Precision Cancer Therapies, Volume 1:

Targeting Oncogenic Drivers and

Signaling Pathways in Lymphoid
Malignancies: From Concept to
Practice Owen A. O'Connor
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Precision Cancer Therapies
Precision Cancer Therapies

Volume 1
Targeting Oncogenic Drivers and Signaling Pathways in Lymphoid Malignancies

From Concept to Practice

Edited by
Owen A. O’Connor
Stephen M. Ansell
John F. Seymour
This edition first published 2023
© 2023 John Wiley & Sons Ltd

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 v

Contents

List of Contributors xix

Volume Foreword xxiv
Volume Preface xxvi
Series Preface xxviii

Section I Biological Basis of the Lymphoid Malignancies 1

1 Fundamental Principles of Lymphomagenesis 3

Pierre Sujobert, Philippe Gaulard, and Laurence de Leval
Take Home Messages 3
Introduction 3
How to Study Lymphomagenesis 3
Before Lymphoma: The Gray Frontier Between Physiology and Pathology 5
Driver Without Disease 5
From In Situ Neoplasms to Asymptomatic Lymphomas 5
Chronic Antigenic Stimulation as an Early Step of Lymphomagenesis 5
The Cell of Origin Concept: A Classification Based on Physiology 6
What Are the Hallmarks of Lymphoma? 7
Epigenetics and Metabolism 7
Apoptosis Escape 8
Proliferation 8
TCR/BCR Signaling 8
Immune Escape 8
Trafficking 8
Microenvironment 8
Conclusion 9
Must Read References 9
References 9

2 Identifying Molecular Drivers of Lymphomagenesis 12

Jennifer Shingleton and Sandeep S. Dave
Take Home Messages 12
Introduction 12
Sequencing and Bioinformatics Methods 13
Functional Validation of Drivers 13
Common Themes in B- and T-cell Lymphoma 14
Genetic Landscapes of Lymphomas 18
Mature B-cell Lymphomas 18
T-cell Lymphomas 18
Genomic Subgrouping Approaches in DLBCL 19
Challenges of Incorporating Genomic Subgrouping Approaches in Clinical Trials 19
vi Contents

Leveraging Underlying Pathophysiology to Inform Therapeutic Consideration 20

Conclusion 22
Must Read References 22
References 22

3 Characterizing the Spectrum of Epigenetic Dysregulation Across Lymphoid Malignancies 25

Sean Harrop, Michael Dickinson, Ricky Johnstone, and Henry Miles Prince
Take Home Messages 25
Introduction: Epigenetics and Lymphoid Malignancies 25
Dysregulation of DNA Methylation and Modification of Histone Proteins 26
Genes Involved in Histone Modification Implicated in Lymphomagenesis 27
Enhancer of Zeste Homolog 2 (EZH2) 27
CREB-binding Protein (CREBBP) and Histone Acetyltransferase P300 (EP300) 27
The H3K4 Methyltransferase Family 27
The Bromodomain and Extra-Terminal Domain (BET) Family 27
Genes Involved in DNA Methylation Implicated in Lymphomagenesis 27
DNA Methyltransferase 3A (DNMT3A) 27
Ten-Eleven Translocation 1/2 (TET1/2) 28
Isocitrate Dehydrogenase 2 (IDH2) 28
The Epigenetic Landscape of Specific Lymphoid Malignancies 28
Follicular Lymphoma 28
Diffuse Large B-cell Lymphoma 29
Marginal Zone Lymphoma 30
Burkitt’s Lymphoma 30
Acute Lymphoblastic Leukemia 31
Chronic Lymphocytic Leukemia 31
Mantle Cell Lymphoma 31
Hodgkin’s Lymphoma 31
Multiple Myeloma 32
Peripheral T-cell Lymphoma – Not Otherwise Specified 32
Angioimmunoblastic T-cell Lymphoma and PTCL with TFH Phenotype 32
Anaplastic Large Cell Lymphoma 33
Adult T-cell Leukemia/Lymphoma 33
Intestinal T-cell Lymphoma 33
Hepatosplenic T-cell Lymphomas 33
NK/T Cell Lymphoma 33
Mycosis Fungoides and Sezary’s Syndrome 34
Summary 34
Must Read References 34
References 34

4 Animal Models of Lymphoid Malignancies 40

Anjali Mishra
Take Home Messages 40
Introduction 40
Optimal Animal Models to Study Lymphoid Neoplasms 41
Zebrafish Model 41
Zebrafish Model of T-cell Neoplasms 41
Zebrafish Model of B-cell Neoplasms 42
Zebrafish Model of NK-cell Neoplasms 43
Patient-Derived Xenograft Models in Zebrafish 43
Fruit Fly Model 43
Non-human Primate Model 44
Mouse Models of Lymphoid Neoplasia 44
 Contents vii

Use of Animal Models in Translational Research 48

Conclusions 49
Must Read References 49
References 50

Section II Targeting the PI3 Kinase-AKT-mTOR Pathway 53

5 Principles of PI3K Biology and Its Role in Lymphoma 55

Ralitsa R. Madsen
Take Home Messages 55
Introduction: Overview 55
Four Decades of PI3K Signaling Research 55
Class I PI3K Enzymes 56
Isoforms 56
Structural Organization 57
Isoform-specific Functions 57
The Essential Phospholipid Second Messenger PIP3 58
PI3K Pathway Effectors 59
AKT, FOXO, and mTORC1 59
TEC Tyrosine Kinases 60
Network Topology and Signal Robustness 60
Dynamic PI3K Signaling in Lymphocyte Biology 61
B-cell Development and Survival 61
The Germinal Center (GC) Reaction 61
TFH Cell Function 63
Naïve and Effector T-cells 63
Lessons from Monogenic Disorders 64
Genetic PI3Kδ Inactivation 64
Genetic PI3Kδ Hyperactivation 64
Corrupted PI3K Signaling in Cancer 65
The Success of PI3Kδ Inhibition in Lymphoid Malignancies 65
Quantitative Biology and Therapeutic Considerations 66
Concluding Remarks 67
Acknowledgments 67
Must Read Reference 67
References 67

6 Pharmacologic Differentiation of Drugs Targeting the PI3K-AKT-mTOR Signaling Pathway 71

Inhye E. Ahn, Jennifer R. Brown, and Matthew S. Davids
Take Home Messages 71
Introduction 71
PI3K Inhibitors Approved by the US Food and Drug Administration (FDA) 72
PI3K Inhibitors in Clinical Development 77
AKT Inhibitors 78
mTOR Inhibitors 79
Conclusions 79
Must Read References 79
References 80

7 Clinical Experience with Phosphatidylinositol 3-Kinase Inhibitors in Hematologic Malignancies 86

Alessandro Broccoli and Pier Luigi Zinzani
Take Home Messages 86
Introduction 86
viii Contents

Idelalisib 87
Copanlisib 91
Duvelisib 93
Umbralisib 95
Parsaclisib 97
Zandelisib 97
Amdizalisib (HMPL-689) 98
Conclusion 98
Must Read References 99
References 99

8 Clinical Experiences with Drugs Targeting mTOR 102

Thomas E. Witzig
Take Home Messages 102
Introduction 102
Rapamycin (Sirolimus) Rapamune® (Pfizer) and Generic Sirolimus 103
The Rapamycin Analogs (Rapalogs) 103
Temsirolimus (CCI-779; Torisel) 103
Everolimus (RAD-001; Afinitor, Zortrees, Evertor) 105
Summary of Lymphoma Studies of Everolimus 107
Ridaforolimus 108
Dual Inhibitors of mTORC1 and mTORC2 108
Side Effects of mTORC1 Inhibitors 108
Future Directions for mTOR Inhibitors in Lymphoma 109
Must Read References 110
References 110

9 PI3 Kinase, AKT, and mTOR Inhibitors 113

Joel McCay and John G. Gribben
Take Home Messages 113
Introduction 113
PI3K Structure and Functions 114
AKT Structure and Functions 114
mTOR Structure and Functions 115
PTEN as a Regulator of the PI3K/AKT/mTOR Pathway 115
mTOR Inhibitors 116
Temsirolimus: Phase 3 Trials 116
PI3K and Dual PI3K/mTOR Inhibitors 116
PI3K Isoforms and Expression Throughout the Body 118
Immune Toxicity and Management 119
Colitis 119
Hepatitis 119
Pneumonitis 120
Skin Rash 120
Homeostatic Toxicity 120
Hypertension and Hyperglycemia 121
Myelosuppression and Opportunistic Infection 121
Myelosuppression 122
Atypical Infection 122
Vaccination 122
Neuropsychiatric Problems 122
PI3K Treatment in NHL 122
 Contents ix

AKT Inhibitors 123

Conclusion 123
Must Read References 126
References 126

Section III Targeting Programmed Cell Death 131

10 Principles for Understanding Mechanisms of Cell Death and Their Role in Cancer Biology 133
Sarah T. Diepstraten, John E. La Marca, David C.S. Huang, and Gemma L. Kelly
Take Home Messages 133
Introduction 133
A Historical Perspective 133
Apoptotic Pathways 134
Other Cell Death Pathways 137
The Role of Intrinsic Apoptosis in Normal Cells – Lessons from Gene Knockout Mice 137
BCL2 Family Pro-survival Proteins 137
BCL2 137
BCL-XL 138
MCL-1 138
A1/BFL-1 138
BCL-W 139
Combined Knockout of Pro-survival Proteins 139
BCL2 Family Pro-apoptotic Effector Proteins 139
BH3-only Proteins 139
The Dysregulation of Apoptosis in Cancer 142
Must Read References 144
References 144

11 Pharmacologic Features of Drugs Targeting BCL2 Family Members 151

Jennifer K. Lue and Owen A. O’Connor
Take Home Messages 151
Introduction 151
Historical Perspective: From the Discovery of BCL2 to Therapeutic Applications 152
BCL2 as a Biomarker 153
Targeting BCL2 Family Members 154
Antisense Approaches for Targeting BCL2 154
Natural Anti-apoptotic Compounds 154
Small Molecule Inhibitors of BCL2 Family Members 154
Novel BCL2 Inhibitors on the Horizon 158
Mechanisms of Resistance to BCL2 Inhibitors 158
Novel Mechanisms to Overcome BCL2 Resistance 159
Targeting MCL1 159
PROTAC Strategies for Targeting Apoptotic Family Members 160
Conclusions 160
Must Read References 161
References 161

12 Clinical Experience with Pro-Apoptotic Agents 165

Thomas E. Lew and John F. Seymour
Take Home Messages 165
Introduction 165
Safety and Toxicities of Pro-apoptotic Agents 166
x Contents

Tumor Lysis Syndrome 166

Myeloid Compartment Toxicities and Infections 167
Gastrointestinal Toxicities 168
Thrombocytopenia and Navitoclax 168
Efficacy of Venetoclax in Chronic Lymphocytic Leukemia/Small Cell Lymphoma 168
Phase 1/2 Studies 168
Combining Venetoclax with Conventional Chemotherapy in CLL/SLL 172
Phase 3 Studies 172
Venetoclax Re-treatment 173
Efficacy of Venetoclax in Other B-cell Neoplasms 173
Mantle Cell Lymphoma 173
Follicular Lymphoma 173
Diffuse Large B-cell Lymphoma and Other Aggressive B-cell Lymphomas 177
Richter Transformation 179
Waldenstrom’s Macroglobulinemia 179
Marginal Zone Lymphoma 179
Acute Lymphoblastic Leukemia/Lymphoma 179
Lessons from Venetoclax in Lymphoid Neoplasms Other than CLL/SLL 180
Associations and Mechanisms of Resistance to Pro-apoptotic Agents 180
Must Read References 181
References 181

13 Promising Combinations of Drugs Targeting Apoptosis 186

William G. Wierda
Take Home Messages 186
Introduction: Background and Disease Perspective 186
Clinical Development of BCL2 Inhibitors 187
Venetoclax Monotherapy for CLL 187
Venetoclax Plus CD20 Monoclonal Antibody for CLL 190
Venetoclax Plus BTK Inhibitor for CLL 190
Venetoclax Plus BTK Inhibitor and CD20 Monoclonal Antibody for CLL 191
Venetoclax Plus Chemoimmunotherapy 191
Venetoclax Toxicities and Side Effects in CLL 192
TLS Risk Mitigation and Management in CLL 192
Venetoclax-associated Neutropenia 192
Risk for Progression and Resistance Mechanisms 193
Current Knowledge Gaps and Opportunities for Future Work with Venetoclax 193
Must Read References 194
References 194

Section IV Targeting the Cancer Epigenome 197

14 The Role of Epigenetic Dysregulation in Lymphoma Biology 199

Qing Deng and Michael R. Green
Take Home Messages 199
Introduction: Germinal Center B (GCB)-cells and GCB-derived Lymphomas 199
Mutations Altering DNA Modifications and Structure 200
TET2 200
Mutations Altering Writers of Histone Post-translational Modifications 202
KMT2D 202
CREBBP 202
EZH2 203
 Contents xi

Mutations Altering Higher Order Chromatin Structure 204

BAF Chromatin Remodeling Complex 205
Linker Histones 205
Must Read References 206
References 206

15 Quantitating and Characterizing the Effects of Epigenetic Targeted Drugs 209

Emily Gruber, Alexander C. Lewis, and Lev M. Kats
Take Home Messages 209
Introduction 209
Experimental Analysis of the Epigenome 210
DNA Methylation 210
Bisulfite Conversion Methods 210
Affinity-based Methods 211
Detection of 5hmC 211
Histone Modifications, Histone Variants, and Chromatin-associated Proteins 211
Antibody-based Techniques for Mapping the Chromatin State 212
Proteomic Analysis of Histones 212
Chromatin Accessibility 212
Genome Organization 213
Emerging Technologies for Epigenomic Analysis of Single Cells 214
Molecular and Cellular Effects of Epigenetic Drugs 216
Concluding Remarks 221
Acknowledgments 221
Must Read References 221
References 221

16 Clinical Experience with Epigenetic Drugs in Lymphoid Malignancies 225

Enrica Marchi, Ipsita Pal, and John Sanil Manavalan
Take Home Messages 225
Introduction 225
Epigenome and Cancer 225
Different Epigenetic Classes of Drugs in Hematologic Malignancies 226
DNMT Inhibitors 226
5-Azacytidine and Decitabine 227
Guadecitabine 229
HDAC Inhibitors 230
Vorinostat 230
Romidepsin 230
Belinostat 231
EZH2 Inhibitors 231
Summary 232
Must Read References 233
References 233

17 Future Prospects for Targeting the Epigenome in Lymphomas 236

Yusuke Isshiki and Ari Melnick
Take Home Messages 236
Introduction 236
Emerging Epigenetic Therapies 236
EZH2- and PRC2-targeted Therapies Are Emerging as Potential Cornerstone Therapies for Lymphomas 236
SETD2, a Novel Therapeutic Target for DLBCLs 237
LSD1, a Case of Bait and Switch 237
A Surprising Indication for KDM5 Histone Demethylase Inhibitors 238
xii Contents

New Opportunities Provided by Emerging Histone Deacetylase Inhibitors 238

Sirtuins, the “Other HDACs,” Potential Therapeutic Targets in B-cell Lymphomas 239
Histone Acetyltransferase Inhibitors, Lacking Selectivity but with Activity in Lymphomas 239
Is There a Potential Role for BET Inhibitors for Lymphoma? 239
DNA Methyltransferase Inhibitors Are Increasingly Relevant for Treatment of Lymphomas 240
Nucleosome Remodeling Complex Inhibitors 240
Precision Epigenetic Therapy 241
Maximizing the Impact of Emerging Epigenetic Therapies 242
Rational Combination of Epigenetic Agents 242
Rational Combination with Immunotherapies 242
Conclusions 244
Acknowledgments 244
Disclosures 244
Major Papers 244
Must Read References 244
References 244

Section V Targeting the B-cell Receptor (BCR) 249

18 The Pathologic Role of BCR Dysregulation in Lymphoid Malignancies 251

Jan A. Burger
Take Home Messages 251
Introduction: The BCR in Normal and Malignant B Lymphocytes 251
BCR Signaling 251
BCR Signaling in B-cell Malignancies 252
B-cell Proliferation in Secondary Lymphatic Organs (SLOs) 254
The BCR Complex in Malignant B-cells 255
CLL 255
BCR Signaling in DLBCL 256
Tonic BCR Signaling in Burkitt’s Lymphoma 257
BCR Signaling in Follicular Lymphoma (FL) 257
BCR Signaling in Mantle Cell Lymphoma (MCL) and Marginal Zone Lymphoma (MZL) 257
Targeting BCR Signaling 257
Bruton’s Tyrosine Kinase (BTK) Inhibitors 258
Ibrutinib 259
Acalabrutinib 259
BTK Inhibitors with Anti-CD20 Antibodies 259
Zanubrutinib 260
Pirtobrutinib 260
Idelalisib 260
Conclusions 260
Acknowledgments 261
Conflict of Interest 261
Must Read References 261
References 261

19 Pharmacologic Features of Drugs Targeting Bruton’s Tyrosine Kinase (BTK) 268

Joel McCay and John G. Gribben
Take Home Messages 268
Introduction 268
BTK and B-cell Activating Factor Receptor (BAFFR) Signaling 270
BTK in Cell Signaling Pathways 270
BTK Inhibitor Development and Mechanisms of Action 271
 Contents xiii

BTK Inhibitors in Malignancy 271

BTK Inhibitors in Solid Cancers 273
BTK Inhibitors in Autoimmune Diseases 273
Mechanisms of Resistance 273
Summary 273
Must Read References 274
References 274

20 Clinical Experience with Drugs Targeting Bruton’s Tyrosine Kinase (BTK) 278
Julia Aronson, Anthony R. Mato, Catherine C. Coombs, Prioty Islam, Lindsey E. Roeker, and Toby Eyre
Take Home Messages 278
Introduction: Chronic Lymphocytic Leukemia (CLL) 278
Ibrutinib: Clinical Trials 278
Ibrutinib: Real-world Evidence 279
Acalabrutinib 280
Ibrutinib Versus Acalabrutinib 281
Zanubrutinib in CLL 281
Pirtobrutinib in CLL 281
BTK Inhibition in Indolent B-cell non-Hodgkin’s Lymphoma 282
Mantle Cell Lymphoma (MCL) 282
Waldenstrom’s Macroglobulinemia (WM) 283
Marginal Zone Lymphoma (MZL) 283
CNS Involvement with B-cell Malignancies 283
Real-world Data 284
Conclusions 284
Must Read References 284
References 284

21 Promising Combinations of BTK Inhibitors with Other Targeted Agents 287

Nicholas J. Schmidt, Michael E. Williams, and Craig A. Portell
Take Home Messages 287
Introduction 287
Limitations of BTK Inhibitor Monotherapy 287
Identifying Synergistic Combinations 288
Combinations of BTK Inhibitors and Targeted Drugs as the Standard of Care 288
BTKi + Anti-CD20 Monoclonal Antibodies 288
Waldenstrom’s Macroglobulinemia – iNNOVATE Study 288
Chronic Lymphocytic Leukemia (CLL) 289
Mantle Cell Lymphoma 291
BTKi and BCL2 Inhibitors 292
CLL 292
Mantle Cell Lymphoma 293
The Future: Ongoing Clinical Trials and Additional BTKi Combinations of Interest 294
BTKi + CDK4/6 Inhibitors 294
BTKi + PI3Kδ Inhibitors 294
BTKi + Proteasome Inhibitors 296
Ibrutinib + Cirmtuzumab, an Anti-ROR1 Monoclonal Antibody 296
BTKi + mTOR Inhibitors 296
BTKi + SYK Inhibitors 296
BTKi + HDAC Inhibitors 297
Ibrutinib + Selinexor 297
Conclusions 297
Must Read References 297
References 297
xiv Contents

Section VI Protein Degraders and Membrane Transport Inhibitors 301

22 The Biological Basis for Targeting Protein Turnover in Malignant Cells 303
Robert Z. Orlowski
Take Home Messages 303
Introduction 303
Biological Basis for Targeting Protein Turnover 303
Approved Drugs Targeting Ubiquitin–Proteasome Pathway 304
Pharmacologic Mechanisms of Proteasome Inhibitors 304
Other Proteasome Inhibitors 306
Immunomodulatory Drugs Affecting Protein Turnover 306
Background 306
Presently Approved Immunomodulatory Drugs 307
Pharmacologic Mechanisms of Currently Approved Immunomodulatory Drugs 307
Other Cereblon Modulating Agents 308
Conclusions 309
Acknowledgments 309
Must Read References 309
References 310

23 Preclinical Overview of Drugs Affecting Protein Turnover in Multiple Myeloma 313

Giada Bianchi, Matthew Ho, and Kenneth C. Anderson
Take Home Messages 313
Introduction 313
Overview of Protein Handling in MM 314
Molecular Chaperones in Protein Folding 314
Ubiquitin–Proteasome System (UPS) 314
Drugs Targeting the UPS 318
Proteasome Inhibitors 318
Inhibitors of Deubiquitinating Enzymes (DUB) 319
Targeting Proteasome Biogenesis 319
Molecular Glue Degraders and Proteolysis-targeting Chimera (PROTACs) 320
Endoplasmic Reticulum (ER) Stress and the Unfolded Protein Response (UPR) 321
Drugs Targeting the UPR 321
Autophagy and Aggresome Pathways 321
Targeting Nutrient Metabolism to Enhance Proteotoxic Stress 322
The Role of Proteasome Inhibition in the Era of Immunotherapy 323
Conclusions and Future Perspectives 323
Must Read References 324
References 324

24 Clinical Experience on Proteasome Inhibitors in Cancer 331

Noa Biran, Pooja Phull, and Andre Goy
Take Home Messages 331
Introduction to Proteasome Inhibitors (Pis) 331
Clinical Activity in Plasma Cell Disorders 333
Role of Proteasome Inhibition in Plasma Cells: Mechanisms of Action and Mechanisms of Resistance 333
Proteasome Inhibitors with Clinical Activity in Multiple Myeloma 334
Bortezomib 334
Carfilzomib 335
Ixazomib 336
Other Oral Proteasome Inhibitors Evaluated for Use in Patients with Multiple Myeloma 336
Role of Proteasome Inhibitors in Amyloidosis 336
 Contents xv

Rationale for Combinations w/ Proteasome Inhibitors 337

PI and Cytotoxic Agents 337
PI + Immunomodulatory Agents (IMIDS) 337
PI and Monoclonal Antibodies 338
PI and HDAC Inhibitors 338
PI and Nuclear Transport Inhibitor Selinexor 338
Future Directions of PI-based Combination Regimens 338
Clinical Activity of Proteasome Inhibitors in Lymphoid Malignancies 338
Clinical Activity of Bortezomib (BTZ) in Mantle Cell Lymphoma (MCL) 338
Bortezomib Phase 2 in R/R MCL Led to Early Approval 338
Importing Bortezomib in the Management of MCL 342
Clinical Activity of Bortezomib in Indolent Lymphoma (iNHL): Follicular Lymphoma, Marginal Zone, and SLL/CLL
Subtypes 345
Clinical Activity of Bortezomib in Diffuse Large B-cell Lymphoma (DLBCL) 346
Bortezomib in Waldenstrom’s Macroglobulinemia (WM) 347
Clinical Activity of Bortezomib in Other Lymphomas 347
T-cell Lymphoma 347
Hodgkin’s Lymphoma 348
Plasmablastic Lymphoma (PBL) 348
Lymphoblastic Lymphoma (LL)/Acute Lymphocytic Leukemia (ALL) 348
EBV Lymphoproliferative Disorders and Other Immunological Conditions 348
Clinical Activity of Proteasome Inhibitors in AML/MDS 349
Clinical Activity of Proteasome Inhibitors in Solid Tumors 349
Overcoming Resistance to Proteasome Inhibitors in Cancer and Next Steps in Proteasome Inhibition 350
Must Read References 352
References 352

25 Targeting Nuclear Protein Transport with XPO Inhibitors in Lymphoma 361

Farheen Manji, Kyla Trkulja, Rob C. Laister, and John Kuruvilla
Take Home Messages 361
Introduction 361
XPO1 Biology 361
Pre-clinical and Clinical Data 362
Phase 1 Evaluation in Non-Hodgkin’s Lymphoma 362
DLBCL 365
CLL 366
T-cell Lymphoma 367
Mantle Cell Lymphoma 367
Toxicity 367
Mechanisms of Intrinsic and Acquired Resistance to Selinexor and SINE Compounds 368
Future Directions 369
Must Read References 370
References 370

26 Heterobifunctional Degraders for the Treatment of Lymphoid Malignancies 372

Ashwin Gollerkeri, Jared Gollob, and Nello Mainolfi
Take Home Messages 372
Biology of Protein Degraders 372
Ubiquitin–Proteasome System and Protein Degradation 372
Targeted Degraders in Clinical Practice 372
Heterobifunctional Small Molecule Degraders 372
Mechanisms of Resistance 373
Rationale for Use of Heterobifunctional Degraders in Oncology 373
xvi Contents

Clinical Experience with Heterobifunctional Degraders 374

Arvinas Phase 1/2 Trials of PR and ER Degraders 375
ARV-110 375
ARV-471 375
Kymera Phase 1 Trial of IRAK4 Degrader KT-474 375
Development of Heterobifunctional Degraders in Lymphoma 375
IRAKIMiD Degraders 375
KT-413 376
BTK Degraders 376
NX-2127 377
NX-5948 377
BGB-16673 377
STAT3 Degraders 377
KT-333 377
Conclusions and Future Directions 378
Must Read References 378
References 378

Section VII Novel Targets and Therapeutic Prospects in Development 381

27 Strategies for Targeting the JAK-STAT Pathway in Lymphoid Malignancies 383

David J. Feith, Johnson Ung, Omar Elghawy, Peibin Yue, James Turkson, and Thomas P. Loughran Jr
Take Home Messages 383
JAK-STAT Signaling and Endogenous Regulators 383
Alternative Regulation and Function of STATs 385
Dysregulated Cytokine Signaling in Lymphoid Malignancies 386
Strategies to Target the JAK-STAT Pathway 387
Direct Targeting Approaches against STAT3 388
Oligonucleotide-based Strategies 389
Direct STAT3 Inhibitors as Standalone Agents 389
Natural Product Inhibitors of STAT3 389
Chemotherapeutic, Cytotoxic Drugs, and Other Modalities that Directly or Indirectly Inhibit STAT3 Pathway 390
Inhibition of STAT3 Function in Combination Strategies to Sensitize Tumors and/or Reverse Resistance 390
Clinical Trials of STAT3 Inhibitors in Lymphoid Malignancy 391
Targeting STAT5 in Lymphoid Malignancy 391
Clinical Trials of JAK Inhibitors in Lymphoid Malignancies 392
Challenges and Opportunities for Clinical Application of JAK-STAT Targeting Agents 395
Acknowledgments 396
Conflict of Interest Disclosures 396
Must Read References 396
References 396

28 Strategies for Targeting MYC 402

Jemma Longley and Andrew Davies
Take Home Messages 402
Introduction 402
Dysregulation of MYC in B-cell Lymphomas 403
Identifying MYC Rearrangement in the Context of HGBL 403
Targeting MYC Transcription 404
Targeting MYC Translation 405
Targeting MYC Stabilization and Downstream Gene Expression 406
Initial Therapy in MYC-R DLBCL 407
 Contents xvii

Future Directions 408

Must Read References 408
References 409

29 Targeting NOTCH in Lymphoid Malignancies 411

Deborah Piffaretti, Georgia Alice Galimberti, and Davide Rossi
Take Home Messages 411
Introduction: NOTCH Signaling 411
Role of NOTCH Signaling in B-cell 414
Genetic and Microenvironmental Mechanisms of NOTCH Signaling Alteration in CLL and Lymphomas 415
Genetic Mechanisms 415
CLL (NOTCH1) 415
MCL 417
FL 417
MZL (NOTCH2) 418
DLBCL (N1 e N2) 419
Other Genes of the Pathway (FBXW7, SPEN) 420
Inhibitors Tested at the Preclinical Level 420
Must Read References 421
References 421

30 Targeting NF-κB in Oncology, an Untapped Therapeutic Potential 428

Matko Kalac
Take Home Messages 428
Introduction 428
Historical Perspective for the Role of NF-κB in Malignancy 429
Canonical NF-κB Pathway 429
Non-canonical NF-κB Pathway 431
NF-κB in Tumorigenesis and Promotion of Malignant Cell Growth 431
Oncogenic Alterations in Lymphoma and Other Hematologic Malignancies 432
Role of NF-κB in Solid Malignancies 434
NF-κB Targeted Therapies 435
Approved Drugs 435
In Development 436
Summary 437
Must Read References 437
References 438

31 Targeting the Cell Cycle and Cyclin-dependent Kinases 444

Chiara Tarantelli and Francesco Bertoni
Take Home Messages 444
Introduction 444
CDK Family and Cyclins 444
CDKs Structure 446
CDKs Activation 446
CDKs Inhibition 446
CDKs Function 447
Cell Cycle-related CDK-cyclin Complexes 447
Transcription-related CDK-cyclin Complexes 447
DNA Damage and Repair 448
CDK-cyclin Deregulation in Cancer 448
Targeting CDKs in Lymphoid Malignancies 448
CDK4/6 Inhibitors 448
xviii Contents

Specific Inhibitors 449

CDK7 Inhibitors 450
Inhibitors Targeting Multiple CDKs 450
Resistance 451
Future Directions 451
Must Read References 452
References 452

Index 457
 xix

List of Contributors

Inhye E. Ahn Istituto di Ematologia “Seràgnoli”

Dana-Farber Cancer Institute Dipartimento di Medicina Specialistica
Harvard Medical School Diagnostica e Sperimentale
Boston, MA, USA Università degli Studi
Bologna, Italy
Kenneth C. Anderson
LeBow Institute for Myeloma Therapeutics and Jerome Jennifer R. Brown
Lipper Multiple Myeloma Center Dana-Farber Cancer Institute
Department of Medical Oncology, Dana Farber Cancer Harvard Medical School
Institute, Harvard Medical School Boston, MA, USA
Boston, MA, USA
Jan A. Burger
Julia Aronson Department of Leukemia
Memorial Sloan Kettering Cancer Center The University of Texas MD Anderson Cancer Center
New York, NY, USA Houston, TX, USA

Francesco Bertoni Catherine C. Coombs

Institute of Oncology Research University of North Carolina
Faculty of Biomedical Sciences Chapel Hill, NC, USA
USI, Bellinzona, Switzerland
Sandeep S. Dave
Oncology Institute of Southern Switzerland
Department of Medicine and Center for Genomic and
Ente Ospedaliero Cantonale
Computational Biology
Bellinzona, Switzerland
Duke Cancer Institute, Duke University
Durham, NC, USA
Giada Bianchi
Amyloidosis Program, Division of Hematology
Matthew S. Davids
Department of Medicine, Brigham and Women’s Hospital
Dana-Farber Cancer Institute
Harvard Medical School
Harvard Medical School
Boston, MA, USA
Boston, MA, USA
Noa Biran
Andrew Davies
John Theurer Cancer Center at HMH and Hackensack
Southampton Cancer Research UK Centre
Meridian School of Medicine
Cancer Sciences Unit, Faculty of Medicine
Hackensack, NJ, USA
University of Southampton, Centre for Cancer Immunology
Southampton General Hospital
Alessandro Broccoli
Southampton SO16 6YD, Hampshire, UK
IRCCS Azienda Ospedaliero-Universitaria di Bologna
Bologna, Italy
xx List of Contributors

Qing Deng Michael R. Green

Department of Lymphoma & Myeloma Department of Lymphoma & Myeloma
University of Texas MD Anderson Cancer Center University of Texas MD Anderson Cancer Center
Houston, TX, USA Houston, TX, USA
Department of Genomic Medicine
Michael Dickinson
University of Texas MD Anderson Cancer Center
Peter MacCallum Cancer Centre
Houston, TX, USA
Melbourne, Victoria, Australia
Sir Peter MacCallum Department of Oncology Ashwin Gollerkeri
University of Melbourne Kymera Therapeutics
Melbourne, Victoria, Australia Watertown, MA, USA

Jared Gollob
Sarah T. Diepstraten Kymera Therapeutics
The Walter and Eliza Hall Institute of Medical Research Watertown, MA, USA
Melbourne, Victoria, Australia
The Department of Medical Biology Andre Goy
The University of Melbourne John Theurer Cancer Center at HMH and Hackensack
Melbourne, Victoria, Australia Meridian School of Medicine
Hackensack, NJ, USA
Omar Elghawy
John G. Gribben
University of Virginia Cancer Center
Centre for Haemato-Oncology, Barts Cancer Institute
University of Virginia School of Medicine
Queen Mary University of London
Charlottesville, VA, USA
London, UK
Department of Medicine
Emily Gruber
Division of Hematology/Oncology
The Peter MacCallum Cancer Centre
University of Virginia School of Medicine
Melbourne, Victoria, Australia
Charlottesville, VA, USA

Sean Harrop
Toby Eyre
Peter MacCallum Cancer Centre
University of Oxford
Melbourne, Victoria, Australia
Oxford, UK

Matthew Ho
David J. Feith
Department of Internal Medicine
University of Virginia Cancer Center
Mayo Clinic, Rochester, MN, USA
University of Virginia School of Medicine
Charlottesville, VA, USA
David C.S. Huang
Department of Medicine The Walter and Eliza Hall Institute of Medical Research
Division of Hematology/Oncology Melbourne, Victoria, Australia
University of Virginia School of Medicine
The Department of Medical Biology
Charlottesville, VA, USA
The University of Melbourne
Melbourne, Victoria, Australia
Georgia Alice Galimberti
Laboratory of Experimental Hematology
Prioty Islam
Institute of Oncology Research
Levine Cancer Center
Bellinzona, Switzerland
Raleigh, NC, USA
Philippe Gaulard
Yusuke Isshiki
Département de Pathologie
Division of Hematology and Oncology
Groupe Hospitalier Henri Mondor
Joan and Sanford I Weill Department of Medicine
AP-HP, Créteil, France
Weill Cornell Medicine
Université Paris-Est New York, NY, USA
INSERM U955, Créteil, France
 List of Contributors xxi

Ricky Johnstone Alexander C. Lewis

Peter MacCallum Cancer Centre The Peter MacCallum Cancer Centre
Melbourne, Victoria, Australia Melbourne, Victoria, Australia
Sir Peter MacCallum Department of Oncology
Jennifer K. Lue
University of Melbourne
Memorial Sloan Kettering Cancer Center
Melbourne, Victoria, Australia
Lymphoma Service
New York, NY, USA
Matko Kalac
Precision Immunology Institute
Jemma Longley
Tisch Cancer Center, Icahn School of Medicine
Southampton Cancer Research UK Centre, Cancer Sciences
at Mount Sinai
Unit, Faculty of Medicine
New York, NY, USA
University of Southampton, Centre for Cancer Immunology
Southampton General Hospital
Lev M. Kats
Southampton SO16 6YD, Hampshire, UK
The Peter MacCallum Cancer Centre
Melbourne, Victoria, Australia
Thomas P. Loughran Jr
The Sir Peter MacCallum Department of Oncology University of Virginia Cancer Center
University of Melbourne University of Virginia School of Medicine
Parkville, Victoria, Australia Charlottesville, VA, USA
Department of Medicine, Division of Hematology/Oncology
Gemma L. Kelly
University of Virginia School of Medicine
The Walter and Eliza Hall Institute of Medical Research
Charlottesville, VA, USA
Melbourne, Victoria, Australia
The Department of Medical Biology Ralitsa R. Madsen
The University of Melbourne University College London Cancer Institute
Melbourne, Victoria, Australia Paul O’Gorman Building
University College London
John Kuruvilla London, UK
Princess Margaret Cancer Centre
University of Toronto Nello Mainolfi
Canada Kymera Therapeutics
Watertown, MA, USA
Rob C. Laister
Princess Margaret Cancer Centre John Sanil Manavalan
University of Toronto Division of Hematology-Oncology
Canada Department of Medicine, University of Virginia
Comprehensive Cancer Center
Laurence de Leval VA, USA
Institute of Pathology
Department of Laboratory Medicine and Pathology Farheen Manji
Lausanne University Hospital and Lausanne University Princess Margaret Cancer Centre
Lausanne, Switzerland University of Toronto
Canada
Thomas E. Lew
Department of Haematology John E. La Marca
The Royal Melbourne Hospital and Peter MacCallum The Walter and Eliza Hall Institute of Medical Research
Cancer Centre Melbourne, Victoria, Australia
Melbourne, Victoria, Australia
The Department of Medical Biology
Blood Cells and Blood Cancer Division The University of Melbourne
Walter and Eliza Hall Institute of Medical Research Melbourne, Victoria, Australia
Parkville, Victoria, Australia
xxii List of Contributors

Enrica Marchi Pooja Phull

Division of Hematology-Oncology John Theurer Cancer Center at HMH and Hackensack
Department of Medicine Meridian School of Medicine
University of Virginia Comprehensive Cancer Center Hackensack, NJ, USA
VA, USA
Henry Miles Prince
Anthony R. Mato Peter MacCallum Cancer Centre
Memorial Sloan Kettering Cancer Center Melbourne, Victoria, Australia
New York, NY, USA Sir Peter MacCallum Department of Oncology
University of Melbourne
Joel McCay Melbourne, Victoria, Australia
Centre for Haemato-Oncology, Barts Cancer Institute
Queen Mary University of London Epworth Healthcare, Sir Peter MacCallum Department of
London, UK Oncology
University of Melbourne
Victoria, Australia
Ari Melnick
Division of Hematology and Oncology
Craig A. Portell
Joan and Sanford I Weill Department of Medicine
Hematology/Oncology Division, University of Virginia
Weill Cornell Medicine
Cancer Center, Charlottesville
New York, NY, USA
VA, USA

Anjali Mishra Lindsey E. Roeker

Division of Hematologic Malignancies and Hematopoietic
Stem Cell Transplantation
Department of Medical Oncology and Department of Cancer
Biology, Sydney Kimmel Cancer Center
Thomas Jefferson University
Philadelphia, PA, USA
Owen A. O’Connor
Department of Medicine, Division of Hematology and
Medical Oncology
T-Cell Malignancies Program University of Virginia
Comprehensive Cancer Center Department of Microbiology
Immunology and Cancer Biology University of Virginia
Charlottesville, VA, USA
Robert Z. Orlowski
Departments of Lymphoma & Myeloma, and
Experimental Therapeutics
The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd., Unit 429, Houston, TX 77030, USA
Memorial Sloan Kettering Cancer Center
New York, NY, USA
Davide Rossi
Laboratory of Experimental Hematology
Institute of Oncology Research
Bellinzona, Switzerland
Clinic of Hematology
Oncology Institute of Southern Switzerland, Ente
Ospedaliero Cantonale, Bellinzona
Bellinzona, Switzerland
Faculty of Biomedical Sciences
Università della Svizzera Italiana
Lugano, Switzerland
Nicholas J. Schmidt
Hematology/Oncology Division, University of Virginia
Cancer Center, Charlottesville
VA, USA

Ipsita Pal John F. Seymour

Division of Hematology-Oncology, Department of Medicine
University of Virginia Comprehensive Cancer Center
VA, USA
Deborah Piffaretti
Laboratory of Experimental Hematology
Institute of Oncology Research
Bellinzona, Switzerland
Department of Haematology
The Royal Melbourne Hospital and Peter MacCallum
Cancer Centre
Melbourne, Victoria, Australia
Faculty of Medicine, Dentistry and Health Sciences
The University of Melbourne
Parkville, Victoria, Australia
 List of Contributors xxiii

Jennifer Shingleton Department of Medicine

Department of Medicine and Center for Genomic and Division of Hematology/Oncology, University of Virginia
Computational Biology School of Medicine
Duke Cancer Institute, Duke University Charlottesville, VA, USA
Durham, NC, USA
William G. Wierda
Pierre Sujobert D.B. Lane Cancer Research Distinguished Professor of
Service d’hématologie biologique Hospices Civils Medicine Section Head
de Lyon, Hôpital Lyon Sud CLL Department of Leukemia Division of Cancer Medicine
France Holcombe Blvd
Unit 428, Houston, TX, USA
Université Lyon, Faculté de médecine et de
maïeutique, Lyon Sud
Thomas E. Witzig
France
Division of Hmeatology
Charles Mérieux, Lymphoma Immunobiology Team Mayo Clinic, Rochester, MN, USA
Pierre Bénite
France Michael E. Williams
Hematology/Oncology Division
Chiara Tarantelli University of Virginia Cancer Center
Institute of Oncology Research VA, USA
Faculty of Biomedical Sciences
USI, Bellinzona, Switzerland Peibin Yue
Department of Medicine
Kyla Trkulja Cedars-Sinai Medical Center
Princess Margaret Cancer Centre Los Angeles, CA, USA
University of Toronto
Canada Pier Luigi Zinzani
IRCCS Azienda Ospedaliero-Universitaria di Bologna
James Turkson Bologna, Italy
Department of Medicine
Istituto di Ematologia “Seràgnoli”
Cedars-Sinai Medical Center
Dipartimento di Medicina Specialistica, Diagnostica e
Los Angeles, CA, USA
Sperimentale, Università degli Studi
Bologna, Italy
Johnson Ung
University of Virginia Cancer Center
University of Virginia School of Medicine
Charlottesville, VA, USA
xxiv
Volume Foreword
The past two decades have seen the emergence of remarkable
new insights into basic cancer biology, with the result that
principles governing the approach to cancer treatment have
undergone fundamental revision and reorganization.
Recognizing the need to address this evolution in our under-
standing of how cancer treatment works, the editors and
authors of Precision Cancer Therapies have set themselves
the daunting task of providing clinicians and researchers
with a basic guide to the underlying biology of cancer and, in
particular, a guide to how this understanding can rationalize
treatment. The first volume explores the biology of lymphoid
cancer, one of the cancer types that has seen the most rapid
accumulation of new agents and approaches, with particular
attention to the role of small molecules and targeted agents
and the nature of those agents’ specific biological targets and
associated pathways. Volume 2 focuses on immunotherapy,
tracing how steadily accumulating insight into how the
extraordinarily complex human immune system works and
how, in recent years, that expanding insight has exploded
with increasingly specific methods to manipulate passive and
active immunity for cancer treatment. The editors’ and
authors’ timing are impeccable. Clinicians, researchers, stu-
dents, trainees, and representatives of funding and regulatory
agencies will all find Precision Cancer Therapies the
timely, in-depth resource they need to guide them through
the blizzard of emerging data, trial results, drug approvals,
and regulatory decisions as cancer therapy becomes ever
more precise.
Throughout a century of modest steps beginning in the late
1800s, improvements in cancer treatment were slowly
achieved employing surgery, radiation therapy, supportive
care, diagnostic tests, and microscopic pathology. The contri-
bution of systemic therapy to cancer treatment began during
the latter half century of the 1900s with empiric interventions
employing nonspecific, cytotoxic agents such as corticoste-
roids, alkylating agents, plant-based toxins, antimetabolites,
hormonal agents, and disruptors of nucleic acid metabolism.
It is only in retrospect that we have come to understand that
these nonspecific interventions fundamentally rested on
differential induction of apoptosis, the programmed self-de-
struction to which cancer cells are often more susceptible
than healthy normal cells. Although much was achieved
employing these cytotoxic agents in the treatment of a short
list of cancers such as Hodgkin’s lymphoma, childhood leu-
kemia, testicular cancer, and choriocarcinoma, the systemic
treatment of cancer had largely stalled by the end of the
century. Genuine progress required improved understanding
of the fundamental biology of cancer and more precise dis-
section of how the immune system works. Everything that
happens in every cell in the body, including normal and can-
cer cells, and, therefore, in every tissue of which these cells
are assembled, is directed by signals that originate in the cel-
lular genome ramified through enormously complex sig-
naling pathways. Precision in cancer treatment thus awaited
progress in genomics, which is now rapidly transforming all
of medicine, especially cancer medicine. In multicellular
organisms, including humans, complex signaling pathways
guide pluri-potential stem cells through stepwise
differentiation to finalized effector cells and then govern how
these cells and the tissues which they constitute accomplish
all the tasks of living including nutrition, energy metabolism,
and cellular repair and replacement. These signaling path-
ways tell cells what to do, where to stay, how to interact with
other cells, how to procreate, and when to die. When muta-
tions, regulatory pathway disruptions, and signaling errors,
lead cells to stray from their assigned tasks, move haphaz-
ardly to inappropriate locations, linger despite obsolescence,
and reproduce when not needed, cancer arises. The modern
era of precision medicine focuses tightly on these signaling
errors, suggesting interventions that are specific to the
individual signaling error and, therefore, having the potential
to exert their effect solely on the broken cells and broken
pathways leaving normal cells, which are not making the sig-
naling errors, untouched. Volume 1 of Precision Cancer
Therapies focuses on the signaling pathways prominent in
lymphomas with particular attention to the drivers of lym-
phomagenesis, phosphoinositide 3-kinase (PI3 kinase) path-
ways, regulatory control of programmed cell death
(apoptosis), the B-cell receptor pathways, proteosome
function and regulation, and epigenetic control of these path-
ways, identifying promising targets within them and what
has been achieved clinically by targeting them.

After its focus on signaling pathways and targets for lym-
phoid cancer treatment in Volume 1, Volume 2 of Precision
Cancer Therapies shifts focus to the equally remarkable
progress that has occurred mimicking and recruiting the
immune system for cancer treatment. After decades of disap-
pointment in clinicians’ ability to manipulate the human
immune system to attack cancers effectively, the past two
decades have seen an unprecedented transformation. Passive
immunotherapy employing monoclonal antibodies and, later,
radioimmunoconjugates and antibody drug conjugates have
now been shown to be powerful, precise ways to attack cancer
cells directly while largely sparing normal cells. Immune
checkpoint inhibition employing antibodies to programmed
death ligand signaling molecules now allows clinicians to
cancel cancer cells’ ability to paralyze immune effector cells.
By neutralizing the immune destruction blockers that cancer
cells employ to escape detection and destruction by cytotoxic
cells of the immune system, first-generation FDA-approved
checkpoint inhibitors such as pembrolizumab and nivolumab,
and an array of second-generation monoclonal antibodies
currently in development, have demonstrated the ability of
such agents to bring the highly potent but equally highly
specific destructive power of the immune system into play to
attack cancer cells. The success of these agents has encour-
aged wider exploration of the potential to recruit immune
effector cells by targeting tumor-associated antigens that are
intrinsic to lymphoid cancers or are expressed in lymphoid
cells whose behavior has been distorted or hijacked by
Epstein–Barr virus. Complementing the descriptions of
passive immunologic intervention offered by monoclonal
antibodies, checkpoint inhibitors, radioimmunotherapy, and
antibody drug conjugates, Volume 2 of Precision Cancer
Therapies also includes several sections devoted to active
cell-based immunotherapy. Building on older experience with
allogeneic hematopoietic stem cell transplantation, these sec-
tions explore the potential of chimeric antigen receptor T-cells
Volume Foreword xxv
(CAR-T cells) to knit together the two remarkable characteris-
tics of the effector cells of the immune system: precise speci-
ficity and extraordinary potency. This technique utilizes
autologous T-cells that have been equipped in the laboratory
with cell surface receptors specific for lymphoid cancer cell
antigens and then clonally expanded to large numbers before
being re-infused into the patient. This use of crafted “hunter-
killer” cells thus brings specificity by employing antigen
receptors tailored to bind to potentially unique antigens on
the lymphoid cancer cells and power by employing the most
potent cytotoxic cells of the immune system.
Systemic cancer treatment is currently in the midst of pro-
found transformation. Although much was accomplished
previously utilizing nonspecific interventions in which the
therapeutic agents employed induce broad cell injury with
the intention that the cancer cells be irreversibly damaged
but normal healthy cells allowed to recover, the limits of this
overall approach have become apparent. Going forward it
has become clear that the key to progress in cancer treatment
is precision. In Precision Cancer Therapies, the editors and
authors provide essential guidance to how this precision is
being achieved. Volume 1 addresses the way in which novel
agents target key signaling pathways in lymphoid cancer
cells, providing precision by focusing on unique vulnerabil-
ities in the malignant cells. Volume 2 explores the ways in
which the specificity and power of the human immune
system can be employed to focus treatment precisely.
Together these two volumes provide clinicians, researchers,
and regulators essential insight in this exciting new era of
cancer treatment.
Joseph M. Connors, MD, CM
Emeritus Professor
BC Cancer Centre for Lymphoid Cancer
University of British Columbia
Vancouver, BC, Canada
xxvi
Volume Preface
What does the future hold?
Treatment for patients with lymphoid malignancies has
changed dramatically in the past 20 years. Two decades ago,
treatment approaches for patients with various lymphomas
typically constituted the use of non-crossresistant chemo-
therapy drugs. These agents were used in combination and
were effective in a subset of patients. However, in relapsing
patients, responses to additional chemotherapy treatments
were typically dramatically shorter than the benefits seen
with the initial regimen, while the subset of patients who
durably benefited from more chemotherapy was typically
limited to those who underwent autologous stem cell trans-
plantation. Since then, a greater understanding of the biology
of lymphoid malignancies has led to to the development of
multiple classes of highly active new drugs. As outlined in
this book, most classes of these novel agents have now been
established as very effective. However, most novel therapies
are not curative even though patients may benefit with
extended durations of remission. As one looks to the future,
rational combination approaches using these novel treat-
ments will clearly be the next logical step.
In determining the most optimal combination, a number of
approaches can be considered. Firstly, one could consider a
“depletion” approach where the primary focus is to suppress
or eradicate the malignant clone or other cells that are facili-
tating the growth of the malignant cell. Clearly, if every malig-
nant cell was eradicated, the patient would be cured of the
disease and treatments that kill every malignant cell would be
favored. Furthermore, the malignant cell often dictates the
composition of the tumor microenvironment creating an
immune niche that favors the growth and survival of the can-
cer cell. Lymphoma cells may also directly suppress immune
cells preventing their ability to lyse the malignant clone.
Additionally, cells such as monocytes and macrophages pre-
sent in the tumor microenvironment, may directly support
and nurture the growth of the malignant cells. Therapeutically,
those populations of cells supporting the cancer clone can also
be targeted and depleted, theortically leading to an improve-
ment in patient outcome. Clearly, this approach has met with
limited success and needs to be improved. Strategies that may
improve a “depletion” approach could include utilizing
targeted therapy such as antibody drug conjugates in
combination with chemotherapy, or by adding immune
depleting agents targeting macrophages or T regulatory cells
to chemotherapy, or sequencing chemotherapy before adding
immunotherapy to first suppress the malignant clone and
then allow for optimal immune activation.
A second combination strategy that could be considered
would be an “inhibition” approach. This approach would
focus on critical intracellular pathways that support the
survival of the malignant cell. A rational approach to inhibi-
tion would include potentially targeting multiple different
pathways that are important to the survival of the cancer cell
or alternatively targeting the same dominant pathway at
multiple levels. One potential risk of this approach may be
upregulation of alternative pathways when one or more criti-
cal pathways are suppressed. Furthermore, novel agents
could be used to specifically upregulate particular pathways
that create an additional vulnerability for the malignant cell.
An example of this could be the use of HDAC inhibitors
which upregulate PD-L1 expression, potentially making a
cell more vulnerable to immune checkpoint therapy when
given in combination. Additionally, pathway inhibitors may
have off target effects that may be of significant benefit. This
could include the immunological effects of BTK inhibitors,
mTOR inhibitors or PI3K inhibitors, all of which have both
direct effects on the malignant B-cells but also effects on
immune cells including normal T-cells.
A third strategy could be an “immune optimization”
approach. While not the primary focus of this book,
Volume 2 of the Precision Cancer Therapies series will
exclusively focus on many of the agents that mediate lym-
phoma cell kill through a variety of immunologic mecha-
nisms. Specific strategies to optimize immune function
could include direct activation of immune cells using
small molecules, immune checkpoint targeted therapy or
the use of bispecific antibodies. Additional strategies that
could be used in an “immune optimization” approach
could specifically suppress cells that inhibit the immune
response such as regulatory T-cells or suppressive mono-
cytes, thereby improving the antitumor response. The
challenge of utilizing single agent therapy to achieve
immune optimization has been the development of

immune exhaustion when cells are non-specifically stim-
ulated. Strategies to improve this “immune optimization”
approach would be to intermittently stimulate the
immune system and thereby avoid exhaustion or to block
inhibitory signals associated with immune exhaustion at a
time when the immune system is activated. All of these
strategies are being evaluated in the laboratory and in
patients, though most have met with mixed results.
Possibly the optimal strategy for the future might be a
“reprogramming” approach that incorporates all of the ele-
ments outlined above. This “reprogramming” strategy would
potentially focus not only on directly depleting the malignant
cell, but also on inhibiting specific pathways on which the cell
is dependent, as well as activating the immune system. These
strategies would be employed all at the same time. Just as in
the past, combination non-cross-resistant chemotherapy
approaches have been our most successful therapies, future
approaches should utilize the varied tools we have in
combination to optimize patient management. Aside from uti-
lizing agents with different mechanisms of action in combination,
future studies will also focus on whether combination treatment
Volume Preface xxvii
should be given at the same time or sequenced in an optimal
order of administration. Furthermore, it may also be necessary
to determine whether some therapies may be required as
longer term maintenance treatment.
All told, the future for treatment of lymphoid malignancies
has many opportunities. Using new drugs and with a greater
understanding of the tumor biology, we have an opportunity
to impact the clinical outcome of many patients. Not only is
the opportunity to increase response rates and durability of
clinical benefit, but also to utilize targeted therapy and mini-
mize toxicities. However, our challenge is to continue the
research and drug development until every patient with a
malignancy can be cured.
Stephen M. Ansell, MD, PhD
Dorotha W. and Grant L. Sundquist Professor in
Hematologic Malignancies Research
Chair, Division of Hematology
Mayo Clinic
xxviii
Series Preface
The pace of growth in scientific literature has been a subject
for scientists who like to study bibliometric data, for decades.
As early as 1951, Derek John de Solla Price, often regarded as
one of the pioneers in studying rates of change in scientific
literature, noted that the development of scientific
information follows the law of exponential growth (de Solla
Price 1951). In 1976, Price concluded that “at any time the
rate of growth is proportional to the … total magnitude
already achieved – the bigger a thing is, the faster it grows”
(de Solla Price 1976). More recently, in 2018, Fortunato et al.
concluded that “early studies discovered an exponential
growth in the volume of scientific literature … a trend that
continues with an average doubling period of 15 years”
(Fortunato et al. 2018). Barabási and Wang suggested that if
the scientific literature doubles every 15 years, “the bulk of
knowledge remains always at the cutting edge” (Barabási and
Wang 2021). That means, that the bulk of what a typical phy-
sician learns in undergraduate, graduate, or medical school is
potentially obsolete by the time they assume responsibility
for the care of patients, or that the information they rely on
today was not yet in the textbooks that laid the foundation for
their career.
For practicing oncologists, there in lies the problem. How
does one stay abreast of these incomprehensible changes in
scientific knowledge, much less understand it in a manner
that can be used to help their patients. Cancer medicine has
become a field where the need to appreciate basic science,
and I emphasize “appreciate” not “comprehensively under-
stand,” has become indispensable. Cancer medicine has
become the place where fundamental cellular biology, phar-
macology, and clinical medicine all collide, as physicians
struggle to understand how they should integrate and eval-
uate diverse streams of information in order to arrive at the
best solution for the patient sitting before them. It has become
a field where translating the details of science has taken on
larger and larger roles as physicians consider how to cure a
disease, palliate pain, or improve the status quo, using only
the information they have at their disposal.
Precision Cancer Therapies is designed to try and meet that
very need. The volumes that will be produced in the series, the
first two of which are devoted to the lymphoid malignancies,
are developed around categories of diseases that share
common themes in their pathogenesis, and, potentially, the
strategies one might consider in targeting their dysregulated
biology. Sections are organized around select mechanistic
themes in disease biology established as being potentially
important in disease pathogenies, followed by a chapter on
the pharmacology of drugs identified as effective in nullifying
that abnormal biology. Subsequent chapters in each section
are focused on the translational aspects: how does one use
the drugs at hand to alter the pathology in a therapeutically
meaningful manner. Succeeding chapters highlight actual
clinical data with specific drugs as both monotherapies and
in “rational” combination. The sections within a volume are
designed to share information using the same kind of logic a
clinician might invoke in thinking about their patient. Here
are some pertinent questions:
i) What is the disease biology causing the problem?
ii) What are the drugs at my disposal?
iii) What is the data for the use of these drugs?
iv) Are there ways to improve on these drugs’ efficacy by
considering combination effects?
The sections take a decidedly translational approach to the
problem.
With the advent of so much web-based learning and now the
passion around how artificial intelligence (AI) might trans-
form our approach, some might suggest, why another book, let
alone a series of books. The answer lies in the simple fact that
there is no substitute or singular surrogate that can replace
your very own fund of knowledge. Perhaps the most widely
recognized and touted AI approach ever to come to our
attention did so in 2011, when we watched, with complete
astonishment I might add, IBMs Watson beat the famed Ken
Jennings and Brad Rutter in Jeopardy. Jennings and Rutter
were the greatest Jeopardy champions of all time: more wins
and more money than any other contestants in the history of
the show. But, despite their intellectual prowess, they were no
match for a computer that had intensely trained for years and
“learned” how to beat Jennings and Rutter by playing
simulated games against 100 of the best Jeopardy contestants
ever. Yes, Watson too had to learn, and read, and assimilate

years of information to compete with the human brain. While
Jeopardy may be the most widely recognized and successful
adventures for a room-sized computer, other forays of AI – and
Watson in particular – in the field of oncology have, thus far at
least, fallen short. IBM’s Watson for Oncology has been in
development since 2012. It is being developed to provide
state-of-the-art personalized treatment recommendations for
patients with very specific kinds of malignant disease. Watson
has undergone extensive “learning” at some of the most presti-
gious cancer centers in the world, being nurtured on the
nuances of cancer medicine. Comprehensive details around
the interpretation of blood tests, pathology, genetics, imaging
data, and patient-oriented detail get fed into the computer.
Then, the computational prowess of Watson combs through
the vast medical literature we discussed above, to generate an
evidence-based treatment recommendation for that specific
patient. Why did Watson outperform on Jeopardy and under-
perform in oncology? One reason may be obvious. The state of
cancer research and its impact on the practice of cancer medi-
cine is extremely dynamic and in constant flux, at times it
relies on instinct and experience, apparently making an
appearance on Jeopardy look easy. Encyclopedic facts about
the real world change slowly, if at all. Acknowledging that this
type of AI technology is in its infancy (though most of us com-
pleted medical school, residency, and fellowship in the time
Watson has been in development), the decade-long experience
of Watson in cancer medicine has to date been less than flatter-
ing. The lay press has taken a decidedly negative impression of
Watson’s first steps (watson-ibm-c), suggesting that while AI
may have enormous appeal to the average observer, it is likely
to never replace the intellectual prowess – and instinct – of that
physician sitting in front of a patient. It re-enforces a centuries-
old and fundamental truth, “knowledge itself is power,” at
least as Sir Francis Bacon understood it.
Series Preface xxix
And so, with some data in hand, and curiosity in end-
less supply, Precision Cancer Therapies intends to help
keep physicians, scientists, health care providers, and the
motivated reader stay up to date on the dynamic and every
growing state of information in our fascinating profession.
Sure, Watson and PubMed and Society Guidelines can
aid us in our decision-making. However, there is nothing
that can replace a good old-fashioned education nor the
instinct of an informed practitioner of this most rewarding
of crafts.
Owen A. O’Connor, MD, PhD
American Cancer Society Research Professor
Professor of Medicine
University of Virginia Comprehensive Cancer Center
References
Barabási, A.-L. and Wang, D. (2021). The Science of Science,
Cambridge University Press.
de Solla Price, D.J. (1951). Quantitative Measures of the
development of science. Archives Internationales d’Histoire
des Sciences 4(14): 85–93, http://garfield.library.upenn.edu/
price/pricequantitativemeasures1951.pdf
de Solla Price, D.J. (1976). General theory of bibliometric and
other cumulative advantage processes. J. Am. Soc. Inf. Sci. 27
(5–6): 292–306, http://garfield.library.upenn.edu/price/
pricetheory1976.pdf
Fortunato, S., Bergstron, C.T., Borner, K. et al. (2018) Science of
science. Science 359 (6379): eaao0185. doi: 10.1126/science.
aao0185.
IBM pitched Watson as a revolution in cancer care. It’s available at:
https://www.statnews.com/2017/09/05/watson-ibm-cancer/
 1

Section I

Biological Basis of the Lymphoid Malignancies


Fundamental Principles of Lymphomagenesis
Pierre Sujobert1, Philippe Gaulard2, and Laurence de Leval3
1
Service d’hématologie biologique Hospices Civils de Lyon, Hôpital Lyon Sud, France; Université Lyon, Faculté de médecine et de maïeutique, Lyon Sud, France; Charles Mérieux,
Lymphoma Immunobiology Team, Pierre Bénite, France
2
Département de Pathologie, Groupe Hospitalier Henri Mondor, AP-HP, Créteil, France; Université Paris-Est, INSERM U955, Créteil, France
3
Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
Take Home Messages
● Lymphomagenesis is a complex process involving environ-
mental and genetic drivers.
● There is a continuum between preneoplastic lesions and
overt lymphomas.
● Lymphoid neoplasms are defined and classified according
to the concept of cell of origin reflecting the resemblance of
lymphoma cells to their normal counterparts.
● The research for new treatment largely relies on the con-
cept of hallmarks of cancer highlighting the targetable
pathways specific to transformed cells.
Introduction
If one asks a cancer scientist a seemingly naive question such as
“what are the hallmarks of cancer cells,” they will probably cite
at first somatic mutations and genomic rearrangement, leading
to excessive proliferation, resistance to apoptosis, and dissemi-
nation potential (Hanahan and Weinberg 2011). Intriguingly, all
of these hallmarks are physiological properties of B- and
T-lymphocytes, selected by evolution because they ensure an
efficient immune response against pathogens. So, it is a fasci-
nating paradox to observe that lymphoma remains a relatively
rare cancer as compared to epithelial cancers. Hence, under-
standing the tumor suppressor mechanisms that mitigate lym-
phomagenesis or eradicate lymphoma cells at preclinical stages
appears an extraordinary challenge. After a short overview of
the current models used to analyze lymphomagenesis, we will
highlight that the frontier between reactive lymphoproliferation
Precision Cancer Therapies: Targeting Oncogenic Drivers and Signaling Pathways in Lymphoid Malignancies: From Concept to Practice, Volume 1,
First Edition. Edited by Owen A. O’Connor, Stephen M. Ansell, and John F. Seymour.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
3
and overt lymphoma is not always clear. Then, we will present
how the classification of lymphomas based on the concept of
cell of origin might reveal important phenotypical properties of
lymphoma subtypes. Finally, we propose an overview of the
main hallmarks of lymphomas and discuss their contribution in
the most frequent subtypes of lymphomas.
How to Study Lymphomagenesis
As in other scientific fields, the nature of our knowledge of lym-
phomagenesis is tightly linked to the tools used to produce this
knowledge. Hence, it seems interesting to start this review with
a methodological perspective, providing a brief overview of the
different scientific approaches which have brought major con-
tributions to our understanding of lymphomagenesis.
Epidemiology was the first approach which shed light on the
mechanisms of lymphomagenesis, by deriving statistical cor-
relations from direct observation of cohorts of patients. First,
epidemiology has established the link between lymphoma inci-
dence and aging. The incidence of most lymphomas follows an
exponential growth after the fifth decade as observed for most
cancers, suggesting that common processes are shared with solid
tumors (Rozhok and DeGregori 2016; Sarkozy et al. 2015). In the
case of Hodgkin’s lymphomas, the bimodal distribution of inci-
dence suggests that specific mechanisms are occurring in young
patients, which have not been fully elucidated to date. Second,
epidemiology has also proven a counterintuitive association
of lymphomas with immunosuppression, either inherited
(common variable immunodepression for example) or acquired
after HIV infection, or immunosuppressive drugs (Kaplan 2012;
4 1 Fundamental Principles of Lymphomagenesis
van Leeuwen et al. 2009). This association revealed the role of the
immune system in repressing the growth of transformed lym-
phocytes, for example by active eradication of tumor cells or by
exerting a competition for resources. Third, the analysis of the geo-
graphic distribution of lymphoma subtypes also shows striking
differences, such as the higher incidence of T-cell lymphoma in
Asia as compared to Western countries (Perry et al. 2016). These
differences suggest two non-mutually exclusive hypotheses,
related to environmental or genetic differences. The fourth major
insight from epidemiological studies was to shed light on the role
of pathogens such as Helicobacter pylori, hepatitis C virus (HCV),
Epstein–Barr virus (EBV), or human T-cell lymphotropic virus
1 (HTLV-1) in specific subtypes of lymphoma (Couronné et al.
2018; Lecuit et al. 2004; Suarez et al. 2006), which has been then
confirmed experimentally. Besides pathogens, epidemiological
studies have also demonstrated the role of environmental expo-
sures such as herbicides in lymphomagenesis, which might have
important consequences for health policies (Weisenburger 2021).
More recently, molecular epidemiology based on genome-wide
association studies has demonstrated the association of host ge-
netic polymorphisms with the risk of specific lymphoma sub-
types (Cerhan et al. 2014), highlighting unsuspected pathways
which can then be experimentally explored.
The other descriptive approach is based on so-called
“-omics” approaches, which have generated much data dur-
ing the past two decades thanks to the technological out-
breaks of next-generation sequencing. The principle of these
studies is to characterize genomic and/or transcriptomic pro-
files of hundreds of cases, in order to discover recurrent
events or associations, to examine the clustering of similar
cases, and to evaluate their correlation with clinical presenta-
tion, response to therapy or prognosis. For example, these
approaches were successfully applied to diffuse large B-cell
lymphomas (DLBCL), which have been classified into germi-
nal center B-cell (GC), activated B-cell (ABC), and unclassi-
fied subtypes after transcriptomic profiling (Alizadeh et al.
2000; Rosenwald et al. 2002), and are now being divided into
genomic subtypes with partial overlap with former transcrip-
tomic classes (Chapuy et al. 2018; Schmitz et al. 2018; Wright
et al. 2020). Importantly, preclinical data has demonstrated
that the transcriptomic subtypes rely on specific pathways
related to proliferation, immune escape, and apoptosis, mak-
ing them more or less sensitive to targeted therapies (Yang et
al. 2012). However, the clinical trials based on these observa-
tions have not been successful so far (Davies et al. 2019;
Younes et al. 2019), highlighting the need to further refine
our experimental approaches to increase the translational
impact of these descriptive approaches.
Beyond these two descriptive approaches, experimental models
have been developed which enable direct testing of hypotheses. An
exhaustive description of all the experimental models available to
study lymphoma biology is beyond the scope of this chapter, but we
will briefly describe three models which have been widely used.
The first one is cell lines, which are derived from primary samples
and can be maintained and expanded in vitro. These are a very
important resource for research, which enables the modulation of
the expression of a gene of interest or to perform whole genome
screens, to test the effects of drugs, and to assess a variety of pheno-
typic characteristics (proliferation, apoptosis, etc.). Accordingly,
this is a model of choice to provide preclinical data supporting per-
sonalized medicine approaches, which aim at choosing the
treatment according to the specific features of the neoplastic cells.
Of note, the cell line model has many limitations such as genetic
drift or contaminations (Drexler et al. 2003). Even more problem-
atic is the fact that the cells grow in suspension and without interac-
tion with other cell types, in a stereotyped metabolic environment
(glucose and amino-acids concentration, or oxygen concentration
for example) which is far from the real in vivo conditions of growth
of lymphoma cells. Refinements of culture conditions might
improve some of these limitations, by reconstitution of cell–cell
interaction with a stroma layer and/or a three-dimensional struc-
ture such as spheroids (Lamaison et al. 2021).
The second major group of experimental models is repre-
sented by lymphomas developed in genetically engineered
mice. After the recognition of recurrent genetic hits in lym-
phomas, various models have been proposed where the genome
of the mice is modified to mimic what is observed in patients.
For example, BCL2 overexpression, which is a hallmark of fol-
licular lymphomas due to the t(14;18) translocation, can drive
an oligoclonal lymphoproliferation in irradiated mice reconsti-
tuted with bone marrow cells expressing the Vav-P BCL2 trans-
gene (Egle 2004). This model has also served as a platform to
assess the oncogenic role of other somatic mutations such as
those occurring in KMT2D, CREBBP, TBL1XR1, or BTG1 (Boice
et al. 2016; Delage et al. 2022; Ortega-Molina et al. 2015;
Venturutti et al. 2020; Zhang et al. 2015), which are not sufficient
to drive lymphomagenesis by themselves.
The third major experimental model of lymphomagenesis is
the xenografting of primary human lymphoma samples into
immunodeficient recipients, usually NSG (NOD.Cg-Prkdcˢcⁱd
Il2rgtm1Wʲˡ / SzJ) mice (Townsend et al. 2016). These strategies
enable the analysis of primary cells in a microenvironment
that recapitulates some of the features of the human microen-
vironment. However, the establishment of such models is
even more difficult for lymphomas than for other hematolog-
ical malignancies like acute leukemias, and many key aspects
of lymphoma biology such as the role of the immune system
are not captured. Alternative recipients might warrant further
evaluation such as zebrafish or chicken embryos (Delloye-
Bourgeois et al. 2017), but none of them will eventually
capture all the features of human lymphoma biology.
Finally, one should be reminded that every model of lym-
phoma describes only a fraction of the disease, and the overall
picture requires the integration of all the data. The main role
of lymphoma models is to generate hypotheses, which should
ideally be tested in clinical trials when possible.

Before Lymphoma: The Gray Frontier
Between Physiology and Pathology
Lymphoma could be defined by a clonal proliferation of B-, T-,
or natural killer (NK)-lymphocytes with tissue involvement
and clinical manifestations, that is, symptoms related to
lesions involving lymph nodes and/or extranodal sites. Similar
to the paradigm proposed for colorectal carcinoma (Fearon
and Vogelstein 1990), the development of lymphoid malig-
nancies is believed to follow a multistep process with progres-
sive accumulation of genetic events. Accordingly, it is not
surprising that early lesions preceding lymphomas have been
observed in healthy individuals. Early steps of lymphomagen-
esis may manifest as “reactive” lymphoproliferations; in situ
lymphomas, – better designated as in situ neoplasms in view
of their limited potential to develop into an overt lymphoma,
and lymphomas with low tumor burden and no clinical
impact. Even more frequent is the identification of oncogenic
translocations associated with lymphoma by sensitive molec-
ular techniques in healthy adults, which will only rarely give
rise to overt lymphomas. In the following section, we will
describe some of these pre-lymphomatous lesions, which
challenge our understanding on how to define lymphoma.
Driver Without Disease
Chromosomal translocations are hallmark features of several
lymphoid malignancies that result in the deregulated expres-
sion of oncogenes or in the generation of novel fusion genes.
Using sensitive molecular studies to screen healthy individ-
uals, translocations such as the t(14;18)(q32;q21), the t(11;14)
(q13; q32), as well as the t(2;5)(p23;q35) resulting in NMP1:ALK
fusion transcript – the hallmark driver events for follicular
lymphoma (FL), mantle cell lymphoma (MCL), and Anaplastic
Lymphoma Kinase (ALK)-positive anaplastic large cell lym-
phoma, respectively – have been detected, though at a low rate,
in circulating cells of healthy individuals (Laurent et al. 2012;
Lecluse et al. 2009; Roulland et al. 2014; Trümper et al. 1998).
The best example is given by the observation that the t(14;18)
(q32;q21) is detectable in the peripheral blood of two-thirds of
healthy adults at a detection threshold of ~ 1 cell per million
B-cells (Roulland et al. 2014). Given that the vast majority of
these patients will never progress to overt FL, it suggests that
such progression requires additional genetic events (Milpied et
al. 2015; Sungalee et al. 2014), and/or an escape from immuno-
logical control of lymphoma outgrowth.
From In Situ Neoplasms to Asymptomatic
Lymphomas
A tissue equivalent of the detection of driver translocations in
the blood of healthy people are the limited lymphoma lesions
discovered incidentally. The best described is “in situ follicular
  Before Lymphoma: The Gray Frontier Between Physiology and Pathology 5
neoplasm,” which is characterized by scattered follicles occu-
pied by clonal B-cells with both t(14;18) as well as BCL2 and
CD10 co-expression (Cong et al. 2002). Similarly, though at a
lower prevalence, “in situ mantle cell neoplasm” due to the
incidental observation of accumulating cyclin D1+ cells in the
mantle zone of otherwise morphologically reactive lymph
nodes has been recognized, which can antedate the occur-
rence of overt MCL.
Another early histological lesion is represented by the
tissue equivalent of monoclonal B-cell lymphocytosis (MBL)
(Gibson et al. 2011; Rawstron et al. 2008). The latter is
defined as the presence of less than 5 × 109/L clonal B-cells
in the peripheral blood which share the phenotypic and ge-
netic characteristics of patients with chronic lymphocytic
leukemia (CLL), or less commonly display a “non-CLL”
phenotype. The absence of clear clinical or biological
parameters that clearly distinguishes MBL from CLL indi-
cates a continuum between both conditions without sharp
delineation (Barrio et al. 2017). This also means that CLL
develops slowly following a prolonged prodromal phase
without clinical symptoms and obvious lymphocytosis, and
this asymptomatic phase may also persist many years in a
proportion of patients with overt CLL. Similarly, mono-
clonal gammopathy of unknown significance is the subclin-
ical precursor lesion to plasma cell myeloma (Scarfò and
Ghia 2016).
Chronic Antigenic Stimulation as an Early Step
of Lymphomagenesis
There is evidence that gastric extranodal marginal zone lym-
phoma arises from a mucosa-associated lymphoid tissue
(MALT) that has been acquired because of Helicobacter pylori
infection. First, H. pylori is present in most gastric MALT lym-
phomas. Second, the therapeutic efficacy of antibiotics on
gastric MALT lymphomas demonstrates the addiction of lym-
phoma cells to chronic antigenic stimulation (Steinbach et al.
1999). Third, in vitro studies also showed that lymphoma
growth could be stimulated by H. pylori strain-specific T-cells
(Wotherspoon et al. 1991). Therefore, H. pylori-induced chronic
gastritis can be regarded as a preneoplastic lesion in which the
lymphoma B-cell clone can be detected preceding the occur-
rence of MALT lymphoma, emphasizing a continuum between
H. pylori chronic inflammation and MALT lymphoma without
sharp delineation (Isaacson et al. 1999).
Regarding the T-cell system, intolerance to gliadin in a
specific HLA context causes celiac disease. Celiac disease is
characterized by chronic antigen stimulation and expansion of
intestinal intraepithelial T lymphocytes (IEL) which subse-
quently favors the development of enteropathy-associated
T-cell lymphomas (EATL). Overt EATL with intestinal tumors
is often associated with mesenteric lymph node involvement
may be preceded by early lesions composed of morphologically
6 1 Fundamental Principles of Lymphomagenesis
non-transformed IEL which are already clonal with an aber-
rant phenotype and genetic lesions, a condition referred to as
refractory celiac disease. Therefore, lymphoma development in
this setting follows a multistep process from celiac disease to
refractory celiac disease – regarded as a preneoplastic condition
or in situ lymphoma – to EATL, following early acquisition of
gain-of-function mutations in genes of the JAK1/STAT3
pathway (Cording et al. 2021; Ettersperger et al. 2016).
EBV-associated B-cell lymphoproliferative disorders
(LPDs) that occur in immunocompromised patients consti-
tute another illustration of the first steps of lymphomagen-
esis. These disorders constitute a heterogeneous group of
lesions ranging from polyclonal polymorphic proliferations
to clonal monomorphic lesions which share common onco-
genic and biological features. In these diseases, EBV is an
important oncogenic driver and the balance between viral
oncogenic proteins, defective immune surveillance, and ge-
netic background likely explains the clinical manifestations,
and their potential response to reduction or withdrawal of
immune-suppression whenever possible (Natkunam et al.
2018).
Another intriguing condition, probably secondary to
chronic antigenic stimulation, is persistent polyclonal B-cell
lymphocytosis (PPBL). This infrequent disorder occurring
mostly in middle-aged smoking women is characterized by
an expansion of dysplastic – binucleated – B-cells which are
polytypic (as assessed by kappa or lambda light chain expres-
sion) but clonal as demonstrated by recurrent cytogenetic
abnormalities such as isochromosome 3q (Callet-Bauchu
et al. 1999). However, this condition is not driven by gene
mutations (Tesson et al. 2017), and the reason why around
10% of PPBL patients develop overt lymphomas remains to be
determined (Lesesve and Troussard 2011).
Another way to tackle the problematic definition of lym-
phomas relies on the cell of origin concept, which is pre-
sented in the next section.
The Cell of Origin Concept: A
Classification Based on Physiology
Lymphomas derive from B-cells, T-cells, or NK-cells at var-
ious stages of differentiation possess many features of their
normal counterparts. These features – including physiological
antigen receptor gene editing, gene expression, immuno-
phenotype, morphology, homing patterns, and prolifera-
tion capacities – in large part dictate the clinical behavior of
these diseases. Thus, understanding the normal counterpart
of neoplastic cells provides a useful framework for under-
standing the biology of the lymphomas, and to a large extent
constitutes the basis for lymphoma classification (Alaggio
et al. 2022; Campo et al. 2022; Swerdlow et al. 2016). Two
major categories of lymphoid neoplasms are recognized:
precursor (lymphoblastic) neoplasms, corresponding to the
earliest stages of differentiation, and peripheral or mature
neoplasms, corresponding to later stages of differentiation.
Lymphoblastic neoplasms tend to be more common in chil-
dren who have large pools of precursor cells, while those
corresponding to mature effector cells tend to be seen more
often in adults; for example, plasma cell myeloma is common
in older adults with large pools of post-germinal center anti-
gen-exposed plasma cells, as is mycosis fungoides which
is a neoplasm derived from effector CD4+ T-cells. Tumors
corresponding to proliferating normal cells such as lympho-
blasts or centroblasts are likely to be rapidly growing and clin-
ically aggressive, while those that correspond to resting stages,
such as small lymphocytic lymphoma/CLL, are more likely
to be indolent. Lymphoid neoplasms also reflect their normal
counterpart in their growth and homing pattern; tumors of
bone marrow-derived precursors become acute leukemias
and those of marrow-homing plasma cells multiple myeloma;
tumors derived from cells of MALT tend to involve MALT
sites; FL cells which represent the neoplastic counterpart to
germinal center centroblasts and centrocytes populate the
follicles of lymphoid tissues throughout the body.
The correspondence of lymphoma entities to normal lym-
phoid subsets or to a specific stage of normal lymphoid
differentiation is particularly well established for mature
B-cell neoplasms. The germinal center reaction which is piv-
otal in normal immune responses also plays a major role in
lymphomagenesis since mutations in many oncogenes are
acquired as a secondary effect of the activation of the somatic
mutation and immunoglobulin heavy chain (IGH) locus
class-switch recombination machinery which physiologically
occurs during T-cell-dependent germinal center reaction and
is mediated by AID (activation-induced cytidine deaminase)
(Robbiani and Nussenzweig 2013). In addition, the analysis
of somatic hypermutations in the variable regions of the
immunoglobulin genes which constitute definitive genomic
imprints of the germinal center reaction has been a major
tool to characterize the cellular origin of various mature
B-cell lymphomas, into naïve or pre-germinal center, germi-
nal center, or post-germinal center neoplasms. Moreover, the
presence of ongoing somatic hypermutations in tumors is
considered a feature of germinal center neoplasms. In CLL,
immunogenetic analysis has proven instrumental in delin-
eating two subgroups of the disease according to their hyper-
mutation status, which translate into differing clinical
courses and are taken into account for patient risk stratifica-
tion and the choice of treatment modalities (Fabbri and
Dalla-Favera 2016).
Interestingly, while the notion of cellular origin is usu-
ally used interchangeably with that of “normal cell coun-
terpart,” in fact it is established that in several instances the
oncogenic process starts at an earlier stage of differentiation.
For example, the translocations involving BCL1 and BCL2

in MCL and FL, respectively, occur in bone marrow lym-
phoid progenitors where they are mediated by the recombi-
nation activating gene (RAG) complex normally involved
in VDJ recombination of immunoglobulin and T cell
receptor (TCR) genes in immature lymphoid cells (Lieber
2016). In the case of T-cell lymphomas with a follicular
helper T-cell phenotype, the mutations in epigenetic modi-
fiers TET2 and DNMT3A target hematopoietic stem cells
not yet committed to the lymphoid lineage (Lemonnier
et al. 2018a).
For T-cell lymphomas, the significance of cell lineage or
cellular counterpart is variably established for the many dif-
ferent entities (Gaulard and de Leval 2014). In the case of
lymphomas derived from the innate immune system, for
example EBV-associated extranodal NK/T-cell lymphomas,
it appears that the derivation from NK versus gamma–delta
(or alpha–beta) T-cells is essentially not relevant clinically
or biologically, and the same applies to primary intestinal or
hepatosplenic T-cell lymphomas, which may express the
alpha–beta or gamma–delta isoform of the TCR, or neither
or both, with no established correlation to biology or out-
come (Travert et al. 2012). Conversely, a neoplastic pheno-
type resembling that of follicular helper T-cells defines a
relatively large group of diseases which have in common
other genotypic and clinical traits (Dobay et al. 2017). The
possibility to identify subgroups among peripheral T-cell
lymphomas, not otherwise specified (PTCL-NOS), based on
expression signatures resembling those of normal T helper
(Th)1 or Th2 cells, appears promising (Amador et al. 2019;
Iqbal et al. 2014).
Of note, the cell of origin concept highlights the similarities
between normal and cancer cells. On the other hand, the con-
cept of cancer hallmarks shed light on the biological prop-
erties that are specific to cancer cells and might be targeted
without excessive toxicity against their normal counterpart
(Figure 1.1).
Apoptosis
escape
Genetic
predisposition Microenvironment
Cell of origin
in situ, preclinical
B, T, NK
Infectious Genetic
agents alterations
Epigenetics
Figure 1.1 Overview of the main hallmarks of lymphomas.
  What Are the Hallmarks of Lymphoma? 7
What Are the Hallmarks of Lymphoma?
Taking into account the considerations proposed above, it is
tempting to adapt the concept of hallmarks of oncogenesis to
B- and T-cell lymphomas. Based on the analysis of epidemiolog-
ical data, pathological features, characteristic molecular drivers,
and experimental models, we can propose a panel of seven hall-
marks of lymphomagenesis which are contributing to various
extents to the development of the main lymphoma subtypes.
Epigenetics and Metabolism
Beyond the coding sequence, the structure of chromatin
is a strong determinant of cell phenotype, which connects
the global control of transcription with the metabolic state
(Goldberg et al. 2007). The most described epigenetic modifica-
tions relate to the DNA molecule itself (cytosine methylation/
demethylation, involving genes such as IDH1 and 2, TET2,
or DNMT3A) and the modifications of the histone proteins
(including among others acetylation [mediated by CREBBP,
EP300] and methylation [mediated by KMT2D, EZH2]). As in
myeloid malignancies, mutations of the genes encoding the
epigenetic machinery are highly recurrent in specific subtypes
of lymphomas, such as FL (KMT2D, CREBBP, EP300, EZH2)
or angioimmunoblastic T-cell lymphomas (TET2, IDH2,
DNMT3A) (García-Ramírez et al. 2017; Lemonnier et al.
2012; Ortega-Molina et al. 2015; Zhang et al. 2015). An inter-
esting hypothesis is that epigenetic marks might represent a
barrier against the transformation of hematological cells just
as spatial organization of tissues acts against the development
of epithelial cancers (Nam et al. 2021). Of note, epigenetics
is now recognized as a therapeutic target with EZH2 inhib-
itors in B-cell malignancies (Morschhauser et al. 2020), or
histone deacetylase (HDAC) inhibitors and hypomethylating
agents in T-cell lymphomas (Falchi et al. 2021; Lemonnier
et al. 2018b; O’Connor et al. 2019).
Metabolism
Proliferation
Lymphoma
Morphology
Trafficking
Immunophenotype
Clinical features
Immune
escape
Antigen receptor
signaling
8 1 Fundamental Principles of Lymphomagenesis
Apoptosis Escape
As in other malignancies, escape from apoptosis is an essential
step in lymphomagenesis. Alterations of the TP53 pathway
are highly prevalent in most of the lymphoma subtypes and
are generally associated with poor response to chemotherapy.
Alternatively, overexpression of the BCL2 gene, for example as
a consequence of the t(14;18) translocation in FL or of a gene
amplification in some DLBCL (Chapuy et al. 2018), inhibits the
mitochondrial outer membrane permeabilization induced by
most pro-apoptotic signals. Here again, resistance to apoptosis is
now targetable by BCL2 inhibitors such as venetoclax.
Proliferation
Escaping apoptosis is probably not sufficient to explain the
outgrowth of large tumor masses as observed in lymphoma
patients. Somatic alterations of the genetic machinery that
controls the cell cycle are very frequent in lymphomas, with
the paradigmatic example of cyclin D1 overexpression in
MCL, resulting from the pathognomonic t(11;14) transloca-
tion. More indirectly, constitutive expression of c-MYC (for
example in Burkitt’s lymphoma as a consequence of tran-
scriptional deregulation related to the rearrangement of the
MYC gene with the promoter of the IGH gene) or constitutive
activation of the NF-κB pathway in ABC-DLBCL also pro-
motes the entry into cell cycle.
TCR/BCR Signaling
Unique to B- and T-lymphocytes is the expression of a specific
antigenic receptor, respectively the B-cell receptor (BCR) and
the T-cell receptor (TCR). These receptors transduce survival
signals and promote proliferation, which is critical to amplify
the immune response in physiological conditions when the
lymphocytes encounter their cognate antigen. However,
these signals are also strongly oncogenic, and many mecha-
nisms are now well described which result in their constitu-
tive activation such as chronic antigenic stimulation due to
HCV, H. pylori, antigen-independent signaling in CLL,
(Dühren-von Minden et al. 2012), and mutations in signaling
genes (for example CD79A and CD79B in B-cell lymphomas,
or PLCG1 and CD28 in T-cell lymphomas) (Vallois et al.
2016). This hallmark is also targetable nowadays (Young and
Staudt 2013), for example with ibrutinib (BTK inhibitor),
which shows impressive efficacy in CLL (Burger et al. 2015).
Immune Escape
Immune evasion plays a critical role in lymphomagenesis,
which is negatively illustrated by the increased incidence of
lymphomas in immunocompromised patients. This mech-
anism is especially important in Hodgkin’s lymphoma
or primary mediastinal B-cell lymphomas, where 9p24.1
amplification leads to overexpression of PDL1 and promotes
anergy of cytotoxic T-cells (Green et al. 2010). Other strat-
egies are observed such as decrease antigen presentation after
CREBBP inactivation by somatic mutations in FL (Green et
al. 2015), inhibition of HLA expression after B2 microglobu-
lin (B2M) mutation/deletion in DLBCL (Challa-Malladi et al.
2011), among others. The escape from the immune system
has been successfully targeted with checkpoint inhibitors
(such as PD1 or PDL1 inhibitors in Hodgkin’s lymphoma), or
with chimeric antigen receptor T-cells.
Trafficking
At the time of diagnosis, lymphoma has often spread to mul-
tiple locations in the body, including distant lymph nodes or
extranodal sites such as bone marrow, central nervous system,
skin, and virtually all organs. This dissemination is associated
with a poor prognosis and is incorporated into clinical staging
systems. Trafficking is a property of lymphocytes, which is
essential for their immune functions. However, lymphoma
cells can also enhance their ability to migrate through muta-
tions of genes involved in germinal center confinement such
as Gα13 or S1PR2 (Muppidi et al. 2014). In DLBCL, extranodal
dissemination is highly frequent is the MCD/C5 subtype
(Chapuy et al. 2018; Schmitz et al. 2018; Wright et al. 2020),
which is associated with recurrent mutations of BTG1, and
recent works demonstrated a link between BTG1 inactivation
and lymphoma dissemination through the activation of the
BCAR1 pathway (Delage et al. 2022).
Microenvironment
Even if lymphomas are aggressive in vivo, they are very diffi-
cult to maintain and grow in vitro, revealing their dependency
on signals from the microenvironment. Of note, the interac-
tion of lymphomas with their microenvironment is hetero-
geneous, with some lymphomas recruiting various cellular
subtypes – the prototype being Hodgkin’s lymphoma where
the neoplastic cells are typically outnumbered by an abun-
dant and usually polymorphous reactive infiltrate; others –
like Burkitt’s lymphoma – destroying the microenvironment,
and others – like FL – modifying the microenvironment to
promote protumoral interactions (Scott and Gascoyne 2014).
The recent release of Ecotyper, a deconvolution method
which enables the characterization of the immune microen-
vironment of cancers, has uncovered a high level of hetero-
geneity of the tumor ecosystem among DLBCL patients, and
will probably shed light onto the role of the interactions of
tumor cells with their niche in other lymphomas (Steen et
al. 2021). Therapeutic approach targeting the microenviron-
ment is an appealing strategy, because normal cells are far
more homogeneous than cancer cells, and accordingly less

prone to resist to treatment. But obviously, targeting normal
cells without excessive toxicities is challenging, even if not
impossible (rituximab for example).
Conclusion
Lymphomas constitute a heterogeneous group of diseases,
which are not always easy to distinguish from physiological
conditions resulting from chronic antigenic stimulation. The
last decades have enabled an extraordinary accumulation of
knowledge which translates into clinical benefits, even if the
road is still long to cure the majority of patients. Understanding
the fundamental principles of lymphomagenesis is a never-
ending process, where our established knowledge is constantly
challenged by technological advances, clinical observations,
and therapeutic innovations. We cannot overemphasize the
importance of collaborations between scientists and medical
doctors to tackle this challenge.
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12
Identifying Molecular Drivers of Lymphomagenesis
Jennifer Shingleton and Sandeep S. Dave
Department of Medicine and Center for Genomic and Computational Biology, Duke Cancer Institute, Duke University, Durham, NC, USA
Take Home Messages
● Next-generation sequencing has enabled tremendous
progress in identifying the molecular drivers of lymphoma.
● Identification of molecular drivers has led to development
of many targeted therapies, but several barriers to clinical
translation remain.
● Barriers to translation include limited sequencing of very
rare lymphoma types, inadequate representation of most
ethnic groups in sequencing studies, and limitations of
preclinical and early phase studies.
● “Basket” clinical trials that enroll patients based on specific
genetic lesions, rather than specific diagnoses, can help
inform the tailoring of drug regimens to the biology of the
disease.
Introduction
Lymphoma drivers confer survival or proliferative advantage
to tumors. These advantages include uncontrolled cell prolif-
eration, avoiding cell death or senescence, and evasion of the
immune system (Hanahan and Weinberg 2011). A driver can
be defined as a genetic alteration that contributes to one or
more of these advantages and helps propel cells along the
path to malignant transformation.
Early cytogenetic research helped identify characteristic
translocations and gene fusions that were clear genetic
drivers in different lymphomas (e.g. MYC and BCL2 trans-
locations in Burkitt’s lymphoma [BL] and follicular lym-
phoma [FL], respectively). Unfortunately, not all molecular
drivers have been as easy to identify, especially given the
high degree of genetic heterogeneity of not just the drivers
but also the genetic mechanisms in most lymphomas. The
Precision Cancer Therapies: Targeting Oncogenic Drivers and Signaling Pathways in Lymphoid Malignancies: From Concept to Practice, Volume 1,
First Edition. Edited by Owen A. O’Connor, Stephen M. Ansell, and John F. Seymour.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
advent of genomic technologies, particularly next-gener-
ation sequencing (NGS), has given us more sophisticated
and powerful techniques to identify these genetic drivers
and their mechanisms. However, these advanced tech-
niques are a double-edged sword as they require greater
sophistication to analyze and interpret results. For in-
stance, the increased sensitivity of NGS allows detection of
potential genetic drivers occurring at very low frequency,
which may represent passenger mutations that have no
effect on lymphomagenesis.
The ever-decreasing cost of NGS has allowed unbiased
whole exome sequencing and whole genome sequencing of
different lymphoma cohorts, which have identified recur-
rently mutated genes and pathways. These studies have been
invaluable for revealing mutation patterns that point to mech-
anisms of lymphomagenesis and for informing patient prog-
nosis. Nearly every lymphoma subtype has been the subject of
such studies. However, the rarity of many subtypes precludes
large cohort sizes, and remains a limiting factor for defining
infrequent or subtle mechanisms implicating new drivers.
Identifying molecular drivers of lymphomagenesis com-
prises two separate but related issues: which variants have an
effect on downstream function and which mutated genes actu-
ally drive malignant transformation? Not every genetic variant
will have a significant effect on protein function, and not every
altered gene can functionally contribute to lymphomagenesis.
Discerning molecular drivers remains an important problem
in drug development since a therapy that targets a passenger
gene will likely have minimal impact on the disease. In
addition, molecular drivers can vary between different sub-
types or lineages, so drug development and clinical trials may
need to be designed in a subtype- or lineage-specific fashion.
In this chapter, we describe our current knowledge and meth-
odologies for defining the genetic landscapes of lymphomas,

noting both common themes and lineage-specific drivers. We
will also cover the various classes of targeted therapies and
how identification of molecular drivers guides therapeutic
development.
Sequencing and Bioinformatics Methods
Many tools have been developed to distinguish molecular
drivers from passengers. Some of these tools identify putative
driver mutations by predicting the functional impact of iden-
tified amino acid changes (Reva et al. 2011; Shihab et al. 2013).
For example, if a protein is normally activated upon phos-
phorylation of a tyrosine residue, then mutation of that tyro-
sine to phenylalanine can lead to constitutive activation.
Nonsense mutations that truncate a protein or frameshift
mutations that alter long stretches of amino acid sequence are
highly likely to abolish protein function. Hotspot mutations
targeting the same amino acid repeatedly across cases are typ-
ically gain-of-function and are highly likely to be drivers.
Investigators can also compare sequencing results to data-
bases of driver genes and variants in other cancers (e.g. The
Cancer Genome Atlas, COSMIC [Forbes et al. 2011, 2015]).
The frequency at which a particular genetic variant is found
within a tumor (expressed as variant allele frequency, VAF)
may also serve as a clue. A high VAF signifies that a high
percentage of tumor cells express that variant; therefore, there
is a higher likelihood that variant is a molecular driver.
However, VAF is not a perfect indicator as a high VAF can also
occur with a neutral mutation that arose early. Other methods
take background mutation rates into account and give weight
to genes with significantly higher mutation frequencies
(Hodis et al. 2012; Lawrence et al. 2013). When feasible, con-
secutive biopsies of the same patient can allow construction of
phylogenetic trees of mutations, which can help pinpoint
drivers. This strategy will become more feasible with con-
tinual improvement in techniques to analyze circulating
tumor DNA from the blood, allowing for frequent, non-inva-
sive sampling.
Another approach analyzes the spatial distribution of vari-
ants within a gene. Variants should occur by random chance
equally along the length of a gene. If a gene is not a driver,
then variants will display an even distribution when assessed
across a cohort of tumors. On the other hand, driver gene var-
iants that confer an advantage will exhibit clusters, usually in
functional domains.
Numerous methods leverage pathway-based or network-
based approaches to identify cancer driver modules that con-
sist of many genes crucial to cancer development (Babaei et
al. 2013; Gao et al. 2017; Jia and Zhao 2014; Leiserson et al.
2015). This approach is useful in settings where any one of
many genes in a pathway could be mutated to achieve the
same effect (e.g. JAK/STAT pathway).
  Functional Validation of Drivers 13
“Meta-predictor” methods and pipelines (Bertrand et al.
2018; Dees et al. 2012; Gonzalez-Perez et al. 2013) rank the can-
didate genes based on the ranking results of several computa-
tional tools that have complementary approaches and analyses.
New techniques are continually under development to
improve performance, including machine-learning approaches
using datasets available from large sequencing studies.
The combination of approaches described above has been
the cornerstone of genomic studies that have collectively
served to define the drivers of most lymphomas.
Functional Validation of Drivers
Functional validation remains the definitive way to estab-
lish whether a particular variant is oncogenic. Such valida-
tion studies can take many forms. These include cell-free
biochemical assays that are able to confirm changes in
protein function, but not necessarily effects on larger cel-
lular processes. These effects must be measured in cell
culture-based assays involving primary or immortalized
cell lines. Specific variants of interest may be expressed,
or genes knocked out to model loss-of-function mutations.
Investigators can then measure changes in cell prolifera-
tion, cell death, gene expression, or other relevant cellular
processes. These types of assays are relatively rapid, cost-ef-
fective, and simple to interpret, but phenotypes are restricted
to those that are independent of the microenvironment. In
addition, it can be challenging to investigate the effects of
oncogenic variants in transformed cell lines because they are
already selected to proliferate rapidly. Patient-derived xeno-
grafts maintain the original genotype(s) of the tumor, but do
not always propagate faithfully and lack critical interactions
with the microenvironment. Organoid-based assays have
been utilized as a way to overcome some of these obstacles
while avoiding the complexities of animal models.
Transgenic animal models can be used to investigate effects
of molecular drivers in a broader physiological context. This
physiological context is particularly important in lymphomas,
where malignant cells communicate with and are affected by
many different cell types in the microenvironment including
other immune cells. Conditional alleles allow tissue-specific
or temporal control of increased gene expression or gene
knockout. Importantly, the tumorigenic process begins with
normal cells within a relevant microenvironment, so investi-
gators can observe the transformative effects of molecular
drivers in a context that more closely resembles a human
patient.
Genome-wide screens can also be used to functionally
identify molecular drivers. Screens can model genetic vari-
ants by insertional mutagenesis, transposons, RNA interfer-
ence, or clustered regularly interspaced short palindromic
repeats (CRISPR)-mediated editing. These screens are
14 2 Identifying Molecular Drivers of Lymphomagenesis

valuable as an orthogonal method to validate results from
genomic studies in patient tumors.
Each of these approaches carries its own significant trad-
eoffs in terms of ease of use, representativeness of the human
tumors, and the ability to test different perturbations
including the effects of targeted therapies. The development
of new models that reflect the molecular spectrum remains
an important and open research question.
Common Themes in B- and T-cell Lymphoma
While Chapter 1 gave a good high-level view of lymphoma-
genesis, there are a number of important and recurring
themes worth emphasizing in the context of identifying
important “drivers” of the pathophysiology. As a whole, lym-
phomas exhibit a high degree of genetic heterogeneity.
Lymphoma cells are susceptible to several mutagenic
processes that are part of normal lymphocyte development:
B/T-cell receptor rearrangement, class-switch recombination
and somatic hypermutation. Each time these processes occur,
there is a risk of incurring an oncogenic mutation.
Lymphomas that arise from various stages along the B- or
T-cell development path have different characteristics
including morphology, surface marker expression, immuno-
globulin (IG) status, and genetic features. Clinicians use
these characteristics to classify lymphomas based on the
normal cell type that they originate from (“cell of origin”)
(Figures 2.1 and 2.2).
There are genetic patterns in lymphomas that reflect
differentiation processes that occurred in the cell of origin.
B-cell precursors undergo V(D)J recombination to assemble
exons that code for the antibody variable region. This process
involves creation of double-stranded breaks at the IG locus,
which can result in translocations that overexpress onco-
genes. Such translocations involving an IG locus can also be
a consequence of class-switch recombination (which also
involves creation of double-stranded breaks) or somatic
hypermutation. These lesions characterize many types of
B-cell lymphoma (see Table 2.1).
Activated mature B-cells undergo several rounds of somatic
hypermutation in germinal centers to increase antigen
affinity. These B-cells also undergo class-switch recombina-
tion to alter the antibody isotype and function. The key
enzyme (activation-induced cytidine deaminase, or AID)
involved in both somatic hypermutation and class-switch
recombination can act aberrantly, leading to accumulation of
both driver and passenger mutations. There is a recognizable
AID mutational signature in these tumors.
Many lymphoma driver genes are related to lympho-
cyte development and function. PAX5 and EBF1 are impor-
tant transcription factors in normal B-cell lymphocyte
development. Both of these genes are genetically altered in
B-cell malignancies. T-cell malignancies, on the other hand,

Lymph node

Marginal
Mantle zone
Plasma cells
zone Germinal
center

Antigen
stimulation

SHM CSR Memory B cells

Mature naive
B cells

MCL GCB-DLBCL NMZL ABC-DLBCL Multiple

BL SMZL LPL myeloma
FL MALT lymphoma
PCFCL PCMZL
PCLBCL

Figure 2.1 B-cell lymphomas and normal cells of origin. Upon antigen stimulation, mature B-cells home to germinal centers where
they undergo somatic hypermutation (SHM) and class-switch recombination (CSR) before terminal differentiation into plasma or memory
B-cells. Examples of lymphomas that can arise at each B-cell stage are noted. MCL, mantle cell lymphoma; GCB-DLBCL, germinal center
B-cell diffuse large B-cell lymphoma; BL, Burkitt’s lymphoma; FL, follicular lymphoma; PCFCL, primary cutaneous follicle center lymphoma;
PCLBCL, primary cutaneous large B-cell lymphoma; NMZL, nodal marginal zone lymphoma; SMZL, splenic marginal zone lymphoma; MALT,
mucosa-associated lymphoid tissue; PCMZL, primary cutaneous marginal zone lymphoma; ABC-DLBCL, activated B-cell like DLBCL; LPL,
lymphoplasmacytic lymphoma.
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