High-risk Diffuse Large B-cell Lymphoma Patients Research Articles

Clinical characteristics and outcomes of patients with diffuse large B cell lymphoma treated with R-CHOP-like or CHOP-like regimens: an 8-year experience from a single center.

The CHOP regimen comprising cyclophosphamide, doxorubicin, vincristine, and prednisone is a basic chemotherapeutic regimen for diffuse large B cell lymphoma (DLBCL). Addition of rituximab (R) to chemotherapy has led to better efficacy than other regimens in clinical trials. However, data of clinical characteristics and outcomes of patients with DLBCL are scarce. Therefore, this study reports the clinical characteristics, treatment, and outcomes of patients with DLBCL in our hospital. We conducted a retrospective analysis of newly diagnosed DLBCL patients treated with CHOP-like or R-CHOP-like regimens at our hospital between 2011 and 2018. We analyzed the data on demography, clinical characteristics, treatment, treatment response, and survival time. Both univariate and multivariate analyses were applied. In total, 570 newly diagnosed DLBCL patients were included, of which 133 were treated with CHOP-like regimens and 437 with R-CHOP-like regimens. The overall response rate was 83.3%. Germinal center B-cell-like (GCB) subtype, R-CHOP-like treatment, Ann Arbor stage I-II, not more than 1 extranodal disease site, Eastern Cooperative Oncology Group (ECOG) score ≤1, normal serum lactate dehydrogenase (LDH) level, normal serum β2 microglobulin (β2-MG) level, absence of B symptoms, and lower International Prognostic Index (IPI) or National Comprehensive Cancer Network-International Prognostic Index (NCCN-IPI) scores were associated with longer overall survival (OS) and progressionfree survival (PFS), and were favorable prognostic factors for OS and PFS. Only GCB subtype, R-CHOPlike treatment, absence of B symptoms, and lower IPI or NCCN-IPI scores were independent favorable prognostic factors for OS and/or PFS. Neither IPI nor NCCN-IPI could accurately and precisely predict the prognosis of high-risk DLBCL patients. This analysis of newly diagnosed DLBCL patients indicates that patients treated with R-CHOP-like regimens or with GCB subtype exhibited better outcomes. Further, IPI and NCCN-IPI have limited prognostic values in high-risk DLBCL patients.

Clinical study of DA-EPOCH regimen combined with or without rituximab in treatment of young newly diagnosed patients with middle and high-risk diffuse large B-cell lymphoma

Objective To observe the clinical efficacy and prognosis of DA-EPOCH regimen combined with or without rituximab [(R)-DA-EPOCH regimen] in treatment of young newly diagnosed patients with middle and high-risk diffuse large B-cell lymphoma (DLBCL). Methods The clinical data of 107 young newly diagnosed middle to high-risk DLBCL patients treated with (R)-DA-EPOCH regimen at Guizhou Cancer Hospital between November 2014 and December 2018 were retrospectively analyzed. The efficacies were analyzed by grouping according to rituximab (65 cases in R-DA-EPOCH group and 42 cases in DA-EPOCH group), and according to involved-filed radiotherapy (IFRT) after chemotherapy (99 cases with chemotherapy indications including 59 cases with IFRT and 40 cases without IFRT). Results The objective response rate (ORR) was 86.0% (92/107). The 1-, 2-year overall survival (OS) rate was 90.6% and 75.3%. The 1-, 2-year progression-free survival (PFS) rate was 79.1% and 56.5%. The ORR, 1-year OS rate, 2-year OS rate, 1-year PFS rate and 2-year PFS rate in R-DA-EPOCH group were higher than those in DA-EPOCH group [87.7% (57/65) vs. 83.3% (35/42), 94.8% vs. 84.9%, 80.4% vs. 68.2%, 90.5% vs. 77.0%, 61.0% vs. 50.8%, respectively), but there were no statistical differences (all P > 0.05). The ORR of IFRT group and non-IFRT group was 98.2% (56/57) and 80.0% (32/40) (χ 2 = 7.225, P = 0.007). The 2-year OS rate was 86.0% and 63.3% (P < 0.05). Main adverse reactions caused by radiotherapy were local skin mucosa reactions of grade Ⅰ-Ⅱ [42.4% (25/59)]. Multivariate analysis showed that albumin value after treatment was an independent prognosis factor affecting OS rate (95% CI 2.709-21.433, P < 0.01). Gender (95% CI 0.020-0.318, P < 0.01), albumin level (95% CI 2.097-12.219, P < 0.01), Beta 2 microglobulin level (95% CI 0.080-0.602, P < 0.01) and absolute lymphocyte count/absolute monocyte count (95% CI 0.113-0.720, P < 0.01) after treatment were independent prognosis factors affecting PFS rate. Conclusions The young newly diagnosed patients with middle and high-risk DLBCL are highly heterogeneous. Rituximab combined with DA-EPOCH regimen can improve the efficacy of patients. IFRT after chemotherapy may increase the short-term efficacy and OS, and the adverse reactions are tolerant. Key words: Lymphoma, large B-cell, diffuse; Chemotherapy, adjuvant; Molecular targeted therapy; Young adult; Prognosis

Traditional Chinese Medicine Is Used to the Maintenance Therapy of Diffuse Large B Cell Lymphoma

Background: Diffuse large B cell lymphoma (DLBCL) is one of the most common malignancy hematologic disease in China. At present, the NCCN recommended first-line therapy to DLBCL is: rituximab combined with cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP) or etoposide, cyclophosphamide, doxorubicin, vincristine, prednisolone (R-EPOCH). For the medium-risk and high-risk adult patients, autologous hematopoietic stem cell transplantation (auto-HSCT) is recommended as consolidation therapy. However, no maintenance therapy is recommended. A number of clinical trials of rituximab or lenadomide for maintenance therapy in DLBCL have been carried out, but the exact effect has not yet been confirmed. Traditional Chinese medicine (TCM) is a unique treatment in China. For economic or other reasons, many Chinese patients with DLBCL choose TCM as maintenance therapy after induction chemotherapy or auto-HSCT. Here we will introduce the application of TCM in maintenance therapy of DLBCL. Methods: We conducted a retrospective analysis of 87 (34 males and 53 females; age ranged from 16 to 86 years old) consecutive patients diagnosed with de novo DLBCL treated at Zhongda Hospital Affiliated to Southeast University between January 2013 and March 2019. All patients were diagnosed by pathology and graded by international prognostic index (IPI) score. All patients enrolled in our cohort were received at least 4 cycles of R-CHOP or R-EPOCH regimen. Then we compared the outcome of maintenance therapy with TCM or rituximab in DLBCL patients who were received standard induction chemotherapy. Results: Survival analysis showed that the overall survival (OS) in maintenance group (including TCM and rituximab) was significantly different from that in non-maintenance group (P=0.036). Among them, the patients received maintenance treatment with rituximab or TCM did not relapse and were still in survival state, but there was no significant difference in OS between the two groups (P&gt;0.05). Because of the short follow-up period of this group, only 5 patients chose TCM and 7 patients chose rituximab for maintenance. Therefore, we will focus on two successful cases of TCM maintenance therapy. Case 1. A 57-year-old woman was diagnosed with DLBCL (stage Ⅳ, group B) in December 2012. After 3 cycles of R-EPOCH regimen chemotherapy, she was assessed as complete remission (CR) by PET/CT. Then auto-HSCT was followed in in May 2013. However, the patient suffered with fatigue and loss of appetite in July 2013. Also, decreased hematopoietic cells were found. Although G-CSF, cyclosporin and androgen were used to stimulate hematopoiesis, the hematopoietic function was still not fully restored. Thinking about the toxic and side effects of chemotherapy, we treated the patient with TCM as maintenance therapy and physical conditioning. After 3 months, the hematopoietic function returned to normal gradually. The symptoms of fatigue and loss of appetite were significantly improved. Then she continued the treatment of TCM for 2 years. The patient reviewd every year and was still in CR state. Case 2. A 46-year-old man was diagnosed with DLBCL (stageⅢ, group B) in June 2015. After 4 cycles of R-CHOP regimen chemotherapy, he was assessed as CR by PET/CT. Then auto-HSCT was followed in November 2015. Because of 2 months' bone marrow depression and skin rashes, the patient chose TCM as maintenance therapy from February 2016 to the present. Up to now, he was still alive and without disease progress. Conclusion: Even after first-line chemotherapy, about 30% high-risk DLBCL patients will be relapse. At present, no maintenance therapy is recommended yet, but more and more clinical trials on cancer-targeting drugs such as rituximab have been carried out these years. TCM is a therapeutic method with Chinese characteristics, which is reported to be used as adjuvant drugs for cancer chemotherapy. Maintenance therapy of TCM is a new option that is expected to be a more economical and effective alternative to rituximab. Due to the small sample size and short follow-up time, there is a certain bias. In the future, we will expand the sample size and extend the follow-up time to obtain more accurate clinical data to verify the effectiveness of TCM maintenance therapy. Disclosures No relevant conflicts of interest to declare.

Ironomycin Induces Diffuse Large B-Cell Lymphoma Cell Death By Targeting Iron Metabolism Addiction

Diffuse large B cell lymphoma (DLBCL) is the most common hematologic malignancy. Although more than half of these patients may achieve long-term remission, the majority of the remaining patients succumb to DLBCL.These patients relapse after conventional Rituximab (R)-based chemotherapy regimen, such as CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) in association with drug resistance. Iron is essential for many fundamental cellular functions, including proliferation and DNA synthesis. Accumulating evidence reveals that abnormal iron metabolism plays an important role in carcinogenesis and in the progression of many tumors. In cancer cells, the demand for iron increases in response to sustained deregulation of cell proliferation and DNA synthesis. Based on these data, we searched to identify if iron metabolism pathway is deregulated in DLBCL and could be exploited to develop novel therapeutic strategies. A list of 63 genes related to iron metabolism in cancer was defined. Using Maxstat R function, we showed that 12 genes out of the 63 investigated have a prognostic value in two independent cohorts of DLBCL patients treated by R-CHOP (Melnick cohort, n=69 and Lenz cohort, n=233). Based on these prognostic genes, we created a gene expression profile (GEP)-based risk score as the sum of the beta coefficients weighted by ±1 according to the patient signal above or below the probe set Maxstat value as previously reported (Herviou L et al. Clinical epigenetics 2018). The iron score was significantly associated with high-risk DLBCL in 3 independent cohorts of patients. GSEA analysis revealed that high-risk DLBCL patients defined by iron score are significantly enriched in genes involved in MYC amplification and MYC targets (p&lt; 0.01). These data demonstrated that high iron score allows to identify DLBCL patients with a poor outcome and that could benefit from targeted therapy. We analyzed the therapeutic interest of Ironomycin, a new promising iron depleting molecule. Ironomycin is known to sequester iron in the lysosome and to induce ferroptosis (Mai TT et al. Nature Chemistry 2017). Ironomycin inhibits DLBCL cell proliferation in a panel of 16 DLBCL cell lines, at nanomolar concentrations (Median IC50: 30nM; range: 7.2 - 91.5 nM) compared to other iron chelators. Ironomycin induces significant cell growth inhibition, apoptosis of DLBCL cells and DNA double strand break accumulation. Furthermore, apoptosis induced by Ironomycin was not reversed by Iron supplementation. Caspase activation and apoptosis induction mediated by Ironomycin could be partially reversed by pan-caspase inhibitor QVD (p&lt;0.001). Ferroptosis inhibitor, Ferrostatin-1, also partially reversed Ironomycin-induced apoptosis (p&lt;0.001). According to ferroptosis induction, Ironomycin induced ROS (CM-H2DCFDA staining), lipid peroxidation (BODIPY-C11 staining) and autophagy (LC3B puncta formation), at 48H, in DLBCL cells. We also identified a delayed progression of replication forks upon Ironomycin treatment in DLBCL cell lines (p&lt;0.0001). Ironomycin induces significant phosphorylation of RPA2 that is a marker of DNA-replication stress and DNA damage response. Interestingly, we identified a significant correlation between basal replication stress monitored by ATR and CHK2 phosphorylation and sensitivity to Ironomycin in DLBCL cell lines. With major importance, we validated the therapeutic interest of Ironomycin in primary DLBCL cells of patients (n=5) without major toxicity for non-tumor cells from the microenvironment. Ironomycin significantly reduces the median number of viable primary DLBCL cells by 69.3% and 77.8%, at respectively 50 and 100nM concentrations (p&lt;0.01 and p&lt;0.001). Furthermore, Ironomycin presented a low toxicity on hematopoietic progenitors (CFU assays, n=5) compared to conventional treatment (p&lt;0.001). We tested the therapeutic interest to combine Ironomycin with conventional chemotherapy used in DLBCL including cyclophosphamide, doxorubicin and etoposide. Interestingly, we identified a significant synergistic effect when Ironomycin is combined with Doxorubicin. Altogether, these data demonstrated that a subgroup of high-risk DLBCL patients could be identified with the iron score and could benefit from Iron metabolism inhibitor treatment. Disclosures Cartron: Roche, Celgene: Consultancy; Sanofi, Gilead, Janssen, Roche, Celgene: Honoraria. Moreaux:Diag2Tec: Other: Co-founder of Diag2Tec company.

Combination of Phosphodiesterase 4 (PDE4) Inhibitor Roflumilast and R-CHOP As First-Line Therapy for High-Risk Diffuse Large B Cell Lymphoma Patients

R-CHOP remains the standard therapy for diffuse large B cell lymphoma (DLBCL), even though long-term disease free survival is achieved in only ~60-70% of the patients. One approach to improve on this cure rate is to implement rationally devised therapeutic strategies that capitalize on a better understanding of lymphoma biology, and on robust pre-clinical data. Still, in many instances clinical translation is limited by the difficulty in inhibiting key lymphomagenic proteins (e.g., MYC), or by subpar clinical responses and/or toxicity associated with the use of inhibitors to well-validated targets (e.g., SYK, BTK, PI3K, VEGF, etc.). Using genome-wide studies, we identified high expression of phosphodiesterase 4B (PDE4B) in fatal DLBCLs (Nat Med. PMID: 11786909). PDE4 hydroxylases cyclic adenosine monophosphate (cAMP) thus terminating its inhibitory signals and promoting B lymphocytes survival. Using in vitro and in vivo models, we showed that PDE4 inhibition augments cAMP signals and suppresses PI3K-AKT activity in DLBCL (Blood, PMID: 15331441). We mapped these events to SYK inhibition downstream of the B cell receptor (BCR) (Blood, PMID: 19369227). PDE4 inhibitors also suppress the pro-angiogenic lymphoma microenvironment by directly inhibiting the endothelium, and by decreasing VEGF production/secretion by the lymphoma cells, as we showed in a mouse engineered to develop lymphoma in a Pde4b KO background (Leukemia, PMID: 26503641). Earlier, we built on these pre-clinical data to test the safety and pharmacodynamics of the PDE4 inhibitor roflumilast (FDA-approved for COPD) in patients with relapsed/refractory mature B cell malignancies. In that first-in-cancer drug-repurposing study (NCT01888952), we found that roflumilast was well tolerated, clinically active, and that it suppressed PI3K activity, which correlated with the degree of clinical response (Clin. Cancer Res PMID: 27542768). Aberrant BCR signaling and angiogenesis are integral to the pathogenesis of DLBCL. Yet, combination of either ibrutinib or bevacizumab with R-CHOP was not beneficial in this disease. Thus, considering the pleiotropic anti-lymphoma properties of PDE4 inhibitors (seeBloodPMID: 27756749), which includes BCR suppression and anti-angiogenesis, we opened a trial to test the combination of roflumilast with R-CHOP in treatment naïve DLBCLs (NCT03458546). This is a single center, phase Ib, open label, non-randomized single arm study of roflumilast + R-CHOP (RR-CHOP) aimed at untreated high-risk DLBCL patients. Key eligibility criteria include: non-GCB DLBCL (Han's algorithm), NCCN-IPI risk score of ≥ 2, Ann Arbor stage II-IV; key exclusion criteria include active CNS involvement and documented history of severe depression (a specific concern related to the use of roflumilast). Patients will receive R-CHOP every 21 days for 6 cycles, and roflumilast PO daily (500 mcg) throughout the 18-week treatment period. Given the anti-angiogenic properties of PDE4 inhibitors that we documented pre-clinically, and the prohibitive cardiotoxicity of bevacizumab + R-CHOP combination, we will monitor serum levels of troponin and B-type natriuretic peptide, as biomarkers for cardiac toxicity. In addition, PBMC, plasma and urine samples will be collected for measurement SYK/PI3K/AKT activity and VEGF levels at baseline and before cycles 3 and 6. Exome sequencing of germline and tumor DNA is to be performed too. Adverse events will be assessed and documented according to the CTCAE version 4.03 criteria. Eligible patients will be included in the intent-to-treat analysis. The primary objective of this study is to test safety and tolerability of RR-CHOP; the secondary objectives are to preliminarily assess anti-tumor efficacy of the combination and the biomarker potential of SYK/PI3K/AKT activity and VEGF levels. Given its exploratory nature, this study was designed for a cohort of 10 patients, in which no statistical assessment of response or sample size calculation was included. To date, we have met ~50% of the target accrual, with half of those patients being of Hispanics ethnicity. If RR-CHOP is proven safe, the next step will be to initiate a randomized trial that compares RR-CHOP to R-CHOP in untreated DLBCL patients, which should conclusively validate (or refute) our extensive, biologically-informed, pre-clinically data on the benefits of PDE4 inhibitors for the treatment of mature B cell malignancies. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: roflumilast - PDE4 inhibitor, FDA-approved for COPD patients.

The IL ‐6 signaling complex is a critical driver, negative prognostic factor, and therapeutic target in diffuse large B‐cell lymphoma

Interleukin‐6 (IL‐6) is a growth factor for normal B cells and plasma cell‐derived malignancies. Here, we show that the IL‐6 signaling pathway is also active in a subset of diffuse large B‐cell lymphoma (DLBCL) patients with particularly poor prognosis. Primary DLBCL cells and DLBCL cell lines expressing IL‐6R engraft and form orthotopic lymphomas in humanized mice that ectopically produce human IL‐6, and in mice reconstituted with a human immune system. We show that a subset of DLBCL cases have evolved mechanisms that ensure constitutive activation of the IL‐6 signaling pathway, i.e., the expression of both chains of the IL‐6R, the expression of the cytokine itself, and the mutational inactivation of a negative regulator of IL‐6 signaling, SOCS1. IL‐6 signaling promotes MYC‐driven lymphomagenesis in a genetically engineered model, and treatment with the IL‐6R‐specific antibody tocilizumab reduces growth of primary DLBCL cells and of DLBCL cell lines in various therapeutic settings. The combined results uncover the IL‐6 signaling pathway as a driver and negative prognosticator in aggressive DLBCL that can be targeted with a safe and well‐tolerated biologic.

Abstract 980: Clinical impact of T-cell exhaustion in patients with diffuse large B-cell lymphoma

Abstract Introduction: Tumor microenvironment (TME) and limited immune surveillance impact lymphoma pathogenesis and survival. Immune checkpoint receptors, such as programmed cell death-1 (PD1), lymphocyte-activation gene-3 (LAG3) and T-cell immunoglobulin and mucin domain-3 (TIM3), mediate signals leading to T-cell exhaustion and immune escape. Here, we have characterized the immunological profiles of diffuse large B-cell lymphoma (DLBCL) and associated the findings with outcome. Methods: We utilized the NanoString nCounter platform with a 770-gene PanCancer Immune panel to profile gene expression from 81 RNA samples collected from high-risk DLBCL patients. Multiplex immunohistochemistry (mIHC) with digital image analysis was used to characterize the T-cell phenotypes (CD3, CD4, CD8, PD1, LAG3, and TIM3) in two DLCBL patient cohorts (n=52 and n=136). The findings from gene expression profiling and mIHC were correlated with clinical parameters and patient outcome (i.e. progression-free survival (PFS) and overall survival (OS)). Results: Gene expression profiling revealed a high degree of heterogeneity among DLCBL. Unsupervised hierarchical clustering identified gene clusters differentially expressed between the patients. The distinct clusters contained genes for cytolytic factors and immune checkpoint molecules (GZMB, PRF1, IFNG, TIM3, LAG3), T-cells (CD3, CD2, CD28), macrophages (CD68, CD163), B-cells (MS4A1, CD19, CD79A/B), and extracellular matrix (FN1, ITGA1/5/6, VEGFA). mIHC revealed that the proportion of CD3+ T-cells varied markedly between the patients (median 24.8%, range 0.5-65.1%). On average, 8.8% (0-34.3%) of the CD3+ T-cells were positive for TIM3, whereas 0.6% (0-5.4%) were positive for LAG3. High content of TIM3+ cells was associated with poor outcome (PFS: HR 1.06, 95%CI 1.02-1.10, P=0.003; OS: HR=1.12, 95%CI 1.04-1.20, P=0.003) in a cohort of 52 DLBCL patients independent of the international prognostic index (IPI). In addition, high proportion of TIM3+CD3+ cells associated with poor survival independently of IPI (PFS: HR 1.07, 95%CI 1.00-1.14, P=0.040; OS: HR 1.087, 95%CI 1.01-1.17, P=0.019). The prognostic impact of TIM3 on survival was validated in a separate mIHC cohort of 136 DLBCL patients (PFS: HR 1.07, 95%CI 1.02-1.14, P=0.014; OS: HR 1.10, 95%CI 1.03-1.16, P=0.002). Conclusions: Our data demonstrates that the molecular immunological profile of DLBCL is heterogenic and that the expression of T-cell exhaustion marker TIM3 correlates with poor prognosis in patients with DLBCL. A more detailed characterization of immune cell composition in the TME and its impact on survival is ongoing. Citation Format: Suvi-Katri Leivonen, Matias Autio, Oscar Bruck, Satu Mustjoki, Judit M. Joergensen, Marja-Liisa Karjalainen-Lindsberg, Klaus Beiske, Harald Holte, Sirpa Leppä. Clinical impact of T-cell exhaustion in patients with diffuse large B-cell lymphoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 980.

Clinical Significance of BCL2, C-MYC, and BCL6 Genetic Abnormalities, Epstein-Barr Virus Infection, CD5 Protein Expression, Germinal Center B Cell/Non-Germinal Center B-Cell Subtypes, Co-expression of MYC/BCL2 Proteins and Co-expression of MYC/BCL2/BCL6 Proteins in Diffuse Large B-Cell Lymphoma: A Clinical and Pathological Correlation Study of 120 Patients.

Background: Clinical significance of germinal center B-cell (GCB) and non-GCB sub-categorization, expression of MYC, BCL2, BCL6, CD5 proteins and Epstein Barr virus encoded RNA (EBER) positivity in diffuse large B-cell lymphoma (DLBCL) remain controversial. Could these biomarkers accurately identify high risk DLBCL patients? Are MYC, BCL2 and BCL6 proteins expression feasible as baseline testing to predict c-Myc, BCL2 or BCL6 gene rearrangements?Aims: To investigate prognostic values of GCB/non-GCB sub-categorization, Double Protein Expression Lymphoma (DPL), Triple Protein Expression Lymphoma (TPL), positivity of CD5 protein and EBER in patients with DLBCL disease. To evaluate correlation between BCL2 , c-Myc and BCL6 gene rearrangements with BCL2, MYC and BCL6 proteins expression.Methods: Diagnostic tissue samples of 120 DLBCL patients between January 2012 to December 2013 from four major hospitals in Malaysia were selected. Samples were subjected to immunohistochemical staining, fluorescent in-situ hybridization (FISH) testing, and central pathological review. Pathological data were correlated with clinical characteristics and treatment outcome.Results: A total of 120 cases were analysed. Mean age of diagnosis was 54.1 years ± 14.6, 64 were males, 56 were females, mean follow up period was 25 months (ranged from 1 to 36 months). Of the 120 cases, 74.2% were non-GCB whereas 25.8% were GCB, 6.7% were EBER positive, 6.7% expressed CD5 protein, 13.3% were DPL and 40% were TPL. The prevalence of c-Myc, BCL2, BCL6 gene rearrangements were 5.8%, 5.8%, and 14.2%, respectively; and 1.6% were Double Hit Lymphoma (DHL). EBER positivity, DPL, TPL, c-Myc gene rearrangement, BCL2 gene rearrangement, extra copies of BCL2 gene and BCL6 gene rearrangement were associated with shorter median overall survival (P<0.05). IPI score was the significant determinants of median overall survival in DPL and TPL (P<0.05). CD5 protein expression and GCB/non-GCB sub-categorization did not affect treatment outcome (P>0.05). Overall, c-Myc, BCL2 and BCL6 gene rearrangements showed weak correlation with expression of MYC, BCL2 and BCL6 proteins (P>0.05). Fluorescent in situ hybridization is the preferred technique for prediction of treatment outcome in DLBCL patients.Conclusion: c-Myc, BCL2, and BCL6 gene rearrangements, EBER expression, DHL, TPL and IPI score are reliable risk stratification tools. MYC, BCL2 and BCL6 proteins expression are not applicable as baseline biomarkers to predict c-Myc, BCL2, and BCL6 gene rearrangements.

Oral Azacitidine (CC-486) Plus R-CHOP in Patients with High-Risk or Previously Untreated Diffuse Large B-Cell Lymphoma, Grade 3B Follicular Lymphoma, or Transformed Lymphoma (AFT-08)

Oral Azacitidine (CC-486) Plus R-CHOP in Patients with High-Risk or Previously Untreated Diffuse Large B-Cell Lymphoma, Grade 3B Follicular Lymphoma, or Transformed Lymphoma (AFT-08)

Pirna-30473 Contributes to Tumorigenesis By Regulating RNA m6A Methylation in DLBCL

N6-methyladenosine (m6A), the most abundant modification on eukaryote messenger RNA (mRNA), functions in various fundamental bioprocesses. However, the role of m6A in diffuse large B-cell lymphoma (DLBCL) remains poorly understood. Here, we reported that piRNA-30473, which expression supported the aggressive phenotype of DLBCL and was correlated with poor prognosis, was a potent regulator of m6a modification through targeting m6a methyltransferase WTAP (Figure 1).Piwi-interacting RNAs (piRNAs), a novel class of small non-coding RNAs, have been documented to be involved in the epigenetic regulation of cancer. A cohort of 42 patients with newly diagnosed DLBCL, uniformly treated and followed, was studied. We show that piRNA-30473 was significantly upregulated in high-risk DLBCL patients compared to low-risk DLBCL patients by microarray assay on 6 samples, further confirmed by qPCR analysis on 42 samples (Figure 2). Moreover, silencing of piRNA-30473 expression reduced proliferation and induced cell cycle arrest, but not apoptosis in SU-DHL-8 and Toledo lymphoma cells. In “human-in-mouse” xenograft DLBCL models, injection of antagomir-30473 into mice led to a significant reduction in tumor volume compared with control(Figure 3).Our data further indicated that the combination of piRNA-30473 signature with the National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) and cytogenetics status had a better prediction for PFS and OS than those without the piRNA-30473 signature in the univariate and multivariate analyses by an AUC analysis with cross-validation.Silencing of piRNA-30473 diminished global m6A level in SU-DHL-8 and Toledo cells and decreased m6a methyltransferase WTAP in mRNA and protein levels. We further identified that piRNA-30473 enhanced WTAP expression through direct binding to its 3' UTR. Consistently, WTAP knockdown decreased the global m6A level and induced cell cycle arrest and growth inhibition in SU-DHL-8 and Toledo cells. Moreover, Silencing of piRNA-30473 displayed decreased cell proliferation, which could be abrogated by WTAP overexpression. Kaplan-Meier analysis showed that high WTAP levels in DLBCL patients were correlated with OS by analyzing the gene expression profiling of DLBCL patients from GEO database (GSE10846) (Figure 4).Next, we mapped the m6A methylomes of siCtrl and siWTAP SU-DHL-8 cells by m6A sequencing (m6A-seq) with independent biological replicates. The RGACH motif (R = G/A; H = A/C/U) were identified to be highly enriched within m6A sites in the SU-DHL-8 cells. M6A peaks in siCtrl and siWTAP SU-DHL-8 cells were abundant in coding sequences (CDSs), 3′ untranslated regions (UTRs), and near stop codons. Remarkably, 85% m6A-Hyper transcripts identified from siCtrl SU-DHL-8 cells turned into m6A-Hypo in siWTAP SU-DHL-8 cells, with approximately 66% of the Hypo-down and 65% of Hypo-up transcripts became Hyperup and Hyper-down, respectively, which might be genuine targets of WTAP. Eleven genes listed in Table 2 showed a significant change between siCtrl and siWTAP SU-DHL-8 cells in m6A peak levels, and abundance of the corresponding mRNA transcript, and were also significantly positively or negatively correlated with WTAP in expression in four datasets of large cohorts of DLBCL. Collectively, our data demonstrate that an enzyme hexokinase II (HK2), which was reported to be a key metabolic driver of the DLBCL phenotype, were functionally important targets of WTAP. WTAP-mediated regulation of HK2 depended on its m6A demethylase activity and the m6A modifications in the target mRNA transcripts (Figure 5).In summary, our finding demonstrate that piRNA-30473 were significantly associated with both PFS and OS in the univariate analysis, and were still statistically significant after adjusting for NCCN-IPI, and adverse cytogenetics in the multivariate analysis. Moreover, we provide compelling evidence demonstrating that WTAP, which was downregulated by piRNA-30473, played a critical oncogenic role in DLBCL, through enhancing m6A levels in mRNA transcripts of its critical target gene HK2 and thereby triggering corresponding signaling cascades. Our study highlights the functional importance of the m6A modification machinery in DLBCL, and provides profound insights into the molecular mechanisms underlying tumorigenesis by revealing a previously unrecognized mechanism of gene regulation in DLBCL. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Voruciclib, a clinical stage oral CDK9 inhibitor, represses MCL-1 and sensitizes high-risk Diffuse Large B-cell Lymphoma to BCL2 inhibition

Aberrant regulation of BCL-2 family members enables evasion of apoptosis and tumor resistance to chemotherapy. BCL-2 and functionally redundant counterpart, MCL-1, are frequently over-expressed in high-risk diffuse large B-cell lymphoma (DLBCL). While clinical inhibition of BCL-2 has been achieved with the BH3 mimetic venetoclax, anti-tumor efficacy is limited by compensatory induction of MCL-1. Voruciclib, an orally bioavailable clinical stage CDK-selective inhibitor, potently blocks CDK9, the transcriptional regulator of MCL-1. Here, we demonstrate that voruciclib represses MCL-1 protein expression in preclinical models of DLBCL. When combined with venetoclax in vivo, voruciclib leads to model-dependent tumor cell apoptosis and tumor growth inhibition. Strongest responses were observed in two models representing high-risk activated B-cell (ABC) DLBCL, while no response was observed in a third ABC model, and intermediate responses were observed in two models of germinal center B-cell like (GCB) DLBCL. Given the range of responses, we show that CIVO, a multiplexed tumor micro-dosing technology, represents a viable functional precision medicine approach for differentiating responders from non-responders to BCL-2/MCL-1 targeted therapy. These findings suggest that the combination of voruciclib and venetoclax holds promise as a novel, exclusively oral combination therapy for a subset of high-risk DLBCL patients.

P1-261 - Up-front high-dose chemotherapy followed by autologous stem cell transplantation for high-risk aggressive lymphoma

Although the addition of Rituximab to chemotherapy has improved not only the response rate but also event-free survival of patients with diffuse large B-cell lymphoma (DLBCL), patients with high-risk DLBCL, including those with IPI high-intermediate (HI)-risk or high-risk diseases, those who are CD5 positive, and those with extranodal involvement, cannot attain sustained remission. Thus, new therapeutic strategies are needed for these patients. The present study retrospectively analyzed the effects of up-front high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (ASCT) on eight high-risk DLBCL patients with one or more of these poor prognostic factors at our institute. Progression-free survival (PFS) was defined as the time from ASCT until disease progression or death. The median age of the patients was 46.5 years (range, 35 to 65 years). Five patients were IPI HI-risk or high-risk, two patients were CD5 positive, and all patients had extranodal disease. The median time from diagnosis to ASCT was 6.6 months (range, 2.2-17.9 months). Patients who achieved a complete response (CR) or partial response (PR) after two to five cycles of R-CHOP followed by one to two cycles of salvage chemotherapy were given high-dose chemotherapy with either the MCVAC regimen (ranimustine, cytarabine, etoposide, and cyclophosphamide) or the LEED regimen (melphalan, cyclophosphamide, etoposide, and dexamethasone). Before transplantation, five patients achieved a CR, and two patients achieved a PR. After transplantation, all patients had a CR. One patient experienced thrombotic microangiopathy, and complete recovery was achieved after plasma exchange. After a median follow-up time of 46 months (range, 15-77 months), the 2-year PFS was 100%. All patients were alive with a CR at the last follow-up. In summary, high-risk DLBCL was effectively treated with up-front high-dose chemotherapy followed by ASCT with minimal treatment-related toxicity.

Silencing heme oxygenase-1 increases the sensitivity of ABC-DLBCL cells to histone deacetylase inhibitor in vitro and in vivo

Heme oxygenase-1 (HO-1) can promote tumor growth and reinforce the resistance of diffuse large B-cell lymphoma (DLBCL) cells to chemotherapeutic drug vincristine. We herein found that HO-1 protein expression was higher in high-risk DLBCL patients than in low-risk ones. Silencing HO-1 gene expression resisted vorinostat-induced apoptosis and arrested cell cycle in the G0/G1 phase of LY-10 cells. Western blot, co-immunoprecipitation and chromatin immunoprecipitation assays confirmed that the possible mechanisms may be increased cleaved caspase-3 protein expression, decreased phospho-histone deacetylase 3 protein expression, and activated histone acetylation of P27Kip1 promoter. Moreover, silencing HO-1 gene expression enhanced vorinostat-induced tumor cell apoptosis, prolonged survival time and promoted P27Kip1 protein expression in a xenograft mouse model.In conclusion, HO-1 is a potential therapeutic target of DLBCL. The findings provide a valuable preclinical evidence for sensitizing DLBCL patients with poor prognosis to histone deacetylase inhibitors.

Prognostic analysis of DLBCL patients and the role of upfront ASCT in high-intermediate and high-risk patients.

The role of autologous stem cell transplantation (ASCT) as a frontline treatment in patients with diffuse large B cell lymphoma (DLBCL) who are in their first remission has not been fully elucidated in the rituximab era. We analyzed 272 DLBCL patients who received 4–6 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) or R-CHOP followed by ASCT, from January 2005 to June 2013 in our institution. Multivariate analysis showed the none germinal center B cell (non-GCB) subtype (P=0.014, P=0.012) and International Prognostic Index (IPI) (3–5) (P=0.004, P=0.016) were independent unfavorable predictors of overall survival (OS) and progression-free survival (PFS), respectively. To investigate the treatment effect of upfront ASCT, we selected 94 high-intermediate and high-risk DLBCL patients who achieved complete remission after R-CHOP, with 41 in the ASCT and 53 in the non-ASCT groups. Survival analysis revealed patients who received upfront ASCT compared with those who did not had better OS (3-year OS: 74.5% vs. 50.4%, P=0.029) or PFS (3-year PFS: 59.6% vs. 32.1%, P=0.004), suggesting up-front ASCT following R-CHOP could improve the outcome of high-intermediate and high-risk DLBCL patients.

Influence of rituximab and central nervous system directed prophylactic therapy on central nervous system relapse in high-risk diffuse large B-cell lymphoma

Background: Central nervous system (CNS) relapse in patients with diffuse large B-cell lymphoma (DLBCL) although rare, can be devastating. Conflicting reports have been published regarding the protective effect of systemic rituximab therapy and likely reduction in incidence of CNS relapse in post-rituximab era. Methods: We retrospectively identified all the DLBCL patients at our institute between 2004 and 2014 who received systemic rituximab-based chemo-therapy at initial presentation. Patients were categorized into two groups, “standard risk” with no risk factors and “high risk” with one or more of the following risk factors, elevated lactate dehydrogenase (LDH) (above the institute normal), international prognostic index (IPI) ≥3, involvement of testis, breast, bone, kidneys, adrenal gland, retroperitoneal lymph nodes, para-meninges, and bone marrow. Descriptive statistics were used to analyze inci-dence of CNS relapse, patient and disease characteristics. Historically reported incidence rates were used for comparison. Results: A total of 122 patients received rituximab-based therapy at the initial diagnosis; 73 patients (60%) qualified for standard risk; 49 patients (40%) met the criteria for “high risk” based on the above definition. Standard risk group received no CNS directed prophylaxis and none of these patients had CNS relapse. Thirty-one of 49 (63%) “high risk” patients received CNS prophylaxis, mainly intrathecal (IT) methotrexate. Five patients (4.0%) developed CNS relapse in the entire study population. Percentage of patients developed CNS relapse in high-risk patients was 10.2% (5/49). Median time to relapse was 8.76 months and median survival after CNS relapse was 9.16 months. Four out of five patients who developed CNS relapse received prophylaxis with IT. Conclusions: CNS relapse continued to be a rare but devas-tating complication in post rituximab era, however our study confirms that majority of the DLBCL patients do not need CNS directed therapy. Current CNS directed therapies are probably inadequate to prevent CNS relapse in high risk DLBCL patients, therefore further research to develop better agents is needed in this area.

Low Expression of the CIITA Gene Predicts Poor Outcome in Diffuse Large B-Cell Lymphoma

BackgroundDespite better therapeutic options and improved survival of diffuse large B-cell lymphoma (DLBCL), 30-40% of the patients still experience relapse with a dismal prognosis. To identify biological correlates for poor survival, we compared differentially expressed genes between high-risk DLBCL patients, who had relapsed or remained in remission after dose-dense chemoimmunotherapy.Design and methodsWe performed genome-wide exon array analysis (Affymetrix Human Exon 1.0 ST) with 38 de novo high-risk (aaIPI>1) DLBCL patients less than 65 years old. The patients were treated in a Nordic phase II protocol with six courses of R-CHOEP-14 followed by systemic central nervous system prophylaxis with one course of high dose methotrexate and high dose cytarabine. We quantified the expression data by MEAP (Multiple Exon Array Preprocessing) algorithm and identified differentially expressed genes between the patients, who relapsed (n=9; poor prognosis group) or remained in long-term remission (n=29; good prognosis group). RNA sequencing and oligonucleotide-based microarray data from 92 (Cancer Genome Characterization Initiative, CGCI) and 233 (Lymphoma/Leukemia Molecular Profiling Project, LLMPP) DLBCL patients were utilized for validation. In both validation cohorts, the patients were treated with chemoimmunotherapy.ResultsGene expression profiling (GEP) identified 215 differentially expressed genes (DEGs) between the good and poor prognosis groups. Of these, 41% were upregulated and 59% suppressed in the patients with poor prognosis. Pathway analyses indicated that the DEGs were enriched in many immune response related processes, such as the antigen processing and presenting pathway. Of note was the observation that major histocompatibility complex class II transactivator (CIITA) and selected human leucocyte antigen- (HLA) genes were significantly suppressed in the poor prognosis group. A correlation between CIITA and HLA gene expression levels was also observed. In Cox univariate analysis with continuous variables, low CIITA expression predicted poor overall survival (OS; p = 0.035). Five-year OS rates were 89% and 50% for the patients with high and low CIITA mRNA levels, respectively (p = 0.007). The prognostic impact of CIITA expression on survival was confirmed in independent CGCI (OS; p = 0.020, PFS; p = 0.002) and LLMPP validation cohorts (OS; p = 0.002, PFS data not available). In the CGCI cohort, the association of CIITA expression with survival was independent of IPI. Consistent with previous data, suppression of certain HLA-genes was also associated with poor outcome.ConclusionsThe results demonstrate that low CIITA expression is a novel independent predictor of poor survival in patients with DLBCL. The loss of CIITA offers, through the loss of MHC class II expression, a mechanism of immune escape and treatment resistance. DisclosuresLeppä:Amgen: Research Funding; CTI Life Sciences: Honoraria; Janssen: Research Funding; Takeda: Honoraria, Other: Travel expenses; Roche: Honoraria, Other: Travel Expenses, Research Funding; Mundipharma: Research Funding; Bayer: Honoraria, Research Funding.

High Risk Diffuse Large B Cell Lymphoma: A Comparison of Aggressive Subtypes Treated with Dose Adjusted Chemotherapy-the University of Texas MD Anderson Experience

Background: Diffuse large B cell lymphoma (DLBCL) is the most common type of non Hodgkin lymphoma (NHL).Nearly 50% of high-risk DLBCL patients are not cured with standard rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (RCHOP). High risk DLBCL may be defined as double hit lymphoma (DHL, translocation of MYC and BCL2 or BCL6), double expressor lymphoma (DEL, over expression of MYC and BCL2), high risk international prognostic index (IPI) of 3-5, high Ki-67, and non-germinal center subtype (non-GCB). The majority of DHL cases occur in the GCB subtype, as opposed to the majority of DEL cases which occur in non-GCB. Hence we sought to compare different high risk subsets treated with dose-adjusted etoposide, doxorubicin, cyclophosphamide, vincristine, prednisone and rituximab (DA) EPOCH-R. In single arm phase II clinical trials, dose adjusted (DA) EPOCH-R has shown promising results, with potential greater efficacy in the GCB subtype in subset analyses (Wilson et al, Hematologica 2012). A randomized phase III study comparing RCHOP with (DA) EPOCH-R in newly diagnosed DLBCL has completed accrual, with highly anticipated results due in late 2016.Methods: We conducted a retrospective reviewof all consecutive, newly diagnosed DLBCL patients treated with (DA) EPOCH-R at MD Anderson Cancer Center from 2010 to 2014. Eligible patients were 18 years or greater, had high-risk DLBCL as determined by the treating physician, and had available data of treatment and response. The cell of origin subtype was determined by immunohistochemistry using Hans algorithm, and MYC and BCL2 positivity were defined as BCL2 positive in at least 70% and MYC positive in at least 40% of cells. DHL was defined as rearrangement of MYC and BCL2 or BCL6 by fluorescent in situ hybridization. The objectives were to analyze demographic, prognostic, and treatment variables in comparison with clinical response and survival outcomes in three sub groups which included 1. DHL (GCB) 2. DLBCL without MYC and BCL2 expression (GCB), and 3. DEL (GCB and non GCB). Complete response (CR), overall survival (OS) and progression free survival (PFS) were calculated using standard methods. Statistical analysis was done using Fishers exact test or Chi-square test / Kruskal-Wallis test. Kaplan-Meier method was used for time-to-event analysis including overall survival and progression free survival. The Log-rank test was used to evaluate the difference in time-to-event endpoints between patient groups.Results: We identified 233 high risk DLBCL patients treated with (DA) EPOCH-R. After filtering the data to identify patients which were included in our three groups, we identified 22 patients with DHL (GCB), 46 patients with non DEL (GCB), and 16 with DEL. The demographic features and outcomes are mentioned in the table 1 below. The DHL group had more frequent bone marrow (BM) involvement, and the DHL and DEL groups were more frequently age >60 years and high IPI in comparison to the non DEL GCB group. The CR rate, OS and PFS at 1 year were not significantly different between these three groups. Figure 1 highlights the OS (A) and PFS (B) results of each group.Conclusions: (DA) EPOCH-R is highly effective in patients with subsets of patients with high-risk DLBCL and may be able to overcome prognostic factors which have been shown to be adverse with RCHOP therapy. The results of this retrospective study suggest that OS in DHL, DEL and non DEL (GCB) are not statistically different. Hence, intensive chemotherapy with (DA) EPOCH-R could be considered as a frontline treatment option for patients with high risk DLBCL, pending further confirmation in randomized trials. [Display omitted] [Display omitted] DisclosuresOki:Novartis: Research Funding. Fowler:Infinity: Consultancy, Research Funding; Roche: Consultancy, Research Funding; TG Therapeutics: Consultancy; Celgene: Consultancy, Research Funding; Jannsen: Consultancy, Research Funding; Gilead: Research Funding. Wang:Pharmacyclics: Research Funding; Juno Therapeutics: Research Funding; Acerta Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Research Funding; BeiGene: Research Funding; Kite Pharma: Research Funding; Onyx: Research Funding; Asana BioSciences: Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Fayad:Seattle Genetics: Consultancy, Research Funding. Westin:ProNAi: Membership on an entity's Board of Directors or advisory committees; Spectrum: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Chugai: Membership on an entity's Board of Directors or advisory committees.

Low Rates of CNS Relapse in High Risk DLBCL Patients Treated with R-CODOX-M and R-IVAC: Results from a Phase 2 UK NCRI/Bloodwise Trial

Introduction: Central nervous system (CNS) relapse of diffuse large B-cell lymphoma (DLBCL) represents a major clinical challenge and is fatal in most patients. Recently Schmitz et al (J ClinOncol 2016), defined an effective risk model, the CNS-IPI, to identify those at highest risk of CNS relapse, based on the international prognostic index (IPI) score and presence of renal or adrenal involvement. For DLBCL patients receiving R-CHOP-like regimens +/- intrathecal methotrexate, the risk of CNS relapse for low, intermediate and high-risk patients was <1%, 3-4% and 10-12%, respectively. The optimum strategy for CNS prophylaxis, however, has yet to be defined.Aim: To assess CNS relapse rates in an intermediate-high risk cohort of patients with DLBCL treated with the R-CODOX-M R-IVAC regimen, incorporating multiple CNS-penetrating agents.Methods: Patients with newly diagnosed DLBCL and an IPI score ≥3 were enrolled in a prospective, multi-centre, phase 2 trial (McMillan et al, Hematol Oncol 2015; 31(S1), 130a) and treated with modified CODOX-M and IVAC, including high dose intravenous methotrexate, cytarabine, ifosfamide and etoposide with 8-12 intrathecal injections (Mead et al, AnnOncol 2002; 23(8):1264-74); plus 8 doses of rituximab. The primary endpoint was progression-free survival (PFS). CNS involvement was diagnosed according to neurological signs, radiological findings and/or demonstration of malignant lymphocytes within the cerebrospinal fluid. Involvement ofextranodal sites was prospectively documented at registration and at relapse. Presence of CNS, adrenal and renal involvement was confirmed using case report forms prior to this post hoc analysis.Results: 108 patients were treated at 32 UK sites between May 2008 and April 2013. Median age was 50 years (18-65 years). Eight patients (7.4%) had CNS involvement at baseline. Eighty-two patients (75.9%) received 4 cycles of treatment. At a median follow-up of 45 months, PFS and overall survival were 65.5% (95% CI: 55.5 - 73.8) and 73.7% (64.0 - 81.2), respectively. Progression or relapse within the CNS occurred in 5 patients (4.6%; Table 1) at a median of 5.5 months after registration (0.9-9.1 months). All patients died within 9 months of CNS relapse, 4 due to DLBCL and one treatment-related death.Excluding those with CNS involvement at baseline or incomplete information (n=4; 2 with missing baseline information (no CNS relapse) and 2 awaiting confirmation of CNS status at relapse), CNS-IPI was evaluable in 96 patients, of which 95% had an elevated LDH, 57% had a performance status of ≥2, and 8% were ≥60 years. All patients had stage III-IV disease, 76% had >1 extranodalsite and 27% had renal or adrenal involvement. Forty-one patients (43%) were intermediate risk (2-3 factors) and 55 (57%) were high risk (4-6 factors) for CNS relapse. 2-year CNS relapse rates were 0% for intermediate risk and 6.2% (2.0 - 18.1) for high risk patients (Figure 1). Of the 3 CNS relapses in high risk patients, 2 occurred concurrently with systemic relapse; there was only one episode of isolated CNS relapse.Of the 8 patients with CNS involvement at baseline, 2 (25%) developed CNS relapse, including 1 isolated CNS relapse. One further patient died of refractory DLBCL whilst 5 (62.5%) are alive and progression free with a minimum of 28 months follow-up.Conclusions: Inclusion of CNS-directed therapy intrinsic to the R-CODOX-M IVAC regimen resulted in very low rates of CNS relapse. Although patient numbers and low event rates make direct comparison difficult, results appear promising alongside historical results with R-CHOP chemotherapy. CNS relapse rates for both intermediate and high risk patients in this trial were below the 95% confidence intervals for CNS relapse reported in large training and validation cohorts by Schmitz et al (0% vs 2.2 - 4.4 and 2.3 - 5.5 for intermediate risk patients and 6.2% vs 6.3 - 14.1 and 7.9 - 16.1 for high risk). Of note, only 2 patients in the whole cohort progressed with isolated CNS disease, one of whom had CNS disease at diagnosis. Thus, where systemic disease was fully treated, treatment failure due to inadequate CNS penetration was rare. Reasonable outcomes were achieved in patients with CNS involvement at diagnosis but greater patient numbers are required to further evaluate this regimen in secondary CNS lymphoma. [Display omitted] [Display omitted] DisclosuresPhillips:Roche: Consultancy. Patmore:Roche: Honoraria; Janssen Cilag: Honoraria. Ardeshna:Roche: Membership on an entity's Board of Directors or advisory committees, Other: Conference Expenses, Research Funding. Montoto:Roche: Honoraria; Gilead: Research Funding.

The Role of MYC and BCL-2 Double Expression the in DLBCL Patients with Advanced Stage and Elevated LDH Who Received Upfront ASCT after R-CHOP

Diffuse large B-cell lymphoma (DLBCL) with MYC and BCL2 protein concurrent expression, double- expressor lymphoma (DEL), by immunohistochemistry (IHC) was related with poor prognosis. To investigate the role of upfront autologous hematopoietic stem cell transplantation (ASCT) in double-expresser lymphoma, we retrospectively evaluated 44 DLBCL patients with advanced stage and elevated LDH who received upfront ASCT. We used the cut off value of BCL2 was 50% and c-MYC was 40%. All patients were treated with frontline rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) chemotherapy.Median age of 44 patients was 52.0 years (range, 23 ~ 64 years). Two-year overall survival (OS) was 83.3% and progression free survival (PFS) was 76.6%. Double-expressor lymphoma (DEL) were detected 14 patients (31.8%). Two-year OS of the patients with DEL was 77.4%, non-DEL was 86.6%. Two-year PFS of the patients with DEL was 77.9% and non-DEL was 80.9%. Eleven (25.0%) patients were germinal center B-cell (GCB) subtype and 33 (75.0%) patients were non-GCB subtype. There was no survival difference between GCB and non-GCB subtype (Figure 1A, 1B). In the patients with GCB subtype, 2 (18.2%) patients were classified to DEL. OS and PFS were not different according to DEL. Among non-GCB subtype, the patients with DEL (n=12) showed the comparable OS and PFS compared to the patient with non-DEL (n=21). Two-year OS of DEL patients was 73.3%, non-DEL was 90.9%. Two-year PFS of DEL patients was 74.1 %, non-DEL was 82.6 (Figure 2A. 2B).In conclusion, MYC and BCL2 concurrent expression did not show the poor outcome among the high risk DLBCL patients treated with upfront ASCT regardless of molecular classification. It will be need to investigate the role of ASCT in these group of patients. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The different roles of molecular classification according to upfront autologous stem cell transplantation in advanced-stage diffuse large B cell lymphoma patients with elevated serum lactate dehydrogenase.

The non-germinal center B cell (non-GCB) subtype of diffuse large B cell lymphoma (DLBCL) is more related to poor prognosis than the GCB subtype. To investigate the role of molecular classification according to upfront autologous hematopoietic stem cell transplantation (ASCT), we retrospectively evaluated 219 newly diagnosed high-risk DLBCL patients. Eighty-one patients were in the ASCT group, and 138 patients were in the non-ASCT group. The ASCT group yielded significantly better overall survival (OS) and progression-free survival (PFS) than the non-ASCT group (p=0.038 and p=0.007), and patients with the non-GCB subtype were more related to inferior PFS than those with the GCB subtype (p=0.020). After performing age-matching by using propensity scores, upfront ASCT continued to show better OS and PFS than non-ASCT (p=0.046 and p=0.026). In the non-ASCT group, the non-GCB subtype showed worse OS and PFS than the GCB subtype (p=0.039 and p=0.007). Patients who achieved complete response showed differences in OS and PFS according to molecular subtype (p=0.007 and p=0.002). In the ASCT group, there were no significant differences in OS and PFS according to molecular classification (p=0.277 and p=0.892). In conclusion, non-GCB subtype DLBCL patients showed poor OS and PFS in the non-ASCT group while they did not show clinical significance in the ASCT group. This suggests the possibility that upfront ASCT may improve the poor prognosis of non-GCB subtype in high-risk DLBCL.