KESIMPULAN DAN SARAN

Klasifikasi Hans CD10, BCL6 dan MUM1

6.1 KESIMPULAN

Beberapa kesimpulan yang didapatkan pada penelitian ini adalah :

1. Pemeriksaan imunohistokimia Caspase-3 didapatkan hasil pada DLBCL subtipe GCB 13 kasus (+) dan 5 kasus (-), sedangkan pada DLBCL subtipe non-GCB 5 kasus (+) dan 18 kasus (-). Penelitian ini memakai cut

off ≥ 50% untuk hasil yang positif.

2. Berdasarkan hasil uji Chi-Square penilaian imunoekpresi Caspase-3 pada DLBCL subtipe GCB dan non-GCB didapatkan nilai p = 0,002 bahwa terdapat hubungan yang bermakna antara imunoekspresi Caspase-3 pada DLBCL subtipe GCB lebih tinggi dibandingkan subtipe non-GCB.

6.2 SARAN :

1. Penelitian dapat dilanjutkan dengan menggunakan metode TUNEL untuk mengetahui bagaimana perbedaan indeks apoptosis kasus-kasus DLBCL subtipe GCB dan non-GCB dibandingkan dengan Caspase-3.

Universitas Indonesia Daftar Pustaka

1. Rosai J. Lymph nodes. In: Rosai J, editor. Rosai and Ackerman’s surgical pathology. 10^th ed. Philadelphia : Elsevier Inc; 2011. p. 1806-38.

2. Weiss L.M. Non-Hodgkin lymphoma. In: Weiss L.M, editor. Lymph Nodes. 1^th ed. New York : Cambridge University Press; 2008. p. 123-75. 3. Jaffe E.S, Harris N.L, Stein H, Campo E, Pileri SA, Swerdlow SH.

Introduction and overview of classification of the lymphoid neoplasms. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al, editors. WHO classification of tumours of the haematopoietic and lymphoid tissues. Lyon : International Agency for Research on Cancer; 2008. p. 158-61.

4. Stein H, Warnke RA, Chan WC, Jaffe ES, Chan JKC, Gatter KC, et al. Diffuse large B-cell lymphoma, not otherwise specified. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al, editors. WHO classification of tumours of the haematopoietic and lymphoid tissues. Lyon : International Agency for Research on Cancer; 2008. p. 233-7. 5. Hans CP, Weisenburger DD, Greiner TC, Gascoyne RD, Delabie J, Ott G,

et al. Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray. Blood. 2004;103:275-81.

6. Provencio M, Martin P, Garcia V, Candia A, Sanchez AC, Bellas C. Caspase 3a: new prognostic marker for diffuse large B-cell lymphoma inrituximab era. Leukemia and Lymphoma. 2010;51:2021-30.

7. Muris JJ, Cillessen SA, Vos W, Houdt IS, Kummer JA, Krieken JH, et al. Immunohistochemical profiling of caspase signaling pathways predicts clinical response to chemotherapy in primary nodal diffuse large B-cell lymphomas. Blood. 2005;105:2916-23.

8. Habara T, Sato Y, Takata K, Iwaki N, Okumura H, Sonobe H, et al. Germinal center B-cell-like versus non-germinal center B-cell-like as important prognostic factor localized nodal DLBCL. J Clin Exp Hematopathol. 2012;52:91-9.

9. Jaffe ES, Harris NL, Stein H, Isaacson PG. Classification of lymphoid neoplasms: the microscope as a tool for disease discovery. Blood. 2008;112:4384-94.

10. Handayani SI, Nasar IM, Ramelan W. Ekspresi P53 mutan dan Ki67 pada berbagai varian limfoma sel B jenis sel besar difus. Maj Kedokt Indon. 2011;61:63-7.

11. Ioachim HL, Medeiros LJ. Diffuse large B-cell lymphoma. In: Ioachim HL, Medeiros LJ, editors. Lymph node pathology. 4^thed. Wolters kluwers: Lippincot Williams and Wilkins. 2008. p. 424-9.

12. Chan AC, Chan JK. Diffuse large B-cell lymphoma. In: Jaffe ES, Harris NL, Vardiman JW, Campo E, Arber DA. Hematopathology. 1^st ed. Missouri: Elsevier Saunders. 2011. p. 349-63.

13. Alizadeh AA, Eisen MB, Davis RE, Ma C, Lossos IS, Rosenwald A, et al. Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling. Nature. 2000;403:503-11.

Universitas Indonesia 14. Dogan A, Bagdi E, Munson P, Isaacson PG. CD10 and BCL-6 expression in paraffin sections of normal lymphoid tissue and B-cell lymphomas. Am J Surg Pathol. 2000;24:846-52.

15. Uherova P, Ross CW, Schnitzer B, Singleton TP, Finn WG. The clinical significance of CD10 antigen expression in diffuse large B-cell lymphoma. Am J Clin Pathol. 2001;115:582-8.

16. Xu Y, McKenna RW, Molberg KH, Kroft SH. Clinicopathologic analysis of CD10⁺ and CD10^- diffuse large B-cell lymphoma identification of a high-risk subset with coexpression of CD10 and bcl-2. Am J Clin Pathol. 2001;116:183-90.

17. Falini B, Fizzotti M, Pileri S, Liso A, Pasqualucci L, Flenghi L. Bcl-6 protein expression in normal and neoplastic lymphoid tissues. Ann Oncol. 1997;8:101-4.

18. Chung KM, Chang ST, Huang WT, Lu CL, Wu HC, Hwang WS. Bcl-6 expression and lactate dehydrogenase level predict prognosis of primary gastric diffuse large B-cell lymphoma. J Formosan Med Assoc; 2013:112:382-9.

19. Falini B, Fizzotti M, Pucciarini A, Bigema B, Marafioti T, Gambacorta M, et al. A monoclonal antibody (MUM1p) detects expression of the MUM1/IRF4 protein in a subset of germinal center B cells, plasma cells and activated T cells. Blood. 2000;95:2084-92.

20. Tsuboi K, Iida S, Inagaki H, Kato M, Hayami Y, Hanamura I, et al. MUM1/IRF4 expression as a frequent event in mature lymphoid malignancies. Leukemia. 2000;14:449-56.

21. Natkuman Y, Warnke RA, Montgomery K, Falini B, Rijn M. Analysis of MUM1/IRF4 protein expression using tissue microarrays and imunohistochemistry. Mod Pathol. 2001;14:686-94.

22. Choi WW, Weisenburger DD, Greiner TC, Piris MA, Banham AH, Delabie J, et al. A new immunostain algorithm classifies diffuse large B-cell lymphoma into molecular subtypes with high accuracy. Clin Cancer Res. 2009;15:5494-5502.

23. Lossos IS, Debra K, Czerwinski BA, Alizadeh AA, Wechser MA, Tibshirari R, et al. Prediction of survival in diffuse large B-cell lymphoma based on the expression of six gene. N Engl J Med. 2000;350:1828-35. 24. Elmore S. Apoptosis: A review of programmed cell death. Toxical Pathol.

2007;35:495-512.

25. Kumar V, Abbas AK, Fausto N, Aster JC. Cellular responses to stress and toxic insults: adaptation, injury and death. In: Kumar V, Abbas AK, editors. Robbins and Cotran pathologic basis of diseases. 8^th ed. Philadelphia: Elsevier; 2010. p. 27-32.

26. Wong RS. Apoptosis in cancer: from pathogenesis to treatment. J Experim Clin Cancer Res. 2011;30:1-14.

27. MacFarlane M, Williams AC. Apoptosis and diseases: a life or death decision. EMBO reports. 2004;5:674-8.

28. Rield SJ, Shi Y. Molecular mechanisms of caspase regulation during apoptosis. Nature Rev Mol Cell Biol. 2004;5:897-906.

29. Lan Q, Morton LM, Amstrong B, Hartge P, Menashe I, Zheng T, et al. Genetic variation in caspase genes and risk of non-Hodgkin lymphoma: a

Universitas Indonesia pooled analysis of 3 population-based case-control studies. Blood. 2009;114:264-7.

30. Mitrovic Z, Ilic I, Aurer I, Kinda SB, Radman I, Dotlic S, et al. Prognostic significance of survivin and Caspase-3 immunohistochemical expression in patients with diffuse large B-cell lymphoma treated with rituximab and CHOP. Pathol Oncol Res. 2011;17:243-7.

31. Donoghue S, Baden HS, Lauder I. Immunohistochemical localization of Caspase-3 correlates with clinical outcome in B-cell diffuse large-cell lymphoma. Cancer Res. 1999;59:5386-91.

32. Soung YW, Lee JW, Kim SY, Park WS, Nam SW, Lee JY, et al. Somatic mutations of CASP3 gene in human cancers. Hum Genet. 2004;115:112-5. 33. Dahlan MS. Besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan. Edisi 3. Jakarta: Salemba Medika; 2013. p. 46. 34. Dahlan MS. Statistik untuk kedokteran dan kesehatan. Edisi 4. Jakarta:

Salemba Medika; 2009. p. 26-7.

35. Krajewski S, Gascoyne RD, Zapata JM, Krajewska M, Kitada S, Chhanabhai M, et al. Immunolocalization of the ICE/Ced-3-family protease, CPP32 (Caspase-3), in non-Hodgkin’s lymphomas, chronic lymphocytic leukemias, and reactive lymph nodes. Blood. 1997;89:3817-25.

36. Cillessen SA, Hess CJ, Hooijberg E, Castricum KC, Kortman P, Denkers F, et al. Inhibition of the intrinsic apoptosis pathway downstream of Caspase-9 activation causes chemotherapy resistance in diffuse large B-cell lymphoma. Clin Cancer Res. 2007;13:7012-21.

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32 Lampiran 1. Tabel induk

kasus no PA RS asal umur

jenis

kelamin lokasi gejala subtipe CD20 CD3 CD10 Bcl6 MUM1 CSP-3 NILAI(%)

1 1204824 RSCM 60 L axilla

tumor jaringan

lunak GCB + - + + + + 87

2 1207320 RSCM 41 L leher kiri sesak GCB + - + + + + 86

3 1207339 RSCM 50 P

intra

abdomen benjolan perut Non-GCB + - - + + - 1

4 1302618 RSCM 58 L orofaring benjolan faring Non-GCB + - - - + - 9

5 1302823 RSCM 43 L sinonasal benjolan Non-GCB + - - + + - 2

6 1305507 RSCM 52 L leher kanan benjolan multipel Non-GCB + - - - + - 8 7 1306267 RSCM 50 L tonsil kiri benjolan multipel Non-GCB + - - + + - 8

8 1306433 RSCM 45 L sinus maksila benjolan GCB + - + + - + 81

9 1307069 RSCM 60 L ketiak kanan benjolan Non-GCB + - - + + + 97

10 1307278 RSCM 51 P nasofaring benjolan Non-GCB + - - + + - 16

11 1307730 RSCM 47 L mata benjolan GCB + - - + - + 87

12 1307379 RSCM 51 P leher kanan benjolan Non-GCB + - - + + - 2

13 1307815 RSCM 65 P usus bab cair Non-GCB + - - - + + 65

14 1308125 RSCM 62 L tonsil benjolan Non-GCB + - - + + - 1

15 1308163 RSCM 48 P leher benjolan Non-GCB + - - + + - 6

16 1308338 RSCM 71 L sinonasal benjolan Non-GCB + - - - + + 83

17 1308373 RSCM 63 L mata kanan benjolan GCB + - + + - - 19

18 1309166 RSCM 44 L leher benjolan Non-GCB + - - + + + 91

19 1309382 RSCM 59 L lidah benjolan Non-GCB + - - - + - 11

20 1309872 RSCM 58 L usus benjolan Non-GCB + - - + + - 7

21 1400104 RSCM 81 L leher benjolan Non-GCB + - - + + - 27

22 1401076 RSCM 54 P leher kanan benjolan Non-GCB + - - + + - 5

23 1402583 RSCM 57 L tonsil benjolan GCB + - + + - + 79

24 1401016 RSCM 43 L leher benjolan Non-GCB + - - - + - 3

kasus no PA RS asal umur

jenis

kelamin lokasi gejala subtipe CD20 CD3 CD10 Bcl6 MUM1 CSP-3 NILAI(%)

26 1405223 RSCM 67 L leher benjolan GCB + - + + + + 100

27 1405705 RSCM 60 L usus benjolan GCB + - + + - + 93

28 141185 RS.CRLS 72 L leher benjolan GCB + - + + + + 100

29 131668 RS.CRLS 42 P pankreas benjolan GCB + - + + + + 96

30 132139 RS.CRLS 32 L abdomen benjolan Non-GCB + - - + + - 25

31 141308 RSFTM 33 L leher benjolan GCB + - + - - + 81

32 2130820 RSFTM 51 L ileum, sekum benjolan GCB + - + + - - 3

33 132819 RSFTM 57 L hipofaring benjolan Non-GCB + - - + + - 10

34 140318 RSPAD 40 L leher benjolan GCB + - + - - - 2

35 132761 RSPAD 57 L faring benjolan Non-GCB + - - + + + 99

36 132788 RSPAD 43 P tonsil benjolan GCB + - + + - + 100

37 5132325 RSPP 32 L abdomen benjolan Non-GCB + - - + + - 36

38 132063 RSPP 65 L leher kanan benjolan GCB + - + + + + 99

39 130533 SPC 70 L

inguinal

kanan benjolan GCB + - + - - - 12

40 14001040 RSI 29 P abdomen benjolan GCB + - + + - - 12

Universitas Indonesia Lampiran 2

Klasifikasi Limfoma Malignum menurut WHO tahun 2008 1. LIMFOMA non-HODGKIN

1.1 PRECURSOR LYMPHOID NEOPLASM B-Lymphoblastic leukaemia/ lymphoma T-lymphoblastic leukaemia/ lymphoma

1.2 MATURE B-CELL NEOPLASM

Chronic lymphocytic leukaemia/ small lymphocytic lymphoma B-cell prolymphocytic leukaemia

Splenic B-cell marginal zone lymphoma Hairy cell leukaemia

Splenic B-cll lymphoma/ leukaemia, unclassifiable Splenic diffuse red pulp small B-cell lymphoma Hairy cell leukaemia-variant

Lymphoplasmacytic lymphoma Waldenstrom macroglobulinemia Heavy chain disease

Alpha heavy chain disease Gamma heavy chain disease Mu heavy chain disease Plasma cell myeloma

Solitary plasmacytoma of bone Extraosseous plasmacytoma

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALTOMA)

Nodal marginal zone lymphoma Follicular lymphoma

Universitas Indonesia Mantle cell lymphoma

Diffuse large B-cell lymphoma (DLBCL), NOS DLBCL associated with chronic inflammation Lymphomatoid granulomatous

Primary mediastinal (thymic) large B-cell lymphoma Intravascular large B-cell lymphoma

ALK positive large B-cell lymphoma Plasmablastic lymphoma

Large B-cell lymphoma arising in HHV8-associated multicentric Castleman

disease

Primary effusion lymphoma Burkitt lymphoma

B-cell lymphoma, unclassifiable, with features intermediate between diffuse large-B-cell lymphoma and Burkitt lymphoma

B-cell lymphoma, unclassifiable, with features intermediate between diffuse large-B-cell lymphoma and classical Hodgkin lymphoma 1.3 MATURE T-CELL AND NK-CELL NEOPLASMS

T-cell prolymphocytic leukaemia

T-cell large granular lymphocytic leukaemia Chronic lymphoproliferative disorder of NK-cells Aggressive NK cell leukaemia

Systemic EBV positive T-cell lymphoproliferative disease of childhood Hydroa vacciniforme-like lymphoma

Adult T-cell leukaemia/ lymphoma

Extranodal NK/T cell lymphoma, nasal type Enteropathy-associated T-cell lymphoma Hepatosplenic T-cell lymphoma

Universitas Indonesia Mycosis fungoides

Sezary syndrome

Primary cutaneous CD30 positive T-cell lymphoproliferative disorders Lymphomatoid papulosis

Primary cutaenous anaplastic large cell lymphoma Primary cutaneous gamma-delta T-cell lymphoma

Primary cutaneous CD8 positive aggressive epidermotropic cytotoxic T-cell

lymphoma

Primary cutaneous CD4 positive small/ medium T-cell lymphoma Peripheral T-cell lymphoma, NOS

Angioimmunoblastic T-cell lymphoma

Anaplastic large cell lymphoma, ALK positive Anaplastic large cell lymphoma, ALK negative 2. LIMFOMA HODGKIN

Nodular lymphocyte predominant Hodgkin lymphoma Classical Hodgkin lymphoma :

Nodular sclerosis Mixed cellularity Lymphocyte-rich Lymphocyte-depleted

Universitas Indonesia Lampiran 3

Chi-Square Penilaian Imunoekspresi Caspase-3 pada DLBCL subtipe GCB dan non-GCB

Case Processing Summary

Cases

Valid Missing Total

N Percent N Percent N Percent

Subtipe DLBCL * penilaian

Caspase-3 ⁴¹ ^100.0% ⁰ ^.0% ⁴¹ ^100.0%

subtipe DLBCL * penilaian Caspase-3 Crosstabulation

penilaian Caspase-3 Total positif negatif Subtipe DLBCL GCB Count 13 5 18 Expected Count 7.9 10.1 18.0 non-GCB Count 5 18 23 Expected Count 10.1 12.9 23.0 Total Count 18 23 41 Expected Count 18.0 23.0 41.0 Chi-Square Tests Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square 10.449a 1 .001 Continuity Correction^b 8.500 1 .004 Likelihood Ratio 10.871 1 .001

Fisher's Exact Test .002 .002

Linear-by-Linear

Association ^10.194 ¹ ^.001

N of Valid Casesb 41

a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 7.90. b. Computed only for a 2x2 table

Universitas Indonesia Lampiran 4

Uji normalitas dan komparatif DLBCL subtipe GCB dan non-GCB

One-Sample Kolmogorov-Smirnov Test

Persentase Caspase-3

N 41

Normal Parametersa Mean 47.71

Std. Deviation 36.967

Most Extreme Differences Absolute .230

Positive .230

Negative -.166

Kolmogorov-Smirnov Z 1.474

Asymp. Sig. (2-tailed) .026

a. Test distribution is Normal.

Uji t tidak berpasangan

Group Statistics

Subtipe

DLBCL N Mean Std. Deviation Std. Error Mean

Persentase Caspase-3 GCB 18 66.94 33.864 7.982

non-GCB 23 32.65 32.539 6.785

Persentase Caspase-3

Universitas Indonesia Lampiran 5

Hubungan DLBCL subtipe GCB dan non-GCB dengan jenis kelamin

Case Processing Summary

Cases

Valid Missing Total

N Percent N Percent N Percent

Subtipe DLBCL * jenis

kelamin ⁴¹ ^100.0% ⁰ ^.0% ⁴¹ ^100.0%

subtipe DLBCL * jenis kelamin Crosstabulation

Jenis kelamin Total Laki-laki Lerempuan Subtipe DLBCL GCB Count 14 4 18 Expected Count 13.2 4.8 18.0 non-GCB Count 16 7 23 Expected Count 16.8 6.2 23.0 Total Count 30 11 41 Expected Count 30.0 11.0 41.0 Value Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square .347^a .556 Continuity Correctionb .055 .815 Likelihood Ratio .351 .554

Fisher's Exact Test .726 .411

Linear-by-Linear Association .338 .561

N of Valid Casesb 41

Universitas Indonesia Lampiran 6

Hubungan DLBCL subtipe GCB dan non-GCB dengan umur pasien

Case Processing Summary

Cases

Valid Missing Total

N Percent N Percent N Percent

Subtipe DLBCL * umur

=<50thn dan >50thn ⁴¹ ^100.0% ⁰ ^.0% ⁴¹ ^100.0%

subtipe DLBCL * umur =<50thn dan >50thn Crosstabulation

Umur =<50thn dan >50thn Total =<50thn >50thn Subtipe DLBCL GCB Count 8 10 18 Expected Count 7.5 10.5 18.0 non-GCB Count 9 14 23 Expected Count 9.5 13.5 23.0 Total Count 17 24 41 Expected Count 17.0 24.0 41.0 Chi-Square Tests Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square .117a 1 .732 Continuity Correction^b .001 1 .981 Likelihood Ratio .117 1 .732

Fisher's Exact Test .760 .490

Linear-by-Linear Association .115 1 .735

N of Valid Casesb 41

a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 7.46. b. Computed only for a 2x2 table

Universitas Indonesia Lampiran 7

Hubungan DLBCL subtipe GCB dan non-GCB dengan lokasi tumor

Descriptive Statistics

N Mean Std. Deviation Minimum Maximum

Lokasi tumor 41 2.10 1.411 1 5 subtipe DLBCL 41 1.56 .502 1 2 Frequencies Subtipe DLBCL N Lokasi tumor GCB 18 non-GCB 23 Total 41 Test Statistics^a lokasi tumor

Most Extreme Differences Absolute .152

Positive .152

Negative -.027

Kolmogorov-Smirnov Z .484

Asymp. Sig. (2-tailed) .973

Universitas Indonesia Lampiran 8

Perhitungan pulasan Caspase-3 subtipe GCB dan non-GCB menggunakan Image J

A. DLBCL subtipe GCB, B. DLBCL subtipe non-GCB

positif : warna merah, negatif : warna biru A

Universitas Indonesia BIODATA

Nama : Rosita Alfi Syahrin Tempat/Tgl. lahir : Jakarta, 7 Februari 1980 Jenis Kelamin : Perempuan

Nomor Mahasiswa : 1006768465

Program Studi : Spesialis I Patologi Anatomik Tanggal Lulus : 18 Desember 2014

Alamat : Jl. Percetakan Negara II no.3, Jakarta Pusat Telpon/HP : - / HP 081289616109

Alamat Email : [email protected]

Judul Tugas Ahir : Perbedaan Imunoekspresi Caspase-3 antara Diffuse Large B-Cell Lymphoma Subtipe Germinal Center B-Cell Like dan Non-Germinal Center B-Cell Like

Riwayat Pendidikan

SD : di SD 07 Jakarta Tahun Lulus : 1992 SMP : di SMPN 76 Jakarta Tahun Lulus : 1995 SMA : di SMUN 68 Jakarta Tahun Lulus : 1998 PT(S1) : di Universitas Sumatera Utara Tahun Lulus : 2006

Tempat WKS/Jabatan : RSUD Cendrawasih Kep. Aru, Maluku tahun 2007-2009

Nama Orang Tua : Ayah : Atom Kosasih Pekerjaan : Pensiun PNS Ibu : Murni Djambak Pekerjaan : Pensiun PNS Anak ke 1 dari 2 bersaudara

Nama Suami : Izghar Zaden

Dalam dokumen PERBEDAAN IMUNOEKSPRESI CASPASE-3 ANTARA DIFFUSE LARGE B-CELL LYMPHOMA SUBTIPE GERMINAL CENTER B-CELL-LIKE DAN NON-GERMINAL CENTER B-CELL-LIKE TESIS (Halaman 40-55)