Diffuse Large B-cell Patients Research Articles

Early CAR- CD4+ T-lymphocytes recovery following CAR-T cell infusion: A worse outcome in diffuse large B cell lymphoma.

CAR- CD4+ T cell lymphopenia is an emerging issue following CAR-T cell therapy. We analyzed the determinants of CD4+ T cell recovery and a possible association with survival in 31 consecutive patients treated with commercial CAR-T for diffuse large B-cell (DLBCL) or mantle cell lymphoma. Circulating immune subpopulations were characterized through multiparametric-flow cytometry. Six-month cumulative incidence of CAR- CD4+ T cell recovery (≥200 cells/μL) was 0.43 (95% confidence interval [CI]: 0.28-0.65). Among possible determinants of CD4+ T cell recovery, we recognized infusion of a 4-1BB product (tisagenlecleucel, TSA) in comparison with a CD28 (axicabtagene/brexucabtagene, AXI/BRX) (hazard ratio [HR] [95% CI]: 5.79 [1.16-24.12] p=0.016). Higher CD4+ T cell counts resulted with TSA at month-1, -2 and -3. Moderate-to-severe infections were registered with prolonged CD4+ T cell lymphopenia. Early, month-1 CD4+ T cell recovery was associated with a worse outcome in the DLBCL cohort, upheld in a multivariate regression model for overall survival (HR: 4.46 [95% CI: 1.12-17.71], p=0.03). We conclude that a faster CAR- CD4+ T cell recovery is associated with TSA as compared to AXI/BRX. Month-1 CAR- CD4+ T cell subset recovery could represent a "red flag" for CAR-T cell therapy failure in DLBCL patients.

Свободно циркулирующая ДНК в плазме у пациентов с диффузной В-крупноклеточной лимфомой и В-клеточной лимфомой высокой степени злокачественности (‘double hit’/’triple hit’)

Aim. To study plasma cell-free DNA (pcfDNA) concentration and B-cell clonality in patients with diffuse large B-cell (DLBCL) and B-cell high-grade lymphomas prior to and at different stages of chemotherapy as well as the correlation between the data obtained and clinical and laboratory parameters.
 Materials & Methods. The study enrolled 23 DLBCL patients and 7 healthy donors (HD). Plasma was prepared from whole blood by centrifugation, pcfDNA was isolated with the commercial kit Qiagen (Germany). The concentration of pcfDNA was determined using fluorometer Qubit (USA). В-cell clonality was estimated by immunoglobulin gene analysis (BIOMED-2 protocol) in the tumor tissue and bone marrow core biopsy specimens obtained on diagnosis date as well as in the pcfDNA at 5 end points: prior to chemotherapy and after cycles 1, 2, 3, and 4.
 Results. Prior to therapy, all DLBCL patients showed significantly higher pcfDNA concentration than HD. Immunochemotherapy cycle 1 resulted in considerable increase in pcfDNA concentration. After cycle 2 and subsequent cycles, pcfDNA concentration gradually decreased. After cycle 4, the mean pcfDNA concentration was comparable with that of HD. In 95 % of patients В-cell clonality in pcfDNA corresponded to that identified in the tumor specimen. After immunochemotherapy cycle 1, В-cell clonality was detected in 50 % of patients, after cycle 2 it was shown by 15 %. Only 1 female patient retained В-cell clonality after therapy cycles 3 and 4. In HD, no В-cell clonality in pcfDNA was identified. Prior to therapy, the analysis revealed no correlation of either pcfDNA concentration or В-cell clonality in pcfDNA with age, sex, tumor spread, presence or absence of extranodal lesions, proliferation index Ki-67, and lactate dehydrogenase concentration.
 Conclusion. In patients with malignant hematological tumors, pcfDNA seems to be an interesting, easily accessible biological material deserving further investigation. Any studies of pcfDNA require long-term dynamical analysis and standardized methods of collection, storage and processing of the data obtained. In the long run, with more and more information, pcfDNA can become an important diagnostic marker of tumor heterogeneity and a reliable relapse predictor.

Cooperative Networks between MYC and XPO1 Associated with Decreased T-Cell Presence and a Depleted Tumor Microenvironment May be Addressed By the Synergistic Combination of AZD4573 and Selinexor

Background: Genomically-targeted Diffuse Large B-cell (DLBCL) treatments for refractory or relapsing patients remain a clinical need alongside the growing success of Chimeric Antigen T-cells (CAR-T), which have ushered in durable responses in 40-70% of patients. However, recent studies have identified factors indicative of an inferior CAR-T response. Recent tumor Ecotype studies from Kotlov and Steen reveal that a Depleted or Cold tumor microenvironment (TME) is associated with poor CAR-T response. Notable features of these environments include a decreased presence of native T-cells alongside oncogenic alterations associated with their exhaustion, namely MYC and XPO1. Few precision treatments exist given the difficulty targeting MYC, but two avenues have shown recent success: inhibition of the downstream oncogene CDK9 via AZD4573 and upstream inhibition of a MYC propagator, the nuclear exportin XPO1 via Selinexor. Herein, we report the first observations of synergy between AZD4573 and Selinexor within DLBCL cell lines and data supporting that these genes may serve as accessible markers for inferior tumor immune microenvironments. Methods: We combined progression vs. response results from four previous CAR-T genomics studies, noting MYC status (Jaeger 2020, Jain 2021, Sworder 2021, and Shouval 2022). We next analyzed a 418-patient de-novo DLBCL patient cohort (Xu-Monette 2020) and 48-patient TCGA cohort after GEDIT immune deconvolution for differential expression and component enrichment between patients expressing high levels of MYC and XPO1 (+1 Standard Deviation) compared to normal counterparts. Significantly expressed genes were evaluated via gene set enrichment analyses. We next assayed AZD4573 and Selinexor vs. 7 DLBCL cell lines, 5 of which harbor MYC alterations, across a series of 9 concentrations (78nM-20µM) across 3-9 replicates. We followed these results by combining treatments in the MYC-altered Ly3, DHL6, and DHL4 cell lines, analyzing results using the BLISS synergy model. Results: Integrative analyses support that MYC alterations are associated with significantly reduced CAR-T outcomes. Of the 93 MYC-altered patients within the total 246-patient cohort, 65.59% of them experienced progression during CAR-T treatment compared to just 50.33% of WT CAR-T patients (p = 0.0242). Differential gene expression analyses between de-novo patients expressing high MYC or XPO1 revealed losses in Cytokine Signaling pathways (FDR = 6.96E-18) and gains in Cell Cycle modulators (FDR = 2.525E-20). Importantly, CD8A expression was significantly lower in these patients (FDR < 0.0001) alongside other key reductions of CDKN1A and TNFAIP3. After immune deconvolution, both High-MYC and High-XPO1 patients displayed significant losses of CD8 T-cell association, respectively (FDR = 0.0005, FDR = 0.0396). Notably, High-MYC patients without a CD8 T-cell presence experienced an inferior survival prognosis compared to High-MYC counterparts with a CD8 presence (p = 0.0272). High MYC or XPO1 patients that experienced a failure event before 24-months (EFS24) had significantly lower activated CD4 T-cell presence compared to normal counterparts as well (FDR = 0.0095, FDR = 0.0069). Next, AZD4573 and Selinexor assays vs. DLBCL cell lines demonstrated dose and MYC-dependent cell inhibition, with ED50 values ranging between 58.1 nM to 8.07 µM. Lastly, the molecules were combined vs. Ly3, DHL6 and DHL4 cell lines, resulting in synergistic reduction of cell viability and BLISS synergy scores of 33.76, and 11.86, and 5.04, respectively. Conclusions: Our results support that the cooperation between MYC and XPO1 is associated with T-cell reductions characteristic of a Depleted or Cold TME, a key issue for CAR-T success. We applied the targeted therapies AZD4573 and Selinexor vs. cell line models to address this pathway, with both displaying anti-tumor effects as single agents. Most importantly, we observed synergistic activity in the MYC-harboring Ly3 and DHL6 cell lines, and in the WT DHL4 cell line when these molecules were combined. These results are supported by integrative analyses that highlight the importance of targeting aberrant MYC signaling via CDK9 and XPO1 inhibition, revealing a potential avenue to address inferior response rates faced by patients harboring MYC-positive, Depleted tumor microenvironments that would otherwise face an inferior CAR-T prognosis.

Cumulative radiation exposure from radiological imaging in patients with Hodgkin and diffuse large b-cell lymphoma not submitted to radiotherapy.

To assess the cumulated exposure to radiation due to imaging in Hodgkin (HL) and diffuse large B-cell (DLBCL) lymphoma patients who were not submitted to radiotherapy. The study population included 51 and 83 adult patients with HL and DLBCL, with a follow-up duration >1 year. The cumulated exposure was expressed using patient-specific data as cumulated effective dose (CED). Fifty-one HL patients (median age 47 years) were followed for a median of 3.5 years. The median total CED per subject was 104 mSv. CT and PET/CT examinations accounted for 75 and 25% of the total CED, respectively. 26 patients (49%) had a total CED ≥ 100 mSv and the maximum CED was 302 mSv. Eighty-three DLBCL patients (median age 66 years) were followed for a median of 3.7 years. The median total CED per subject over the study period was 134 mSv. CT and PET/CT for 86% and 13% of the total CED, respectively. 56 patients (67%) had a total CED ≥100 mSv. The maximum CED was 557 mSv. Our study demonstrated the large number of imaging procedures performed for patients with lymphoma. Overall, 61% of the patients accrued a CED ≥ 100 mSv. Imaging policies were only in a partial agreement with current international guidelines. The cumulated exposure radiation exposure may be of concern in HL patients and the contribution of CT procedures to the total CED is significant. The standardisation of clinical guidelines for managing patients with lymphoma is warranted.

EFS24 Failure, BRD4 Expression, and TP53 Are Linked to Reduced CDKN1A Expression in DLBCL and May be Targeted By Single-Agent Protac ARV-825 or in Synergistic Combination with the CDK4/6 Inhibitor Abemaciclib

Background: Genomically-targeted Diffuse Large B-cell (DLBCL) treatments for refractory or relapsing patients remain a clinical need alongside the growing success of Chimeric Antigen T-cells (CAR-T), which have ushered in durable responses in 40-70% of patients. Recent studies have identified factors associated with progression, including alterations to the TP53 tumor suppressor and a cold immune environment, among others. The BRD4 bromodomain protein has emerged as an actionable target in recent years given its role orchestrating numerous oncogenic processes that drive aggressive DLBCL capable of rejecting R-CHOP regimens. Specifically, Proteolysis targeting chimera technology - PROTACs - have arisen as a novel mechanism to degrade target oncogenes in hematological malignancies. The BRD4-degrading PROTAC ARV-825 represents the next generation of this technology. Herein, we report integrative analyses supporting that CDKN1A restoration via BRD4 degradation represents a treatment avenue for DLBCL patients with a cold immune microenvironment predictive of inferior CAR-T response, the first observations of single-agent ARV-825 efficacy vs. DLBCL cell lines, and in-vitro synergy between ARV-825 and the CDK4/6 inhibitor Abemaciclib. Methods: We analyzed 2 de-novo DLBCL patient cohorts (Xu-Monette et. al. 2020 and the TCGA) for differential expression based on Event-free 24-month survival (EFS24), TP53 alteration status, and BRD4 overexpression. Profiles expressing 1+ Standard deviations above the BRD4 mean were classified as BRD4-High. We integrated post-BRD4-degradation gene expression fold change values from Jain et. al. 2019 alongside these data. We next assayed ARV-825 vs. 7 DLBCL cell lines, 5 of which bear TP53 alterations, across a series of 9 concentrations (78nM-20µM) across 3-9 replicates. We followed these results by combining ARV-825 with Abemaciclib in the TP53-impaired DHL6 cell lines, analyzing results using the BLISS synergy model. Results: Integrative analyses revealed that EFS24 failure was most associated with alterations to TP53 (P = 0.0069) and greater BRD4 expression (P = 0.0217), with BRD4 as the greatest differentially expressed gene in these patients. Overall survival matched this trend, with TP53 alteration (0.0005) and High BRD4-expressing (P = 0.0352) patients facing inferior outlooks. Interestingly, these factors were associated with each other, as BRD4 expression was greater in TP53-mutant profiles (FDR = 0.0663). Tumors harboring either factor were associated with significantly reduced expression of Regulation of Programmed Cell Death (FDR = 9.080E-19) and Cytokine Signaling in Immune System (FDR = 1.029E-12) genes. Genes with significantly greater expression were unsurprisingly most associated with the cell cycle (FDR = 2.550E-12). Notably, the CDK1NA tumor suppressor responsible for inhibiting the CDK4/6 oncogenes was significantly reduced in patients with TP53 alterations and/or High BRD4 expression (FDR = 9.840E-09), collectively serving as the greatest loss within this population. Significant renewal of CDKN1A expression may be accomplished via BRD4 inhibition (q-value = 0.0132, Fold Change = 2.024) based on post-ARV-771 DLBCL cell line treatment results from Jain et. al. 2019. Following these results, we assayed ARV-825 vs. DLBCL cell lines, demonstrating sub-micromolar efficacy in all 7 models. ED50 values ranged between 41nM and 440nM. ARV-825 was next combined with the CDK4/6 inhibitor Abemaciclib in the TP53-imparied DHL6 cell line, resulting in synergistic reduction of cell viability across a range of doses and a BLISS synergy score of 12.946. Conclusions: Our results suggest that increased BRD4 expression alongside TP53 alterations are associated with EFS24 failure, a cold immune microenvironment, and the loss of critical tumor suppressors, namely CDKN1A. We assayed the BRD4-degrading PROTAC ARV-825 vs. cell line models and are the first to report the substantial preclinical efficacy of this molecule in DLBCL. We are also the first to report synergistic reductions in cell viability in a TP53-imparied DLBCL cell line when ARV-825 was combined with the CDK4/6 inhibitor Abemaciclib. These results highlight the potential efficacy of PROTACs within DLBCL and how targeted treatment of a population facing inferior CAR-T prognosis may emerge via the restoration of CDKN1A. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The DLBCL Axis of Low TNFRSF10B Expression, TP53 Loss, and a Cold Immune Microenvironment May be Addressed By the Synergistic Combination of Eprenetapopt and Idasnutlin

Background: Genomically-targeted Diffuse Large B-cell (DLBCL) treatments for refractory or relapsing patients remain a clinical need alongside the growing success of Chimeric Antigen T-cells (CAR-T), which have ushered in durable responses in 40-70% of patients. However, recent studies have identified factors indicative of an inferior CAR-T response. These include a "cold" immune microenvironment, downregulation of extrinsic cell death factors such as TNFRSF10B, and alterations to the TP53 tumor suppressor. Few precision treatments exist capable of addressing the consequences, although two avenues are being pursued in clinical trials for lymphoma: inhibition of the TP53 negative regulator MDM2 via Idasnutlin and TP53 reactivation via the unique molecule Eprenetapopt (APR-246). Herein, we report the first observations of synergy between Idasnutlin and Eprenetapopt within DLBCL cell lines and data supporting that TP53 restoration may revive extrinsic apoptosis and immunological pathways capable of modulating CAR-T success. Methods: We analyzed 2 de-novo DLBCL patient cohorts (Xu-Monette et. al. 2020 and the TCGA) for differential expression and pathway analysis between TP53-mutant and Low TNFRSF10B (-1 Standard Deviation) patients versus normal counterparts. We integrated data from 3 additional sources to uncover actionable vulnerabilities within patients faced with dismal CAR-T response: differential gene expression between TP53-mutant and WT rrDLBCL patients (Shouval et. al. 2022), in-vitro CAR-T sgRNA-cytotoxicity scores (Dufva et. al. 2020), and gene expression following MDM2 inhibition (Louise et. al. 2021). We next assayed Idasnutlin and Eprenetapopt vs. 7 DLBCL cell lines, 5 of which harbor TP53 alterations, across a series of 9 concentrations (78nM-20µM) across 3-9 replicates. We followed these results by combining treatments in the TP53-impaired DHL6 and U2932 cell lines, analyzing results using the HSA synergy model. Lastly, we performed Western blot analysis to measure protein expression of TNFRSF10B following 24-hour single-agent or combination treatment. Results: Integrative analyses support that DNA alterations to TP53 are associated with significantly reduced T-cell activation and extrinsic apoptosis genes. TNFSRF10B was significantly reduced in these cases as well (FDR = 0.0034), and genes with significantly reduced expression in both TP53-mut and Low TNFRSF10B expression were associated with the loss of Immune System Development genes (FDR = 3.66E-09). The Staudt lab IFNG-Up and STAT-Up gene signature pathways were significantly reduced in TP53-mut patients (P < 0.0001, P = 0.483) and in Low TNFRSF10B Patients (P < 0.0001, P = 0.488). TNFRSF10B was also the only gene with significantly reduced expression in TP53-mut rrDLBCL patients, importance for CAR-T cytotoxicity, and increased expression following MDM2 inhibition. Our Western blot results support these observations, showcasing upregulation of TNFRS10B following treatment. Idasnutlin and Eprenetapopt assays vs. DLBCL cell lines demonstrated dose and TP53-dependent cell inhibition, with ED50 values ranging between 880nM to 19.6µM, independent of COO. The homozygous-impaired TP53 cell line Karpas-422 was the least sensitive. The molecules were next combined vs. DHL6 and U2932 cell lines, resulting in synergistic reduction of cell viability and HSA synergy scores of 10.94, and 5.32, respectively. Combined treatments of 400 nM Idasnutlin and Eprenetapopt reduced cell viability significantly greater than single agent treatments at the same concentration in DHL6 (P = 0.0001; P = 0.0176) and U2932 (P = 0.0012; P = 0.0322). Conclusions: Our results suggest the presence of an interconnected genomic DLBCL phenotype characterized by TP53 loss, reduced TNFRSF10B expression, and a debilitated immune presence, collectively predictive of an inferior CD19 CAR-T response. We applied the targeted therapies Eprenetapopt and Idasnutlin vs. cell line models, with both displaying anti-tumor activity as single agents. Most importantly, we observed synergistic activity in TP53-imparied DLBCL cell lines when the molecules were combined. These results are buoyed by integrative and Western blot analyses that highlight the promise of TNFRSF10B revival afforded by these agents, revealing a potential avenue to address inferior CAR-T response rates faced by patients harboring TP53 alterations. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Targeting a Novel G-Quadruplex in the CARD11 Oncogene Promoter with Naptho(2,1-b)furan-1-ethanol,2-nitro- Requires the Nitro Group.

The aggressive nature of the activated B cell such as (ABC) subtype of diffuse large B cell (DLBCL) is frequently associated with altered B cell Receptor (BCR) signaling through the activation of key components including the scaffolding protein, CARD11. Most inhibitors, such as ibrutinib, target downstream BCR kinases with often modest and temporary responses for DLBCL patients. Here, we pursue an alternative strategy to target the BCR pathway by leveraging a novel DNA secondary structure to repress transcription. We discovered that a highly guanine (G)-rich element within the CARD11 promoter forms a stable G-quadruplex (G4) using circular dichroism and polymerase stop biophysical techniques. We then identified a small molecule, naptho(2,1-b)furan-1-ethanol,2-nitro- (NSC373981), from a fluorescence-resonance energy transfer-based screen that stabilized CARD11 G4 and inhibited CARD11 transcription in DLBCL cells. In generating and testing analogs of NSC373981, we determined that the nitro group is likely essential for the downregulation of CARD11 and interaction with CARD11 G4, and the removal of the ethanol side chain enhanced this activity. Of note, the expression of BCL2 and MYC, two other key oncogenes in DLBCL pathology with known promoter G4 structures, were often concurrently repressed with NSC373981 and the highly potent R158 analog. Our findings highlight a novel approach to treat aggressive DLBCL by silencing CARD11 gene expression that warrants further investigation.

Excess Mortality by Multimorbidity, Socioeconomic, and Healthcare Factors, amongst Patients Diagnosed with Diffuse Large B-Cell or Follicular Lymphoma in England.

Simple SummaryDiffuse large B-cell (DLBCL) and follicular lymphoma (FL) account for most non-Hodgkin lymphoma diagnoses: around 35% and 20% in England, respectively. Despite the vast contrast in survival between the subtypes, similar socioeconomic inequalities in survival have persisted over the past two decades, possibly due to the presence of comorbidities. The aim of our study was to assess the association between socioeconomic status and survival from DLBCL or FL accounting for patient and health system characteristics. We found that, for both DLBCL and FL, the most deprived patients had a higher excess mortality hazard compared to the least deprived, regardless of the comorbidity status. Our results show the need for the current framework of the National Health Service to improve the survival of DLBCL and FL patients in the most deprived areas of England, and further consideration is needed for patient-tailored management plans amongst patients with comorbidities or multimorbidities.(1) Background: Socioeconomic inequalities of survival in patients with lymphoma persist, which may be explained by patients’ comorbidities. We aimed to assess the association between comorbidities and the survival of patients diagnosed with diffuse large B-cell (DLBCL) or follicular lymphoma (FL) in England accounting for other socio-demographic characteristics. (2) Methods: Population-based cancer registry data were linked to Hospital Episode Statistics. We used a flexible multilevel excess hazard model to estimate excess mortality and net survival by patient’s comorbidity status, adjusted for sociodemographic, economic, and healthcare factors, and accounting for the patient’s area of residence. We used the latent normal joint modelling multiple imputation approach for missing data. (3) Results: Overall, 15,516 and 29,898 patients were diagnosed with FL and DLBCL in England between 2005 and 2013, respectively. Amongst DLBCL and FL patients, respectively, those in the most deprived areas showed 1.22 (95% confidence interval (CI): 1.18–1.27) and 1.45 (95% CI: 1.30–1.62) times higher excess mortality hazard compared to those in the least deprived areas, adjusted for comorbidity status, age at diagnosis, sex, ethnicity, and route to diagnosis. (4) Conclusions: Deprivation is consistently associated with poorer survival among patients diagnosed with DLBCL or FL, after adjusting for co/multimorbidities. Comorbidities and multimorbidities need to be considered when planning public health interventions targeting haematological malignancies in England.

Investigating the inequalities in route to diagnosis amongst patients with diffuse large B-cell or follicular lymphoma in England

IntroductionDiagnostic delay is associated with lower chances of cancer survival. Underlying comorbidities are known to affect the timely diagnosis of cancer. Diffuse large B-cell (DLBCL) and follicular lymphomas (FL) are primarily diagnosed amongst older patients, who are more likely to have comorbidities. Characteristics of clinical commissioning groups (CCG) are also known to impact diagnostic delay. We assess the association between comorbidities and diagnostic delay amongst patients with DLBCL or FL in England during 2005–2013.MethodsMultivariable generalised linear mixed-effect models were used to assess the main association. Empirical Bayes estimates of the random effects were used to explore between-cluster variation. The latent normal joint modelling multiple imputation approach was used to account for partially observed variables.ResultsWe included 30,078 and 15,551 patients diagnosed with DLBCL or FL, respectively. Amongst patients from the same CCG, having multimorbidity was strongly associated with the emergency route to diagnosis (DLBCL: odds ratio 1.56, CI 1.40–1.73; FL: odds ratio 1.80, CI 1.45–2.23). Amongst DLBCL patients, the diagnostic delay was possibly correlated with CCGs that had higher population densities.ConclusionsUnderlying comorbidity is associated with diagnostic delay amongst patients with DLBCL or FL. Results suggest a possible correlation between CCGs with higher population densities and diagnostic delay of aggressive lymphomas.

Routine Prophylaxis of Pneumocystis Pneumonia from the Fourth Cycle of R-CHOP Regimen in DLBCL Patients

▪Introduction: In our previous report, approximately 10% of diffuse large B cell (DLBCL) patients experienced non-neutropenic fever (NNF) during R-CHOP chemotherapy, and interstitial pneumonitis comprised approximately 55% of NNF cases. Pneumocystis jirovecii is one of the most common pathogens causing interstitial pneumonia, and increasing evidences suggest that R-CHOP may increase the risk of PJP with reported incidence of 5%.Method: A total of 404 patients with newly diagnosed DLBCL between Jan 2012 and Aug 2016 who were registered in the prospective study and were treated with R-CHOP were analyzed in this study. Before Mar 2014, primary prophylaxis for Pneumocystis jirovecii pneumonia (PJP) was not performed, whereas, bactrim (1 table daily) was dosed from the initiation of 4th cycle of R-CHOP chemotherapy thereafter. With this change of institutional strategy, we hypothesized that the incidence of PJP may differ by prophylaxis strategy.Results: The median age was 56 years (range, 20-85) and 297 patients (73.5%) completed 6 cycles of R-CHOP chemotherapy. The rest completed 1 (n=18, 4.5%), 2 (n=4, 1.0%), 3 (n=23, 5.7%), 4 (n=37, 9.2%), 5 (n=14, 3.5%), 7 (n=3, 0.7%) and 8 (n=8, 2.0%) cycles of treatment. Overall, 3 (0.7%) and 9 patients (2.2%) were diagnosed with definite and probable PJP during the period, and the incidence of definite plus probable PJP was 5.4%. Of 404 patients in the cohort, 220 (54.5%) patients were the candidates for routine prophylaxis with Bactrim. The incidence of definite and probable PJP before prophylaxis was 4.9% (9 out of 184 patients), which was decreased to 1.4% (3 out of 220 patients) after routine prophylaxis with bactrim (p=0.038). In the era of prophylaxis, 3 cases of PJP were all occurred before the 4th cycle and there was no PJP cases after the 4th cycle, while 6 PJP cases before Mar 2014 were noticed after 4-6 cycles of R-CHOP (0% vs 3.3%, p=0.007).Conclusion: Routine prophylaxis with bactrim during later cycles of R-CHOP regimen significantly reduces the incidence rate of PJP in DLBCL patients. DisclosuresKim:Novartis: Research Funding; Donga: Research Funding; Takeda: Research Funding; J&J: Research Funding; Kyowa-Kirin: Research Funding; Celltrion, Inc: Consultancy, Honoraria; Mundipharma: Research Funding; Roche: Research Funding.

Novel Therapies for Relapsed or Refractory Diffuse Large B-Cell Lymphoma.

The most common type of non-Hodgkin lymphoma in adults is diffuse large B-cell (DLBCL). There is a historical unmet need for more effective therapies in the 2nd and 3rd line setting. Emerging immunochemotherapies have shown activity in small studies of heavily pre-treated patients with prolonged remissions achieved in some patients. Anti-CD19 CAR (chimeric antigen receptor) T cells are potentially curative in the 3rd line and beyond setting and are under investigation in earlier lines of therapy. Antibody-drug conjugates (ADC’s) such as polatuzumab vedotin targeting the pan-B-cell marker CD79b has proven effectiveness in multiply-relapsed DLBCL patients. Tafasitamab (MOR208) is an anti-CD19 monoclonal antibody producing prolonged remissions when combined with Lenalidomide (LEN) in patients who were not candidates for salvage chemotherapy or autologous stem cell transplant. Selinexor, an oral, small-molecule selective inhibitor of XPO1-mediated nuclear export (SINE), demonstrated prolonged activity against heavily-pretreated DLBCL without cumulative toxicity and is being investigated as part of an oral, chemotherapy-free regimen for relapsed aggressive lymphoma. This article reviews current strategies and novel therapies for relapsed/refractory DLBCL.

Genomic Analysis of R2CHOP-Treated DLBCL Reveals a High-Risk Population Driven By Inflammatory Pathways

Genomic Analysis of R2CHOP-Treated DLBCL Reveals a High-Risk Population Driven By Inflammatory Pathways

Targeting B-Cell Maturation Antigen (BCMA) with CC-93269, a 2+1 T Cell Engager, Elicits Significant Apoptosis in Diffuse Large B-Cell Lymphoma Preclinical Models

B-cell maturation antigen (BCMA), a member of the TNF receptor superfamily, serves as the cell surface receptor for B-cell activating factor (BAFF). Upon binding of BAFF to BCMA, an intracellular signaling cascade is initiated resulting in upregulation of JNK pathway signaling events and NFkB mediated transcription. The canonical expression pattern of BCMA begins on germinal center B-cells and becomes maximally expressed on mature cells such as plasma cells. Given the high degree of expression of BCMA on multiple myeloma (MM) cells, the malignant counterpart to plasma cells, it has become a target of interest for CAR T and antibody mediated modalities such as antibody drug conjugates and bispecific molecules. Recent clinical data from clinical trials employing BCMA targeted CAR T cells or T cell engager (TCE) antibodies have demonstrated significant responses in heavily pretreated myeloma patients with overall response rates ranging from 70% to 80%. As BCMA is known to be expressed in earlier B-cell lineages, we sought to explore the expression of BCMA in non-Hodgkin lymphoma (NHL) and its sensitivity to CC-93269, a 2+1 TCE currently being clinically investigated in MM. NHL is a heterogeneous collection of lymphomas that can be classified into two major subgroups; aggressive lymphomas of which diffuse large B-cell (DLBCL) is the most prevalent subtype and indolent lymphomas of which follicular lymphoma is the largest constituent. We first sought to directly quantitate cell surface expression of BCMA utilizing a flow cytometry system based on a logarithmic dilution of phycoerythrin beads of a known quantity. In a panel of 43 NHL cell lines, we determined that BCMA expression ranged from 43 to 17,048 molecules per cell (median, 420). An isogenic pair of K562 that is null for BCMA expression and K562 constitutively overexpressing BCMA (K562-BCMA) (15,866 molecules/cell) served as negative and positive controls, respectively. Additionally, the MM cell line H929 was profiled to serve as an additional control with a BCMA expression level of 7,065 molecules/cell. Next, utilizing quantitative PCR we found that relative BCMA mRNA expression in the lymphoma cell lines ranged from 0.001 to 0.17-fold when normalized to the H929 MM cell line. Furthermore, we were able to determine that in the lymphoma cells there is a poor correlation between protein expression (mean fluorescent intensity) and mRNA expression (r2, 0.33). We next examined if there was any correlation between BCMA surface expression and T-cell mediated cytotoxicity after administration of CC-93269 in a co-culture assay. We selected 11 DLBCL cell lines with a surface expression ranging from 45 molecules to 17,000 molecules per cells and incubated them in a co-culture system with a defined 1:5 target:effector ratio with CC-93269 (0-200 ng/ml) for five days. Significant apoptosis as measured by annexin V and ToPro-3 staining of CFSE positive target cells was observed in 10 of the 11 cell lines profiled with an IC50 of 0.1 to 38 ng/ml for CC-93269. As controls, the K562 isogenic pair were also profiled with the K562-BCMA cell line exhibiting an IC50 of 0.5 ng/ml and no activity observed against the parental K562 cell line. Additionally, a bispecific antibody where the two binding domains for BCMA was altered to target HEL (hen egg lysozyme) demonstrated no activity against any of the cell lines profiled at a defined dose of 200 ng/ml. No association between CC-93269 activity and BCMA expression or cell of origin was found. To determine the expression of BCMA in primary DLBCL biopsy samples, we developed a novel monoclonal BCMA immunohistochemistry antibody (clone: G12). The antibody and IHC staining protocol were validated to have good on-target specificity in both cell lines and tissues, including MM and DLBCL biopsies, with a range of stain intensity (1-3+) observed in both the golgi and on the plasma membrane. A proof of concept study on a cohort of 110 commercial DLBCL samples is currently underway. Cumulatively, our data demonstrate that BCMA is expressed on the cell surface of a broad panel of NHL cell lines and in primary DLBCL lymph node biopsies. Additionally, the expression levels of BCMA in these preclinical cell line models was sufficient to elicit significant CC-93269 mediated cytotoxicity. These data highlight the potential for the treatment of DLBCL patients with a 2+1 T-cell engager targeting BCMA. Disclosures Hagner: Celgene Corporation: Employment, Equity Ownership, Patents &amp; Royalties. Waldman:Celgene: Employment, Equity Ownership, Patents &amp; Royalties. Gray:Celgene: Employment, Equity Ownership. Yura:Celgene: Employment, Equity Ownership. Hersey:Celgene: Employment, Equity Ownership. Chan:Celgene: Employment, Equity Ownership. Zhang:Celgene: Employment, Equity Ownership. Boss:Celgene Corporation: Employment, Equity Ownership. Gandhi:Celgene Corporation: Employment, Equity Ownership, Patents &amp; Royalties.

Proteasomal cysteine deubiquitinase inhibitor b-AP15 suppresses migration and induces apoptosis in diffuse large B cell lymphoma

BackgroundThe first line therapy for patients with diffuse large B cell (DLBCL) is R-CHOP. About half of DLBCL patients are either refractory to, or will relapse, after the treatment. Therefore, identifying novel drug targets and effective therapeutic agents is urgently needed for improving DLBCL patient survival. b-AP15, a selective small molecule inhibitor of proteasomal USP14 and UCHL5 deubiquitinases (DUBs), has shown selectivity and efficacy in several other types of cancer cells. This is the first study to report the effect of b-AP15 in DLBCL.MethodsCell lines of two DLBCL subtypes, Germinal Center B Cell/ GCB (SU-DHL-4, OCI-LY-1, OCI-LY-19) and Activated B Cell/ABC (SU-DHL-2), were used in the current study. Cell viability was measured by MTS assay, proliferation by trypan blue exclusion staining assay, cellular apoptosis by Annexin V-FITC/PI staining and mitochondrial outer membrane permeability assays, the activities of 20S proteasome peptidases by cleavage of specific fluorogenic substrates, and cell migration was detected by transwell assay in these GCB- and ABC-DLBCL cell lines. Mouse xenograft models of SU-DHL-4 and SU-DHL-2 cells were used to determine in vivo effects of b-AP15 in DLBCL tumors.Resultsb-AP15 inhibited proteasome DUB activities and activated cell death pathway, as evident by caspase activation and mitochondria apoptosis in GCB- and ABC- DLBCL cell lines. b-AP15 treatment suppressed migration of GCB- and ABC-DLBCL cells via inhibiting Wnt/β-catenin and TGFβ/Smad pathways. Additionally, b-AP15 significantly inhibited the growth of GCB- and ABC DLBCL in xenograft models.ConclusionsThese results indicate that b-AP15 inhibits cell migration and induces apoptosis in GCB- and ABC-DLBCL cells, and suggest that inhibition of 19S proteasomal DUB should be a novel strategy for DLBCL treatment.

Lenalidomide in Combination with Standard R-CHOP Overcomes the Negative Prognostic Value of Peripheral Blood Absolute Lymphocyte/Monocyte Ratio at Diagnosis and during Treatment in Patients with Diffuse Large B-Cell Lymphoma

Introduction. The peripheral blood absolute lymphocyte (ALC)/monocyte (AMC) ratio (ALC/AMC), as a surrogate of host immunity (i.e. ALC) and tumor microenvironment (i.e. AMC), is a predictive biomarker for clinical outcomes in diffuse large B-cell (DLBCL) patients. An ALC/AMC ratio ≥ 1.1 has been shown to be predictive of better survival both at baseline and during each therapy cycle in patients treated with R-CHOP [Porrata et al, 2014]. Lenalidomide is an immunomodulatory drug, effective in DLBCL patients, with various mechanisms of actions on the tumor microenvironment and the host immune response. In this study we analyze the prognostic value of ALC/AMC ratio in a cohort of newly diagnosed DLBCL patients treated with Lenalidomide plus R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone, R2-CHOP) in a phase II trial (MC078E trial, [Nowakowski et al, 2015]).Methods. All patients with de-novo DLBCL enrolled in the phase II trial MC078E and treated at diagnosis with R2-CHOP regimen were included in the analysis. We investigated the ALC/AMC ratio at baseline and each R2-CHOP cycle as predictor of progression-free survival (PFS) and overall survival (OS). The ALC/AMC ratio was obtained by dividing the ALC by the AMC from the automated white blood cell differential obtained from the complete blood cell count on day 0 of each treatment cycle (range from day -3 to day 0 of each course). Patients were then divided in 4 groups on the basis of pattern of ALC/AMC ratio during treatment: group A: patients with ALC/AMC ratio ≥ 1.1 throughout all cycles; group B: patients with ALC/AMC ratio ≥ 1.1 at baseline, but then obtained an ALC/AMC < 1.1 during treatment; group C: patients with ALC/AMC ratio < 1.1 at baseline, but then gained an ALC/AMC ≥ 1.1 during treatment; group D: patients with ALC/AMC ratio < 1.1 throughout all cycles. PFS and OS were analyzed in the different groups. We separately conducted the same analysis in a matched control cohort of 94 DLBCL patients from the Mayo Clinic Lymphoma Database treated with standard R-CHOP.Results. A total of 63 patients with de-novo DLBCL treated with R2CHOP regimen at diagnosis were included in the analysis. Clinical characteristics were: median age 67 years (22-87), male sex 61.9%, III-IV advance stage 87.3%, elevated LDH serum levels 66.7%, intermediate-high/high International Prognostic index (IPI) score in 54% cases. No differences in 3y-PFS and 3y-OS in patients with ALC/AMC ratio ≥ 1.1 vs ALC/AMC < 1.1 at baseline and at each R2-CHOP course have been observed. In a landmark analysis from day 0 of the last cycle, 3y-PFS in group A vs B vs C vs D was: 71.4% vs 67.1% vs 66.7% vs 85.7%, respectively (p 0.80); 3y-OS in group A vs B vs C vs D was: 85.7% vs 86.5% vs 66.7% vs 100%, respectively (p 0.74). No differences in both 3y-PFS and 3y-OS were observed comparing group A vs B, in group C vs D, and in group A vs D. Unlike what was observed in the R-CHOP treated DLBCL patients, in a univariate analysis ALC/AMC < 1.1 during all cycles of R2CHOP was not a predictor for inferior outcomes (Figure 1.a). In the matched cohort of patients treated with standard R-CHOP, ALC/AMC < 1.1 at baseline and at each course demonstrated to be predictive of worse outcome (p <0.01),survival was significantly different in the 4 groups identified according to ALC/AMC ratio during treatment and ALC/AMC < 1.1 maintained during all cycles of R2CHOP was predictive of worse PFS and OS (Figure 1.b).Conclusions. Lenalidomide in combination with standard R-CHOP (R2-CHOP), in previously untreated DLBCL patients, appears to overcome the negative prognostic value of ALC/AMC ratio observed in patients treated with R-CHOP alone. This could reflect the additional effect of lenalidomide to standard therapy on tumor microenvironment and on host immunity response.Figure 1: Landmark Analysis for Progression Free Survival and Overall Survival by ALC/AMC groups within R2CHOP (1.A) and R-CHOP (1.B). Group A: ALC/AMC >=1.1 for all cycles; Group B: ALC/AMC >=1.1 at baseline and obtained <1.1 during treatment; Group C: ALC/AMC <1.1 at baseline and obtained >=1.1 during treatment; Group D: ALC/AMC <1.1 for all cycles. [Display omitted] DisclosuresWitzig:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Effect of thalidomide on the efficacy of diffuse large B-cell lymphoma and the expressions of Th17 cells and related cytokines

Objective To investigate the effect of thalidomide on the expressions of Th17 cells, interleukin 17 (IL-17), macrophage inflammatory protein 3α (MIP3α) in peripheral blood of patients with diffuse large B-cell (DLBCL) and 3-year survival rate. Methods Sixty patients with DLBCL from January 2009 to January 2013 in the Affiliated Hospital of Hebei University of Engineering were enrolled. According to envelope method, the patients were randomly divided into the combined group (n = 30, thalidomide combined with CHOP regimen) and chemotherapy group (n = 30, CHOP regimen alone). Clinical adverse reactions, efficacy, the expressions of Th17 cells, IL-17, MIP3α in peripheral blood before and after treatment, and 3-year survival rate between two groups were compared. Results The total effective rate and 3-year survival rate were 73.3% (22/30) vs. 46.7% (14/30), 87.4% vs. 40.7% respectively in the combined group and the chemotherapy group (both P 0.05). The levels of IL-17 and MIP3α mRNA in peripheral serum before and after treatment in the combined group were 8.51±0.23 vs.13.96±0.89, 27.4±1.5 vs. 83.0±8.5 (both P 0.05). There was no statistical difference in the adverse reactions between the combined group and the chemotherapy group (P > 0.05). Conclusion Thalidomide may prolong survival time of DLBCL patients by intervening Th17 cells and associated cytokines. Key words: Lymphoma, large B-cell, diffuse; Drug therapy, combination; Thalidomide; Th17 cells; Survival period

MYC Gene Rearrangements Are Closely Associated with Poor Survival of Diffuse Large B Cell Lymphoma with Hepatitis B Virus Infection

The aim of this study was to identify clinical adverse prognostic factors affecting overall survival (OS) of diffuse large B cell (DLBCL) patients with hepatitis B virus (HBV) infection. In this study, 30 DLBCL patients with HBV infection and 51 DLBCL patients with HBV-free were reviewed retrospectively. As of July 2016, the median follow-up period was 26.4 months (3.0~65.0 months). The median OS of patients in HBV infection group was 38.6 months, while that of patients in HBV-free group was not reached (P = 0.042); the median progression-free survival (PFS) of patients in HBV infection group was worse than that in HBV-free group, 18.5 months and 38.5 months (P = 0.118), respectively. The rate of MYC and BCL2 gene rearrangements in HBV infection group was significantly higher than that in HBV-free group, 20.0% versus 3.9% (P = 0.019) and 23.3% versus 5.9% (P = 0.021), respectively. Multivariable analysis indicated that IPI (P = 0.002), chemotherapy regimens (P = 0.017), and MYC gene rearrangements (P = 0.004) were independent adverse prognostic factors for all DLBCL patients in this study. Results demonstrated that the poor survival of DLBCL patients with HBV infection was closely involved in chemotherapy regimens, IPI, and MYC gene rearrangements.

A Single-Center Retrospective Study of 140 Patients with Post-Transplant Lymphoproliferative Disorder Following Solid Organ Transplantation

Background: Post-transplant lymphoproliferative disorder (PTLD) is an uncommon, heterogeneous disease that occurs in the setting of immune suppression following solid organ transplantation. As the transplant population ages over time, the spectrum of PTLD histologies and their treatment has evolved; we report here our recent experience with PTLD from a large multi-organ transplant program.Methods: We identified patients from the Multi-Organ Transplant Program at University Health Network (UHN) who were diagnosed with PTLD between January 1, 2000 and December 31, 2015. We describe the characteristics and outcomes of this cohort, with a focus on the outcome of patients with the diffuse large B cell (DLBCL) subtype of PTLD treated in the rituximab era.Results: A total of 140 patients were diagnosed with PTLD at UHN during this time period (Table 1): 38% were female and median age at time of diagnosis was 50 (interquartile range, IQR Q1/Q3, 37 to 62 years). The most commonly implicated transplants were liver and kidney (33% and 32%), as well as lung (20%) and heart (7%). The median time from organ transplantation to PTLD diagnosis was 61 months (IQR 9 to 136), with 70% of cases occurring more than 12 months following solid organ transplant. Pathologically, the majority of the patients had monomorphic PTLD, with DLBCL (n = 86) being most common. Where classifiable by the Hans algorithm (n = 68), the majority of the DLBCL types were of the non-germinal center B cell type (non-GCB, 76.5%). Of 24 DLBCL patients with available FISH, 7 had a MYC translocation (29%).Treatment and outcome varied by PTLD subtype (Table 2). For the overall cohort (n = 140), the median OS was 5.1 years. Highlighting competing risks, less than half of patients died of PTLD, with the remainder of mortality due to complications of solid organ transplantation, or less commonly, due to treatment-related mortality. Polymorphic PTLD (n = 17) was treated in a variety of ways ranging from reduction in immunosuppression (RIS) alone to R-CHOP; median OS was 10.3 years. Less common histologic subtypes (Hodgkin, Burkitt, T cell) were treated with therapies specific to those lymphomas. For DLBCL (n = 86), treatment consisted of RIS alone (10.5%; OS 4.4 years) or RIS followed by local treatment (involved field radiation or surgical resection) (7.0%; OS not reached); single agent rituximab (R) (22.1%; OS not reached); sequential R followed by CHOP (11.6%; OS 1.5 years), or upfront R-CHOP (43.0%; OS 3.4 years). Median OS for patients classified as non-GCB was not worse than those classified as GCB (OS 6.2 vs. 4.7 years, p = 0.93).In the DLBCL cohort, 20 patients had progression during or after first line therapy, with 14 patients receiving additional treatment. Patients with early relapse during initial therapy or within the first 3 months (n = 13) did poorly compared to patients with later relapse occurring after 3 months (n = 7; median OS 0.7 vs 5.6 years, p < 0.01). This was similar to the entire cohort, where 40 patients relapsed and early relapsed/refractory patients also had poor outcomes compared to late relapsing patients (median OS 0.8 vs. 5.1 years, p <0.01). Six patients in the overall cohort had an autologous stem cell transplant for progressive disease; 4 remain in remission after 5 years (range, 1.3 to 5.8 years follow-up).Conclusion: In this recent retrospective cohort, PTLD was generally late onset and the median OS of all patients was 5 years. The most common histology was DLBCL (non-GCB subtype), but cell of origin did not influence outcome. Patients with early relapse or refractory disease had poor overall survival. Due to competing risks and comorbidities, many PTLD patients continue to have poor outcomes despite modern treatment strategies. [Display omitted] [Display omitted] DisclosuresJain:Roche Canada: Research Funding. Prica:Janssen: Honoraria. Kukreti:Celgene: Honoraria; Amgen: Honoraria; Lundbeck: Honoraria. Kuruvilla:Abbvie: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Amgen: Honoraria; Roche Canada: Consultancy, Honoraria, Research Funding; Merck: Honoraria; Seattle Genetics: Consultancy, Honoraria; Lundbeck: Honoraria.

Prognostic Value of Pre-Transplant PET Scan in Patients with Diffuse Large B-Cell (DLBCL) Lymphoma Undergoing Autologous Stem Cell Transplantation (ASCT)

Background: Recent data have shown that pre-transplant FDG-PET is prognostic in DLBCL patients undergoing autologous stem cell transplantation (ASCT). We retrospectively analyzed data on patients with DLBCL treated with ASCT to assess the impact of pre-transplant FDG-PET on relapse-free survival (RFS) and overall survival (OS).Methods: We reviewed medical records of 32 patients with DLBCL who underwent ASCT using high dose busulfan, cyclophosphamide, and etoposide (Bu/Cy/VP) at Cleveland Clinic from June 2008 to December 2012 and had both a relapse FDG-PET as well as a pre-transplant FDG-PET available for review. All images were interpreted by a staff nuclear medicine radiologist blinded to the outcomes. Visual analysis was performed using the Deauville five-point scale and semiquantitative analysis was done by measuring the maximum standardized uptake value (SUVmax). ΔSUVmax was calculated by determining the difference between the SUVmax at the time of relapse and the SUVmax immediately prior to transplant. Patients were grouped into pre-transplant Deauville score 1-3 or 4-5. Baseline characteristics were compared between groups using the Chi-square test or Wilcoxon rank test. Cox proportional hazards analysis was used to identify prognostic factors. Outcomes were calculated from the date of ASCT. Overall survival (OS) and relapse-free survival (RFS) were estimated using the Kaplan-Meier method and compared using the log-rank testResults: The median age of the patients at transplant was 57 and 69% were male. There was no significant difference in baseline characteristics of patients who had a Deauville score 1-3 compared to patients who had a Deauville score 4-5 including mean age, gender, race, Karnofsky performance status, number of prior chemotherapy regimens, prior radiation therapy, and IPI at diagnosis and transplant. There was a trend towards significance in the median SUVmax at relapse in the Deauville 1-3 group compared to the Deauville 4-5 group (11.1 vs. 18.1, p=0.08) and a significant difference in the median pre-transplant SUVmax (2.3 vs. 8.1, p<0.001). Deauville score 4-5 was the only baseline variable that was prognostic for both RFS (HR=4.2, CI 1.6-11.5, p=0.004) and OS (HR=5.5, CI 1.6-18.9, p=0.006). The 3-year RFS for patients in the Deauville 1-3 group was 64% compared to 12% in the Deauville 4-5 group (p=0.002) and the 3-year OS for patients in the Deauville 1-3 group was 84% compared to 30%, respectively (p=0.002 [Figure 1]). The median ΔSUVmax was 74%. There was no difference in RFS or OS in patients who had a ΔSUVmax above or below this median. However, a high pre-transplant SUVmax(>6 vs. <6) was associated with significantly inferior RFS (p=0.03 [Figure 2]).Conclusions: Pre-transplant FDG-PET Deauville score is prognostic of RFS and OS in patients with DLBCL undergoing ASCT. High SUVmax(>6) prior to transplant is predictive of poor RFS. Pre-transplant PET is a powerful tool for identifying DLBCL patients at high risk for treatment failure with ASCT and could be used to risk-stratify patients in prospective clinical trials of novel transplant strategies. [Display omitted] [Display omitted] DisclosuresSmith:celegene, spectrum, genentech: Honoraria. Majhail:Gamida Cell Ltd.: Consultancy; Anthem Inc.: Consultancy.

Non-Hodgkin Lymphomas: Impact of Rituximab on Overall Survival of Patients with Diffuse Large B-Cell and Follicular Lymphoma

Information comparing treatment outcome for diffuse large Bcell (DLBCL) and follicular (FL) non-Hodgkin lymphoma (NHL) patients treated with schemes with and without rituximab from low- and middle-income countries is scarce. Clinical characteristics, response to therapy and long-term outcome of DLBCL and FL patients were studied. Patients with DLBCL and FL diagnosed over 8years at a reference center in northeast Mexico were included. Kaplan-Meier method was used to determine overall survival (OS) and progression-free survival (PFS). Cox regression model was used to evaluate the association between risk factors, rituximab therapy and clinical outcome. One hundred-sixteen patients with DLBCL and 65 with FL in advanced stages were included. Median age was 57.8 and 56years, respectively. Clinical characteristics between groups receiving or not receiving rituximab were comparable. Stages III and IV were found in 63.8% of DLBCL and 84.6% in FL patients, respectively. OS and PFS at 60months were 63.8 and 51.2% in DLBCL and 70.6 and 33.8% in FL. No difference in OS was found in DLBCL and FL when rituximab-based regimens vs. non rituximab-based regimens were compared, but a statistically significant difference was documented in PFS in FL patients. Addition of rituximab to CHOP-like regimens did not improve OS in DLBCL and FL NHL subtypes. In comparison to developed countries, diagnosis of NHL was made a decade earlier and in advanced clinical stages. Cost-efficiency of adding rituximab to therapy for these patients should be assessed.