Aggressive B-cell Lymphoma Research Articles

Mutational, immune microenvironment, and clinicopathological profiles of diffuse large B-cell lymphoma and follicular lymphoma with BCL6 rearrangement.

BCL6-rearrangement (BCL6-R) is associated with a favorable prognosis of follicular lymphoma (FL), but the mechanism is unknown. We analyzed the clinicopathological, immune microenvironment (immune checkpoint, immuno-oncology markers), and mutational profiles of 10 BCL6-R-positive FL, and 19 BCL6-R-positive diffuse large B-cell lymphoma (DLBCL) cases (both BCL2-R and MYC-R negative). A custom-made panel included 168 genes related to aggressive B-cell lymphomas and FL. FL cases were nodal, histological grade 3A in 70%, low Ki67; and had a favorable overall and progression-free survival. DLBCL cases were extranodal in 60%, IPI high in 63%, non-GCB in 60%, EBER-negative; and had a progression-free survival comparable to that of DLBCL NOS. The microenvironment had variable infiltration of M2-like tumor-associated macrophages (TAMs) that were CD163, CSF1R, LAIR1, PD-L1, and CD85A (LILRB3) positive; but had low IL10 and PTX3 expression. In comparison to FL, DLBCL had higher TAMs, IL10, and PTX3 expression. Both lymphoma subtypes shared a common mutational profile with mutations in relevant pathogenic genes such as KMT2D, OSBPL10, CREBBP, and HLA-B (related to chromatin remodeling, metabolism, epigenetic modification, and antigen presentation). FL cases were characterized by a higher frequency of mutations of ARID1B, ATM, CD36, RHOA, PLOD2, and PRPRD (p < 0.05). DLBCL cases were characterized by mutations of BTG2, and PIM1; and mutations of HIST1H1E and MFHAS1 to disease progression (p < 0.05). Interestingly, mutations of genes usually associated with poor prognosis, such as NOTCH1/2 and CDKN2A, were infrequent in both lymphoma subtypes. Some high-confidence variant calls were likely oncogenic, loss-of-function. MYD88 L265P gain-of-function was found in 32% of DLBCL. In conclusion, both BCL6-R-positive FL and BCL6-R-positive DLBCL had a common mutational profile; but also, differences. DLBCL cases had a higher density of microenvironment markers.

Transformation risk and associated survival outcome of marginal zone lymphoma: A nationwide study.

Histological transformation into an aggressive B-cell lymphoma indicates a poor survival outcome for patients with indolent marginal zone lymphoma (MZL), which has been less studied. Large-scale data with long-term follow-up to investigate MZL transformation is limited. Here, by reporting a US-Nationwide cohort of 30,619 MZL patients diagnosed between 2000 and 2019, we found that transformation occurred in 2.08% (N = 624) of MZL cases, with the transformation incidence of 3.1 per 1,000 person-years. Advanced Ann Arbor stage, nodal MZL (NMZL) and splenic MZL (SMZL) were associated with an elevated risk of transformation. Certain subtype-specific characteristics, such as non-gastric extra-nodal MZL (vs. gastric, HR, 1.51, 95%CI 1.13-2.04; p = 0.006), and receiving splenectomy for SMZL (HR, 2.04, 95%CI 1.28-3.26; p = 0.003), also indicated a higher risk of transformation. Besides, transformation independently increased the overall mortality risk (HR, 1.38, 95%CI 1.24-1.53, p < 0.001), especially the higher lymphoma-caused mortality risk (HR, 3.21, 95%CI 2.81-3.67, p < 0.001). Transformation was also associated with a higher percentage of lymphoma-caused deaths. The post-transformation prognostic analyses demonstrated that female gender and age ≥ 65 years independently affected patients' mortalities. These findings, based on the largest cohort to date, contribute to a better understanding of transformed MZL, and provide valuable reference points for guidelines and patient counseling.

Abstract P35: High-grade B-cell lymphomas with 11q aberrations show a dark zone expression profile similar to Burkitt lymphoma but with additional extension towards intermediate germinal center B-cells

Abstract P35: High-grade B-cell lymphomas with 11q aberrations show a dark zone expression profile similar to Burkitt lymphoma but with additional extension towards intermediate germinal center B-cells

Treatment of Diffuse Large B-Cell Lymphoma at the Moscow City Clinical Hospital No. 52: A Retrospective Clinical Trial Based on the Single-Center Experience and Analysis of Data from Its In-House Registry

Background. The term diffuse large B-cell lymphoma (DLBCL) defines a heterogeneous group of lymphatic tumors. DLBCL is the most frequent immunomorphological variant among aggressive non-Hodgkin lymphomas (NHLs) in adults. It accounts for 30–40 % of all NHLs. Long-term results of treating newly diagnosed DLBCL have not been reliably evidenced in healthcare practice and, therefore, require further study.&#x0D; Aim. To assess the efficacy of chemotherapy for newly diagnosed DLBCL in terms of the 5-year progression-free survival (PFS) based on the analysis of data from the in-house hematology service registry at the Moscow City Clinical Hospital No. 52.&#x0D; Materials &amp; Methods. The study enrolled 156 patients with newly diagnosed DLBCL in the period from 2015 to 2022. The patients were 35–85 years of age (median 65 years).&#x0D; Results. First-line R-CHOP/R-miniCHOP chemotherapy was administered to 70 % of patients, 28 % of patients received R-DA-EPOCH, and 2 % were treated either with R-B or R-CVP. Complete response was achieved in 100 (65 %) patients: 75 out of them (75 %) received R-CHOP/R-miniCHOP, whereas 25 (25 %) received R-DA-EPOCH. Induction mortality was below 2.5 %. The 5-year PFS was 32 % with the survival median of 20 months. As confirmed by the multivariate analysis, the age over 60 years (p = 0.003), high IPI risk group (p = 0.015), advanced stage of the disease (p = 0.002), and non-GCB subtype of tumor (p = 0.045) can be regarded as independent predictors of early DLBCL progression.&#x0D; Conclusion. DLBCL is an aggressive B-cell lymphoma and one of the most frequent immunomorphological NHL variants in the clinical practice of the Moscow City Clinical Hospital No. 52. Despite the use of generally accepted standard immunochemotherapy regimens, the results attained by the present study illustrate unresolved challenges in chemotherapy for newly diagnosed DLBCL patients. By now, more effective first-line DLBCL therapy methods already exist, which are confirmed by the results of clinical trials. As it is sometimes impossible to further escalate immunochemotherapy for obvious reasons (age restrictions, health status, co-morbidities, etc.), a new promising strategy appears to be the personalized chemotherapy based on the study of genetic DLBCL profile of each particular patient.

Comparison of genomic alterations in Epstein-Barr virus-positive and Epstein-Barr virus-negative diffuse large B-cell lymphoma.

Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (EBV-posDLBCL) is an aggressive B-cell lymphoma that often presents similar morphological and immune phenotype features to that of EBV-negative DLBCL (EBV-negDLBCL). To better understand their difference in genomic landscape, we performed whole-exome sequencing (WES) of EBV-posDLBCL and EBV-negDLBCL. This analysis revealed a new mutational signature 17 (unknown) and signature 29 (smoking) in EBV-posDLBCL as well as a specific mutational signature 24 (associated with aflatoxin) in EBV-negDLBCL. Compared with EBV-negDLBCL, more somatic copy number alterations (CNAs) and deletions were detected in EBV-posDLBCL (p = 0.01). The most frequent CNAs specifically detected in EBV-posDLBCL were gains at 9p24.1 (PDL1 and JAK2), 8q22.2-q24.23 (DEPTOR and MYC), and 7q31.31-q32.2 (MET), which were validated in additional EBV-posDLBCL cases. Overall, 53.7% (22/41) and 62.9% (22/35) of the cases expressed PD-L1 and c-MET, respectively, in neoplastic cells, whereas only 15.4% (4/26) expressed c-MYC. Neoplastic c-MET expression was positively correlated with PD-L1 (p < 0.001) and MYC expression (p = 0.016). However, EBV-posDLBCL cases did not show any differences in overall survival between PD-L1-, c-MET-, or c-MYC-positive and -negative cases or between age-related groups. Analysis of the association between somatic mutation load and EBV status showed no difference in the distribution of tumor mutant burden between the two lymphomas (p = 0.41). Recurrent mutations in EBV-posDLBCL implicated several genes, including DCAF8L1, KLF2, and NOL9, while in EBV-negDLBCL, ANK2, BPTF, and CNIH3 were more frequently mutated. Additionally, PIM1 is the most altered gene in all the WES-detected cases. Our results confirm that genomic alteration differs significantly between EBV-posDLBCL and EBV-negDLBCL, and reveal new genetic alterations in EBV-posDLBCL. The positive correlation of c-MET and PD-L1/c-Myc expression may be involved in the pathogenesis of EBV-posDLBCL, which is should be explored prospectively in trials involving MET-directed therapies.

MALT Lymphoma in Histologic Transformation: FDG-Avid but Pentixafor-Negative.

An 81-year-old woman experienced compression symptoms due to diffuse enlargement of the thyroid gland. The cytopathological results of thyroid fine-needle suggested malignancy. Therefore, she underwent bilateral thyroidectomy. Postoperative pathology indicated mucosa-associated lymphoid tissue (MALT) lymphoma. Three months later, she found a progressively enlarged mass in her neck. The biopsy showed MALT lymphoma with highly aggressive B-cell lymphoma transformation. 18F-FDG PET/CT showed increased metabolism in multiple lymph nodes. However, some of these lymph nodes were negative in 68Ga-pentxafor PET/CT. Our case demonstrated that 68Ga-pentixafor may have limited value in evaluating MALT lymphoma transformation.

Progress in treatment of primary mediastinal large B-cell lymphoma

Primary mediastinal large B-cell lymphoma (PMBCL) is an aggressive B-cell lymphoma originating from the thymus, which has different clinical and biological characteristics from diffuse large B-cell lymphoma, NOS. PMBCL tends to occur in young women, usually presenting as a large anterior mediastinal mass. Most patients are in stage Ⅰ-Ⅱ at the time of presentation. There is no standard prognostic scoring system for PMBCL. Immunochemotherapy is commonly used in the treatment of PMBCL, but the optimal first-line treatment has not been determined, and the status of radiotherapy is controversial. The value of PET-CT guided therapy needs to be further verified. Relapsed/refractory PMBCL has a poor prognosis, while novel therapies such as PD-1 inhibitors, brentuximab vedotin, and CAR-T can help improve survival in these patients.

Hypofractionated radiotherapy for refractory or relapsed aggressive B-cell lymphoma in the rituximab era

BackgroundRadiotherapy (RT) is an effective and available local treatment for patients with refractory or relapsed (R/R) aggressive B-cell lymphomas. However, the value of hypofractionated RT in this setting has not been confirmed.MethodsWe retrospectively analyzed patients with R/R aggressive B-cell lymphoma who received hypofractionated RT between January 2020 and August 2022 at a single institution. The objective response rate (ORR), overall survival (OS), progression-free survival (PFS) and acute side effects were analyzed.ResultsA total of 30 patients were included. The median dose for residual disease was 36 Gy, at a dose per fraction of 2.3–5 Gy. After RT, the ORR and complete response (CR) rates were 90% and 80%, respectively. With a median follow-up of 10 months (range, 2–27 months), 10 patients (33.3%) experienced disease progression and three died. The 1-year OS and PFS rates for all patients were 81.8% and 66.3%, respectively. The majority (8/10) of post-RT progressions involved out-of-field relapses. Patients with relapsed diseases, no response to systemic therapy, multiple lesions at the time of RT, and no response to RT were associated with out-of-field relapses. PFS was associated with response to RT (P = 0.001) and numbers of residual sites (P < 0.001). No serious non-hematological adverse effects (≥ grade 3) associated with RT were reported.ConclusionThese data suggest that hypofractionated RT was effective and tolerable for patients with R/R aggressive B-cell lymphoma, especially for those that exhibited localized residual disease.

Parotid Burkitt Lymphoma: Case Report

Salivary gland tumors are rare counting only 0.5% of all cancers, only 2% among them are lymphomas. Burkitt lymphomas is an aggressive mature non-Hodgkin B-cell lymphoma characterized by MYC oncogene activation, commonly occurring in nodal sites, however the extranodal sites are mostly seen in immunodeficiency associated Burkitt lymphoma as it is seen in patients with HIV infection. Clinically, the symptoms are related to the acute enlargement of gland due to the fast growing of the tumor and its rapid cells turnover. Diagnostic assessment requires biological investigations as well as cytological, histological and immunohistochemical exams to put out the diagnosis of Burkitt lymphoma. However, imaging is paramount by CT and MRI which finds its interest in its sensibility to characterize salivary gland tumors by the diffusion sequence and the estimation of apparent coefficient of diffusion. That being said, the diagnosis of parotid gland lymphoma is a differential diagnosis of parotid tumor because of its rarity. Our case is about a middle-aged woman suffering from a unilateral parotid swelling, its uncommon evolution pushed the investigations which leads to discovering a HIV infection, a diagnose the patient with a HIV-associated Burkitt lymphoma. We put the light on salivary gland location of this cancer by screening literature on this subject which benefitted from important advances of treatments, offering good outcomes in terms of freedom of event and overall survival.

Epidemiologic Characteristics, Treatment Patterns, and Survival Analysis of Plasmablastic Lymphoma in the United States: A SEER and NCDB Analysis

BackgroundPlasmablastic Lymphoma (PBL) is a rare aggressive B-cell lymphoma that primarily affects immunocompromised individuals, including those living with HIV. Historically, survival estimates are dismal and range from 8 to 15 months. We aimed to evaluate epidemiologic characteristics, treatment patterns and survival trends on a national scale. Patients and MethodsPatients diagnosed with PBL from 2010 to 2020 were identified in the National Cancer Database (NCDB) and in the Surveillance, Epidemiology, and End Results (SEER) program. Incidence rates were calculated using SEER. Demographic features, treatment characteristics, and overall survival (OS) were identified using the NCDB. ResultsWe identified 1153 patients in the SEER database and 1822 patients in the NCDB. The incidence of PBL is 0.07 cases per 100,000 US population per year. PBL is more common in males (77%), and white patients (77%), with 50% of cases in patients with HIV. Patients who were treated with multiagent chemotherapy had a median OS of 58.6 months. On multivariate Cox regression, we found that HIV status did not have a significant impact on OS. Factors associated with worse OS included advancing age and stage. ConclusionWe present the largest study to date on PBL. Among treated patients, we described a median OS of 58.6 months, greatly improved from previously reported estimates. We found that HIV status did not have a significant impact on OS. While OS remains poor, therapeutic advances over the last decade are promising and highlight the need for continued clinical advances aimed at improving therapeutic options for this rare lymphoma.

Clinicopathological and genetic landscape of plasmablastic lymphoma in Taiwan

Plasmablastic lymphoma (PBL) is an aggressive large B-cell lymphoma with a terminal B-cell differentiation phenotype and is frequently associated with immunodeficiency. We aimed to investigate the clinicopathological and immunophenotypic features, genetic alterations, and mutational landscape of PBL in Taiwan. We retrospectively recruited 26 cases. Five (5/18; 28%) patients were HIV-positive and 21 (81%) presented extranodally. There were two morphological groups: one with purely monomorphic large cells (85%) and the other comprising large cells admixed with plasmacytic cells (15%). Phenotypically, the tumors expressed MYC (8/10; 80%), CD138 (20/26; 77%), and MUM1 (20/20; 100%), but not CD20 (n = 26; 0%). Fourteen (54%) cases were positive for EBV by in situ hybridization; the EBV-positive cases were more frequently HIV infected (p = 0.036), with extranodal presentation (p = 0.012) and CD79a expression (p = 0.012), but less frequent light chain restriction (p = 0.029). Using fluorescence in situ hybridization, we identified 13q14 deletion, MYC rearrangement, and CCND1 rearrangement in 74%, 30%, and 5% cases, respectively, without any cases having rearranged BCL6 or IGH::FGFR3 fusion. In the 15 cases with adequate tissue for whole exome sequencing, the most frequent recurrent mutations were STAT3 (40%), NRAS (27%), and KRAS (20%). In conclusion, most PBL cases in Taiwan were HIV-unrelated. Around half of the cases were positive for EBV, with distinct clinicopathological features. Deletion of chromosome 13q14 was frequent. The PBL cases in Taiwan showed recurrent mutations involving JAK-STAT, RAS-MAPK, epigenetic regulation, and NOTCH signaling pathways, findings similar to that from the West.

An extranodal Richter’s syndrome presenting with cardiac diffuse large B-cell lymphoma: a case report

BackgroundRichter’s syndrome (RS) defines the transformation of chronic lymphocytic leukemia into high-grade lymphoma, which usually involves lymph nodes and bone marrow. Extranodal involvement of the heart is an extremely rare condition. Patients with heart involvement tended to have a low response to chemotherapy and relative poor prognosis. The transformation process of RS is often insidious and nonspecific making it challenging to diagnose.Case presentationA 64-year-old woman wih a history of chronic lymphocytic leukemia (CLL) presented with intermittent chest pain and was diagnosed with non-ST-elevation myocardial infarction (NSTEMI). However, the contrast enhanced echocardiography revealed a large irregular mass, measuring about 75.4 mm × 37.5 mm, located on the lateral and posterior wall of the right ventricle. Biopsy of the cardiac mass and the results revealed diffuse large B-cell lymphoma.ConclusionsWe present a case of a 64-year-old woman with aggressive diffuse large B-cell lymphoma involving the heart. This case could provide some insights in the diagnosis of cardiac lymphoma.

Intravascular Lymphoma-Associated Stroke: A Systematic Review of Case Studies.

Intravascular lymphoma (IVL) is an aggressive systemic large B-cell lymphoma that is a rare cause of stroke. The clinical characteristics of stroke associated with IVL remain underexplored, contributing to diagnostic complexities and a high mortality rate. This study endeavors to elucidate the salient clinical and investigative features of stroke linked to this condition. A systematic review was performed using the PubMed database from the incident to August 2023 including search categories for IVL and stroke. All studies, excluding review articles, were included in this study. There were 58 cases with a confirmed diagnosis of IVL associated with stroke, with a mean age of 62.9 ± 9.6 years (female 50%). Classical lateralizing stroke symptoms were noted in only 69% of cases. Other clinical syndromes included altered sensorium (31%), rapidly progressive cognitive impairment (23%), seizures (22%), and gait disturbances (19%). Common hematological abnormalities included elevated lactate dehydrogenase (LDH, 97%), erythrocyte sedimentation rate (ESR, 79%), C-reactive protein (CRP, 61%), interleukin-2, microglobulins, and cerebrospinal fluid (CSF) protein. CSF flow cytometry was not diagnostic, and cytology was mostly negative. The dynamic pattern for DWI/T2 lesions was predominant and primarily located in the subcortical regions. Diffuse background slowing (64%) was a major finding in the electroencephalogram. Seventy-one percent of cases died (n=45) mostly due to delayed diagnosis. Only 31% were treated with first-line R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, prednisone) chemotherapy, among whom 25% died. This study suggests that IVL-associated strokes carry a high mortality rate, largely due to challenges in timely diagnosis and therapy. Unlike classical stroke syndrome, key indicators to aid in early diagnosis include a clinical syndrome of multiple non-lateralizing neurological symptoms, dynamic MRI DWI/T2-lesions primarily located in subcortical regions, elevated serum LDH, ESR, CRP, interleukins, microglobulin, CSF protein, and CSF polymerase chain reaction analysis, apart from tissue examination. Larger studies should be performed to establish diagnostic and predictive scores.

The Immune Checkpoint Siglec-15 in Promoting Immune Dysregulation in Non-Hodgkin's Lymphomas

Outcomes for patients with relapsed or refractory (r/r) hematologic malignancies remain dismal despite therapeutic advances over the last several years. This is particularly striking in patients with r/r aggressive mature B-cell lymphomas such as Diffuse Large B-cell Lymphoma (DLBCL) and Burkitt's Lymphoma (BL). With use of intensive multiagent chemo-immunotherapy, DLBCL, which accounts for approximately 10-20% of pediatric Non-Hodgkin's Lymphoma (NHL) cases and is the most common subtype in adults, is highly curable with 5-year event free survival &amp;gt;75%. However, approximately 30-40% of adults diagnosed with DLBCL will become refractory to or relapse after first-line treatment. Yet even with intensive salvage regimens, r/r DLBCL remains a clinical challenge. There remains an unmet need to identify specific defects in the immune response, among other pathways, that drive lymphomagenesis that will in turn inform the development of novel therapeutics to improve survival in this population of patients. Siglec-15 (Sig-15), a member of the sialic acid binding immunoglobulin-like lectin family of proteins, has recently been identified as a critical immune suppressor that is highly expressed in human cancers and intra-tumoral myeloid cells. Importantly, recent reports have demonstrated inhibition of Sig-15, has a restorative effect on local anti-tumor immune responses and abrogated tumor progression. While reported in solid malignancies and acute leukemias, a role for Siglec-15 in promoting disease progression in aggressive B-cell lymphomas has not yet been described. We have found higher expression of SIGLEC15 in DLBCL cell lines compared to normal B cells at the RNA level, through analyses of the publicly available ONCOMINE database. This was confirmed at the protein level by western blot demonstrating higher Sig-15 expression in various lymphoma cell lines (RAJI, SUDHL6, OCI-LY10, HBL-1) compared to healthy donor PBMCs. Further, immunohistochemistry evaluating Sig-15 expression was performed on a tumor microarray consisting of 139 cases of DLBCL from adult patients along with validation samples from 15 primary pediatric lymphoma cases (DLBCL, BL and Anaplastic Large Cell Lymphoma (ALCL)). Sig-15 was found to be highly expressed, with histologic scores ranging from weak (1+) to strong (3+) in 124 out of the 139 adult cases (Figure 1A) and in all pediatric lymphoma samples but with distinct staining patterns observed in the aggressive B-cell lymphomas. Specifically, Sig-15 appears to be highly expressed and associated with the cell membrane in most DLBCL and Burkitt's lymphoma. Expression is more variable in ALCL, primarily elevated in the cytoplasm at low levels and/or in macrophages (Figure 1A). There is heterogeneity in Sig-15 expression with preliminary analysis of RNA-seq data from a cohort of 693 DLBCL patient samples demonstrates higher levels in the germinal center B-cell (GCB) versus activated B-cell molecular (ABC) subtype of DLBCL when compared to healthy controls (Kruskal-Wallis, *p = 0.041). Finally, using a well-established murine lymphoma model, A20 cells were stably transduced with control, non-silencing shRNA (shNS) or shRNA against Sig-15 and injected into un-irradiated immune competent (wild type, WT) or immune deficient ( Rag1 -/-) BALB/C mice and monitored for signs of lymphoma development. Knockdown of Sig-15 in A20 cells abrogates disease progression in WT but not immune deficient mice (Log-rank, **p &amp;lt;0.0001, n=10 mice/group), consistent with a role for Sig-15 in immune evasion in lymphoma (Figure 1B). Together, these data implicate Sig-15 as an immune checkpoint that may be inhibited therapeutically to promote an immune response to lymphoma cells.

Clinical Impact of Neoantigen Burden and HLA Loss in Aggressive B-Cell Lymphomas Treated with CD19 CAR T-Cell

INTRODUCTION: CD19-directed chimeric antigen receptor (CAR-19) T cells have revolutionized clinical outcomes in heavily pretreated patients with aggressive B-cell lymphoma. Notably, emerging evidence suggests that the efficacy of CAR-19 therapy extends beyond direct tumor killing and includes its ability to stimulate and guide the host immune system in the fight against tumor cells. To delve deeper into this crucial aspect, our study utilized whole-genome sequencing (WGS) data to explore the impact of neoantigen burden and HLA loss in patients with aggressive large B-cell lymphoma (rrLBCL) who received CAR-19 therapy (WGS; Jain et al. Blood 2022). METHODS: To characterize the importance of genomic immunogenicity in rrLBCL, we conducted a comprehensive analysis of 61 whole-genome sequencing (WGS) and 54 RNA sequencing samples from 54 rrLBCL patients who underwent CAR-19 therapy. Among these samples, 39 were collected at baseline and 15 at relapse, with samples from 7 patients obtained both before and after treatment. Our analytical workflow defined HLA class I mono- or biallelic loss by integrating copy number variants, structural variants, single nucleotide variants, and small insertion-deletion data with allele-specific HLA loss information obtained from LOHHLA software. pVACseq algorithm was used to predict the number of clonal neoantigens in each sample, along with the corresponding HLA allele presenting each of them. RESULTS: HLA class I loss was detected in 38.9% of the patients, with no impact on progression free survival (PFS). Interestingly 7 patients had biallelic loss of HLA-B, and all of them experienced progression within the first year (p=0.03). To expand our analysis, we explored B2M an essential component of HLA class I complexes. B2M was lost in 33.3% of the patients without showing any association with shorter PFS. However, restricting the analysis to patients with B2M biallelic loss (defined as presence of deletions of both alleles, or deletion and mutation with high impact in the structure and function of the B2M protein) 4/4 patients progressed. Overall, all 11 patients with genomic events leading to biallelic loss of HLA class I progressed (p=0.007). Notably, in one patient (CAR_39), biallelic inactivation of HLA class I was not detected at baseline but emerged with the dominant clone at disease progression. HLA class I biallelic loss was associated with genomic drivers previously identified in our study as significantly associated with CAR-19 failure: APOBEC (3/11) and SBS18 (oxygen radical stress; 2/11) mutational signatures, chromothripsis (4/11), RHOA deletions (6/11), and double minutes (4/11). Next, we analyzed the impact of the neoantigen burden corrected for their HLA affinity and allelic status on the outcome of CAR-19 treatment. Patients with high number of neoantigens had shorter PFS (p=0.0095) and were enriched for genomic drivers associated with poor response after CAR-19 (e.g., APOBEC and SBS18). Interestingly, the neoantigen burden had a bimodal distribution across patients that progressed with two distinct groups: one with high neoantigen burden, biallelic loss of HLA, and high genomic complexity and the other with low genomic complexity and low neoantigen burden. Restricting the analysis to patients with retained HLA and low genomic complexity, high neoantigen burden associated with prolonged and favorable response to CAR-T therapy (p=0.04). CONCLUSION: This study offers evidence that there is a critical relationship between CAR-19 efficacy, LBCL immunogenicity, and the endogenous immune response.

Hypofractionated Radiotherapy in Aggressive B-Cell Lymphoma

Background and purpose: Radiotherapy (RT) is an effective and available local treatment for patients with refractory or relapsed (R/R) aggressive B-cell lymphomas. However, the value of comprehensive hypofractionated RT in this setting has not been confirmed. Materials and methods : We retrospectively analyzed patients with R/R aggressive B-cell lymphoma who received comprehensive hypofractionated RT between January 2020 and August 2022 at a single institution. The objective response rate (ORR), overall survival (OS), progression-free survival (PFS) and acute side effects were analyzed. Results : A total of 30 patients were included. The median dose for residual disease was 36 Gy, at a dose per fraction of 2.3-5 Gy. After RT, the ORR and complete response (CR) rates were 90% and 80%, respectively. With a median follow-up of 10 months (range, 2-27 months), 10 patients (33.3%) experienced disease progression and three died. The 1-year OS and PFS rates for all patients were 81.8% and 66.3%, respectively. The majority (8/10) of post-RT progressions involved out-field relapses. Patients with relapsed diseases, no response to systemic therapy, multiple lesions at the time of RT, and no response to RT were associated with out-field relapses. PFS was associated with response to RT (P=0.001) and numbers of residual sites (P&amp;lt;0.001). No serious non-hematological adverse effects (≥grade 3) associated with RT were reported. Conclusion: These data suggest that comprehensive hypofractionated RT was effective and tolerable for patients with R/R aggressive B-cell lymphoma, especially for those that exhibited localized residual disease.

Clinical Utility of Circulating Tumor (ct)DNA Quantity and Kinetics in Patients Undergoing CAR T-Cell Therapy for Relapsed/Refractory Aggressive B-Cell Lymphoma

Background: CD19-targeted CAR T-cells are approved for relapsed and/or refractory (RR) aggressive B-cell lymphomas. While some patients experience durable remissions, others do not respond or relapse. Improved patient selection and early identification of patients who may need additional therapies are thus necessary. ctDNA is a promising biomarker for prognostication in DLBCL and has the potential to guide therapeutic decisions. We aimed to explore the possible clinical utility of ctDNA quantitation in patients with aggressive B-cell lymphomas undergoing CAR T-cell therapy. Methods: Twenty-eight patients undergoing CAR T-cell therapy as part of standard of care pathways for RR aggressive B-cell lymphoma were included. Pre- and post-CAR T-cell infusion ctDNA samples were retrospectively analyzed with a panel of over 400 genes relevant to B-NHL using a modified version of the AVENIO ctDNA analysis workflow (Roche; Research Use Only) based on the previously described CAPP-Seq workflow (Kurtz, J Clin Oncol 2018). Peripheral blood was used as a source of germline DNA to allow selection of tumor-specific variants in the ctDNA. ctDNA levels were expressed as mean mutant molecules per mL (MMPM) and ctDNA clearance was determined using a detection cutoff of p = 0.005. ctDNA results were correlated with clinical findings and outcomes including response rate, PFS and OS. Results: Eighteen male and 10 female patients were included in the analysis (median age 63). Sixteen (57%) patients had a diagnosis of DLBCL while the remainder had transformed FL or MZL (n=6), HGBL (n=4) and PMBL (n=2). Seventeen patients were treated with tisagenlecleucel and 11 with axicabtagene ciloleucel. Twenty-five (89%) patients had stage III or IV disease and 15 (54%) patients had ≥3 lines of prior therapy. The median number of tumor-specific variants in baseline ctDNA samples was 31 (range 1-252). ctDNA levels correlated with metabolic tumor volumes across all time points (Spearman r=0.69, p&amp;lt;0.0001). There was a greater reduction in ctDNA quantity observed in those who achieved CR/PR (n=21) at day 28 vs those who progressed (n=7) (median MMPM log-fold reduction 1.3 vs -0.9). Baseline ctDNA quantity was significantly higher in those with an elevated LDH pre-lymphodepletion compared to those with a normal LDH (median MMPM 228.5 vs 7.6, p = 0.0003). Survival also correlated with baseline ctDNA measurement with patients with a ctDNA quantity above the median of the cohort having a significantly shorter OS compared to those below the median (median OS 6.7 mo vs not reached, p=0.0012). Four patients had no detectable ctDNA at day 28 post CAR T-cell infusion including 1 patient with pseudoprogression on imaging (SUVMax 10) who had no evidence of lymphoma on biopsy and remained in CR. Of the 4 patients who were ctDNA negative at day 28, 3 remained in long-term remission. In summary, measurement of ctDNA quantity and kinetics shows promising clinical utility in the context of CAR T-cell treatment for aggressive B-cell lymphoma including prediction of outcome and resolving radiological pseudoprogression. Larger prospective cohorts and standardized methodological approaches are required to optimize predictive thresholds for clinical outcomes.

Diagnosis to Treatment Interval (DTI) Informs Outcomes across Subtypes of Aggressive B-Cell Lymphoma

Background: Shorter diagnosis to treatment interval (DTI) has been shown to be associated with more aggressive disease features and inferior outcomes in diffuse large B-cell lymphoma (DLBCL; Maurer et al, JCO 2018). Additional confirmatory studies have also shown that DTI is related to tumor volume (Alig et al, JCO 2021) and molecular phenotype (Aluaij et al, Blood 2023). Here we evaluate DTI in a large multicenter cohort of patients prospectively enrolled and followed as part of the Lymphoma Epidemiology of Outcome (LEO) cohort. Methods: Patients were enrolled within 6 months of diagnosis at one the 8 LEO cohort academic medical centers in the United States between 2015 and 2020. Patients in this analysis had aggressive B-cell lymphoma (BCL) treated with anthracycline-based chemotherapy. DTI was defined as the initial lymphoma biopsy date until the start of initial chemotherapy; patients with DTI between 0-100 days were evaluated. Short DTI was defined as DTI ≤ 14 days (DTI≤14) as previously described in prior publications (e.g. Maurer et al, JCO 2018) and confirmed via examination of functional forms via splines. Event-free survival (EFS) was defined as the time from start of treatment until progression/relapse, retreatment, or death due to any cause. Overall survival (OS) was defined as the time from start of treatment until death due to any cause. Results: 2565 patients with aggressive B-cell lymphoma were evaluated. Median age was 62 years (IQR 51-71) and 1469 (57%) were male. 297 patients (12%) were self-reported non-White race and 314 patients (12%) were self-reported Hispanic or Latino. The majority had DLBCL, NOS subtype (N=1927, 75%), while 227 (9%) had high-grade BCL with MYC and BCL2 and/or BCL6 rearrangements (HG, DH) and 90 (4%) had high-grade BCL NOS (HG, NOS). Clinical characteristics are summarized in the table. At median follow-up of 49 months (IQR 36-68), 800 patients (31%) had an event and 578 patients (23%) died. EFS at 24 months (EFS24) was 76% (95% CI: 74-77). Median DTI across all subtypes was 21 days (IQR 12-33) and 845 patients (33%) had DTI≤14. Patients with DTI≤14 were significantly younger (median age 59 years) but there was no association between DTI and gender, race, or ethnicity. Patients with DTI≤14 were more likely to have HG, DH or HG NOS subtypes, ECOG PS 2-4, advanced stage, elevated LDH, CNS involvement, B symptoms, and bulky disease ( see table). Patients with DTI≤14 were more likely to receive R-EPOCH-based or intensive therapies (41%) and less likely to receive 1L therapy on a clinical trial (3.8%) compared to DTI&amp;gt;14 (26% and 10.1%, respectively). Consistent with previously reported data, DTI≤14 was associated with inferior EFS (HR=1.62, 95% CI: 1.41-1.87, figure), OS (HR=1.73, 95% CI: 1.47-2.04), and EFS24 (OR=1.93, 95% CI: 1.60-2.38). The association between DTI and outcomes remained significant after stratifying for subtype (EFS HR=1.68, 95% CI: 1.46-1.94; OS HR=1.78, 95% CI: 1.50-2.10) and adjustment for IPI (EFS HR=1.43, 95% CI: 1.24-1.65; OS HR=1.47, 95% CI: 1.24-1.74). In subset analysis, DTI≤14 was significantly associated with inferior outcomes within the subtypes of HG, DH (EFS HR=2.70, 95% CI: 1.82-4.01; OS HR=2.97, 95% CI: 1.92-4.60); HG, NOS (EFS HR=2.07, 95% CI: 0.93-4.60; OS HR=2.36, 95% CI: 1.03-5.43); and DLBCL, NOS (EFS HR=1.51, 95% CI: 1.27-1.78; OS HR=1.52, 95% CI: 1.45-1.85). Analysis was limited in other subtypes due to number of events. Notably, within the subset of patients with DTI&amp;gt;14, there was no significant difference in EFS between subtypes for DLBCL, NOS (EFS24=80%, EFS HR=ref), HG, DH (EFS24=73%, EFS HR=1.26, 95% CI: 0.92-1.73) and HG, NOS (EFS24=83%, EFS HR =0.84, 95% CI: 0.40-1.78), logrank p=0.29; similar results were observed for OS (p=0.22). Conclusions: Patients requiring early initiation of therapy for aggressive B-cell lymphoma represent a distinct population of patients with more aggressive clinical features and inferior outcomes. In patients with longer DTI, high grade subtypes had similar outcomes to DLBCL, NOS. Efforts should be made to include patients with anticipated short DTI in clinical trials and translational studies to fully capture the spectrum of patients with aggressive B-cell lymphoma.

Health-Related Quality of Life Profile and Symptom Burden of Patients with Aggressive B-Cell Lymphomas Just before CAR-T-Cell Therapy: A Real-World Study By the Gimema

Background Although efficacy and safety data on chimeric antigenic receptor (CAR) T-cell therapy for patients aggressive B-cell lymphomas are being accumulated, there is limited research on health-related quality of life (HRQoL) and symptom burden of these patients. Additionally, the few HRQoL data available mainly stems from selected patients enrolled in clinical trial settings. Objective The primary objective of this study was to compare HRQoL of patients with relapsed/refractory aggressive B-cell lymphomas just before receiving CAR T-cell infusion in real-life, with that of their peers in the general population. Secondary objectives were to describe the prevalence of disease-specific symptoms and worries, and to investigate the relationships between symptom burden and HRQoL and functional outcomes. Methods: Baseline data from an ongoing prospective observational study by the Italian GIMEMA Group were analyzed. Inclusion criteria were: adult patients with diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and DLBCL transformed by indolent lymphoma and mantle cell lymphoma, scheduled to receive CAR T-cell therapy. HRQoL was assessed with the EORTC QLQ-C30 and its recently validated module for patients with high-grade non-Hodgkin lymphoma (EORTC QLQ-NHL-HG29). Multivariable linear regression analyses were performed to estimate the overall mean difference in the QLQ-C30 scores between patients and the general population, adjusting for age, sex and comorbidity. Evidence-based guidelines for interpretation of the QLQ-C30 were used to determine clinically meaningful differences between groups. The prevalence of patients who reported symptoms and worries on the QLQ-NHL-HG29 was based on the number of patients who answered, “a little,” “quite a bit,” or “very much” on a given item. This was assessed overall and by age groups. For descriptive purposes, we divided the sample by the median age, deriving two subgroups: younger (with a median age of 50 years; IQR: 41 - 56) and older patients (with a median age of 65 years; IQR: 63 - 71). Mean scores of functional and global QoL scales of the EORTC QLQ-C30 were analyzed by severity of symptom burden. Patients were categorized as having high or low symptom burden based on the median score of the validated symptom burden scale of the QLQ-NHL-HG29 questionnaire. Results Overall, 65 patients enrolled across 9 centers were analyzed. Median age at study entry was 61 years (IQR, 50-65) and 21 (32%) were women. Median time since diagnosis was 2 years (IQR, 1-4). Eighteen patients (28%) had already received autologous hematopoietic stem cell transplantation (auto-HSCT) before study inclusion. Median number of previous lines of therapy was 2 (IQR: 2-3), and eleven patients (18%) reported at least 1 comorbidity. Patients reported statistically and clinically meaningful worse scores across several domains, compared with their peers in the general population. The top three largest statistically and clinically meaningful differences with regard to functional scales were observed for role functioning (Δ=26.8, p&amp;lt;.001), social functioning (Δ=17.6, p&amp;lt;.001) and the global QoL scale (Δ=14.3, p&amp;lt;.001). With regard to symptoms, the two largest statistically and clinically meaningful worse symptoms, compared to the general population, were observed for fatigue (Δ=14.2, P&amp;lt;.001), dyspnea (Δ=10.9, p=.003) and financial difficulty (Δ=10.6, p=.001). Prevalence of symptoms and worries was high with more than 50% of patients reporting 14 different symptoms and worries. Younger patients tended to report a higher prevalence in regard to specific worries. The top ten most prevalent symptoms and worries by the QLQ-NHL-HG29, overall and by age groups, are reported in Table 1. Patients with a greater symptom burden had a clinically meaningful worse global QoL, and worse physical, role, social, and cognitive functioning compared to those with a lower symptom burden (Figure 1). Conclusion: Using a validated disease-specific measure for high-grade non-Hodgkin lymphoma, we observed that just before CAR T-cell therapy in real-life, patients report substantial HRQoL impairments and a high prevalence of symptoms and worries. Our findings also suggest to pay special attention to patients with a greater symptom burden, being a vulnerable group with important HRQoL and functional impairments.

Differences in Observed Toxicities for Adolescent and Young Adult Patients with Aggressive Mature B-Cell Lymphomas Treated at Adult Versus Pediatric Cancer Center - a Comparative Cohort Study

Introduction: Standard treatment regimens for pediatric and adult patients with mature B-cell lymphomas vary significantly. For adolescent or young adult (AYA) patients, who may be candidates for either pediatric or adult regimens, limited data are available regarding comparative toxicities and efficacy for adult versus pediatric therapies. Methods: A retrospective review was completed for individuals aged 12-39 years at diagnosis with aggressive mature B-cell lymphomas seen between 2011 to 2023 at Ohio State University Comprehensive Care Center (adult cohort) and Nationwide Children's Hospital (pediatric cohort). Diagnoses included diffuse large B cell lymphoma (DLBCL), double hit lymphoma (DHL), Burkitt lymphoma (BL), primary mediastinal B cell lymphoma (PMBCL), grey zone lymphoma (GZL), and unclassifiable high-grade B cell lymphoma (HGBCL). Progression free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method and compared by log-rank test. Differences between adult and pediatric cohort were compared using Fisher's exact test and Chi-squared test. Cox regression model was used to identify prognostic factors for PFS. Results: Among 180 eligible AYA patients, 156 were treated at the adult center and 24 at the pediatric center. The median age was 30 years (median 15 pediatric [range 12-18] and 31 adult [range 21-39; p&amp;lt;0.001]). Other characteristics included male sex in 75% of pediatric vs 65% adult patients (p=0.3), stage 4 disease in 25% vs 47%(p&amp;lt;0.001), CNS involvement in 8.3% vs 5.4% (p=0.6), and LDH &amp;gt;2x upper limit of normal in 21% vs 31% (p=0.2). The overall median follow-up was 4.8 years (4.5 vs 4.8, p=0.7). Adult center histology included DLBCL (95); DHL (9); BL (8); PMBCL (31); GZL (4); and HGBCL (9). Pediatric diagnoses were DLBCL (13); BL (8); PMBCL (2); and HGBCL (1). The most common treatments included R-CHOP (57), R-EPOCH (56), RM-CHOP (20), and R-CODOX-M/R-IVAC (16) at the adult center and CCG5961 (7), ANHL1131 (15), and ANHL0221 (1) protocols at the pediatric center. CCG5961 Group B protocol includes pre-phase, induction, and consolidation phases of COP, COPADM, and CYM. Group C includes the same pre-phase and induction, except for higher doses of MTX, with CYVE consolidation with high-dose MTX and randomization to 1 or 4 cycles of maintenance. ANHL1131 protocol was like CCG5961; major differences include randomization to receive rituximab during induction and consolidation and 2 cycles of maintenance for group C patients. ANHL0221, a PTLD protocol, involves 2 cycles of cyclophosphamide, prednisone, and rituximab followed by 4 cycles of cyclophosphamide and prednisone. A greater incidence of unplanned hospitalization (79% pediatric vs 50% adult, p=0.007), grade 3 mucositis (38% vs 12%, p=0.005), febrile neutropenia (67% vs 44%, p=0.035), and fungal infections (25% vs 3%, p&amp;lt;0.001) were observed for the pediatric cohort (Table 1). Patients in the adult cohort were more likely to receive radiation therapy (26% vs 0%, p=0.004) and experience neuropathy at last follow-up (22% v 0%, p=0.009). Among all patients, other adverse events during follow-up included diagnosis of depression/anxiety (93), heart failure (16), impaired renal function (20), and secondary malignancy (6) (Table 1). For the total population, 2-year PFS was 78% (88% pediatric vs 77% adult, p=0.35), and 2-year OS was 93% (96% vs 92%, p=0.31). For patients with DLBCL or DHL, there was a trend towards improved PFS in the pediatric versus adult cohort (p=0.06, Figure 1), and on univariable analysis a trend towards lower risk for progression with receipt of a more intensive regimen compared with R-CHOP/R-MCHOP (hazard ratio 0.46, 95% confidence interval 0.2-1.1, p=0.07). Conclusions: We observed a higher incidence of short-term adverse effects including severe mucositis, febrile neutropenia, and fungal infection, but lower rates of radiation consolidation and ongoing neuropathy in AYA patients with aggressive mature B-cell lymphoma treated with pediatric versus adult regimens. Relatively higher dose intensity (compared to adult treatments), standard use of CNS prophylaxis, and lower dosage of vinca-alkaloids likely account for the greater incidence of short-term adverse effects and lower rates of neuropathy seen in patients treated at pediatric centers. Further study is needed to evaluate differences in efficacy between treatment approaches in AYA patients with DLBCL/DHL.