The scale of the problem that motivated the study is considerable. According to the 2022 GLOBOCAN report, non-Hodgkin lymphoma ranks as the tenth most common cancer worldwide and the eleventh leading cause of cancer death, striking males more often than females. But the geographic distribution of the pediatric burden is strikingly skewed: roughly 84 percent of cases in children under 16 occur in Latin America, Africa, Asia, the Caribbean, and Polynesia, and an estimated 80 percent of children who develop these tumors live in developing countries. In Ghana specifically, non-Hodgkin lymphoma is the third leading cause of childhood cancer death and accounts for about 7 percent of childhood neoplasms. A three-year review at Korle Bu Teaching Hospital found that lymphomas made up over 60 percent of childhood malignancies, with Burkitt lymphoma the most common type.

Diagnosing and classifying these tumors accurately is far harder than it might seem. The World Health Organization recognizes more than 50 subtypes of non-Hodgkin lymphoma, distinguished by clinical presentation, tumor cell morphology, antigenic marker expression, and genetic features. Morphology alone—the appearance of cells under a microscope after standard hematoxylin and eosin staining—is often insufficient, because many subtypes closely resemble one another. The WHO explicitly warns that morphological assessment by itself risks discordant reports even among experienced pathologists, complicating the identification of rare and heterogeneous cases and hindering the planning of targeted therapy. In well-resourced health systems, immunophenotypic testing, cytogenetics, and molecular assays are routinely folded into the diagnostic workup, and there is solid evidence that this integration improves clinical outcomes and overall survival. In Ghana and much of Africa, however, treatment typically proceeds on the basis of clinical and histological information alone, because laboratories lack equipment, reagents are costly, and trained personnel are scarce.

The consequence, the researchers note, is that many children may be treated without a definitive pathological diagnosis—either undertreated, or given unnecessarily high doses of chemotherapy that are toxic and harmful. Against this backdrop, the team set out to evaluate the immunophenotypic characteristics of three non-Hodgkin lymphoma subtypes and the survival outcomes of the children bearing them, using three markers with distinct biological roles: CD3, which broadly marks T lymphocytes and helps establish tumor cell lineage; CD25, the interleukin-2 receptor alpha chain, which reflects host immune response within the tumor microenvironment; and BCL-2, a protein that blocks programmed cell death and is associated with resistance to apoptosis and chemotherapy.

The methodology was meticulous given the constraints. The team retrieved formalin-fixed, paraffin-embedded tissue blocks from the hospital’s pathology archives, identifying 133 cases of children under 18 who were clinically diagnosed with non-Hodgkin lymphoma between 2018 and 2022. Children with incomplete data, inadequate tissue, or HIV co-infection were excluded. Thin sections cut from each block were stained with hematoxylin and eosin, and two independent pathologists at the Kwame Nkrumah University of Science and Technology reviewed every slide while blinded to previous reports; any disagreement was adjudicated by a third pathologist. Of the initial 133 cases, 38 were confirmed as showing the histomorphological features of non-Hodgkin lymphoma—diffuse effacement of normal nodal architecture, atypical lymphoid proliferation, increased mitotic activity, and loss of normal germinal center structures—and were suitable for immunohistochemistry.

For the immunohistochemical analysis, serial sections underwent heat-induced epitope retrieval in citrate buffer, blocking of endogenous peroxidase and non-specific protein binding, and staining with mouse monoclonal antibodies against CD3, CD25, and BCL-2. Signal was detected with an enzyme-conjugated secondary antibody and a chromogenic substrate, producing brown staining visible under a light microscope. Known positive control tissues—tonsil for CD3 and reactive lymph node for BCL-2 and CD25—accompanied each staining batch, while negative controls omitted the primary antibody. Two pathologists independently scored both staining intensity, on a scale from zero to strong, and the proportion of tumor cells stained, from under 20 percent to over 80 percent, with a third pathologist resolving discrepancies. Combined scores ranked each case as showing no, low, moderate, or high expression.

The results revealed a distinctly heterogeneous immunophenotypic landscape. BCL-2 was the most frequently expressed marker, present in 55.3 percent of cases, followed by CD3 in 36.8 percent, while CD25 was expressed in only 5.3 percent of patients. Co-expression occurred at varying levels, with 28.9 percent of cases expressing both BCL-2 and CD3, and 5.3 percent expressing all three markers simultaneously. Stratifying expression by clinical aggressiveness added nuance: BCL-2 showed high expression in 76.9 percent of low-grade cases, moderate expression in half of high-grade cases, and low expression in 36.4 percent of Burkitt lymphomas. Notably, although Burkitt lymphoma is classically characterized by absent or low BCL-2 expression, a substantial subset of the Burkitt cases in this cohort were positive—consistent with emerging evidence from other studies, including reports of BCL-2 positivity in roughly 23 percent of Burkitt lymphoma cases in European and adult series, which challenges the diagnostic utility of this marker and underscores the biological heterogeneity of these tumors.

The survival data were sobering. Of the 38 participants, 21 had complete follow-up data for survival analysis. Median overall survival from diagnosis was 22 months, with survival rates of 76 percent at 10 months, 61 percent at 20 months, 40 percent at 30 months, and 20 percent at 40 months—a steep and steady decline. The clinical outcomes were equally stark: 30.6 percent of patients died while on admission for chemotherapy, 27.8 percent abandoned treatment, 2.8 percent died shortly after discharge, and only 38.8 percent survived and were discharged. When the researchers used log-rank tests to identify factors associated with survival, age, gender, duration of symptoms, CD3 expression, CD25 expression, and clinical aggressiveness showed no significant association. But BCL-2 expression was significantly linked to inferior survival (p = 0.030)—patients expressing the marker had a median survival of 12 months versus 30 months for those who did not—and nodal or extranodal involvement was even more strongly associated (p < 0.001). This aligns with the biology: BCL-2 proteins downregulate apoptosis and promote chemoresistance, while spread to multiple nodal and extranodal sites signals advanced, aggressive disease, a principle embedded in the staging systems used for pediatric lymphoma.

The study’s limitations temper its conclusions, and the authors are candid about them. Poor archiving systems meant many tissue blocks could not be retrieved, shrinking the sample and limiting statistical power—the cohort was underpowered for multivariable Cox proportional hazards modeling, so survival findings warrant caution. The retrospective design prevented standardization of chemotherapy and clinical care, and survivors were not followed long-term. Because no B-cell lineage markers such as CD20, MYC, CD10, BCL6, or Ki-67 were included, the lineage of CD3-negative tumors could not be definitively determined, and CD3 positivity alone cannot distinguish neoplastic T cells from background reactive infiltrates—meaning the apparent proportion of T-cell lymphomas should be interpreted cautiously, even though it was higher than previously reported in Ghana. Cases were also grouped by clinical aggressiveness rather than formal WHO classification. Yet the core message stands: in a setting where most children present with advanced disease, treatment abandonment is common, and advanced immunophenotypic stratification is unavailable, simple and affordable biomarker panels like the one tested here could offer a practical first step toward effective patient stratification and, ultimately, better survival outcomes for children with non-Hodgkin lymphoma in Ghana and similar resource-limited settings.

Subject of Research: Immunophenotypic biomarker expression and survival outcomes in childhood non-Hodgkin lymphoma in Ghana

Article Title: Assessment of Selected Immunophenotypic Markers in Childhood Non‐Hodgkin's Lymphomas in Ghana: A Possible Tool for Effective Stratification of Patients and Assessment of Survival Outcomes

Article References: Assessment of Selected Immunophenotypic Markers in Childhood Non‐Hodgkin's Lymphomas in Ghana: A Possible Tool for Effective Stratification of Patients and Assessment of Survival Outcomes. (n.d.). https://doi.org/10.1002/cnr2.70711

Image Credits: AI Generated

DOI: 10.1002/cnr2.70711

Keywords: non-Hodgkin lymphoma, pediatric oncology, Ghana, BCL-2, CD3, CD25, immunohistochemistry, survival analysis, Burkitt lymphoma, resource-limited settings, biomarkers, treatment abandonment