# Toll-like receptor 9 (TLR9) expression correlates with cell of origin and predicts clinical outcome in diffuse large B-cell lymphoma

## TL;DR

This study shows that TLR9 expression is linked to a more aggressive type of lymphoma and worse outcomes, suggesting it could help guide treatment decisions.

## Contribution

TLR9 is identified as a novel prognostic marker in diffuse large B-cell lymphoma, independent of existing classifications.

## Key findings

- TLR9 gene and protein expression are higher in ABC DLBCL compared to GCB DLBCL.
- High TLR9 protein expression correlates with poor clinical outcomes in DLBCL patients.
- Inhibiting TLR9 activity reduced growth in ABC DLBCL cell lines.

## Abstract

Biological insights beyond the cell-of-origin (COO) classification can support clinical management in diffuse large B-cell lymphoma (DLBCL). We investigated if Toll-like receptor 9 (TLR9) expression could serve as a prognostic marker in DLBCL.

TLR9 gene expression was analysed in four publicly available cohorts (n = 2474), and protein expression was investigated in germinal centre B-cell (GCB) and activated B-cell (ABC) DLBCL cell lines. Next, TLR9 protein expression was analysed in 120 diagnostic samples from R-CHOP-treated patients with relapsed/refractory disease (poor outcome, n = 50) or in complete remission (good outcome, n = 70). Associations were evaluated using logistic regression, estimating odds ratios (OR) and 95% confidence intervals (CI).

TLR9 gene expression was higher in ABC DLBCL compared to GCB DLBCL in external cohorts, and similar results were obtained for protein expression in cell lines. In patient samples, high TLR9 protein expression correlated with non-GCB type (p = 0.003) and poor outcome (p = 0.0016). High TLR9 expression remained associated with poor outcome in multivariable analysis after adjusting for COO and other clinical features (OR = 3.36, 95% CI 1.41–8.04). In exploratory analyses, a decrease of cell growth in ABC cell lines following inhibition of TLR9 activity with ODN4084-F was suggested.

We conclude that TLR9 correlates with ABC/non-GCB phenotype and is a potential predictor of poor prognosis in DLBCL.

The online version contains supplementary material available at 10.1186/s12885-025-14359-7.