Diffuse Large B-cell Lymphoma Group Research Articles

Epstein-Barr virus infection and gene promoter hypermethylation in rheumatoid arthritis patients with methotrexate-associated B cell lymphoproliferative disorders.

We analyzed CpG-island hypermethylation status in 12 genes of paraffin-embedded tissues from 38 rheumatoid arthritis (RA) patients with methotrexate (MTX)-associated large B cell lymphoproliferative disorder (BLPD), 11 RA patients with non-MTX-associated BLPD (non-MTX-BLPD), 22 controls with diffuse large B cell lymphoma (DLBCL), and 10 controls with Epstein-Barr virus (EBV)+ DLBCL. Among them, tumor cells from EBV+ MTX-BLPD patients and control EBV+ DLBCL patients had significantly lower median incidence of CpG island methylator phenotype (CIMP) than those from non-MTX-BLPD and control DLBCL groups (2.3 and 1.7 vs. 4.3 and 4.4; P<0.01 for each). In the MTX-BLPD group, EBV+ patients showed lower median CIMP than EBV- patients (2.3 vs. 3.2); they also had significantly lower hypermethylation incidence in four apoptosis-related genes, especially death-associated protein kinase (14 vs. 55%), higher incidence of massive tumor necrosis (86 vs. 27%), and lower BCL2 protein expression (19 vs. 86%) than did the control DLBCL group (P<0.01 for all). In all clinical stages, EBV+ MTX-BLPD patients had better prognoses than the EBV- MTX-BLPD (P=0.011), non-MTX-BLPD (P=0.002), and control DLBCL groups (P=0.015). MTX-BLPD patients without hypermethylated RAS-associated domain family-1A (RASSF1A) or O 6 -methyl guanine-DNA methyltransferase (MGMT) had significantly better prognosis than those with hypermethylation of those genes (P=0.033). We conclude that in RA patients with MTX-BLPD, EBV infection is associated with a lower incidence of CIMP, apoptosis-related gene hypermethylation, and BCL2 expression, which can induce tumor regression by MTX withdrawal and lead to better prognoses.

Expression of OCT4 and SALL4 in Diffuse Large B-cell Lymphoma: An Analysis of 145 Consecutive Cases and Testicular Lymphomas.

OCT4 and SALL4 are transcription factors within a complex network that functions to maintain pluripotency in primitive stem cells and germ cells. Nuclear expression of OCT4 is widely cited as sensitive and specific for primary and metastatic germ cell tumors and is commonly used in the diagnosis of central nervous system (CNS) germinomas. Studies have failed to systematically examine the expression of OCT4 or SALL4 in diffuse large B-cell lymphoma (DLBCL), although this entity enters the morphologic differential diagnosis of some germ cell tumors. A retrospective review was conducted on 145 consecutive cases of DLBCL and testicular lymphoma to evaluate the prevalence of OCT4 and SALL4 expression. Nuclear OCT4 expression was present in 2/11 (18%) testicular DLBCLs and 6/134 (4.5%) nontesticular DLBCLs. Most OCT4 cases demonstrated moderate to strong expression in >50% of neoplastic cells. Rare, weak nuclear SALL4 expression was detected in only 3 nontesticular DLBCLs. Within the extratesticular DLBCL group, 2/6 (33%) primary CNS DLBCLs expressed nuclear OCT4. In addition, OCT4 DLBCL showed an overall predilection toward non-germinal center B-cell phenotype (7/8; 88%) and had a higher than expected rate of CD5 coexpression (4/8, 50%). These results are cautionary against using OCT4 as a sole marker of germ cell differentiation in testicular and extratesticular sites, especially in the CNS. The apparent associations of OCT4 expression with primary CNS DLBCL, non-germinal center B-cell phenotype, and CD5 coexpression raise the question of whether OCT4 expression in DLBCL may reflect more aggressive biology.

Expression of c-myc, Bmi-1, serum insulin-like growth factor-I and insulin-like growth factor binding protein-3 and their significances in diffuse large B-cell lymphoma

Objective To detect the expressions of c-myc, Bmi-1 , serum insulin-like growth factor-Ⅰ (IGF-Ⅰ) and insulin-like growth factor binding protein-3 (IGFBP-3) in diffuse large B-cell lymphoma (DLBCL), and to analyze their relations with clinical stages, efficacy and prognosis. Methods 102 cases of incipient patients with DLBCL and 60 patients or health examination volunteers were chosen as DLBCL group and control group, respectively. Immunohistochemical method was used to detect expressions of c-myc and Bmi-1 in DLBCL wax samples. Chemiluminescence immunoassay method was used to determine the levels of serum IGF-I and serum IGFBP-3. The expression differences of these factors between DLBCL group and control group and their relations with pathological types, clinical stage, IPI and chemotherapy were analyzed. Results The positive rates of c-myc and Bmi-1 were 71.6 % (73/102) and 61.8 % (64/102) in the tissues of DLBCL, respectively. The positive rates of c-myc and Bmi-1 in non-GCB group were higher than those in GCB group [c-myc: 80.0 % (48/60) vs 59.5 % (25/42); Bmi-1: 71.7 % (43/60) vs 50.0 % (21/42)]. With the increase of IPI score, the expressions of c-myc and Bmi-1 were enhanced, but there were no statistical differences between Ⅲ-Ⅳ group andⅠ-Ⅱ group (P> 0.01). The differences of 3-year progression free survival (PFS) rate and 3-year overall survival (OS) rate between c-myc gene or Bmi-1 gene normal and abnormal had statistical significance, and 3-year PFS rate and 3-year OS rate of double-hit of c-myc gene and Bmi-1 were lower. C-myc gene and Bmi-1 gene aberrant were the independent prognosis factors. The levels of serum IGF-Ⅰ and serum IGFBP-3 in DLBCL group were significantly lower than those in the control group (P 0.01). Their levels in stage Ⅳ group or high risk group were significantly lower than those in other groups. Serum IGF-Ⅰ level and serum IGFBP-3 level had no significant differences between the c-myc gene or Bmi-1 gene abnormal group and normal group (P> 0.01), but their levels were lower in both c-myc gene and Bmi-1 gene abnormal group than those in normal group. Conclusions C-myc and Bmi-1 are related with the biological characteristics and prognosis of DLBCL. Serum IGF-Ⅰ level and serum IGFBP-3 level reflect clinical stages of DLBCL and the efficacy in a certain degree. The expressions of c-myc and Bmi-1 have some correlation with the levels of serum IGF-Ⅰ and IGFBP-3 in DLBCL. Key words: Lymphoma, large B-cell, diffuse; C-myc; Bmi-1; Serum insulin-like growth factor-Ⅰ; Serum insulin-like growth factor binding protein-3

Rituximab impacts Th17 cells and related cytokines in patients with diffuse large B-cell lymphoma in vitro

Objective To explore the impact of rituximab on Th17 cells and related cytokines in patients with diffuse large B-cell lymphoma (DLBCL) in vitro and its significance. Methods 20 cases of DLBCL untreated patients and 20 healthy subjects were enrolled in the name of DLBCL group and health control group, respectively. 4 peripheral blood samples were collected from every case to separate peripheral blood mononuclear cells (PBMCs), which were assigned to 4 subgroups according to different culture conditions: blank subgroup(subgroup A), rituximab subgroup (subgroup B), rituximab and serum subgroup (subgroup C) and polarization subgroup (subgroup D) (added IL-6 and TGF-β). After cultured in vitro, the percentage of Th17 cells in each subgroup was tested by flow cytometry, and the cytokine IL-17 in the above-mentioned culture fluid was measured by enzyme-linked immunosorbent assay (ELISA). Results In health control group, the percentage of Th17 cells and the level of IL-17 in subgroup D [(17.12 ± 4.90) % and (45.735±10.012) pg/ml] were significantly higher than those in subgroup A, B, C (P 0.05). The percentage of Th17 cells and the level of IL-17 in the DLBCL subgroup A were significantly lower than those in health control subgroup A [(0.69±0.24) % and (6.012±1.312) pg/ml vs (2.43± 0.61) % and (8.217±1.681) pg/ml (P< 0.05)]. In DLBCL group, after cultured with rituximab, the percentages of Th17 cells in subgroup B, C, D were (2.34±0.48) %, (2.31±0.53) % and(16.92±4.81) %, and the levels of IL-17 were (7.944 ± 1.538) pg/ml, (7.957 ± 1.533) pg/ml and (44.417 ± 9.881) pg/ml, respectively, which were all significantly higher than those in subgroup A. Besides, the percentage of Th17 cells and the level of IL-17 in DLBCL subgroup D were significantly higher than those in subgroup B, C (P < 0.05), while there was no difference between subgroup B and subgroup C. Conclusion Experiments in vitro confirmed that the percentage of Th17 cells in PBMCs of DLBCL patients was lower than that in healthy persons, and rituximab could elevate the percentage of Th17 cells in PBMCs of DLBCL patients. Key words: Lymphoma, large B-cell, diffuse; Rituximab; Th17 cells; Interleukin-17; In vitro experiment

Prognostic Significance of EBV Association in Diffuse Large B-Cell Lymphoma in the Rituximab Era

Introduction: Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous group of diseases in terms of morphology, immunohistochemistry and molecular features. The prognostic factors of DLBCL in the rituximab era are different from previously reported prognostic factors. Hans, et al. reported that patients with non-germinal center B-cell like (GCB)-type DLBCL had a significantly poorer prognosis than those with GCB-type DLBCL in the pre-rituximab era. In patients who received rituximab combination chemotherapy, there is a report that did not find a difference in survival ratio between those with GCB DLBCL or non-GCB DLBCL. On the other hand, there was a report that found a difference in survival ratio between patients with GCB DLBCL and those with non-GCB DLBCL. In addition, the previously reported that patients with Epstein-Barr virus (EBV)-positive DLBCL had a significantly poorer prognosis than those with EBV-negative DLBCL in the pre-rituximab era. In the present study, we considered the prognostic factors of DLBCL patients who received rituximab combined chemotherapy.Patients and Methods: The subjects were 209 DLBCL patients in whom immunohistochemical markers (CD20, CD5, CD10, BCL-2, BCL-6, MUM-1) could be analyzed. In addition, 86 patients were examined EBV-encoded RNA (EBER) in situ hybridization. Pathologic evaluation of the materials from each patient was performedat several central review meetings by six hematopathologists in the ALTSG pathology review board. Patients were treated with cyclophosphamide, vincristine, bleomycin, etoposide, doxorubicin, and prednisolone (CyclOBEAP) regimen or CHOP regimen. Rituximab was administered to all patients. One hundred forty-six DLBCL patients who underwent CHOP-like therapy were assumed as historical controls. The median follow-up period was 69 months (range, 46-88months).Results: In the R-chemotherapy and CHOP-like groups, patients with stage III or IV disease comprised 57% and 67%, respectively, patients with performance status≧2 comprised 32% and 23%, respectively, and patients with serum LDH >normal comprised 61% and 69%, respectively. There were no significant differences in clinical characteristics between the R-chemotherapy group and CHOP-like group. BCL2 was positive in 72 (55%) of the 131 patients who received the R-chemotherapy and in 71 (50%) of the 142 patients who received the CHOP-like regimen. When the 209 patients who received the R- chemotherapy group were divided into the GCB group and the non-GCB group, the GCB group consisted of 74 patients (35%) and the non-GCB group consisted of 135 patients. The relationships between immunohistological markers and outcome among the patients with DLBCL who received CHOP-like therapy were studied. CD5, CD10, and BCL6 had no prognostic impact on 5-year overall survival (OS) and progression-free survival (PFS) rates. When the patients were divided into the GCB DLBCL and non-GCB DLBCL groups, the 5-year PFS of the GCB group was 78% and that of the non-GCB group was 48% (p=0.0008). Next, the effect of rituximab with chemotherapy was examined. CD5, CD10, BCL2, BCL6, and MUM-1 had no prognostic impact on 5-year OS and PFS rates. When the patients were divided into the GCB DLBCL (n=74) and non-GCB DLBCL (n=135) groups, the 4-year PFS of the GCB group was 79% and that of the non-GCB group was 73%, showing no significant difference.We also evaluated the significance of EBER expression among patients by incorporating the EBV-positive DLBCL (n=14) and EBV-negative DLBCL (n=72).There were no significant differences in immunophenotyping analysis between the EBV-positive DLBCL and EBV-negative DLBCL. As for EBER expression in DLBCL, the 4-year PFS of the EBER-positive group was 37% and that of the EBER-negative group was 75% (P=0.007), indicating that the EBER-positive group showed significantly poorer prognosis. The 4-year OS of the EBER-positive group was 50% and the EBER-negative group was 86% (P=0.0005).Conclusions: The EBER may be an important prognostic factor in patients with DLBCL who underwent R-chemotherapy therapy. DisclosuresNo relevant conflicts of interest to declare.

Outcome of Gastric Diffuse Large B-Cell Lymphoma and Usefulness of PET-CT in Detecting Gastric Lesion

Background:The standard therapy for primary gastric diffuse large B-cell lymphoma (DLBCL) is chemotherapy of R-CHOP with/without involved-field radiation therapy. Although some reports indicated that gastrointestinal complications after chemotherapy for DLBCL occur at a rate of 0-26%, little is known about riskfactors for the complications. In addition, to detect DLBCL in gastric lesion, both of positron emission tomography-computed tomography (PET-CT) and esophagogastroduodenoscopy (EGD) are useful tools. However, there have been few reports comparing them. The aim of this study is to show the outcomes including treatment-related complications in patients with gastric DLBCL and risk factors for the gastric complications. Moreover, we evaluated whether PET-CT is sufficient to detect DLBCL in gastric lesion by comparing with EGD.Patients and methods:This retrospective study included consecutive patients with newly diagnosed DLBCL between October 2003 and July 2014 who underwent EGD and were treated with R-CHOP in our hospital. We classified the patients into three groups. Group A-1: patients who had documented DLBCL in gastric lesion by EGD and underwent PET-CT; group A-2: patients who had documented DLBCL in gastric lesion by EGD and did not underwent PET-CT; group B: patients who had no documented DLBCL in gastric lesion by EGD and underwent PET-CT. Suspected lymphomatous lesions by EGD were biopsied and immunopathologically examined. Gastric DLBCL was defined only when pathologically confirmed. In PET-CT, gastric lesions with SUV max ≥ 5 were considered positive. Outcomes and risk factors for complications among group A were analyzed using the logistic regression model. We evaluated significance of PET-CT and EGD in group A-1 and B by the positive predictive value (PPV) and the negative predictive value (NPV).Results:Among 448 patients diagnosed with DLBCL, 178 patients were enrolled for our study: 55 in group A-1, 28 in group A-2 and 95 in group B. Among 83 patients with gastric DLBCL (group A), the median age was 69 years (range, 29-85). The numbers of patients with clinical stage (Ann Arbor classification) I, II, III, and IV were 27, 18, 5, and 33, respectively. The rate of complete remission was 87%, and the median 3- and 5-year over survival (OS) were 81% and 75%, respectively. The median 3-year OS of patients with very good, good, and poor grade of Revised International Prognostic Index (R-IPI) was 100%, 77%, and 63%, respectively (Figure, P =0.025). Ten patients had gastric complications: 6 with bleeding that needed blood transfusion and 3 with gastrointestinal stenosis defined as ordinary endoscopy could not pass, no patients had gastrointestinal perforation. Most of bleeding (66.7%) occurred during the first cycle of R-CHOP (median, 15 days; range, 1-206). A multivariate analysis showed that low serum albumin (ALB) at diagnosis was an independent risk factor for gastric complications (odds ratio 10.75, p <0.001). The numbers of patients with positive or negative results examined by PET-CT or EGD in group A-1 and B were shown in Table. PPV and NPV of PET-CT were 0.90 and 0.97, respectively.Conclusions:The present study showed that R-IPI was also predictive of survival in gastric DLBCL and low ALB at diagnosis as a significant risk factor for gastric complications following R-CHOP. In addition, our data suggested that PET-CT may be sufficient in the role of detecting gastric lesion of DLBCL because of high PPV and NPV. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

T-Cell Defect in Diffuse Large B-Cell Lymphomas Involves Expansion of Myeloid Derived Suppressor Cells Expressing IL-10, PD-L1, and S100A12

Introduction: In diffuse large B-cell lymphoma (DLBCL), the number of circulating monocytes and neutrophils represents an independent prognostic factor. These cells include monocytic and granulocytic myeloid derived suppressor cells (M- and G-MDSCs) defined by their ability to suppress T-cell responses. MDSCs are a heterogeneous population described in inflammatory or infectious diseases as well as in numerous tumors including multiple myeloma, chronic lymphocytic leukemia and DLBCL. However, their mechanisms of action in DLBCL remain unclear. The aim of the study was to investigate the presence and mechanisms of suppression of MDSC subsets in DLBCL.Methods: Whole blood from 56 DLBCL at diagnosis and 45 healthy donors (HD) were analyzed by flow cytometry. Quantitative Real Time PCR were analyzed on Taqman@ array microfluidic cards. Cytokine levels in plasma and culture supernatants were measured by Luminex and Elisa. T-cell proliferation after monocyte depletion or treatment with inhibitors, was analyzed by CFSE assay.Results: By flow cytometry, we identified an expansion of G-MDSC (Linneg HLA-DRneg CD33pos CD11bpos) and M-MDSC (CD14pos HLA-DRlow) in DLBCL compared to HD (p<0.001). Interestingly, only M-MDSC number was correlated with the International Prognostic Index (IPI), the event-free survival (EFS), and the number of circulating Treg. Furthermore, T-cell proliferation was restored after monocyte depletion. To identify the mechanism of suppression involved, we evaluated the gene expression of key enzymes (ARG1, IDO1, NOS2, HO-1 and PTGS2) or immunomodulatory molecules (IL10, TGF β1, CD274/PD-L1, S100A8, S100A9, S100A12) involved in MDSC biology. ARG1, IDO1, IL10, CD274/PD-L1 and S100A12 were significantly up-regulated in DLBCL (p<0.05). At the protein level arginase 1, IL-10 and S100A12 were increased in DLBCL plasma, whereas PD-L1 expression on monocyte was increased in DLBCL compared to HD (p=0.03). Arginase 1 and IDO activities where increased in DLBCL patients. In DLBCL, IL-10 and S100A12 were detected in culture supernatants from stimulated PBMC and these molecules were decreased after CD14pos depletion (p<0.05). Finally, we defined 2 groups of DLBCL depending on M-MDSC content and analyzed the percentage of proliferating T cells after CD3/CD28 stimulation in the presence of various inhibitors or blocking antibodies (L-1MT, nor-NOHA, anti-IL-10, anti-PD-1 and anti-S100A12). In the group of patients with circulating MDSC, neutralizing IL-10, PDL-1 and S100A12 resulted in an increase of CD4 and/or CD8 T-cell proliferation.Conclusion: In summary, we identified MDSC subsets expanded in DLBCL as well as new mechanisms of immunosuppression in DLBCL. Myeloid-dependent T-cell suppression is attributed to a release of IL-10 and S100A12 and an increase of PD-L1 expression. DisclosuresCartron:Roche: Consultancy, Honoraria; GSK: Honoraria; Celgene: Honoraria; Sanofi: Honoraria; Gilead: Honoraria.

Comprehensive Analyses of Genetic Features Identify Coordinate Signatures in Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is a genetically heterogeneous disease characterized by multiple low-frequency alterations including somatic mutations, copy number alterations (CNAs) and chromosomal rearrangements. We sought to identify previously unrecognized low-frequency genetic events, integrate recurrent alterations into comprehensive signatures and associate these signatures with clinical parameters. For these reasons, our multi-institutional international group assembled a cohort of 304 primary DLBCLs from newly diagnosed patients, 87% of whom were uniformly treated with state-of-the-art therapy (rituximab-containing CHOP regimen) and had long term followup.Tumors were subjected to whole exome sequencing with an extended bait set that included custom probes designed to capture recurrent chromosomal rearrangements. In this cohort, 47% of samples had available transcriptional profiling and assignment to associated disease subtypes. Analytical pipelines developed at the Broad Institute were used to detect mutations (MuTect), CNAs (Recapseq+Allelic Capseq) and chromosomal rearrangements (dRanger+Breakpointer) and assess clonality (Absolute). To analyze formalin-fixed paraffin-embedded tumors without paired normals we developed a method which utilized 8334 unrelated normal samples to stringently filter recurrent germline events and artifacts. Significant mutational drivers were identified using the MutSig2CV algorithm and recurrent CNAs were assessed with GISTIC2.0. In addition, we utilized a recently developed algorithm, CLUMPS2, to prioritize somatic mutations which cluster in 3-dimensional protein structure. With this approach, we identified > 90 recurrently mutated genes, 34 focal amplifications and 41 focal deletions, 20 arm-level events and > 200 chromosomal rearrangements in the DLBCL series. Of note, 33% of the mutational drivers were also perturbed by chromosomal rearrangements or CNAs, underscoring the importance of a comprehensive genetic analysis.In the large DLBCL series, we identified several previously unrecognized but potentially targetable alterations including mutations in NOTCH2 (8%) and TET2 (5%). The majority of identified chromosomal rearrangements involved translocations of potent regulatory regions to intact gene coding sequences. The most frequently rearrangements involved Ig regulatory elements which were translocated to BCL2, MYC, BCL6 and several additional genes with known roles in germinal center B-cell biology.After identifying recurrent somatic mutations, CNAs and chromosomal rearrangements, we performed hierarchical clustering and identified subsets of DLBCLs with comprehensive signatures comprised of specific alterations. A large subset of tumors shared recurrent alterations previously associated with follicular lymphoma including mutations of chromatin modifiers such as CREBBP, MLL2, and EZH2 in association with alterations of TNFRSF14 and GNA13 and translocations of BCL2. This cluster was enriched in GCB-type DLBCLs and contained a subset with select genetic alterations associated with an unfavorable outcome.An additional cohort of tumors was characterized by alterations perturbing B-cell differentiation including recurrent BCL6 translocations or alterations of PRDM1. A subset of these DLBCLs had alterations of NOTCH2 and additional pathway components or mutations of MYD88 in association with TNFAIP3, CD70 and EBF1, a master regulator of B-cell differentiation.An additional group of DLBCLs exhibited frequent MYD88 mutations in association with alterations of CD79B, PIM1, TBL1XR1 and ETV6 and BCL2 copy gain; these tumors were highly enriched for ABC-type DLBCLs. This coordinate signature and additional alterations of p53 pathway components were associated with outcome.We explored bases for the identified genetic alterations in DLBCL by performing an in silico mutational signature analysis. The most frequent mutational signatures were those of spontaneous deamination (aging) and AID with rare cases of microsatellite instability. We also assessed the clonality of identified genetic features to define cancer cell fraction and establish the timing of specific genetic events.The comprehensive genetic signatures of clinically annotated DLBCLs provide new insights regarding approaches to targeted therapy. DisclosuresLink:Kite Pharma: Research Funding; Genentech: Consultancy, Research Funding. Rodig:Perkin Elmer: Membership on an entity's Board of Directors or advisory committees; BMS: Research Funding. Pfreundschuh:Boehringer Ingelheim, Celegene, Roche, Spectrum: Other: Advisory board; Roche: Honoraria; Amgen, Roche, Spectrum: Research Funding. Shipp:Gilead: Consultancy; Sanofi: Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Clinical features, tumor biology, and prognosis associated with MYC rearrangement and Myc overexpression in diffuse large B-cell lymphoma patients treated with rituximab-CHOP

MYC dysregulation, including MYC gene rearrangement and Myc protein overexpression, is of increasing clinical importance in diffuse large B-cell lymphoma (DLBCL). However, the roles of MYC and the relative importance of rearrangement vs overexpression remain to be refined. Gaining knowledge about the tumor biology associated with MYC dysregulation is important to understand the roles of MYC and MYC-associated biology in lymphomagenesis. In this study, we determined MYC rearrangement status (n=344) and Myc expression (n=535) in a well-characterized DLBCL cohort, individually assessed the clinical and pathobiological features of patients with MYC rearrangement and Myc protein overexpression, and analyzed the prognosis and gene expression profiling signatures associated with these MYC abnormalities in germinal center B-cell-like and activated B-cell-like DLBCL. Our results showed that the prognostic importance of MYC rearrangement vs Myc overexpression is significantly different in germinal center B-cell-like vs activated B-cell-like DLBCL. In germinal center B-cell-like DLBCL, MYC-rearranged germinal center B-cell-like DLBCL patients with Myc overexpression significantly contributed to the clinical, biological, and prognostic characteristics of the overall Myc-overexpressing germinal center B-cell-like DLBCL group. In contrast, in activated B-cell-like DLBCL, the occurrence, clinical and biological features, and prognosis of Myc overexpression were independent of MYC rearrangement. High Myc levels and Myc-independent mechanisms, either tumor cell intrinsic or related to tumor microenvironment, conferred significantly worse survival to MYC-rearranged germinal center B-cell-like DLBCL patients, even among MychighBcl-2high DLBCL patients. This study provides new insight into the tumor biology and prognostic effects associated with MYC dysregulation and suggest that detection of both MYC translocations and evaluation of Myc and Bcl-2 expression is necessary to predict the prognosis of DLBCL patients.

High-resolution copy number analysis of paired normal-tumor samples from diffuse large B cell lymphoma.

Copy number analysis can be useful for assessing prognosis in diffuse large B cell lymphoma (DLBCL). We analyzed copy number data from tumor samples of 60 patients diagnosed with DLBCL de novo and their matched normal samples. We detected 63 recurrent copy number alterations (CNAs), including 33 gains, 30 losses, and nine recurrent acquired copy number neutral loss of heterozygosity (CNN-LOH). Interestingly, 20% of cases acquired CNN-LOH of 6p21 locus, which involves the HLA region. In normal cells, there were no CNAs but we observed CNN-LOH involving some key lymphoma regions such as 6p21 and 9p24.1 (5%) and 17p13.1 (2.5%) in DLBCL patients. Furthermore, a model with some specific CNA was able to predict the subtype of DLBCL, 1p36.32 and 10q23.31 losses being restricted to germinal center B cell-like (GCB) DLBCL. In contrast, 8p23.3 losses and 11q24.3 gains were strongly associated with the non-GCB subtype. A poor prognosis was associated with biallelic inactivation of TP53 or 18p11.32 losses, while prognosis was better in cases carrying 11q24.3 gains. In summary, CNA abnormalities identify specific DLBCL groups, and we describe CNN-LOH in germline cells from DLBCL patients that are associated with genes that probably play a key role in DLBCL development.

IX. Is it only about MYC? How to approach the diagnosis of diffuse large B-cell lymphomas.

Keywords: diffuse large B-cell lymphoma; cell of origin; genetic alterations; double hit; double expresser; MYC; BCL2; BCLU

The single nucleotide polymorphism and haplotype analysis of MDR1 in Chinese diffuse large B cell lymphoma patients.

We investigated whether the MDR1 (multidrug resistance 1) gene single nucleotide polymorphism (SNP) and haplotype variants were associated with the susceptibility to diffuse large B-cell lymphoma (DLBCL). A total of 129 DLBCL patients and 208 healthy controls from Jiangsu Han population were enrolled in this study. They were genotyped by polymerase chain reaction-allele specific primers (PCR-ASP) method or DNA direct sequencing at three common loci: C1236T, G2677T/A and C3435T. At locus G2677T/A, allele G and genotype GT were significantly more common in DLBCL (G: OR=1.48, 95% CI: 1.08-2.02, Pc=0.03; GT: OR=1.96, 95% CI: 1.25-3.07, Pc<0.01), while genotype AT in this locus seemed to be protective (OR=0.29, 95% CI: 0.02-0.72, Pc=0.03). TT genotype at locus C3435T showed a risk factor in DLBCL (OR=2.38, 95% CI: 1.52-3.74, Pc<0.01). The frequency of T-G-T haplotype was significantly increased in DLBCL group (OR=5.21, 95% CI: 2.58-10.54, Pc<0.01); haplotype of G-T in 2677-3435 and diplotype of 2677GT/3435TT were significantly more frequent in DLBCL group (G-T: OR=3.97, 95% CI: 2.31-6.85, Pc<0.01; 2677GT/3435TT: OR=4.55, 95% CI: 2.02-10.22, Pc<0.01). Our findings demonstrate that G, GT at locus G2677T/A, and TT at locus C3435T might contribute to the susceptibility to DLBCL, as well as haplotype of T-G-T, G-T in 2677-3435 and diplotype of 2677GT/3435TT, while AT at locus G2677T/A might be a protective genotype. These findings could provide evidence that the MDR1 SNPs may modify the susceptibility to DLBCL and shade new lights in disease association studies.

The Effects of Radiation Therapy (RT) and Surgical Resection on Overall Survival in Gastric Lymphoma

Introduction:Lymphoma of the stomach is an uncommon tumor. However, it is the most common extra-nodal manifestation of Non-Hodgkin lymphoma. Over the last few decades, preferred treatment for gastric lymphoma has shifted from surgical resection to non-surgical methods involving chemotherapy and RT. The current standard treatment is chemo-immunotherapy. The role of RT and surgery, if any, is unclear.Methods:We reviewed data which was obtained from the Surveillance, Epidemiology and End Results (SEER) data registry for patients with gastric lymphoma from 1973 until 2011. The data was analyzed using Microsoft Excel and statistical analysis was performed using SPSS statistical software. The SEER registry does not provide information about chemotherapy (CT) administered.Results:We analyzed 13,659 patients with the diagnosis of gastric lymphoma in the SEER database. The three most prevalent subtypes were diffuse large B-cell lymphoma (DLBCL) with 6,134 (44.9%) cases, extranodal marginal zone lymphoma (MZL) with 4,318 (31.6%) cases and chronic lymphocytic leukemia (CLL/SLL) with 352 (2.5%) cases.In the DLBCL group, the median (range) age was 71 (4 – 105) years, of which 44.7% were female and 55.3% male. Of the group, 4,992 (81%) patients were White, 447 (7%) Black, and the remainder were Asian, Pacific Islander, or Native American. The median overall survival (OS) in patients who did and did not receive RT was 63 vs. 34 months (p<0.01). Analysis by stage shows median OS with and without RT was 108 vs. 65 months in Stage I disease (p<0.01), 71 vs. 62 months (p=0.41) in Stage II disease, 59 vs. 25 months in Stage III disease (p=0.52), and 8 vs. 8 months in Stage IV disease (p=0.46).The median OS in patients who underwent surgical resection, at least partial gastrectomy, is 76 months compared to 28 months in patients who did not undergo resection (p<0.01) (Fig.1). Analyzed by stage, the median OS in patients who did and who did not undergo surgery was 114 vs. 59 months in Stage I disease (p<0.01), 70 vs. 54 months in Stage II disease (p=0.03), 50 vs. 22 months in Stage III disease (p=0.63), and 10 vs. 8 months in Stage IV disease (p=0.85).Since widespread use of rituximab started in 2001, we analyzed patients treated before and after that year. Among patients with DLBCL, 2,719 (44%) were diagnosed prior to 2001 and 3,415 (56%) were diagnosed in 2001 or afterwards. Median OS with and without RT was 43 months vs. 31 months prior to 2001 and 97 months vs. 39 months after 2001 (p<0.01). The median OS with and without surgery is 81 vs. 12 months prior to 2001 (Fig. 2) and 57 vs. 51 months after 2001 (Fig. 3) (p<0.01).In the MZL group, the median (range) age was 68 (10 – 101) years of which 50.5% were female and 49.5% male. Of the group, 3,457 (80%) patients were White, 392 (9%) Black, and the remainder were Asian, Pacific Islander, or Native American. The median OS of patients with MZL who had surgery and who did not was 146 vs. 145 months (p=0.372). Analysis by stage shows no significance difference in OS either. The median OS of patients who did not undergo RT was 132 months and was not yet reached in patients who underwent RT (p<0.01). Analysis by stage shows RT significantly benefitted patients with Stage I and II disease but not stage III and IV disease.Conclusion:Our analysis shows that patients with DLBCL who undergo RT have improved median OS. The benefit is limited to Stage I disease. Improved median OS is seen in patients with DLBCL who undergo surgical resection which is contrary to recent data. The benefit of surgical resection is seen only in Stage I and II but not in Stage III and IV. The benefit of surgery was present prior to 2001 but not seen after 2001 - after the widespread use of rituximab. In MZL, surgical resection has no impact on median OS; whereas RT improves OS, particularly in Stage I and II disease. While our analysis is limited due to the lack of data regarding chemotherapy administered, this large population based analysis supports the benefit of RT and surgery in select disease stages. Prospective clinical trials may better address the benefits of each modality independently. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Relation between Caspase recruitment domain-containing membrane-associated guanylate kinase protein 1, clinicopathological features of gastrointestinal lymphoma also and Helicobacter pylori infection

Objective To investigate the relation between the expression of Caspase recruitment domain-containing membrane-associated guanylate kinase protein 1 (CARMA1),clinicopathological features of gastrointestinal mucosa-associated lymphoid tissue (MALT) lymphoma,diffuse large B cell lymphoma (DLBCL),and Helicobacter pylori (H.pylori) infection.Methods From January 1999 to March 2011,34 patients with DLBCL and 20 patients with MALT lymphoma were selected,and at same period 21 cases with reactive hyperplasia of gastrointestinal lymphoid tissue were enrolled in as control.The expression of CARMA1,Ki-67 and cytotoxin-associated gene A (CagA) at protein level were examined by immunohistochemistry.The relative expression quantity of CARMA1 mRNA was detected by real-time polymerase chain reaction (PCR).The condition of H.pylori infection in 25 gastric lymphoma and 10 controls was detected by methylene boric acid and blue staining or semi-nested PCR.Chi-square test was used for counting data analysis,t test for measurement data.Multivariate COX regression analysis was implemented for survival analysis.Survival curve was drawn by Kaplan-Meier method and analyzed by Log-rank test.Results The relative expression quantity of CARMA1 mRNA of 28 patients with DLBLC (3.073±1.846) was higher than that of 14 patients with MALT lymphoma,and the difference was statistically significant (F 0.975,P＜ 0.05).The positive rate of CARMA1 expression at protein level of gastrointestinal lymphoma group (75.9 ％,41/54) was higher than that of control group (47.6％,10/21),and the difference was statistically significant (x2 =5.568,P＜0.05),and the positive rate of CARMA1 expression of MALT lymphoma group (11/20) was lower than that of DLBCL group (88.2％,30/34),and the difference was statistically significant (x2 =5.900,P＜0.05).Among 42 patients with gastrointestinal lymphoma who received surgery,the relative expression quantity of CARMA1 mRNA in cases with high proliferation (2.885±1.837) was higher than that in cases with low proliferation.The expression of CARMA1 mRNA in the cases at advanced stage of the disease (4.416± 1.010) was higher than that in cases at early stage,and the difference was statistically significant (F=3.317 and 2.972,both P＜0.05).Among 54 patients with gastrointestinal lymphoma,the positive rate of CARMA1 expression at protein level of patients with high proliferation (88.6％,31/35) was higher that that of patients with low proliferation (10/19),and the difference was statistically significant (x22 ＝ 6.847,P＜0.05).There were no significant differences in relative expression quantity of CARMA1 mRNA and the positive rate of CARMA1 expression at protein level between 11 gastric lymphoma patients without H.pylori infection and 14 gastric lymphoma patients with H.pylori infection (both P＞0.05).The positive rate of CARMA1 expression at protein level of CagA positive and CagA negative H.pylori infected gastric lymphoma patients was 11/11 and 2/3.The expression of CARMA1 at protein level was correlated with the prognosis of gastrointestinal lymphoma (RR＝4.160,P＜0.05).In the 29 cases of patients with gastrointestinal MALT lymphoma and 18 cases of patients with DLBCL who were followed up,the survival situation of gastrointestinal lymphoma patients with CARMA1 positive expression rate over 50％ was worse than that of patients with the rate less than 50％,and the difference was statistically significant (x2=5.383 and 4.028,both P＜0.05).Conclusions CARMA1 might be involved in the pathogenesis and progression of MALT and DLBCL; and it might be a related factor of poor prognosis.There was no correlation between the expression of CARMA1 and H.pylori infection in these two lymphomas. Key words: Lymphoma; CARMA1; Helicobacter pylori

Correlations between Functional Imaging Markers Derived from PET/CT and Diffusion-Weighted MRI in Diffuse Large B-Cell Lymphoma and Follicular Lymphoma

ObjectivesTo investigate the correlations between functional imaging markers derived from positron emission tomography/computed tomography (PET/CT) and diffusion-weighted magnetic resonance imaging (DWI) in diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL). Further to compare the usefulness of these tumor markers in differentiating diagnosis of the two common types of Non-Hodgkin's lymphoma (NHL).Materials and MethodsThirty-four consecutive pre-therapy adult patients with proven NHL (23 DLBCL and 11 FL) underwent PET/CT and MRI examinations and laboratory tests. The maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and metabolic tumor burden (MTB) were determined from the PET/CT images. DWI was performed in addition to conventional MRI sequences using two b values (0 and 800 s/mm2). The minimum and mean apparent diffusion coefficient (ADCmin and ADCmean) were measured on the parametric ADC maps.ResultsThe SUVmax correlated inversely with the ADCmin (r = −0.35, p<0.05). The ADCmin, ADCmean, serum thymidine kinase (TK), Beta 2-microglobulin (B2m), lactate dehydrogenase (LD), and C-reactive protein (CRP) correlated with both whole-body MTV and whole-body MTB (p<0.05 or 0.01). The SUVmax, TK, LD, and CRP were significantly higher in the DLBCL group than in the FL group. Receiver operating characteristic curve analysis showed that they were reasonable predictors in differentiating DLBCL from FL.ConclusionsThe functional imaging markers determined from PET/CT and DWI are associated, and the SUVmax is superior to the ADCmin in differentiating DLBCL from FL. All the measured serum markers are associated with functional imaging markers. Serum LD, TK, and CRP are useful in differentiating DLBCL from FL.

Diffuse large B-cell lymphoma and mantle cell lymphoma of the ocular adnexal region, and lymphoma of the lacrimal gland: an investigation of clinical and histopathological features

Diffuse large B-cell lymphoma (DLBCL) and mantle cell lymphoma (MCL) constitute two distinct subtypes of non-Hodgkin lymphoma (NHL) displaying marked diversities with regard to molecular biology and clinical features. Because these differences could be related to the location of the lymphoma, it is of interest to investigate the clinical and histopathological features of DLBCL and MCL involving the ocular adnexal region (i.e. the orbit, eyelids, conjunctiva, lacrimal gland and lacrimal sac). Similarly, the lacrimal gland is the only glandular structure within the orbit. Because the lacrimal gland represents an important part of the immunological system, it is of interest to investigate lymphomas involving this location with regard to clinical and histological characteristics. The purpose of this thesis was to characterize the clinical and histopathological features of Danish patients with DLBCL of the ocular adnexal region between 1980 and 2009 and of Danish patients with ocular adnexal MCL from 1980 to 2005 (Rasmussen 2013). Furthermore, the aim was to review all specimens from patients with lacrimal gland lymphoma in Denmark between 1975 and 2009 to determine the distribution of lymphoma subtypes of the lacrimal gland and to describe the clinicopathological features of these patients. A total of 34 patients with DLBCL and 21 with MCL of the ocular adnexal region were identified (Rasmussen et al. 2009, 2013). Twenty-seven patients had lacrimal gland lymphoma (Rasmussen et al. 2011). Elderly patients predominated in all three groups, with median ages of 78, 75 and 69 years in the DLBCL, the MCL and the lacrimal gland lymphoma groups, respectively. Patients with MCL had a preponderance of men (Rasmussen et al. 2009), whereas women prevailed among patients with lacrimal gland lymphoma (Rasmussen et al. 2011). The orbit was the most common site of involvement in DLBCL and MCL. The majority of lacrimal gland lymphomas were low grade, and the distribution of subtypes was as follows: extranodal marginal zone lymphoma, 10 (37%); follicular lymphoma, 5 (19%); DLBCL, 4 (15%); MCL, 3 (11%); chronic lymphocytic leukaemia/small lymphatic lymphoma, 2 (7%); and unclassified B-cell lymphoma, 3 (11%) (Rasmussen et al. 2011). The 5-year overall survival rate for the DLBCL and MCL groups was 20% and 22%, respectively (Rasmussen et al. 2009; Rasmussen 2013). However, 83% of the patients with MCL who received rituximab-containing chemotherapy were alive after 5 years from the time of diagnosis. The 5-year overall survival rate of patients with lacrimal gland lymphoma was 70% (Rasmussen et al. 2011). In conclusion, DLBCL and MCL involving the ocular adnexal region, and lymphoma of the lacrimal gland are prevalent among elderly patients. The overall prognosis in DLBCL and MCL was poor, whereas the prognosis for patients with lacrimal gland lymphoma was relatively good. Chemotherapy containing rituximab significantly improved survival in patients with MCL. Note from the Editor: This PhD thesis is published as an electronic supplement, see: Rasmussen PK (2013): Diffuse large B-cell lymphoma and mantle cell lymphoma of the ocular adnexal region, and lymphoma of the lacrimal gland: an investigation of clinical and histopathological features. Acta Ophthalmol. 91 (thesis 5): 1–27

STAT3 Expression and Clinical Implications In De Novo Diffuse Large B-Cell Lymphoma: A Report From The International DLBCL Rituximab-CHOP Consortium Program

IntroductionExpression of signal transducer and activator of transcription 3 (STAT3) in de novo diffuse large B-cell lymphoma (DLBCL) has not been studied broadly and the prognostic value of STAT3 expression in DLBCL is controversial. MethodsThe study group included 876 de novo DLBCL patients. All patients were treated with rituximab, cyclophosphamide, hydroxydoxorubicin, vincristine and prednisone (R-CHOP). Cases excluded from the study group included large cell transformation from low-grade B-cell lymphoma, primary cutaneous large B-cell lymphoma, primary mediastinal large B-cell lymphoma, primary DLBCL of the central nervous system and cases associated with Epstein-Barr virus or human immunodeficiency virus. Immunohistochemical (IHC) studies for several biomarkers were performed using fixed, paraffin embedded sections of tissue microarrays. Fluorescence in situ hybridization (FISH) for BCL2, BCL6, MYC, and TP53 were performed andTP53 was also sequenced Gene expression profiling (GEP) was performed on 500 cases and the cell of origin (COO) classification was determined by GEP (gold standard) and immunohistochemistry. ResultsSTAT3 was positive in 240 (32.9%) patients, including 133 men and 107 women. The median age of STAT3+ DLBCL patients was 65 years (range, 21-93) and was similar to STAT3- DLBCL patients (63, range 12-95). B symptoms (44.4% vs. 35.2%, P=0.021) and advanced stage (60.5% vs. 52.1%, P=0.035) were more commonly present in STAT3+ DLBCL compared with STAT3- DLBCL patients. Other clinical characteristics were similar between the groups. STAT3+ DBLCLs were more often activated B-cell (ABC) type than STAT3- DLBCLs (61.8% vs. 41.1%, P<0.001). STAT3+ DLBCLs more often expressed MYC (76.7% vs. 56.5%, P<0.001), p50 (43.3% vs. 34.1%, P=0.018), and p65 (33.9% vs. 25.3%, P=0.017) than STAT3- DLBCLs. c-Rel, however, was less commonly expressed in STAT3+ DLBCL (18.9% vs. 27.2%, P=0.018). Expression of BCL2 was similar between the two groups. Genetic aberrations involving BCL2 (10.9%), MYC (7.6%) and TP53 deletion (8.1%) by FISH were uncommon. Aberrations of BCL6 were present in 24.6% of STAT3+ DLBCL. TP53 mutation was found in 27 patients (20.1%). The frequency of genetic aberrations by FISH was similar in the STAT3+ and STAT3- DLBCL groups. Patients with STAT3+ versus STAT3- DLBCL had similar OS (P=0.494) and PFS (P=0.224). When looking at all DLBCL cases divided into GCB versus ABC type, STAT3 expression did not predict survival in the GCB (OS, P=0.945 and PFS, P=0.604) or ABC types (OS, P=0.211 and PFS, P=0.079, respectively). In multivariate analysis, STAT3 expression did not show an increased hazard ratio (HR 0.806, 95% CI 0.578-1.125, P=0.205). ConclusionSTAT3 is expressed in approximately 1/3 of de novo DLBCLs. STAT3 expression is associated with B symptoms, advanced stage of disease, ABC type, and expression of MYC. Expression of p50 and p65 are more frequently expressed in STAT3+ DLBCL, illustrating activated NF-κB through canonical pathway. C-Rel is less commonly expressed in STAT3+ DLBCL, suggesting p65 is the principal partner for p50. Genetic aberrations are rare. Although STAT3 expression is associated with several adverse prognostic parameters, it does not confer inferior OS and PFS in DLBCL overall, suggestive of the presence of yet unidentified putative tumor suppressive functions in STAT3+ DLBCL patients. Disclosures:Winter:Millenium: Research Funding; Novartis : Research Funding; Pfizer (Wyeth): Research Funding; Seattle Genetics: Research Funding; Spectrum: Research Funding; Janssen (Pharmacyclics): Research Funding; Spectrum (Allos): Consultancy; Sanofi Aventis: Consultancy; Tgen: Consultancy; AMBIT Biosciences (Spouse): Research Funding; Celgene (Spouse): DSMB, DSMB Other, Research Funding; Ariad Pharmaceuticals (Spouse): Research Funding; Novartis (Spouse): Consultancy, Research Funding; Amgen (Spouse): Consultancy, Research Funding; Astellas (Spouse): Research Funding; Caremark/CVS: Consultancy; Pfizer (Spouse): Consultancy; Sanofi Aventis (Spouse): DSMB, DSMB Other; Bristol Myers Squibb (Spouse): DSMB, DSMB Other; UptoDate, Inc.(Spouse): Patents & Royalties.

Radiation Therapy Significantly Improves Survival Of Patients With Diffuse Large B-Cell Lymphoma Associated With MYC Translocation: A Report From The International DLBCL Rituximab-CHOP Consortium Program

▪ Context and objectiveApproximately 5-10% of diffuse large B-cell lymphoma (DLBCL) patients carry MYC gene translocations (MYC-translocation+) with a poor prognosis after standard chemotherapy. MYC-translocation+ DLBCL patients carrying BCL2 translocations (MYC+/BCL2+ double-hit lymphoma) have a worse survival. The efficacy of adjuvant radiotherapy in this setting is unknown. The purpose of this study is to evaluate the efficacy of radiotherapy as a part of the therapeutic regimen for patients with MYC-translocation+ DLBCL. Patients and methodsFrom the International DLBCL R-CHOP consortium program, we selected 581 patients with de novo DLBCL treated with standard R-CHOP immunochemotherapy (diagnosed and treated from 2000 to 2010). We excluded patients with transformed DLBCL, primary mediastinal, cutaneous, testicular or central nervous system large B-cell lymphomas, patients with HIV infection, and patients not treated with R-CHOP. The median follow-up was 54.9 months. Fluorescence in situ hybridization assessing MYC was performed for all the patients (n=581) and results were correlated with available clinical data to identify clinicopathologic features associated with MYC translocation, and to evaluate the prognostic significance of MYC translocations regarding overall survival (OS, from the time of diagnosis to death from any cause) and progression-free survival (PFS, from the time of diagnosis to relapse or death from any cause). In the MYC-translocation+ DLBCL group, 38 patients received chemotherapy alone and 21 patients received chemotherapy with adjuvant radiation therapy. The clinicopathologic features and survival of MYC-translocation+ DLBCL patients treated with (n=21) and without radiotherapy (n=38) after immunochemotherapy were compared to in order to evaluate the radiotherapy efficacy and other confounding factors. ResultsMYC translocations were detected in 59 DLBCL patients (10.2%). Patients with MYC-translocation+ DLBCL more often had bulky tumors, involvement of multiple extranodal sites, and poorer OS (hazard ratio [HR]: 2.0, 95% confidence interval [CI]: 1.20 - 3.35, P= .0083) and PFS (HR: 1.96, 95% CI: 1.22 - 3.13, P= .0005) independent of the International Prognostic Index score. Poor survival was primarily attributable to patients with MYC+/BCL2+ double-hit DLBCL who were predominantly of germinal center B-cell subtype. Among MYC-translocation+ DLBCL patients, a better survival was achieved in patients who received radiotherapy (for OS, HR: .32, 95% CI: .15 - .71, P= .0049; for PFS, HR: .35, 95% CI: .17 - .73, P= .0043). Conversely, radiotherapy abolished the adverse impact of MYC translocations. In addition, radiotherapy was associated with better survival in the subset of patients with MYC+/BCL2+ double-hit lymphoma (P = .017 for OS, and P = .05 for PFS). However, owing to the common use of radiotherapy as consolidation therapy, the favorable prognoses in the group of patients who received radiotherapy could also be attributed to limited-stage disease and more frequent complete remission (CR) after first-line treatment and therefore these factors confound interpretation of the data. To address these issues, we evaluated radiotherapy efficacy in separate patient groups: patients who achieved CR, non-CR (PR/SD/PD) patients, and patient with stage I/II, or stage III/IV disease. The efficacy of radiotherapy appeared more apparent in patients with advanced disease who did not achieve CR after first-line chemotherapy. Multivariate analysis after adjustment for stage and IPI score validated that radiotherapy significantly improved OS (HR: .28, 95% CI: .10 - .81, P= .018) and PFS (HR: .32, 95% CI: .13 - .80, P= .015) of MYC-translocation+ DLBCL patients. ConclusionsThe presence of MYC translocations in DLBCL is an important biomarker that facilitates prognostic prediction and treatment stratification independent of the IPI score. For chemoresistant MYC-translocation+ DLBCL patients, radiotherapy seems to be an effective adjuvant regimen likely due to the higher frequency of extranodal involvement and bulky disease in MYC-translocation+ DLBCL patients. Our results provide a rationale for larger scale studies to assess the potential role of radiotherapy in the management of MYC-translocation+ DLBCL patients, particularly patients with MYC+/BCL2+double-hit DLBCL. Disclosures:Winter:Millenium: Research Funding; Novartis : Research Funding; Pfizer (Wyeth): Research Funding; Seattle Genetics: Research Funding; Spectrum: Research Funding; Janssen (Pharmacyclics): Research Funding; Spectrum (Allos): Consultancy; Sanofi Aventis: Consultancy; Tgen: Consultancy; AMBIT Biosciences (Spouse): Research Funding; Celgene (Spouse): DSMB, DSMB Other, Research Funding; Ariad Pharmaceuticals (Spouse): Research Funding; Novartis (Spouse): Consultancy, Research Funding; Amgen (Spouse): Consultancy, Research Funding; Astellas (Spouse): Research Funding; Caremark/CVS: Consultancy; Pfizer (Spouse): Consultancy; Sanofi Aventis (Spouse): DSMB, DSMB Other; Bristol Myers Squibb (Spouse): DSMB, DSMB Other; UptoDate, Inc.(Spouse): Patents & Royalties.

Radiation Therapy Significantly Improves Survival Of Patients With Diffuse Large B-Cell Lymphoma Associated With MYC Translocation: A Report From The International DLBCL Rituximab-CHOP Consortium Program

▪ Context and objectiveApproximately 5-10% of diffuse large B-cell lymphoma (DLBCL) patients carry MYC gene translocations (MYC-translocation+) with a poor prognosis after standard chemotherapy. MYC-translocation+ DLBCL patients carrying BCL2 translocations (MYC+/BCL2+ double-hit lymphoma) have a worse survival. The efficacy of adjuvant radiotherapy in this setting is unknown. The purpose of this study is to evaluate the efficacy of radiotherapy as a part of the therapeutic regimen for patients with MYC-translocation+ DLBCL. Patients and methodsFrom the International DLBCL R-CHOP consortium program, we selected 581 patients with de novo DLBCL treated with standard R-CHOP immunochemotherapy (diagnosed and treated from 2000 to 2010). We excluded patients with transformed DLBCL, primary mediastinal, cutaneous, testicular or central nervous system large B-cell lymphomas, patients with HIV infection, and patients not treated with R-CHOP. The median follow-up was 54.9 months. Fluorescence in situ hybridization assessing MYC was performed for all the patients (n=581) and results were correlated with available clinical data to identify clinicopathologic features associated with MYC translocation, and to evaluate the prognostic significance of MYC translocations regarding overall survival (OS, from the time of diagnosis to death from any cause) and progression-free survival (PFS, from the time of diagnosis to relapse or death from any cause). In the MYC-translocation+ DLBCL group, 38 patients received chemotherapy alone and 21 patients received chemotherapy with adjuvant radiation therapy. The clinicopathologic features and survival of MYC-translocation+ DLBCL patients treated with (n=21) and without radiotherapy (n=38) after immunochemotherapy were compared to in order to evaluate the radiotherapy efficacy and other confounding factors. ResultsMYC translocations were detected in 59 DLBCL patients (10.2%). Patients with MYC-translocation+ DLBCL more often had bulky tumors, involvement of multiple extranodal sites, and poorer OS (hazard ratio [HR]: 2.0, 95% confidence interval [CI]: 1.20 - 3.35, P= .0083) and PFS (HR: 1.96, 95% CI: 1.22 - 3.13, P= .0005) independent of the International Prognostic Index score. Poor survival was primarily attributable to patients with MYC+/BCL2+ double-hit DLBCL who were predominantly of germinal center B-cell subtype. Among MYC-translocation+ DLBCL patients, a better survival was achieved in patients who received radiotherapy (for OS, HR: .32, 95% CI: .15 - .71, P= .0049; for PFS, HR: .35, 95% CI: .17 - .73, P= .0043). Conversely, radiotherapy abolished the adverse impact of MYC translocations. In addition, radiotherapy was associated with better survival in the subset of patients with MYC+/BCL2+ double-hit lymphoma (P = .017 for OS, and P = .05 for PFS). However, owing to the common use of radiotherapy as consolidation therapy, the favorable prognoses in the group of patients who received radiotherapy could also be attributed to limited-stage disease and more frequent complete remission (CR) after first-line treatment and therefore these factors confound interpretation of the data. To address these issues, we evaluated radiotherapy efficacy in separate patient groups: patients who achieved CR, non-CR (PR/SD/PD) patients, and patient with stage I/II, or stage III/IV disease. The efficacy of radiotherapy appeared more apparent in patients with advanced disease who did not achieve CR after first-line chemotherapy. Multivariate analysis after adjustment for stage and IPI score validated that radiotherapy significantly improved OS (HR: .28, 95% CI: .10 - .81, P= .018) and PFS (HR: .32, 95% CI: .13 - .80, P= .015) of MYC-translocation+ DLBCL patients. ConclusionsThe presence of MYC translocations in DLBCL is an important biomarker that facilitates prognostic prediction and treatment stratification independent of the IPI score. For chemoresistant MYC-translocation+ DLBCL patients, radiotherapy seems to be an effective adjuvant regimen likely due to the higher frequency of extranodal involvement and bulky disease in MYC-translocation+ DLBCL patients. Our results provide a rationale for larger scale studies to assess the potential role of radiotherapy in the management of MYC-translocation+ DLBCL patients, particularly patients with MYC+/BCL2+double-hit DLBCL. Disclosures:Winter:Millenium: Research Funding; Novartis : Research Funding; Pfizer (Wyeth): Research Funding; Seattle Genetics: Research Funding; Spectrum: Research Funding; Janssen (Pharmacyclics): Research Funding; Spectrum (Allos): Consultancy; Sanofi Aventis: Consultancy; Tgen: Consultancy; AMBIT Biosciences (Spouse): Research Funding; Celgene (Spouse): DSMB, DSMB Other, Research Funding; Ariad Pharmaceuticals (Spouse): Research Funding; Novartis (Spouse): Consultancy, Research Funding; Amgen (Spouse): Consultancy, Research Funding; Astellas (Spouse): Research Funding; Caremark/CVS: Consultancy; Pfizer (Spouse): Consultancy; Sanofi Aventis (Spouse): DSMB, DSMB Other; Bristol Myers Squibb (Spouse): DSMB, DSMB Other; UptoDate, Inc.(Spouse): Patents & Royalties.

Open-Label Phase 2 Study Of The Bispecific T-Cell Engager (BiTE®) Blinatumomab In Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma

IntroductionBlinatumomab, a bispecific T-cell engager (BiTE®) that redirects cytotoxic T cells to CD19+ B-lineage cells, has shown anticancer activity and acceptable toxicity in a phase 1 study in patients with relapsed/refractory non-Hodgkin lymphoma, including diffuse large B-cell lymphoma (DLBCL). Using a stepwise dose escalation treatment, the overall response rate (ORR) in patients with DLBCL was 55% (Goebeler et al. Hematol Oncol 2013;31[suppl 1]:197). This open-label phase 2 study has been initiated to investigate the efficacy and tolerability of blinatumomab in patients with relapsed/refractory DLBCL, comparing stepwise dose escalation with constant target dosing. MethodsIn this ongoing study, eligible patients must be ≥18 years of age, must have relapsed/refractory DLBCL and Eastern Cooperative Oncology Group performance status ≤2. Blinatumomab is administered by continuous intravenous infusion over 8 weeks. In part 1 of the study, two cohorts were evaluated using a double-step or flat dose escalation regimen, respectively, in order to achieve the target dose of 112 μg/d. Part 2 will investigate the selected treatment schedule from part 1. Data from part 1 (cohorts I and II) are presented herein. Patients in cohort I received stepwise blinatumomab dosing of 9, 28, and 112 μg/d during weeks 1, 2, and thereafter, respectively; patients in cohort II received blinatumomab at 112 μg/d throughout. After a 4-week treatment-free period, patients achieving an objective response were permitted to receive a 4-week consolidation cycle. All patients received prophylactic dexamethasone. The primary endpoint is ORR by Cheson (2007) revised response criteria for malignant lymphomas. ResultsTo date, 11 patients have been enrolled and treated in part 1 of the study: nine in cohort I and two in cohort II. The median age was 73 years (range, 55–85); 64% of patients were women. Six (55%) patients had received ≥3 lines of previous systemic antitumor therapy; study treatment was given as fourth-line (median) systemic treatment. Three patients had received autologous hematopoietic stem cell transplantation. At the time of this analysis, seven patients were evaluable for response (cohort I, n=6; cohort II, n=1). The ORR based on independent radiological assessment was 57% (cohort I: complete response, n=1; partial response, n=2; cohort II: partial response, n=1). Three patients had progressive disease (all in cohort I). Four patients were not evaluable for ORR per protocol definition: early treatment discontinuation after <1 week on target dose in absence of disease progression, n=3; transformed DLBCL, patient only pre-treated for follicular lymphoma (patient achieved a CR), n=1. The most common adverse events (AEs) regardless of causality were tremor (64%), diarrhea (46%), and fatigue (46%). Ten of 11 patients had at least one grade ≥3 AE regardless of causality, with two patients (both in cohort II) experiencing grade 4 AEs (one patient with neutropenia and leucopenia; one with respiratory insufficiency). There were no grade 5 AEs. Ten of 11 patients had central nervous system (CNS) AEs, mostly tremor (64%), speech disorder (36%), and disorientation (27%). Five patients (cohort I, n=3; cohort II, n=2) had grade 3 CNS AEs (there were no grade 4 or 5 CNS events). The overall benefit/risk assessment revealed the dose administered in cohort I (stepwise dosing: 9, 28, 112 μg/d) to be the recommended dose for part 2 of the protocol. ConclusionsIn this ongoing phase 2 study, blinatumomab was tolerable and showed antitumor activity in adult, heavily pretreated patients with relapsed/refractory DLBCL. Part 1 of the study established a recommended blinatumomab dose for this patient population. The study continues to enroll patients in part 2 (cohort III). Disclosures:Libicher:Amgen Inc.: Consultancy. Degenhard:Amgen Research (Munich) GmbH: Employment; Amgen Inc.: Equity Ownership. Stieglmaier:Amgen Research (Munich) GmbH: Employment; Amgen Inc.: Equity Ownership. Zhang:Amgen Inc.: Employment; Amgen Inc.: Equity Ownership. Nagorsen:Amgen Inc.: Employment; Amgen Inc.: Equity Ownership. Bargou:University of Würzburg: Consultancy; University of Würzburg: Honoraria; Amgen Inc.: patent, patent Other.