Double-hit Lymphoma Research Articles

Impact of Myc-Altered Pathology on Radiotherapy Efficacy Among Patients with Relapsed/Refractory Large-B Cell Lymphoma: A Collaborative Study by XXX: Impact of double hit pathology on RT efficacy.

Presence of MYC and BCL2 translocations (i.e. double-hit lymphoma, DHL) in large B-cell lymphoma (LBCL) is associated with reduced chemosensitivity, but less is known on its impact on radiotherapy (RT) efficacy. Patients with LBCL that received their first course of RT for relapsed/refractory (r/r) disease between 2008-2020 were eligible if there was adequate pathologic evaluation to be categorized as DHL versus non-DHL as per WHO (5th edition). Separate analyses were conducted by treatment intent. Predictors for response (complete and partial) and local recurrence (LR) were evaluated using Cox regression analysis. LR analysis was restricted to curative-intent patients to ensure adequate follow-up. 383 patients (102 DHL, 281 non-DHL, 44% curative) were treated to 447 sites. Median time from diagnosis to RT was 11.6 months, with 38.7% patients having primary chemorefractory disease, 37.4% having received >2 lines of systemic therapy, and 24% status post stem cell transplant. Median biological equivalent dose (alpha/beta 10) was 28 Gy (range 3.2-60.0) for palliative and 46.9 Gy (range 6.4-84.0) for curative-intent patients. With a median follow-up of 41.1 and 41.5 months among curative and palliative patients, respectively, response was high (81.1% curative, 60.1% palliative). On univariate analysis, DHL pathology was not associated with RT response in either curative or palliative patients. Among curative patients, 2-year LR rate was 38.8%. On multivariable analysis, DHL pathology was associated with a 2 times higher risk of LR (95% CI 1.05-3.67,p=.03), with a crude LR rate of 42.9% (DHL) versus 28.9% (non-DHL). RT was well tolerated with low rates of grade 3 or higher acute toxicity (1.8% curative, 2.9% palliative). Relapsed/refractory LBCL remains radioresponsive with 60-80% response rate to RT. While DHL pathology does not appear to influence RT response, its presence is associated with higher rates of local recurrence, suggesting it may be more radioresistant.

CNS relapse in high-grade B-cell lymphoma with MYC and BCL2 rearrangements and dark-zone signature–expressing DLBCL

AbstractHigh-grade B-cell lymphoma with MYC and BCL2 rearrangements (HGBCL-DH-BCL2), or “double-hit lymphoma,” has been associated with a high risk of central nervous system (CNS) relapse. However, historic estimates are impacted by selection bias. We report CNS relapse rates associated with HGBCL-DH-BCL2 from a population-based cohort with complete fluorescence in situ hybridization testing, as well as diffuse large B-cell lymphoma morphology (DLBCL) tumors expressing the dark-zone gene expression signature (DZsig), which was originally derived from HGBCL-DH-BCL2. The 2-year CNS relapse risk in HGBCL-DH-BCL2 was 6.8%. CNS relapses were early, predominantly leptomeningeal (73%), and co-occurred with systemic relapse (64%). High-risk CNS International Prognostic Index (CNS-IPI) and concordant bone marrow involvement were associated with an elevated CNS relapse risk in HGBCL-DH-BCL2. The “refined cell-of-origin” classification assigned 20% of DLBCL morphology tumors with germinal center B-cell–like phenotype (GCB-DLBCL) into a distinct subgroup based on DZsig expression (DZsig+). CNS relapse risk in DZsig+ (2 year: 6.4%) was independent of HGBCL-DH-BCL2 status and was further stratified by the CNS-IPI. CNS relapse in DZsig-negative GCB-DLBCL was rare (2-year risk, 1.4%; P = .04 vs DZsig+) and exclusively parenchymal. Altogether, the CNS relapse risk in HGBCL-DH-BCL2 is lower than previously reported, and DZsig refines risk stratification in GCB-DLBCL.

CODOX-M/IVAC-R versus DA-EPOCH-R in double hit/triple hit lymphoma patients aged 60 years or under.

Intensified chemoimmunotherapy regimens are often used in young patients with double hit and triple hit lymphoma (DHL/THL) despite no survival benefit compared to R-CHOP. Favorable retrospective reports on the application of CODOX-M/IVAC-R are subject to selection bias as only young fit patients can tolerate this treatment. We conducted a retrospective analysis to investigate outcome differences between CODOX-M/IVAC-R and DA-EPOCH-R in DHL/THL patients aged 60 years or younger. 113 patients were identified; CODOX-M/IVAC-R (N=49) and DA-EPOCH-R (N=64). 80% (39/49) achieved complete (CR) after completing CODOX-M/IVAC-R compared to 58% (37/64) with DA-EPOCH-R. The median follow-up was 5.3 years and 3.3 years for the CODOX-M/IVAC-R and DA-EPOCH-R group respectively. CODOX-M/IVAC-R demonstrated superior EFS on univariate (HR=0.54, 95%CI=0.31-0.97) and multivariable analysis adjusted for age, BCL translocation (BCL2 vs BCL6 vs both), IPI score and receipt of ASCT (aHR=0.52, 95%CI=0.29-0.93); however there was no significant influence on OS (aHR=0.92, 95%CI=0.46-1.84). The 1, 2 and 5 years EFS in the CODOX-M/IVAC-R group was 68.3%, 64.1% and 61.5% respectively compared to 52.4%, 48.9% and 39.5% respectively in the DA-EPOCH-R group. Primary refractory disease or relapse occurred in 33% (16/49) of CODOX-M/IVAC-R and 54% (35/64) of DA-EPOCH-R recipients, and produced median OS of 10.3 months and 33.7 months, respectively, indicating poor outcomes in the CODOX-M/IVAC-R subgroup with R/R disease. More patients were able to receive subsequent salvage therapies in the DA-EPOCH-R group. No patients died of regimen toxicity and the rates of CNS relapse and therapy related hematologic neoplasms were similar in both groups.

Molecular Classification of Large B-Cell Lymphoma and High-Grade B-Cell Lymphoma Cases and Association with Outcomes in Morocco

Background: High-grade B-cell lymphoma with c-MYC and BCL2 and/or BCL6 rearrangements (HGBL-DHL/THL) is a recently identified category in the most recent World Health Organization (WHO) classification. For all tumors displaying the appearance of diffuse large B-cell lymphoma (DLBCL) or high-grade B-cell lymphoma (HGBL), it is necessary to perform fluorescence in situ hybridization (FISH) in order to achieve an accurate diagnosis. The findings of FISH and immunohistochemistry (IHC) examinations from 50 DLBCL/HGBL samples obtained from Hassan II University Hospital in Fez/Morocco are reported. Methods: This retrospective study included 50 patients diagnosed with DLBCL/HGBL over a period of nine years (2013–2022) and treated with RCHOP chemotherapy protocol. All patients underwent a histological study followed by an immunohistochemical study to confirm the diagnosis and to classify patients according to cell of origin into non-GCB and GCB subtypes; then, a cytogenetic study using FISH was performed to classify patients according to the presence or absence of rearrangements in the c-MYC, BCL2 and BCL6 genes. A comparison was made between the molecular subtypes of DLBCL/HGBL in relation to clinicopathological features and outcomes. Results: Among the 50 cases studied in our population, we found 5 cases of HGBL with DLBCL morphology and 45 cases of DLBCL, which consisted of 13 cases (28.89%) of GCB subtype and 32 cases (71.11%) of non-GCB subtype based on the immunohistochemistry Hans algorithm. After FISH testing of all cases, we found three cases of double-hit lymphoma (DHL) and one case of triple-hit lymphoma (THL). Thus, HGBL-DHL/THL accounted for 8% of the cases. Furthermore, two cases were detected with only one rearrangement in the BCL2 gene and one case harboring a rearrangement in the BCL6 gene. DHL and THL patients and patients with a single rearrangement (BCL2 or BCL6) have a worse prognosis than patients with no rearrangement. Conclusions: DHL and THL are an aggressive entity of HGBL with poorer outcomes in comparison to DLBCL/HGBL NOS. First-line treatment with the RCHOP chemotherapy protocol may not be effective for all aggressive DLBCL cases. More targeted treatment is crucial for better patient outcomes.

Imatinib mesylate reduces c-MYC expression in double-hit lymphoma cells by suppressing inducible cytidine deaminase

BackgroundDouble-hit lymphoma (DHL) with c-MYC gene translocation is highly aggressive and has a poor prognosis. In DHL cells, activation-induced cytidine deaminase (AID) promotes antibody class switch recombination (CSR), ultimately leading to c-MYC gene translocation caused by Myc/IgH DNA double-strand breaks. However, currently there is still no method to suppress the expression of AID.MethodsIn this study, we compared the clinical significance of AID expression in DHL, Additionally, two human double-hit lymphoma cell lines were used to analyze the effect of imatinib mesylate on c-MYC in vitro, and the therapeutic effect was also evaluated in xenograft mouse models.ResultsImatinib mesylate downregulated the AID and c-MYC proteins in patients with chronic myelogenous leukemia associated with DHL. In addition, imatinib mesylate reduced AID and c-MYC expression in SU-DHL-4 and OCI-Ly18DHL cells. Imatinib mesylate exerted significant inhibitory effects on the proliferation and metastasis of SU-DHL-4 and OCI-Ly18 cells. Finally, imatinib mesylate reduced not only tumor burden in DHL mouse models, but also AID and c-MYC expression in vivo.ConclusionThese findings reveal that imatinib mesylate effectively reduces the carcinogenic function of c-MYC in DHL, providing novel strategies for developing therapies targeting c-MYC-driven DHL.Graphical abstract

Double-hit primary central nervous system lymphoma with histogenetically proven bone marrow infiltration: a case report and a review of the literature.

Double-hit lymphoma (DHL) formerly referred to high-grade B-cell lymphoma with concurrent MYC and BCL2 or BCL6 rearrangements, however, the updated 2022 World Health Organization Classification (5th edition online) excludes those with MYC and BCL 6 rearrangements from the high-grade category. DHL confined to the central nervous system (CNS), known as double-hit primary CNS lymphoma (DH-PCNSL), is rare with poorly understood clinical features. Here, we report a case of a 64-year-old man with multiple brain tumors diagnosed with DH-PCNSL who showed bone marrow (BM) infiltration early in the clinical course. The histological diagnosis was high-grade B-cell lymphoma with MYC and BCL6 rearrangements. Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed no abnormal accumulation except in the CNS. The patient received whole-brain radiotherapy following the failure of high-dose methotrexate. After completion of radiotherapy, the patient developed thrombocytopenia, and BM biopsy showed infiltration of DHL cells, which were not detected by repeated FDG-PET. This is the first report of DH-PCNSL where identical gene rearrangements were confirmed in both the resected CNS tumor and BM tissue. Patients with DH-PCNSL require careful follow-up because they may be at a potential risk of BM infiltration, which may be undetectable by FDG-PET, particularly early in the disease course.

Characterizing the Mutational Landscape of Diffuse Large B-Cell Lymphoma in a Prospective Cohort of Mexican Patients.

Diffuse large B-cell lymphoma (DLBCL) is the most common B-cell malignancy worldwide. Molecular classifications have tried to improve cure rates. We prospectively examined and correlated the mutational landscape with the clinical features and outcomes of 185 Mexican patients (median age 59.3 years, 50% women) with newly diagnosed DLBCL. A customized panel of 79 genes was designed, based on previous international series. Most patients had ECOG performance status (PS) < 2 (69.2%), advanced-stage disease (72.4%), germinal-center phenotype (68.1%), and double-hit lymphomas (14.1%). One hundred and ten (59.5%) patients had at least one gene with driver mutations. The most common mutated genes were as follows: TP53, EZH2, CREBBP, NOTCH1, and KMT2D. The median follow-up was 42 months, and the 5-year relapse-free survival (RFS) and overall survival (OS) rates were 70% and 72%, respectively. In the multivariate analysis, both age > 50 years and ECOG PS > 2 were significantly associated with a worse OS. Our investigation did not reveal any discernible correlation between the presence of a specific mutation and survival. In conclusion, using a customized panel, we characterized the mutational landscape of a large cohort of Mexican DLBCL patients. These results need to be confirmed in further studies.

New classifications of B-cell neoplasms: a comparison of 5th WHO and International Consensus classifications.

In 2024, the World Health Organization (WHO) launched a new classification of lymphoid neoplasms, a revision of the previously used Revised 4th Edition of their classification (WHO-4R). However, this means that two classifications are now in simultaneous use: the 5th Edition of the WHO classification (WHO-5) and the International Consensus Classification (ICC). Instead of a comprehensive review of each disease entity, as already described elsewhere, this review focuses on revisions made in both the WHO-5 and ICC from WHO-4R and discrepancies between them regarding B-cell neoplasms. Similarities include cutaneous marginal zone lymphoma, cold agglutinin disease, non-primary effusion lymphoma-type effusion-based lymphoma, and gray zone lymphoma. Differences include plasma cell neoplasms, high-grade B-cell lymphoma (double hit lymphoma), follicular lymphoma, LPD with immune deficiency and dysregulation, extranodal large B-cell lymphoma, transformations of indolent B-cell lymphomas, and diffuse large B-cell lymphoma, not otherwise specified. Understanding the similarities and differences between the two latest classifications will aid daily diagnostic practice and future research on lymphoid neoplasms.

CAR T cells vs bispecific antibody as third- or later-line large B-cell lymphoma therapy: a meta-analysis

AbstractThis meta-analysis evaluates the efficacy and safety of chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies for relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL). We searched MEDLINE, Embase, and Cochrane databases until July 2023 for trials assessing CAR T-cell therapies and CD20×CD3 bispecific antibodies as third or subsequent lines in R/R DLBCL. Random-effects models estimated the complete response (CR) rate and secondary outcomes, with meta-regressions adjusting for relevant covariates. Sixteen studies comprising 1347 patients were included in the pooled analysis. The pooled CR rate for bispecific antibodies was 0.36 (95% confidence interval [CI], 0.29-0.43), compared with 0.51 (95% CI, 0.46-0.56) for CAR T-cell therapy (P < .01). This superiority persisted when comparing the CAR T-cell–naive patients within the bispecific antibody group, with a CR rate of 0.37 (95% CI, 0.32-0.43). Multivariable meta-regression also revealed better efficacy of CAR T cells with adjustment for the proportion of double-hit lymphoma. The pooled 1-year progression-free survival rate mirrored these findings (0.32 [95% CI, 0.26-0.38] vs 0.44 [95% CI, 0.41-0.48]; P < .01). For adverse events of grade ≥3, the bispecific antibody had incidences of 0.02 (95% CI, 0.01-0.04) for cytokine release syndrome, 0.01 (95% CI, 0.00-0.01) for neurotoxicity, and 0.10 (95% CI, 0.03-0.16) for infections. The CAR T cell had rates of 0.08 (95% CI, 0.03-0.12), 0.11 (95% CI, 0.06-0.17), and 0.17 (95% CI, 0.11-0.22), respectively, with significant differences observed in the first 2 categories. In summary, CAR T-cell therapy outperformed bispecific antibody in achieving higher CR rates, although with an increase in severe adverse events.

Molecular Profiling of High-Grade B-Cell Non-Hodgkin Lymphomas and Its Clinicopathologic Correlation in an Indian Tertiary Cancer Care Center

Abstract Introduction Double-expressor and double-hit lymphomas (DHL) are known to be more aggressive and have poor outcomes with standard chemotherapy regimens. Objectives To assess the incidence of DHL and triple-hit lymphomas (THL) and correlate them with clinicopathologic parameters. Materials and Methods Patients who were diagnosed with high-grade lymphomas from April 2021 to September 2022 were prospectively followed up, and details comprising clinical and pathological parameters, including the immunohistochemistry expression status and gene rearrangements of MYC, BCL2, and BCL6, were recorded. Results The incidence of DHL and THL in our study was 16.43%. The separate incidence of the DHL-BCL2, DHL-BCL6, and THL groups was 16.43, 13.69, and 2.73%, respectively. The germinal center B cell subtype of histology was predominantly seen in DHLs. MYC, BCL2, and BCL6 expressions do not correlate well with translocations of these genes. Conclusion Double protein expression cannot be used for screening to decide which patients should undergo fluorescence in situ hybridization, as this would result in missing 4.5% of DHLs.

Do Double-Expressor High-Grade B-Cell Lymphomas Really Need Intensified Treatment? A Report from the Real-Life Series of High-Grade B-Cell Lymphomas Treated with Different Therapeutic Protocols at the Institute of Oncology Ljubljana.

High-grade B-cell lymphomas with MYC and BCL2 and/or BCL6 rearrangements are known for their aggressive clinical course and so are the ones with MYC and BCL2 protein overexpression. The optimal therapy for these lymphomas remains to be elucidated. A retrospective analysis of all diffuse large B-cell lymphomas and high-grade B-cell lymphomas with MYC and BCL2 and/or BCL6 rearrangements diagnosed between 2017 and 2021 at the Institute of Oncology Ljubljana, Slovenia, has been performed. Only patients with double-expressor lymphoma (DEL), double-hit lymphoma (DHL), or triple-hit lymphoma (THL) were included. Demographic and clinical parameters were assessed, as well as progression-free survival (PFS) and overall survival (OS). In total, 161 cases out of 309 (161/309; 52,1%) were classified as DEL. Sixteen patients had DHL, MYC/BCL2 rearrangement was observed in eleven patients, and MYC/BCL6 rearrangement was observed in five patients. Five patients were diagnosed with THL. Out of 154 patients (according to inclusion/exclusion criteria) included in further evaluation, one-hundred and thirty-five patients had double-expressor lymphoma (DEL), sixteen patients had DHL, and three patients had THL. In total, 169 patients were treated with R-CHOP, 10 with R-CHOP and intermediate-dose methotrexate, 19 with R-DA-EPOCH, and 16 with other regimens. The median follow-up was 22 months. The 5-year OS for the whole DEL group was 57.1% (95% CI 45.9-68.3%) and the 5-year PFS was 76.5% (95% CI 72.6-80.4%). The log-rank test disclosed no differences in survival between treatment groups (p = 0.712) while the high-risk international prognostic index (IPI) carried a significantly higher risk of death (HR 7.68, 95% CI 2.32-25.49, p = 0.001). The 5-year OS for DHL patients was 32.4% (95% CI 16.6-48.2%) while all three TH patients were deceased or lost to follow-up. Our analyses of real-life data disclose that the R-CHOP protocol with CNS prophylaxis is a successful and curative treatment for a substantial proportion of DEL patients.

Noncoding mutations cause super-enhancer retargeting resulting in protein synthesis dysregulation during B cell lymphoma progression

Whole-genome sequencing of longitudinal tumor pairs representing transformation of follicular lymphoma to high-grade B cell lymphoma with MYC and BCL2 rearrangements (double-hit lymphoma) identified coding and noncoding genomic alterations acquired during lymphoma progression. Many of these transformation-associated alterations recurrently and focally occur at topologically associating domain resident regulatory DNA elements, including H3K4me3 promoter marks located within H3K27ac super-enhancer clusters in B cell non-Hodgkin lymphoma. One region found to undergo recurrent alteration upon transformation overlaps a super-enhancer affecting the expression of the PAX5/ZCCHC7 gene pair. ZCCHC7 encodes a subunit of the Trf4/5-Air1/2-Mtr4 polyadenylation-like complex and demonstrated copy number gain, chromosomal translocation and enhancer retargeting-mediated transcriptional upregulation upon lymphoma transformation. Consequently, lymphoma cells demonstrate nucleolar dysregulation via altered noncoding 5.8S ribosomal RNA processing. We find that a noncoding mutation acquired during lymphoma progression affects noncoding rRNA processing, thereby rewiring protein synthesis leading to oncogenic changes in the lymphoma proteome.

Abstract C076: Evidence of TCR and BCR clonal dynamics with enitociclib monotherapy in patients with MYC+ non-Hodgkin lymphoma (NHL)

Abstract Introduction: Enitociclib (VIP152) is a potent and selective CDK9 inhibitor with robust MYC downregulation (Frigault ASH 2021). We have previously reported safety, efficacy and MYC downregulation from 16 patients with B-cell lymphoma treated with enitociclib monotherapy, including 2 patients with double-hit diffuse large B-cell lymphoma (DH-DLBCL) who achieved complete metabolic remissions (CR) for 5.5+ and 4.0+ years (Diamond Clin Can Res 2022, Shadman ASH 2022). DH-DLBCL is characterized by MYC and BCL2/BCL6 rearrangements, and MYC+ NHL patients are known to be refractory to immune-oncology (IO) therapies. Herein, we evaluate the IO effect of enitociclib monotherapy in the blood of MYC+ NHL patients. Methods: Enitociclib is being evaluated in a phase 1 trial in patients with NHL receiving 30 mg i.v. once weekly (NCT02635672). From the previously reported 16-patient cohort (Shadman ASH 2022), 12 have evidence of MYC+ and had whole blood collections taken before and after dosing for at least 2 enitociclib doses (204 samples). RNA was purified from whole blood and bulk RNA seq performed by Illumina stranded total RNA prep with RiboZeroTM plus rRNA depletion and globin reduction RNA library preparation with strand-specific sequencing 50M paired reads (Discovery Life Science, AL, USA). TCR and BCR sequences were reconstructed using the TRUST4 algorithm (Song Nature Methods 2021). TCR beta chain (TRBC) sequences were annotated with antigen specificity data from VDJdb, McPAS-TCR and IEDB databases. Results: Demographics of the 12-patient cohort are described: 11 men; median age 68 (58-84) years; median prior therapy 2.5 (1-7); and includes DH-DLBCL (10; 2 CR, 8 clinical progression [PD]), triple hit-DLBCL (1 PD), and transformed follicular lymphoma (1 stable disease, currently on study). Simpson clonality of TRBC after 2 weeks of enitociclib compared with baseline correlates with response (CR, PD); however, the small sample size in each response category limits generalizability. Assuming BCR disease clones are identified by high frequency IGKC or lambda (IGLC), disease clonal switching occurs in 2 patients: DH-DLBCL (CR) from IGLC to IGKC and DH-DLBCL (PD) in reverse. In the CR patient, clearance of the top IGLC with enitociclib treatment is observed with simultaneous expansion of a high frequency TRBC. Although a viral specific TRBC is present in this patient, this top TRBC is unmapped to publicly known antigens suggesting the possibility of a cancer-specific TRBC. The second CR patient had low frequency TRBC. Tumor immune microenvironment deconvolution to describe dynamics of phenotypes will be presented to complement these findings. Conclusions: These data suggest that an IO mechanism of action may contribute to the durable 5.5 year CR observed in a DH-DLBCL patient treated with enitociclib monotherapy. Analysis in expanded datasets is required to support this preliminary observation including following active patients. Citation Format: Melanie M. Frigault, Joseph Birkett, Xin Huang, Raquel Izumi, Amy J. Johnson, Beatrix Stelte-Ludwig, Arushi Mithal, Ahmed Hamdy, Vanessa D. Jonsson. Evidence of TCR and BCR clonal dynamics with enitociclib monotherapy in patients with MYC+ non-Hodgkin lymphoma (NHL) [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr C076.

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

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

Differences in Observed Toxicities for Adolescent and Young Adult Patients with Aggressive Mature B-Cell Lymphomas Treated at Adult Versus Pediatric Cancer Center - a Comparative Cohort Study

Introduction: Standard treatment regimens for pediatric and adult patients with mature B-cell lymphomas vary significantly. For adolescent or young adult (AYA) patients, who may be candidates for either pediatric or adult regimens, limited data are available regarding comparative toxicities and efficacy for adult versus pediatric therapies. Methods: A retrospective review was completed for individuals aged 12-39 years at diagnosis with aggressive mature B-cell lymphomas seen between 2011 to 2023 at Ohio State University Comprehensive Care Center (adult cohort) and Nationwide Children's Hospital (pediatric cohort). Diagnoses included diffuse large B cell lymphoma (DLBCL), double hit lymphoma (DHL), Burkitt lymphoma (BL), primary mediastinal B cell lymphoma (PMBCL), grey zone lymphoma (GZL), and unclassifiable high-grade B cell lymphoma (HGBCL). Progression free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method and compared by log-rank test. Differences between adult and pediatric cohort were compared using Fisher's exact test and Chi-squared test. Cox regression model was used to identify prognostic factors for PFS. Results: Among 180 eligible AYA patients, 156 were treated at the adult center and 24 at the pediatric center. The median age was 30 years (median 15 pediatric [range 12-18] and 31 adult [range 21-39; p&amp;lt;0.001]). Other characteristics included male sex in 75% of pediatric vs 65% adult patients (p=0.3), stage 4 disease in 25% vs 47%(p&amp;lt;0.001), CNS involvement in 8.3% vs 5.4% (p=0.6), and LDH &amp;gt;2x upper limit of normal in 21% vs 31% (p=0.2). The overall median follow-up was 4.8 years (4.5 vs 4.8, p=0.7). Adult center histology included DLBCL (95); DHL (9); BL (8); PMBCL (31); GZL (4); and HGBCL (9). Pediatric diagnoses were DLBCL (13); BL (8); PMBCL (2); and HGBCL (1). The most common treatments included R-CHOP (57), R-EPOCH (56), RM-CHOP (20), and R-CODOX-M/R-IVAC (16) at the adult center and CCG5961 (7), ANHL1131 (15), and ANHL0221 (1) protocols at the pediatric center. CCG5961 Group B protocol includes pre-phase, induction, and consolidation phases of COP, COPADM, and CYM. Group C includes the same pre-phase and induction, except for higher doses of MTX, with CYVE consolidation with high-dose MTX and randomization to 1 or 4 cycles of maintenance. ANHL1131 protocol was like CCG5961; major differences include randomization to receive rituximab during induction and consolidation and 2 cycles of maintenance for group C patients. ANHL0221, a PTLD protocol, involves 2 cycles of cyclophosphamide, prednisone, and rituximab followed by 4 cycles of cyclophosphamide and prednisone. A greater incidence of unplanned hospitalization (79% pediatric vs 50% adult, p=0.007), grade 3 mucositis (38% vs 12%, p=0.005), febrile neutropenia (67% vs 44%, p=0.035), and fungal infections (25% vs 3%, p&amp;lt;0.001) were observed for the pediatric cohort (Table 1). Patients in the adult cohort were more likely to receive radiation therapy (26% vs 0%, p=0.004) and experience neuropathy at last follow-up (22% v 0%, p=0.009). Among all patients, other adverse events during follow-up included diagnosis of depression/anxiety (93), heart failure (16), impaired renal function (20), and secondary malignancy (6) (Table 1). For the total population, 2-year PFS was 78% (88% pediatric vs 77% adult, p=0.35), and 2-year OS was 93% (96% vs 92%, p=0.31). For patients with DLBCL or DHL, there was a trend towards improved PFS in the pediatric versus adult cohort (p=0.06, Figure 1), and on univariable analysis a trend towards lower risk for progression with receipt of a more intensive regimen compared with R-CHOP/R-MCHOP (hazard ratio 0.46, 95% confidence interval 0.2-1.1, p=0.07). Conclusions: We observed a higher incidence of short-term adverse effects including severe mucositis, febrile neutropenia, and fungal infection, but lower rates of radiation consolidation and ongoing neuropathy in AYA patients with aggressive mature B-cell lymphoma treated with pediatric versus adult regimens. Relatively higher dose intensity (compared to adult treatments), standard use of CNS prophylaxis, and lower dosage of vinca-alkaloids likely account for the greater incidence of short-term adverse effects and lower rates of neuropathy seen in patients treated at pediatric centers. Further study is needed to evaluate differences in efficacy between treatment approaches in AYA patients with DLBCL/DHL.

Impact of Genetic Mutations on Survival Following Receipt of Commercial CART19 for Patients Diagnosed with Aggressive B Cell Lymphoma

Introduction Anti-CD19 chimeric antigen receptor-modified T cell therapies (CART19) have revolutionized treatment of patients (pts) with relapsed/refractory (R/R) diffuse large B cell lymphoma (DLBCL) and high grade B cell lymphoma (HGBL). However, progression of disease following receipt of CART19 is common with only approximately one-third of pts achieving long-term remission in the standard-of-care setting (Transplant Cell Ther. 2022 Sep;28(9):581.e1-581.e8, Blood (2022) 140 (Supplement 1): 1584-1587). While loss of CD19 antigen expression antigen is one mechanism of CART19 failure, other tumor-intrinsic factors which may result in CART19 failure remain poorly defined. Clinical laboratory mutation analysis (CLMA) performed on tumor specimens can identify recurring genetic mutations which may predict for clinical outcomes; however, the predictive value of CMLA has not been well-established for DLBCL/HGBL pts treated with CART19. Here, we analyze the impact of genetic mutations as detected by CLMA, along with other clinicopathologic characteristics, on survival outcomes of DLBCL/HGBL pts following receipt of CART19. Methods We collected data from 46 pts with DLBCL or HGBL treated at the University of Pennsylvania between 2018 and 2021. Patient tumors were sequenced with one of three sequencing panels comprised of 41-116 genes prior to receiving commercial CART19. Cox proportional hazards regression was used to assess the impact of clinicopathologic characteristics on disease progression and death, with characteristics demonstrating p &amp;lt;0.10 on univariate analysis included in multivariate analysis. Estimated progression free survival (PFS) and overall survival (OS) from the time of CART19 infusion were calculated using Kaplan-Meier estimates. Results Baseline clinicopathologic characteristics are listed in Table 1. A total of 30 of 46 pts had at least one tumor mutation detected prior to receiving CART19, with 22 genes mutated in at least two pts (Figure 1). The most frequent mutations were TP53 (15 of 46, 32.7%), BCL2 (3 of 12, 25%), MYC (4 of 20, 20%), SOCS1 (5 of 38, 13.2%), CD79B (5 of 38, 13.2%), CREBBP (5 of 38, 13.2%), EZH2 (5 of 46, 10.9%), STAT3 (4 of 38, 10.5%), TNFRSF14 (4 of 38, 10.5%) and DNMT3A (2 of 20, 10%). The median length of follow-up from the time of CART19 infusion was 29.6 months. For all pts, the rates of 2 year (y) PFS and OS were 21% (95% confidence interval [CI] 10-34%) and 56% (95% CI 40-69%), respectively. Univariate analysis of mutations present in ≥10% of cases revealed that TNFRSF14 mutations predicted for lower risk of disease progression at 2y (HR 0.16, 95% CI 0.02-1.186, p = 0.07). No other mutation was associated with either disease progression or death at 2y. Univariate analysis of baseline clinicopathologic characteristics also identified International Prognostic Index (IPI) score ≥3 at the time of relapse preceding CART19, HGBL classification, no history of indolent lymphoma (IL), MYC rearrangement (-R) and double hit lymphoma (DHL) as predictive of disease progression at 2y; however, none of these characteristics remained predictive on multivariate analysis. Additionally, IPI score ≥3 at the time of relapse preceding CART19, HGBL classification, no history of IL, MYC-R and DHL were also predictive of death at 2y on univariate analysis; however, none of these characteristics remained predictive on multivariate analysis. Conclusions Tumor characteristics, including recurring genetic mutations as detected by CLMA, may not independently predict for survival outcomes for DLBCL/HGBL pts following receipt of CART19. However, our finding that TNFRSF14 mutations predict for a lower rate of disease progression at 2y on univariate analysis may be explained by loss of the inhibitory effect of HVEM on T helper cells through binding of B and T lymphocyte attenuator (BTLA) (Cell. 2016 Oct 6;167(2):405-418.e13). Additionally, our finding that TP53 mutations did not predict for inferior PFS following receipt of CART19 is in agreement with that of a prior analysis (J Clin Oncol. 2022 Feb 1;40(4):369-381). Performance of CLMA on a larger number of tumor samples from DLBCL/HGBL pts subsequently treated with CART19, which is planned, may be informative.

PD-1 Blockade Combined with R-CHOP in Patients with Newly Diagnosed EBV-Positive Diffuse Large B-Cell Lymphoma: A Retrospective Analysis

Background Epstein-Barr virus (EBV) -positive diffuse large B cell lymphoma (EBV+ DLBCL) is a relatively rare aggressive B-cell lymphoma. Most patients present with advanced disease, high incidence of extranodal involvement of 30% to 80% (Keane, Eur J Haematol, 2019), as well as poor prognosis when treated with immunochemotherapy. However, no consensus on standard treatment has been established by now. It was found that the expression of programmed death ligand-1 (PD-L1) was increased in EBV+ DLBCL (Kim, Cancer Res Treat, 2019). In addition, chronic EBV infection results in T-cell exhaustion that can be reversed by PD-1 blockade. Compared with PD-L1-positive EBV-negative DLBCL cell lines, the application of PD-1 blockade in PD-L1-positive EBV+ DLBCL cell lines can significantly restore T cell proliferation and activity(Quan, PLoS One, 2015), suggesting that targeting the PD-L1/PD-1 pathway represents a potential therapy for EBV+ DLBCL. Therefore, we retrospectively analyzed the data of nineteen patients with EBV+ DLBCL who were treated with PD-1 blockade combined with RCHOP in our center, hoping to provide reference for subsequent research. Methods Eligible pts had treatment-naive histologically confirmed diagnosis of EBV+ DLBCL. Additional eligibility criteria included at least one measurable lesion, acceptable haptic and hematological function. Pts with primary CNS lymphoma, primary mediastinal large B-cell lymphoma, secondary CNS involvement were excluded. Additional exclusion criteria included history of immune system disease, uncontrolled infection. Once deemed eligible, pts will receive six cycles of RCHOP combined with PD-1 blockade(21 days per cycle) as induction therapy and subsequently maintenance with PD-1 blockade for 1 year(21 days per cycle). End of treatment(EOT) responses were assessed by PET-CT according to the Lugano Classification 2014. The primary objective was to assess the overall response rate(ORR) at EOT. Results Between May 1, 2019, and Sep 1, 2022, 19 pts were enrolled. Pts' baseline demographics, clinical and pathological characteristics are shown in Table 1. The median age was 64 years old without significant gender difference. The majority of pts were intermediate- to high-risk by IPI. EBV DNA can be detected in blood serum at diagnosis in more than half of all patients. No patient was diagnosed with double expressor lymphoma among 18 specimens that were detected c-Myc and BCL-2 with immumohistochemical staining. EBV-encoded RNA (EBER) was positive(&amp;gt;80% of the tumor cells) in all specimens. PD-L1 positivity(&amp;gt;10% of the tumor cells) or CD30 positivity(&amp;gt;5% of the tumor cells) was also quite common. Besides, no double hit lymphoma was confirmed in patient with Fluorescence situ hybridization test(n=13). Treatment course and efficacy evaluation of all pts are summarized in Figure 1. All patients enrolled in this study had completed 6 cycles of induction therapy. Totally, the ORR at EOT was 94.7%, and all achieved CMR. The ORR of patients with PD-L1 positivity(n=10) was numerically higher than that of patients with negative PD-L1 expression (n=5) (100% vs 80%). EBV DNA detected in blood serum of thirteen patients have decreased to undetectable level after induction therapy. The immune-related adverse events (irAEs) were emphatically analyzed. One patient had recurrent fever after every dose of PD-1 blockade without obvious evidence of infection. Another patient developed grade 3 diarrhea since the second cycle of PD-1 blockade maintenance. Colonoscopy showed mucosal swelling and multiple superficial ulcers in the whole colon, which indicated immune colonitis. Maintenance therapy was therefore discontinued. No irAE was observed in the rest of patients. With a median follow-up time of 13.1m (7.2-38.5m), the median PFS and OS were not reached. Both of 1 year OS and PFS was 89.5%. Overall, 2 pts experienced disease progression (1 at EOT, 1 at 2 months after ASCT), 2 pts died (1 due to progressive disease, 1 due to COVID-19 infection ). Conclusions PD-1 blockade combined with R-CHOP as induction therapy in patients with newly diagnosed EBV+ DLBCL has demonstrated satisfactory response and limited irAEs. Longer follow-up is still warranted to confirm the long-term benefit, especially for patients with maintenance of PD-1 blockade. Still, we believe this therapeutic strategy can be regarded as a successful attempt at improving prognosis for pts with EBV+ DLBCL.

Mutational Landscape of Diffuse Large B-Cell Lymphoma (DLBCL) in Mexican Patients

Background. Diffuse Large B Cell Lymphoma (DLBCL) is the most common B-cell malignancy (1), recently classified with genomic sequencing and exome analysis into clusters with clinical implications (2,3). However, this analysis has not been informed neither in Mexican, or Latin-American population. The aim of this study was to describe the mutational landscape and its correlation with the clinical outcome in Mexican patients with DLBCL. Material and methods. A prospective, observational study of patients with diagnosis of DLBCL, attended at the National Cancer Institute in Mexico City. Inclusion criteria: patients &amp;gt; 18 years, diagnosis of DLBCL, without previous treatment and candidate to be treated with RCHOP. IRB approval was: Register number CEI/966/15. All signed informed consent. Clinical &amp; pathological variables were analyzed. All patients were treated with 6 cycles of RCHOP. Clinical response was evaluated by PET-CT. Samples: DNA was extracted from paraffin-embedded tissue of the primary neoplasm using the kit Quick-DNA/RNA FFPE kit (Zymo Research). A custom panel (6,026 oligos) was used for the sequencing of coding regions and splicing sites of 79 genes associated with lymphomas. Therafter, the bioinformatic analysiswas carried out using Ion Torrent Suite Browser version 5.0 and Ion Reporter version 5.18. Variant calling was performed with Torrent Variant Caller. The following databases were used: Cancer Genome Interprteter (CGI), ClinVar (201706), COSMIC (v86), PolyPhen (v2.2.2), SIFT (v5.2.2), FATHMM (v2.1), gnomAD (r2.0.1), and the Variant Effect Predictor (v93.2). All variants had a depth greater than 500X. Statistical analysis. Descriptive statistics for clinical variables. Associations between clinical and pathological characteristics were assessed with the frequency of SNVs and InDels. Survival curves were estimated using the Kaplan-Meier method. The association of the overall survival (OS) and the recurrence-free survival (RFS) was evaluated with Log-Rank test. Statistical significance was set at p-value &amp;lt; 0.05. Cox proportional-hazard regression analysis was used to identify the variables predicting overall survival (OS). All statistical analyses were performed using R software (v4.2.2) (https://cran.r-project.org, accessed on 23rd May 2023) and SPSS version 25 software (IBM, Corp., Armonk, NY). Results We included 185 patients, median + SD age 59.3 + 14.1 years. Most (n=128, 69.2 %) were in ECOG score &amp;lt; 2, without B symptoms (n=131, 70.8 %), in advanced disease (n=134, 72.4%), and were germinal-center (GC) (n=126, 68.1 %), and 26 (14.1 %) were double hit lymphomas. At least a driver mutation was found in 110 cases (59.4 %). The genes with driver mutations most frequently were: TP53, EZH2, CREBBP, NOTCH1 and KMT2D. ( figure 1). The EZH2 mutations and KMT2D mutations were more frequent in female: ( EZH2 mutated [n=22/34, 64.7%], p=0.047]) ( KMT2D mutated, 75%, p=0.034), and had a higher frequency of bulky disease (63.3 %, p= 0.05). In contrast, MYD88 mutations were more frequent in male (MYD88 mutations: 76.9 %], p= 0.042). Response to R-CHOP treatment was: Complete (n= 129 (69.7%), partial (n=10, 5.4 %), or stable disease (n=3, 1.6 %); 26 patients (14 %) progressed during treatment. Median follow-up + SD was 41.99 + 21.4 months. The RFS was 60 % to 80 months and OS was 70 % to 84 months. ECOG &amp;gt;2 (p=0.002 [95 %CI: 1.52-3.97]), mutations at genes EZH2 (p=0.007 [95% CI: 0.193 -0.0.58), CREBBP (p=0.004 [95 % CI: 1.59 - 11.85]), and ARID1A (p= 0.027 [95 % CI: 1.34 - 131.45] were factors influencing on OS by univariate analysis. The multivariate analysis confirmed that an ECOG &amp;gt;2 (p=0.001 [95 CI: 1.46-3.34]) had a negative impact on OS. In contrast, EZH2 mutations (p=0.025 [95 % CI: 0.12 -0.86]) were a protective factor. Conclusions: This is the first approach to describe the genomic landscape in Latino-american population. The presence of EZH2 and KMT2 mutations were more frequent in female patients with mediastinal and bulky disease. After multivariate analysis, only the presence of EZH2 mutations was the only genomic factor influencing on OS. These results require to be confirmed by further studies.

A Retrospective Study on Outcomes of Secondary CNS Lymphoma: Pattern of Relapse, Prognostic Factors, and Role of Consolidation Therapy

Introduction Secondary CNS lymphoma (SCNSL) remains a treatment challenge in patients (pts) with aggressive lymphoma. Outcome of SCNSL is poor. Pts are often treated with high dose Methotrexate (HD-MTX) based regimens followed by autologous stem cell transplant (auto SCT). However, the benefit of consolidation therapy is not well established. There is limited data on the treatments and outcomes of SCNSL. In this single institution study, we aim to analyze the role of consolidation therapy and potential prognostic factors of outcomes in SCNSL. Method All pts with a diagnosis SCNSL who presented to Moffitt Cancer Center, FL, USA between 2017 and 2022 were included. The hazard ratios (HRs) were evaluated in the univariate and multivariate analysis using the cox proportional hazard mode. All analyses were done using SAS 9.4. Results A total of 60 pts with SCNSL were identified. The median age was 63 years (range 26-83 years); 27 (45%) were female; 13 (21.7%) had Eastern cooperative oncology group performance status (ECOG) ≥2. Entire cohort was divided in 3 subgroups: pts with concurrent CNS involvement at the time of initial diagnosis with systemic lymphoma (Sys-CNS) [22 (36.7%)]; pts with isolated CNS relapse (R-SCNS) [30 (50.0%)]; and pts with simultaneous CNS and systemic relapse (R-Sys-CNS) [8 (13.3%)]. 31 (51.7%) pts had brain parenchymal involvement, 24 (40%) had leptomeningeal disease, 4 (6.7%) had both leptomeningeal and parenchymal involvement, and 1 (1.7%) had ocular disease. 58(96.6%) pts had diffuse large B cell lymphoma (DLBCL) histology; 9 (15%) had DLBCL with MYC and BCL2 rearrangement; 10 (16.7%) had DLBCL MYC and BCL2 expression. For induction therapy of SCNSL, 53 (88.3%) of pts received HD MTX-based chemotherapy; 2 (3.3%) received Bruton tyrosine kinase inhibitor (BTKi), and 5 (8.3%) with meningeal disease alone received IT chemotherapy and/or rituximab(R). Sys-CNS pts also received R-CHOP or DA-R-EPOCH while R-Sys-CNS pts received R-Polatuzumab or Polatuzumab-R-Bendamustine. 20 (33.3%) received consolidation either by WBRT [13 (21.7%)] or auto SCT [4 (6.7%)]; 3 (5.0%) proceeded with chimeric antigen receptor (CAR-T) therapy. The overall response rate (ORR) for entire cohort was 55.2% (34.5% complete response CR and 20.7% partial response PR). However, improved ORR and CR were observed with 14(73.68%) and 9 (47.37%) respectively in pts who received consolidation. ORR and CR for pts with Sys-CNS, R-SCNS, R-Sys-CNS were 13 (61.9%)/ 10 (47.6%), 14 (48.3%)/9 (31%) and 2 (25%)/ 2 (25%), respectively. After a median follow up of 33.6 months, median OS was 8.3 months with a 2-year survival probability of 33.8% (95% CI: 21.7-46.3%); the PFS was 6.5 months with a 2-year PFS probability of 32.9% (95% CI: 20.7-45.6%). Consolidation therapy with either auto SCT or WBRT had significant survival benefit. In this subgroup, median OS is not reached (NR) and the 2-year OS probability was 59.6% (95% CI: 32.9-78.7%); median PFS was 25.6 months and 2-year PFS probability was 53.3% (95% CI: 27.5-73.6%). After the first-line therapy for CNS disease, 21(35%) pts experienced relapsed. However, relapse rate in consolidation group [7 (36.8%)] was almost similar to those who did not receive consolidation [14 (34.2%)] (table 1). 39 (65%) pts died; 29 (48.33%) from disease progression, 3 (5%) from therapy related side effect and 7(11.7%) from other causes. In the univariate analysis, ECOG PS ≥2 [HR 3.60 (CI:1.80-7.20), p&amp;lt;0.001], lack of consolidation therapy [2.45 (CI:1.12-5.36), p=0.024], &amp;lt;3 cycles of HD-MTX containing regimen [2.85 (CI: 1.47-5.520), p=0.002] and double hit lymphoma [2.27 (CI: 1.02-5.06), p=0.045] were associated with worse OS. In the multivariate analysis, R-SYS-CNS, &amp;lt;3 cycles of HD-MTX, ECOG ≥2 and lack of consolidation remained significant. Lack of consolidation and receiving &amp;lt;3 cycles of HD-MTX were associated with inferior PFS in both univariate and multivariate analysis (figure 1). Conclusion Outcomes of aggressive B cell lymphoma with CNS involvement remain poor. The median OS was 8.3 months in our cohort. After adjusting for confounding factors, receiving &amp;gt;3 cycles of HD-MTX based regimen and consolidation with either WBRT or auto SCT were associated with improved outcomes. Pts with simultaneous CNS and systemic relapse had worse OS. Prospective studies are needed to evaluate optimal treatment for SCNSL.

RCHOP Plus High-Dose Methotrexate As First-Line Therapy in Large B-Cell Lymphoma with Testis Involvement

Primary testicular lymphoma (PTL) and diffuse large B-cell lymphoma with secondary testicular involvement (DLBCL-T) are rare subtypes of lymphomas associated with poor prognosis and a high risk of central nervous system (CNS) relapse. The optimal CNS prophylaxis strategy for these subtypes remains uncertain. High-dose methotrexate (HD-MTX) is debated for CNS prophylaxis, but its efficacy in this setting is unknown. This study aimed to retrospectively analyze the use of HD-MTX in combination with chemotherapy (R HD-MTX CHOP) as frontline treatment for PTL and DLBCL-T and to compare the biological characteristics of these two forms of testicular involvement. Data from patients who received R HD-MTX CHOP as first-line treatment for DLBCL-T or PTL between 2010 and 2020 were collected retrospectively. The study included 15 patients, 5 with PTL and 10 with DLBCL-T. The overall response rate was 86%, with 73% of patients achieving complete remission. Treatment-related adverse events were generally manageable, with febrile neutropenia being the most common. Two patients experienced CNS relapse, both from the DLBCL-T subgroup, with a median time of 10.7 months from diagnosis to CNS relapse. None of the PTL patients receiving HD-MTX experienced relapse during the median follow-up of 6.08 years (Figure 1A), compared to 8/10 DLBCL-T (p=0.007). All five PTL cases had a non-germinal center phenotype, while 7 out of 10 DLBCL-T cases were non-germinal center. One DLBCL-T case exhibited high-grade lymphoma. Myc expression was positive in 3 out of 10 patients assessed, of whom all were double expressors. Bcl-2 expression was positive in all 13 assessable patients, while Bcl-6 expression was positive in 6 patients. Myc, Bcl-2, and Bcl-6 rearrangements were assessed in 10 patients and were present in 1 patient who was found to have triple-hit lymphoma. No other patient had double-hit lymphoma or any significant rearrangement. Polysomy of Myc, Bcl-2, and/or Bcl-6 was found in 2 patients. PDL1 expression was observed in one out of six patients analyzed, while no PD1 expression was detected. In 8 out of 15 patients with available tissue material, next-generation sequencing using a panel targeting 43 lymphoid genes was performed. Among these 8 patients, 87% exhibited gain-of-function mutations in MYD88 (MYD88 L265P), and 62% had missense mutations in CD79B at position Y196. Multiple mutations in the PIM1 gene, a known target of aberrant somatic hypermutation, were also observed in 7 patients. Non-recurrent mutations were detected in various genes, including PRDM1, CD58, B2M, CREBBP, CIITA, CARD11, CDKN2A, EP300, CCDND3, FOXO1, IRF4, NFKBIE, and TCF3 (Figure 1B). Ig rearrangement was analyzed in 4/9 patients with available DNA. All 4 were clonal, with distinct but mutated VH segments (sequence identity between 81 and 89%). This study suggests that HD-MTX in combination with RCHOP chemotherapy is highly effective in preventing CNS relapse in PTL but less so in DLBCL-T. DLBCL-T had a higher risk of CNS relapse and poorer outcomes compared to PTL. Further studies are needed to determine the optimal timing and sequence of HD-MTX in DLBCL-T, as well as alternative treatment approaches. PTL and DLBCL-T have distinct clinical presentations and responses to frontline chemotherapy with HD-MTX prophylaxis. PTL may benefit from HD-MTX in preventing relapse, while alternative treatments should be explored for DLBCL-T. Future studies should consider PTL and DLBCL-T as separate entities to better understand their characteristics and optimize treatment strategies.