Aberrant Co-Expression of Key Transcription Factors BCL6, IRF4 and FOXP1 Are Frequently Observed in Diffuse Large B-Cell Lymphoma
Authors: Boll Maayke , Barrans Sharon L , McManamy Charles S , Jack Andrew S 
Published: October 2019

Abstract
Diffuse Large B-cell Lymphoma (DLBCL) is classified into germinal centre (GCB) and activated B-cell (ABC) type by comparison with the phenotype of normal B-cells. Using single-color immunocytochemistry, tumors can be classified using a simple algorithm based on the expression of CD10, BCL6 and IRF4. This classification may have prognostic relevance and correlates with balanced translocations involving the immunoglobulin locus. However, the phenotypic differences between normal and neoplastic cells may be of greater relevance to understanding the pathogenesis of DLBCL and in developing effective diagnostic techniques. To investigate this we examined the co-expression of BCL6, IRF4 and FOXP1. These are key transcription factors that regulate the process of germinal centre and post germinal centre B-cell differentiation. Abnormal co-expression of these molecules would be expected to have major effects on the overall cellular phenotype. A multi-color immunofluorescence (MCIF) technique was developed that allowed the co-expression of these markers to be assessed in relation to the PAX5 positive B-cell population. The use of a multi-color technique allows the distinction between co-expression at the level of individual cells and differentiation within the tumor as a whole. We first determined the pattern of expression of these transcription factors in normal B-cells. In reactive lymph nodes the expression of BCL6, IRF4 and FOXP1 was almost mutually exclusive with only a small proportion of co-expressing cells. In a series of 61 DLBCL co-expression of both BCL6/IRF4 and IRF4/FOXP1 was found in 41/61 (67%) of the cases. In most of these cases the level of co-expression was greater than 50% of the PAX5 positive large lymphoid cells. Co-expression was not present in 11/61 (18%) of the tumors. In the remaining cases there was co-expression of either BCL6/IRF4 or IRF4/FOXP1. There was no correlation between the occurrence of co-expression of these combinations of transcription factors and the expression of CD10 or the classification into GCB and ABC phenotypes. In 16 of the cases the sample used was a small needle core biopsy in which assessment of nodal architecture was impossible. In these cases it was possible to confidently determine the presence of abnormal co-expression in 14/16 (87.5%) of the cases. One explanation for the aberrant co-expression of BCL6 and IRF4 in DLBCL would be the presence of a 3q27 rearrangement leading to dysregulation of BCL6 expression. However, in this series there was no correlation between BCL6/IRF4 co-expression and abnormalities of 3q27 detected by interphase FISH. These results show that in the majority of cases of DLBCL the key transcription factors regulating post germinal centre B-cell differentiation are expressed in combinations not seen in normal B-cells. This is likely to be a central element in the pathogenesis of these tumors. The ability to reliably identify these abnormalities by MCIF has potential value in improving the reliability of diagnosis of DLBCL when only small biopsy samples are available and it is likely that this approach can be extended to other types of lymphoma.