Double-expressor DLBCL Research Articles

Increased CCL2/CCR2 axis promotes tumor progression by increasing M2 macrophages in MYC/BCL2 double-expressor DLBCL

AbstractThe pathogenesis of myelocytomatosis oncogene (MYC) and B-cell lymphoma 2 (BCL2) double-expressor diffuse large B-cell lymphoma (DE-DLBCL) remains unclear. To investigate how MYC and BCL2 contribute to tumor aggressiveness, we analyzed tumors from 14 patients each with DE-DLBCL and non–DE-DLBCL using whole transcriptome sequencing. Validation was performed using publicly available data sets, tumor tissues from 126 patients, DLBCL cell lines, and a syngeneic mouse lymphoma model. Our transcriptome analysis revealed significantly elevated messenger RNA levels of C-C motif chemokine ligand 2 (CCL2) and C-C chemokine receptor type 2 (CCR2) in DE-DLBCLs when compared with non–DE-DLBCLs (adjusted P value < .05). Transcriptomic analysis of public data sets and immunohistochemistry corroborated these findings, indicating increased levels of M2 macrophages but a reduction in T-cell infiltration in DE-DLBCLs when compared with non–DE-DLBCLs (all P < .05). CCR2 expression was observed mainly in tumor-infiltrating macrophages and not in DLBCL cells. Increased expression of CCL2 and CCR2 was significantly associated with a poor prognosis in patients with DLBCL. In the in vitro analyses, MYChigh/BCL2high DLBCL cells showed higher CCL2 expression and secretion than MYClow/BCL2low cells. MYC and BCL2 increased CCL2 expression and secretion by upregulation of nuclear factor κB p65 in DLBCL cells, and CCL2 promoted M2 polarization of macrophages. In a mouse lymphoma model, CCL2 contributed to the immunosuppressive microenvironment and tumor growth of MYChigh/BCL2high tumors. We demonstrated that the increased CCL2/CCR2 axis confers aggressiveness to DE-DLBCL by increasing M2 polarization and can be a potential therapeutic target.

Rituximab, chidamide, and zanubrutinib (ZCR) ± CHOP as a regimen for treatment naive (TN) double-expressor DLBCL (DE-DLBCL).

e19053 Background: DLBCL patients with co-expression of MYC (≥40%) and BCL2 (≥50%) by immunohistochemistry are considered as DE-DLBCL. The prognosis of DE-DLBCL is usually worse than DLBCL-NOS. The Smart Start trial had established the feasibility of chemotherapy-free targeted therapy before 1L chemotherapy. The BTK inhibitor Zanubrutinib (Z) or epigenetic drug Chidamide (C) with R-CHOP regimen has a potential synergistic effect in the treatment of DE-DLBCL. Under the inspiration of Smart Start, this trial aim to explore the feasibility of ZCR±CHOP regimen in TN DE-DLBCL. Methods: This is a multicenter, open-label, single-arm phase 2 study (NCT05527912) conducted in China. If patients achieve complete response (CR) after cycle-2 (C2), ZCR will be continued for up to 8 cycles. Otherwise, ZCR-CHOP will be given for another 6 cycles. The primary endpoint is CR rate at the end of treatment (CRR-EOT); secondary endpoints included ORR (overall response rate) ,2y-PFS, and 2y-OS. Plasma samples were collected at baseline, C2 and the EOT. In evaluable samples, circulating tumor DNA (ctDNA) assays were performed. Results: From February 2023 till now, 34 TN DE-DLBCL patients were enrolled, with 32 patients evaluable. The median age was 52y (range: 22-68), 55.9% were male, 79.4% were Non-GCB (Table 1). 12 patients who achieved CR by C2 were continued with RCZ chemo-free therapy, and CHOP were added to the 14 PR and 3 SD patients. In the 32 evaluable patients, ORR after C2 of RCZ was 81.25% (26/32, CR 37.5%, PR 43.75%, SD 9.4%, PD 9.4%). Up to now, 12 patients have completed 8 courses (C8) and all of them have achieved CR, both ORR and CR are 100% (12/12). 3 patients withdrew due to PD. For safety information in the trial, 64.3% patients reported grade (G)-3/4 AEs. In the Chemo-Free subgroup, only 4 patients (36.4%, 4/11) reported G-3/4 AEs. the majority of G-3/4 AEs is hematological events, including leukopenia, neutropenia and thrombocytopenia. The CR rate at C2 was 66.7% (6/9) in patients with negative baseline ctDNA results. The patients with BCL6 fusion of ctDNA at baseline were more prone to PD (3/4, 75.0%). Compared to baseline, plasma ctDNA levels decreased significantly after C2. 29 patients were evaluable for ctDNA after C2, 100% (12/12) of C2-CR patients and 58.8% (10/17) of non-C2-CR patients were negative, P=0.023. Compared with Non-C2-CR patients, the number of detected mutations and average VAF level were decreased in C2-CR patients. Conclusions: This trial demonstrates ZCR±CHOP could be a promising regimen with active antitumor effect and acceptable toxicity in TN DE-DLBCL patients. Clinical trial information: NCT05527912 .

Primary diffuse large B-cell lymphoma of the prostate: Histopathological diagnosis of a rare entity in the prostate.

Lymphoma of the prostate is rare whether it is primary extranodal lymphoma or secondary involvement of the prostate by primary lymphoma elsewhere. Of all the lymphomas of the prostate, primary lymphomas of the prostrate are very rare. Although less frequent, it should be a differential diagnosis when evaluating prostate tumors. Here, we report a case of a 61-year-old man who presented with hematuria with clot retention. A cystoscopy with clot removal and transurethral resection of the prostate (TURP) was performed. This biopsy was sent for histopathological examination at an external center, where a diagnosis of benign prostatic hyperplasia was given. Fifteen days later, the patient presented with hematuria again. On examination, clots were present in the bladder. There was significant prostatomegaly. A re-resection of the prostate was performed and sent for another review to us. The biopsy was reported as high-grade round cell neoplasm, most likely lymphoma. Immunohistochemistry (IHC) was recommended for confirmation. Tumor cells showed immunoreactivity for CD20, B-cell Lymphoma (BCL)-2, BCL-6, Myelocytomatosis (c-Myc), and multiple myeloma 1 (MUM1). Cluster Differentiation (CD)10 was negative. Kiel-67 was high. A final diagnosis of double-expressor diffuse large B-cell lymphoma (DLBCL) of non-germinal center type was made. We share this case to emphasize the fact that primary lymphoma of the prostate is primarily a histopathological diagnosis as the clinical presentation is not unique. Owing to its rarity, the clinical and histopathological suspicion is low. Hence, keeping the differential in mind while evaluating prostate biopsy is beneficial in a timely diagnosis of the entity as the management of prostatic carcinoma and lymphoma is different.

Real-world efficacy of chidamide plus R-CHOP in newly diagnosed double-expressor diffuse large B-cell lymphoma

Background: Approximately 20%–30% of diffuse large B-cell lymphoma (DLBCL) cases are classified as double-expressor lymphoma (DEL), characterized by the co-expression of the MYC and BCL2 proteins. However, the most effective therapeutic strategy for DEL remains unidentified. Objectives: To evaluate the efficacy of a novel histone deacetylase inhibitor, chidamide, in combination with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (CR-CHOP) in the treatment of DEL. Design: This was a retrospective study. Methods: This study included 62 DEL patients from December 2016 to December 2020. All patients were administered a first-line treatment with CR-CHOP. The short-term efficacy, survival status, and adverse reactions in this population were observed, and the prognostic factors were analyzed. Results: The median age was 53.9 years (range, 19–77). All patients received a median of six cycles (range, 1–8) of treatment, with 79.0% achieving complete response (CR) and an overall response rate of 88.7%. With a median follow-up of 45.5 months (range, 1–82), the median progression-free survival (PFS) and median overall survival (OS) had not yet been reached. However, the 3-year PFS rate was 71% (95% CI: 61–83), the 3-year OS rate was 87% (95% CI: 79–96), the 5-year PFS rate was 67% (95% CI: 55–80), and the 5-year OS rate was 85% (95% CI: 77–95). Age and autologous stem cell transplantation after CR or partial response were independent prognostic factors for PFS, while various clinical factors were not associated with OS outcomes. The most common grades 3–4 hematologic and nonhematologic toxicity were leukopenia (46.7%) and infection (21%), respectively. Conclusion: This long-term follow-up study indicates that CR-CHOP in untreated DLBCL with the DEL phenotype demonstrates high short-term efficacy and safety as well as promising survival outcomes.

Clinical Features and Prognosis Analysis of 168 Cases of MYC/BCL2 Double Expression Diffuse Large B Lymphoma

Objective: A retrospective study of the clinical features and prognosis of MYC/BCL2 double-expressor diffuse large B-cell lymphoma (DEL). Methods: A retrospective analysis was conducted on patients diagnosed with MYC/BCL2 double-expressor diffuse large B-cell lymphoma (DEL) for the first time by pathological and fluorescence in situ hybridization (FISH) techniques at Fujian Medical University Affiliated Union Hospital from January 2017 to December 2021. Clinical features, immunohistochemistry, laboratory tests, treatment plans, and follow-up information of all patients were collected. Kaplan-Meier analysis was used for univariate analysis, and Cox proportional hazards model was used for multivariate analysis. Results: Clinical characteristics:Among the 168 patients with diffuse large B-cell lymphoma (DLBCL), 13 cases (7.7%) involved the primary central nervous system. Of the patients, 95 (56.55%) were male and 73 (43.45%) were female, resulting in a male-to-female ratio of 1.3:1. The age of onset was at least 60 years for 93 cases (55.36%), with the youngest being 22 years old and the oldest being 88 years old. The median age was 62 years old. A total of 113 cases (72.90%) were classified as stage III-IV by the Ann Arbor staging system, 40 cases (23.81%) had B symptoms, 82 cases (52.90%) had an International Prognostic Index (IPI) score of 3-4, 84 cases (54.19%) had involvement of two or more extranodal sites, 87 cases (51.79%) had a β2-microglobulin (β2-MG) level of ≥2.53mg/L, 122 cases (72.62%) had a serum albumin (SA) level of &amp;lt;35g/L, and 103 cases (61.31%) had elevated levels of lactate dehydrogenase (LDH).Survival status: Complete follow-up data were available for 162 DEL patients, with a median follow-up time of 20.38 (1-73) months. The median overall survival (OS) was not reached, while the median progression-free survival (PFS) was 37.1 months. Among them, and 58 (34.5%) died. Survival analysis was performed on 168 DEL patients, with 1-year, 3-year, and 5-year OS rates of 82.1%, 61.1%, and 58.9%, respectively. The 1-year, 3-year, and 5-year PFS rates were 69.5%, 51.4%, and 45.6%, respectively. Among the 93 elderly (≥60 years old) DEL patients, the 1-year, 3-year, and 5-year OS rates were 77.2%, 52.7%, and 48.6%, respectively, and the 1-year, 3-year, and 5-year PFS rates were 67.4%, 47.4%, and 43.7%, respectively. The 1-year and 3-year OS rates of the 13 patients with primary central nervous system DLBCL were 25.50%, and the 1-year and 3-year PFS rates were 16.70%.Clinical efficacy analysis: Among 168 patients with DEL, the complete remission (CR) rate was 62.5% (105/168), the partial remission (PR) rate was 3.5% (6/168), the overall effective rate (ORR) was 66.1%, and the relapse/progression rate was 25.6% (43/168). Comparing the efficacy of 88 patients treated with the R-CHOP regimen with 32 patients treated with sildalafil combined with the R-CHOP regimen, the results showed a higher CR rate (81.25% vs. 67.05%) and a lower relapse rate (3.13% vs. 12.5%) in patients treated with sildalafil combined with the R-CHOP regimen.4. Univariate analysis: Age over 60 years ( P=0.031), B symptoms ( P=0.031), advanced Ann Arbor stage (P=0.003), high IPI score ( P&amp;lt;0.001), elevated LDH ( P=0.031), and elevated β2-MG( P&amp;lt;0.001) were significantly correlated with poor prognosis in DEL patients, and were identified as adverse prognostic factors. Non-GCB subtype ( P=0.029), B symptoms ( P&amp;lt;0.001), advanced Ann Arbor stage ( P&amp;lt;0.001), high IPI score ( P&amp;lt;0.001), decreased serum albumin ( P&amp;lt;0.001), elevated LDH (P=0.085), and elevated β2-MG(P&amp;lt;0.001) were significantly associated with poorer progression-free survival (PFS) among DEL patients.5.Multivariate analysis revealed that elevated β2-MG levels and high IPI scores were independent risk factors for poor overall survival (OS) in DEL patients, with HR values of 2.363 and 7.090, respectively. B symptoms, elevated β2-MG levels, and reduced serum albumin (SA) levels were independent risk factors for poor progression-free survival (PFS) in DEL patients, with HR values of 1.819, 2.879, and 1.987, respectively. Conclusion: Elevated β2-microglobulin and high IPI scores in DEL patients are risk factors for OS, while B symptoms, elevated β2-microglobulin, and decreased serum albumin are risk factors for PFS. Keywords: Lymphoma, diffuse large B-cell, clinical features, prognosis, double- expression lymphoma

The Universal Antitumor Activity of TAS0612, a Triple Inhibitor for RSK, AKT, and S6K, in B-Cell Lymphomas Regardless of Disease Subtype

B-cell lymphomas (BCLs) are the most common disease entity among hematological malignancies and have various genetically and molecularly distinct subtypes. Although the prognosis of most BCL subtypes has been greatly improved by the advancements of disease subtype-oriented molecular-targeted therapeutics, there remain patients who are incurable with currently available therapeutics. Therefore, further development of new therapies that are effective regardless of disease subtypes is still awaited. 3-phosphoinositide dependent protein kinase 1 (PDPK1) is the master serine-threonine kinase of &amp;gt;20 AGC kinases, including RSK family proteins, AKT, S6K, and several non-AGC kinases. By regulating a series of downstream molecules and mediating the RAS/ERK/RSK2 and PI3K/AKT pathways, PDPK1 plays a pivotal role in disease development and progression in various malignancies. We have also shown that PDPK1/RSK2 axis plays pivotal roles in the pathophysiology of multiple myeloma and mantle cell lymphoma (MCL) (Chinen Y, Cancer Res 2014; Shimura Y, Mol Cancer Ther 2012; Matsumura-Kimoto Y, Cancer Med 2020). In the search for novel molecular targeted therapy for BCLs, these provoked us to investigate the role of PDPK1 and its effector molecules as the therapeutic targets in a broad range of BCLs. We first revealed that the blockade of phosphoinositide-dependent kinase-1 (PDPK1) using its specific inhibitor BX-912 induces a growth inhibition via G2/M cell cycle arrest and the induction of apoptosis in all 8 BCL-derived cell lines examined, including two from activated B-cell-like diffuse large B cell lymphoma (DLBCL), two from double expressor DLBCL, two from Burkitt lymphoma, and two from follicular lymphoma (FL). By using specific inhibitors for the downstream kinases of PDPK1, we also demonstrated that RSK2, AKT, and S6K, but not other PDPK1 substrates, such as PLK1, SGK, or PKC, plays critical roles for cell survival and proliferation as target molecules of PDPK1 in these cell lines examined. In addition, RSK2 plays a central role and AKT and S6K play subsidiary functional roles as the downstream effectors of PDPK1. Following these results, we next investigated the anti-BCL efficacy of TAS0612 which is the triple inhibitor for total RSK, including RSK2, AKT, and S6K, by inhibiting the binding of its target RSK, AKT, and S6K with their substrate molecules (Shibata T, Mol Cancer Ther 2020). As the results, TAS0612 showed the antiproliferative effect in all 8 BCL-derived cell lines examined with IC80s ranging from 1.18 to 8.46 µM, leading to G1 or G2/M cell cycle blockade, and induced apoptosis. At the protein level, TAS0612 caused the accumulation of its direct substrates p-total RSK Ser380, p-AKT Ser473, and p-S6K Thr389 in most cell lines examined as the results of the inhibition of binding to their respective substrates, and the subsequent inactivation through dephosphorylation of their respective target substrates in all cell lines examined. The 72-hour treatment with TAS0612 at 2.5 and 5.0 µM also showed the ex vivo antiproliferative effect in 25 patients-derived lymphoma cells of various disease subtypes, including nine DLBCLs, seven FLs, three MCLs, one mucosa-associated lymphoid tissue lymphoma, one splenic marginal zone B cell lymphoma, one chronic lymphocytic leukemia, and three B-lymphoblastic lymphomas. We finally examined the global molecular effects of TAS0612 using gene expression profiling. Among several tumor suppressor genes upregulated by TAS0612, we found the increased expression of tumor protein 53 inducible nuclear protein 1 (TP53INP1) in cell lines regardless of disease subtypes. Moreover, gene set enrichment analysis identified that TAS0612 significantly downregulated the gene sets driven by the upregulation of MYC and mTORC1, reactive oxygen species, and the unfolded protein response. Thus, this study revealed that the concomitant blockade of RSK2, AKT, and S6K, which are the pivotal downstream substrates of PDPK1, is a novel universally active therapeutic target for the various disease subtypes of BCLs, and line up TAS0612 as an attractive candidate agent for BCLs for future clinical development.

Genetic Mutations in Primary Refractory Diffuse Large B-Cell Lymphoma: Next Generation Sequencing Analysis

Introduction Diffuse large B-cell lymphoma (DLBCL) accounts for 30-40% of newly diagnosed adult non-Hodgkin lymphoma. About 60-70% of DLBCL patients could be cured with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP), while the other patients show chemo-refractory or relapse of disease and have poor prognosis. The prognostic difference between DLBCL patients is not fully understood, and many attempts to classify DLBCL have been made. Recently, with the development of the next generation sequencing (NGS) technique, Schmitz et al. identified four prominent genetic subtypes named MCD, BN2, N1, EZB. In this study, we performed targeted deep sequencing in DLBCL patients and analyzed whether there is any genetic difference between the patients who are primary refractory disease and the patients who are not. Methods Totally, 77 patients who was diagnosed with DLBCL and treated with R-CHOP from January 2021 to April 2023 were included in this analysis. Formalin-fixed, paraffin-embedded (FFPE) tumor samples obtained at diagnosis were archived. Genomic DNA was extracted using QIAmp DNA FFPE tissue kit according to the manufacturer's protocol. Genetic profiling included the targeted deep sequencing of 424 genes, which had been selected based on recurrent mutations from previous studies, and sequenced using an Illumina Nextseq. The threshold of mutation positivity as a variant allele frequency ≥2% for SNV/Indel and as a copy number ≥4.0(gain) for CNV. Patients were assigned as germinal center B-cell (GCB) or non-GCB subtype based on the immunohistochemistry (IHC) algorithm. BCL-2 and MYC FISH were conducted in patients with double-expressor DLBCL with non-GCB subtype. Results Median age of the patients were 66 years (24-86 years), and 49 patients (63.6%) were male. Forty-five patients (58.5%) were advanced stage. Twenty-four patients (31.2%) were GCB subtype and 51 patients (66.2%) were non-GCB subtype. Among the GCB type DLBCL patients, 10 patients were double expressor DLBCL, and there was no case of double hit lymphoma. As a result of targeted deep sequencing, 317 mutations were found in at least 1 patient, and the patients had a median number of 16 mutations (4-50). KMT2D was the most commonly detected mutation (22/77, 29.3%), followed by MYD88 (19/77, 25.3%), PCLO (19/77, 25.3%), PIM1 (19/77, 25.3%), TP53 (18/77, 24.0%). According to NGS analysis, 26 patients (33.85%) were assigned to MCD subgroup, 13 patients (16.9%) to BN2, 11 patients (14.3%) to N1, 10 patients (13.0%) to EZB, and 17 patients (17%) were not assigned to any subrgroup. Median follow-up of the patients was 13.8 months (0.4-22.8 months), and 12 patients (15.6%) relapsed and 5 patients (6.5%) died. Median PFS and OS were not reached. Among relapsed patients, 7 patients were primary refractory to R-CHOP. In primary refractory DLBCL patients, TP53 (3/7, 42.9%) and CIITA (3/7, 42.9%) were most commonly detected. CIITA is known to be associated with immune escape and treatment resistance. CIITA, RASSF54, STAT6, SYK significantly more mutated in the primary refractory patients than the other ( CIITA, 42.9% vs. 8.6%, p=0.031; RASSF54, 28.6% vs. 2.9%, p=0.039; STAT6, 28.6% vs. 1.4%, p=0.021; SYK, 28.6% vs. 2.9%, p=0.039) (Table 1). Conclusion CIITA, RASSF54, STAT6, SYK were frequently mutated in primary refractory DLBCL in this study. Because of the small sample size, however, the prognostic significance of these mutations needed to be studied in further researches.

Preliminary Results of Nathali-01: A First-in-Human Phase I/IIa Study of UCART20x22, a Dual Allogeneic CAR-T Cell Product Targeting CD20 and CD22, in Relapsed or Refractory (R/R) Non-Hodgkin Lymphoma (NHL)

Background: UCART20x22 is a dual targeted allogeneic CAR T-cell product candidate generated from healthy donor T-cells. Donor-derived T-cells are transduced with a bicistronic lentiviral vector to express CARs targeting CD20 and CD22. TALEN ® gene editing technology is used to inactivate the TRAC and CD52 genes to minimize graft-versus-host disease (GvHD) and allow for the use of alemtuzumab (CLLS52, an anti-CD52 monoclonal antibody) in the lymphodepletion (LD) regimen, respectively. UCART20x22 previously demonstrated robust and sustained activity in vitro and in vivo (Aranda-Orgilles B, et al. Cancer Immunol Res 2023). Here we present the initial preliminary results from the NatHaLi-01 trial (NCT05607420), the first-in-human Phase 1/2a dose-finding and expansion study evaluating UCART20x22 in R/R B-cell NHL. Methods: The primary endpoints are safety, tolerability, and determining the recommended phase 2 dose of UCART20x22. Additional endpoints include anti-lymphoma activity and cellular kinetics of UCART20x22. Key eligibility criteria are age 18-80y, lymphoma expression of CD20 and/or CD22 by local assessment, and ≥ 2 prior treatment regimens including autologous CD19 CAR T-cell therapy (CAR19), if eligible. After LD with FCA (fludarabine 30 mg/m 2 × 3d, cyclophosphamide 0.5g/m 2 × 3d, CLLS52 12 mg on D1, 24 mg on D2, D3), a single infusion of UCART20x22 is administered at a flat dose level ([DL1] 50 x 10 6 cells; [DL2] 150 x 10 6 cells; and [DL3] 450 x 10 6 cells). Results: As of 01 July 2023, 3 pts were enrolled and treated at DL1. Pt 1 is a 76yo female with double-expressor diffuse large B-cell lymphoma (DLBCL) relapsed after R-CHOP, radiation therapy, and polatuzumab vedotin with bendamustine/rituximab (BR) and was considered ineligible for CAR19 due to recent high dose bendamustine. Pt 2 is a 65yo female with R/R triple-hit lymphoma transformed from follicular lymphoma who was previously treated with radiation therapy, BR, dose-adjusted R-EPOCH, and two separate CAR19 treatments. Pt 3 is an 18yo female with R/R DLBCL transformed from marginal zone lymphoma who previously received chemoimmunotherapy, venetoclax, ibrutinib, BR, CAR19, obinutuzumab, glofitamab, tafasitamab, lenalidomide, and an experimental epigenetic modifier. Cytokine release syndrome (CRS) occurred in all patients. Pt 1 had G1 CRS and received tocilizumab (toci) x3 and dexamethasone (dex) x1. Pt 2 had G2 CRS and received toci and dex x1. Pt 3 had G1 CRS and received toci x1. All pts' CRS resolved with treatment. No immune effector cell associated neurotoxicity (ICANS) or GvHD was observed. There were no UCART20x22 dose limiting toxicities (DLTs), and there was 1 CLLS52 SAE and 1 DLT. The SAE was G3 CMV reactivation and was managed with IV antivirals. The DLT was in Pt 2, who entered the study with G1/2 cytopenias and a hypocellular bone marrow and had prolonged bone marrow aplasia after treatment thought to be due to cumulative chemotherapy exposure. This pt proceeded to allogeneic hematopoietic stem cell transplant (HSCT) from a matched donor while in complete remission from UCART20x22 treatment. Responses were assessed per Lugano criteria beginning on D28. At D28, all 3 pts responded with 2 CRs and 1 PR. Host lymphocytes remained suppressed through D28 for all pts. UCART20x22 expansion was observed by flow cytometry in 3/3 pts and was initially detected on D7 followed by peaks between D9-14. Peak expansion ranged from 16-682 cells/μL and was predominantly CD8 T-cells. Ferritin levels and increases in serum cytokines, including IFNγ, TNFα, IL-2, and IL-6, correlated closely with UCART20x22 expansion. Summary: Treatment with UCART20x22 at DL1 has been safe and well-tolerated, with no UCART20x22 DLTs or ICANS, and CRS was &amp;lt;G3 in all pts. There was 1 DLT of prolonged bone marrow aplasia in a pt with impaired hematopoietic reserve at study entry. UCART20x22 was active at DL1, with all 3 pts responding, including 2 CRs in pts who had previously received CAR19. UCART20x22 expansion was observed in all pts. These initial data support the continued study of UCART20x22 in R/R NHL, and updated results will be presented.

Triple targeting of RSK, AKT, and S6K as pivotal downstream effectors of PDPK1 by TAS0612 in B-cell lymphomas.

B-cell lymphomas (BCLs) are the most common disease entity among hematological malignancies and have various genetically and molecularly distinct subtypes. In this study, we revealed that the blockade of phosphoinositide-dependent kinase-1 (PDPK1), the master kinase of AGC kinases, induces a growth inhibition via cell cycle arrest and the induction of apoptosis in all eight BCL-derived cell lines examined, including those from activated B-cell-like diffuse large B-cell lymphoma (DLBCL), double expressor DLBCL, Burkitt lymphoma, and follicular lymphoma. We also demonstrated that, in these cell lines, RSK2, AKT, and S6K, but not PLK1, SGK, or PKC, are the major downstream therapeutic target molecules of PDPK1 and that RSK2 plays a central role and AKT and S6K play subsidiary functional roles as the downstream effectors of PDPK1 in cell survival and proliferation. Following these results, we confirmed the antilymphoma efficacy of TAS0612, a triple inhibitor for total RSK, including RSK2, AKT, and S6K, not only in these cell lines, regardless of disease subtypes, but also in all 25 patient-derived B lymphoma cells of various disease subtypes. At the molecular level, TAS0612 caused significant downregulation of MYC and mTOR target genes while inducing the tumor suppressor TP53INP1 protein in these cell lines. These results prove that the simultaneous blockade of RSK2, AKT, and S6K, which are the pivotal downstream substrates of PDPK1, is a novel therapeutic target for the various disease subtypes of BCLs and line up TAS0612 as an attractive candidate agent for BCLs for future clinical development.

Clinicopathologic and genetic features of the starry-sky pattern in double-expressor diffuse large B-cell lymphoma

Double expressor lymphoma (DEL) is a subset of diffuse large B-cell lymphoma (DLBCL) characterized by the co-expression of MYC and BCL2 proteins with a poor prognosis. However, there are no standard criteria for evaluating the morphologic features of DEL. We aimed to analyze the prognostic value of the starry-sky pattern (SSP) and its correlation with clinicopathologic and genetic features in 153 DEL cases. The SSP was significantly associated with aggressive parameters, including c-MYC overexpression, CD5 expression, higher IPI, and age-adjusted IPI. In the univariate survival analyses, the presence of SSP was associated with unfavorable progression-free survival (PFS) (p=0.040), and tended towards an adverse overall survival (OS) (p=0.061). However, when c-MYC was overexpressed, SSP was significantly correlated with inferior OS (p=0.019). In the multivariate survival analysis, SSP was also associated with poor PFS (p=0.048). Additionally, next-generation sequencing data revealed SSP was significantly associated with the KMT2D mutation and had different genetic mutation profiles from non-SSP. In conclusion, SSP may represent morphologic characteristics of aggressiveness in DEL.

Venetoclax improves CD20 immunotherapy in a mouse model of MYC/BCL2 double-expressor diffuse large B-cell lymphoma

BackgroundApproximately one-third of diffuse large B cell lymphoma (DLBCL) patients exhibit co-expression of MYC and BCL2 (double-expressor lymphoma, DEL) and have a dismal prognosis. Targeted inhibition of the anti-apoptotic protein...

CD5- and CD10-positive MYC and BCL2 double-expressor diffuse large B-cell lymphoma with MYD88L265P mutation: a case report and literature review

A 75-year-old man who had lymphadenopathy was admitted to our hospital. Histopathological examination of cervical lymph node biopsy specimens showed diffuse proliferation of lymphoma cells with large nuclei. In immunohistochemistry, the lymphoma cells were positive for CD5, CD10, CD20, BCL2, BCL6, and MYC. The patient was diagnosed with CD5- and CD10-positive diffuse large B-cell lymphoma (DLBCL). MYD88L265P mutations have been detected in DLBCL. Partial response was achieved after six courses of R-THP-COP therapy. However, the patient died because of disease progression 18 months after the diagnosis. On autopsy, lymphoma cells were found in the lymph nodes throughout the body, central nervous system, adrenals, and skin. CD5- and CD10-positive DLBCL account for 0.5-1% of DLBCL cases and have a very poor disease prognosis. This is a rare case of CD5- and CD10-positive DLBCL with MYC and BCL2 expressions harboring MYD88L265P mutation.

Preliminary Result of Lenalidomide Combined with R-CHOP(R2-CHOP) in Newly Diagnosed Double-Expressor Diffuse Large B-Cell Lymphoma: A Prospective Phase II Clinical Trial

Background: Double expressor lymphoma (DEL) is a subtype of diffuse large B-cell lymphoma (DLBCL) defined as having increased expression of MYC (≥40%) and BCL-2 (≥50%) by immunohistochemistry (IHC). Patients with DEL have inferior outcomes when treated with standard immunochemotherapy. Previous studies illustrated that lenalidomide showed a significant clinical response in non-GCB DLBCL, and well tolerated when combined with R-CHOP. This study aims to investigate the efficacy and safety of lenalidomide combined with R-CHOP (R2-CHOP) in newly diagnosed DEL patients. Methods: Histologic diagnosis of DLBCL and MYC/BCL-2 expression by IHC were confirmed by central pathology prior to study therapy. Treatment regimen included lenalidomide 25 mg/d orally days 1-10 per 21days, plus standard R-CHOP21 for 6 cycles. The primary end point was 2-year progression free survival (PFS) per independent central radiology review. Secondary end points included 2-year event-free survival (EFS), overall response rate (ORR), overall survival (OS), and safety. Results: Between Oct 2019 and Aug 2021, 67 eligible patients were enrolled in this study. Median age was 58 (range 27-75) years. Forty-one (61.2%) patients were stage III-IV, and 35.8% of patients were IPI score ≥3. Non-GCB subtype was determined in 44 (65.7%) patients. Three patients detected double-hit lymphoma withdrew from the study per investigator's decision. Sixty patients were evaluable for response. Fifty-seven patients responded to therapy, with overall response rate of 95% (57/60), and complete response rate of 80% (48/60). With a median follow-up of 17.8 months, the estimated 1-year PFS rate was 85.3% (95%CI 75.9%-95.2%). And the 1-year EFS rate was 79% (95%CI 68.8%-90.3%). Median OS was not reached, and 1-year OS rate was 90.9% (95%CI 84.1%-98.1%). Grade 3 or 4 hematologic toxicities included neutropenia (67.2%), thrombocytopenia (19.4%), and anemia (4.5%). The most common nonhematologic adverse events were grade 1 to 2, including nausea, vomiting, fatigue, diarrhea, and mucositis. Grade 3 pneumonia occurred in 5 patients. Dose modification of lenalidomide or R-CHOP due to AEs were noted in 43.3% and 20.9% patients. No treatment-related death occurred in the study. Conclusion: Our preliminary data indicate promising activity of lenalidomide combined with R-CHOP for newly diagnosed DEL patients. R2CHOP regimen was feasible, with predictable and manageable adverse events. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prevalence and prognostic value of MYD88 and CD79B mutations in ocular adnexal large B-cell lymphoma: a reclassification of ocular adnexal large B-cell lymphoma

AimsTo (1) reclassify ocular adnexal large B-cell lymphomas (OA-LBCLs) per 2016 WHO lymphoma classification and (2) determine the prevalence of MYD88 and CD79B mutations and their association with clinical parameters...

The Incidence and Treatment Response of Double Expression of MYC and BCL2 in Patients with Diffuse Large B-Cell Lymphoma: A Systematic Review and Meta-Analysis.

Simple SummaryDiffuse large B-cell lymphoma (DLBCL) with co-expression of MYC and BCL2 proteins is referred to as double expressor lymphoma. Multiple studies have identified double expressor status to be an adverse predictive factor for response to standard chemotherapy regimens. The revised 2016 WHO classification recommends cutoff values of 40% for MYC and 50% for BCL2 protein expression; however, actual cutoff values have varied widely among published studies. Increasing recognition of the potential prognostic value of double expressor status prompted this systematic review and meta-analysis of the worldwide literature. Our findings indicate that approximately 23% of de novo DLBCL tumors express both MYC and BCL2 proteins above the indicated thresholds. Remarkably, different immunohistochemical cutoff values did not significantly affect the proportion of tumors attaining double expressor status. Cases lacking MYC/BCL2 co-expression were associated with a significantly higher probability of complete remission, thereby reaffirming the value of this predictive biomarker.MYC/BCL2 protein co-expression (i.e., double expressor) has been shown to be a negative predictor of outcome in diffuse large B-cell lymphoma (DLBCL). We aimed to establish the incidence of double expressor status in patients with de novo DLBCL and identify the predictive value of this biomarker on treatment response through systematic review and meta-analysis. PubMed and Embase were searched for studies published through December 2019 that reported proportions of double expressor DLBCL. The pooled proportions of MYC and BCL2 expression, both alone and in combination, were computed using the inverse variance method for calculating weights and by the DerSimonian–Laird method. The pooled odds ratios (ORs) of complete remission (CR) rate were calculated, and meta-regression analysis was conducted to explore heterogeneity. Forty-one studies (7054 patients) were included. The pooled incidence of double expressor status in DLBCL was 23% (95% confidence interval [CI], 20–26%), with an adjusted estimate of 31% (95% CI, 27–36%). Neither MYC/BCL2 protein cutoff values, race, mean, or median age of included patients, or overall study quality was a significant factor of heterogeneity (p ≥ 0.20). Cases without double expressor status demonstrated a higher probability of CR to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone treatment (OR, 2.69; 95% CI, 1.55–4.67). Our results reaffirm the predictive power of this important biomarker.

Combination of BR101801 and Venetoclax Demonstrates Synergistic Activity in DLBCL Cell Lines Harboring Double Hit and Double Expressor Alterations

Introduction: Double hit DLBCL with concurrent rearrangement of c-Myc and BCL-2 as well as double expressor DLBCL with concomitant overexpression of c-Myc and BCL-2 are characterized to have very poor outcomes in the following standard R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) therapy as well as short survival in progressing clinical courses. In DLBCL patients, about 20% to 30% of patients have shown the dual c-Myc and BCL-2 aberrance. Thus, several new drugs are being developed to achieve a durable response in double hit and double expressor DLBCL. The phase I study in patients with RR DLBCL using Venetoclax monotherapy which is a BCL-2 inhibitor, showed a disappointing objective response [CR:4/34(12%), PR:2/34(6%)]. This result shows that a combined approach involving a c-Myc controlling agent and BCL-2 inhibitor may be required to overcome the poor response of RR DLBCL, especially double hit and double expressor DLBCL. BR101801 is a first-in-class, oral, dual target inhibitor of DNA-PK and PI3Kδ. The combined inhibition of dual targets tightly regulates the protein stability of c-Myc independent of genetic alterations such as translocation, amplification, and overexpression. The purpose of this study is to investigate the functional significance of BR101801 on the growth inhibition and c-Myc regulation in double hit and double expressor DLBCL cell lines.Methods: Westernblot of protein expression levels was analyzed with the human DLBCL cell lines that were treated with BR101801, PI3Kδ-specific inhibitors (Idelalisib, TGR-1202) and DNA-PK inhibitor (NU-7441) or DMSO for 24 hr. After treating SU-DHL-4 cell with cyclohexamide (CHX, 20 ug/ml), and BR101801 (0.5 μM) alone or in combination, the lysates was analyzed with the westernblot. Cells (5x103/well) were incubated with various concentrations of compounds and the cell viability was determined after 72 hr by the WST-8 assay. Cell lines were classified as c-Myc translocation (DOHH2, SU-DHL-6, SU-DHL-10, OCI-LY-18), c-Myc amplification (SU-DHL-4, OCI-LY-3), and c-Myc expressor (U2932). Cell lines additionally showed BCL-2 alteration such as translocation (DOHH2, SU-DHL-4, SU-DHL-6, OCI-LY-18) and amplification (OCI-LY-3, U2932).Results: BR101801 showed potent inhibitory activity on c-Myc protein stability whereas no activity was found in Idelalisib, TGR-1202, or NU7441 (Figure 1A; SU-SHL-4, 1B; SU-DHL-6). Using CHX to block de novo protein synthesis on SU-DHL-4 cells, the increased rate of c-Myc degradation by GSK3β regulation was observed (Figure 1C). SU-DHL-10 cell lines harboring c-Myc alterations exhibited no sensitivity to the PI3Kδ inhibitor such as Idelalisib (IC50≒4.4 μM) and TGR-1202 (IC50>10 μM) and DNA-PK inhibitor such as NU7441 (IC50≒1.1 μM). However, the combination of Idelalisib and NU7441 resulted in 200-fold (IC50≒ 0.02 uM) growth inhibition (Figure 1D), which was comparable to the effect of BR101801. SU-DHL-6 cells showed low sensitivity to Venetoclax alone with IC50≒0.16 μM. However, the IC50 value of Venetoclax at 0.1, 1, 10 nM of BR101801 was decreased to 0.12 uM, 0.003 uM and < 0.001 uM (11 pM), respectively in a dose-dependent manner (Figure 1E).Conclusions: In this study, the rationale of co-targeting of PI3Kδ and DNA-PK in c-Myc regulation and growth inhibition were demonstrated. The dual targets of DNA-PK and PI3Kδ were essential to control the protein stability of c-Myc in DLBCL cell lines harboring various c-Myc alterations. In conclusion, the potent effect of BR101801 with Venetoclax in DLBCL cells harboring alterations on both c-Myc and BCL-2 suggests a mechanistic rationale as a breakthrough treatment for RR DLBCL patients. To ensure translation to humans, the study on the efficacy of BR101801 in primary cells isolated from double hit and double expressor as well as RR DLBCL patients is currently conducted. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Lenalidomide and Obinutuzumab with CHOP for Newly Diagnosed Diffuse Large B-Cell Lymphoma: Final Phase I/II Results

▪Introduction:Diffuse large B-cell Lymphoma (DLBCL) is the most common lymphoid cancer in the United States with 30K diagnoses each year. The standard therapy for all newly diagnosed patients is rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) which cures ~60% of patients. Lenalidomide (L) and obinutuzumab (O) have both shown promising efficacy and acceptable toxicity in DLBCL patients. Obinutuzumab, a humanized CD20 monoclonal antibody with increased pre-clinical affinity to the FcGRIIIa receptor in comparison to rituximab, may have increased antibody dependent cell-mediated cytotoxicity (ADCC). Lenalidomide, a potent immunomodulatory, is toxic to DLBCL via interferon signaling stimulation. As single agents, O and L achieve overall response rates (ORR) of 32% and 28%, respectively, in patients with relapsed DLBCL (Morschhauser, 2013, Hernandez-Ilizaliturri, 2011). The addition of L to RCHOP may overcome adverse outcomes of the non-germinal center (non-GCB) subtype of DLBCL. Randomized phase III clinical trials evaluating RCHOP +/- Len in non-GCB DLBCL are highly anticipated. The GOYA study found RCHOP was as effective as OCHOP in patients with unselected newly diagnosed DLBCL. We hypothesize the combination of OL-CHOP will result in enhanced NK cell-mediated cytotoxicity, down-regulation of interferon regulatory factor 4, and a complete response (CR) rate ≥ to OCHOP (57% in GOYA trial, Vitolo et al, ASH 2016).Methods: Newly diagnosed, CD20+ DLBCL patients were eligible if they have measurable disease, age ≥18 years, and adequate organ function. In the Phase Ib trial, Obinutuzumab was dosed at 1000mg IV days (d) 1, 8, and 15 during cycle 1, and d 1 on cycles 2-6. Lenalidomide dose was 15mg d 1 - 14 cycles 1 - 6 in the first cohort, with lower dose cohorts if toxicities occurred, using a 3+3 design. CHOP was dosed in standard fashion. Once the maximum tolerated dose (MTD) was identified, phase II was initiated with a planned total of at least 50 evaluable patients at the MTD. The primary objectives of this phase Ib/II trial were to determine the MTD and efficacy of LOCHOP. Correlative studies, including minimal disease assessment, cell of origin determination, and immune profiling are planned on blood and tumor samples.Results: Fifty three patients were enrolled, 6 in Phase Ib trial, 47 in Phase II with all evaluable for safety and 51 for efficacy. Two patients withdrew consent after 1 cycle of therapy. The median age was 62 years (26-83), with 42% males and a median IPI of 2 and NCCN IPI of 3. Five patients had double hit DLBCL, 5 patients had Double Expressor DLBCL, and 21 patients were non-GCB DLBCL. No dose limiting toxicities were identified in in Phase Ib. Toxicities encountered in PhIb include neutropenia (Grade 3: 50%, Grade 4 33%), thrombocytopenia (grade 3: 17%), and rash (grade 2: 17%), with similar findings in PhII. All six patients in PhIb achieved a complete response (CR). In the Phase II trial, 50 patients have end of therapy response assessment as of 8/2/17, with 45 with CR, 4 with partial response, 1 with progression. In the combined evaluable patients, the overall response rate is 98%, with CR of 90%. The CR rate was 90% in non-GCB and 92% in GCB. The median follow up 11 months and the median progression free and overall survival are not reached. There have been no deaths. Additional follow up and analyses will be presented at the meeting.Conclusions: The combination of Obinutuzumab, Lenalidomide, and CHOP is well tolerated, with no dose limiting toxicity encountered in the phase Ib trial, and efficacy is impressive in this single center single arm Phase Ib/II trial. Adverse events do not appear to be different than expected with standard RCHOP. Final results and correlative analyses will be presented at the ASH meeting [Display omitted] DisclosuresWestin:Apotex: Membership on an entity's Board of Directors or advisory committees; Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees; Kite Pharma: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees. Nastoupil:TG Therapeutics: Honoraria, Research Funding; Gilead: Honoraria; Abbvie: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Genentech: Honoraria, Research Funding; Karus Therapeutics: Research Funding; Celgene: Honoraria, Research Funding. Neelapu:Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Poseida Therapeutics, Inc: Research Funding; Cellectis Inc.: Research Funding; Kite Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Research Funding; Karus: Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Lee:KITE PHARMA: Consultancy.

Double-Expressor Phenotype (BCL-2/c-MYC Co-expression) of Diffuse Large B-Cell Lymphoma and Its Clinicopathological Correlation.

IntroductionDiffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease, the spectrum of which is increasing with time. The 2016 World Health Organization (WHO) update on hematopoietic tumors recognized a prognostic subgroup of DLBCL called double-expressor DLBCL. Double-expressor DLBCL is defined by the co-expression of c-MYC and BCL-2 by using immunohistochemical (IHC) studies. To our knowledge, very few studies have looked into the pathological features of this newly defined prognostic category of DLBCL; therefore, in this study we evaluated the frequency of the double-expressor phenotype of DLBCL and its association with other clinicopathological parameters.MethodsWe conducted a retrospective observational study in the Department of Histopathology, Liaquat National Hospital and Medical College, from November 2017 till December 2020. Pathological and clinical records were retrieved from departmental archives. All cases diagnosed as DLBCL were included in the study. More than 40% c-MYC expression in the presence of more than 50% BCL-2 expression was defined as double-expressor DLBCL.ResultsThe mean age of the patients was 52.1±16.9 years. The mean Ki67 index was 73.0±17.0%. A total of 48.6% cases were of germinal center B-cell-like (GCB) subtype, and 59.6% cases were nodal. Double-expressor phenotype was noted in 35.8% of DLBCL cases. A significant association of double-expressor phenotype was noted with age, gender, Ki67 index and subtype of DLBCL. Double-expressor DLBCL had a higher mean age than non-double-expressor DLBCL. Similarly, double-expressor DLBCL had a higher Ki67 index. Moreover, double-expressor phenotype was associated with non-GCB subtype DLBCL.ConclusionWe found a high proportion of double-expressor phenotype DLBCL in our population. Moreover, double-expressor phenotype DLBCL was associated with female gender, higher age, higher Ki67 and non-GCB subtype. The association of double-expressor DLBCL with a high Ki67 index and non-GCB subtype confers a poor prognostic significance of this variant of DLBCL, requiring more aggressive therapy.

Left-sided primary cardiac lymphoma: a case report

BackgroundPrimary cardiac lymphoma (PCL) is a rare neoplasm, defined as lymphoma with the main bulk localized in the heart; diffuse large B cell lymphoma (DLBCL) is the most common type. It usually involves the pericardium and the right heart and has a poor prognosis with a median survival of less than 1 year.Case presentationA 62-year-old female presented to the emergency department for palpitations and recent-onset dyspnea. The echocardiogram showed a round-shaped mass (33 x 32 mm) in the left atrium, a mild circumferential pericardial effusion, and a hyperechogenic mass at the level of the atrio-ventricular junction. A thoracic CT scan demonstrated the presence of a bulky mediastinal mass, strictly attached to the left heart and infiltrating its posterior wall, the left pulmonary veins, and the inferior lobar bronchus. The patient underwent CT-guided biopsy, and the diagnosis of double-expressor DLBCL was made. Given the potential risk of heart rupture during chemotherapy, the first cycle of R-CHOP was performed in an in-hospital setting, with initial benefit. After completing 6 cycles of R-CHOP, imaging studies showed rapid progression of the disease; the patient was started on the salvation protocol R-DHAOX but died of septic shock 10 months later.ConclusionsPCL is rare and accounts for less than 2% of primary cardiac tumors; double-expressor DLBCL carries a poor prognosis.As in most cases, the diagnosis was made after the onset of nonspecific symptoms (dyspnea) but—despite the strong predilection for right heart involvement reported in literature—our patient had a predominant left atrial infiltration.

Analysis of primary central nervous system large B-cell lymphoma in the era of high-grade B-cell lymphoma: Detection of two cases with MYC and BCL6 rearrangements in a cohort of 12 cases

High-grade diffuse large B-cell lymphoma (HG-DLBCL) refers to DLBCL with MYC and BCL2 and/or BCL6 rearrangements (double-hit or triple-hit DLBCL) that exhibits poor prognosis. Double-expressor DLBCL (c-myc+/bcl-2+) has intermediate prognosis when compared to HG-DLBCL. Primary central nervous system lymphoma (PCNSL) has distinct pathophysiology (frequent non-germinal center-like subtype and double-expressor) and has worse prognosis than systemic DLBCL. By fluorescence in situ hybridization (FISH), 25–30% of PCNSLs harbor BCL6 abnormalities with rare alterations in MYC, BCL2, double-hit or triple-hit events. We describe the clinicopathologic features and status of MYC, BCL2 and BCL6 in 12 PCNSLs (7 women, 5 men; median age 63 years; range: 28–79). Six cases showed focal starry-sky pattern. Immunohistochemically, all (100%) were of non-germinal center-like subtype, and 8/10 (80%) cases were double-expressors. Ki-67 ranged from 70 to 100%. FISH was positive in 9/12 (75%) cases: 4 (33%) harbored a BCL6 rearrangement, 3 (25%) had a gain of BCL2, 2 (17%) cases each had a gain of BCL6 and gain of IGH, and gain of MYC and deletion of MYC were observed in 1 case each (8%). Two (16%) cases were MYC/BCL6 double-hit PCNSLs. No MYC/BCL2 or triple-hit cases were identified. Eleven (92%) patients received chemotherapy and one also received whole brain radiation. The median time of follow-up was 4.4 months (range, 0.3–40.3). Seven (58%) patients are alive, 4 (33%) have died, and 1 (8%) had no follow-up. Five alive patients are in remission, including one MYC/BCL6 double-hit PCNSL. Our results add two new cases of rare double-hit PCNSL to the literature.