Aggressive non-Hodgkin Lymphoma Research Articles

Prognostic Understanding in Newly Diagnosed Older Adults with Diffuse Large B Cell Lymphoma (DLBCL) or DLBCL/High Grade B-Cell Lymphoma with MYC and BCL2 rearrangements

Background: Diffuse large B cell lymphoma (DLBCL) is an aggressive lymphoid malignancy that often affects older adults. Therapy is potentially curative, with up to two-thirds of patients cured with chemoimmunotherapy but carries substantial risk of toxicity. Treatment of older adults must balance the potential for cure with the risk of therapy toxicity and intensive healthcare utilization. Therefore, prognostic understanding is a crucial component of informed decision-making for this patient population. Yet, data regarding prognostic understanding in older adults with DLBCL are lacking. Methods: We conducted a prospective study of older adults with aggressive non-Hodgkin lymphomas at two tertiary care hospitals between 9/2020 and 01/2023. Eligible patients were age >= 65 years at time of treatment initiation receiving a combination chemoimmunotherapy. Patients could enroll up until cycle 1 day 8 of therapy. Patients completed questionnaires at baseline that assessed demographics as well as information preferences and prognostic understanding (Prognosis and Treatment Perception Questionnaire) and underwent a comprehensive geriatric assessment. We used descriptive statistics to examine patient beliefs regarding likelihood of cure, the importance of knowing about prognosis, and preferences for information about treatment at baseline. We focused on the subset of patients (N=92) with DLBCL or DLBCL/high grade B-cell lymphoma with MYC and BCL2 translocations (double hit lymphoma) in order to have a relatively homogenous population for prognosis and likelihood of cure. Results: The parent study enrolled 106/163 (65.0%) patients, with 92 patients having DLBCL or double hit lymphoma. 88/92 enrolled patients with DLBCL (95.7%) submitted the prognostic understanding questionnaire. Among DLBCL/double hit lymphoma patients (N=92), the median age was 74 years (range: 66-99), and most were male gender (63%), White race (96.7%), and married/with a life partner (73.9%). 48/91 (52.7%) had an age-adjusted International Prognostic Index of 2 or 3, 30/92 (32.6%) had a Charlson comorbidity index of 2+ (not counting the patients' lymphoma), 14/92 (15.2%) had an Eastern Cooperative Group performance status of 2-4, and 50% (46/92) were frail based on comprehensive geriatric assessment. When asked about their likelihood of cure, 37.5% (33/88) selected >90% chance, 37.5% (33/88) selected 75-90% chance, 20.5% (18/88) selected 50-74% chance, 3.4% (3/88) selected 25-49% chance, and 1.1% (1/88) selected 10-24% chance of cure. Most (88.6%;78/88) patients believed that the primary goal of their current treatment was to cure their cancer, and most (93%; 80/86) believed that was their oncologist's primary goal. When asked if they would prefer a course of treatment focused on extending life as much as possible even if it meant more pain and discomfort versus a plan of care focused on relieving pain and discomfort as much as possible, even if it meant not living as long, 30.0% (26/88) chose extending life as much as possible, 40.9% (36/88) chose relieving pain as much as possible, and 30.0% (26/88) did not know. 94.0% (78/83) reported that they had a conversation about prognosis with their oncologist. The majority (91%; 78/86) felt it was extremely important or very important to know about their prognosis over time, and felt (81.4%; 70/86) they had just the right amount of information about their prognosis. Patients stated that knowing about their prognosis was extremely helpful in making decisions about treatment (75.3%; 61/81), preparing for the future (68.3%; 56/82), maintaining hope (79.3%; 65/82), and coping with the disease (72.5%; 58/80). 74.4% (61/82) said that overall knowing about prognosis was extremely helpful. Conclusion: In this cohort of older adults receiving treatment for DLBCL or double hit lymphoma, the vast majority felt it was important to know prognostic information over time and found that this information was helpful for decision making. Our finding that the majority estimated their likelihood of cure to exceed 75% despite most having aa-IPI scores indicating average cure rates < 60 suggests that older adults with newly diagnosed DLBCL hold overly optimistic views of their prognosis.

Mitoxantrone Hydrochloride Liposome, Gemcitabine, Vinorelbine with or without Rituximab (GVM±R) in Patients with Relapsed or Refractory Aggressive Non-Hodgkin's Lymphoma

Background: In patients with relapsed/refractory (r/r) aggressive non-Hodgkin lymphoma (aNHL), achieving a response to salvage therapy is a crucial predictor for long-term survival, as only chemosensitive patients have the opportunity to undergo autologous stem cell transplantation. Mitoxantrone hydrochloride liposome (PLM60) has shown good efficacy and safety in r/r peripheral T-cell lymphoma (PTCL) based on a prior study, with an objective response rate (ORR) of 40.7% and a complete response rate (CRR) of 20.4% (2020 ASH abstract 42). To determine the appropriate dosage of PLM60 in a multi-drug combination chemotherapy, we conducted a phase I clinical study aiming to explore the maximum tolerated dose (MTD) of PLM60 when combined with gemcitabine, vinorelbine, with or without rituximab (GVM±R). This trial was registered at www.clinicaltrials.gov as NCT05299164. Methods: The study was a prospective, single-center, single-arm, 3+3 dose-escalation study involving patients aged 18-70 years with r/r aNHL. PLM60 was administered on day 1 at four different dose levels (DL) (DL1: 16 mg/m 2, DL2: 18 mg/m 2, DL3: 20 mg/m 2, DL4: 22 mg/m 2), gemcitabine on day 1 and 8 at 800 mg/m 2, vinorelbine on day 1 and 8 at 20 mg/m 2, and rituximab on day 0 at 375 mg/m 2 (only administered in CD20+ lymphoma based on the investigator's judgment). The treatment was repeated every 21 days. Up to 6 cycles of therapy were planned. After the first cycle, dose-limiting toxicity (DLT) was assessed to determine the MTD of PLM60 in the GVM±R regimen. Results: As of July 15, 2023, the study had enrolled 12 eligible patients (DL1: n=6, DL2: n=6), with different aNHL subtypes, including 6 with diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS), 3 with angioimmunoblastic T-cell lymphoma (AITL), 2 with PTCL, NOS, and 1 with sezary syndrome (SS). The median age of the patients was 49 years (range, 23 to 69), with 41.7% being male. All patients had advanced-stage disease, with 33.3% in stage III and 66.7% in stage IV. They had received a median of 2.5 lines of therapy (range, 2 to 7), and 91.7% (11/12) of patients had received anthracycline-containing chemotherapy in their prior treatment. All patients with DLBCL, NOS had received rituximab during their prior therapy. 66.7% (8/12) of the patients were refractory to their last line therapy, and 2 out of the 6 patients with DLBCL, NOS experienced relapse after anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapy. During the study, two patients experienced DLTs of grade 4 neutropenia lasting for more than 7 days, with one occurring in the DL1 group and the other in the DL2 group. In response to these observations, an additional three patients were enrolled in each of the groups. The most common grade 3/4 TRAEs with an incidence ≥10% were leucopenia (91.7%), neutropenia (83.3%), thrombocytopenia (66.7%), anemia (41.7%), febrile neutropenia (25.0%), pneumonia (25.0%), and hypokalemia (25.0%). With a median follow-up of 2.5 months, 11 patients were evaluated for efficacy, showing an ORR of 72.7% (95% CI 39.0% to 94.0%) and a CRR of 45.5% (95% CI 16.8% to 76.6%). In the DL1 group (16 mg/m 2), the CRR was 50.0% (3/6), and the ORR was 66.7% (4/6), while the DL2 group (18 mg/m 2) had a CRR of 40.0% (2/5) and an ORR of 80.0% (4/5) (Table 1). Among the DLBCL patients, the CRR was 60.0% (3/5), and among AITL patients, the CRR was 66.7% (2/3). Patients with PTCL NOS and SS achieved partial responses (PR). Two DLBCL patients who had previously received multiple lines of therapy, including anti-CD19 CAR T-cell therapy, achieved CR after GVM±R treatment. Conclusions: The GVM±R regimen exhibited manageable safety and encouraging efficacy in patients with r/r aNHL, despite the fact that the majority of these patients had received anthracycline-containing chemotherapy in their previous treatment. The trial is still ongoing to determine the recommended phase 2 dose for the subsequent phase 2 clinical study.

CD19-Directed CAR T-Cells (CD19-CAR) Combined with Acalabrutinib Achieves Durable Remissions in Patients with Relapsed or Refractory (r/r) Mantle Cell Lymphoma (MCL)

Background: MCL is an aggressive non-Hodgkin lymphoma (NHL) subtype which remains incurable despite improvements in progression free survival with consolidative autologous transplant and the introduction of novel targeted therapies [Dreyling et al. Blood 2012]. CD19-directed chimeric antigen receptor (CAR) T-cell therapy (CD19-CAR) has shown durable disease control in r/r MCL, but current standard of care products are limited by high rates of grade 3+ immune-related toxicities [Wang et al. NEJM 2020]. We hypothesized that combining a naïve/stem-memory (T N/SCM) phenotype-enriched CD19-CAR T-cell product with the selective BTK inhibitor (BTKi) acalabrutinib would attenuate the rates of severe toxicities, improve durable remission rates, and obviate the need for indefinite use of acalabrutinib in r/r MCL. Methods: We conducted a phase 1 single center, prospective clinical trial (NCT04484012) evaluating a single infusion of T N/SCM-enriched CD19.28.z.EGFRt-CAR at a target dose of either 2x10 8 (DL1) or 5x10 8 (DL2) CAR+ cells (≤20% lower dose allowed) in combination with ongoing acalabrutinib 100 mg twice daily for patients with r/r MCL after at least 1 prior line of therapy. Patients were required to undergo at least 3 months but less than 7 months of treatment with a BTKi prior to enrollment without evidence of progression and with measurable disease per Lugano criteria. All patients were switched to acalabrutinib for protocol therapy prior to lymphodepletion, and planned to continue until day 180 post CD19-CAR infusion at which time all therapy would be discontinued. We report outcomes from the dose finding portion of the study. Descriptive statistics were utilized for baseline characteristics and survival analyses were calculated utilizing the Kaplan-Meier method. Investigator-assessed response rates were based on Lugano criteria. Minimal residual disease (MRD) status was determined using either multiparameter flow cytometry (FCM) or next-generation sequencing (NGS). Results: To date, 8 patients enrolled and have received CD19-CAR (n=4 at DL1; n=4 at DL2). Manufacturing was successful in 100% of patients. Median time from leukapheresis to product infusion was 53 days (range, 41-114). Treated patients were 75% male; with a median age of 63 years (range, 38-70); and median number of prior therapies of 2 (range, 2-3). All patients had bone marrow involvement, and had high risk features including progression of disease within 24 months (n=6), relapse after autologous HCT (n=2), TP53 mutations (n=6), Ki-67 ≥30% (n=4), and/or complex karyotype (n=1). Prior to enrollment, all patients had received BTKi (n=8 acalabrutinib) for a median of 6.1 months (range, 4.5-7.3). No BTK and PLC-γ mutations were detected in patients with available samples. The combination of acalabrutinib and CD19-CAR was well tolerated; 5 patients (63%; n=1 grade 2; n=4 grade 1) had cytokine release syndrome (CRS), with no severe cases. No patients (0%) had immune effector cell associated neurotoxicity syndrome (ICANS) [Figure 1A]. No patient required corticosteroids for toxicity management, and only 2 patients (n=2/5, 40%) required tocilizumab for CRS. There were no serious adverse events (SAEs), and no treatment discontinuations due to AEs observed. The best ORR was 88% [n=6 CR (75%); n=1 PR (13%)], with median time to best response of 28 days. In those 6 patients who achieved CR, 2 patients were FCM-MRD negative (<10 -4) and 2 were NGS-MRD negative (<10 -6) (n=4/6, 67%) [Figure 1B]. After a median follow-up of 18.5 months (range, 8.3-28.9), 5 of 6 patients remain in CR, while1 patient who achieved an initial CR relapsed at 9.2 months. At 1-year post-infusion, the cumulative incidence of relapse and NRM were 30% (95% CI, 3%-67%) and 0%, respectively. The 1-year PFS and OS were 70% (95% CI: 22%-92%) and 100%, respectively. Conclusion: The combination of CD19-CAR with acalabrutinib was well tolerated and effective, yielding an ORR 88% and MRD- rate 50% in a cohort of patients with high-risk MCL. Notably, CRS events were manageable and low grade, and no ICANS was observed. Enrollment is ongoing in the expansion cohort (DL2), and additional clinical and correlative analyses will be presented at the meeting.

Trial in Progress: A Phase I/II Study of Tafasitamab Plus Lenalidomide in Patients with Relapsed CNS Lymphoma

Background and Significance The development of novel, more effective biological strategies to prevent secondary CNS lymphoma (CNSL) and to treat primary and secondary CNSL would have significant impact. It is well established that the CD19 transmembrane glycoprotein is expressed by B-cells throughout differentiation, by the majority of B cell malignancies, and by follicular dendritic cells. Given the high incidence of neurotoxicity associated with blood-brain barrier disruption with CD19-directed CAR-T cells and bi-specific T-cell engager antibodies, Parker et al. recently investigated the possibility of CD19 expression by previously unrecognized cell population(s) in the brain. Single-cell RNA sequencing data demonstrated CD19 expression in brain mural cells, an integral component of the neurovascular unit that regulates integrity of the blood-brain barrier.(Cell, 2020; 183:126-42). Given these observations and the compelling problem of relapsed primary and secondary CNS lymphoma, we are evaluating tafasitamab, an anti-CD19 humanized monoclonal antibody, as a novel therapeutic for refractory CNS lymphomas. We hypothesize that tafasitamab may modulate blood-brain barrier integrity by perturbation of CD19 expressed on mural cells; but without recruitment of cytotoxic T cells and resultant cytokine release syndrome. Our rationale is supported by the Phase II L-MIND study, in which tafasitamab plus lenalidomide exhibited synergistic efficacy against relapsed/refractory aggressive non-Hodgkin lymphoma, with overall response rate of 60%, complete response rate of 43%, and a favorable toxicity profile compared to CAR-T without neurotoxicity. Notably, the L-MIND trial excluded patients previously treated with immunomodulatory drugs as well as CNS lymphoma. (Lancet Oncology 2020: 21:978-88). We also recently reported that tafasitamab plus lenalidomide induced brain parenchymal regressions in two consecutive CNS lymphoma patients with disease refractory to lenalidomide, pomalidomide and rituximab. (British Journal of Haematology 2023 201(1):154-157). Study Design and Methods This single-arm, open-label, multicenter Phase I/II study (NCT05351593) assesses safety, CNS pharmacokinetics and preliminary efficacy of tafasitamab plus lenalidomide in patients with relapsed primary and secondary CNSL. The Phase I portion of the study will determine tolerated dose (MTD) and recommended Phase II dose (RP2D) of lenalidomide in combination with tafasitamab. We are applying 3+3 dose escalation rules to examine lenalidomide 10mg, 15mg and 20 mg plus tafasitamab at 12 mg/kg. After the RP2D is identified, the Phase II portion of the study will begin. The primary objective of the Phase II expansion is to evaluate the clinical benefit rate (stable disease or better) via Simon's minimax two-stage design. Exploratory endpoints include assessment of effect of tafasitamab on blood-brain barrier permeability, correlation of the relationships between tumor response or resistance with tumor mutational profile, and changes in CSF and blood immune cell phenotypes. The study plans to enroll up to 35 patients. Eligibility mandates age ≥ 18 years, anticipated survival >2 months, ECOG PS 0-1, and receipt of at least one prior systemic therapy. Patients with prior exposure to lenalidomide or pomalidomide or concomitant systemic lymphoma are allowed. Patients with HIV infection, CNS PTLD, and those who previously received a CD19-targeting CAR-T product are ineligible. The study is currently enrolling at the University of California San Francisco, with plans to expand enrollment to other institutions within the United States.

Zilovertamab Vedotin (MK-2140) in Relapsed or Refractory Diffuse Large B-Cell Lymphoma (DLBCL): Updated Results from the Phase 2 Waveline-004 Study

Background: DLBCL is an aggressive non-Hodgkin lymphoma (NHL) that is often curable with frontline therapy, but up to 50% of patients (pts) will develop relapsed or refractory (R/R) disease. Treatment options are limited for pts with R/R DLBCL who have progressed after or are ineligible for autologous stem cell transplant (ASCT) or chimeric antigen receptor (CAR) T-cell therapy. ROR1 is an oncofetal transmembrane protein that is expressed in DLBCL. Zilovertamab vedotin, an antibody-drug conjugate comprising a humanized monoclonal antibody against ROR1, a proteolytically cleavable linker, and the antimicrotubule agent monomethyl auristatin E (MMAE), initially demonstrated promising antitumor activity and manageable safety in R/R NHL in the phase 1 waveLINE-001 study. Early results from the single-arm, open-label, phase 2 waveLINE-004 study (NCT05144841) showed that zilovertamab vedotin had clinically meaningful antitumor activity and manageable safety in pts with R/R DLBCL who progressed after or were ineligible for ASCT and/or CAR T-cell therapy. We present updated results from waveLINE-004. Methods: Eligible pts were ≥18 y, had histologically confirmed R/R DLBCL per WHO classification, measurable disease per Lugano 2014 criteria, PET-positive disease, and an ECOG performance status of 0 to 2. Pts were required to have disease progression after ≥2 prior lines of therapy including an alkylating agent, anthracycline, and an anti-CD20 antibody, and had progressed after or were ineligible for ASCT and CAR T-cell therapy. Pts received zilovertamab vedotin 2.5 mg/kg IV Q3W until disease progression, unacceptable toxicity, or withdrawal. Primary end point was ORR per Lugano 2014 criteria. Secondary end points were DOR and safety and tolerability. PFS and OS were exploratory. Efficacy is reported for pts who had ≥1 postbaseline assessment available. Safety is reported for all pts who received ≥1 dose of zilovertamab vedotin. Results: At the data cutoff (April 26, 2023), 98 pts had been enrolled and received ≥1 dose of zilovertamab vedotin; 61 pts (62%) had discontinued treatment predominantly because of disease progression (38%); 37 pts (38%) were ongoing. Median age was 66 y (range, 19-88), 63 pts (64%) were male, and 86 (92%) had an ECOG performance status of 0 or 1. Most pts (n = 70; 71%) had received ≥3 prior lines of therapy. Forty-one (42%) and 13 pts (13%) had high-intermediate and high-risk NCCN-IPI scores, respectively. Fifteen pts (15%) had undergone prior ASCT, 18 (18%) had undergone prior CAR T-cell therapy, and 5 (5%) had undergone both ASCT and CAR T-cell therapy. Median time from first dose to data cutoff was 4.5 mo (range, 0.2-13.2) for pts who received ≥1 dose of zilovertamab vedotin, and 5.6 mo (range, 0.9-13.2) for the 79 pts who had ≥1 postbaseline scan (efficacy analysis population). ORR per investigator review was 29% (95% CI, 19.4-40.4), with 10 pts (13%) having a complete response and 13 (16%) a partial response; 10 pts (13%) had stable disease, for a disease control rate of 42% (95% CI, 30.8-53.4). Median DOR was 3.0 mo (range, 0.0+ to 8.8+). Median PFS was 2.5 mo (95% CI, 1.9-3.0); 6-mo PFS was 15%. Median OS for all 98 pts was 10.6 mo (95% CI, 5.1-NR); 6-mo OS was 62%. Treatment-related AEs occurred in 78 pts (80%), most commonly (≥20%) neutrophil count decreased (n = 47; 48%), anemia (n = 25; 26%), diarrhea (n = 23; 23%), and white blood cell count decreased (n = 20; 20%). Grade 3-5 treatment-related AEs occurred in 51 pts (52%), most commonly (≥10%) neutrophil count decreased (n = 38; 39%), anemia (n = 15; 15%), and white blood cell count decreased (n = 12; 12%). Two pts (2%) died because of treatment-related AEs (septic shock, acute kidney injury). Four pts (4%) discontinued zilovertamab vedotin because of treatment-related AEs (2 diabetic ketoacidosis, 1 septic shock, 1 acute kidney injury). Peripheral neuropathy occurred in 18 pts (18%), 2 (2%) of whom had a grade 3/4 event. Dose modification because of peripheral neuropathy was required for 10 pts (10%). One pt (1%) experienced a grade 2 treatment-related infusion reaction. Conclusions: In this updated analysis of waveLINE-004, zilovertamab vedotin continued to demonstrate clinically meaningful antitumor activity in pts with R/R DLBCL who had progressed after or were ineligible for ASCT and/or CAR T-cell therapy. The safety profile of zilovertamab vedotin was manageable, and consistent with the known profile of MMAE-containing agents.

Preliminary Results of a Phase Ⅱ Study of Lenalidomide Combined with Immunochemotherapy in Patients with Primary Central Nervous System Lymphoma

Conclusion Introduction：PCNSL is a diffuse large B cell lymphoma (DLBCL) occurring exclusively in the brain, spinal cord, cranial nerves, leptomeninges and/or eyes. Pathophysiology is incompletely understood, although a central role seems to comprise immunoglobulins binding to self-proteins expressed in the central nervous system (CNS) and alterations of genes involved in B cell receptor, Toll-like receptor and NF-κB signalling. Standard of care includes methotrexate-based polychemotherapy followed by age-tailored thiotepa-based conditioned autologous stem cell transplantation, whole-brain radiotherapy or singledrug maintenance。Lenalidomide, an immunomodulatory agent that penetrates the CNS, has shown promise in relapsed/refractory (R/R) aggressive NHL, with well-demonstrated singleagent activity and tolerability. We hypothesized that lenalidomide combined with immunochemotherapy(MTX-based regimen)might be a favorable option for PCNSL pts. Here, we present preliminary data from the phase 2 trial of lenalidomide combined with immunochemotherapy in PCNSL pts (NCT04737889). To investigate the efficacy of lenalidomide combined with immunochemotherapy in untreated PCNSL.The primary objective is 2-year progression free survival(PFS). The secondary objectives are objective response rate (ORR), incidence of grade 3/4 adverse event (AE), and overall survival (OS). aged 18-75 years untreated PCNSL and adequate organ function are being enrolled.Lenalidomide(25mg qd po,totally 10 days/cycle) plus R-MT(Rituximab-Methotrexate+Temozolomide) was administered in TN PCNSL. A totally of 6 cycles of treatment was planned for pts. Completed responders(CR) undergo autologous stem cell transplantation (ASCT) 、reduced dose whole brain radiotherapy or lenalidomide maintenance for 24 months, based on the patient's fitness and preference. RESULTS：From March 2019 to 18 April 2023, 24 pts have been enrolled . Their baseline characteristics are displayed in Table 1. By 30 May 2025, all pts had been evaluated for response. There were 19 CRs (79.2%), 3 PRs (12.5%) and 2 PDs(8.3%) . The median follow-up time was10 (1.2 - 51.4) months . One pt withdrew informed consent due to grade 3 renal toxicity , One died from non-tumor-related disease. Two year progression-free survival (PFS) and overall survival was 62% and 67%，respectively,the median PFS and OS not achieved. The most common adverse events were hematologic toxicities. Grade 3/4 AEs occurred in ≥20% pts were neutropenia, leukopenia .Grade 3/4 non-hematologic AEs occurred in ≥20% pts was hepatic injury. Lenalidomide combined with immunochemotherapy showed encouraging activity and acceptable tolerance in pts with TN PCNSL.The study is still ongoing and it is worth looking forward to updating the long-term survival data.

Englumafusp Alfa (CD19-4-1BBL) and Glofitamab Combination in Patients with Relapsed/Refractory Non-Hodgkin Lymphoma (R/R NHL): Biomarker Results from a Phase I Dose-Escalation Trial

Background: Englumafusp alfa is an antibody-like fusion protein that simultaneously targets CD19 on B cells and 4-1BB on T cells and other immune cells. In the presence of a T-cell receptor signal and strictly dependent on CD19 crosslinking, englumafusp alfa co-stimulates T cells via 4-1BB agonism that boosts T-cell effector functions and prevents T-cell anergy. An ongoing Phase I dose-escalation study (NCT04077723) is investigating the safety, efficacy, pharmacokinetics, and pharmacodynamics (PD) of intravenous administration of englumafusp alfa in combination with glofitamab in patients (pts) with R/R NHL. We recently presented preliminary clinical data demonstrating promising clinical activity and good tolerability in R/R NHL (Hutchings et al, ICML 2023). Here, we report preliminary peripheral blood (PB) and tissue biomarker analyses to demonstrate mechanisms of action (MoA), dose relationship, and baseline features associated with response. Methods: Exploratory biomarker analyses included data from 84 pts with indolent or aggressive NHL (aNHL) dosed with 0.36-75mg englumafusp alfa, starting on Cycle 2 Day 8 (C2D8) and followed by combination with the fixed target dose of glofitamab (30mg), once every 3 weeks, from C3D1 for up to 12 cycles. Immune profiling of PB by flow cytometry and plasma cytokines analysis by ELLA were performed. Circulating tumor DNA (ctDNA) dynamics were evaluated by the Avenio NHL CAPP-Seq assay (Stokowski et al, ASH 2022) at C3D1, C5D1, and the end of 12-cycle treatment (EoT) in patients with aNHL. Baseline tumor biopsies (n=65) were analyzed by immunohistochemistry/immunofluorescence assays. On-treatment (OT) PD changes during the first five cycles of treatment were evaluated and compared to historical glofitamab monotherapy PD data generated in a phase I/II study (NCT03075696). Results: Englumafusp alfa in combination with glofitamab induced PD changes in PB at all tested doses. Specifically, in a dose-dependent manner, englumafusp alfa in combination with glofitamab limited the PB expansion of fully differentiated PD1+ CD8+ effector memory T cells re-expressing CD45RA (Temra), previously shown to expand dose-dependently following glofitamab monotherapy (Broeske et al, Blood Advances 2022). Additionally, the combination also resulted in a significant PB expansion of the activated (HLA-DR+) and effector memory CD8+ T (T EM) cells, and the ratio of T EM to central memory and naïve CD8+ T cells compared to glofitamab monotherapy. Furthermore, we detected no significantly added cytokine release with the combination to that previously observed with glofitamab monotherapy, in line with the clinically observed safety profile. Preliminary analysis of ctDNA dynamics showed that at C3D1 33% (18/55), at C5D1 40% (15/38), and at EoT 53% (9/17) of the pts had no detectable ctDNA. Notably, 61% of pts with aNHL who achieved complete metabolic response (CMR) had no detectable ctDNA at any OT visit. Our preliminary analysis also indicated a significant (p=0.03) association between the observed OT expansion of CD8+ T EM cells and the extent of decrease in ctDNA levels (mean mutant molecules per milliliter) at EoT relative to baseline. Finally, we observed ~60% of pts with low tumor infiltrating CD8+ T cells (<500 cells/mm 2 CD8+) and a more aggressive disease (>5000 cells/mm 2 proliferative (Ki67+) tumor cells) at baseline, both poor outcome correlates of glofitamab monotherapy, achieved a CMR with higher doses of englumafusp alfa. Conclusions: In this study, we demonstrated the MoA of englumafusp alfa in R/R NHL and key PD effects in combination versus glofitamab monotherapy that will support optimal biological dose finding. Furthermore, the observed association between expansion of T EM cells in PB and changes in ctDNA dynamics at EoT, albeit preliminary, supports ctDNA as a marker for depth and durability of response. Overall, our PD and biomarker observations so far strengthen the rationale of combining glofitamab with englumafusp alfa to drive long-term responses in this heavily pre-treated NHL patient population. Acknowledgments: This study was sponsored by F. Hoffmann-La Roche Ltd. The authors would like to thank the patients who participated in this trial, their families, and their caregivers. Special thanks also to Daria Rukina, Iva Lelios, Philip Knuckles, Kat Reyskens, Grigori Singovski, and Joanne Hayward for their contributions to this work.

Prognostic Factors in Hospitalized Patients with HIV-Associated Burkitt's Lymphoma - Real World Data Analysis

Introduction Burkitt Lymphoma (BL) is a highly aggressive and rare B-cell non-Hodgkin Lymphoma, characterized by translocation and dysregulation of the MYC gene. BL comes in three distinct forms: endemic, sporadic, and immunodeficiency related, which is most commonly secondary to HIV. Despite improvements in antiretroviral therapy (ART), the reported incidence of BL has remained stable over time. BL is a highly curable disease in patients able to tolerate aggressive therapies. However, little is known about real-world outcomes in United States patients with HIV- related BL. Our study highlights multiple factors associated with inpatient mortality and morbidity. Methods The National Inpatient Sample database was queried from October 2015 to December 2020. Adults aged >= 18 with a primary diagnosis of BL were identified and stratified into those with and without HIV. Complications included were queried using ICD codes most found in the secondary diagnosis variables. Baseline characteristics, inpatient complications, and outcomes were compared using chi-squared and Wilcoxon rank-sum tests. Logistic regression analysis was performed to assess the risk of death before and after adjusting for multiple risk factors. Results We found 3,650 admissions with a primary diagnosis of BL, 400 (11%) of whom had HIV. Patients with HIV were younger, 49% were younger than 40 years old as compared to 29% in patients with no HIV. There was a higher percentage of black patients 115 (29%), and most had Medicaid 170 (44%), there was no difference between income, hospital bed size or geographical region. Interestingly, in multivariable analysis, there were no significant differences in length of stay, race, or mortality between patients with and without HIV. The factors associated with mortality in HIV patients included acute renal failure OR 11.4 (1.22 to 107) and Sepsis OR 38.6 (1.62 to 921) Conclusion BL is an increasingly important disease in HIV-infected patients given that the incidence remains high despite advances in ART. This nationwide data analysis demonstrates the demographic characteristics of patients with HIV-associated BL in the US and the encouraging findings that outcomes are not significantly different between patients with and without HIV. Yet our study demonstrates the disproportionate distribution of HIV-BL in females and black patients. Further studies are needed to examine gender and racial disparities.

Lymphoma-Derived IL-10 Is a Key Immunomodulatory Factor at the Tumor Microenvironment of Activated B-Cell Diffuse Large B-Cell Lymphoma and Influences In Vivo Responses to Immunotherapy

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of aggressive non-Hodgkin's lymphoma with ~40% of patients experiencing refractory or relapsed disease to R-CHOP immunochemotherapy. These higher risk patients often exhibit gene expression profiles that resemble a late germinal center-derived activated B-cell (ABC) phenotype, where diverse specific mutations in genes along BCR and TLR signaling pathways converge into constitutive activation of the NF-κB pathway. Identification of factors that contribute to the survival of malignant ABC-DLBCL cells is crucial for designing specific interventions. In this setting, previous in vitro studies in DLBCL cell lines have evidenced that IL-10 is a direct target of NF-κB signaling that sustains lymphoma cell survival by an auto-stimulatory loop via STAT3 signaling. However, the action of IL-10 could be more complex within the lymphoma microenvironment, as IL-10 can have both stimulatory and inhibitory effects depending on the cellular source of IL-10, the timing of its secretion, and the type of immune cells that receives signals via IL-10 receptor (IL-10R). To explore in vivo the relevance of lymphoma-derived IL-10, we have generated a novel quintuple transgenic mouse model that we call pBIC10, after crossing our previous ABC-DLBCL-like pBIC mice carrying constitutive NF-κB signaling (Pascual et al., Blood 2019) to mice with a floxed Il10 gene for conditional knock-out of IL-10 specifically in malignant ABC-DLBCL cells. As expected, increased intracellular IL-10 signaling was detected in primary murine DLBCL cells from pBIC mice but not in IL-10 deficient pBIC10 mice, which promoted lymphoma cell survival ex vivo as revealed by perturbation studies of the IL-10/JAK1/STAT3 autocrine loop with blocking monoclonal antibodies or selected inhibitors. However, in vivo genetic deletion of lymphoma-derived IL-10 did not offer improved overall survival but, on the contrary, notably accelerated DLBCL progression in pBIC10 mice (Figure 1A, left). A comprehensive integration of multiparametric flow cytometry and transcriptomic analyses using bulk and single-cell RNA-seq of lymphoma cells and the tumor microenvironment coupled with BCR- and TCR-seq, identified lymphoma-derived IL-10 as a key immunomodulator of the DLBCL microenvironment, including unexpected protective paracrine functions in the progression of DLBCL. By comparing IL-10-proficient (pBIC) and -deficient (pBIC10) murine DLBCL models, we observed a multifaceted role of IL-10 produced by DLBCL cells, enabling immune-effector processes (facilitating immune chemotaxis, antigen presentation, and IFNγ responses) that yielded higher percentages of long-lived stem-like CD8 +TCF-1 +PD-1 lo/int T cells and dendritic cells, while restraining PD-1/LAG3-driven T-cell exhaustion and reducing immunosuppression by CD4 +CD25 +FOXP3 + regulatory T (Treg) cells. Thus, depletion of lymphoma-derived IL-10 decreased T-cell cytotoxicity and increased Treg-driven immunosuppression, which collectively accelerated lymphoma development. Consequently, T-cell targeted immune-checkpoint therapy (with anti-PD-1 antibodies) was effective only in IL-10-proficient DLBCL but not in IL-10-deficient pBIC10 mice (Figure 1A, right). Further comparative studies between pBIC and pBIC10 mice showed that tumor vascularization and expression of B-cell calcium channels, which have been previously associated with sensitivity to rituximab, were counteracted by lymphoma-derived IL-10. Accordingly, anti-CD20-based targeting of lymphoma cells (with rituximab surrogate antibodies) showed best in vivo responses in IL-10-deficient DLBCL mice with respect to pBIC mice (Figure 1A, right). Consistent with this preclinical data, analyses of transcriptional IL-10-associated hallmarks to stratify DLBCL patients (Schmitz et al., NEJM 2018) identified better clinical responses to R-CHOP in patients with pBIC10-like DLBCL phenotype (Figure 1B). Collectively, our study provides new functional and mechanistic insights into the role of lymphoma-derived IL-10 in the pathogenesis of DLBCL and the restraint of an immunosuppressed tumor microenvironment, which holds predictive potential as a biomarker for immunotherapy responses in DLBCL.

Extrachromosomal Circular DNA Drives the Progression of DLBCL through Activating the Sting Pathway

Objective Chromosome instability (CIN) as a hallmark of cancer is correlated with the prognosis of patients with diffuse large B cell lymphoma (DLBCL). However, little is known about how it drives the tumorigenesis and progression. DNA damage affects CIN and accumulated cytosolic DNA which activates the DNA sensing machinery cGAS-STING pathway in a sequence-independent manner. Extrachromosomal circular DNA (eccDNA), a type of circular DNA that derived from genomic DNA is independent of chromosomes. Existing widely in nature, eccDNA could be involved in tumorigenesis, heterogeneity and drug resistance. The purpose of this study is to reveal the expression profile of eccDNA in DLBCL, and to explore how eccDNA promotes the occurrence and development of the disease through the cGAS-independent STING pathway. Methods The expression profile of eccDNA in DLBCL was detected through multi-omics sequencing analysis including circular DNA sequencing (circle-seq), single-cell sequencing (scRNA-seq), whole exome sequencing (WES) and atomic force microscopy. CCK8, scRNA-seq, etc. were used to reveal the activation of eccDNA on the STING pathway to promote cell proliferation. In vivo and in vitro models were treated with chemotherapeutic drugs to verify the hypothesis that DNA damage induces the production of eccDNA, thereby activating the cGAS-independent STING pathway. GEO databases were applied to verify the prognosis of eccDNA-related gene sets, animal models to explore the anti-tumor effect of DNA damage therapy combined with STING inhibitors. Results Through the integration of multi-omics analysis results of 18 DLBCL cell lines, we divided DLBCL cells into two groups with high (H group) or low (L group) eccDNA abundance separately and confirmed that cells with high wGII were accompanied by abundant eccDNA. It suggested the potential roles of eccDNA in prognostic evaluation. Subsequent research revealed that eccDNA was upregulated in patients with DLBCL especially in R/R DLBCL. Pseudo-time analysis indicated that cells developed in two different differentiation directions. GSEA analysis demonstrated that high abundance of eccDNA contributed to the cell proliferative potential. To verify the role of eccDNA in cell proliferation, eccDNA extracted from H group cells were transfected into L group cells. As a result, cells transfected with eccDNA showed a significantly higher rate of propagation. These results confirmed that eccDNA had the promotional effects on proliferation DLBCL cells. GEO databases (GSE31312, GSE10846 and GSE87371) were applied to verify the prognosis of eccDNA-related gene sets. Gens that upregulated in H group was selected to construct a panel and overall survival analysis showed that patients with high levels of the panel had a worse prognosis. DNA damage repair mechanism is a key component to maintain the stability of genome. Numerous studies have suggested that DNA damage repair is conducive to the generation of eccDNA. Here, we found that cells with serious DNA damage degree were accompanied with increased γH2AX levels. EccDNA was induced with the treatment of DNA damage agents (cisplatin, doxorubicin, irinotecan and olaparib). Meanwhile, the levels of p-STING and downstream proteins were significantly upregulated. This phenomenon was also confirmed with immunodeficient and immunocompetent mice. H-151, the inhibitor of STING showed effective inhibitory effect on DLBCL through in vitro and in vivo assay. cells with high eccDNA abundance, and the results were further confirmed with scRNA-seq analysis. The combinational effects of STING inhibitor with DNA damage agents were observed. These results suggested that cells with high eccDNA abundance were more sensitive to the inhibition of STING pathway and the combined use of chemotherapy drugs and STING inhibitors can significantly enhance the anti-tumor effect. Conclusion DLBCL is a highly heterogeneous aggressive non-Hodgkin's lymphoma. STING plays a double-edged role in tumor development and immune regulation. However, its role in DLBCL and related mechanisms have not been reported so far. Our study reveals the expression, function and clinical significance of eccDNA in DLBCL for the first time, clarifies the mechanism of eccDNA-mediated STING pathway activation in disease progression and drug resistance, and provides a new theoretical basis for clinical treatment and prognosis evaluation of DLBCL.

Axicabtagene Ciloleucel in Patients Aged 75 and Older: A Retrospective Cohort Study

Background The treatment of older patients with relapsed/refractory (R/R) aggressive non-Hodgkin B-cell lymphomas (NHL) remains a significant clinical challenge. Chimeric antigen receptor T-cell (CAR-T) therapy represents a potentially curative option, but elderly patients remain underrepresented in relevant clinical trials, and less is known about the safety of CAR-T among patients older than 75 years. Toxicities including cytokine release syndrome (CRS), neurotoxicity (ICANS), arrhythmias, renal failure, and cytopenias may pose higher risk in elderly patients with comorbidities and decreased physiologic reserve compared to younger CAR-T recipients. We sought to characterize outcomes and toxicities of axicabtagene ciloleucel (axi-cel) in a cohort of patients aged ≥ 75 years. Methods This was a retrospective analysis of consecutive patients aged ≥ 75 years with R/R NHL who received axi-cel at New York-Presbyterian/Weill Cornell Medical Center. Data collected included patient characteristics and outcomes including response rates, event-free and overall survival, rates of CRS, ICANS, arrhythmias and severe cytopenias, and length of hospital stay. CRS and ICANS severity were graded following the ASTCT consensus criteria. Cytopenias were graded as per NCI-CTCAE v5.0. Event free survival (EFS) was defined as time to disease progression or death. Results We identified 15 patients with a median age of 78 (range 75-87) years; 6 (40%) were ≥ 80 years of age. 14 patients had a diagnosis of large B-cell lymphoma and 1 had multiply relapsed follicular lymphoma. Ten patients (67%) had received 3 or more prior lines of therapy. Additional baseline characteristics are summarized in Table 1. Among 10 patients (67%) who developed CRS of any grade, only 1 (7%) experienced grade ≥3 CRS; this CRS event was fatal. Five (33%) patients developed ICANS with only 1 patient (7%) developing grade ≥3 ICANS. Two (13%) patients and 10 (67%) patients developed grades 3 and 4 cytopenias within 30 days of infusion, respectively. Four (27%) patients required blood or platelet transfusions within 100 days of infusion. Febrile neutropenia was seen in 8 (53%) patients, and 8 patients had culture or PCR-verified bacterial (33%), viral (40%), or fungal (7%) infections. Only 1 (7%) patient developed a new abnormality on EKG within 30 days of infusion (right ventricular conduction delay). Median length of inpatient stay was 17 days (range 13-35), and 2 (13%) required re-hospitalization within 100 days of infusion. Overall and complete response rates at 100 days post-infusion were 13 (86%) and 11 (73%), respectively. At one year, overall and event-free survival were 72.2% (95% CI: 54.4-99.6%) and 53.3% (95% CI: 33.2%-85.6%), respectively. The median overall survival was 30.8 months with a median follow-up of 21.4 months. One patient experienced treatment-related mortality due to CRS, and 5 (33%) had subsequent disease relapse. Conclusion These results suggest that axi-cel is an effective and well-tolerated treatment for patients age ≥ 75 with R/R NHL. Only 1/15 patients developed grade ≥3 CRS or ICANS which is comparable to reported rates of toxicities in younger patients. Although multiple studies have identified cytopenias and cardiac arrhythmias as major CAR-T toxicities, a minority of our cohort required transfusions, and none developed life-threatening arrhythmias. OS and EFS were also comparable to real-world experience seen in younger patients. This study may be limited by the selection of a relatively fit population of elderly patients; however, the median Karnofsky Performance Score was 80 and ranged as low as 60. Overall, these findings show that axi-cel may be an appropriate strategy for relapsed aggressive NHL in carefully selected patients in their eighth and even ninth decades of life.

Comprehensive Geriatric Assessment and Geriatric Intervention in Older Patients with Newly Diagnosed Lymphoma: A Prospective Study

Introduction: Aggressive and indolent non-Hodgkin lymphomas have a median age at diagnosis of 70 years. Above this age, this population is very heterogeneous and clinical outcomes may be worsened due to patient's frailty phenotype. Very few studies of comprehensive geriatric assessment (CGA) guided approach to care have been published. Methods: A prospective follow-up with baseline CGA were performed in a cohort of consecutive patients older than 70 years with newly diagnosed Hodgkin and non-Hodgkin lymphoma as standard of care. CGA tools are described in Table 1. Clinical outcome has been analyzed in patients diagnosed between May 2016 and March 2021. Results: Ninety-three consecutive patients (55.9% of them were women) were included in this analysis, with a median age of 81.1 years (+/- 5.7). 23 patients (24.7%) were classified as robust (type I), 30 patients (32.3%) as pre-frail (type II) with potentially reversable impairments, 38 patients (40.9%) as frail (type III), and only 2 patients (2.2%) as unfit (type IV). Patients' characteristics are shown in Table 1. All patients received antineoplastic therapy. Treatment modifications were carried out in 64.5% of patients based on CGA results. In the follow-up, with a median follow-up 27.3 months (range 18-74 months), the relapse rate was of 25.8%, with no differences between groups. Overall survival was around 2-fold higher among the fit patients (type I) (42.5 ±19.6 months) than in the disabled patient's group (types III-IV) (23.7 ±20.5 months) (p 0.002) Statistically significant differences in overall survival (p 0.002), response to treatment (p<0.001) and likelihood of increased frailty at the end of treatment (p 0.024) were observed among groups, with type III-IV patients showing worse overall survival (Figure 1), lower response rates, and higher incidence of frailty. Conclusion: Systematic CGA allows physicians to address the functional reserve or resilience in older patients with lymphoma in the need of antineoplastic treatment. A frailty-guide approach to care may allow to improve clinical outcomes in this group of high-risk patients.

Leukostasis Twist in Mantle Cell Lymphoma: Systematic Review and Case Report

Introduction: Mantle cell lymphoma (MCL) is an aggressive B-cell non-Hodgkin lymphoma. Patients often present with lymphadenopathy, early satiety, and B-symptoms. Despite up to 92% of MCL patients having peripheral blood involvement by flow cytometry, presentation with leukemic involvement and hyperleukocytosis are uncommon. Hyperleukocytosis, marked by a white blood count (WBC) >100 x 10 9/L, often leads to symptomatic leukostasis due to tissue hypoxia, generally found in acute leukemias. We conducted a systematic review of leukostasis in MCL, and present a case we encountered in our clinical practice of a non-nodal MCL variant showing leukostasis, spontaneous tumour lysis syndrome (TLS), and severe anemia to identify treatment strategies and outcomes. Methods: We searched PubMed for peer-reviewed articles and abstracts on “mantle cell lymphoma,” “hyperleukocytosis,” and “leukostasis.” All articles and abstracts that discuss hyperleukocytosis leading to leukostasis in MCL were included. Results: The search yielded eight results. After exclusions, five case reports and abstracts were included. These studies featured different MCL variants, presenting WBCs ranging from 121 to 1227 x 10 9/L, and various leukostasis symptoms. Leukapheresis was used in all five published cases, leading to lower WBCs and symptom improvement. Results are summarized in Table 1. Our patient was found to have the small lymphocyte variant of MCL, with WBC of 543.3 x 10 9/L on presentation. Our facility does not have leukapheresis capability. As a result, our initial treatment consisted of only supportive care and escalating doses of corticosteroids, with close monitoring for TLS. To our knowledge, this report is the first demonstration that IV methylprednisolone, without leukapheresis, is effective for acute management of leukostasis. Our patient's WBC reduced from 543.3 x 10 9/L to 230 x 10 9/L, leading to improved neurological function and oxygenation. Steroids were particularly useful in our patient with secondary, MCL-related warm autoimmune hemolytic anemia. Conclusion: This review highlights the importance of recognizing non-specific leukostasis symptoms, even in patients with mature B-cell lymphoproliferative disorders. Leukapheresis is effective in treating leukostasis in MCL patients. In hospitals without leukapheresis, escalating doses of IV methylprednisolone can be considered as a safe and effective strategy.

A Multicenter Phase2 Trial of Linperlisib in Relapsed or Refractory Peripheral T/NK Cell Lymphomas

Introduction Peripheral T/NK cell lymphomas (PTCLs) are a group of aggressive heterogeneous non-Hodgkin's lymphomas where in relapsed or refractory (r/r) disease, the approved standard therapies are limited with a median progression free survival (mPFS) of only 3-4 months. PI3Kdelta inhibitors have demonstrated clinical activities in T-cell and B-cell lymphomas, owing to the multiple cellular activities in the T, B, and myeloid cell tumor microenvironment. However, application of these agents has been hampered by poor tolerabilities, particularly with toxicities such as diarrhea/colitis, hepatotoxicity, pneumonitis, hyperglycemia, and rash. As a new PI3Kdelta-selective oral agent, linperlisib was shown to be efficacious and indicated a favorable safety profile in phase 1 and 2 clinical trials in r/r Follicular Lymphoma (FL) and PTCL. Linperlisib received marketing approval in China in 2022 for r/r FL patients (pts) with 2 prior systemic therapies. Here we report the efficacy and safety findings for linperlisib in a pivotal phase 2 trial in r/r PTCL. Methods Ninety-eight pts were enrolled in the open-label phase 2 registration trial (CTR20210333) from May 2021 to October 2022 at 25 sites in China. The trial had a representation of different PTCL subtypes: AITL (48 pts), PTCL-NOS (24 pts), NKT (8 pts), ALCL (2 pts), MEITL (2 pts), Other (4 pts), and 10pt did not qualify as PTCL confirmed by independent pathology review, yielding a Full Analysis Set (FAS) of 88 pts for efficacy evaluation. Linperlisib was orally dosed at 80 mg QD (RP2D) continuously until disease progression, intolerable toxicity, or study withdrawal. Tumor assessments performed every 2 treatment cycles (28-day cycle) were evaluated with Lugano 2014 criteria by an Independent Review Committee. Safety was evaluated according to CTCAE v5.0. Results In this phase 2 study, the median age was 57 years, ECOG 0-1 (100%). Most patients were diagnosed with Lugano 2014 Stage III (29 pts, 33%), or IV (49pts, 56%) diseases, and were refractory or relapsed to a median of 2 prior systemic therapies. Sixty-four pts (73%) had refractory diseases, 59 pts (67%) had relapsed diseases, and 35 pts (40%) were with both r/r. Treatment related adverse events (TRAE) were observed in 94 pts (95.9%) , with the most common TRAEs (≥10%) being neutropenia (59%), leukopenia (47%), thrombocytopenia (32%), anaemia (24%), elevated alanine aminotransferase (23%), elevated aspartate aminotransferase (20%), pneumonia (20%), lymphocytopenia (17%), hypertriglyceridemia (15%), fever (15%), diarrhea (14%), elevated lipase (13%), hyperuricemia (13%), rash (13%), hypercholesterolemia (12%), hyponatremia (11%), elevated lactate dehydrogenase (10%), elevated creatinine (10%). AEs of ≥Grade 3 (≥5%) were neutropenia (32%), pneumonia (14%), leukopenia (10%), anaemia (6%), thrombocytopenia (5%), upper respiratory tract infection (5%) and lymphocytopenia (5%). The most frequent Serious Adverse Event (drug-related) was pneumonia (11%). Twenty-two pts (22.4%) had dose reductions, and 9 pts (9.2%) discontinued from the study due to AEs. The safety profile was consistent with all previously reported in linperlisib clinical studies. Among the 88 FAS pts, the objective response rate (ORR) was 48%, including 30% (26 pts) complete response, 18% (16 pts) partial response, and 20% (18 pts) stable disease. The disease control rate was 68%. Responses were demonstrated in all subtypes, including AITL, PTCL-NOS, NKT, and others. As of April 24, 2023, the median duration of response had not been reached (95%CI: 7.8, NR), and mPFS was 5.5 months (95%CI: 3.5, 15.6). All pts had ≥6 months of follow-up as of the safety and efficacy analysis data cut off (April 24, 2023); median follow-up was 13.9 months. The 6-month OS rate was 75% (95% CI: 64.51%, 82.74%), the median OS was 14.2 months (95%CI: 7.9, NR), 16 pts continued to receive linperlisib treatment. Conclusions Linperlisib, as a new PI3Kdelta-selective oral agent, showed a well-tolerated safety profile with low levels of severe gastrointestinal and liver toxicities seen with other PI3K agents. In r/r PTCL, linperlisib had promising durable efficacies, with 48% ORR (30% CR) and a median duration of response that was not reached. As in previous lymphoma studies with linperlisib, a high proportion of responses were CRs, and responses were observed across almost all PTCL subtypes. A phase 2 r/r PTCL and CTCL trial in the US/EU is ongoing.

Combination of Selinexor with BTK Inhibitor for Central Nervous System Diffuse Large B-Cell Lymphoma, Possible Mechanisms and Therapeutic Potential Exploration

Background: Primary central nervous system lymphoma (PCNSL) is a rare aggressive extra-nodal non-Hodgkin lymphoma (NHL) of which over 90% are diffuse large B-cell lymphoma (DLBCL). High-dose methotrexate (HD-MTX)-based regimens are the dominant therapy for newly diagnosed PCNSL, but the patients' complete remission rate (CRR) is merely about 50%. Bruton tyrosine kinase (BTK), a critical kinase in the B cell receptor (BCR) signaling pathway, contributes to the degradation of FOXO3a and promotes abnormal B cell proliferation. Recent studies revealed that BTK inhibitors (BTKi) play a role in various B cell lymphomas, including DLBCL, and have also shown promising efficacy in PCNSL. However, the clinical management of PCNSL is still challenging for its limited treatment options and poor prognosis, especially when patients developed acquired resistance to BTKi. Selinexor (KPT-330) is a first-ever oral small molecule Exportin-1 (nuclear output protein XPO1) inhibitor with a molecular weight of 443.31 Da, which can efficiently cross the blood-brain barrier. Currently Selinexor was found to promote the aggregation of FOXO3a and could synergistically inhibit PI3K/AKT and NF-κB pathways with BTKi to overcome acquired BTKi resistance. To investigate the therapeutic potential of Selinexor and BTKi in PCNSL, we examined the combination both in DLBCL cells and A20 transplantation mice, and further explored the clinical efficacy in PCNSL patients. Methods and Results: ABC-DLBCL cell lines (OCI-LY3 and OCI-LY10) were treated with Selinexor for 48 hours. Western blot analysis showed that Selinexor inhibited NF-κB, P-STAT3, and NFATc1 signaling pathways in DLBCL in vitro. Combining Selinexor(1μM) with ICP-022(2μM), a BTKi, resulted in more notable inhibition of the above tumor signaling pathways. A20 murine B-cell lymphoma transplantation models were divided into a control group, Selinexor monotherapy group, ICP-022 monotherapy group, and combination group. Tumor volume was measured after 30 days (Figures 1A), and the number of CD4+ T cells and CD8+ T cells and the corresponding cellular expression of PD-1 and TIM-3 in the spleen and tumor tissues of mice were detected. The results showed that the tumor volume in the combination group was minimized, and the number of CD4+ T cells and CD8+ T cells in spleens and tumors in this group was significantly increased, while PD-1 and TIM-3 expression was downregulated (Figures 1B-C). Based on these results, a prospective, open-label, single-arm, multicenter study was conducted with MSZ regimen (MTX, BTKi, Selinexor) for the treatment of PCNSL (Trial Registration Number: ChiCTR2200062154). Newly diagnosed primary and secondary central DLBCL patients (18-80 years old) received a 6-cycle MSZ regimen (HDMTX 3.5 g/m 2 3-h infusion d1, Zanubrutinib 160 mg Bid po, Selinexor 40 mg Biw po, 3 weeks per cycle) and evaluated by MRI/PET. 5 patients (2 GCB-DLBCL, 3 ABC-DLBCL) were enrolled, with a median age of 65 years (range: 54-73 years), 100% achieved metabolic remission (Figure 2A) and maintained long-term efficacy. 4 patients achieved early deep remissions of over 75% reduction with 1 cycle of treatment, and 1 patient had a complete remission after 2 cycles of treatment (Figures 2B). 3 patients chose radiation therapy as consolidation after the end of induction chemotherapy. 2 others were on maintenance therapy with Selinexor combined with Zanubrutinib, one of them has completed the two-year maintenance treatment and maintained sustained remission till now. Only 1 patient experienced several grade 3 adverse events (AEs) including anemia, decreased white blood cell and platelet counts, and elevated alanine aminotransferase.1 patient developed mild renal insufficiency, which recovered 6 months after the end of treatment. Patients were generally well-tolerated and there were no treatment-related deaths. Conclusion: This is the first report describing that Selinexor combined with BTKi can synergistically inhibit the DLBCL tumor signaling pathway and repairing the immune microenvironment. Correspondingly, in treatment of central DLBCL patients, the novel therapeutic strategy of MSZ regimen has achieved impressive results, with a CRR of 100%. Most patients attained early and rapid deep remissions with durable efficacy. This study provides theoretical support and preliminary clinical data for the combined application of Selinexor and BTK inhibitors.

Impact of Deployment on Survival in Military Personnel with Non-Hodgkin Lymphoma

Introduction: It is estimated that approximately 3.5 million active duty service members (ADSM) have deployed to Afghanistan and Iraq from 2001-2022. There has been concern about potential exposure to carcinogenic or environmental hazards during overseas deployment. A recent study found ADSM with no prior deployments had an increased risk of cancer mortality compared to those who had served in Operation Iraqi Freedom/Operation Enduring Freedom. Moreover, Nordic personnel with military deployments were also found to have a lower risk of cancer related death when compared to the general population. While there may be a link between potential environmental exposures, there is a lack of data on non-Hodgkin lymphoma (NHL) survival in servicemembers who have previously deployed. Additionally, there are no studies comparing risk of aggressive B-cell lymphoma in these patient populations. Methods: Documented cases of NHL in the DoD's Tumor Registry (Oncolog) from 2001-2022 were obtained. This information was compared to the Defense Manpower Data Center's deployment data and the two datasets were merged. ADSMs and retirees were included; dependents were excluded. A multivariable logistic regression analysis was done to assess the impact of prior deployment on cancer survival in NHL, accounting for age, race, cancer stage, ethnicity, and gender. Results: There were 2,295 servicemembers and retirees diagnosed with NHL from 2001-2022. About 20% had previously deployed (n=467). Median age at diagnosis in those who had deployed was 35 years compared to 54 years for non-deployed (p<0.001). Race, ethnicity, and gender were similar between both arms. Multivariable logistic regression analysis demonstrated prior deployment was associated with better survival after accounting for age, race, stage, ethnicity, and gender (OR 0.63, 95% CI 0.40-0.97, p=0.037). In addition to deployment status, other variables that influenced survival were age (OR 1.04, 95% CI 1.03-1.54, p<0.001), stage (OR 2.92 for stage IV vs. stage I, 95% CI 2.06-4.15, p<0.001), and race (OR 1.97 for black vs. white race, 95% CI 1.37-2.83, p<0.001). To assess whether NHL subtype played a role in these findings, a post-hoc analysis was performed on patients with B-cell NHLs, revealing that ADSM with prior deployment were equally likely to have indolent and aggressive subtypes of B-cell NHL as ADSM who had never deployed. Among personnel with prior deployment, 29.6% and 70.4% had indolent and aggressive B-cell NHLs respectively, compared to 32.9% and 67.1% amongst those who never deployed (p=0.25). Conclusions: Military personnel with NHL who had previously deployed lived longer than those with no prior deployment, even after adjusting for age differences between the two cohorts. These findings are not attributable to B-cell NHL subtype (i.e. deployed personnel did not have more indolent NHLs than non-deployed personnel). These results highlight the healthy deployer effect, in which ADSM who are deployable are required to meet minimum fitness standards, undergo a physical health assessment, and do not have disqualifying comorbidities. This study did not evaluate whether an overseas deployment is associated with an increased risk of NHL, but it does appear to provide evidence that potential deployment-related exposures do not appear to alter the biology or subtype of B-cell NHLs. Disclaimer: The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of the Department of Defense (DoD) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Development and Characterization of a Novel Murine Peripheral T-Cell Lymphoma Cell Line Which Closely Mimics Human Disease

Peripheral T-cell lymphoma (PTCL) represents a heterogenous group of aggressive non-Hodgkin lymphomas with poor prognostic outcomes and limited treatment options. Despite the advances in genomic sequencing and molecular characterization, the complex and elusive nature of PTCL's underlying biology has proven difficult to fully understand and manage effectively. The development and refinement of therapeutic strategies for PTCL are impeded by a paucity of reliable preclinical models that accurately mimic the disease's pathophysiology. There is a dire need for more physiologically relevant models for PTCL. Improved models allow for a better understanding of the disease's molecular and cellular mechanisms, facilitate the development of innovative therapeutic strategies, and ultimately improve patient outcomes. Here we described a new T-cell lymphoma cell line (LM-23) derived from a 12-week-old female Balb/cJ mouse which developed diffuse adenopathy and splenomegaly. Tumors from this mouse were cultured in cRPMI + 10% fetal bovine serum for 4 weeks without supplementation of additional cytokines and passaged 3-4 times per week where we found the cells to be non-adherent. Immunophenotyping of LM-23 demonstrated positivity for CD90, CD3, TCR-beta, CD4(partial/subset), CD8, PD1 (positive), ICOS (positive) and negative for B-cell and myeloid lineage markers (Fig. 1B). This immunophenotype most closely resembles PTCL-NOS in humans at an immunophenotypic characterization level. Whole exome sequencing is in progress and will be presented. Intravenous administration of this cell line to syngeneic Balb/cJ mice resulted in rapid establishment of diffuse adenopathy, splenomegaly, and liver metastases. Bulky adenopathy was observable within 14 days of administration. Histologically, these tumors consisted of sheets of medium to large sized lymphocytes with clumped chromatin and prominent nucleoli, similar to human T-cell lymphomas (Fig. 1A). Subcutaneous administration demonstrated rapid tumor growth with mice reaching terminal endpoints (>2,000mm 3) within 21 days following administration. As CHOP-based (cyclophosphamide, doxorubicin, vincristine, and prednisone) therapies are the primary backbone for treatment of PTCL, we tested whether CHOP therapy alone had anti-tumor activity to LM-23. Tumor bearing mice (~150mm 3) were treated with CHOP and monitored for tumor growth. All mice treated were non-responsive to CHOP therapy with no difference in tumor growth compared to untreated mice. Additionally, LM-23 bearing mice treated with anti-PD1 showed signs of hyperprogression, which has been observed in human patients in clinical trials (Gao Y et al. JCI Insight 2023, Bennani NN et al. Blood Supplement 2019). Additional therapeutic target testing is underway and will be presented. In conclusion, the newly established LM-23 T-cell lymphoma cell line provides a novel, physiologically relevant preclinical model for the study of PTCL. Its phenotypic characteristics, rapid growth, and metastatic behavior in syngeneic mice, along with its resistance to CHOP therapy and hyperprogression upon anti-PD1 treatment, mimicking the clinical scenarios observed in some human PTCL patients. These features highlight LM-23's potential as a valuable tool for understanding the biological mechanisms underlying PTCL and for the development and testing of innovative therapeutic strategies. We hope that the LM-23 cell line will contribute significantly to these efforts, ultimately improving outcomes for patients afflicted with PTCL.

Primary Analysis and Results of Bendamustine, Rituximab, and Venetoclax (BR-VEN) for Initial Treatment of Mantle Cell Lymphoma in Subjects over 60 Years of Age (PrE0405)

Background Mantle cell lymphoma (MCL) is an incurable form of aggressive non-Hodgkin lymphoma. Treatment choice at diagnosis is based on tolerability of cytarabine and high-dose chemotherapy. With a median age of 60-70 years, many patients are ineligible for aggressive treatment. Bendamustine and rituximab (BR) is a reasonable treatment option (E1411, Smith MR et al. ASH 2022) for this patient population and venetoclax (VEN) has shown pre-clinical evidence of synergy with chemoimmunotherapy. PrECOG 0405 was designed to evaluate the addition of VEN to BR in previously untreated patients with MCL aged over 60 years. Methods Eligible patients included those that were previously untreated and diagnosed with MCL as defined as the presence of t(11;14) by FISH or cyclin D1 expression by IHC. Patients must have been at least 60 years of age or older on D1C1 of therapy with a good performance status (ECOG 0-2). Adequate marrow and organ function was required, specifically a creatinine clearance of ≥ 40 mL/min. Treatment administration is summarized in Figure 1. Dose of bendamustine was either 90mg/m 2 D1&2; or, for subjects over the age of 75 years, 70mg/m 2 was allowed per investigator discretion. VEN was dose escalated during Cycle 1 to 200mg. At the time of C2, BR was repeated and VEN was also escalated to 400mg. With C2-6, VEN 400mg PO daily was given D1-10 only. Primary endpoint was PET-negative complete response (CR) rate at end of treatment (EOT) by Lugano Criteria. A negative bone marrow biopsy was required to confirm CR if involved at screening. Minimal residual disease (MRD) by next-generation sequencing was performed at the EOT. Maintenance rituximab was encouraged per investigator discretion. This was a single arm study with an original accrual goal of 53 subjects to detect a 15% improvement in CR rate compared to historical data. However, due to slow study accrual during COVID pandemic and preliminary efficacy data from E1411 study, the statistical parameters were updated after 25 subjects had been accrued. The revised accrual goal was 33 patients to obtain 32 eligible and treated patients, which provided 81.8% statistical power to detect a 17% difference in CR rate (from 60% [E1411 data] to 77%) using an exact binomial test with a 1-sided alpha of 11.6%. This combination regimen will be considered promising if 23 or more (out of 32) patients attain CR. Results From January 2020 to March 2022, 33 subjects enrolled and were treated on study. Subject characteristics are listed in Table 1. Seven (21%) unique subjects were treated with 70mg/m 2 of bendamustine during induction cycles. Laboratory tumor lysis syndrome (TLS) was seen in 2/33 during C1 only; clinical TLS was not seen. Treatment was generally well tolerated with treatment-related adverse events (TRAE) of Grade ≥3 and occurring in >10% of subjects being neutropenia (n=5, 15%), thrombocytopenia (n=5, 15%) and lymphopenia (n=9, 27%). Other common non-hematologic TRAE of all grades were nausea/vomiting (n=26, 79%), diarrhea (n=10, 30%), and fatigue (n=17, 52%). There were 4 (12%) instances of COVID-19/COVID-19 pneumonia considered treatment related. Dose adjustments and delays for any drug occurred in 36% and 67% of subjects respectively. 22/33 (66.7%) subjects completed 6 cycles of BR-VEN. Maintenance rituximab was administered in 19/33 (57.6%) of subjects. Overall response rate was 97% (32/33) and PET-negative bone marrow biopsy confirmed CR Rate at EOT was 85% (28/33), achieving the primary endpoint (≥23 CRs). MRD at EOT is under analysis. With a median survival follow up of 21.5 months (mo), Median PFS and OS were not reached; estimated 2-year PFS and OS was 69.7% and 81.1% respectively. During follow up, there have been 6 deaths, 4 from COVID-19 (all in remission), one from influenza A (in remission), and one from disease progression (non-responding pt). There have been 2 other progression events who are alive. Conclusions BR-VEN was generally well-tolerated in this older patient population though GI toxicities were common. With a PET-negative CR rate of 85%, the combination is promising but longer follow-up is needed. There was a competing risk of death related to upper respiratory viruses identified, mostly COVID-19, as has been seen in other BR-based protocols during the COVID-19 pandemic. MRD analysis and survival data will be updated.

Circulating Tumor DNA (ctDNA) for Plasma Genotyping and Disease Monitoring in ALK-Positive Anaplastic Lymphoma (ALK+ALCL): A Proof of Concept Study

Introduction Circulating tumor DNA (ctDNA) detection has not been reported yet in ALK-positive anaplastic large cell lymphoma (ALK+ALCL), a rare aggressive non-Hodgkin lymphoma with a peak incidence in children, adolescents and young adults. In this study, we aimed to evaluate whether ctDNA can be detected, characterized and used to monitor minimal residual disease (MRD) in ALK+ALCL. Patients and Methods Plasma samples were collected from 23 French patients diagnosed with ALK+ALCL between November 2020 and March 2023. Based on cell-free DNA (cfDNA) extracted from plasma, we performed shallow whole genome sequencing (shWGS) and a comprehensive genomic profiling (CGP) of more than 500 genes covered at a median depth of over 3000 unique reads to assess ctDNA content. In this study, we defined samples as positive if they had a tumor fraction over 3%, evaluated by shWGS analysis, or if ALK rearrangements were identified using CGP. Additionally, ALK rearrangement genomic breakpoint were defined by CGP analysis. For each patient, specific digital droplet PCR (ddPCR) assays were designed based on the identified breakpoints to monitor ctDNA content during the ALK+ALCL disease follow-up. Results The median age of patients at the time of diagnosis was 13 years (range: 4-54). Sixteen patients, (69.6%) received at least one ALK tyrosine kinase inhibitor (TKI). A total of 80 plasma samples were collected at various time points from the 23 patients, with a median of 3 samples per patient (range: 1 - 20). Four samples failed for DNA extraction, resulting in 76 samples available for molecular analysis Of the 76 samples, 43 (56.6%) were analyzed using shWGS, 19 (25%) using CGP among which, 14 were analyzed using both techniques. CGP was found to be a more sensitive method for detecting ctDNA in ALK+ALCL compared to shWGS, with 12 out of 14 samples (85.7%) tested positive with CGP, compared to 5 out of 14 samples (35.7%) with shWGS (p<0.01). Of the 19 samples tested with CGP, ALK rearrangement was identified in 14 samples (73.7%), with NPM1:: ALK fusion detected in 11 samples, and ATIC:: ALK, TRAF1:: ALK and EEF1G:: ALK detected in one sample each. The average tumor mutational burden was low, with 5.3 mutations per megabase (mut/Mb) (range: 0-14.5 mut/Mb). No microsatellite instability was detected. Amplification of MDM4 and MYC genes was observed in three patients each. ANKRD26 was the most frequently mutated gene in the study, with four patients affected. LRP1B, epigenetic modifiers such as EP300 and KMT2A, and TP53 were mutated in three patients each. Interestingly, CGP allowed the identification of the ALK:c.3520T>C;p.(Phe1174Leu) mutation in a plasma sample collected during disease progression while the patient was on long lasting crizotinib therapy. Finally, we monitored MRD, based on ctDNA detection in 49 samples from 12 patients using ddPCR assays. Our results were compared with the established gold standard for MRD monitoring in ALK+ALCL, i.e. RT-PCR on circulating cells performed on the same samples. The ddPCR assay showed a 87% sensitivity, 100% specificity, 100% positive predictive value, and 83% negative predictive value. However, four samples had false-negative results due to pre-analytical sampling issues. These samples had been stored at room temperature without undergoing centrifugation for more than 24 hours. Conclusion To date, this study is the first to report on the feasibility and clinical value of ctDNA for the management of ALK+ALCL patients. CGP demonstrated high sensitivity in detecting ctDNA, identifying the genomic breakpoint within the ALK gene and, for the first time in ALK+ALCL, detecting resistance mutations to ALK TKI. Additionally, our unique patient-specific ddPCR approach was proven to be a cost-effective method for MRD monitoring. Altogether, these findings serve as a proof-of-concept for the development of ctDNA techniques in the clinical management of ALK+ALCL.

Overall Survival Following First and Second Relapse of DLBCL Treated with Therapies Including Autologous Transplant and CAR-T Cells: Results from the Lion Prospective Observational Registry

Background: Diffuse large B cell lymphoma (DLBCL) is the most common subtype of aggressive non-Hodgkin lymphoma (NHL) and is curable with first-line conventional chemotherapy, but a significant fraction of patients relapse or do not respond to initial therapy. There are a variety of treatments available for relapsed/refractory (RR) disease, including platinum-based salvage chemotherapy often used historically both with or without autologous stem cell transplant, and chimeric antigen receptor T-cell (CAR-T) therapy emerging more recently as a second-line option. We report survival data following 2 nd and 3 rd line therapy for RR DLBCL in a large contemporary prospective cohort. Methods: We selected patients (pts) from the Lymphoma Innovations ORIEN Network (LION) with diffuse large B-cell lymphoma, not otherwise specified and high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements (“double-hit” lymphoma) who had previously received R-CHOP chemotherapy. All patients had signed written consent. Clinical data were abstracted from medical records using standardized protocol. Overall survival was estimated using Kaplan-Meier and defined as time from start of 2 nd (OS2) or 3 rd (OS3) line treatment until death, censoring patients alive at last follow-up. Comparisons of OS were performed using the log-rank test. Results: A total of 328 patients with RR DLBCL who received 2 nd line treatment were included, 177 of whom went on to receive 3 rd line therapy. Baseline characteristics included male sex in 205 pts (65%), stage III/IV disease in 244 pts (81%), and extranodal involvement in 183 pts (63%). Second line treatments included platinum-based salvage chemotherapy both with (99 pts) and without (88 pts) autologous stem cell transplant, rituximab plus gemcitabine and oxaliplatin (30 pts, grouped distinctly from platinum-based salvage chemotherapy), CAR-T therapy (43 pts), polatuzumab vedotin (17 pts), and other classes of treatment (51 pts). Median OS2 for 2 nd line platinum-based salvage chemotherapy with autologous transplant was 110.4 months compared with 50.4 months for platinum-based salvage chemotherapy without transplant. OS2 for platinum-based salvage chemotherapy with autologous transplant was 96.5% (95% CI 90-99) at 12 months, 90.7% (95% CI 81-96) at 24 months, and 79.3% (95% CI 67-88) at 60 months compared with 77.1% (95% CI 66-85) at 12 months, 65.5% (95% CI 52-76) at 24 months, and 38.1% (95% CI 21-55) for platinum-based salvage without transplant. OS2 for rituximab plus gemcitabine and oxaliplatin was 81.7% (95% CI 58-93) at 12 months, still 81.7% (95% CI 58-93) at 24 months, and 70.1% (95% CI 37-88) at 60 months. OS2 for CAR-T cell therapy was 75% (95% CI 50-89) at 12 months and 62.5% (95% CI 36-80) at 24 months, it could not be calculated at 60 months. OS2 for polatuzumab vedotin was 73.5% (95% CI 36-91) at 12 months and could not be calculated at 24 or 60 months. OS3 for platinum-based salvage chemotherapy with autologous transplant was 100% at 12 months and 83.3% (95% CI 27-98) at 24 months compared with 70.7% (95% CI 34-90) at both 12 and 24 months for platinum-based salvage without transplant. OS3 for rituximab plus gemcitabine and oxaliplatin was 75% (95% CI 13-96) at 12 months and 50% (95% CI 6-85). OS3 for CAR-T therapy was 86.3% (95% CI 75-93) at 12 months, 65.8% (95% CI 50-78) and 46.3% (95% CI 22-68) at 60 months. OS3 for polatuzumab vedotin was 53.4% (95% CI 24-76) at 12 months and 40.1% (95% CI 12-67) at 24 months. Conclusions: We observed a statistically significant difference by log-rank in OS2 in patients receiving platinum-based salvage chemotherapy followed by autologous stem cell transplant compared to other therapies in a contemporary cohort of pts with RR DLBCL. This difference is likely driven in part by transplant being a surrogate marker for efficacy of salvage chemotherapy. OS3 was also highest at 12, 24, and 60 months in patients receiving platinum-based salvage chemotherapy followed by transplant. Other therapies including CAR-T cells, polatuzumab vedotin, and rituximab plus gemcitabine and oxaliplatin did not demonstrate significantly different rates of overall survival in the 2 nd or 3 rd line setting.