Diffuse Large B-cell Research Articles

Efficacy of 90Y-Ibritumomab Tiuxetan in the Older Population with Non-Hodgkin Lymphoma Pre-Treated with Rituximab-Based Regimens: A Single-Institution Experience

Background: The use of (90)Y-Ibritumomab tiuxetan (90Y-IT) as radioimmunotherapy in the treatment of B-cell non-Hodgkin lymphoma (NHL) has been approved for consolidation and salvage treatment of follicular and indolent lymphoma. It has also been studied in the treatment of diffuse large B-cell and mantle cell lymphoma. Toxicities primarily include myelosuppression with a risk of treatment-associated myelodysplastic syndrome (t-MDS).Methods: Retrospective cohort analysis of patients with B-cell NHL who received 90Y-IT from 2010 to 2016 at Geisinger Medical Center. 90Y-IT was administered as both consolidation and salvage treatment according to recommended dosing guidelines and cytopenia was monitored at routine intervals. A random subset of patients received maintenance Rituximab (R) at 375 mg/m2 every three months for eight doses.Results: Sixty-six patients with NHL received 90Y-IT at a median age of 68 years (range 32-91), 33 (50%) patients were male, and 37 (56%) were greater than 65 years of age. Disease subtypes included: follicular center cell (n=31, 47%), diffuse large B-cell (n=22, 33%), mantle cell (n=3, 4.5%), marginal zone (n=7, 10.6%), small lymphocytic (n=1, 1.5%), and Waldenstrom macroglobulinema (n=2, 3.03%). Thirty-three patients (50.0%) had aggressive NHL and 38 (57.6%) had stage III/IV disease. Disease status prior to 90Y-IT was as follows: CR (n=33, 50%), PR (n=22, 33.3%), and relapse/refractory (n=11, 16.7%).Twenty-nine patients (43.9%) received >1 line of treatment prior to 90Y-IT therapy. The median duration of disease prior to 90Y-IT was 18 months (range 4-184). Sixty-four patients received R prior to 90Y-IT and no patient received fludarabine-based therapy. The median PFS and OS were 27 and 30 months, respectively, for all patients. There was no significant difference in PFS and OS between patients younger and older than 65 years of age, between patients in CR and not in CR at the time of 90Y-IT, or between patients with aggressive and indolent disease.The median follow-up period was 30 months (range 15-87). The overall response rate (ORR) was 92.4% (n=61) with a PR-to-CR conversion rate of 22.7%. In the salvage setting, the ORR was 84.8%. In the relapse/refractory setting, the ORR was 72.7%. Patients not in CR at the time of 90Y-IT were found to be responsive to R maintenance: PFS improved from median 21 to 56 months and OS improved from median 28 to 66.5 months (p=0.002).Fifteen patients (22.7%) received R maintenance after 90Y-IT and demonstrated improvement in PFS (mean 26.9 to 49.8 months, p=0.0004) and OS (mean 32.7 to 55.7 months, p=0.0004). In the diffuse large B-cell lymphoma population, the patients with R maintenance had demonstrated benefit in PFS (mean 21.4 to 46.0 months, p=0.0423) and OS (mean 23.7 to 46.0 months, p=0.0417). Among the indolent lymphomas, the addition of R maintenance demonstrated improvement in OS from 35.4 to 57.1 months (p=0.0197).Among patients with grade 3/4 hematologic toxicities, six (9.1%) required blood transfusion, four (6.1%) needed platelet transfusion, and 17 (25.8%) received pegfilgastrim. Two patients required hospitalization for febrile neutropenia. Ten patients (15.2%) relapsed after 90Y-IT at median 65.0 months, and one patient (1.5%) developed t-MDS (del 5q, del 20q) 54 months after treatment. There were 14 deaths (six were secondary to progressive lymphoma or chemotherapy-related neutropenic sepsis).Conclusions: This is one of the largest single-center experiences of 90Y-IT administered to a predominantly elderly population with B-cell NHL pre-treated with Rituximab-based regimens. This study demonstrates the safety and feasibility of 90Y-IT in the elderly population with manageable toxicity, with no increased risk of treatment-related myelodysplastic events. This study also demonstrated PFS and OS benefit in administering Rituximab maintenance post 90Y-IT to both indolent and aggressive B-cell NHL and should be further investigated in future studies. DisclosuresKhan:Spectrum Pharmaceuticals, Inc.: Other: Advisory Board, Speakers Bureau.

The Cambridge University Hospitals and Anglia Regional Experience of Using PEP-C As Palliative Chemotherapy in Lymphoma

PEP-C (prednisolone, etoposide, procarbazine, and cyclophosphamide) is an orally administered chemotherapy regimen used with palliative intent in relapsed or refractory lymphoma. To our knowledge no data on PEP-C have been reported since the original group described the regimen (Coleman et al., (2008) Leuk & Lymph 49, 447). Here we present a cohort from 3 centres describing our use of PEP-C over an 8 year period. Within the limitations of a retrospective cohort we find that PEP-C can give sustained responses and is well tolerated.PEP-C is usually administered as daily oral medication in three phases (Coleman et al., as above). Firstly, there is an induction phase where PEP-C is given daily until the white cell count falls below 3.0x109/L; then there is a break in treatment whilst the marrow recovers; and finally, PEP-C is re-started with the number of days per week on which it is given being titrated to keep the white cell count above 3.0x109/L. Variations to this schedule are possible.We identified 70 patients who received PEP-C at our centres and data from all is included. To achieve meaningful group sizes for analysis we classified patients as having high grade (43/70 (61%), mainly diffuse large B-cell) or low grade (27/70 (39%), mainly mantle cell) lymphoma.The median age when starting PEP-C was 74 years. Ninety three percent of patients had stage 3 or 4 disease, and 26% had a performance status of 3 or 4. Our cohort was therefore relatively frail.Of the 70 patients treated, 39% had a complete or partial response, and 44% had stable or progressive disease. In the remainder of cases there was no suitably objective measure by which to assess response. We assessed predictors of response by multivariate logistic regression and found the significant predictors to be whether disease was low or high grade, and whether or not a patient had responded to the line of chemotherapy prior to PEP-C (chemosensitive versus chemoresistant). Eleven out of 43 patients (26%) with high grade disease responded to PEP-C compared to 16 out of 27 (59%) with low grade disease (odds ratio=0.15 [95% CI 0.04 to 0.61]; p=0.008). Similarly, 5 out of 26 patients (19%) with chemoresistant disease responded to PEP-C compared to 19 out of 38 (50%) with chemosensitive disease (odds ratio=0.15 [95% CI 0.03 to 0.69]; p=0.014). There was no interaction between the predictors.As might be expected, whether or not a patient responded to PEP-C translated into a difference in overall survival. Patients who did not respond to PEP-C had a median overall survival from starting PEP-C of 70 days versus 599 days in patients who did respond (hazard ratio 4.9 [95% CI 2.4 to 9.9]; log rank p<0.001).Whether or not a patient responds to PEP-C cannot, however, be used a priori to make a decision about whether a patient might benefit from treatment. We therefore built Cox regression models to find other predictors of overall survival and found the significant predictor to be whether or not a patient was ‘chemosensitive’ as defined above. Chemosensitive patients had a median overall survival of 465 days compared to 77 days for chemoresistant patients (hazard ratio 0.47 [95%CI 0.26 to 0.85]; log rank p=0.011). For high versus low grade lymphoma the overall survivals were 116 and 411 days respectively but this trend did not reach statistical significance (p=0.050). For all patients the median overall survival was 167 days.The median time spent on treatment with PEP-C was 62 days, but there was considerable variation (range 4 to 1237 days). Interestingly, whilst chemosensitive patients had a median overall survival of 465 days from starting PEP-C (see above), they only spent a median of 90 days on treatment. This suggests that the optimum duration of treatment needs to be better defined as a shorter course may confer some ongoing benefit.Twenty two out of 70 patients (31%) discontinued PEP-C due to toxicity (uncomplicated marrow suppression in 10, non-neutropenic sepsis in 5, and neutropenic sepsis in 4). Thirteen patients (19%) died whilst on treatment with PEP-C but it is not clear that these deaths were a direct result of the treatment.In summary we suggest that PEP-C can be an effective palliative treatment for lymphoma, particularly but not exclusively where the lymphoma is known to be chemosensitive. The regimen has a tolerable side effect profile, and also has the advantage of being cheap. The cost of the ‘median’ course of treatment with PEP-C in our cohort was a little over £500 (BNF 73, 2017). DisclosuresFollows:Janssen: Other: advisory board and lecturing; Gilead: Other: advisory board and lecturing; Roche: Other: advisory board and lecturing; Abbvie: Other: advisory board and lecturing.

Long-Term Follow up of 90y-Ibritumomab Tiuxetan, Fluadarabine and TBI Based Non-Myeloablative Allogeneic Transplant Conditioning for Persistent High-Risk B-Cell Lymphoma

Purpose:Non-myeloablative allogeneic hematopoietic cell transplantation (NMA-HCT) can provide prolonged remissions in patients with advanced B-cell lymphoma (B-NHL) via the graft versus lymphoma (GVL) effect, though inferior results are seen in patients with chemoresistant, bulky, or aggressive disease. Radioimmunotherapy (RIT) can safely induce responses in B-NHL with little non-hematologic toxicity. Initial results of this approach demonstrated early safety and disease control (Blood, 2011) but with short follow up. Here we report the long-term outcomes of patients treated on this study with specific emphasis on patients achieving early remissions.Patients and Methods:Eligible patients with persistent CD20+ B-NHL or CLL, with HLA-matched related or unrelated donors, and adequate organ function, underwent NMA-HCT. Patients were not excluded based on cytopenia or marrow involvement with lymphoma. Conditioning included 0.4 mCi/kg (max 32mCi) 90Y-ibritumomab tiuxetan (day-14), fludarabine (days -7 to -5) and 2 Gy total body irradiation (day 0) followed by transplantation from HLA-matched related or unrelated donors along with post-grafting immunosuppression with cyclosporine and mycophenolate mofetil. Long-term follow up was updated through July 1, 2017.Results:We accrued 40 patients to this prospective trial. Baseline features included: median age 58 years (range 29-69), median prior regimens = 6 (range 3 to 12), chemosensitive disease = 6 (15%), CR pretransplant = 0 (0%), bulk >5 cm = 17 cm (range 5.2-18.6cm, 43%), >25% bone marrow involvement with B-NHL = 10 (25%, range of marrow involvement 40-95%), comorbidity score ≥1 = 35 (85%), median comorbiditiy score 3 (range 0-10), pretransplant IPI ≥3 = 21 (53%). Histologies included: indolent (18; CLL/SLL-10, follicular lymphoma-6, hairy cell leukemia-1, and marginal zone lymphoma-1), Diffuse large B-cell (DLBCL, 14), and mantle cell lymphoma (MCL, 8). Patients received HCT from 15 matched related or from 25 matched unrelated donors.Eleven of 40 patients are alive with a median follow up of 9 years (range 5.3-10.2). There were 14 (35%) deaths due to disease progression, and 14 (35%) deaths attributed to complications from HSCT. One patient died of a Merkel cell carcinoma. The median progression-free and overall survival of the entire group was 1.1 years and 2.9 years, respectively (Figure 1). The best outcomes were observed in patients with indolent histology with an estimated 5-year PFS and OS of 44% and 67% respectively (Figure 2). Early CR/PR was achieved by 7/8 (83%) patients with indolent lymphoma, 4/1 (36%) with DLBCL, and 2/2 (50%) with MCL. Long-term PFS was observed in 7 of 15 of patients with indolent NHL and 2 of 4 MCL with early remission. None of the patients with DLBCL were long-term disease free survivors regardless of early remission status. No late complications attributable to RIT (such as secondary myeloid malignancies) were observed in any patient.Conclusions:Long-term disease control of high-risk B-NHL not in CR who underwent NMA-HCT with 90Y-ibritumomab tiuxetan conditioning varied by histology. 90Y-ibritumomab tiuxetan based allografting induced high-early response rates and favorable long-term outcomes in patients with indolent histologies likely based on both the efficacy of RIT and GVL effect in this population. Only early MCL responders to RIT had long term PFS, and none of the DLBCL patients survived regardless of response. Improved strategies are needed for these populations. Our current study escalates the dose of 90Y-ibritumomab tiuxetan prior to NMA-HCT for DLBCL for this purpose. [Display omitted] DisclosuresFlowers:Pharmacyclics: Consultancy. Maloney:Juno Theraapeutics: Other: Advisory board, Patents & Royalties, Research Funding; Roche/Genetech: Other: Advisory board; Celgene: Other: Advisory board; Kite Pharmaceuticals: Other: Advisory board. Press:Roche: Honoraria, Research Funding; BMS: Honoraria; Bayer: Consultancy. Gopal:Seattle Genetics: Consultancy, Research Funding.

IMPAIRED HUMORAL RESPONSE IN LYMPHOMA PATIENTS SURVIVING THE ACUTE PHASE OF COVID‐19

Introduction: The ability to generate an adequate and durable immune response to SARS-CoV-2 in B-cell lymphoma patients (pts) treated with immunochemotherapy is still unclear. We monitored antibody levels during convalescence in COVID-19 survivors with lymphoma, compared to other hematologic diseases (HemD) and healthy controls (Ctrls). Methods: Seventeen pts with non-Hodgkin lymphoma (NHL) [follicular (FL): 9; diffuse large B-cell (DLBCL): 8] surviving the acute phase of virologic-proven COVID-19 were evaluated at 3 timepoints (TP) after nasal swab negativity: +1 (TP1), +3 (TP3), and +6 (TP6) months; 28 pts affected by HemD (10 multiple myeloma, 8 chronic lymphoproliferative disorders, 10 myelodysplastic/chronic myeloproliferative syndromes) and 17 Ctrls were also evaluated at the same TP. Antibody (Ab) levels to nucleocapsid (N-Ab) and spike (S-Ab) virus proteins were measured using a highly sensitive luciferase-immunoprecipitation system (LIPS) assay. Positive levels were 125000 LU for N-Ab and 45000 LU for S-Ab. Results: Mean N- and S-Ab levels were lower in FL and DLBCL than in other HemD pts, both at TP1 (N-Ab 1217517 vs 2205610 LU, p = 0.03; S-Ab 580444 vs 1184453 LU, p = 0.049) and at TP3 (N-Ab 850510 vs 2094487 LU p = 0.012, S-Ab 605284 vs 1230946 LU, p = 0.074). At TP6 N-Ab levels declined in all subgroups, while S-Ab levels remained stable. At TP1, compared to HemD, significantly less FL and DLCBL pts reached positive levels of N-Ab (93% vs 59% p = 0.017) and of S-Ab (86% vs 47%; P: 0.008). Positive levels of N-Ab and S-Ab were also more frequent in Ctrls (100% and 87%; p = 0.007 and 0.028) than in NHL pts. Rates of seroprotection remained lower in NHL pts also at TP3 and TP6. Rituximab (RTX) had been given to 14/17 NHL pts, either ≥6 months in 5 (prior RTX) or <6 months in 9 pts (ongoing RTX) before Covid-19 diagnosis. Ongoing RTX had a markedly negative effect on S-Ab levels since none of 9 patients seroconverted at TP1 compared to 5/5 prior RTX pts (P = 0.0005). No changes occurred in the rate of seroprotected pts also at TP3 and TP6 except for 1 ongoing RTX pt who reached protective levels at TP6 (see figure). Overall seroprotective Ab at any TP were present in 2 of 18 determinations in ongoing RTX pts, despite RTX treatment discontinuation, and in 15 of 15 determination in prior RTX pts (p = 0.0001). Keywords: Aggressive B-cell non-Hodgkin lymphoma, Indolent non-Hodgkin lymphoma No conflicts of interests pertinent to the abstract.

Primary disease sites and patterns of spread in cases of neurolymphomatosis in the orbit associated with lymphoma

BackgroundNeurolymphomatosis involving the cranial nerves (CNs) is rare. We sought a better understanding of the primary disease sites and patterns of spread in neurolymphomatosis of the orbit and retro-orbital cranial nerves.MethodsPatients with lymphoma and MRI evidence of neurolymphomatosis of CN II, III, IV, V1, or V2 were retrospectively reviewed. Demographics and primary disease site and sites of neurolymphomatosis on MRI were recorded. Wilcoxon rank sum test was used to compare number of sites of neurolymphomatosis with lymphoma type and survival.ResultsThe study included 18 patients. The most frequent types of lymphoma were diffuse large B-cell (DLBCL) (n = 9) and marginal zone (n = 3). In 9 patients, lymphoma presented as a mass (n = 7) or infiltrative disease (n = 2) directly involving the orbit; in 6, a maxillofacial mass spread directly to CNs; and in 3, lymphoma at remote sites spread to orbital CNs. Overall, 81 sites of neurolymphomatosis were noted. The most common sites were the maxillary nerve (V2) including at the infraorbital fissure or foramen rotundum (17 patients; 19 nerves), pterygopalatine fossa (16 patients; 19 nerves), and cavernous sinus (9 patients; 12 nerves). Number of sites of neurolymphomatosis was significantly lower for DLBCL than for other lymphoma types (p = 0.007). Number of sites of neurolymphomatosis did not affect survival (p = 0.26). The mean interval between the pathologic diagnosis and MRI documentation of the full extent of neurolymphomatosis was 39 days after pathologic diagnosis.ConclusionsBased on our study results, neurolymphomatosis in the orbit appears to be frequently associated with an orbital and/or maxillofacial mass and commonly involves CN V2, the pterygopalatine fossa, and the cavernous sinus. DLBCL may be associated with fewer sites of neurolymphomatosis than other lymphomas. In patients with lymphoma, a systematic search for neurolymphomatosis is imperative for early detection.

Cachexia is an independent factor for negative clinical and functional outcomes in lymphoma patients receiving CART therapy.

e19504 Background: Cachexia is a known independent factor for negative outcomes in several cancer populations at early and late stages, but has not been in investigated in cancer patients receiving Chimeric Antigen Receptor T-cell therapy (CART). Our objective was to evaluate the relationship between cachexia and clinical and functional outcomes in patients with lymphoma receiving CART. Methods: Design: Retrospective cohort study including 70 adult patients with aggressive B-cell lymphomas (Diffuse Large B-cell or Mantle Cell Lymphoma) who received CART. Cachexia markers: body weight loss (BWL), BMI, albumin, creatinine, and neutrophil-to-lymphocyte ratio (NLR) – each captured at diagnosis, pre-collection, CART initiation, and through day 360 post-CART. Outcome measures: Primary outcomes: Disease relapse after CART and 90-day mortality. Secondary outcome: Need for rehabilitation services post-acute care (inpatient rehabilitation or home physical therapy). Statistical analyses: Linear regression modeling, area under the curve analysis, and multivariate modeling (any univariates with p &lt; 0.25). Co-variates: age, ECOG PS, IPI, cell of origin, MYC status, number of prior cancer therapies, time from diagnosis to CART, and need for bridging / steroid pre-CART. Results: In longitudinal modeling from diagnosis to day 360, CART patients who relapsed had linear associations over time with BWL since diagnosis (p &lt; 0.01), NLR (p &lt; 0.0001), creatinine (p = 0.045), and albumin (p &lt; 0.001). In univariate analyses (see table): at pre-collection, high NLR and BWL increased odds of relapse; at treatment, high NLR and CRP increased odds of mortality; and at D30, and BWL and high NLR increased odds of relapse and mortality, respectively. In multivariate analyses (see table, # = independent association), BWL and high NLR independently associated with relapse and mortality, respectively. Significant covariates included need for bridging (p = 0.02), steroid therapy pre-CART (p &lt; 0.01), and time from diagnosis to CART (p = 0.02). Secondarily, BWL and low albumin pre-CART increased odds of needing rehabilitation services, with BWL independently associating in multivariate models (OR = infinity, p &lt; 0.001). Conclusions: Cachexia markers, such as BWL from diagnosis and NLR, are candidate predictors of relapse and mortality after CART. Specific markers could also assign patients to neo/adjuvant rehabilitative and medical therapies targeted towards cachexia. Overall, this study suggests that cachexia may alter the clinical and functional trajectory of lymphoma patients receiving CART.[Table: see text]

Low-cost transcriptional diagnostic to accurately categorize lymphomas in low- and middle-income countries

Inadequate diagnostics compromise cancer care across lower- and middle-income countries (LMICs). We hypothesized that an inexpensive gene expression assay using paraffin-embedded biopsy specimens from LMICs could distinguish lymphoma subtypes without pathologist input. We reviewed all biopsy specimens obtained at the Instituto de Cancerología y Hospital Dr. Bernardo Del Valle in Guatemala City between 2006 and 2018 for suspicion of lymphoma. Diagnoses were established based on the World Health Organization classification and then binned into 9 categories: nonmalignant, aggressive B-cell, diffuse large B-cell, follicular, Hodgkin, mantle cell, marginal zone, natural killer/T-cell, or mature T-cell lymphoma. We established a chemical ligation probe-based assay (CLPA) that quantifies expression of 37 genes by capillary electrophoresis with reagent/consumable cost of approximately $10/sample. To assign bins based on gene expression, 13 models were evaluated as candidate base learners, and class probabilities from each model were then used as predictors in an extreme gradient boosting super learner. Cases with call probabilities < 60% were classified as indeterminate. Four (2%) of 194 biopsy specimens in storage <3 years experienced assay failure. Diagnostic samples were divided into 70% (n = 397) training and 30% (n = 163) validation cohorts. Overall accuracy for the validation cohort was 86% (95% confidence interval [CI]: 80%-91%). After excluding 28 (17%) indeterminate calls, accuracy increased to 94% (95% CI: 89%-97%). Concordance was 97% for a set of high-probability calls (n = 37) assayed by CLPA in both the United States and Guatemala. Accuracy for a cohort of relapsed/refractory biopsy specimens (n = 39) was 79% and 88%, respectively, after excluding indeterminate cases. Machine-learning analysis of gene expression accurately classifies paraffin-embedded lymphoma biopsy specimens and could transform diagnosis in LMICs.

Malignancy Risk in 18F-FDG-Avid Thyroid Incidentalomas: Controversies and Limitations

Introduction: The prevalence of malignancy in thyroid incidentalomas (TI) discovered on 18F-FDG-PET or PET/CT varies between 0% and 63.6%. The pooled malignancy rate according to three systematic reviews is 33-35%. The 2015 American Thyroid Association (ATA) guidelines recommend that such nodules, when one centimeter or larger in size, should undergo further investigation with thyroid ultrasound (US) and fine-needle aspiration (FNA) cytology. Objectives: The objective of our study was to determine the rate of malignancy amongst TI discovered incidentally on 18F-FDG-PET or PET/CT, examine their clinicopathologic characteristics, and assess the usefulness of maximum standardized uptake values (SUVmax) in differentiating benign and malignant lesions. Methods: We performed an electronic medical record search looking at all 18F-FDG-PET or PET/CT reports during the study period of 12/01/2015 to 05/31/2019 that included the keyword ‘thyroid’ in the impression. Exclusion criteria included a history of thyroid disease or malignancy, known lesion(s) detected on previous clinical or radiological examinations and diffuse radiotracer uptake. Of the 476 reports reviewed, 136 cases were included in the study. Results: Common indications included initial staging or restaging of lymphoma (diffuse large B-cell, mantle-cell, T-cell types) (27.9%), lung adenocarcinoma (18.4%), head and neck cancer (16.9%) and breast cancer (11%). Fifty-eight (42.6%) patients had metabolically inactive lesions; five (8.6%) underwent further investigation with thyroid US and 3 subsequently with FNA (5%). All 3 had benign cytology. Seventy-seven (56.6%) patients had metabolically active lesions and 25 (32.5%) underwent imaging with thyroid US. Twelve (15.6%) had FNA; eight (66.7%) had benign cytology, two (16.7%) revealed atypia of undetermined significance and two (16.7%) were malignant. Biopsy for the two patients with malignant cytology showed follicular cell neoplasm of oncocytic hurtle cell type, and invasive follicular carcinoma with focal insular and papillary features and extensive capsular and vascular invasion. The mean SUVmax in malignant vs benign lesions was 9.05 and 6.41 respectively. Conclusion: The malignancy rate was 2.6% amongst all patients with 18F-FDG-avid TI and 8% amongst patients with metabolically active lesions who were investigated with thyroid US+/- FNA. This is significantly lower than malignancy rates previously reported in the literature. The evident inhomogeneity in the literature is likely multifactorial and may be explained in part by a dissimilarity among studies, and an informed decision by some to avoid invasive testing in the context of poor prognosis from underlying non-thyroidal cancer. Research is needed to determine the cohort of patients who could potentially benefit from further evaluation and treatment.

Neurolymphomatosis of the median nerve, optic nerve, L4 spinal nerve root and cauda equina in patients with B-cell malignancies: a case series

BackgroundNeurolymphomatosis is rare. Neoplastic lymphocytes are seen to invade nerves (cranial or peripheral), nerve roots or other related structures in patients with hematological malignancy. It is a separate entity from central nervous system lymphoma. Neurolymphomatosis has most commonly been described in association with B-cell non-Hodgkin lymphoma. Neurolymphomatosis in the context of Burkitt lymphoma and the post-renal transplant setting has not been described before.Case reportsWe report for the first time in the Arabian Gulf countries and nearby Arab states four cases of neurolymphomatosis (one Asian, and the other 3 are from Arabic nationals) occurring between 2012 and 2017 involving the median nerve, optic nerve, nerve root and cauda equina in patients with Burkitt lymphoma, Philadelphia chromosome-positive B-cell acute lymphoblastic leukemia and diffuse large B-cell lymphoma.ConclusionsNeurolymphomatosis is rare and can be difficult to diagnose by biopsy but reliably confirmed by a combined imaging approach. Prior treatment with high-dose dexamethasone might suppress 18F-fluorodeoxyglucose (FDG) activity and decrease the sensitivity of positron emission tomography/computed tomography (PET/CT). The prognosis is generally poor but using high-dose methotrexate as well as high-dose chemotherapy and autologous stem cell transplantation may be an effective way to treat neurolymphomatosis.

Understanding the Immune-Stroma Microenvironment in B Cell Malignancies for Effective Immunotherapy.

Cancers, including lymphomas, develop in complex tissue environments where malignant cells actively promote the creation of a pro-tumoral niche that suppresses effective anti-tumor effector T cell responses. Research is revealing that the tumor microenvironment (TME) differs between different types of lymphoma, covering inflamed environments, as exemplified by Hodgkin lymphoma, to non-inflamed TMEs as seen in chronic lymphocytic leukemia (CLL) or diffuse-large B-cell lymphoma (DLBCL). In this review we consider how T cells and interferon-driven inflammatory signaling contribute to the regulation of anti-tumor immune responses, as well as sensitivity to anti-PD-1 immune checkpoint blockade immunotherapy. We discuss tumor intrinsic and extrinsic mechanisms critical to anti-tumor immune responses, as well as sensitivity to immunotherapies, before adding an additional layer of complexity within the TME: the immunoregulatory role of non-hematopoietic stromal cells that co-evolve with tumors. Studying the intricate interactions between the immune-stroma lymphoma TME should help to design next-generation immunotherapies and combination treatment strategies to overcome complex TME-driven immune suppression.

Promoter usage regulating the surface density of CAR molecules may modulate the kinetics of CAR-T cells in vivo

Although chimeric antigen receptor T (CAR-T) cell therapy achieves high remission rates, challenges (e.g., toxicity management and relapse prevention) remain. The major risks are cytokine release syndrome and related neurological toxicity. The influence of the CAR surface density on the efficacy/safety of CAR-T cell therapy and the factors determining CAR density were not elucidated comprehensively. Here, we discovered that the use of the MND promoter increased the transduction rate and reduced the CAR surface density. Additionally, MND-driven CAR-T cells had prolonged antileukemia activity in a mouse model. In an initial dual-armed anti-CD19 CAR-T cell pilot study (ClinicalTrials.gov: NCT03840317), eight and six subjects were infused with MND and EF1α promoter-driven autologous CAR-T cells (3 × 105 CAR-T cells/kg), respectively. MND subjects developed mild fever and lower interferon gamma (IFN-γ) concentrations than in the EF1A19 group. All but one subject in each cohort reached minimal residual disease (MRD)-negative complete remission after the first month of evaluation. These results represent the first comprehensive study on the promoter-driven modulation of CAR-T cell functionality. These findings encourage further evaluation of the potential of the MND promoter to drive CAR-T cells as a broadly applicable cellular product for anticancer immunotherapy.

Aspirin and other nonsteroidal anti-inflammatory drugs, statins and risk of non-Hodgkin lymphoma.

Non-steroidal anti-inflammatory drugs (NSAIDs) and statin drugs may protect against the development of non-Hodgkin lymphoma (NHL), but data are limited, particularly for NHL subtypes. Furthermore, some in vitro, animal and epidemiologic data suggest there may be a synergistic effect of these two agents, but there has been no test of this hypothesis in NHL. We evaluated the self-reported use of NSAIDs and statins in a clinic-based study of 1703 NHL patients and 2199 frequency-matched controls. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for potential confounding variables. We observed an inverse association of regular use of low-dose aspirin with risk of NHL (OR = 0.82; 95% CI 0.70-0.96) that was stronger with longer duration of use (P < .01). There were no associations for use of regular or extra-strength aspirin, ibuprofen, other NSAIDs, statins or other cholesterol-lowering drugs with NHL risk, while an inverse association with COX-2 inhibitors was equivocal. There was also no interaction of low-dose aspirin and statins on NHL risk. Inverse associations of similar magnitude to all NHL were observed for regular use of low-dose aspirin with diffuse large B-cell, follicular, marginal zone and all other lymphomas, although not all associations were statistically significant. In conclusion, low-dose aspirin but not regular/extra strength aspirin, other NSAIDs or statin use was associated with lower risk of NHL. Beyond the potential for the primary prevention of NHL, these data also point to a role of anti-platelet or other effects of low-dose aspirin in lymphomagenesis that warrant follow-up.

A French multicentric prospective prognostic cohort with epidemiological, clinical, biological and treatment information to improve knowledge on lymphoma patients: study protocol of the \u201cREal world dAta in LYmphoma and survival in adults\u201d (REALYSA) cohort

BackgroundAge-adjusted lymphoma incidence rates continue to rise in France since the early 80’s, although rates have slowed since 2010 and vary across subtypes. Recent improvements in patient survival in major lymphoma subtypes at population level raise new questions about patient outcomes (i.e. quality of life, long-term sequelae). Epidemiological studies have investigated factors related to lymphoma risk, but few have addressed the extent to which socioeconomic status, social institutional context (i.e. healthcare system), social relationships, environmental context (exposures), individual behaviours (lifestyle) or genetic determinants influence lymphoma outcomes, especially in the general population. Moreover, the knowledge of the disease behaviour mainly obtained from clinical trials data is partly biased because of patient selection.MethodsThe REALYSA (“REal world dAta in LYmphoma and Survival in Adults”) study is a real-life multicentric cohort set up in French areas covered by population-based cancer registries to study the prognostic value of epidemiological, clinical and biological factors with a prospective 9-year follow-up. We aim to include 6000 patients over 4 to 5 years. Adult patients without lymphoma history and newly diagnosed with one of the following 7 lymphoma subtypes (diffuse large B-cell, follicular, marginal zone, mantle cell, Burkitt, Hodgkin, mature T-cell) are invited to participate during a medical consultation with their hematologist. Exclusion criteria are: having already received anti-lymphoma treatment (except pre-phase) and having a documented HIV infection. Patients are treated according to the standard practice in their center. Clinical data, including treatment received, are extracted from patients’ medical records. Patients’ risk factors exposures and other epidemiological data are obtained at baseline by filling out a questionnaire during an interview led by a clinical research assistant. Biological samples are collected at baseline and during treatment. A virtual tumor biobank is constituted for baseline tumor samples. Follow-up data, both clinical and epidemiological, are collected every 6 months in the first 3 years and every year thereafter.DiscussionThis cohort constitutes an innovative platform for clinical, biological, epidemiological and socio-economic research projects and provides an opportunity to improve knowledge on factors associated to outcome of lymphoma patients in real life.Trial registration2018-A01332–53, ClinicalTrials.gov identifier: NCT03869619.

Osteoclast-derived small extracellular vesicles induce osteogenic differentiation via inhibiting ARHGAP1

Activated osteoclasts release large amounts of small extracellular vesicles (sEVs) during bone remodeling. However, little is known about whether osteoclast-derived sEVs affect surrounding cells. In this study, osteoclasts were generated by stimulating bone marrow macrophages (BMMs) with macrophage colony stimulating factor (M-CSF) and receptor activator of nuclear actor κB ligand (RANKL). We performed microarray analysis of sEV-microRNAs (miRNAs)s secreted from osteoclast at different stages and identified four miRNAs that were highly expressed in mature osteoclast-derived sEVs. One of these miRNAs, miR-324, significantly induced osteogenic differentiation and mineralization of primary mesenchymal stem cells (MSCs) in vitro by targeting ARHGAP1, a negative regulator of osteogenic differentiation. We next fabricated an sEV-modified scaffold by coating decalcified bone matrix (DBM) with osteoclast-derived sEVs, and the pro-osteogenic regeneration activities of the sEV-modified scaffold were validated in a mouse calvarial defect model. Notably, miR-324-enriched sEV-modified scaffold showed the highest capacity on bone regeneration, whereas inhibition of miR-324 in sEVs abrogated these effects. Taken together, our findings suggest that miR-324-contained sEVs released from mature osteoclast play an essential role in the regulation of osteogenic differentiation and potentially bridge the coupling between osteoclasts and MSCs.

Loss of Synergistic Transcriptional Feedback Loops Drives Diverse B-Cell Cancers

Background: The most common B-cell cancers, chronic lymphocytic leukemia/lymphoma (CLL), follicular and diffuse large B-cell (FL, DLBCL) lymphomas, have distinct clinical courses, yet overlapping “cell-of-origin”. Dynamic changes to the epigenome are essential regulators of B-cell differentiation. Therefore, we reasoned that these distinct cancers may be driven by shared mechanisms of disruption in transcriptional circuitry. Methods: We compared purified malignant B-cells from 52 patients with normal B-cell subsets (germinal center centrocytes and centroblasts, naive and memory B-cells) from 36 donor tonsils using >325 high-resolution molecular profiling assays for histone modifications, open chromatin (ChIP-, FAIRE-seq), transcriptome (RNA-seq), transcription factor (TF) binding, and genome copy number (microarrays). Findings: From the resulting data, we identified gains in active chromatin in enhancers/super-enhancers that likely promote unchecked B-cell receptor signaling, including one we validated near the immunoglobulin superfamily receptors FCMR and PIGR. More striking and pervasive was the profound loss of key B-cell identity TFs, tumor suppressors and their super-enhancers, including EBF1, OCT2(POU2F2), and RUNX3. Using a novel approach to identify transcriptional feedback, we showed that these core transcriptional circuitries are self-regulating. Their selective gain and loss form a complex, iterative, and interactive process that likely curbs B-cell maturation and spurs proliferation. Interpretation: Our study is the first to map the transcriptional circuitry of the most common blood cancers. We demonstrate that a critical subset of B-cell TFs and their cognate enhancers form self-regulatory transcriptional feedback loops whose disruption is a shared mechanism underlying these diverse subtypes of B-cell lymphoma. Funding: National Institute of Health, Siteman Cancer Center, Barnes-Jewish Hospital Foundation, Doris Duke Foundation. Declaration of Interest: None to declare. Ethical Approval: De-identified peripheral blood, lymph node biopsies, and excised tonsils were obtained from FL, DLBCL, or CLL or healthy tonsillectomy patients (Table 1 and Fig. S1A) seen at Washington University School of Medicine who provided informed consent under IRB-approved protocols in concordance with the Declaration of Helsinki. Due to yield constraints, some samples were not subjected to all assays.

Whole Body 3.0 T Magnetic Resonance Imaging in Lymphomas: Comparison of Different Sequence Combinations for Staging Hodgkin's and Diffuse Large B Cell Lymphomas.

To investigate the diagnostic value of different whole-body magnetic resonance imaging (WB-MRI) protocols for staging Hodgkin and diffuse-large B-cell lymphomas (HL and DLBCL), twenty-two patients (M/F 12/10, median age 32, range 22–87, HL/DLBCL 14/8) underwent baseline WB-MRI and 18F-2-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography (PET) fused with computed tomography (CT) scan 18F-FDG-PET-CT. The 3.0 T WB-MRI was performed using pre-contrast modified Dixon (mDixon), T2-weighted turbo-spin-echo (TSE), diffusion-weighted-imaging (DWI), dynamic-contrast-enhanced (DCE) liver/spleen, contrast-enhanced (CE) lung MRI and CE whole-body mDixon. WB-MRI scans were divided into: (1) “WB-MRI DWI+IP”: whole-body DWI + in-phase mDixon (2) “WB-MRI T2-TSE”: whole-body T2-TSE (3) “WB-MRI Post-C”: whole-body CE mDixon + DCE liver/spleen and CE lung mDixon (4) “WB-MRI All “: the entire protocol. Two radiologists evaluated WB-MRIs at random, independently and then in consensus. Two nuclear-medicine-physicians reviewed 18F-FDG PET-CT in consensus. An enhanced-reference-standard (ERS) was derived using all available baseline and follow-up imaging. The sensitivity and specificity of WB-MRI protocols for nodal and extra-nodal staging was derived against the ERS. Agreement between the WB-MRI protocols and the ERS for overall staging was assessed using kappa statistic. For consensus WB-MRI, the sensitivity and specificity for nodal staging were 75%, 98% for WB-MRI DWI+IP, 76%, 98% for WB-MRI Post-C, 83%, 99% for WB-MRI T2-TSE and 87%, 100% for WB-MRI All. The sensitivity and specificity for extra-nodal staging were 67% 100% for WB-MRI DWI+IP, 89%, 100% for WB-MRI Post-C, 89%, 100% for WB-MRI T2-TSE and 100%, 100% for the WB-MRI All. The consensus WB-MRI All read had perfect agreement with the ERS for overall staging [kappa = 1.00 (95% CI: 1.00-1.00)]. The best diagnostic performance is achieved combining all available WB-MRI sequences.

Prognostic Significance of T-Cell Phenotype in Aggressive Non-Hodgkin's Lymphomas

Peripheral T-cell lymphomas (PTCL) have been generally reported to have a worse prognosis than B-cell lymphomas (BCL). Because of their heterogeneity and scarcity, the outcomes of the different histological subtypes have not been compared. From October 1987 to March 1993, 1,883 patients with diffuse aggressive non-Hodgkin's lymphomas (NHL) included in the LNH87 protocol could be assessed for both morphology and immunophenotyping. Among them, 288 (15%) had PTCL and 1,595 (85%) had BCL. According to the Kiel classification, most PTCL were classified as angioimmunoblastic (AIL; 23%), pleomorphic medium and large T-cell (PML; 49%), or anaplastic large cell (ALCL; 20%) lymphomas. Comparing PTCL with BCL patients, the former had more disseminated disease (78% v 58%), B symptoms (57% v 40%), bone marrow involvement (31% v 17%), skin involvement (21% v 4%), and increased beta2-microglobulin (50% v 34%), whereas BCL patients had more bulky disease (41% v 26%). According to the International Prognostic Index (IPI), PTCL and BCL scores were, respectively: 0 factors, 13% and 15%; 1 factor, 17% and 22%; 2 factors, 24% and 25%; >/=3 factors, 45% and 37% (P = .09). For BCL and PTCL, respectively, complete remission rates were 63% and 54% (P = .004); the 5-year overall survival (OS) rates were 53% and 41% (P = .0004) and event-free survival (EFS) rates were 42% and 33% (P < . 0001). Comparison of the different histological subtypes of lymphoma showed that the 5-year OS rate for T-ALCL (64%) was superior to those of other PTCL (35%) as well as diffuse large B-cell (53%) NHL. When multivariate analysis was applied using the IPI score as one factor, nonanaplastic PTCL remained an independent parameter (P = . 0004). Although the poor prognosis of non-ALCL PTCL could be due in part to the presence of adverse prognostic factors at diagnosis, this study shows that the T-cell phenotype is an independent significant factor, which should be incorporated into the definition of prognostic groups.

Primary Breast Extranodal Marginal Zone Lymphoma in Primary Sjögren Syndrome: Case Presentation and Relevant Literature.

The association between autoimmune diseases, mostly rheumatoid arthritis, systemic lupus erythematosus, celiac disease and Sjögren syndrome, and lymphoma, has been widely demonstrated by several epidemiologic studies. By a mechanism which has not yet been entirely elucidated, chronic activation/stimulation of the immune system, along with the administration of specific treatments, may lead to the onset of different types of lymphoma in such patients. Specifically, patients affected by Sjögren syndrome may develop lymphomas many years after the original diagnosis. Several epidemiologic, hematologic, and histological features may anticipate the progression from Sjögren syndrome into lymphoma but, to the best of our knowledge, a definite pathogenetic mechanism for such progression is still missing. In fact, while the association between Sjögren syndrome and non-Hodgkin lymphoma, mostly extranodal marginal zone lymphomas and, less often, diffuse large B-cell, is well established, many other variables, such as time of onset, gender predilection, sites of occurrence, subtype of lymphoma, and predictive factors, still remain unclear. We report on a rare case of primary breast lymphoma occurring three years after the diagnosis of Sjögren syndrome in a 57-year-old patient. The diagnostic work-up, including radiograms, core needle biopsy, and histological examination, is discussed, along with emerging data from the recent literature, thus highlighting the usefulness of breast surveillance in Sjögren syndrome patients.

Analysis of clinical characteristics, treatment and survival of elderly patients with large diffuse B-cell lymphoma

Objective: To analyze the clinical feature,treatment and survival outcome of elderly patients older than 80 years with large diffuse B-cell lymphoma. Methods: A total of 46 patients aged over 80 years with large diffuse B-cell lymphoma who were treated in Third Hospital of Peking University during the period from 2002 to 2018 were retrospectively analyzed, and the clinical features, laboratory data, survival and prognostic factors were included in Kaplan-Meier and prognostic analysis. Results: Patients older than 80 years old accounted for 15.7% (46/293) in all elderly patients, and the median age was 83 years old. There were 78.3% (36/46)patients who belonged to stage Ⅲ or Ⅳ, 63%(29/46) who had more than two extranodal organ involvement, and the higher proliferation index(Ki-67≥80%) was present in 53.7%(22/41) patients. Immunohistochemistry showed that 37% patients in 27 cases were double-expressed DLBCL. With a median follow-up of 25 months, the overall response rate (ORR) for the whole group was 63.0%, the complete response (CR) rate was 36.4%, the 2, 3-year progression-free survival (PFS) rate was 49.9% and 41.7%, the 2, 3-year overall survival (OS) rate was 54.6% and 43.6% respectively. The ORR for patients who received anthracycline-based therapies and non-anthracycline-based therapies were 81.8% and 55.0%, and the 3-year OS rate were 50.0% and 39.0%, respectively, but the difference was not statistically significant (P>0.05). 45.5% patients had hematologic toxicity of Grade Ⅲ or above, and 56.8% patients experienced infections during the treatment. Among the patients who died, the treatment-related mortality rate in group with high score of Charlson comorbidity index(CCI) was higher (43.8% vs 16.7%, P=0.03) . The National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) score, nodal involvement area ≥3, 6 cycles of chemotherapy, CCI score, initial treatment outcome and refractory-relapsed were predictive of overall survival. Multivariate analysis indicated the CCI score (HR=6.463, P=0.008) and initial treatment outcome (HR=0.086, P=0.001) were independent prognostic risk factors. Conclusions: The clinical and pathological features of patients older than 80 years were highly aggressive with poor chemotherapy tolerance and high adverse reaction rate. Anthracycline-based therapies may be less important in the treatment of DLBCL patients aged over 80 years. Patients with high CCI score have higher treatment-related mortality and CCI can help identify elderly patients who are suitable for larger chemotherapy dose.

Multiplexed Functional Assessment of Genetic Variants in CARD11

SummaryGenetic testing has increased the number of variants identified in disease genes, but the diagnostic utility is limited by lack of understanding variant function. CARD11 encodes an adaptor protein that expresses dominant-negative and gain-of-function variants associated with distinct immunodeficiencies. Here, we used a “cloning-free” saturation genome editing approach in a diploid cell line to simultaneously score 2,542 variants for decreased or increased function in the region of CARD11 associated with immunodeficiency. We also described an exon-skipping mechanism for CARD11 dominant-negative activity. The classification of reported clinical variants was sensitive (94.6%) and specific (88.9%), which rendered the data immediately useful for interpretation of seven coding and splicing variants implicated in immunodeficiency found in our clinic. This approach is generalizable for variant interpretation in many other clinically actionable genes, in any relevant cell type.