De-novo Diffuse Large B-cell Lymphoma Research Articles

CNS Prophylaxis Among Patients with HIV-Associated Diffuse Large B-Cell Lymphoma - a Single Center Retrospective Study

Title: CNS Prophylaxis Among Patients with HIV-Associated Diffuse Large B-Cell Lymphoma - A Single Center Retrospective Study Introduction: Patients with Human Immunodeficiency Virus (HIV) are known to develop Lymphoma at a higher rate compared with the general population, with Diffuse Large B-Cell Lymphoma (DLBCL) being the most common subtype. Historically, before the advent of HIV treatment with antiretroviral therapy (ART), HIV-associated DLBCL was considered a more aggressive type of lymphoma and all patients were treated with central nervous system (CNS) prophylaxis. However, since ART has been widely adopted, there is some data to suggest that HIV-associated DLBCL among those taking ART more closely resembles de-novo DLBCL and may not need to be universally treated with CNS prophylaxis. There are no good prospective trials evaluating which patients who develop HIV-associated DLBCL while on ART should receive CNS prophylaxis. Furthermore, studies that tried to predict which DLBCL patients are at greater risk for CNS relapse explicitly excluded patients with HIV. Despite the absence of data, guidelines have shifted and current NCCN guidelines now recommend that HIV patients with DLBCL should be risk stratified as de-novo DLBCL patients with respect to CNS directed therapy. In this study, patients with HIV-associated DLBCL were retrospectively analyzed to understand the patterns of CNS prophylaxis and effects on relapse free survival. Methods: The Electronic Medical Record was queried at a large academic medical center in New York City for patients with HIV-associated DLBCL between the years of 2012 and 2021 using ICD-10 codes. Other subtypes of Lymphoma such as Burkitt's or Plasmablastic Lymphoma were excluded. Patients who did not receive their entire treatment course within the institution were also excluded. Clinical characteristics at diagnosis, treatment type, CNS prophylaxis, and survival data was collected and analyzed. Results: A total of 38 patients were identified according to the inclusion criteria. 26 patients (68%) underwent screening lumbar punctures (LPs) for CNS disease while 12 patients (32%) did not. The two groups were not statistically different within any categories except for LDH, where the LP group had a median LDH of 492 units/L and the non-LP group had a median LDH of 241 units/L (p-value: 0.031). The two groups were not statistically different in cell of origin subtypes, stage, bone marrow involvement, kidney/adrenal involvement, the use of ART prior to diagnosis, IPI or CNS-IPI scores. In addition, among the group that had an LP done with no CNS involvement (n=25), there was no statistical difference in relapse-free survival among those who received adequate CNS prophylaxis and those who did not (p-value 0.886). Conclusions: Among patients with HIV-associated DLBCL in a large academic medical center in New York City, there is no reliable indicator to predict which were offered screening lumbar punctures and which were not. Clinicians may be using additional measures of aggressiveness not accounted for in standard IPI and CNS-IPI scoring algorithms. Furthermore, there was no clear benefit in relapse free survival among high-risk patients who received adequate CNS prophylaxis versus those who did not in this limited sample size. Further research is needed to determine whether patients with HIV-associated DLBCL should be risk stratified similarly to de-novo DLBCL patients with respect to CNS prophylactic therapy.

Nanochip Technology for Monitoring Chemotherapy Response Using Extracellular RNAs and Proteins in Patient Plasma with Diffuse Large B-Cell Lymphoma As Biomarkers

Introduction Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Assessment of therapeutic response and monitoring for relapse are important components of clinical care in this entity. Although circulating tumor DNA (ctDNA) has shown to be a potential biomarker, it is affected by gene dysregulation and limited by cost, as it requires high amplification, especially in early stage DLBCL since only ~100 ng free DNA fragments are detected in 1 mL blood. Extracellular vesicles (EVs), on the other hand, are abundant in the blood (1011 - 1012 in 1 mL blood), making quantitative analysis easier and less expensive. This OSU based technology has been extensively studied in lung and pancreatic cancer as well as chronic lymphocytic leukemia and multiple myeloma with promising results. Hence, we sought to evaluate whether Immune Lipoplex Nanoparticle (ILN) biochip-based testing (the first of its kind to monitor patients with lymphomas) can serve as a useful means to follow select biomarkers for monitoring therapeutic response. Methods This is a single-center prospective study of de-novo DLBCL patients wherein the patient samples were longitudinally collected before, during, and after chemotherapy upto 2 years every 3 months. The patients were classified as responders if they achieved complete remission (CR) to chemotherapy following cycle 6 (C6), and non-responders/primary progressors if they had progression. In ILN biochip assay, tethered antibodies on the chip surface can capture and sort an EV subpopulation rich with specific membrane proteins after washing. The fluorescence labeled antibodies or cationic lipoplex nanoparticles (CLNs) containing molecular beacons (MBs) are then added to fuse with captured EVs for the detection of membrane protein or mRNA targets respectively. Well known B-cell markers (CD10, CD19, CD20, MUM1, BCL2, BCL6, and cMYC) and a relatively new lymphoma biomarker, CD47 was measured in plasma samples from DLBCL patients before and after chemotherapy with ILN biochips. EV subpopulations rich in CD20 and/or CD19 (DLBCL markers) or CD63/CD9/CD81 (exosome markers) were captured by antibodies tethered on the biochip surface. Subsequently, ILN biomarker measurements were obtained for CD10, CD19 and CD20 protein expressions by fluorescence-labeled antibodies on anti-CD19/CD20 captured B-cell dominated EV subpopulation; MUM1, BCL2, BCL6, cMYC, and PRMT5 mRNA expressions by MBs encapsulated in CLNs in anti-CD63/CD9/CD81 captured exosome-dominated EV subpopulation; and CD47 protein expression by fluorescence-labeled antibodies on the anti-CD47 captured/ CD47-rich EV subpopulation. Results For plasma samples taken before treatment (C0), the exosomal cMYC, BCL2, and BCL6 mRNA expressions could discriminate between healthy donors (HDs, n=17) and patients (n=27), while other B-cell markers did not perform well (Figure 1A). Since BCL2 and BCL6 detection demonstrated similar trends with BCL2 performing slightly better, exosomal cMYC and BCL2 mRNA expressions were selected as the biomarker classifiers. CD47 protein expression by CD47-rich EVs also discriminated between HDs and patients well in pre-treatment (C0) samples (Figure 1A). During chemotherapy, the EV CD47 expression demonstrated a greater decrease in responder samples (n=20) than in non-responder samples (n=7) obtained after C3 showing a statistically significant difference (Figure 1B). Longitudinal CD47 expression (i.e., C1 and C3) on CD47+ EVs could serve as a potential biomarker to discriminate between responders and non-responders of DLBCL patients undergoing chemotherapy with AUC~0.80 (Figure 2). The results of the longitudinal tri-biomarkers, i.e., CD47(C3)/cMYC(C0)/BCL2(C0) expressions will be presented at the meeting. Conclusions We discovered a new longitudinal tri-biomarker classifier based on CD47/cMYC/BCL2 expression after early chemotherapy treatment (C0 and C3) for monitoring chemotherapy response in DCBCL. However, the sample size, particularly in the non-responder cohort (n=7) is small to make any statistically meaningful conclusions. Additional patient samples are being collected to validate these findings. Lastly, to improve the biomarker classifier performance for chemotherapy monitoring (and maybe relapse surveillance), we are conducting an EV mRNA profiling study to identify novel biomarker candidates. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Distinct Chemokine Receptor Expression Profiles in De Novo DLBCL, Transformed Follicular Lymphoma, Richter's Trans-Formed DLBCL and Germinal Center B-Cells.

Chemokine receptors and their ligands have been identified as playing an important role in the development of diffuse large B-cell lymphoma (DLBCL), follicular lymphoma, and Richter syndrome (RS). Our aim was to investigate the different expression profiles in de novo DLBCL, transformed follicular lymphoma (tFL), and RS. Here, we profiled the mRNA expression levels of 18 chemokine receptors (CCR1–CCR9, CXCR1–CXCR7, CX3CR1 and XCR1) using RQ-PCR, as well as immunohistochemistry of seven chemokine receptors (CCR1, CCR4–CCR8 and CXCR2) in RS, de novo DLBCL, and tFL biopsy-derived tissues. Tonsil-derived germinal center B-cells (GC-B) served as non-neoplastic controls. The chemokine receptor expression profiles of de novo DLBCL and tFL substantially differed from those of GC-B, with at least 5-fold higher expression of 15 out of the 18 investigated chemokine receptors (CCR1–CCR9, CXCR1, CXCR2, CXCR6, CXCR7, CX3CR1 and XCR1) in these lymphoma subtypes. Interestingly, the de novo DLBCL and tFL exhibited at least 22-fold higher expression of CCR1, CCR5, CCR8, and CXCR6 compared with RS, whereas no significant difference in chemokine receptor expression profile was detected when comparing de novo DLBCL with tFL. Furthermore, in de novo DLBCL and tFLs, a high expression of CCR7 was associated with a poor overall survival in our study cohort, as well as in an independent patient cohort. Our data indicate that the chemokine receptor expression profile of RS differs substantially from that of de novo DLBCL and tFL. Thus, these multiple dysregulated chemokine receptors could represent novel clinical markers as diagnostic and prognostic tools. Moreover, this study highlights the relevance of chemokine signaling crosstalk in the tumor microenvironment of aggressive lymphomas.

PB2132: COPANLISIB PLUS RITUXIMAB-BENDAMUSTINE FOR RELAPSED-REFRACTORY DIFFUSE LARGE B-CELL LYMPHOMA: RECRUITMENT UPDATE ON AN ONGOING PHASE II TRIAL OF THE FONDAZIONE ITALIANA LINFOMI (FIL_COPA-RB)

Background: Diffuse large B cell lymphoma (DLBCL) is curable in 50-60% of cases with frontline RCHOP. Relapsed/refractory (R/R) DLBCL can be cured with salvage treatments in roughly 40-50% of cases with standard available treatments which include high dose-chemotherapy plus autologous stem cell transplant (ASCT) in fit patients, and chimeric antigen receptor T-cells (CAR-T), permitted as third or subsequent line in patients with no major comorbidities. The outcome of R/R DLBCL unresponsive or ineligible to ASCT or CAR-T is highly unfavorable and new treatment options are needed. Rituximab plus bendamustine (RB) is active in R/R DLBCL with overall response rates (ORR) of 40-60% but generally short-lasting. Copanlisib is an intravenous pan-class I PI3K inhibitor with predominant activity against PI3K-α and -δ isoforms, active as single agent in DLBCL with ORR 25% (NCT02391116). The combination of copanlisib plus RB (Copa-RB) has showed a safe toxicity profile in R/R indolent lymphomas (iNHL) (NCT02626455). Aims: To assess the safety and efficacy of Copa-RB followed by copanlisib maintenance in R/R DLBCL not eligible or relapsed after ASCT or CAR-T. Methods: FIL Copa-RB is a multicentric open-label single arm, phase II trial. An estimated 81 patients will be enrolled, from 30 centers in Italy. Main inclusion criteria are patients aged ≥ 18 affected by DLBCL (including de-novo DLBCL, DLBCL transformed by iNHL and high-grade lymphoma) or FL grade IIIb R/R after ≤ 3 previous lines of therapy, ineligible or R/R to ASCT or CART, ECOG PS ≤ 2. Patients with primary mediastinal B cell lymphoma histology, significant organ dysfunction, uncontrolled hypertension and hyperglycemia (HbA1c> 8.5%) are excluded. Treatment consists of an induction phase with six 28-day cycles of Copa-RB (copanlisib 60 mg intravenously on day (D) 1, D8 and D15, rituximab 375 mg/m2 on D1, bendamustine 90 mg/m2 on D1-D2) followed by a maintenance phase of twelve 28-day cycles of copanlisib 60 mg given on D1 and D15. The primary endpoint is progression free survival (PFS) defined as the time between the date of enrolment and the date of disease progression, relapse or death from any cause, whichever occurs earlier, with an expected improvement of 12-month PFS from 20% to 35%. Secondary endpoints include overall survival, ORR, complete response (CR) rate, duration of response and rate of response improvement during maintenance. Exploratory analysis will include association between outcome and cell of origin, MYC, BCL2 and BCL6 overexpression and rearrangements, and mutational analysis of selected genes possibly involved in predicting response to copanlisib. The expected study duration from first patient’s first visit to last patient’s last visit is approximately 4 years. Results: The recruitment started in November 2020; at March 1st, 27/81 patients have been enrolled. Results for this study are not yet available. Summary/Conclusion: The treatment of R/R DLBCL ineligible or R/R to ASCT or CAR-T is still an unmet clinical need and new therapeutic strategies are warranted. Copanlisib as single agent has been already shown a moderate activity in DLBCL and the association Copa-RB plus copanlisib maintenance could be a new treatment option to improve the outcome of these patients. Biomarkers studies may further elucidate patients who are more likely to respond to this treatment. Funding: The study is sponsored by the Fondazione Italiana Linfomi; Bayer partly supported the study and kindly provided Copanlisib; Sandoz kindly provided Rituximab.

R-CHOP Chemotherapy Including Biosimilar Rituximab (Redditux ®) for De-Novo Diffuse Large B-Cell Lymphoma Patients: Real-Life Single Center Experience

BackgroundThe biosimilar rituximab (Redditux) was approved in Turkey for all indications of the reference molecule (MabThera) in March 2018. Large clinical trials and real-life experiences are lacking in hematological malignancies.AimsWe aimed to evaluate the efficacy and safety of Redditux in de-novo diffuse large B-cell lymphoma (DLBCL).MethodsOur institution decided to provide Redditux for hematological indications since February 2019. We retrospectively analyzed medical records of 51 consecutive de-novo DLBCL patients (pts) diagnosed between February 2019 and September 2019 in the hematology department of Istanbul University Istanbul Medical Faculty. We compared the response rates with historical controls treated with MabThera-CHOP at Cerrahpaşa Medical Faculty. Our study was approved by I.U. Istanbul Medical Faculty Ethical Committee (2019/1454).ResultsA total of 51 pts without CNS involvement received Redditux-CHOP. Median follow-up was 24 months (range: 8-31). A median of 6 cycles of biosimilar (range: 4-8) was administered. Four pts with high CNS-IPI score received four intrathecal methotrexate injections and 13 pts had additional radiotherapy for their initial bulky disease. The patient characteristics and response rates of the Redditux and historical MabThera cohorts are summarized in Table 1.Apart from 6 cases who were refractory to Redditux-CHOP, 8 pts had progressive disease (6 with CR, 1 with PR and 1with SD) in the follow-up. The median time to relapse was 11.5 months for 6 cases who had CR following first-line treatment. Five of 8 cases with PD experienced CNS relapse. Their CNS-IPI score (Schmitz et al. J Clin Oncol 2016) were low in 2 pts, intermediate in 2 pts and high in 1 patient. Of 11 pts with bone involvement at the time of diagnosis, three cases had CNS relapse (p=0.028). Two pts with CNS relapse were treated with intrathecal chemotherapy only due to their poor performance status. Eight pts received salvage combination chemotherapy [R-ICE (n=3); R-benda (n=3); R-DHAP (n=1); MATRix (n=1)] and two of them responded. One of these 2 cases underwent auto-SCT and the other proceeded to allo-SCT; however, he died during conditioning treatment.Ten pts died in the follow-up. Causes of death were progressive disease (n=7, two cases with CNS involvement), infection during allo-conditioning (n=1), post-COVID herpes zoster infection (n=1) and unknown (n=1).The 24 month PFS and OS rates were 75.8% (95% CI: 0.61-0.85) and 80.3% (95% CI: 0.67-0.89) for Redditux cohort, respectively. In the historical MabThera group, the 24 month PFS and OS rates were 85.2 (95% CI: 0.79-0.90) and 81.4% (95% CI: 0.75-0.86), respectively.For pts with high R-IPI score in the Redditux cohort (3-5); the 24-month PFS and OS rates were 54.2% (95% CI: 0.29-0.74) and 55.6% (95% CI: 0.31-0.75), respectively. In the historical Mabthera group, the 24-month PFS and OS rates were 68.7% (95% CI: 0.53-0.80) and 59.4% (95% CI: 0.47-0.70), respectively. Although the PFS rates seems to be worse in high R-IPI cases receiving Redditux, the difference was not significant (p=0.18; Figure 1).AEs were reported in 51% (n=26) of patients. Most common AE was grade 2 infusion reactions (shivering, nausea, fever) requiring medical intervention in 20% of pts, accompanied with rash in half of them. Grade 3&4 AEs were leucopenia (n=2; 4%), neutropenia (n=20; 39%) febrile in 2 cases, anemia (n=6; 12%), thrombocytopenia (n=3; 6%). Grade 2 pneumonia (n=2) and urinary tract infections (n=2) were other infectious complications.ConclusionAlthough the PFS rate at 24 months in high-IPI group treated with Redditux seems to be lower compared to MabThera treated historical control group, survival rates were not significantly different. Our results should be cautiously evaluated due to small sample size. Compared to the original trial of MabThera added to CHOP based regimen, (Coiffier et al N Eng J Med. 2002), our CR rates in stage 2-4 pts seem to be slightly lower (70.7% vs 76%), although the OS rates are quite similar (86.3% vs 82%). Grade 3&4 neutropenia requiring empirical administration of G-CSF was 39% in our cohort. Infusion reactions were observed in 20% of pts, which was reported to be around 30% with original molecule (Patel et al. Clin Lymphoma Myeloma Leuk 2019). The CNS relapse rate was relatively high (9.8%) in our cohort. Prospective randomized clinical trials are needed to determine the efficacy and safety profile of Redditux. [Display omitted] DisclosuresFerhanoglu: Takeda Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees.

CD38 expression is an important prognostic marker indiffuse large B-cell lymphoma.

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous group of diseases with variable outcomes. Although several prognostic markers have been developed, specific biomarkers for stratifying treatment strategies have not been fully investigated. This study aimed to analyze the clinical impact of the expression of cluster of differentiation (CD) 38, which is associated with cellular proliferation and disease progression, in patients with de-novo DLBCL. Using flow cytometry analysis, 137 cases with DLBCL were investigated for surface expression of CD38. Based on the cut-off value by the survival classification and regression tree analysis, the patients were categorized into a CD38HIGH group (n=37) and CD38LOW group (n=100). The 4-years progression-free survival (PFS) was 31.6% in the CD38HIGH group and 60.7% in the CD38LOW group (p<0.001). Multivariate analysis showed the CD38HIGH group to be associated with significantly worse PFS (adjusted hazard ratio [aHR], 2.15, 95% CI: 1.26-3.68, p=0.005) and poor overall survival (OS) (aHR, 2.54, 95% CI: 1.25-5.19, p=0.010) than the CD38LOW group. In conclusion, we demonstrated that high CD38 expression is an independent adverse prognostic factor associated with poor clinical outcomes compared to low CD38 expression. CD38 expression in DLBCL cells might be useful for predicting outcomes and designing risk-adapted therapies for patients with de-novo DLBCL.

The Efficacy and Safety of Anti-CD19 CAR T-Cell Therapy in Young Adults with Relapsed and Refractory Aggressive B-Cell Malignancies—the Experience of a Single Center in Israel

Background: Early encouraging results from pharma sponsored phase 2 studies on treatment with autologous T-cells expressing anti-CD19 chimeric antigen receptor (CAR T-cells) in relapsed/refractory (R/R) aggressive B non-Hodgkin lymphomas are emerging. The outcome of patients reported in these studies compares favorably with historical data for patients treated with current standards of care. However, centralized manufacturing of these cells by pharma industry after commercialization may cause enormous logistical and financial burden to distant treating centers, especially those located outside the US. We report here our initial experience with local production of CD19-directed CAR T-cells and clinical results of young adult patients treated at Sheba Medical Center.Methods: A phase 1b/2 study of anti-CD19 CAR T-cell therapy in pediatric and young adults with B-cell Malignancies (NCT02772198) is now underway. Patients, age 1-50 years, with R/R B-cell malignancies and adequate organ function are eligible. CD19 expression on at least 70% of malignant cells is required. The approach uses a CAR construct that is composed of an anti CD19 single-chain Fv, FMC63, CD28 co-stimulatory and CD3-zeta intracellular domains. The CAR, which was designed by the NCI, is transfected by retrovirus into bulk-stimulated autologous peripheral blood (PBL) cells. Treatment includes lymphodepletion with fludarabine 30 mg/m2 X 3 days and cyclophosphamide 900 mg/m2 x 1 day, followed by infusion of fresh transduced T cells after 9-10 days of culture. The primary end points are safety and best overall response rates (ORR), documented 28 days after infusion.Results: As of November 2016, 8 adult patients were enrolled. The characteristics of the patients and their status following treatment are listed in the table. Briefly, 7 of them were male. Median age was 36 years (range 23-47). Four patients were diagnosed with de-novo diffuse large B cell lymphoma (DLBCL), 1 - transformed DLBCL, 1- primary mediastinal B cell lymphoma, 1 - extramedullary relapse of B-acute lymphoblastic leukemia (ALL), and 1 - Burkitt lymphoma (BL). Median number of prior therapies was 3 (range 2-5). All patients were refractory to their last therapy, including 3 cycles of blinatumomab given to the patient with B-ALL. Three had prior stem cell transplantation (1 allogeneic and 2 autologous). Patients received CAR T-cells in a dose range of 0.3 -1.5 x 106/kg, median 1 x 106/kg. The number of CAR-positive blood cells, detected by qPCR on DNA of PBL mononuclear cells, peaked between 7-14 days. Four patients developed cytokine release syndrome (CRS): 3 patients had grade 1, while one patient had concomitant grade 3 CRS and neurologic toxicity (encephalopathy and seizures). This patient was treated with tocilizumab and high dose dexamethasone, achieving complete recovery. The patient with BL had gastric sealed-perforation at the site of tumor due to therapy related necrosis, and was successfully managed with supportive care only. Seven patients are evaluable for response. At day 28 after infusion of CAR T-cells the ORR was 70% (5/7, 3 in complete response and 2 with partial response, see table) and all responses are ongoing at a median follow up of 2.5 months (range 0.7-8.4). The CAR T-cell therapy was used as a bridge to allogeneic transplantation in responding patients. Allogeneic transplantation was performed in two patients and is also scheduled for the other three responders. One patient died with progressive disease. No deaths were attributed to therapy. Enrollment of patients to this program continues.Conclusion: Commercialization of CAR T-cell technology is inevitable and appears to be very expensive. Our preliminary results show that in-house production of CD19 directed CAR T-cells and treatment of patients with R/R aggressive B-cell malignancies using this approach in the same center is feasible and effective. Performing this entire approach in one center within a local region abrogates the need for cryopreservation and shipment of cells, and definitely reduces costs involved. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Prognostic Model Incorporating Tumor Lesion Morphology and Texture Features Identifies High-Risk Patient Subpopulations in De Novo DLBCL and FL

Background: Despite effective first-line (1L) treatment options for patients with NHL almost 40% of patients with diffuse large B cell lymphoma (DLBCL) will have a poor response or disease progression after 1L treatment. In follicular lymphoma (FL) 15-20% of patients experience early relapse, and almost 8% may develop transformation to more aggressive forms of the disease (such as DLBCL) after 1L treatment. More accurate identification of patients at high-risk for a poor prognosis with the standard of care could lead to improved outcomes. Although the International Prognostic Index (IPI) and its FL extension (FLIPI) are often used to stratify patients by prognosis, they have relatively modest sensitivity and specificity for predicting individualized risk. Radiomics is a promising approach to improve upon existing prognostic models because it provides a comprehensive quantification of tumor lesion morphology and texture derived from FDG-PET scans and may provide new and important information about disease biology and progression risk on an individual level. Methods: A collection of 107 radiomics features [pyradiomics v2.20] that describe shape, size or volume and texture of tumor lesions, including complex features that are believed to reflect the underlying biological tumor phenotype and microenvironment, were derived for n=1093 de novo DLBCL patients with available baseline FDG-PET scans from the Phase III GOYA study (NCT01287741) evaluating obinutuzumab plus CHOP chemotherapy (G-CHOP) versus rituximab plus CHOP chemotherapy (R-CHOP) (Vitolo, et al. J Clin Oncol 2017). The same set of features were also extracted from n=451 de novo FL patients with available baseline FDG-PET scans from the Phase III GALLIUM study (NCT01332968) comparing obinutuzumab plus chemotherapy with rituximab plus chemotherapy [Marcus, et al. N Engl J Med 2017]. To investigate the association between the derived radiomics features along with baseline clinical variables and progression-free survival (PFS), a Cox proportional hazard model with L1 regularization was trained and internally validated using the GOYA study. We used a nested Monte Carlo Cross Validation (nMCCV) strategy to train our model and provide high- and low-risk group predictions on held-out samples of data. This modeling strategy allows us to make a group prediction on all GOYA patients while reducing overfitting. To evaluate prognostic performance, we ported the final model trained using the GOYA study (called the Li prognostic model) to the fully independent GALLIUM study. Results: Using our nMCCV approach we identified 11 factors, with an inclusion probability of &amp;gt;50%, that are associated with PFS of DLBCL patients (Figure A). Included within the top features are several image-derived morphometric (i.e. metabolic tumor volume, surface area) and radiomics features (i.e. tumor elongation, NGTDM contrast, GLCM inverse variance). When stratifying patients on the predicted (via majority vote) low-risk vs high-risk groupings we found that our high-risk group had significantly worse prognosis vs the low-risk group (Figure B). In comparison, the high-risk group from the IPI model (defined as IPI &amp;gt; 2) had significantly worse prognosis vs the low-risk group, but the performance was slightly worse than our model (Figure C). PFS probability estimates at 2 and 5 years for predicted high-risk patients was 72.7% [70.0-76.6] and 59.8% [54.8-65.2] (vs 74% [70.0-78.2] and 60.4% [55.1-66.2] for the IPI model). After training and testing in the DLBCL population, we evaluated the prognostic performance of our model in an independent set of FL patients. We found that high-risk FL patients had a significantly worse prognosis than the low-risk group (Figure D). PFS probability estimates at 2 and 5 years for predicted high-risk patients was 77.4% [69.8-85.8] and 48.9% [39.5-60.5] (vs. 80% [0.748-0.856] and 58.3% [51.6-65.9] in the full group). Conclusions: Radiomics features are prognostic in DLBCL and provide a modest improvement in prognostic performance when combined with traditional IPI scores, clinical features, and lab values (vs IPI alone). Our prognostic signature, developed in DLBCL, has significant prognostic performance in an independent dataset of patients with FL. While these results are promising, our FL validation dataset was relatively small and further evidence is required to confirm our findings. Disclosures Li: Genentech, Inc.: Current Employment; F. Hoffmann-La Roche: Current Employment, Current equity holder in publicly-traded company. Jemaa:F. Hoffmann-La Roche: Current equity holder in publicly-traded company; Genentech, Inc.: Current Employment. Carano:F. Hoffmann-La Roche: Current equity holder in publicly-traded company; Genentech, Inc.: Current Employment. Bengtsson:Genentech, Inc.: Current Employment; F. Hoffmann-La Roche: Current equity holder in publicly-traded company. Paulson:F. Hoffmann-La Roche: Current equity holder in private company, Current equity holder in publicly-traded company; Genentech, Inc.: Current Employment. Jansen:F. Hoffmann-La Roche: Current Employment; Molecular Health GmbH: Ended employment in the past 24 months; F. Hoffmann-La Roche, Abbvie, Alphabet, other (non-healthcare), indexed funds and ETFs: Current equity holder in publicly-traded company. Nielsen:F. Hoffmann-La Roche: Current Employment, Current equity holder in publicly-traded company. Hibar:Genentech, Inc.: Current Employment; F. Hoffmann-La Roche: Current equity holder in publicly-traded company.

The Prognostic Impact of Comorbidities in Patients with De-Novo Diffuse Large B-Cell Lymphoma Treated with R-CHOP Immunochemotherapy in Curative Intent.

Background: Patient-related factors, namely comorbidities, impact the clinical outcome of patients with diffuse large B-cell lymphoma (DLBCL). Methods: The prevalence and prognostic impact of comorbidities were examined using the validated scores Charlson Comorbidity Index (CCI) and Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) in 181 patients with DLBCL at initial diagnosis before treatment with rituximab, cyclophosphamide, vincristine, doxorubicin and prednisone (R-CHOP). Results: Pronounced comorbidities as defined by CCI and HCT-CI scoring of ≥2 were detected in 9.9% and 28.2% of patients, respectively, and occurred more frequently at advanced age (p < 0.001). Higher CCI scoring was associated with lower complete response rate (p = 0.020). Both advanced CCI and HCT-CI were significantly associated with shortened overall survival (3-year OS: CCI ≥2 vs. 0–1, 38.9% vs. 81.3%, p < 0.001; HCT-CI ≥2 vs. 0–1, 56.9% vs. 84.9%, p < 0.001). Both comorbidity scores remained independent risk factors in the multivariate analysis (HCT-CI ≥2 HR: 2.6, p = 0.004; CCI ≥2 HR: 3.6, p = 0.001). Conclusion: This study demonstrates the prognostic relevance of comorbidities classified by CCI and HCT-CI in patients with DLBCL undergoing curative treatment with R-CHOP. A structured evaluation of comorbidities might refine prognostication alongside currently used prognostic parameters, namely age, and should be evaluated in prospective trials.

Recapitulation of Prognostic Mutational Subtyping Utilizing F1H in GOYA and CAVALLI and the Potential to Highlight Benefit of Targeted Therapy in De Novo DLBCL

Introduction: Diffuse large B-cell lymphoma (DLBCL), is a genetically and clinically heterogeneous disease. Building on existing clinical prognostic scores in the era of genomic risk modeling is critical to improve patient (pt) outcomes and inform future trials. With advances in next-generation sequencing, the interrogation of genetic drivers to refine prognostic subgroups over and above histological cell of origin (COO) subtypes has been of keen interest. The application of an unsupervised prognostic clustering approach, non-negative matrix factorization (NMF) algorithm, to whole exome sequence (WES) data has led to identification of six distinct molecular clusters with potential clinical relevance (Chapuy et al. Nature Med, 2018). Here, we applied the NMF clustering approach to targeted exome-sequencing data utilizing the FoundationOne HemeTM panel and analyzed RNA gene expression data from the randomized Phase 3 GOYA and Phase 1b/2 CAVALLI studies in de novo DLBCL. Methods: Biopsy samples, clinical outcomes (overall survival [OS], progression-free survival [PFS]), and targeted exome-sequencing data were available for 499 pts from the GOYA trial (NCT01287741; ITT=1418; obinutuzumab [G]-CHOP vs rituximab [R]-CHOP) and 106 pts from the CAVALLI trial (NCT02055820; ITT=267, venetoclax+[G/R]-CHOP). The FoundationOne HemeTM panel of 465 genes (F1H, Foundation Medicine Inc. [FMI]) was used to define single nucleotide variants, copy number amplifications, and rearrangements. Clustering methodology was implemented using the R package NMF (Gaujoux and Seoighe, BMC Bioinformatics 2010). All models were adjusted for treatment (where applicable), age, International Prognostic Index (IPI), sex, COO (NanoString), and BCL2 by IHC. Results: Applying the NMF algorithm, de novo pts in GOYA clustered similarly into four of the six groups recently reported by Chapuy et al.: MYD88/CD79B, BCL2/EZH2, NOTCH2/TNFAIP3, and no mutations (Fig 1A). The mutation profiles and COO subset distribution were also similar to those previously described. Furthermore, the MYD88/CD79B and BCL2/EZH2 groups remained associated with inferior clinical outcomes (Fig 1B), with observed poor prognosis over the NOTCH2/TNFAIP3 and no mutations groups (OS: hazard ratio [HR], 2.0; 95% CI: 0.97, 3.90; PFS: HR, 1.60; 95% CI: 0.93, 2.80), even when adjusting for known prognostic factors. Application of NMF to pts treated with the BCL2-inhibitor venetoclax in combination with R-CHOP (CAVALLI) yielded only MYD88/CD79B- and BCL2/EZH2-like groups due to enrollment. However, in contrast to the BCL2/EZH2 subgroup reported in both Chapuy et al. and GOYA, these pts demonstrated a trend towards improved outcomes over MYD88/CD79B (OS: HR, 0.12; 95% CI: 0.01, 1.60; PFS: HR, 0.11; 95% CI: 0.01, 1.10; Fig 1D). The difference between studies is potentially explained by the ability of venetoclax treatment to overcome the adverse prognostic impact of BCL2 over-expression. BCL2 IHC positive (BCL2+) pts were enriched in high-risk groups in GOYA (MYD88/CD79B and BCL2/EZH2) (odds ratio [OR], 5.0; 95% CI: 3.13, 8.33) and CAVALLI (MYD88/CD79B) (OR, 2.0; 95% CI: 0.63, 6.67). In GOYA, a prognostic trend for BCL2+ status is observed within low-risk pts (OS BCL2+ HR, 1.9; 95% CI: 0.55, 6.3; PFS BCL2+ HR, 2.7; 95% CI: 1.0, 6.8), but not within high-risk groups (OS BCL2+ HR, 0.55; 95% CI: 0.29, 1.00; PFS BCL2+ HR, 0.76; 95% CI: 0.45, 1.30; Fig 1C). Additional genetic risk models will be presented, e.g. as per Reddy et al. (Cell, 2017), as well as differential expression analysis. Conclusions: Important findings from the present work include: 1) utility of targeted mutational data from F1H in recapitulating molecular clusters, previously identified using WES, that further subclassify established prognostic groups such as COO and IPI; and 2) a trend towards improved survival outcomes for patients in the BCL2/EZH2 cluster upon treatment with the BCL2 inhibitor venetoclax. This highlights the potential for utilizing novel genetic signatures as a means of identifying patients suitable for targeted therapies in the era of personalized health care. Disclosures Kim: Genentech, Inc.: Employment. Fan:Genentech, Inc.: Employment. Bolen:F. Hoffmann-La Roche: Equity Ownership; Genentech, Inc.: Employment. Bazeos:Roche Products Ltd: Employment, Equity Ownership. Jiang:Genentech: Employment, Equity Ownership; F. Hoffman-La Roche: Equity Ownership. Balasubramanian:Roche-Genentech: Employment; F. Hoffman-La Roche: Equity Ownership. Balakrishnan:Genentech, Inc.: Employment. Knapp:F. Hoffmann-La Roche Ltd: Employment. Humphrey:F. Hoffmann-La Roche Ltd: Employment. Nielsen:F. Hoffmann-La Roche Ltd: Employment, Equity Ownership. Venstrom:F. Hoffmann-La Roche Ltd: Employment. Hernandez:Genentech, Inc.: Employment, Equity Ownership. Paulson:F. Hoffman-La Roche: Equity Ownership; Genentech: Employment.

The metronomic all-oral DEVEC is an effective schedule in elderly patients with diffuse large b-cell lymphoma.

Metronomic-chemotherapy (M-CHT) has been rarely assessed in non-Hodgkin-lymphoma (NHL). Therefore, in 2011 we started experimenting a new all-oral M-CHT schedule termed DEVEC (Deltacortene®, etoposide, vinorelbine, cyclophosphamide, +/-Rituximab) in diffuse-large-B-cell lymphoma (DLBCL) patients. Methods Patients with stage Ib-IV were enrolled as follows: 1) treatment-naïve, frail ≥65y, or unfit ≥85y; and 2) relapsed/refractory (R/R) ≥55y. Data were prospectively collected from six Italian centres and compared for efficacy to two reference groups, treated with established iv Rituximab-CHT in 1st and 2nd line respectively. Results from April-2011 to March-2018, 17/51(33%) naïve, 21/51(41%) refractory and 13/51(25.5%) relapsed patients started DEVEC; 39/51(76.5%) were de-novo DLBCL; 10/51(19.6%) transformed-DLBCL and 2/51(3.9%) unclassifiable-DLBCL/classical-Hodgkin-lymphoma. The median age was 85y (range=77-93) and 78y (range=57-91) in naïve and R/R respectively and overall the DEVEC patients had very poor features compared to the reference. The rate of grade≥3 haematological-AEs was 43%(95CI=29-58%): G3-neutropenia was the most frequent; grade≥3 extra-haematological-AEs was 13.7% (95%CI=5.4-25.9%), the most frequent was infection. One-year OS and PFS were 67% and 61% for naive, 60% and 50% for reference-naïve respectively; Cox proportional hazard ratio (Cox-PH-ratio) for OS and PFS were 0.69 (95%CI=0.27-1.76;p=.441) and 0.68 (95%CI=0.28-1.62;p=.381) respectively. One-year OS and PFS were 48% and 39% in the R/R, 36% and 17% in the reference-R/R respectively; Cox-PH-ratio for OS and PFS, were 0.76 (95%CI=0.42-1.40; p=.386) and 0.48 (95%CI=0.28-0.82; p=.007) respectively. Conclusion The favourable activity of DEVEC compared to a real-life series and the convenience of an oral administration, may possibly lay the groundwork for a paradigm-shift in the treatment of elderly DLBCL.

Does Cell of Origin Classification Impact Outcomes in Diffuse Large B-Cell Lymphoma after Autologous Stem Cell Transplant

Background The cell of origin (COO) classification has been shown to predict survival outcomes in de-novo diffuse large B-cell lymphoma (DLBCL), however, it is unclear if this holds true following high-dose chemotherapy and autologous stem cell transplantation (auto-SCT) in relapsed DLBCL patients. The current analysis aims to compare survival outcomes based on COO classification in relapsed DLBCL patients who received auto-HCT. Methods This retrospective study includes relapsed/refractory DLBCL patients, aged 18 and above, who received auto-HCT with standard of care conditioning from January 2007 to December 2016 at our institution. Hans algorithm using CD10, BCL6 and MUM1 markers was performed to classify patients as per COO into the GCB and non-GCB types. Kaplan Meier method was used to estimate progression free survival (PFS) and overall survival (OS). Results A total of 122 DLBCL (71 GCB, 51 non-GCB) patients were analyzed. Detailed patient characteristics are provided in Table 1. Except for GCB cohort being older (64 vs. 58 years, p 70 (HR=2.9, p=0.03) and IPI score 0 (HR=0.3, p=0.005) were significant variables in predicting PFS. After adjusting for these variables, no significant differences were seen in PFS between two groups. The median OS has not yet been reached in both groups therefore a difference in OS cannot be analyzed. Conclusion Our results suggest that cell of origin is not prognostic for patients with relapsed/refractory DLBCL treated with high dose chemotherapy followed by auto-SCT.

Efficacy of Rituximab Maintenance for Diffuse Large B Cell Lymphoma with Transformation

<Introduction>The transformation of indolent lymphoma is biologic event leading to aggressive lymphoma status. As same de-novo diffuse large B cell lymphoma (DLBCL), the outcome of DLBCL with transformation has improved by the use of rituximab contained therapy. However, the effects of rituximab maintenance for DLBCL with transformation remain unknown. We performed a retrospective analysis to evaluate the efficacy of rituximab maintenance for DLBCL with transformation.<Patients and Methods>We studied patients newly diagnosed as transformed DLBCL from March 2005 to November 2017 in our institution. The pathological diagnosis was performed based on morphological and immunohistochemical analyses. Transformed DLBCL was defined in our study as a coexistence with components of follicular lymphoma (FL) or MALT lymphoma and DLBCL in a biopsied tissue at the diagnosis. Almost all patients were treated with R-CHOP chemotherapy (2 were treated by radiation with or without rituximab therapy, one was R-ICE chemotherapy). 15 patients received rituximab maintenance therapy for two years after achieving good PR or more by first therapy. PET-CT was used to evaluate the stage at the diagnosis and the response after therapy. The statistical analyses of characteristics of patients were performed by Fisher's exact test. The survivals were calculated by the Kaplan Meier method, and statistical analysis were performed by log rank test. Factors affecting OS and PFS were evaluated using Cox proportional hazard model.<Results>We analyzed 52 transformed patients. Median age was 64 years old (range 43-87), 35 patients were male (67%) and 17 were female (33%), 44 (84%) were transformed from FL and 8 (16%) were from MALT lymphoma. Germinal center B cell (GCB) type were 35 (67%) and activated B cell (ABC) were 16 (30%). An ECOG performance status (PS) ≧2 was only 1 patient (1.9%). 3 (5.7%) had B symptoms, 16 (30%) had LDH ≧ULN, 28 (53%) had stage of Ⅲ or Ⅳ, 5 (9.6%) had bone marrow invasion, 13 (25%) had IPI score ≧3, and 26 (50%) had one or more extranodal diseases. There were no significant differences in characteristics between rituximab maintenance group and no maintenance group. After induction therapy, CR was achieved in 48 (92%) and PR was 4 (8%). With a median follow up of 66 months (range 7-143), 5-year OS and 5-year PFS were 95.6% (range 83.3-98.9) and 71.7% (range 55.4-83.0) respectively. There were not statistically significant in OS and PFS between the rituximab maintenance group and the observation group (5-year OS: 100% vs 93.6%, p=0.0895, 5-year PFS: 100% vs 65.7%, p=0.0792). However, subgroup analyses showed that rituximab maintenance group was significantly superior to no maintenance group in PFS in the cases of stage III or more (5-year PFS 100% vs 30.7%, p=0.0137), males (100% vs 56.7%, p=0.0436), and GCB type (100% vs 60.0%, p=0.029). The rituximab maintenance (P=0.0356: HR 0.20; 95% CI 0.046-0.899) was indicated as the clinical parameters related to PFS by multivariate analysis.<Discussion and Conclusion>Generally, DLBCL with transformation have poor prognosis. There are several previous reports about rituximab maintenance for patients with aggressive B-cell lymphoma, which concluded that rituximab maintenance in first remission didn't provide an advantage to OS and PFS. NHL 13 trial demonstrated statistical benefit of rituximab maintenance for males and low IPI group. Regard to transformed lymphoma, the study for maintenance of rituximab was really few. Hany R et al reported the outcome of patients with transformation that rituximab maintenance post R-CHOP and the number of maintenance rituximab cycles were associated with better PFS. Our data provided that rituximab maintenance was effective in transformed DLBCL with regard to prolonged PFS in subgroups of progressive stage, men, and GCB. In conclusion, from our study it was suggested that rituximab maintenance therapy have possible to improve outcomes for DLBCL with transformation. DisclosuresMishima:Chugai pharmaceutical inc, Roche: Other: commissioned work. Yokoyama:Chugai pharmaceutical inc, Roche: Other: commissioned work. Nishimura:Chugai pharmaceutical inc, Roche: Other: commissioned work. Terui:Takeda pharmaceutical: Honoraria; Janssen Pharmaceutical KK: Honoraria; Celgene: Honoraria; Bristol myers Squib: Honoraria; Novartis pharma: Honoraria.

Targeted Next-Generation Sequencing of Cell-Free DNA in Diffuse Large B-Cell Lymphoma

Background: Minimal residual disease (MRD) has an emerging diagnostic and prognostic role in Diffuse Large B-cell Lymphoma (DLBCL). However, repetitious bone marrow aspirations or lymph node biopsies would bring great pains to patients. At present, deep next-generation sequencing (NGS) based on circulating tumor DNA (ctDNA), allows quantitative mutational analysis with high sensitivity simultaneously, thereby providing us a promising non-invasive and radiation-free approach to monitor MRD and track sophisticated dynamic evolution of tumor clones.Methods: A total of 21 patients with denovo DLBCL and 6 patients with transformed DLBCL treated at our center were enrolled in this study. Formalin-fixed paraffin-embedded (FFPE) tissues at diagnosis were collected. Peripheral blood samples were obtained at the time of DLBCL diagnosed, remission, relapse, or other specific points in follow-up duration. Genomic DNA (gDNA) and cell-free DNA (cfDNA) were extracted from FFPE specimens and plasma samples, respectively. Targeted sequencing based on Illumina HiSeq 2000 were performed in all samples, which covering the whole coding sequences or hotspot regions in 61 genes known to be significantly associated with DLBCL. Library was prepared using unique molecular identifiers (UMI), which enabled the reduction of most synthesis-based errors. Sequencing depth was performed up to 2000× for FFPE specimens and 25000× for plasma samples, respectively. All mutations detected by cfDNA were validated by droplet digital PCR using Bio-Rad QX200TM. Concordance of filtered variants was determined between FFPE specimens and plasma samples at diagnosis. Correlation between clinical conditions and variant allele frequency (VAF) was also analyzed. This study was approved by Institutional Review Board of Tongji Hospital.Results: The median sequencing depth of FFPE specimens and cfDNA samples was 2312× and 28211×, respectively. Compared sequencing results of FFPE specimens with paired plasma samples at diagnosis, the number of cases with complete concordance, partial concordance, and complete discordance were 7, 12, and 8. For ultimate filtered variants detected in FFPE specimens and plasma at diagnosis, the consistency was 70% in transformed DLBCL and 55% in de novo DLBCL. Taking International Prognostic Index (IPI) score into consideration, the consistency of detection of denovo DLBCL patients with IPI score ≤ 2 was significant lower than that of patients with IPI score ≥ 3 (37% vs. 74%, P < 0.001). Besides, the presence of mutations in cfDNA also predicted MRD-positivity even though the patients achieved complete remission (CR), and the dynamic change of variant allele frequency is also associated with the evolution of tumor clones in most cases. Finally, long-last negativity of variants in cfDNA after treatment was significantly associated with superior progression-free survival.Conclusions: Our study indicated that targeted NGS of cfDNA in DLBCL is a promising test that facilitate disease monitoring and individualized therapy. A high level of concordance between FFPE specimens and plasma samples is associated with progression or evolvement that underlies clinical conditions, and ctDNA analysis may be a practical testing method to assess the prognosis of patients, although further investigations based on an extended sequencing panel and study cohort are warranted. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prevalence and Prognostic Significance of CD5 Immunohistochemistry in De-Novo DLBCL in a Western Population Cohort

Abstract Background: Various subsets of Diffuse Large B-cell lymphoma (DLBCL) are distinguished based on molecular and Immunohistochemical features. CD5 expressing DLBCL (CD5+ DLBCL) is increasingly recognized as a subtype of DLBCL with an aggressive disease course in small elderly Asian population cohorts comprising 5-10% of de-novo DLBCL. We attempt to describe its prevalence and prognostic implications in concert with IHC expression profiles of biomarkers Methods: A retrospective review of elderly patients (65yr-92yr) with de-novo Diffuse Large B-Cell lymphoma (DLBCL) uniformly treated with RCHOP was conducted between Jan 98 and Dec 2016. Patient demographics, clinical parameters and IHC markers were collected. Analysis using chi square, or Fisher exact where appropriate, was performed. Kaplan-Meier analysis and univariate and multivariate Cox regression analysis identified associations with overall survival. The protocol, and subsequent modifications, were reviewed and approved by the IRB at the Texas Tech University Health Sciences Center Results: One hundred fourteen de-novo DLBCL with known CD5 IHC status, Ki67, c-MYC, BCL2, BCL6, MUM1, CD10 marker status and Han's classifiers were evaluated. Median age of the CD5 negative cohort was 75yrs ±12.8 vs 80yrs±9.3 in the CD5+ subgroup (p=0.51). Median OS 6.7 years (SD 62.3mo; Range 1-256). CD5+ expression on IHC was seen in 23/110 (21%) patients. IHC marker status showed c-myc (12%), BCL2(42%) and BCL6(39%) respectively. Compared with matched group of patients with CD5 negative DLBCL, CD5+ DLBCL were more likely to be non-GCB type (14/23 vs 9/87; p 2 (14/23 vs 23/81; p=0.009) and Stage >III (p=0.004). Three patients with CNS involvement all had CD5 expression. Kaplan-Meier analysis showed that Han's non-GCB classification (p 70% (HR=0.33, P=0.017), BCL6 (HR=0.47, P=0.019) and CD10 (HR=0.2, P=0.003) were associated with worse outcomes. CD5+ expression was not significantly associated with OS (HR=0.76; -1.4 to 0.8; p=0.64) in multivariate model, however was significant in a univariate analysis (P Conclusion: CD5+ DLBCL subset is more common in this elderly western cohort than historically seen in the Asian population with a signal toward Hans non-GCB, higher R-IPI, higher Stage and perhaps higher risk of CNS involvement. More data is needed to evaluate if CD5+ de-novo DLBCL has any correlation with other antiapoptotic or proliferative markers like BCL2,6 and c-MYC and larger patient subset and prospective studies are needed to corroborate these findings Disclosures No relevant conflicts of interest to declare.

Diffuse Large B-Cell Lymphomas Transformed from or with Concurrent Follicular Lymphoma Demonstrate Similar Clinical Outcomes As De-Novo Diffuse Large B-Cell Lymphomas, Except for Cases Harboring Double Hit Rearrangements

▪Introduction:Follicular lymphoma (FL) is characterized by an indolent clinical course, but patients with this disease bear a risk of transformation to diffuse large B-cell lymphoma (DLBCL) or high-grade B-cell lymphoma (HGBL). DLBCL transformed from FL (tDLBCL) traditionally has been associated with an aggressive course and a post-transformation survival of 0.6-1.7 years. However, a more recent study showed longer survivals in these patients, challenging the notion that transformation universally portends a poor prognosis in the immunotherapy era. Presence of concurrent FL at the time of diagnosis of DLBCL (cDLBCL/FL) also raises the possibility of transformation, but its clinical significance has not been elucidated in the literature. In this study, we analyzed and compared outcomes of tDLBCL, cDLBCL/FL, and de novo DLBCL. We also characterized the prevalence of MYC/BCL2/BCL6 gene rearrangements in tDLBCL and cDLBCL/FL cohorts and evaluated the impact of dual rearrangements (double hit, DH) on clinical outcomes.Methods:Patients diagnosed with DLBCL or B cell lymphoma unclassifiable with features intermediate between DLBCL and Burkitt lymphoma, also known as HGBL (BCLU/HGBL), treated at Northwestern University or University of Pennsylvania from 1/2010 to 7/2016 were included. Patients with Burkitt lymphoma, primary CNS and HIV-associated lymphoma were excluded. Transformation was defined as presence of DLBCL/ BCLU/HGBL in cases with an antecedent diagnosis of FL by at least 6 months. We divided our cohort into three groups: 1. De novo DLBCL or BCLU/HGBL with no prior history of FL (dDLBCL) 2. Transformed FL (tDLBCL) and 3. DLBCL or BCLU/HGBL with concurrent FL (cDLBCL/FL). Progression free survival (PFS) was defined as time from diagnosis to radiographic progression, regimen change, death or last follow-up. Overall survival (OS) was defined as time from diagnosis to death or last follow-up. Kaplan-Meier (KM) survival analyses, using a log-rank p-values were performed for PFS and OS to compare the three diagnosis groups (dDLBCL, tDLBCL, and cDLBCL; alpha=0.05) and pairwise comparisons of combinations of diagnosis (dDLBCL and tDLBCL+cDLBCL) and double hit status (accounting for multiple comparisons with a Bonferroni corrected alpha=0.013). Fluorescence in situ hybridization for MYC, BCL2 and BCL6 rearrangements was performed using break-apart probes per the policy of each institution.Results:A total of 293 pts, including 233 dDLBCL, 37 tDLBCL, and 23 cDLBCL/FL were included. 50% of the tDLBCL received at cytotoxic chemotherapy before transformation for precedent FL. Age and sex distribution, as well as clinical characteristics including stage, ECOG performance status, IPI score, and primary refractoriness were similar amongst the three groups. LDH was more likely to be elevated in dDLBCL (75%), as compared to tDLBCL(63%) and cDLBCL/FL (47%)(p=0.02%). Additionally, non-bone marrow extra-nodal disease was seen more often in dDLBCL (72%), as compared with tDLBCL (53%) and cDLBCL/FL (43%)(p <0.01). DH were seen more often in tDLBCL(32%) and cDLBCL/FL (30%), compared with the dDLBCL (11%)(p <0.01). The cell of origin was germinal-center type in 92% of the tDLBCL and 91% cDLBCL/FL, compared with 64% of dDLBCL (p <0.01). Intensive chemotherapy regimens (R-EPOCH or R-hyperCVAD) and autologous stem cell transplantation was used more often in tDLBCL (43% and 19%, respectively), compared with dDLBCL (30% and 3%, respectively) and cDLBCL/FL (28% and 8% respectively). For all pts, the median length of follow-up was 13.8 months (range 0.2-59.2). OS and PFS were similar in the three subgroups (p=0.90 and p=0.77, respectively; Figure 1). We then analyzed the survival based on the presence of DH in two separate subgroups: 1) dDLBCL and 2) tDLBCL + cDLBCL/FL (combined as one group given low number of cases). OS was significantly shorter in lymphomas with DH, compared to non-DH in both subgroups (p <0.001 for dDLBCL and p=0.004 for tDLBCL + cDLBCL/FL). Comparison of the OS in DH of dDLBCL versus DH of tDLBCL + cDLBCL/FL showed no statistical difference (p=0.15), similar to the OS of non-DH cases the two groups(p=0.31).Conclusions:DLBCLs transformed from FL or with concurrent diagnosis of FL (composite lymphoma) demonstrated similar clinical outcomes in our study. However, dual rearrangements are more prevalent in these patients and drive inferior survival similar to DH status in de novo DLBCL. [Display omitted] DisclosuresLandsburg:Curis: Consultancy, Research Funding; Takeda: Research Funding. Winter:Merck: Research Funding; Glaxo-Smith-Kline: Research Funding. Pro:Seattle Genetics: Consultancy; Takeda: Consultancy, Research Funding; Celgene: Consultancy, Research Funding. Gordon:Janssen: Other: Data Monitoring Committee. Karmali:Celgene: Speakers Bureau. Kaplan:Millennium: Research Funding; Takeda: Research Funding; Seattle Genetics: Research Funding; Janssen: Research Funding.

MYC protein dysregulation is driven by BCR-PI3K signalling in diffuse large B-cell lymphoma.

MYC overexpression is a common feature of diffuse large B-cell lymphoma (DLBCL) and is associated with poor prognosis in patients with this neoplasm. We aimed to investigate the underlying mechanisms of MYC dysregulation, as they have not been fully determined. We immunohistochemically evaluated the correlation between B-cell receptor (BCR)-phosphoinositide 3-kinase (PI3K) pathway activity and MYC level in 108 cases of de-novo DLBCL, 25 of which featured loss of BCR, and investigated the effects of BCR-PI3K signalling on MYC level and phosphorylation in DLBCL cell lines. The expression levels of phospho-SYK and phospho-AKT correlated with MYC expression in BCR-positive DLBCL. MYC expression was significantly lower in BCR-negative tumour tissues than in BCR-positive tumour tissues. Upon BCR stimulation, the BCR-positive cell lines showed active BCR-PI3K signalling and decreased MYC phosphorylation at T58, leading to an increased overall level of MYC. Conversely, inhibition of BCR-PI3K signalling increased MYC phosphorylation and thus resulted in a decreased overall level of MYC. No effects were observed in the BCR-negative cell lines. Overexpression of MYC in DLBCL can be driven by the BCR-PI3K signalling pathway via dephosphorylation at T58, and BCR inhibitors may exert their functions by down-regulation of MYC.

Myc and Bcl2 Overexpression and Traslocation Assessed By Immunohystochemistry (IHC) and FISH: Retrospective Analysis in a Series of De Novo DLBCL Homogeneously Treated with Rituximab-CHOP

Introduction: MYC and BCL2 overexpression assessed by IHC and rearrangement detected by FISH are important prognostic factor in Diffuse Large B-Cell Lymphoma (DLBCL). Double Hit Lymphoma (DHL) patients have a poor prognosis with conventional therapy and Double expressor Lymphoma (DE) have worse outcome compared with conventional DLBCL although data are controversial. Aimed at a better knowledge of this issue, we performed a retrospective analysis to determine prevalence and outcome of Single Hit Lymphoma (SHL), DHL and DE in patients with de-novo DLBCL treated with Rituximab and CHOP.Methods: de novo DLBCL treated with R-CHOP between January 2003 and December 2013 were included in the study. BCL2 and BCL6 expression were evaluated by IHC at diagnosis while MYC expression was retrospectively investigated with Tissue Micro Arrays (TMA) technique; cases were considered positive for MYC, BCL2 or BCL6 expression by IHC if >40%, >40% or >25% of cells stained positive, respectively. FISH analysis for MYC and BCL2 rearrangements were performed with dual color break apart probes on TMA. PFS and OS were estimated with Kaplan-Meier method and compared between groups with the Cox model.We further evaluated in this series the IHC score proposed by Botto et al. (Blood 2014 124:2964) in DLBCL. The score was based on the assessment in IHC of the expression of MYC, BCL2 and BCL6. The three variable contributed with different risk in the multivariate analysis and an IHC sum additive score of 0-5 was calculated proportionally to the coefficient estimated (coefficient [Log hazard ratio] 0.92 for MYC+, 0.73 for BCL2+ and 0.48 for BCL6-), assigning an individual risk of 2 points for MYC or BCL2 positivity and 1 point for BCL6 negativity. Patients were stratified in three different risk groups; Low risk (0-1 point), Intermediate risk (2 points) and High risk (≥3 points).Results: Of a total of299 DLBCL screened, 267 were evaluable for survival analysis; median age was 65 years (range 20-90). 154 patients had complete immunohystochemical data and 101 were fully investigated by IHC and FISH. No significant differences in clinical presentation or in the outcome were seen between patients with or without available histologic tissue for IHC and FISH. Among 154 patients with complete IHC data we found 12 (8%) DLBCL without expression (DLBCL), 96 (62%) Single expressor (SE), 46 DE (30%). With a median follow up of 60 months, 5-year PFS rates were: DLBCL 90%, SE 60% and DE 43% respectively (fig 1) (HR 8.25 (95% CI: 1.12 -60.99) p 0.039); 5ys OS rates were 91%, 68% and 57% respectively (HR 5.72 (95% CI: 0.77 - 42.82) p 0.08).Applying the prognostic model (adjusted for IPI and age) defined in our previous pilot study we recorded 12/154 patients with low risk score, 61/154 with intermediate and 81/154 patients in high risk group. 5y-PFS rates were 91% vs 67% vs 45% (p=0.014) respectively (HR 1.74 (95% CI: 1.12 -2.69) p 0.014). Among 101 patients investigated by FISH we recorded 10 SHL (10%) and 8 DHL (8%). Clinical characteristics were superimposable among DLBCL, SHL and DHL with a prevalence of non GCB phenotype in DE group (56%). Among 101 patients fully investigated for FISH and IHC, 38 patients had MYC overexpression by IHC; 11 of them had also a MYC translocation. We found 3 cases with MYC rearrangement without protein overexpression. With a median follow up of 60 months PFS in DLBCL, SHL and DHL was 65%, 58% and 25% respectively (fig. 2); 5 ys OS was 70%, 77% and 25% respectively. The worse prognosis of DHL was statistically significant with an HR of 3.3 (95% CI: 1.37- 7.94, p 0.008) in terms of PFS and 3.9 (95% CI:1.59- 9.52 p 0.003) in terms of OS.Conclusion: Our data confirmed that our IHC prognostic score based on MYC, BCL2 and BCL6 expression, is a simple, reproducible and valid prognostic assessment that identify three groups with a different outcome in a large cohort of DLBCL. Moreover these data confirm intermediate prognosis for patients with DE lymphoma and poor prognosis of DHL treated with conventional chemoimmunotherapy. [Display omitted] [Display omitted] DisclosuresChiappella:Roche: Speakers Bureau; Celgene: Speakers Bureau; Janssen-Cilag: Speakers Bureau; Teva: Speakers Bureau; Pfizer: Speakers Bureau; Amgen: Speakers Bureau. Cavallo:Celgene: Honoraria; Onyx: Honoraria; Janssen-Cilag: Honoraria. Vitolo:Celgene: Honoraria; Gilead: Honoraria; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria; Roche: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

18f]PET-CT Scan Is Highly Accurate in Identifying Marrow Involvement of Diffuse Large B-Cell Lymphoma

BACKGROUNDRecent advances in imaging and the use of prognostic indices and molecular profiling have improved our ability to characterize disease and predict outcomes in diffuse large B cell lymphoma (DLBCL). About 1/3rd of patients with DLBCL have bone marrow involvement (BMI) at the time of diagnosis, and bone marrow aspirate/biopsy (BMAB) is considered the gold standard to detect such involvement. [18F] fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (PET-CT), has become a standard pre-treatment imaging in DLBCL and may be a noninvasive alternative to BMAB to ascertain BMI. Prior studies have suggested that PET-CT scan may obviate the need for BMAB as a component for staging patients with newly diagnosed DLBCL, but owing to a variety of reasons this is not yet a standard of practice. The aim of this retrospective study which included 99 patients with newly diagnosed de-novo DLBCL, who had undergone both BMAB and PET-CT, was to determine the accuracy of PET-CT in detecting BMI in DLBCL and define overall survival (OS) in these patients based on BMI by BMAB vs. PET-CT. METHODSThis study is a single institution retrospective review of patients' medical records. All patients with newly diagnosed DLBCL at Virginia Mason Medical Center between January 2004 to December 2013 who underwent pretreatment PET-CT and BMAB were included. PET-CT images were visually assessed for BMI including the posterior iliac crest. Patients with primary mediastinal DLBCL, previous history or co-existence of another lymphoma subtype and those with a non-diagnostic BMAB, and in whom the PET-CT did not show marrow signal abnormality were excluded from the analysis. Ann Arbor stage was determined using PET-CT with and without the contribution of BMAB, and the proportion of stage IV cases by each method was measured. RESULTS99 eligible patients were identified. The median age was 62 years (range, 24-88), 62 (59%) were male, 53 (50%) had elevated LDH and 17 (16%) had an ECOG performance status of >2. Thirteen (12%) patients had > 1 extra-nodal site of lymphoma involvement. R-IPI score was 1 in 39 (37%), 2 in 42 (40%), 3 in 20 (19%), and 4 in 4 (4%) patients. A total of 38 (36%) patients had BMI established by either PET-CT (n=24, 19%), BMAB (n=14, 13%), or both (n=12, 11%). 12 of the 24 patients (50%) with positive PET-CT had BMI by DLBCL, while only 2 of the 81 patients (2%) with negative PET-CT showed BMI. BMAB upstaged 1 of the 53 (2%) stage I/II patients to stage IV. The sensitivity of PET-CT scan to detect BMI by DLBCL was 86% while the specificity was 87%. 84 patients (85%) had concordant results between lymphomatous BMAB and PET-CT (12 patients were positive for both, and 72 patients were negative for both), but 15 patients (15%) had a discordant interpretation (3 patients were positive by BMAB and negative by PET-CT, and 12 patients were negative by BMAB and positive by PET-CT). PET-CT was highly accurate for detecting BMI at diagnosis in de-novo DLBCL. Although patients with positive BMAB patients had inferior 5 year OS estimates compared to negative BMAB (66% vs. 85%), no difference was demonstrated between PET-CT positive vs. PET- CT negative patients. (79% vs. 83%) (Table 1) CONCLUSIONSIn patients with newly diagnosed DLBCL, PET-CT is highly accurate in detecting BMI by lymphoma. In clinical practice, routine BMAB may no longer be necessary for all patients with DLBCL, who are staged by PET-CT, unless the results would change both staging and therapy. The prognostic implication of BMI identified by PET-CT compared to BMAB remains unknown. Whether a PET-CT precludes the need for a BMAB in patients with DLBCL remains to be evaluated in a prospective study. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prognostic impact of immunohistochemical stratification of diffuse large B-cell lymphoma into germinal and nongerminal subtypes

Objectives The aim of this study was to investigate the difference between germinal and nongerminal diffuse large B-cell lymphoma (DLBCL) cases regarding their clinicopathological features, including survival and response to therapy. Background DLBCL is the most common subtype of non-Hodgkin's lymphoma in Egypt. It represents about 49% of non-Hodgkin's lymphoma cases according to the latest registry of National Cancer Institute, Cairo University. DLBCL is a heterogeneous group, especially as regards biological behavior, which includes response to chemotherapy and ultimate outcome. Previous studies suggested that classification of DLBCL into germinal and nongerminal subtypes had prognostic importance. Patients and methods This retrospective study included 61 de-novo DLBCL cases collected from the archival material of Pathology Department, Faculty of Medicine, Menoufia University, and treated at Menoufia Cancer Institute. Results Using Hans' algorithm, 31 (50.8%) cases were of germinal center B-cell (GCB) and 30 (49.8%) cases were of non-GCB subtype. Non-GCB cases showed significant association with splenic involvement (P = 0.01) and larger tumor size (P = 0.03). Overall, 90% of DLBCL cases with poor performance status were of GCB subtype. No significant difference regarding overall survival was noticed between GCB and non-GCB subtypes. Conclusion DLBCL should be classified into GCB and non-GCB subtypes because they differ prognostically. Hans' algorthim is a simple and reliable method for the classification of DLBCL, but it should be applied on a large number of cases to be used as a routine method for DLBCL evaluation.