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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Analysis of Diffuse Large B-cell Lymphoma using Immunohistochemical Algorithm: A Cross-sectional Study
Correspondence Address :
ER Jyothi Rani,
Krishna House, Thalayi Street, Edacheri Post, Vadakara, Kozhikode-673502, Kerala, India.
E-mail: jyothiranier@gmail.com
Introduction: Diffuse Large B-cell Lymphoma (DLBCL) is the most common Non-Hodgkin’s Lymphoma (NHL). Using Gene Expression Profiling (GEP) DLBCL has been subtyped into two groups of prognostic importance, Germinal Center B-cell (GCB) like and activated B-cell like. GCB DLBCL has a better survival and can be identified using Hans algorithm with three immunohistochemical markers Cluster Differentiation (CD10), B-cell lymphoma 6 (BCL6) and Multiple Myeloma Oncogene-1 (MUM1).
Aim: To analyse DLBCL using Hans algorithm as both GCB lymphoma and non GCB lymphoma have different treatment and prognosis.
Materials and Methods: This was a cross-sectional study conducted in the Department of Pathology, Government Medical College, Kozhikode, Kerala, India, from January 2019 to December 2020. A total of 97 DLBCL cases received in the Department of Pathology, from January 2016 to December 2019 were included in the study were subtyped using Hans algorithm. CD10, BCL6 and MUM1 were considered positive, if more than 30% of the tumour cells showed staining by the respective antibodies. The relation between DLBCL subtypes and the age, gender, symptoms, site of initial involvement, organomegaly, Ann Arbor stage, treatment response and overall survival. Findings in the patients were analysed using Chi-square test. Statistical Package for Social Sciences (SPSS) software version 18.0. Overall survival was estimated using Kaplan-Meier method.
Results: The median age of study population was 60 years (age range: 31-85 years) and there were 55 (56.7%) males and 42 (43.3%) females. Out of the 97 DLBCL cases 47 (48.5%) were GCB and 50 (51.5%) were non GCB subtype. Statistical analysis was done only in 88 patients (excluded nine recurrent lymphoma patients, which may have a different outcome). There was significant association (p-value=0.003) between stage and subtypes as majority of the non GCB cases presented in an advanced stage. The rate of complete remission with Rituximab Cyclophosphamid Hydroxydaunorubicin Oncovin Prednisone (RCHOP) chemotherapy was higher in GCB (58.75%) compared to non GCB (15.25%) subtypes (p-value=0.001). Overall survival rate of GCB was 74.4% and non GCB was 31% with a p-value of 0.001. There was no statistically significant relation between DLBCL subtypes and other clinicopathological factors.
Conclusion: In the present study, the patients within the GCB subtype had better treatment response and overall survival rate compared to non GCB subtype. Non germinal center subtype presented in advanced stage and had a worse prognosis. Therefore, it is essential to subtype DLBCL in all cases to identify non GCB subtype, which may need additional treatment after RCHOP chemotherapy.
Algorithm, Germinal center, Hans algorithm, Survival rate
The DLBCL is the most common type of NHL, with several morphologic and clinicopathologic variants. DLBCL comprises about 30-40% of all NHL cases (1). Distinctive molecular and genetic abnormalities have been identified in DLBCL, and patients with this disease exhibit a wide range of clinical presentations and variable outcome (2). The Cell of Origin (COO) classification has been the most significant development in the understanding of DLBCL biology. The gold standard test to identify COO is GEP (3). Recent GEP has subtyped DLBCL into two main prognostically important subgroups GCB type and non GCB type with the germinal center type showing overall better survival (4). Determination of gene expression profiles requires fresh or frozen tissue for extraction of Ribonucleic Acid (RNA), which is costly and difficult to implement in regular clinical practice. To subtype DLBCL for guiding the treatment and predicting the prognosis many studies have proposed the use of Immunohistochemistry (IHC) with antibodies that represent different B-cell differentiation stages which are more easier and economical (5). Hans CP et al., postulated an IHC algorithm to classify DLBCL into GCB and non GCB subtypes using three markers CD10, BCL6 and MUM1 (3),(6).
The IHC algorithmic subtyping of DLBCL is helpful for clinicians to differentiate which patient requires further treatment after RCHOP based chemotherapy, as non GCB type requires it to improve their outcome. At present there is RCHOP plus treatment with Lenalidomide, Bortezomib in many centres for non germinal centre type DLBCL (7). The goal of the current study was to subtype DLBCL using Hans algorithm into GCB lymphoma and non GCB lymphoma and to assess their overall survival and treatment response.
This was a cross-sectional study conducted in the in the Department of Pathology, Government Medical College, Kozhikode, Kerala, India, from January 2019 to December 2020. A total of 97 patients with histopathological diagnosis of DLBCL received from January 2016 to December 2019 were included in the study. After obtaining approval from Institutional Ethics Committee (Ref.No.GMCKKD/RP 2019/IEC/55 dated 19-1-2019).
Inclusion criteria: All patients with confirmed histopathological diagnosis of DLBCL from both nodal and extranodal sites and whose tissue blocks are available in the Department of Pathology were included in the study.
Exclusion criteria: Patients with past history of any lymphoma were excluded from the study.
Study Procedure
The patients were retrospectively selected and analysed after subtyping immunohistochemically into GCB and non GCB subtypes. Treatment response status of patients was assessed after a minimum period of six months following the treatment. The clinical records were reviewed in all patients with particular reference to age at diagnosis, gender, presence of B symptoms, site of involvement, organomegaly, bone marrow infiltration, Ann Arbor stage (8), response to treatment and overall survival.
Haematoxylin and Eosin (H&E) stained sections were examined to identify the morphology. Formalin-fixed paraffin sections of 3 μm thick were used for Immunohistochemistry (IHC) staining. The staining of CD10 (Dako clone 56C6), BCL6 (Dakoclone PG-B6p) and MUM1 (PathnSitu clone EP-190) were done manually. Specifications of the antibodies used in the present study are shown in the table (Table/Fig 1). These antibodies were considered positive when more than 30% cells were stained with the respective antibody. For each case, the foci with the highest percentage of tumour cells stained were used for analysis. Hans’s algorithm was used for the classification of subjects into two subgroups (Table/Fig 2) (3). According to the algorithm, cases were subtyped to the GCB subgroup, if CD10 alone was positive. CD10 negative cases were further stained with BCL6. If BCL6 was negative, then the case was subtyped to the non GCB subgroup. Cases with BCL6 positivity were further stained with MUM1; if MUM1 was positive, then the case was assigned to the non GCB subgroup and negative cases were grouped under the GCB subgroup.
Statistical Analysis
The present study was carried out to analyse DLBCL cases using immunohistochemical algorithm and to assess their treatment response. Findings in the patients were studied and tabulated using Microsoft Excel and statistical analyses were done using SPSS software version 18.0 in windows. The Kaplan-Meier method was used to estimate the overall survival rate and log rank test was used to compare the survival distribution. A p-value of <0.05 was considered statistically significant by applying Chi-square test.
A total of 97 patients were analysed which includes 55 (56.7%) males and 42 (43.3%) females with a median age of 60 years (31-85 years). Among this 38 (39.2%) were in the age group of 55-64 years. Out of the 97 DLBCL cases 47 (48.5%) were GCB and 50 (51.5%) were non GCB subtype. Among the total study group, 62 (63.9%) had presented with lymph node involvement while extranodal presentation was seen in 35 (36.1%) cases. Out of the 35 (36.1%) extranodal DLBCL, the major sites involved were 26head and neck in 13 (13.4%) and Gastrointestinal Tract (GIT) in 12 (12.3%) patients. Among the total 97 patients, 30 (30.9%) had associated B symptoms, while rest were free of these symptoms. In the present study, 5 (5.20%) were with organ involvement, 1 (1%) with peripheral smear involvement and 9 (9.3%) with bone marrow involvement. With regard to Ann Arbor staging, out of the 97 cases studied, majority presented in stage-III (Table/Fig 3). Out of the total patients, 47 (48.5%) had limited disease (Ann Arbor stage-I and II), while 50 (51.5%) had advanced disease (Ann Arbor stage-III and IV) by using Hans algorithm, GCB type was found in 47 (48.5%) cases, and non GCB type in 50 (51.5%) cases. CD10 positive GCB comprise 47 (48.5%) (Table/Fig 4)a,b. CD10 and BCL6 negative non GCB comprise 48 (49.45%) (Table/Fig 5)a-c. BCL6 and MUM1 positive and CD10 negative cases constitute 2 (2.1%) cases (Table/Fig 6)a-d.
Among the total 97 cases, nine patients with a past history of lymphoma were excluded from the statistical analysis as they would have a different behaviour. Thus, statistical analysis was done in 88 (90.75%) cases, which included 42 (47.7%) GCB subtype and 46 (52.3%) non GCB subtype. There was no significant relation between DLBCL subtypes and other clinicopathological factors. Out of the total 88 DLBCL patients, follow-up regarding the treatment taken was obtained in 81 cases, and it was found that 46 (52.3%) patients could complete RCHOP chemotherapy. Response of the 46 (52.3%) cases, who had completed the whole six cycles of RCHOP chemotherapy was noted and is illustrated in (Table/Fig 7).
There was no association between DLBCL subtypes and age as p-value was 0.45. The present study could find a statistically significant association between DLBCL subtypes and stage as majority of the non GCB had advanced disease, whereas GCB had limited disease (Table/Fig 7). But there was no significant statistical relation between DLBCL subtypes with gender, B symptoms, site of initial involvement, organomegaly and bone marrow infiltration as shown in the table (Table/Fig 7). Association between DLBCL subtypes and treatment response was statistically significant (Table/Fig 7). Majority of the GCB cases achieved complete response to chemotherapy compared to non GCB subtype. Disease recurrence and death was more in non GCB subtype compared to GCB.
Overall survival rate was 51.9% and mean survival time was 30.15 months with a standard error of 2.9 (Table/Fig 8). In this group, 32 (39.5%) had a follow-up period of more than 20 months and mean follow-up period was 17.8 months. Patients who had completed RCHOP chemotherapy had better overall survival rate with a statistically significant p-value of 0.001 (p-value <0.05) mean survival time of GCB patients was 40.286 months with a standard error of 4.368 and non GCB patients was 20.965 months with a standard error of 3.437 (Table/Fig 9). GCB patients had better overall survival rate (74.4%) than non GCB type (31%) with a statistically significant p-value of 0.001 (p-value <0.05).
The DLBCL is the most common type of B-cell lymphoma. Heterogeneity at molecular and clinical level of DLBCL makes it difficult for prognostication and treatment (9). The intention of the study was to classify DLBCL into two prognostically important subtypes (GCB type and Non GCB type) and to find their relative proportion.
In the present study, all DLBCL cases received during the study period were analysed. Compared to the study done by Hans CP et al., where among 152 patients, non GCB predominated {n=88 (58%)} over GCB {n=64 (42%)}. In the present study out of 97 patients, both were almost of equal proportion with GCB being 47 (48.5%) and non GCB being 50 (51.5%) (6). But in other Indian studies (Dwivedi A et al., Gogia A et al., and Sahai K et al., they found GCB subtype cases to be more than that of non GCB (10),(11),(12). This may be due to difference in genetic factors of the study group that may influence the lymphoma genesis. In the present study, the cases ranged from a minimum age of 31 years to a maximum of 85 years with a median age of 60 years. Majority (39.20%) of the study population was in the age group 55-64 years. Like in the study done by Hans CP et al., (p-value=0.56) and Ichiki A et al., (p-value=0.06) in the present study too there was no significant relation with age and DLBCL subtypes (p-value=0.45) (6),(13). In the present study out of 88 cases, 56.7% were males and 43.3% were females with a male to female ratio of 1.26:1. Similar to other studies in literature (Dwivedi A et al., Ichiki A et al., and Berglund M et al., the present study also did not find a statistically significant relationship between gender and DLBCL subtypes (9),(10),(13).
Regarding relationship between B symptoms and DLBCL in the present study, there was no statistically significant relation and this matched the results obtained by Ichiki A et al., and Berglund M et al., (9),(13). Unlike the study done by Ichiki A et al., where 47.18% of non GCB had extranodal involvement with a statistically significant p-value of 0.008. In the current study, there was no statistically significant relationship between site of involvement and DLBCL subtypes (13). In the present study, among the total number of cases, there was only 38.6% with extranodal involvement while the major bulk of the cases studied by Ichiki A et al., had extranodal involvement (66.8%) (13). This may be the reason why this study did not get a relation between extranodal presentation and DLBCL subtypes. Similarly study done by Ichiki A et al., also could not find any significant relationship between bone marrow infiltrate and DLBCL subtypes (13). Unlike studies done by Hans CP et al., and Dwivedi A et al., the present study found statistically significant association between stage and DLBCL subtypes (6),(10).
Among the 88 cases, follow-up was obtained in 81 cases and of these 46 (52.3%) patients were able to complete RCHOP chemotherapy. The rate of complete remission was higher in GCB phenotype (58.75%) compared to non GCB (15.25%) showing a statistically significant p-value of 0.001. This was in concordance with the study done by Ichiki A et al., where it was showing a complete response of 77.5% for GCB and 52.6% for non GCB type with a p-value=<0.0001. Disease progression was seen in six cases even after RCHOP chemotherapy and among this five cases were of non GCB phenotype (13).
The present study found that overall survival rate of all DLBCL patients excluding those with past history of lymphoma was 51.9% with a mean survival time of 31 months. Compared to the GCB, the non GCB subtype showed higher incidence of disease recurrence and also higher mortality rate even after completion of chemotherapy. Among the patients who expired during chemotherapy, a higher number were of the non GCB subtype. This indicates that it is important to differentiate between these two subtypes. The present study found a significant difference in the overall survival of GCB subtype (74.4%) which is more than twice that of non GCB subtype (31%) with a p-value of 0.001. In the study done by Ichiki A et al., also they had a higher five year overall survival rate among GCB subtype (78%) compared to non GCB subtype (54%) with a p-value of 0.0012 (13). However, the study done by Dwivedi A et al., could not find any statistically significant correlation between overall survival and these subtypes (p-value=0.51) (10).
Limitation(s)
The limitations of the present study were LDH level and Karnofsky score were not available for calculating the International Prognostic Index (IPI). The present study could not attribute the exact cause of death of the patients who had expired during chemotherapy or after the completion of chemotherapy, whether it was disease related or chemotherapy related. GEP to compare the subtypes which had been done by other studies in literature was not done in these patients as it was not locally available and affordable. Since the present study duration was from 2016-2019 with a mean follow-up period of 17.81 months, further follow-up of the surviving patients may be needed for calculating five year overall survival rate.
The DLBCL can be subtyped using Hans algorithm and IHC into germinal center and non germinal center subtypes. In the present study, GCB type had better overall survival and treatment response and non GCB subtype presented in an advanced stage compared to GCB subtypes. Therefore, it is essential to subtype DLBCL in all cases to identify non GCB subtype which may need further treatment after RCHOP chemotherapy.
The authors are extremely thankful to Dr. Feroze M, Former Professor, Department of Pathology, Government Medical College, Kozhikode, Kerala, India for his guidance and support. The authors acknowledge the help rendered by Dr. Biju George, Associate Professor, Department of Community Medicine, Government Medical College, Kozhikode in statistical analysis for present study. The authors express their gratitude to Mrs. Sreeja, Mrs. Usha, technicians of Histopathology laboratory, Government Medical College, Kozhikode and Mrs. Silja, technician of Multidisciplinary Research Unit of Government Medical College, Kozhikode, Kerala, India.
DOI: 10.7860/JCDR/2023/63127.18193
Date of Submission: Jan 29, 2023
Date of Peer Review: Mar 21, 2023
Date of Acceptance: May 01, 2023
Date of Publishing: Jul 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 09, 2023
• Manual Googling: Mar 24, 2023
• iThenticate Software: Apr 25, 2023 (18%)
ETYMOLOGY: Author Origin
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