A Biologic Definition of Burkitt's Lymphoma from Transcriptional and Genomic Profiling
Michael Hummel, Ph.D., Stefan Bentink, M.S., Hilmar Berger, M.D., Wolfram Klapper, M.D., Swen Wessendorf, M.D., Thomas F.E. Barth, M.D., Heinz-Wolfram Bernd, M.D., Sergio B. Cogliatti, M.D., Judith Dierlamm, M.D., Ph.D., Alfred C. Feller, M.D., Martin-Leo Hansmann, M.D., Eugenia Haralambieva, M.D., Lana Harder, M.D., Dirk Hasenclever, Ph.D., Michael Kühn, Dido Lenze, Ph.D., Peter Lichter, Ph.D., Jose Ignacio Martin-Subero, Ph.D., Peter Möller, M.D., Hans-Konrad Müller-Hermelink, M.D., German Ott, M.D., Reza M. Parwaresch, M.D., Christiane Pott, M.D., Andreas Rosenwald, M.D., Maciej Rosolowski, Ph.D., Carsten Schwaenen, M.D., Benjamin Stürzenhofecker, Ph.D., Monika Szczepanowski, Ph.D., Heiko Trautmann, M.S., Hans-Heinrich Wacker, M.D., Rainer Spang, Ph.D., Markus Loeffler, M.D., Ph.D., Lorenz Trümper, M.D., Harald Stein, M.D., Reiner Siebert, M.D., for the Molecular Mechanisms in Malignant Lymphomas Network Project of the Deutsche Krebshilfe
Background The distinction between Burkitt's lymphoma and diffuselarge-B-cell lymphoma is unclear. We used transcriptional andgenomic profiling to define Burkitt's lymphoma more preciselyand to distinguish subgroups in other types of mature aggressiveB-cell lymphomas.
Methods We performed gene-expression profiling using AffymetrixU133A GeneChips with RNA from 220 mature aggressive B-cell lymphomas,including a core group of 8 Burkitt's lymphomas that met allWorld Health Organization (WHO) criteria. A molecular signaturefor Burkitt's lymphoma was generated, and chromosomal abnormalitieswere detected with interphase fluorescence in situ hybridizationand array-based comparative genomic hybridization.
Results We used the molecular signature for Burkitt's lymphomato identify 44 cases: 11 had the morphologic features of diffuselarge-B-cell lymphomas, 4 were unclassifiable mature aggressiveB-cell lymphomas, and 29 had a classic or atypical Burkitt'smorphologic appearance. Also, five did not have a detectableIG-myc Burkitt's translocation, whereas the others containedan IG-myc fusion, mostly in simple karyotypes. Of the 176 lymphomaswithout the molecular signature for Burkitt's lymphoma, 155were diffuse large-B-cell lymphomas. Of these 155 cases, 21percent had a chromosomal breakpoint at the myc locus associatedwith complex chromosomal changes and an unfavorable clinicalcourse.
Conclusions Our molecular definition of Burkitt's lymphoma clarifiesand extends the spectrum of the WHO criteria for Burkitt's lymphoma.In mature aggressive B-cell lymphomas without a gene signaturefor Burkitt's lymphoma, chromosomal breakpoints at the myc locuswere associated with an adverse clinical outcome.
Burkitt's lymphoma and diffuse large-B-cell lymphoma are matureaggressive B-cell lymphomas. If left untreated, they followa rapid clinical course and are fatal within months. Burkitt'slymphoma is a distinct entity that includes endemic and sporadictypes and cases associated with immunodeficiency or immunosuppression.1With the use of chemotherapy regimens that involve methotrexateand cytarabine, cure rates for sporadic Burkitt's lymphoma approach90 percent in children and 70 percent in adults.2 Diffuse large-B-celllymphoma, by contrast, is biologically and clinically heterogeneousand comprises five morphologic variants and three subtypes.3Treatment with a combination of chemotherapy based on cyclophosphamide,doxorubicin, vincristine, and prednisone (CHOP) and the monoclonalantibody rituximab can induce lengthy remissions in many patients.4Approximately 30 percent of patients with diffuse large-B-celllymphoma, however, have disease that is resistant to this treatmentor relapse soon after receiving it.2,5
The distinction between Burkitt's lymphoma and diffuse large-B-celllymphoma is not reliably reproducible with the use of the currentcriteria of morphology, immunophenotype, and genetic abnormalities.6,7The Burkitt's translocation or its variants, which juxtaposethe locus of the myc oncogene and one of the three immunoglobulin(IG) loci, are present in almost all Burkitt's lymphomas.8,9Nevertheless, myc translocations are not specific for Burkitt'slymphoma since they also occur in other lymphomas, includingdiffuse large-B-cell lymphoma. In the latter, chromosomal breakpointsat the myc locus are recurrently associated with non-IG partnerloci and complex chromosomal alterations.10,11,12,13,14,15,16,17
The imprecise distinction between Burkitt's lymphoma and diffuselarge-B-cell lymphoma on diagnosis may lead to the inadequatetreatment of some patients with a mature aggressive B-cell lymphoma.Studies involving gene-expression profiling indicate that diffuselarge-B-cell lymphomas comprise two or more main biologic subgroupswith different clinical behaviors.18,19,20,21 Until now, however,to our knowledge there has been no signature of gene expressionthat distinguishes Burkitt's lymphoma from diffuse large-B-celllymphoma.
Our aim was to establish a molecular definition of Burkitt'slymphoma and to search for other clinically relevant subgroupsof diffuse large-B-cell lymphoma. For this purpose, we performedgene-expression and genomic profiling of 220 mature aggressiveB-cell lymphomas that had been diagnosed by a panel of experthematopathologists.
Methods
This study was conducted from July 2003 through November 2005.It was approved by the local ethics commission (CharitéUniversity Hospital, Berlin). The data discussed are availablefrom the Gene Expression Omnibus of the National Center forBiotechnology Information (www.ncbi.nlm.nih.gov/geo/) throughGEO accession number GSE4475
[NCBI GEO]
.
Gene Expression and Genetic Analyses
RNA and DNA were extracted from frozen sections (Qiagen). AffymetrixU133A GeneChip hybridization of all 220 specimens was performedin accordance with the manufacturer's recommendations, involving5 µg of total RNA. We also performed array-based comparativegenomic hybridization in 185 cases, applying a BAC/PAC arraycontaining 2799 DNA fragments.22,23 The number of imbalancesper case was determined as an indicator of genetic complexity(explained in detail in the Supplementary Appendix, availablewith the full text of this article at www.nejm.org).
Interphase fluorescence in situ hybridization was performedon frozen or paraffin-embedded tissues from 217 cases with theuse of probes for IGH, IGK, IGL, myc, BCL6 and BCL2 loci24,25,26(see the Supplementary Appendix). Tumor-biopsy specimens inwhich myc was fused to IGH, IGK, or IGL were referred to as"IG-myc"; lymphomas with myc breakpoints without fusion of mycto an IG locus were called "nonIG-myc."
Analysis of Microarray Data
Probe intensities were normalized according to a variance-stabilizationmethod.27 Gene-expression levels were estimated by fitting anadditive model according to Irizarry et al.28 Germinal-centerand activated B-celllike lymphomas were diagnosed accordingto the method of Wright et al.29 (Further details and algorithmsunderlying the core-group extension are given in the Supplementary Appendix.)The raw gene-expression data are available at www.ncbi.nlm.nih.gov/geo.
Statistical Analysis
The MannWhitney U test, chi-square test, Fisher's exacttest, and log-rank test were used to test for differences amonggroups. Survival was calculated from the day of diagnosis untildeath or until the end of follow-up. The Cox proportional-hazardsmodel was used to analyze prognostic factors. Since not allvariables of the international prognostic index were availablefor all patients, the age at diagnosis and Ann Arbor stage wereused to adjust for known prognostic factors.30
Results
Patients and Diagnoses
Biopsy specimens of 220 mature aggressive B-cell lymphomas (i.e.,classic Burkitt's lymphomas, atypical Burkitt's lymphomas, anddiffuse large-B-cell lymphomas), in which at least 70 percentof all cells were tumor cells, were included in this retrospectivestudy. All specimens were reviewed by a panel of expert hematopathologistsusing the criteria of the World Health Organization (WHO) (providedin the Supplementary Appendix).
Clinical data were available for 146 patients (median year ofcollection, 1994) who had received a variety of primary treatments.The median follow-up was 60 months (range, 0 to 209). Characteristicsof the tumors and patients are given in Table 1 and Table 2,respectively, and in Tables S1, S2, and S3 of the Supplementary Appendix.
Table 2. Clinical Characteristics of the Patients.
Molecular Signature of Burkitt's Lymphoma
To derive a molecular signature of Burkitt's lymphoma, we deviseda computational algorithm called "core-group extension." Givena predefined core group of expression profiles, the algorithmidentifies additional cases that have a similar pattern of geneexpression and provides a gene-expression signature for theextended group. The method is described in detail in the Supplementary Appendix.
The core group consisted of eight cases that satisfied the WHOcriteria for Burkitt's lymphoma (a consensus histologic classificationof classic or atypical Burkitt's lymphoma [Figure 1A], CD20+,BCL6+, CD10+, BCL2, CD5, Ki-67 score 95 percent,IG-myc+). We applied core-group extension to a training setof 105 lymphomas and identified 58 genes that constituted themolecular Burkitt's lymphoma (mBL) signature (see the Supplementary Appendix).Each case was assigned an mBL-signature index score between0 and 1, with a higher score reflecting a greater similarityof gene expression in the sample to that in the core group.Cases with an index score greater than 0.95 were classifiedas mBL, and those with an index score of less than 0.05 weredesignated nonmolecular Burkitt's lymphoma (non-mBL).The remaining cases were considered intermediate (Figure 2).By rerunning the core-group extension algorithm 1000 times withrandom perturbations of the core-group data (bootstrapping),we evaluated the stability of the mBL signature (Figure 2).Although the mBL signature was stable at the extremes, the indexscores between mBL cases and non-mBL cases were continuous (Figure 2).Results obtained in an independent test set of 107 cases wereconsistent with the training set with regard to the histologicand genetic characteristics of the mBL and non-mBL cases andthe size and stability during bootstrap validation (Figure 2).
Figure 1. Histomorphologic Appearance of Cases with an mBL Gene Signature (Hematoxylin and Eosin).
Panel A shows the classic morphologic appearance of Burkitt's lymphoma; cytogenetically, this case was classified as a lymphoma with an IG-myc fusion and a low chromosomal complexity score (<6) that does not have an IGH-BCL2 fusion or a BCL6 breakpoint (called "myc-simple"). Panel B shows the morphologic appearance of diffuse large-B-cell lymphoma; cytogenetically, this case was classified as myc-simple.
Figure 2. Identification by Core-Group Extension of Cases with an mBL Signature.
Panel A shows the results for the training set of 105 cases, and Panel B the results for the test set of 107 cases. Genomic complexity is described in the bar plots at the top of the panels, with complexity increasing with height; the dotted horizontal line represents the mean complexity of each group. The second plot shows the stability of the core-group extension with respect to random perturbations of the core-group data (bootstrap analysis). The frequency of the perturbed mBL-signature index scores (from 0 to 1, bottom of plot to top) obtained from 1000 runs of the algorithm is indicated by color (very low frequency, orange; low, yellow; medium, green; high, blue; very high, red). The vertical lines delineate the three groups of lymphomas (mBL, intermediate, and non-mBL) as well as the core group of cases (Panel A) and the dashed horizontal lines indicate the index-score cutoffs defining the mBL group (0.95) and the non-mBL group (0.05). Among the mBL cases, the index score is close to 1 for all bootstrap perturbations, whereas in the non-mBL group it is near 0, demonstrating the stability of the signature. The mBL-signature index scores resulting from the nonbootstrapped signatures are represented as a dashed curve. Below, the heat map shows the gene-expression levels of the 58 mBL-signature genes, with 1 gene shown per row. Bright blue indicates a low level of expression (3 SD below the average of all cases), bright yellow indicates a high level of expression (3 SD above the average), and black the average level of expression across all samples. The cases are ordered from left to right on the basis of decreasing mBL-signature index score, given below the heat map. Green represents a high index score (mBL), and red a low index score (non-mBL). The color gradient in the intermediate group highlights the continuous transition of the index score between the mBL and non-mBL cases. The myc translocation partners are shown according to type: IG-myc fusion (bright green), nonIG-myc fusion (dark green), myc-breakpoint absent (red), and no data available (gray). Finally, the histologic diagnosis is shown at the bottom. Bright green indicates Burkitt's lymphoma in the core group; dark green, atypical Burkitt's lymphoma; red, diffuse large-B-cell lymphoma; and gray, unclassifiable mature aggressive B-cell lymphoma.
Features of Mature Aggressive B-Cell Lymphomas with the mBL Signature
We identified 36 lymphomas with an mBL-signature index scoreof greater than 0.95 in addition to the 8 core Burkitt's lymphomas,for a total of 44 mBL cases. The 8 core cases were similar tothe additional 36 cases with regard to age distribution andgenetic features (Table 1, and Table S1 in the Supplementary Appendix),as well as clinical course. Of the additional 36 mBL cases,21 were categorized as atypical Burkitt's lymphomas becauseof their Burkitt-like morphology or their deviant immunophenotype.It is important to note that 11 of these 36 cases had the distinctivemorphologic appearance of diffuse large-B-cell lymphoma (Figure 1B).The remaining four mBL cases had the morphologic appearanceof mature aggressive B-cell lymphoma but could not be furtherclassified histologically. With regard to immunophenotype, CD10and BCL6 were consistently expressed in the 42 and 39 mBL cases,respectively, that could be evaluated. BCL2 was detected ata low level in seven of these mBL cases and at a high levelin two.
Features of Mature Aggressive B-Cell Lymphomas without the mBL Signature
Of all 220 lymphomas, 176 had an mBL-signature index score ofless than 0.95. Of these 176 cases, 128 had an mBL-signatureindex score of less than 0.05 and were thus assigned to thenon-mBL group. The remaining 48 cases had an mBL-signature indexscore between 0.05 and 0.95 and thus could not be assigned unambiguouslyto the mBL or non-mBL group. These cases were assigned to theintermediate group, representing the transition zone betweenthe mBL and non-mBL groups.
With few exceptions (12 cases), the histologic diagnosis inthe non-mBL cases was diffuse large-B-cell lymphoma (Table 1).The histologic diagnosis of 39 (81 percent) of the intermediatecases was also diffuse large-B-cell lymphoma. Non-mBL and intermediatecases showed strong concordance regarding age distribution,immunophenotype, growth fraction (Ki-67 score), and chromosomalcomplexity (Table 1).
Genetic Aberrations and Gene Expression
We were able to evaluate 43 mBL cases for the presence of myctranslocations by using fluorescence in situ hybridization.All but five cases (88 percent) carried an IG-myc fusion andone of these five had both nonIG-myc and IGH-BCL2 fusions.In the 38 mBL cases with IG-myc fusion, IGH-BCL2 fusion andBCL6 breakpoints were absent. The average chromosomal complexityscore was low in the 38 mBL cases with IG-myc fusion but washigh in the 5 mBL cases without IG-myc fusion (median complexityscore, 2 vs. 9; P<0.001).
The frequency of myc breakpoints (regardless of translocationpartner) was significantly lower in the intermediate and non-mBLgroups (present in 35 of the 171 cases that could be evaluated[20 percent]) than in the mBL group (present in 39 of 43 cases[91 percent], P<0.001) (Table 1). It is remarkable that mycbreakpoints were common in the intermediate group (26 of 48cases [54 percent]), whereas they were uncommon in the non-mBLgroup (9 of 123 cases [7 percent]). Non-IG partners were frequentlyinvolved in myc translocation in both the intermediate group(10 of 26 cases [38 percent]) and the non-mBL group (4 of 9cases [44 percent]). Among the 35 myc-positive intermediateand non-mBL cases, 16 (46 percent) had a concurrent IGH-BCL2fusion, BCL6 breakpoint, or both. The chromosomal complexityscore was significantly higher in the intermediate and non-mBLgroups than in the mBL group (median complexity score, 8.5 vs.2; P<0.001) regardless of the presence of myc breakpoints(median complexity score, 7.5) or absence of myc breakpoints(median complexity score, 9).
On the basis of these data, we distinguished three main cytogeneticgroups within the mature aggressive B-cell lymphomas. The firstis called "myc-simple": lymphomas with IG-myc fusions and alow chromosomal complexity score (<6) that do not have IGH-BCL2fusions and BCL6 breakpoints. The second is called "myc-complex":all lymphomas with nonIG-myc fusions or all lymphomaswith IG-myc fusions that have a high chromosomal complexityscore (6), an IGH-BCL2 fusion, or BCL6 breakpoint, or any combinationof these. The third is called "myc-negative," comprising myc-negativelymphomas. The mBL group predominantly consisted of myc-simplelymphomas; the non-mBL group predominantly consisted of myc-negativelymphomas. In contrast, the intermediate group contained mostof the myc-complex cases but also occasional myc-simple andseveral myc-negative cases (Table 1).
Correlation of Molecular and Clinical Features
No significant differences were observed regarding the morphologiccharacteristics, immunophenotype, or gene-expression patternbetween the 146 patients with survival data and the 74 patientswithout or with incomplete clinical information (Table S2 andFigure S1 in the Supplementary Appendix). The clinical dataavailable for the 146 patients (Figure S1 in the Supplementary Appendix)suggest that the tissue specimens were obtained during a periodof relapse in less than 10 percent; this percentage was assumedto be representative of those without clinical information.
Patients with lymphomas classified as mBL or myc-simple hada significantly better five-year survival rate than patientswith non-mBL or intermediate lymphomas (75 percent vs. 39 percent,P=0.003 [Figure 3]) or with myc-complex or myc-negative lymphomas(70 percent vs. 41 percent, P=0.005 [Figure S3 in the Supplementary Appendix]).However, the results of multivariate regression analysis showedthat even if we ignored the different treatments received bythese patients, the favorable outcome among patients with mBLor myc-simple lymphomas could largely be explained by the onsetof the disease at a young age and the limited stage of the disease(Table 2 and Table 3).
Figure 3. KaplanMeier Estimates of Survival According to the mBL Signature.
Overall survival among patients with an mBL-signature index score greater than 0.95 was significantly greater than that among the patients with non-mBL or intermediate lymphoma (P=0.003 by the log-rank test). Tick marks denote patients alive at the time of last follow-up.
Table 3. Results of Multivariate Survival Analyses.
Among the 82 patients with non-mBL or intermediate lymphomasfor whom clinical information was available, the presence ofa myc breakpoint, as compared with its absence, was associatedwith a poor five-year survival rate (15 percent vs. 44 percent)(Figure S2 in the Supplementary Appendix). In the non-mBL andintermediate groups, the presence of a myc breakpoint which occurred mainly in myc-complex lymphomas (82 percent) was associated with a significantly worse survival rate,independently of Ann Arbor stage and age (hazard ratio for death,2.85; 95 percent confidence interval, 1.43 to 5.68; P=0.003)(Table 3 and Figure S3 in the Supplementary Appendix).
When we applied the signature for activated B-celllikeor germinal-center B-celllike large-B-cell lymphomasdescribed by Rosenwald et al.19 to our non-mBL and intermediatecases, we found that lymphomas with a germinal-center B-celllikesignature were associated with a significantly better five-yearsurvival rate than activated B-celllike lymphomas (51percent vs. 12 percent, P=0.003) (Figure S4 in the Supplementary Appendix).The hazard ratio for death for lymphomas carrying a germinal-centerB-celllike signature as compared with activated B-celllikesignature (1.79; 95 percent confidence interval, 0.94 to 3.42;P=0.08) was in the same range as that reported by Rosenwaldet al.19 (Table 3).
Discussion
The distinction between Burkitt's lymphoma and diffuse large-B-celllymphoma is clinically important, because these lymphomas aretreated with different chemotherapeutic protocols and differin their outcome.31 Even with the use of current diagnosticcriteria, the distinction is not precise; agreement among experthematopathologists on the pathological diagnosis of classicBurkitt's lymphoma, atypical Burkitt's lymphoma, and diffuselarge-B-cell lymphomas is only 53 percent.6,7 Our results providea molecular definition of Burkitt's lymphoma that reliably andreproducibly distinguishes it from other mature aggressive B-celllymphomas.
Of the 220 mature aggressive B-cell lymphomas studied, we identified44 with a consistent pattern of gene expression that was characteristicof mBL. The distinctive mBL signature consisted of 58 genes,including several target genes of the nuclear factor-B pathway(i.e., BCL2A1, FLIP, CD44, NFKBIA, BCL3, and STAT3) that areknown to distinguish activated B-celllike or germinal-centerB-celllike lymphomas.19,29 It is notable that these geneswere expressed at lower levels in mBL cases than in cases ofgerminal-center B-celllike diffuse large-B-cell lymphoma.
The mBL signature extends the WHO definition of Burkitt's lymphoma1to cases with the morphologic characteristics of diffuse large-B-celllymphoma and expression of BCL2. Yet not all cases with morphologicor immunophenotypical features of Burkitt's lymphoma were classifiedas mBL. Parallel analyses of genetic features by meansof interphase fluorescence in situ hybridization and array-basedcomparative genomic hybridization strongly support thebiologic relevance of the mBL signature. Of the 38 mBL casesfor which we had genetic data, 29 (76 percent) were classifiedas myc-simple, irrespective of their morphologic appearance.However, in four mBL cases, no IG-myc fusion was detectable,and one case was found to have a nonIG-myc translocation.
Clinically, all patients with mBL had a favorable prognosis(five-year survival rate, 75 percent). There was no significantdifference in survival between patients whose tumors had a morphologicappearance of classic or atypical Burkitt's lymphoma and thosewith a morphologic appearance of diffuse large-B-cell lymphoma,irrespective of the presence or absence of a myc breakpoint(data not shown). Our results suggest that a molecular diagnosisof Burkitt's lymphoma yields a more precise definition of thisentity than do current diagnostic criteria.
Of the 220 mature aggressive B-cell lymphomas, 176 had an mBL-signatureindex below 0.95 and thus were not classified as mBL. Most ofthese 176 cases had the morphologic appearance of diffuse large-B-celllymphoma. In line with a previous report,19 there was a differencein five-year survival between cases with a germinal-center B-celllikegene signature and an activated B-celllike gene signature(51 percent vs. 12 percent). More striking, the presence ofbreakpoints at the myc locus was strongly associated with anunfavorable five-year survival rate, as compared with the absenceof such breakpoints (15 percent vs. 44 percent). This associationwas independent of stage, age, and whether the tumor was classifiedas activated B-celllike or germinal-center B-celllike.In addition, 46 percent of cases with IG-myc and nonIG-mycbreakpoints had concurrent BCL2 and BCL6 translocations, suggestingthat the myc breakpoint arose during clonal evolution and conferredclinical aggressiveness.32
In the 208 cases that could be evaluated genetically, the patternof chromosomal aberrations allowed us to define three cytogeneticgroups. The myc-simple group comprises lymphomas with an IG-mycfusion and a low number of chromosomal imbalances (complexityscore, less than 6). This group included cases in which theBurkitt's translocation is most likely to constitute the primaryoncogenic event. The myc-simple cases largely overlapped withthe mBL cases and were associated with a favorable clinicaloutcome. In contrast, myc-complex status was associated witha poor outcome, independently of age and clinical stage (five-yearsurvival rate, 21 percent). The myc-complex cases were commonin the intermediate group. We speculate that in these intermediatecases, a primary genetic aberration induced a gene-expressionprofile that was subsequently shifted toward the mBL profileby a myc translocation.
In summary, we have devised a molecular definition of Burkitt'slymphoma by global gene-expression and genomic profiling. Matureaggressive B-cell lymphomas with both the mBL signature andthe cytogenetic myc-simple status have a favorable outcome andcan be regarded as biologic Burkitt's lymphoma. Mature aggressiveB-cell lymphomas with myc breakpoints but without an mBL signatureare clearly distinct from biologic Burkitt's lymphoma and areassociated with a poor clinical outcome. The few cases thatmet only one of the two criteria for biologic Burkitt's lymphomarequire further investigation. The distinction between biologicBurkitt's lymphoma and other mature aggressive B-cell lymphomaswith myc breakpoints or without them is a prerequisite for planningclinical trials of the treatment of mature aggressive B-celllymphomas. Such trials should clarify whether Burkitt's lymphomasand aggressive B-cell lymphomas (with myc breakpoints or withoutthem) should be treated differently.
Supported by a grant from the Deutsche Krebshilfe (70-3173-Tr3)and funding from the Schweizerische Arbeitsgemeinschaft fürKlinische Krebsforschung. No potential conflict of interestrelevant to this article was reported.
This article is dedicated to the memory of Reza M. Parwaresch.
* The authors' affiliations and the members of the Molecular Mechanismsin Malignant Lymphomas Network Project of the Deutsche Krebshilfeare listed in the Appendix.
Source Information
Mr. Bentink and Drs. Berger, Klapper, and Wessendorf contributed equally to this article.
Address reprint requests to Dr. Stein at Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Institute of Pathology, Hindenburgdamm 30, D-12200 Berlin Germany, or at Harald.Stein{at}charite.de.
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Appendix
The authors' affiliations are as follows: the Institute of Pathology,Campus Benjamin Franklin, Charité Universitätsmedizin,Berlin (M.H., M.K., D.L., H.S.); the Max Planck Institute forMolecular Genetics, Department of Computational Molecular Biology,Computational Diagnostics Group, Berlin (S.B., R. Spang); theInstitute for Medical Informatics, Statistics, and Epidemiology,Universität Leipzig, Leipzig (H.B., D.H., M.L.); the Instituteof Hematopathology and Lymph Node Registry (W.K., R.M.P., M.S.,H.-H.W.), the Institute of Human Genetics (L.H., J.I.M.-S.,R. Siebert), and the Second Medical Department (C.P., H.T.),Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel;Cytogenetic and Molecular Diagnostics, Internal Medicine III(S.W., C.S.), and the Institute of Pathology (T.F.E.B., P.M.),Universitätsklinikum Ulm, Ulm; the Institute of Pathology,Universitätsklinikum Schleswig-Holstein, Campus Lübeck,Lübeck (H.-W.B., A.C.F.); the Department of Oncology andHematology, Universitätsklinikum Hamburg-Eppendorf, Hamburg(J.D.); the Institute of Pathology, UniversitätsklinikumFrankfurt, Frankfurt (M.-L.H.); the Institute of Pathology,Universität Würzburg, Würzburg (E.H., H.-K.M.-H.,G.O., A.R.); the German Cancer Research Center, Heidelberg (P.L.);the Interdisciplinary Center for Bioinformatics, Leipzig (M.R.);and the Department of Hematology and Oncology, Georg-AugustUniversität, Göttingen (B.S., L.T.) all inGermany; and the Institute of Pathology, Kantonsspital St. Gallen,St. Gallen, Switzerland (S.B.C.).
The members of the Molecular Mechanisms in Malignant LymphomasNetwork Project are as follows: Writing Committee M.Hummel, M. Loeffler, A. Rosenwald, R. Siebert, H. Stein, L.Trümper; Steering Committee M. Loeffler, R. Siebert,H. Stein, L. Trümper; Reference Pathology Panel T.F.E. Barth, H.-W. Bernd, S.B. Cogliatti, A.C. Feller, M.-L.Hansmann, W. Klapper, P. Möller, H.-K. Müller-Hermelink,G. Ott, R.M. Parwaresch, T. Rüdiger, H. Stein, H.-H. Wacker;Gene Expression E. Berg, M. Hummel, M. Kühn, H.Lammert, D. Lenze, R. Zollinger; Tissue Processing and RNA andDNA Extraction and Analysis E. Berg, C. Burek, M. Frank,J. Helfrich, A. Juhl, H. Lammert, R. Liebertz, S.W. Popov, C.Pott, E. Sevecke-Wessels, M. Szczepanowski, H. Trautmann; InterphaseCytogenetics T.F.E. Barth, P. Behrmann, C. Becher, H.Brückner, M. Buck, J. Dierlamm, I. Eichelbrönner,E. Haralambieva, L. Harder, S. Hartmann, K. Hinz, J.-I. Martin-Subero,E.M. Murga Penas, G. Ott, S. Pries, M. Ratjen, A. Rosenwald,D. Schuster, R. Siebert, R. Zühlke-Jenisch; Array-BasedComparative Genomic Hybridization M. Bentz, Z. Keresmann,P. Lichter, S. Ruf, C. Schwaenen, S. Wessendorf; Bioinformaticsand Biostatistical Analyses H. Berger, S. Bentink, D.Hasenclever, D. Kostka, M. Loeffler, M. Rosolowski, R. Spang;and Clinical Data Collection and Interpretation H. Berger,S. Höller, M. Loeffler, C. Pott, U. Schönwiese, B.Stürzenhofecker, L. Trümper.
Genomic Diagnosis of Burkitt's Lymphoma
Lin B. T., Dave S. S., Staudt L. M., Hummel M., Stein H., Siebert R., the Molecular Mechanisms in Malignant Lymphomas Network Project of the Deutsche Krebshilfe
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