixed paraffin-embedded sections were mounted on positively charged slides. We performed de-waxing of the sections in xylene, dehydrating in ascending grades of ethanol; we immersed the slides in methanol which contain 0.3% hydrogen peroxide for fifteen minutes to block endogenous peroxidase activity. Antigen retrieval was done for the slides by heating in an autoclave in citrated buffer (10 mM, pH 6.0) for about ninety seconds. The specimens were incubated for two hours at 37 °C with rabbit monoclonal anti PD-L1 (E1L3N) XP_ antibody (mAb) (Cell Signaling Technology, Danvers, MA, USA) 1:100 dilution, rabbit polyclonal anti-FOXP-1 antibody 1:200 dilution (Abcam ab16645, Cambridge, UK); rabbit polyclonal anti-STAT-3 antibody 1:100 dilution (sc-7179, Santa Cruz Biotechnology).
Evaluation of PDL-1, FOXP-1 and STAT3 immunohistochemical staining
We evaluated and assessed markers expression in tumor cells only and neglect any positivity in tumor infiltrating benign inflammatory cells. Evaluation of markers depends on the intensity and proportion of cells showing membranous staining and/or cytoplasmic staining for PD-L1, nuclear stain for FOXP-1 and nuclear stain for STAT-3. The presence of subcellular localization for STAT-3 staining in the nucleus and cytoplasm nuclear represents different cell compartments, where we included assessment of nuclear STAT3 protein expression only as it is accepted as a marker of STAT-3 activation and phosphorylation.
Previous history of hepatitis viral B infection was analyzed for all patients and correlated with markers expression.
The extent of markers expression was scored as follows: 0, no positive cells/high-power field; 1, fewer than 10% positive cells/ high-power field; 2, 10 to 30% positive cells/high-power field; 3, more than 30% positive cells/high power fields on average. The intensity of positive cells was scored as follows: 1, weak; 2, moderate; and 3, strong staining (ZL et al. 2011; LY et al. 2017; Kwon et al. 2016). Scores of the intensity and extent are multiplied to give the final stain score of values from 0 to 9, we used the cut off value of 3 above which is considered high expression and below which is considered low expression to facilitate statistical analysis. Each case was randomly selected at least 5 fields and quantified. Sections from adenocarcinoma of the colon were used as positive control for PD-L1, squamous cell carcinoma of the cervix as a positive control for FOXP-1, and invasive duct carcinoma of the breast as a STAT-3 positive, while for negative controls; the primary antibodies were totally replaced by phosphate buffered saline. Both positive and negative controls were put on independent slides simultaneously. Figs. 1, 2 and 3.
The statistics were performed using SPSS 22.0 for windows (SPSS Inc., Chicago, IL, USA) and MedCalc windows (Software bvba 13, Ostend, Belgium). Continuous variables were checked for normality by using Shapiro-Wilk test. Percent of categorical variables were compared using Pearson’s Chi-square test or Fisher’s exact test when was appropriate. Overall Survival (OS) was calculated as the duration from tumor diagnosis to death or the most new follow-up contact. Relapse Free Survival (RFS) was calculated as the time from start of treatment to date of relapse or the most recent follow-up contact that patient was known as relapse free.
Stratification of OS and RFS was done according to PDL-1, FOXP-1 and STAT3 expression in tumor cells.
These rates were estimated using the method of Kaplan-Meier plot, and compared using two-sided exact log-rank test. A p-value < 0.05 was considered significant.
Among the 50 patients with DLBCL there were 31 (62%) male and 19 (38%) female. All demographic data are shown in Table 1. Hepatitis B viral infection was negative in 42 (84%) of the cases; there was no association between this infection and the expression of any of the 3 markers.
High PD-L1 expression was present in 19 (38%) in DLBCL patients and its expression was positively correlated with older age of the patient (p < 0.001), presence of B symptoms, fever, weight loss, night sweating, bone marrow involvement (p = 0.004), bulky lymph nodes and extra-nodal involvement by the tumor (p = 0.006).
High expression of PD-L1 was present in 2 cases (18.2%) of stage I, 3 cases (18.8%) of stage II, 7 cases (53.8%) of stage III and 7 cases (70%) of stage IV, its expression was positively associated with advanced stage of the tumor (p = 0.003) and high IPI risk group (p = 0.001). No significant association was found between PD-L1 expression, sex of the patients or previous history of hepatitis B infection.
High FOXP-1 expression was present in 21 (42%) in DLBCL and its expression was positively correlated with advanced age of the patient (p < 0.001), presence of B symptoms, presence of fever, weight loss, night seating, bone marrow involvement, bulky lymph nodes and extra-nodal involvement (p < 0.001).
High expression of FOXP-1 was present in 2 cases (18.2%) of stage I, 3 cases (18.8%) of stage II, 8 cases (61%) of stage III and 8 cases (80%) of stage IV, its expression was positively associated with advanced stage of the tumor and high IPI risk group (p < 0.001). No significant association was found between FOXP1 expression, sex of the patients or previous history of hepatitis B infection.
High STAT-3 expression was present in 23 (46%) in DLBCL and its expression was positively correlated with advanced age of the patient (p < 0.001), presence of B symptoms, presence of fever, weight loss, night seating, bone marrow involvement (p = 0.002), bulky lymph nodes and extra-nodal involvement (p = 0.009),
High expression of STAT-3 was present in 2 cases (18.2%) of stage I, 5 cases (31.2%) of stage II, 9 cases (69.2%) of stage III and 7 cases (70%) of stage IV, its expression was positively associated with advanced stage of the tumor (p = 0.003) and high IPI risk group (p = 0.005). No significant association was found between STAT-3 expression, sex of the patients or previous history of hepatitis B infection.
Images for both positive and negative control of the three markers are all included in with figures of their corresponding markers.
The detailed treatment regimens were taken according to the clinical stage and prognostic group. Chemotherapy, radiotherapy and/or combined modalities are described in Table 1 and we correlated the response of therapy to markers expression, we found that high expression of PD-L1, FOXP-1 and STAT-3 was related to absent response to chemotherapy, higher incidence of resistance to first line chemotherapy (p = 0.13, 0.030, 0.044 respectively) higher incidence of disease progression poor OS rate and RFS rates (p < 0.001).
We have found a positive association between PD-L1 and FOXP-1; Phi coefficient = + 0.753, PD-L1 and STAT-3; Phi coefficient = + 0.766, FOXP1 and STAT 3; Phi coefficient = + 0.515 (p < 0.001).
It has been suggested that immunotherapy directed against PD-1/PD-L1 axis could be combined with targeted therapy for adequate management and improvement of prognosis of patients’ with different malignancies including DLBCL (Goodman et al. 2017; Jelinek et al. 2017; Ok and Young 2017). In the current study we have chosen to assess the expression of PD-L1 in tissues of such malignant lymphoid tumor, we assessed its expression in all cases of DLBCL and exclude assessing its level in Med LBCL, and in EBV-positive cases as such subtypes tend to display variable PD-L1 expression patterns and are considered a different tumor type.
We have proved that PD-L1 is overexpressed in tumor cells of DLBCL patients and its expression is related to poor prognosis and dismal patients’ outcome which was similarly, results of many previous reports (ZL et al. 2011; Gravelle et al. 2017; Jo et al. 2017; Xing et al. 2016). Moreover, we proved that, PD-L1 was found to be an independent predictor for poor OS, additionally; PD-L1 expression in tumor cells was associated with advanced clinical stage as it was expressed in stages; III and IV more than stages; I and II, demonstrating its role as an adverse prognostic factor in DLBCL. Kiyasu et al., showed results also similar to ours; PD-L1 expression level was positively correlated with the poor clinical outcomes of patients with DLBCL (Kiyasu et al. 2015). Fang et al., add to the previous results that low PD-L1 expression in DLBCL tissues is associated with favorable prognosis of some cases of such malignancy (Fang et al. 2017). In the Hu et al., study have found that PD-L1 expression in tumor cells was significantly associated with poor prognosis (ZL et al. 2011). We also found that PD-L1 expression in tumor cells was associated with resistance to first line chemotherapy, similarly, Hu et al., showed that PD-L1 expression is associated with chemoresistance (ZL et al. 2011). DLBCL have several pathways to escape from the antitumor immunity which is essential in these aggressive lymphomas which explain the reason of PD-L 1 overexpression and association with poor prognosis in such malignancy (Song et al. 2016). The mechanisms explaining the relationship between increased PD-L1 expression and poor prognosis of DLBCL patients are still not clear (ZL et al. 2011). The activation of Janus kinase (JAK)/ STAT3 signaling increased the constitutive expression of PD-L1 in DLBCL and leads to poor outcome (ZL et al. 2011; Green et al. 2010). So, immunotherapies that are targeting the JAK/STAT3 signaling pathway might benefit patients with such aggressive subtype of disease. Most DLBCL patients are cured with standard chemo-immunotherapy but about 30% still die of due to disease progression which needed a novel targeted therapy to improve their outcome (Juárez-Salcedoa et al. 2017). The first published experience with check point inhibition in DLBCL was with ipilimumab (anti-CTL4 antibody) (Ansell et al. 2009). It was found that the successful uses of PD1/PD-L1 block-age in solid tumors with advanced stages generally, and in DLBCL particularly, have established a new era in oncologic therapeutics by altering one of the hallmarks of cancer; the tumor immune evasion. But, the principles of PD1/PD-L1mediated immune evasion and checkpoint inhibition cannot be generalized on all lymphomas, as they have relatively different natural history. So in the current study we have specified results on DLBCL which is an example of aggressive high grade lymphomas which have high proliferative activity and they can be cured with intensive courses of combined chemo-immuno-therapy regimens. Graveled et al., (Gravelle et al. 2017) reviewed the results of previous studies about PD-L1 expression in lymphomas and have concluded similar results to us and, that hence PD-L1 overexpression is associated with the poorest prognosis in several types of aggressive NHLs; namely DLBCL, so, monoclonal antibodies which are selectively blocking the PD-1/PD-L1 axis could preserve tumor infiltrating lymphocytes (TILs) from exhaustion and could promote antitumor immunity as an effective therapeutic strategy for NHL generally and DLBCL particularly. Moreover the cell surface expression of PD-1/PD-L1 is considered a critical determinant for the identification of DLBCL patients who will be eligible for immune checkpoint blockade therapies. To add to results of our study we assessed another marker which is realted to disturbed tumor immunity; FOXP-1, as it was found that dys-regulation of FOXP-1 expression is seen in tissues of many tumors (Yu et al. 2011).
Many previous researches regarding FOXP-1 expression have been limited to nodal DLBCL. But, few data were available regarding the FOXP-1 expression in extra-nodal DLBCL. Our current study was the first one which investigated the expression of FOXP1 in DLBCL which occurred both in lymph nodes and in extra-nodal sites, and we proved that high expression of FOXP-1 in nuclei of tumor cells of patients with DLBCL was associated with poor pathological criteria as advanced patients stage, poor patients outcome, poor survival rates and resistance to chemotherapy in addition to positive association with PD-L1 expression in tumor cells. Similarly Yu et al., showed that FOXP-1 was, expressed both in nodal and extra-nodal DLBCLs and they concluded that FOXP-1 is involved in the progression of both nodal and extra-nodal DLBCL, but the mechanisms its function could be different (Yu et al. 2011), moreover our study demonstrates that evaluation of FOXP-1 tissue protein expression in DLBCL was of greater prognostic importance regarding worse OS rate that was similar to results of previous studies (Bellas et al. 2014; Banham et al. 2005; Barrans et al. 2004; Sagaert et al. 2006; Hoefnagel et al. 2006; Kodama et al. 2005), while others found that tissue protein expression of FOXP-1 had no effect on pathological criteria, clinical outcomes, or survival rates (Davis et al. 2001; Lam et al. 2008), such apparent discrepancy might be explained by different criteria in detecting antigen expression and different cutoff values (Barrans et al. 2004). Sagaert et al. found that increased tissue protein expression of FOXP-1 is a significant predictor of unfavorable clinical outcome in MALT lymphoma which is at risk of transforming into aggressive subtypes of DLBCLs (Sagaert et al. 2006). There are many mechanisms which may be incriminated in FOXP-1 deregulation in DLBCL. Primarily, there is a reported significant association between the high FOXP-1 expression and high proliferation rates, between the high FOXP1 expression MYC overexpression in DLBCL tissues (Bellas et al. 2014). Additionally, FOXP-1 was associated with the expression of Bcl2 (Xing et al. 2016), and in plethora of patients with DLBCL, Bcl2 up-regulation may be mediated through NF-κB pathway that is continuously expressed and has an essential role in its pathogenesis, progression and poor prognosis (Davis et al. 2001). As we have found a positive correlation between PD-L1 expression and FOXP-1 expression and as both markers were associated with poor prognosis in DLBCL patients, so there is a role of immune dysfunction in such malignancy and both agents may be used as novel prognostic parameters of such cancer as proved by findings of our study. Due to conflicting results of previous studies regarding the prognostic role of both markers, we assessed the prognostic role of a third marker with them to strengthen the assessment of their prognostic role in DLBCL patients that is STAT-3. Up to our knowledge, it is the first study that assessed those three markers expression in DLBCL tissues using immunohistochemistry. Previous studies proved that DLBCL had the highest level of STAT-3 mRNA and such expression is associated with dismal outcome of those patients (Sun et al. 2017; Lam et al. 2008; Scuto et al. 2011). In the study, we investigated the tissue protein expression level of STAT-3 in DLBCL and we have proved that high expression is associated with advanced stage, dismal patients’ outcome and poor survival rates. Our study and ZL et al., demonstrated the possibility of using immunohistochemistry to detect tissue protein STAT-3 expression in routine pathologic specimens that might enable us to identify DLBCL cases with poor clinical outcome, and subsequently guides us to make more intensive treatment for those patients (ZL et al. 2011). Additionally, we have shown that high nuclear expression of STAT-3 in DLBCL was correlated with poor overall survival rate, especially in patients receiving CHOP regimen, which was similar to results of; Sun et al., ZL et al and Huang et al., who found similar results and that targeting the STAT-3 pathway might lead to reverse CHOP resistance in patients with DLBCL (Sun et al. 2017; ZL et al. 2011; Huang et al. 2013).
Lam et al. reported that DLBCL had higher level of STAT3 mRNA and protein levels as detected with immunohistochemistry and such high levels were associated with poor outcome and with inferior overall survival (Lam et al. 2008). Such association is explained by that STAT-3 regulates the expression of plethora of genes like, survivin, bcl-xl, mcl-1which modulate cell survival, and proliferation, c-myc, cyclin D1, p21, cyclin E and matrix metalloproteinase-9 which control malignant cells invasion and metastasis (Ding et al. 2008), vascular endothelial growth factor which control angiogenesis (Dechow et al. 2004). Moreover, STAT-3 found to suppress the anti-tumor immune responses (Baran-Marszak et al. 2010; Kujawski et al. 2008; Kortylewski et al. 2009; Wang et al. 2009) and could regulate many cancer-promoting inflammatory mediators that could initiate and promote ontogenesis, genetic and epigenetic changes in cancer cells (Yin et al. 2011; Ok et al. 2014).
We have found a positive association between expression of PD-L1 and FOXP-1 in DLBCL which is similar to results of Anastasiadou et al. that found similar results in NSCLC (Anastasiadou et al. 2018). We found a positive association between PD-L1 and STAT-3 expression in DLBCL which was similar to results of Song et al., that performed novel functional and structural characterization of STAT-3 activating mutations and detected a regulatory role of STAT-3 activation in PD-L1 expression and both of them is associated with poor prognosis (Song et al. 2018). Targeting STAT-3 could have a synergistic effect in immune checkpoint blockade therapy. To our knowledge, we are the first study that assessed the association between PD-L1, FOXP-1 and STAT-3 tissue protein expression in DLBCL patients.
Previous studies assessed each two markers together in lymphoma and other solid tumors (Song et al. 2018; Atsaves et al. 2017; Kataoka et al. 2016; Bu et al. 2017), but our findings regarding their expression in DLBCL were novel and detect positive correlations between the PD-L1, FOXP-1 and STAT-3 and all are associated with poor prognosis and dismal outcome of patients.
We have evaluated the expression of PD-L1, FOXP-1 and STAT-3 in tissues of DLBCL patients and we have correlated their expression with pathological, clinical and follow-up data of patients and we have found a positive association between their expression and poor pathological criteria, advanced clinical stage, poor response to therapy and dismal outcome of patients. Our results point to the possibility of using such markers as novel prognostic markers of such malignancy which might help the better classification of patients and improve DLBCL patients’ prognosis.
Limitations of the work and recommendations
The limitations of our study are; the small number of included cases in addition to difficulty in separating neoplastic cell from infiltrating reactive cells during immunohistochemical evaluation of markers expression so we have recommended performing a large scale study on a huge number of patients using different methods of assessment as genetic studies to prove our results and improve the findings.
It remains unclear whether high levels of expression of PD-L1, FOXP-1 and STAT-3 plays a key role that is associated with the clinical outcome of DLBCL patients, so further integration of genomic and clinical data is needed to deepen our understanding of their roles in DLBCL.
Diffue large B-cell lymphoma
- EBV-positive DLBCL:
EBV-positive diffuse large B-cell lymphomas
- FOXP-1 :
Forkhead transcription factor
International Prognostic Index
- Med LBCL:
Mediastinal large B-cell lymphomas
Programmed cell death-ligand 1
Relapse Free Survival
- STAT-3 :
Signal transducer and activator of transcription-3
Anastasiadou E, Stroopinsky D, Alimperti S, Jiao AL, Pyzer AR, Cippitelli C et al (2018) Epstein−Barr virus-encoded EBNA2 alters immune checkpoint PD-L1 expression by downregulating miR-34a in B-cell lymphomas. J Oncology 30(4): 345-354.
Ansell SM, Hurvitz SA, Koenig PA et al (2009) Phase I study of ipilimumab, ananti-CTLA-4 monoclonal antibody, in patients with relapsed and refractoryB-cell non-Hodgkin lymphoma. Clin Cancer Res 15(20):6446–6453
Atsaves V, Tsesmetzis N, Chioureas D, Kis L, Leventaki V, Drakos E et al (2017) PD-L1 is commonly expressed and transcriptionally regulated by STAT3 and MYC in ALK-negative anaplastic large-cell lymphoma. Leukemia. 31(7):1633–1637
Banham AH, Connors JM, Brown PJ et al (2005) Expression of the FOXP1 transcription factor is strongly associated with inferior survival in patients with diffuse large B-cell lymphoma. Clin Cancer Res 11:1065–1072
Baran-Marszak F, Boukhiar M, Harel S, Laguillier C, Roger C, Gressin R et al (2010) Constitutive and B-cell receptor-induced activation of STAT3 are important signaling pathways targeted by bortezomib in leukemic mantle cell lymphoma. Haematologica 95(11):1865–1872
Barrans SL, Fenton JA, Banham A, Owen RG, Jack AS (2004) Strong expression of FOXP1 identifies a distinct subset of diffuse large B-cell lymphoma (DLBCL) patients with poor outcome. Blood 104:2933–2935
Bellas C, García D, Vicente Y, Kilany L, Abraira V, Navarro B, Provencio M, Martı’n P (2014) Immunohistochemical and molecular characteristics with prognostic significance in diffuse large B-cell lymphoma. PLoS One 9(6):98169–98180
Bu LL, Yu GT, Wu L, Mao L, Deng WW, Liu JF et al (2017) STAT3 induces immunosuppression by upregulating PD-1/PD-L1 in HNSCC. J Dent Res 96(9):1027–1034
Cheson BD, Fisher RI, Barrington SF et al (2014) Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 32:3059–3068
Davis RE, Brown KD, Siebenlist U, Staudt LM (2001) Constitutive nuclear factor kappaB activity is required for survival of activated B cell-like diffuse large B cell lymphoma cells. J Exp Med 194:1861–1874
Dechow TN, Pedranzini L, Leitch A, Leslie K, Gerald WL, Linkov I et al (2004) Requirement of matrix metalloproteinase-9 for the transformation of human mammary epithelial cells by Stat3-C. Proc Natl Acad Sci U S A 101(29):10602–10607
Ding BB, Yu JJ, Yu RY, Mendez LM, Shaknovich R, Zhang Y et al (2008) Constitutively activated STAT3 promotes cell proliferation and survival in the activated B-cell subtype of diffuse large B-cell lymphomas. Blood 111(3):1515–1523
Fang X, Xiu B, Yang Z, Qiu W, Zhang L, Zhang S et al (2017) The expression and clinical relevance of PD-1, PD-L1, and TP63 in patients with diffuse large B-cell lymphoma. Medicine. 96(15):e6398
Gao Y, Li S, Xu D, Chen S, Cai Y, Jiang W et al (2017) Prognostic value of programmed death-1, programmed death-ligand 1, programmed death ligand 2 expression, and CD8(+) T cell density in primary tumors and metastatic lymph nodes from patients with stage T1-4N + M0 gastric adenocarcinoma. Chin J Cancer 36(1):61
Goodman A, Patel SP, Kurzrock R (2017) PD-1-PD-L1 immune-checkpoint blockade in B-cell lymphomas. Nat Rev Clin Oncol 14(4):203
Gravelle P, Burroni B, Péricart S, Rossi C, Bezombes CH, Tosolini M, Damotte D et al (2017) Mechanisms of PD-1/PD-L1 expression and prognostic relevance in non-Hodgkin lymphoma: a summary of immunohistochemical studies. Oncotarget 8:44960–44975
Green MR, Monti S, Rodig SJ, Juszczynski P, Currie T, O’Donnell E et al (2010) Integrative analysis reveals selective 9p24.1 amplification, increased PD-1 ligand expression, and further induction via JAK2 in nodular sclerosing Hodgkin lymphoma and primary mediastinal large B-cell lymphoma. Blood. 116(17):3268–3277
Hoefnagel JJ, Mulder MM, Dreef E et al (2006) Expression of B-cell transcription factors in primary cutaneous B-cell lymphoma. Mod Pathol 19:1270–1276
Huang X, Meng B, Iqbal J, Ding BB, Perry AM, Cao W et al (2013) Activation of the STAT3 signaling pathway is associated with poor survival in diffuse large B-cell lymphoma treated with R-CHOP. J Clin Oncol 31:4520–4528
Jelinek T, Mihalyova J, Kascak M, Duras J, Hajek R (2017) PD-1/PD-L1 inhibitors in haematological malignancies. Immunology. 152(3):357–371
Jo JC, Kim M, Choi Y, Kim HJ, Kim JE, Chae SW et al (2017) Expression of programmed cell death 1 and programmed cell death ligand 1 in extranodal NK/T-cell lymphoma, nasal type. Ann Hematol 96(1):25–31
Juárez-Salcedoa LM, Sandoval-Susb J, Sokolb L, Chavezb JC, Daliac S (2017) The role of anti-PD-1 and anti-PD-L1 agents in the treatment ofdiffuse large B-cell lymphoma: the future is now. Crit Rev Oncol Hematol 113:52–62
Kataoka K, Shiraishi Y, Takeda Y, Sakata S, Matsumoto M, Nagano S et al (2016) Aberrant PD-L1 expression through 3′-UTR disruption in multiple cancers. Nature. 534(7607):402–406
Kiyasu J, Miyoshi H, Hirata A, Arakawa F, Ichikawa A, Niino D et al (2015) Expression of programmed cell death ligand 1 is associated with poor overall survival in patients with diffuse large B-cell lymphoma. Blood. 126(19):2193–2201
Kodama K, Massone C, Chott A, Metze D, Kerl H, Cerroni L (2005) Primary cutaneous large B-cell lymphomas: clinicopathologic features, classification, and prognostic factors in a large series of patients. Blood 106:2491–2497
Kortylewski M, Xin H, Kujawski M, Lee H, Liu Y, Harris T et al (2009) Regulation of the IL-23 and IL-12 balance by Stat3 signaling the tumor microenvironment. Cancer Cell 15:114–123
Kujawski M, Kortylewski M, Lee H, Herrmann A, Kay H, Yu H (2008) Stat3 mediates myeloid cell dependent tumor angiogenesis in mice. J Clin Invest 118:3367–3377
Kwon D, Kim S, Kim PJ et al (2016) Clinicopathological analysis of programmed cell death 1 and programmed cell death ligand 1 expression in the tumour microenvironments of diffuse large B cell lymphomas. Histopathology 68:1079–1089
Lam LT, Wright G, Davis RE, Lenz G, Farinha P, Dang L et al (2008) Cooperative signaling through the signal transducer and activator of transcription 3 and nuclear factor-B pathways in subtypes of diffuse large B-cell lymphoma. Blood. 111(7):3701–3713
Liu J, Quan L, Zhang C, Liu A, Tong D, Wang J (2018) Over‑activated PD‑1/PD‑L1 axis facilitates the chemoresistance of diffuse large B‑cell lymphoma cells to the CHOP regimen. Oncol Lett 15:3321–3328
LY H, XL X, HL R, Chen J, Lai RC, Huang HQ et al (2017) Expression and clinical value of programmed cell death-ligand 1 (PD-L1) in diffuse large B cell lymphoma: a retrospective study. Chin J Cancer 36:94
Ok CY, Chen J, Xu-Monette ZY, Tzankov A, Manyam GC, Li L et al (2014) Clinical implications of phosphorylated STAT3 expression in de novo diffuse large B-cell lymphoma. Clin Cancer Res 20:5113–5123
Ok CY, Young KH (2017) Checkpoint inhibitors in hematological malignancies. J Hematol Oncol 10(1):103
Sagaert X, Paepe PD, Libbrecht L et al (2006) Forkhead box protein P1 expression in mucosa-associated lymphoid tissue lymphomas predicts poor prognosis and transformation to diffuse large B-cell lymphoma. J Clin Oncol 24:2490–2497
Scuto A, Kujawski M, Kowolik C, Krymskaya L, Wang L, Weiss LM, Digiusto D, Yu H, Forman S, Jove R (2011) STAT3 inhibition is a therapeutic strategy for ABC-like diffuse large B-cell lymphoma. Cancer Res 71(9):3182–3188
Sehn LH, Berry B, Chhanabhai M, Fitzgerald C, Gill K, Hoskins P et al (2007) The revised international prognostic index (R-IPI) is a better predictor of outcome than the standard IPI for patients with diffuse large B-cell lymphoma treated with R-CHOP. Blood 109(5):1857–1861
Silva CM (2004) Role of STATs as downstream signal transducers in src family kinase-mediated tumorigenesis. Oncogene. 23(48):8017–8023
Song TL, Nairismägi ML, Laurensia Y, Lim JQ, Tan J, Li ZM et al (2018) Oncogenic activation of STAT3 pathway drives PD-L1 expression in natural killer/T cell lymphoma. Blood. 35(4):342-351
Song Z, Yu X, Cheng G, Zhang Y (2016) Programmed death-ligand 1 expression associated with molecular characteristics in surgically resected lung adenocarcinoma. J Transl Med 14(1):1–7
Sun J, Li B, Xie B, Xu Z, Chang G, Tao Y et al (2017) DCZ3301, a novel cytotoxic agent, inhibits proliferation in diffuse large B-cell lymphoma via the STAT3 pathway. Cell Death Dis 8:3111
Talaulikar D, Shadbolt B, Dahlstrom JE, McDonald A (2009) Routine use of ancillary investigations in staging diffuse large B-cell lymphoma improves the international prognostic index (IPI). J Hematol Oncol 22:2–49
van Keimpema M, Grüneberg LJ, Schilder-Tol EJ, Oud ME et al (2017) The small FOXP1 isoform predominantly expressed in activated B cell-like diffuse large B-cell lymphoma and full-length FOXP1 exert similar oncogenic and transcriptional activity in human B cells. Haematologica. 102(3):573–583
Wang L, Yi T, Kortylewski M, Pardoll D, Zeng D, Yu H (2009) IL-17 can promote tumor growth through an IL-6/Stat3 signaling pathway. J Exp Med 206:1457–1464
Westin JR, Chu F, Zhang M, Fayad LE, Kwak LW, Fowler N et al (2014) Safety and activity of PD-1 blockade by pidilizumab in combination with rituximab in patients with relapsed follicular lymphoma: a single group, open-label, phase 2 trial. Lancet Oncol 15(1):69–77
Xing W, Dresser K, Zhang R, Evens AM, Yu H, Woda BA et al (2016) PD-L1 expression in EBV-negative diffuse large B-cell lymphoma: clinicopathologic features and prognostic implications. Oncotarget. 7(37):59976–59986
Yin Q, Zha X, Yang L, Chen S, Zhou Y, Wu X et al (2011) Generation of diffuse large B cell lymphoma-associated antigen-specific Vα6/Vβ13+T cells by TCR gene transfer. J Hematol Oncol 4:2–9
Yu BH, Zhou XY, Li BZ, Xiao XY, Yan SHY, Shi DR (2011) FOXP1 expression and its clinicopathologic significance in nodal and extranodal diffuse large B-cell lymphoma. Ann Hematol 90:701–708
ZL W, YQ S, YF SH, Zhu J (2011) High nuclear expression of STAT3 is associated with unfavorable prognosis in diffuse large B-cell lymphoma ZL et al. J Hematol Oncol 4:31
No funds were received
Availability of data and materials
All data are available and acquired by the authors from Zagazig University, Faculty of Medicine, Departments
Ethics approval and consent to participate
The study complied with the guidelines of the local ethics committee of Faculty of Medicine, Zagazig University, Zagazig, Egypt.
Consent for publication
Were taken from all the contributing authors
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Harb, O.A., Kaf, R.M., Taha, H.F. et al. Prognostic values and clinical implications of programmed cell death-ligand 1 (PD-L1), fork head transcription factor P-1 (FOXP-1) and signal transducer and activator of transcription-3 (STAT-3) expression in diffuse large B-cell lymphoma (DLBCL); an immunohistochemical study. Surg Exp Pathol 2, 15 (2019). https://doi.org/10.1186/s42047-019-0038-7