Double Hit Status Research Articles

Diffuse Large B-Cell Lymphoma CNS Relapse Prophylaxis with Intrathecal or High-Dose Intravenous Methotrexate

Introduction: Central nervous system (CNS) relapse is a relatively infrequent but often fatal complication of the most common subtype of non-Hodgkin lymphoma, diffuse large B-cell lymphoma (DLBCL). Median overall survival (OS) after DLBCL relapse in the CNS is about 4 months. Despite identifying patients at high risk of developing CNS relapse using the CNS international prognostic index (CNS-IPI) score, it has been difficult to validate any specific strategy. Various chemotherapies and administration methods have been tested. Thus far, only the addition of rituximab to chemotherapy has yielded significant results. Our objective is to determine if administering prophylactic chemotherapy is efficacious in preventing DLBCL relapse in the CNS. Methodology: We collected retrospective data for patients with newly diagnosed DLBCL treated with rituximab and anthracycline-based chemotherapy from 2010 to 2020 in the Northwell Health system to determine the efficacy of CNS prophylaxis. Patients with CNS disease at diagnosis, primary testicular lymphoma, primary mediastinal large B-cell lymphoma, and HIV-associated lymphoma were excluded from this study. CNS prophylaxis was defined as receiving at least two doses of prophylactic chemotherapy, whether intravenous or intrathecal. Follow up for at least one year after diagnosis was required for inclusion. Overall survival (OS) was defined as the time difference between the date of definitive diagnosis to death or last date of contact. Other potential prognostic factors including double hit status and cell of origin, germinal center B-cell (GCB) vs. non-germinal center B-cell (non-GCB), were also evaluated. Pearson's chi-square analysis was used to compare the rate of DLBCL relapse in the CNS based on whether patients received CNS prophylaxis. Low risk was defined as CNS-IPI score 0 to 3 and high risk as CNS-IPI score 4 to 6. Kaplan-Meier analysis with log-rank (Mantel-Cox) testing was used to determine if any significant OS benefit was observed for the low and high-risk groups based on CNS-IPI score. Results: Of the 437 charts reviewed, 127 were eligible for inclusion. Most patients were male (56.7%). Median age was 69 years and median Eastern Cooperative Oncology Group (ECOG) performance status was 1. Most cases were non-GCB (44.9%, as 25% of cases were missing data) and not double hit (85%). Of the 35 patients at high risk for CNS relapse, 27 (77%) received prophylaxis. Intrathecal methotrexate (IT MTX) was given to 26 patients (96%) and high dose intravenous methotrexate (HD MTX) was given to 1 patient. CNS relapse occurred in 6 patients, of which 5 had a low-risk CNS-IPI score. One of the five patients in the low-risk group and the one patient in the high-risk group that had CNS relapse received prophylaxis. No significant difference in overall relapse rates were observed based on whether prophylaxis was given, X 2 (1, N = 127) = 0.30, p = .59. Kaplan-Meier analysis showed no difference in OS after stratification of patients by CNS-IPI score into the high-risk ( p = .50) and low-risk ( p = .24) groups. HD MTX was not administered frequently enough to determine its efficacy. Neither cell of origin (X 2 (1, N = 95) = 2.95, p = .086) nor double hit status (X 2 (1, N = 127) = 1.512, p = .22) had any significant effect on OS. Conclusions: We did not observe any clear benefit for administering IT MTX to prevent DLBCL relapse in the CNS. Most of the CNS relapse events occurred in the low-risk group, even though 8 patients in the high-risk group did not receive any CNS prophylaxis. This study did not have sufficient power to make a definitive conclusion. As CNS relapse is a rare event, a much larger sample size is required to determine the true efficacy of CNS prophylaxis. Non-GCB cell origin and positive double hit status are not included in the CNS-IPI score but their potential association with risk of DLBCL relapse in the CNS is understudied. Future studies should build upon these findings.

R-CHOP Versus CHOP-R: Influence of Rituximab Timing on Real-World Outcomes in Patients with Diffuse Large B Cell Lymphoma

Diffuse large B cell lymphoma (DLBCL) is the most common aggressive lymphoma and is conventionally treated with the chemotherapy regimen R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). The major clinical trials of R-CHOP administered rituximab on the same day as CHOP chemotherapy (R-CHOP). However, in real-world community oncology settings physicians often delay rituximab treatment until after chemotherapy is complete (CHOP-R). This is due to both concerns about drug reimbursement rates in the hospital versus outpatient setting and toxicity considerations. In particular, there is anecdotal evidence and limited retrospective data (Hannawa et al, J Oncol Pharm Pract 2011) that infusion reactions with rituximab may be lessened if rituximab administration is delayed until after CHOP chemotherapy. The current study aims to compare the incidence of infusion reactions, tumor lysis syndrome (TLS), and treatment efficacy in a retrospective cohort of DLBCL patients who received rituximab administration before chemotherapy (R-CHOP) versus those who received it after chemotherapy (CHOP-R). In the current study, we reviewed 178 adult patients with DLBCL who received R-CHOP or CHOP-R between 9/1/2011 and 9/1/2021 at our institution. Treatment groups were defined based on the treatment received during the first cycle of chemotherapy. Patients were identified and data was extracted from electronic health records using Epic's SlicerDicer tool and integrated with data from manual chart review. A two-tailed Fisher's exact test with a significance level of 0.05 was used to analyze 2x2 tables describing the incidence of infusion reactions and tumor lysis syndrome. The study cohort consisted of 178 patients including 139 patients (78%) in R-CHOP group and 39 patients (22%) in CHOP-R group. The median age at diagnosis was 65 years (range 22-92) in the R-CHOP group and 72 years (range 29-86) in the CHOP-R group. The R-CHOP group was approximately evenly split between female (51%) and male (49%), however the CHOP-R group was mostly male (69%). Double hit status was known in 96 patients (3 patients positive and 93 patients negative) in the R-CHOP group and 34 patients (4 patients positive and 30 patients negative) in the CHOP-R group. More patients in CHOP-R group had stage III/IV lymphoma (82%) as compared to the R-CHOP group (61%). HIV associated lymphoma at the time of diagnosis was reported in 3 patients in R-CHOP group vs 1 patient in CHOP-R. Median rituximab -containing cycles received in R-CHOP group were 6 (range 1-6) and CHOP-R group were 5 (range 1-6). We examined the incidence of acute infusion reactions within 24 hours of rituximab administration during the first cycle of chemotherapy. Symptoms/signs of infusion reactions that we examined included fever, chills, rigors, hypotension, hypertension, hypoxia and tachycardia. Patients who did not have adequate data available were excluded from analysis. A total of 29% of patients in the R-CHOP group experienced any infusion reaction as compared to 21% of patients in the CHOP-R group. Data on the incidence of TLS, defined as per the Cairo-Bishop criteria, was collected. Patients who had limited laboratory data available were excluded from analysis. A total of 12% of patients in the R-CHOP group experienced TLS as compared to 17% in the CHOP-R group (p=0.52). Most TLS was present prior to the initiation of treatment. In conclusion, our study found no statistically significant difference in the incidence of acute infusion reactions or tumor lysis syndrome when rituximab administration is delayed. Data on efficacy and survival outcomes will be presented.

Characterizing Diffuse Large B Cell Lymphoma (DLBCL) Disease Biology Features and Survival Outcomes By Patient Racial Groups Using Real World Data

Background Various real world data (RWD) studies have highlighted differences in the survival outcomes of DLBCL patients of different ethnicities and racial groups. However, few studies have examined the differences in DLBCL biology features in patients of different racial groups. Using RWD, we evaluated both biology features and survival outcomes of DLBCL patients from different racial groups. Method Our retrospective analysis used de-identified, real-world patient data from the Flatiron Health electronic health record-derived database. Inclusion criteria were patients with an initial diagnosis of DLBCL (ICD 9: 200x, 202x; ICD 10: C82x, C83x, C84x, C85x, C86x, C88x, C96x) between 1 January 2011 to 31 May 2022 and who had at least two documented clinical visits. Patients’ racial groups were classified into Asian, Black or African American, White, Others and Unknown; the Others group were patients not included in the other racial groups. The DLBCL disease features included cell-of-origin (COO) subtypes, double hit status (MYC and BCL2 translocations), double expressor status (MYC and BCL2 expression by immunohistochemistry) and International Prognostic Index (IPI) scores. Differences among racial groups were examined using the chi-square test with p-value<0.05 considered significant. Differences in overall survival (OS) by patients racial groups were analyzed using Kaplan Meier survival analysis and an adjusted Cox regression model for multivariable analysis. Results In total there were 8289 evaluable patients. The racial group distribution of the cohort was as follows: White (n = 5659, 68.3%), Others (n =1084, 13.1%) Black or African American ( n = 509, 6.1%), Asian (n = 185, 2.2%) and Unknown (n = 852, 10.3%); Fig. 1a. Disease biology features among patients of different racial groups were evaluated. There was a significant difference in the racial distribution between the two COO subtypes (p=0.045). Higher proportion of White patients had the germinal-center B-cell-like (GCB) subtype (n=1888/3127, 60.4%) compared to Asian (n=58/119, 48.7%) and Others (n=351/626, 56.1%) patients. Asian patients had the highest proportion of activated B-cell-like (ABC) subtype (n=61/119, 51.3%) compared to the other racial groups. No significant difference in racial group distribution was seen in double hit status. In terms of double expressor status, there was a significant difference in racial distribution (p = 0.008). More Asian patients had positive double expressor status (n=30/185, 16.2%) compared to the other racial groups. Racial distribution was significantly different between IPI categories (p = 0.028). Higher proportion of White patients presented with higher IPI scores compared to Asian, Black or African American patients. The univariate analysis showed that White patients had worse overall survival (median OS 85.3 months) than Black or African American patients (median OS 111.2 months), Asian patients (median OS 102.6 months) or Others patients (median OS 107.0 months); Fig. 1b. However, multivariable analysis, adjusted for age, gender, IPI and COO, showed no significant difference in OS between White patients and Black or African American (HR 0.89, 95% CI 0.75 - 1.06, p = 0.18) or Asian patients (HR 0.86, 95% CI 0.65 - 1.16, p = 0.31); though was a difference with the Others patients (HR 0.87, 95% CI 0.77-0.98, p =0.024) . Conclusions Using a RWD cohort, we described the disease characteristics and OS between DLBCL patients of different racial groups. Although differences were seen in COO and IPI scores, OS was not significantly different between racial groups in multivariable analysis except between White and Others patients . As the Others patients were a heterogenous group, in-depth study is warranted in the future to delineate true differences. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of Double Expression of MYC and BCL-2 on Outcomes in Primary CNS Lymphoma: A UK Multicentre Analysis

Introduction Primary central nervous system lymphoma (PCNSL) is a rare B cell lymphoma with an aggressive course. Relapses remain common even with intensive immuno-chemotherapy treatment options such as MATRix and consolidation with autologous stem cell transplant (ASCT), and prognostic tools are limited. Although, double expressor status (co-expression of both MYC and BCL-2) is well established in systemic de novo DLBCL, its prognostic impact in PCNSL has been understudied. Here we evaluated the prognostic value of BCL-2, BCL-6, and MYC expression in a retrospective cohort of treated PCNSL patients diagnosed at 7 academic centres in the UK. Methods We performed this retrospective analysis on histologically-confirmed PCNSL patients diagnosed consecutively between 1st May 2015 and 31st May 2020. Treatment with a high-dose methotrexate-based chemotherapy regimen was a mandatory inclusion criterion. BCL-2 and MYC immunohistochemistry (IHC) protein expression data were collated from local diagnostic histology reports and double expressor (DE) status was defined as per WHO criteria (MYC: surface expression > 40% of cells and BCL-2: >50% of cells). Outcomes included response rates, progression-free survival (PFS) and overall survival (OS). Where available, diagnostic fluorescence in situ hybridisation (FISH) data was collected for BCL-2, BCL-6 and MYC loci translocations. Cox-regression for PFS and OS were used to determine baseline predictors of response and survival and to construct multivariable models for factors associated with outcome. Results In total, 242 patients were analysed. Key baseline patient characteristics and IHC data are summarised in Table 1. Median age was 65 years (IQR 56-71), 60% were male and 64% of patients had an ECOG performance status (PS) of 0-1. One hundred and seventy-four (72%) patients received treatment with MATRix chemotherapy; these patients were younger (median age 62 vs. 73 years, p< 0.01), had better baseline PS (PS ≤ 1: 75% vs. 37%, p< 0.01) and higher rates of consolidation with BCNU-thiotepa ASCT (58% vs. 7%, p< 0.01). Double expressor (DE) status was assessable in 169/242 (69%) patients. Reasons for absent DE status were missing IHC expression data (BCL-2: n=28; MYC: n=44) or IHC expression data not reported in line with WHO recommended criteria (BCL-2: n=45; MYC: n=7). In the DE-assessable cohort (n = 169 patients), 40% of patients had DE PCNSL, higher than estimates of DE prevalence in systemic DLBCL (reported rates between 20 and 30%). As only 40 cases (17%) underwent FISH assessment for concurrent MYC and BCL-2 loci translocation (double hit status), correlation between double hit and DE status was not possible. DE status was not associated with patient age at diagnosis, baseline PS or treatment received. With a median follow up of 1.7 years, 34% of patients relapsed and 45% died. Although single MYC or BCL-2 expression alone had no significant association with OS or PFS in the entire cohort, DE status was associated with significantly poorer PFS, and earlier relapse (median 0.86 years vs. 2.77 years; HR 1.61 (1.07 - 2.41); p=0.021) (Fig. 1). In a subgroup analysis restricted to patients treated with MATRix chemotherapy (n = 116 patients), there was a trend towards inferior PFS and OS, although this did not reach significance in a univariable analysis. However, the adverse prognostic impact of DE status on PFS was maintained in a multivariable analysis modelling age, baseline PS, treatment received, ASCT consolidation status and DE status both for the entire cohort (HR 1.75 (1.15 - 2.66); p<0.01) and the MATRix treated subgroup (HR 1.91 (1.08 - 3.36); p=0.03). A trend towards an association between DE status and OS was noted but did not reach significance in either a univariable or multivariable analysis. We observed no significant difference in PFS or OS between DE-PCNSL and non-DE-PCNSL patients who received MATRix and consolidation with ASCT, perhaps indicating that the adverse impact of DE status is modified by this treatment strategy, although the sample size was small (n=66). Conclusions In a large, retrospective cohort of PCNSL patients treated at 7 UK academic treatment centres, double expression of MYC and BCL-2 by IHC was associated with inferior PFS even in patients treated with MATRix chemotherapy. Validation of this finding in independent cohorts is warranted. ___ JO, CPF and KC share senior authorship Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Real-World Outcomes of Consolidative Autotransplant for High-Risk Large B-Cell Lymphoma

Background: Although there have been significant recent advances in the treatment of relapsed/refractory (r/r) large B-cell lymphoma (LBCL), there remains a substantial unmet need to optimize the frontline management of high-risk LBCL. Patients with high International Prognostic Index (IPI) scores 4-5 have particularly poor progression-free survival (PFS) rates of ~50% with R-CHOP, and 2-year PFS may be as low as 10-25% for patients with positive interim PET scans. In the phase III DLCL04 and SWOG-9704 trials, the use of upfront consolidative autologous stem cell transplantation (ASCT) after R-CHOP resulted in significant improvements in PFS, with the latter study also demonstrating a significant improvement in overall survival (OS) in the age-adjusted high IPI subgroup. Furthermore, the GAINED trial demonstrated favorable outcomes using an interim PET-adapted strategy, where consolidative ASCT appeared to overcome the poor prognostic impact of a positive interim PET. However, there is only limited and conflicting data from prospective or retrospective studies concerning ASCT consolidation for the highest risk patients with LBCL and IPI score 4-5, particularly those with positive interim PET scans. Methods: This retrospective, multicenter study included consecutive patients with newly diagnosed LBCL and high IPI score 4-5 who received consolidative ASCT as a planned part of first-line therapy at the Tom Baker Cancer Centre and Cross Cancer Institute in Alberta, Canada. Patients were excluded if they had primary central nervous system (CNS) lymphoma, previously treated indolent B-cell lymphoma, or underwent ASCT for r/r LBCL. PFS, OS, and disease-specific survival (DSS) were determined using the Kaplan-Meier method. Results: We included 114 patients with median age 60 years (range 18-73) and median follow-up time 5.6 years. High-risk features at diagnosis included IPI score 4 in 81 (71%), IPI score 5 in 33 (29%), stage IV in 112 (98%), >1 extranodal site in 109 (96%), non-GCB cell of origin by Hans’ algorithm in 32 (28%), double-hit lymphoma in 26 (23%), and secondary CNS involvement in 15 (13%). The most common induction regimen was R-CHOP (n=102) and 25 (22%) patients received 1-3 cycles, 71 (62%) received 4 cycles, and 18 (16%) received 5-6 cycles of induction. Rituximab with dose-intensive cyclophosphamide, etoposide, and cisplatin (R-DICEP) was frequently used (n=69) to intensify induction and for peripheral blood stem cell mobilization. Interim PET was performed during induction for 45 patients and was positive (Deauville 4-5) in 24 (53%) and negative (Deauville 1-3) in 21 (47%). Pre-ASCT disease status was complete response (CR) in 68 (60%), partial response (PR) in 43 (38%), and unknown in 3 (3%) patients. The most common ASCT conditioning regimens were BEAM in 41 (36%), BuMel in 39 (34%), and TBM in 13 (11%) patients. At 2 years, PFS was 82% (95% CI 74-88%), OS was 86% (95% CI 78-91%), and DSS was 87% (95% CI 79-92%). At 5 years, PFS was 72% (95% CI 62-80%), OS was 74% (95% CI 64-81%), and DSS was 80% (95% CI 71-87%). Relapse occurred in 21 (18%) patients at median 284 days (range 168-2229) after ASCT. There was 1 (1%) death due to early transplant-related infection and 3 (3%) late deaths from pulmonary fibrosis and therapy-related myeloid neoplasms. There were no significant differences in DSS for patients with versus without CNS involvement (77% vs. 80%, p=0.62), double-hit lymphoma versus DLBCL NOS (85% vs. 78%, p=0.80), GCB versus non-GCB cell of origin (78% vs. 80%, p=0.89) and positive versus negative interim PET (83% vs. 74%, p=0.51). Discussion: In this study of 114 selected patients with high-risk LBCL with IPI score 4-5, consolidative ASCT was associated with excellent outcomes with long-term disease-specific survival in 80%. Importantly, the efficacy of consolidative ASCT appeared to be independent of adverse prognostic factors including CNS involvement, double-hit status, non-GCB cell of origin, and interim PET positivity. The results of our study are consistent with those of previous clinical trials and provide real-world evidence confirming that consolidative ASCT can be considered a reasonable treatment option for eligible patients with high-risk LBCL. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of BCL2/MYC Protein Dual Expression and Other Clinical Factors on the Risk of Central Nervous System Progression in Patients with Primary Breast Diffuse Large B-Cell Lymphoma

Background Primary breast diffuse large B-cell lymphoma (DLBCL) has poor outcomes with frequent extranodal failures, particularly in the central nervous system (CNS). Recent studies have reported that cell-of-origin (COO), BCL2/MYC dual expression (DE), and MYC and BCL2 and/or BCL6 rearrangements, so-called double hit (DH) and triple hit, are associated with a high risk of CNS progression in DLBCL; however, the impact of these biologic markers in primary breast DLBCL on CNS progression remains unknown. Methods CNS progression was analyzed in newly diagnosed primary breast DLBCL patients identified from 2 sources: the prospective study of the Consortium for Improving Survival of Lymphoma (CISL) study group conducted from January 2012 to July 2017, and the retrospective cohort included patients who were treated outside clinical trial at any CISL institutions between January 2012 and December 2020. Briefly, the prospective study (Yhim HY et al. Cancers 2020;12:2192) included 33 patients (20-75 years of age) with primary breast DLBCL, and treatment consisted of 6 cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and 4 doses of intrathecal (IT) methotrexate (MTX) at a 3-week interval. The eligibility criteria for the retrospective cohort were virtually the same as the prospective cohort, except for no age limit. 26 patients were screened, 6 of whom were excluded because of incomplete data (n=4) and secondary breast DLBCL (n=2). Thus, the retrospective cohort included 20 patients treated with 6 cycles of R-CHOP ± radiotherapy. CNS prophylaxis was not considered for eligibility in this cohort but was done in 17 patients (4-6 doses of IT MTX [n=14] and systemic high-dose MTX [n=3]). Expert hematopathologists centrally assessed COO and DE status. COO was determined using the Hans algorithm. MYC (≥40%) and BCL2 (≥50%) protein expressions were used to assign DE. Fluorescence in situ hybridization testing was used to determine DH lymphoma. The risk of CNS progression was estimated using the cumulative incidence method. The impact of variables of interest on CNS progression was assessed using a multivariable Cox model. Results We identified 53 patients from 2 data sources. The median age was 55 years (range, 29-78), and all were female. Most patients had unilateral (n=50, 94%), localized-stage (n=48, 91%), and ECOG performance status ≤1 (n=51, 95%). Serum LDH level was elevated in 14 (26%). Hence, IPI and CNS-IPI risks were mainly low (n=45, 85%). No patients had CNS disease at diagnosis. With a median follow-up of 58.8 months (IQR, 30.3-72.9), 7 patients developed CNS progression (parenchymal only, n=4; leptomeningeal only, n=2; parenchymal and leptomeningeal, n=1). The 4-year cumulative incidence of CNS progression was 15.6% (95% CI, 6.7-27.9; Fig A). The Cox analysis revealed bilateral breast involvement (HR, 9.39; 95% CI, 1.69-52.18) was an independent factor for CNS progression in this population. Of the 53 patients, 36 were selected as a histologic data-available population because of a lack of diagnostic materials for COO and DE in 17 patients. Baseline characteristics of the histologic data-available population (n=36) were similar to the overall population (n=53). In the 36 patients with histologic data available, 4 patients had CNS progression (parenchymal only, n=2; leptomeningeal only, n=1; parenchymal and leptomeningeal, n=1), and the 4-year CNS progression rate was 14.2% (95% CI, 0.4-26.3; Fig B). According to the Hans algorithm, 30 (83%) and 6 (17%) were classified as having non-GCB and GCB, respectively. 14 patients (39%) had BCL2/MYC DE, of whom 13 were non-GCB subtype (Fig C). The CNS progression rate of non-GCB did not differ significantly from that of the GCB subtype (4-year, 17.4% vs. 0%; p=0.326), but BCL2/MYC DE had a higher risk of CNS progression than non-DE (4-year, 30.7% vs. 0%, p=0.021; Fig D). 20 patients had sufficient tissue to test DH status, but no DH cases were identified. The multivariable Cox analysis of these 36 patients showed bilateral involvement (HR, 3.73; 95% CI, 1.28-10.86) and BCL2/MYC DE (HR, 2.42×104; 95% CI, 0.51×104-10.60×104) were independent predictors for CNS progression. Conclusion Our data suggested that bilateral breast involvement and BCL2/MYC DE were independent risk factors for CNS events in patients with primary breast DLBCL. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of Comorbidities on Outcomes and Toxicity in Patients Treated with CAR T-Cell Therapy for Diffuse Large B Cell Lymphoma (DLBCL): A Multicenter Rwe Study

Impact of Comorbidities on Outcomes and Toxicity in Patients Treated with CAR T-Cell Therapy for Diffuse Large B Cell Lymphoma (DLBCL): A Multicenter Rwe Study

SPARC-positive macrophages are the superior prognostic factor in the microenvironment of diffuse large B-cell lymphoma and independent of MYC rearrangement and double-/triple-hit status

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease with respect to outcome. Features of the tumor microenvironment (TME) are associated with prognosis when assessed by gene expression profiling. However, it is uncertain whether assessment of the microenvironment can add prognostic information to the most relevant and clinically well-established molecular subgroups when analyzed by immunohistochemistry (IHC). We carried out a histopathologic analysis of biomarkers related to TME in a very large cohort (n= 455) of DLBCL treated in prospective trials and correlated with clinicopathologic and molecular data, including chromosomal rearrangements and gene expression profiles for cell-of-origin and TME. The content of PD1+, FoxP3+ and CD8+, as well as vessel density, was not associated with outcome. However, we found a low content of CD68+ macrophages to be associated with inferior progression-free survival (PFS) and overall survival (OS; P= 0.023 and 0.040, respectively) at both univariable and multivariable analyses, adjusted for the factors of the International Prognostic Index (IPI), MYC break and BCL2/MYC and BCL6/MYC double-hit status. The subgroup of PDL1+ macrophages was not associated with survival. Instead, secreted protein acidic and cysteine rich (SPARC)-positive macrophages were identified as the subtype of macrophages most associated with survival. SPARC-positive macrophages and stromal cells directly correlated with favorable PFS and OS (both, P[log rank] <0.001, P[trend] < 0.001). The association of SPARC with prognosis was independent of the factors of the IPI, MYC double-/triple-hit status, Bcl2/c-myc double expression, cell-of-origin subtype and a recently published gene expression signature [lymphoma-associated macrophage interaction signature (LAMIS)]. SPARC expression in the TME detected by a single IHC staining with fair-to-good interobserver reproducibility is a powerful prognostic parameter. Thus SPARC expression is a strong candidate for risk assessment in DLBCL in daily practice.

A Simulation Analysis to Evaluate the Effect of Prospective Biomarker Testing on Progression-Free Survival (PFS) in DLBCL

Introduction. Novel treatment regimens that combine chemotherapy with targeted agents are being developed for DLBCL. Evaluation of these targeted agents in clinical trials may require prospective biomarker testing, such as immunohistochemistry (IHC), to select patients based on relevant molecular features. However, prospective biomarker testing takes days and there is concern that the delay in treatment may prevent enrollment of patients with the most aggressive disease, biasing the trial population. Here, using data from the Phase 3 GOYA trial (NCT01287741) in first-line DLBCL, we evaluate the impact on PFS of a treatment delay that simulates the additional screening time required for prospective IHC testing.Methods. In GOYA, previously untreated DLBCL patients were randomized 1:1 to obinutuzumab or rituximab plus 6 or 8 cycles of CHOP. Median times from clinical diagnosis to initiation of screening (“DTIS interval”), and from initiation of screening to randomization (“screening time”) were determined in patients with IPI 2-5 (n=1124 patients with timeline information available, no prospective testing). A two-step analysis of PFS was conducted by dividing the evaluable patient population into three groups of varying DTIS intervals (Figure 1, Step 1), and then into additional groups of varying screening times (Figure 1, Step 2). Groups for screening times were 1) <6 days (based on median screening time of 6 days in GOYA; 2) between 6-9 days (based on median screening time of 9 days in Roche clinical trial with prospective IHC testing - NCT02366143); and 3) above 9 days. We asked whether the clinical outcome (PFS), assessed by Kaplan-Meier survival analysis, correlated with either the DTIS interval (Step1) or the screening times (Step 2).Results. Median time from diagnosis to randomization was 24 days (range 2 to 1106 days, 95th percentile of 66 days). Patients with times from diagnosis to randomization below 15 days (n=250) had significantly worse outcome than patients that were randomized in 15 or more days (n=413 for 15-28 days and n=466 for >28 days; p<0.0001; Table 1; Figure 2 A). 3-year PFS was 56% for patients with <15 days, 70% for 15-28 and 73% for >28 days from diagnosis to randomization. In Step 1 of the two-step analysis, DTIS times of <8 days, 8-14 days, and >14 days were observed for 190, 228 and 706 patients, respectively. Patients with a DTIS interval of <8 days were enriched with BCL2-positive and Double Hit status (Table 2). Patients with a DTIS interval of <8 days had shorter PFS than patients with longer DTIS intervals (p=0.0011 Table 1; Figure 2 B); 3-year PFS was 55% for patients with <8 days, 66% for patients with 8-14 days and 72% for patients with >14 days from diagnosis to screening; no additional difference in 3-year PFS was observed in subgroups beyond 14 days. In Step 2, we asked if a longer screening interval (screening to randomization in Figure 1), simulating additional time for prospective testing, affected patient outcome. Of the 190 patients with the shortest DTIS interval (<8 days from diagnosis to screening) and the shortest PFS from Step 1, 70 patients had screening times of <6 days, 75 between 6-9 days and 45 above 9 days (max 26 days). All cohorts showed indistinguishable PFS curves (p=0.7652; Table 1; Figure 2C). Similarly, no differences in PFS were observed for groups of increasing screening times in the DTIS cohorts of 8-14 days and >14 days (not shown).Conclusion. In GOYA, short PFS was associated with <15 days from diagnosis to randomization and <8 days from diagnosis to screening, possibly attributable to high-risk biology, such as high expression of BCL2 and DH. Despite seemingly expedited work-up, these high-risk patients do poorly, highlighting the need for targeted therapies and innovative trial designs. In this example, additional screening time similar to the time required for prospective testing did not adversely affect PFS. Our results may have implications for designing precision medicine trials in DLBCL. [Display omitted] DisclosuresSzafer-Glusman:Genentech: Employment. Liu:F. Hoffmann-La Roche: Employment. Peale:Genentech / Roche: Employment, Equity Ownership. Farazi:Genentech: Employment. Ray:Genentech/Roche: Employment. Horn:F. Hoffmann-La Roche Ltd: Employment. Oestergaard:F. Hoffmann-La Roche Ltd: Employment. Kornacker:F. Hoffmann-La Roche: Employment; Roche: Equity Ownership. Sehn:Janssen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Roche/Genentech: Consultancy, Honoraria. Fingerle-Rowson:F. Hoffmann-La Roche Ltd: Employment, Equity Ownership. Venstrom:Genentech, Inc.: Employment. Byrtek:Genentech: Employment, Equity Ownership. Punnoose:Genentech: Employment.

Dose Adjusted R-EPOCH Does Not Improve Outcomes in High Grade B Cell Lymphoma with Double Expressor Status or Gain of MYC/BCL2

Introduction: Diffuse large B cell lymphoma is a heterogenous disease with prognosis known to vary based on histological changes including immunohistochemistry and gene rearrangements by florescence in situ hybridisation (FISH). Both immunohistochemical overexpression as well as gene rearrangements in MYC, BCL2 and BCL6 are thought to contribute to poor prognosis. The benefit of high dose chemotherapy is unclear for those with high grade B cell lymphoma with double hit status (DHL) by FISH , double expressor status (DEL) or gain of MYC/BCL2. The purpose of this study was to retrospectively analyse the effect of escalated chemotherapy in this population over a 5 year period. Methods: All patients with DLBCL treated between 2012-2017 were screened retrospectively for inclusion in the study based on immunohistochemistry and FISH at time of initial diagnosis. Immunohistochemistry was assessed on formalin fixed, paraffin embedded specimens with BCL2 and MYC considered positive at over 40% and 50% respectively. FISH was assessed using dual colour break apart probe. Results: 135 patients were diagnosed with DLBCL of which 53 patients had immunohistochemistry and FISH at diagnosis confirming either, DEL or gain of MYC/BCL2 status. The mean age was 65 years and median follow up 21 months. The overall response rate in DH treated with DA-R-EPOCH was 57%. There were insufficient cases treated with R-CHOP for comparison. Overall response rates in DEL were 94% for DA-R-EPOCH and 93% for R-CHOP. Overall survival (OS) and disease free survival (DFS) in DHL was 6 months and 2 months respectively when treated with DA-R-EPOCH. There was no significant difference in OS or DFS in DEL treated with DA-R-EPOCH compared with R-CHOP (OS: 42 months vs 38 months respectively (p=0.962), DFS 36 months vs 30 months (p=0.931)). Gain of MYC/BCL2 did not affect OS (p= 0.539) or DFS (p=0.439) when comparing treatment regimen. Conclusion: DA-R-EPOCH did not improve treatment response rates OS or DFS in patients with double expresser lymphoma or gain of MYC/BCL2. This study also confirms the previously reported poor outcomes associated with DHL Disclosures No relevant conflicts of interest to declare.

Prevalence and the Impact of Hypogammaglobulinemia in Newly Diagnosed, Untreated Diffuse Large B Cell Lymphoma

Background: While there is evidence in the literature of increased prevalence of hypogammaglobulinemia in chronic lymphocytic leukemia (CLL), there are no studies evaluating the prevalence of hypogammaglobulinemia in newly diagnosed diffuse large B cell lymphoma (DLBCL) or the relationship between hypogammaglobulinemia and presentation or outcomes. The objective of this study was to examine the prevalence of hypogammaglobulinemia in newly diagnosed DLBCL patients and to test the hypothesis that DLBCL patients with baseline hypogammaglobulinemia have a distinct clinical profile and outcome. Methods: We obtained banked frozen sera from 200 newly diagnosed, treatment-naïve, DLBCL patients from the Lymphoma SPORE Molecular Epidemiology Resource (MER), a prospective cohort study conducted at the Mayo Clinic and the University of Iowa. IgG/A/M levels were measured using immunoturbidimetric assay whereas IgE level was measured using electrochemiluminescence immunoassay; deficiency was defined using standard reference ranges. IgE levels were considered deficient if &amp;lt;2 UI/ml. The associations between Ig deficiencies and clinical factors were evaluated with Wilcoxon rank sum and chi-squared (Fisher's exact, where appropriate) tests. Event-free survival (EFS) was defined as time from diagnosis to progression, relapse, retreatment, or death, and EFS24 was defined as EFS at 24 months after diagnosis (achieve or failure to achieve EFS24). The association of Ig levels with EFS24 was estimated using odds ratios (OR) and 95% confidence intervals (CI) from logistic regression, and with EFS, overall survival (OS), and lymphoma-specific survival (LSS) was estimated using Kaplan-Meier curves and hazard ratios (HR) and 95% CI from Cox regression. Results: The mean age (SD) of the cohort was 65.6 (13.4) years, 54% were males and 98% of the patients were white. Over a median follow-up of five years, there were 59 (29.5%) deaths. The prevalence of hypogammaglobulinemia, defined as any deficiency, in newly diagnosed, treatment-naïve DLBCL was 22.1% (44/199) in our cohort, and the most common Ig deficiency was for IgG (&amp;lt;700 mg/dL, 13.5%), followed by IgM (&amp;lt;40 mg/dL, 9.0%), IgE (&amp;lt;2 UI/ml, 7.5%) and IgA (&amp;lt;70 mg/dL, 4.0%) (Table1). There were no statistically significant differences between Ig deficient and non-deficient patients in terms of age at diagnosis, gender, stage, cell of origin, or MYC double hit status. However, median LDH levels were higher in Ig deficient patients (228 vs 194, p&amp;lt;0.01). Any immunoglobulin deficiency was associated with inferior EFS (HR 1.94, 95% CI 1.16-3.24) (Figure 1) and OS (HR 2.02, 95% CI 1.17-3.49), and these associations were not attenuated after adjustment for the international prognostic index (IPI). Any Ig deficiency was also associated with failure to achieve EFS24 (OR=2.13, 95% CI 1.00-4.60) after adjusting for IPI. Conclusions: To the best of our knowledge, this is the first study to report the prevalence of hypogammaglobulinemia in treatment naïve DLBCL. We found that any Ig deficiency was not uncommon in our cohort and it was associated with an inferior EFS and OS in DLBCL patients. The prevalence of hypogammaglobulinemia in DLBCL patients seems to be lower than has been described in CLL patients. While the underlying relationship between these two immunologic disorders deserves further study, our findings highlight the interaction between global immune dysfunction and emergence of a clonal B cell process. Disclosures Nowakowski: Genentech, Inc.: Research Funding; F. Hoffmann-La Roche Ltd: Research Funding; Curis: Research Funding; Bayer: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Selvita: Membership on an entity's Board of Directors or advisory committees; NanoString: Research Funding; MorphoSys: Consultancy, Research Funding. Farooq:Celgene: Honoraria; Kite Pharma: Research Funding. Cerhan:NanoString: Research Funding; Celgene: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees.

COO and MYC/BCL2 status do not predict outcome among patients with stage I/II DLBCL: a retrospective multicenter study

AbstractIn advanced-stage diffuse large B-cell lymphoma (DLBCL), the presence of an activated B-cell phenotype or a non–germinal center (GCB) phenotype, coexpression of MYC and BCL2 by immunohistochemistry, and the cooccurrence of MYC and BCL2 or BCL6 rearrangements are associated with inferior outcomes. It is unclear whether these variables remain prognostic in stage I/II patients. In this retrospective study, we evaluated the prognostic impact of cell of origin (COO), as well as dual-expressor (DE) status and molecular double-hit (DH) status, in stage I/II DLBCL by positron emission tomography with computed tomography (PET-CT). A total of 211 patients treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)–like regimens, with or without radiotherapy, was included. The median follow-up in the entire cohort was 4 years (range, 0.4-9.4), with estimated 4-year progression-free survival (PFS) and overall survival (OS) rates of 85% (95% confidence interval [CI], 79-89) and 88% (95% CI, 83-92), respectively. By univariable analysis, DE (PFS: hazard ratio [HR], 1.27; 95% CI, 0.58-2.81, P = .55 and OS: HR, 1.40; 95% CI, 0.60-3.30; P = .44), DH (PFS: HR, 1.21; 95% CI, 0.27-5.31; P = .80 and OS: HR, 0.61; 95% CI, 0.08-4.73; P = .64), and non-GCB status (PFS: HR, 1.59; 95% CI, 0.83-3.03; P = .16 and OS: HR, 1.80; 95% CI, 0.89-3.67; P = .10) were associated with poorer outcomes. In patients with PET-CT–defined stage I/II DLBCL treated with R-CHOP–like therapy, with or without radiation, COO and DE and DH status were not significantly associated with inferior PFS or OS.

Survival outcomes of diffuse large B-cell lymphoma by association with concurrent or antecedent follicular lymphoma and double hit status

Diffuse large B-cell lymphoma (DLBCL) transformed from follicular lymphoma (FL) (tDLBCL) has been traditionally associated with an aggressive course, but more recent studies have shown longer survivals. The clinical significance of concurrent FL at the time of diagnosis of DLBCL (cDLBCL/FL) is less clear. We compared outcomes of tDLBCL, cDLBCL/FL, and de novo DLBCL (dDLBCL) and then evaluated the impact of double hit (DH) rearrangements (MYC with BCL2 and/or BCL6) in these subgroups’ outcomes. The progression free survival (PFS) and overall survival (OS) were not significantly different among the three groups (dDLBCL, tDLBCL, and cDLBCL/FL). The effect of DH on survival was then analyzed in two subgroups: (1) dDLBCL and (2) tDLBCL + cDLBCL/FL. PFS and OS were significantly shorter in lymphomas with DH in each of these two subgroups. We conclude that DH status drives outcomes in all DLBCLs, regardless of their transformation status.

Outcomes of Patients with Limited-Stage Aggressive Large B-Cell Lymphoma with MYC Rearrangement with and without BCL2 and/or BCL6 Rearrangements: A Retrospective Analysis from 15 US Academic Centers

Outcomes of Patients with Limited-Stage Aggressive Large B-Cell Lymphoma with MYC Rearrangement with and without BCL2 and/or BCL6 Rearrangements: A Retrospective Analysis from 15 US Academic Centers

Young High Risk Patients with MYC/BCL2 Double Hit Lymphoma, BCL2+ and/or Germinal Centre B-Cell like Diffuse Large B-Cell Lymphoma Benefit from Dose-Dense Chemoimmunotherapy Including Early CNS Prophylaxis: Analysis of Data from the Nordic Lymphoma Group CRY-04 and Chic Trials

Background. Survival of patients with high-risk diffuse large B-cell lymphoma (DLBCL) is suboptimal, and the risk of central nervous system (CNS) progression is relatively high. We investigated the efficacy of dose-dense chemoimmunotherapy and systemic CNS prophylaxis in two Nordic trials including patients less than 65 years with high-risk DLBCL. We combined individual patient data from these trials to compare clinical outcome and biological prognostic factors in patients treated with CNS prophylaxis given in the beginning (CHIC) versus at the end (CRY-04) of therapy.Patients and methods. In CRY-04 study, patients were treated with six courses of R-CHOEP14 followed by HD-Mtx and HD-Ara-C. In CHIC trial, treatment started with two courses of HD-Mtx in combination with R-CHOP14, followed by four courses of R-CHOEP-14 and one course of R-HD-AraC. In addition, liposomal AraC was administered intrathecally at courses 1, 3 and 5. For the correlative studies, formalin fixed paraffin embedded pretreatment tumor samples were analyzed by fluorescent in situ hybridization for BCL2 and c-MYC breakpoints and by immunochemistry for CD10, BCL6, MUM1, MYC and BCL2 expression. Germinal center B-cell-like (GCB)/non-GCB) subclassification was performed according to Hans algorithm.Results. Among 303 patients enrolled in the trials (CRY-04, n=160 and CHIC, n=143), 295 (CRY-04, n=154 and CHIC, n=139) were evaluable for baseline characteristics and outcome. Median age (54 and 56 years, p=0.222), male/female ratio, stage, and aaIPI scores were comparable in the two cohorts. CHIC regimen improved outcome over CRY-04; the findings included 4-year estimates of PFS (81% vs 66%, p=0.003), OS (83% and 79%, p=ns) and cumulative incidence rates of CNS progression (2.4% and 5.0%, p=ns). Treatment with the CHIC regimen reduced the risk of systemic progression (aaIPI adjusted RR=0.489, 95%CI 0.308-0.777, p=0.002). PFS benefit with CHIC over CRY-04 was observed across pre-specified subgroups, and particularly in patients less than 60 years old (p=0.008).In the entire study population, dual protein expression (DPE) of BCL2 and MYC was the only parameter to be significantly correlated with a worse PFS (4-y PFS 77% vs 50%, p=0.024; RR=2.300, 95% CI 1.088-4.860, p=0.029). Neither any single immunohistochemical marker nor the GCB/non-GCB subtype or MYC/BCL2-translocations significantly affected outcome. However, when treatment interaction was tested, MYC/BCL2 double hit status (DHL; 13%) predicted poor outcome among patients treated with CRY-04 regimen compared with patients who received CHIC regimen (4-y PFS; 38% vs 78%, p=0.086). GCB subtype and BCL2 positivity were also associated with better outcome in the CHIC cohort (4 y PFS; 63% vs 84%, p=0.011 and 61% vs 80%, p=0.007, respectively), whereas there were no significant survival differences between these regimens among the patients with non-GCB subtype, BCL2 negative DLBCL or DPE lymphomas.Conclusions. Our results derived from trial data with homogenous treatment support the use of HD-Mtx in the beginning rather than at the end of therapy. The survival benefit related to CHIC regimen over CRY-04 is due to better systemic control of the disease, and at least partly linked to improved survival among patients with GCB subtype, BCL2 positivity and DHL. DisclosuresLeppa:Takeda: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Bayer: Research Funding; Roche: Consultancy, Honoraria, Research Funding; Celgene: Consultancy. Holte:Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees; Roche, Norway: Research Funding.

Double-hit or dual expression of MYC and BCL2 in primary cutaneous large B-cell lymphomas

In nodal diffuse large B-cell lymphoma, the search for double-hit with MYC and BCL2 and/or BCL6 rearrangements or for dual expression of BCL2 and MYC defines subgroups of patients with altered prognosis that has not been evaluated in primary cutaneous large B-cell lymphoma. Our objectives were to assess the double-hit and dual expressor status in a cohort of 44 patients with primary cutaneous large B-cell lymphoma according to the histological subtype and to evaluate their prognosis relevance. The 44 cases defined by the presence of more than 80% of large B-cells in the dermis corresponded to 21 primary cutaneous follicle centre lymphoma with large cell morphology and 23 primary cutaneous diffuse large B-cell lymphoma, leg type. Thirty-one cases (70%) expressed BCL2 and 29 (66%) expressed MYC. Dual expressor profile was observed in 25 cases (57%) of either subtypes (n = 6 or n = 19, respectively). Only one primary cutaneous follicle centre lymphoma, large-cell case had a double-hit status (2%). Specific survival was significantly worse in primary cutaneous diffuse large B-cell lymphoma, leg type than in primary cutaneous follicle centre lymphoma, large cell (p = 0.021) and for the dual expressor primary cutaneous large B-cell lymphoma group (p = 0.030). Both overall survival and specific survival were worse for patients belonging to the dual expressor primary cutaneous diffuse large B-cell lymphoma, leg type subgroup (p = 0.001 and p = 0.046, respectively). Expression of either MYC and/or BCL2 negatively impacted overall survival (p = 0.017 and p = 0.018 respectively). As the differential diagnosis between primary cutaneous follicle centre lymphoma, large cell and primary cutaneous diffuse large B-cell lymphoma, leg type has a major impact on prognosis, dual-expression of BCL2 and MYC may represent a new diagnostic criterion for primary cutaneous diffuse large B-cell lymphoma, leg type subtype and further identifies patients with impaired survival. Finally, the double-hit assessment does not appear clinically relevant in primary cutaneous large B-cell lymphoma.

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

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

Patterns of Failure Analysis of Patients With Double Hit or Double Expressor Lymphomas: Implications for Radiation Therapy

Lymphomas with MYC and either BLC2 or BCL6 rearrangements or protein overexpression, classified as double-hit (DHL) or double expressor (DEL) lymphomas, are associated with poorer response to immunochemotherapy. However, little information exists on the contribution of failure at initially involved disease sites or the benefit of radiotherapy in DHL/DEL. This study aimed to describe the patterns of failure of DHL and DEL. A retrospective single institution study of 793 patients diagnosed with non-Hodgkin lymphoma between 2011 and 2015 was performed. Double hit status was determined by fluorescence in-situ hybridization, and double expression status was determined by immunohistochemistry (MYC expression ≥40%), both of which were routinely performed starting in 2014. Triple hit and expressor patients were included, whereas patients acquiring double-hit or double expressor status after relapse or upon transformation were excluded. Progression-free survival (PFS) and overall survival (OS) were calculated from the end of chemotherapy using the Kaplan-Meier method. Forty-nine (6.2%) patients were DHL or DEL: 34 with DHL, 8 with DEL, and 7 with a triple hit. Median follow-up was 17 months for surviving patients. Most (73%) were advanced stage at diagnosis. Thirty-four (69%) patients had extra-nodal involvement, 17 (35%) had bulky (≥7.5 cm) disease, and 15 (31%) had skeletal site involvement. Chemotherapy was DA-R-EPOCH (33%), R-CHOP (31%), or other (36%). Ten patients received consolidative radiation therapy (RT). PFS and OS at 1 year was 51.8% and 72.5%. Twenty-four patients recurred (49%), 14/24 (58%) at initial sites of disease, of which 7/14 (50%) were isolated failures. Thirteen patients had primary refractory disease, which included initially involved site progression in 8 (62%). Of the remaining 11 patients relapsing after initial response to therapy, 6 (55%) failed at initially involved sites. Of these 6, 4 (67%) were isolated initial site relapses. No patient receiving consolidative RT failed in-field. In contrast, bulky site relapse occurred in 2/9 patients and skeletal site relapse occurred in 3/15 patients. These features were not associated with PFS or initially involved site relapse risk. While consolidative radiotherapy was associated with improved PFS in the overall cohort (HR = 0.14; CI = 0.06-0.382), it did not remain so when adjusting for stage and primary refractory status in multivariable analysis. DHL and DEL were associated with high rates of primary refractory and relapsed disease and marked by high rates of progression at initially involved sites. However, no patient failed at the site of radiotherapy. While the small size of our study limited a multivariable analysis, this provides a rationale for the continued role of RT in the treatment of DHL and DEL and requires validation in larger cohort.

Molecular Subtyping in Diffuse Large B Cell Lymphoma: Closer to an Approach of Precision Therapy.

It has become clear that there is immense biological heterogeneity in diffuse large B cell lymphoma (DLBCL). Developing technology has allowed better characterization of patient subsets at a molecular level, allowing for a link of phenotype and clinical outcomes to oncogenic mechanisms and biologic signatures. Cell of origin and double hit status are able to identify aggressive subsets, with molecular profiling allowing for a clearer understanding of biologic pathways that contribute to cellular resistance to conventional treatment in these subsets. Although the standard treatment for DLBCL remains R-CHOP or R-CHOP-like therapy at present, rational drug targets have been established with novel classes of drugs under investigation. In germinal center (GC) DLBCL, mechanisms of therapeutic interest include anti-apoptosis mediated by BCL-2, PI3K/AKT/mTOR, and EZH2, whereas drug interventions are directed at BCR, NF-κB, and/or JAK-STAT pathways in activated B cell (ABC) DLBCL. There is also evidence for cooperation of various oncogenic pathways in these subsets. As such, we are arguably on the verge of shifting to a more tailored approach using single and combinatorial strategies-this, however, relies on prioritizing the exploration of biomarkers for patient selection for validating novel treatment strategies.

Mutations in TP53 Gene Is Independent Prognostic Factor for High Grade B-Cell Lymphoma

Background.TP53 mutations were described to have a negative impact on prognosis of patients with B-chronic lymphoid leukemia and diffuse large cell lymphoma. However, a role of TP53 mutations in high-grade B-cell lymphomas (HGL) is not well defined in context of other genetic aberrations.Materials and methods. 23 patients (7 males and 16 females) had diagnosis of HGL were treated in National Research Center for hematology, Moscow, Russia. Median age was 49 years old (30-76). 5 patients had HGL with c-MYC (MYC-R) and BCL2 genes rearrangements and 2 - HGB with MYC-R and BCL6 rearrangements. 17 (74%) patients had MYC-R, 11/23 (48%) had double expresser lymphoma (MYC≥40%, BCL2≥50%) (DE). Median of observation time was 29,1 months (6,3-99,8). 19 (82%) of patients had IPI score 3-5 points. 16 patients underwent LM-B-04 with rituximab (Table 1), 5 - R-(DA)-EPOCH, 2 - R-CHOP-21. In 5 cases autologous stem cell transplantation was performed. Sanger sequencing was performed to identify mutations in exons 5-8 of TP53 gene using DNA extracted from formalin fixed paraffin embedded tissue («Extra-DNA» kit, «Genetechnology» LLC). Primers to TP53 gene were synthesized based on nucleotide sequences data available online on website ncbi.com by «Evrogene». To evaluate an influence of such factors as TP53 mutation (TP53mut), MYC-R, DHL, DE, gender, therapy on overall survival (OS) and time to progression (TTP) were performed multivariate dispersion analysis and Cox regression analysis (STATISTICA 10).Results: 8 (35%) cases with TP53mut were identified: c.535C>T 45,6% p.H179Y, c.524G>C 15,6% p.R175P, c.743G>A 75,6% p.R247Q, c.487T>A 25,2% p.Y163N, c.824G>A 75% p.C275Y, c.713G>A 87,7% p.C238Y, c.745A>G 31,9% p.R249G, c.639A>G 41,8% p.R213R. 7/8 of them harbored MYC-R, 2/8 had DHL. In univariate (Picture 1, 2) and multivariate analysis pts harboring TP53mut had worse OS (median OS was 6,2 (0,7-9,5) vs 25,5 (0,7-99,8) months, p=0,004) and shorter TTP (median TTP 3,5 (0,7-9,5) vs 23,1 (0,7-99,8) months, p=0,027) than patients without TP53mut. DHL status had also an adverse effect on OS with lower significance than in pts with TP53mut (p=0,022). Adverse effect of TP53mut trends to play a role in combination with c-MYC gene rearrangement, thus5 pts TP53mut/MYC-R had shorter TTP than 5 DHL pts (3,4 (1,1-9,5) vs 7,3 (0,6-67,1) months, p=0,07).Conclusion: High-grade lymphoma has a more powerful and independent prognostic factor than double-hit status - TP53 mutation that contribute inferior prognosis. This factor shouldn't be underestimated in routine diagnostics because of its frequency and requirement of a different therapeutic approach. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.