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CD20 is expressed in most B‐cell lymphomas and is a critical molecular target of rituximab. Some  B ‐cell lymphomas show aberrant  CD 20 expression, and rituximab use in these patients is controversial. Here we show both the molecular mechanisms and the clinical significance of  de novo  diffuse large  B ‐cell lymphomas (DLBCL) that show a  CD 20 immunohistochemistry ( IHC )‐positive and flow cytometry ( FCM )‐ negative (IHC[+]/FCM[−]) phenotype. Both  IHC  and  FCM  using anti‐ CD 20 antibodies  L 26 and  B 1, respectively, were analyzed in 37 of the 106 cases of  de novo   DLBCL ; 8 (22%) of these cases were  CD 79a(+)/ CD 20(+) with  IHC  and  CD 19(+)/ CD 20(−) with  FCM .  CD20  ( MS4A1 )  mRNA  expression was significantly lower in  IHC (+)/ FCM (−) cells than in  IHC (+)/ FCM (+) cells (  P   = 0.0005). No genetic mutations were detected in  MS4A1  promoter and coding regions. Rituximab‐mediated cytotoxicity in the  CDC  assay using  IHC (+)/ FCM (−) primary cells was significantly lower than in  IHC (+)/ FCM (+) cells (  P   < 0.05); however, partial effectiveness was confirmed. FCM using rituximab detected  CD 20 more efficiently than  B 1. No significant difference was observed between  IHC (+)/ FCM (−) and  IHC (+)/ FCM (+) patients in overall survival (  P   = 0.664). Thus, lower expression of  CD20   mRNA  is critical for the  CD 20  IHC (+)/ FCM (−) phenotype. Lower  CD 20 expression with  FCM  does not rule out rituximab use in these patients if expression is confirmed with  IHC . FCM using rituximab may be more informative than  B 1 for predicting rituximab effectiveness in  IHC (+)/ FCM (−) cases.

cancer science

De novo  diffuse large  B ‐cell lymphoma with a  CD 20 immunohistochemistry‐positive and flow cytometry‐negative phenotype: Molecular mechanisms and correlation with rituximab sensitivity