Subtype Of Lymphoma Research Articles

Abstract C112: L1CAM targeting antibody-based therapy as a novel approach for L1CAM positive lymphomas

Abstract Background. L1CAM (L1 Cell Adhesion Molecule) is a glycoprotein identified as a key mediator of the metastatic process in many different tumor types. It facilitates the detachment of tumor cells from the primary tumor and their entry into the circulation. By promoting cell-cell interactions, it also directly stimulates the colonization of distant organs by circulating tumor cells. The expression and role of L1CAM in B and T cell lymphomas is poorly explored. The aim of this project was to evaluate L1CAM expression in different subtypes of lymphoma and its role as novel therapeutic target. Methods. RNA was extracted with Monarch Total RNA Miniprep Kit and qPCR performed with QuantiFast SYBR Green RT-PCR. For flow cytometry (FACS), cells were stained either with anti-L1CAM antibody or isotype control at a dilution of 1:1000. For immunohistochemistry (IHC) samples were stained for 20 minutes at a dilution of 1:100. For direct killing assay, cells were exposed six days to compounds, followed by MTT assay. Antibody dependent cellular cytotoxicity (ADCC) was performed with ADCC Reporter Bioassay (Promega). Results. L1CAM mRNA expression was assessed in 59 lymphoma cell lines. Whereas expression in most cell lines appeared low, a subgroup of cells displayed high to very high expression of L1CAM. Surface L1CAM expression was confirmed by FACS. L1CAM mRNA and protein expression levels correlated well across the cell lines and revealed that Sezary syndrome (SS) cell lines displayed the highest expression, followed by mantle cell lymphoma (MCL) and activated B cell diffuse large B cell lymphoma (ABC DLBCL) cell lines. By IHC L1CAM expression was assessed on different tissue microarrays covering multiple lymphoma subtypes; L1CAM expression was observed especially in a subset of cutaneous T-cell lymphoma and MCL. The data confirmed the findings in lymphoma cell lines. Anti-L1CAM monoclonal antibody (mAb) and four L1CAM targeting antibody drug conjugates (ADCs) (ADC1, ADC4, ADC5, ADC6), differing for the linker and payload, were tested in L1CAM positive and negative cell lines. mAB did not show any sign of direct antitumoral activity. Among ADCs, highest activity was observed with ADC6 (SG3199 payload), followed by ADC4 (MMAE payload). ADC1 and ADC5 (also containing MMAE as payload) showed limited activity. ADC6 showed the best correlation between killing activity and L1CAM expression levels, indicating a high level of target specific activity. The in vitro activity of ADC4 and ADC6 was validated in an in vivo xenograft using the MCL cell line Z138. Finally, mAb and a bispecific anti-CD3/L1CAM antibody were tested for their ability to induce ADCC. Both induced strong intracellular signaling in the reporter cell line upon co-incubation with L1CAM expressing lymphoma cells, indicative of the induction of killing activity in effector cells. Conclusions. In summary, we have demonstrated the in vitro and in vivo activity of anti-L1CAM antibody-based therapeutic approach as novel treatment for L1CAM positive lymphomas. Citation Format: Filippo Spriano, Giulio Sartori, Luca Aresu, Luciano Cascione, Elisa Civanelli, Afua A. Mensah, Chiara Tarantelli, Stefano Pileri, Flavio Mehli, Gunther Spohn, Francesco Bertoni. L1CAM targeting antibody-based therapy as a novel approach for L1CAM positive lymphomas [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr C112.

Abstract A081: Patient-derived xenograft models from hematological malignancies for preclinical drug development and biomarker research

Abstract Background: Acute leukemias and lymphomas encompass a diverse group of hematologic malignancies, posing significant challenges in clinical practice. They often exhibit resistance to standard-of-care (SoC) treatments and have a high recurrence rate. Recent advancements in molecular profiling have identified potential drivers for various leukemia and lymphoma subtypes, offering new therapeutic targets. However, the validation of these targets and the development of drugs rely heavily on preclinical models that faithfully represent the different clinical subtypes. These models play a crucial role in refining target selection and facilitating drug development projects. Methods: AML- and ALL-PDX were derived from bone marrow aspirates or peripheral blood samples, from primary or relapsed acute leukemia patients. Purified cells were transplanted either intravenously (i.v.) and/or subcutaneously (s.c.) into immunodeficient mice. Some mice developed a systemic AML, which was monitored by flow cytometric analysis of blood samples. Non-Hodgkin (NHL) - or Hodgkin lymphoma (HL)-PDX were derived from peripheral blood, lymph node extirpations or core needle biopsies, and were usually transplanted subcutaneously into immunodeficient mice. Results: More than 45 PDX models from AML, ALL, NHL and HL have been successfully established and characterized. Highly individual response rates to SoC and investigational drugs were observed and correlated with mutation and gene expression data. An individual Human Leucocyte Antigen (HLA) profile of each PDX was determined by RNA-seq and a comprehensive HLA matching analysis of the models and peripheral blood mononuclear cell (PBMC) donors was performed to enable personalized, preclinical immuno-oncology studies. Conclusions: Our extensively characterized PDX models derived from hematologic malignancies serve as valuable tools for evaluating novel targeted and immunological therapies. These models provide an exceptional platform for identifying and validating new targets, as well as preclinical screening of compounds and combinations for translational research projects in this field. Citation Format: Antje Siegert, Bernadette Brzezicha, Stephan Fuhrmann, Martin Janz, Clemens Schmitt, Ulrich Keller, Christian Rupp, Wolfgang Walther, Jens Hoffmann. Patient-derived xenograft models from hematological malignancies for preclinical drug development and biomarker research [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr A081.

Abstract B170: The in vitro anti-tumor activity of the multi-kinase inhibitor nemtabrutinib (ARQ-531, MK-1026) is seen across multiple B-cell lymphoma subtypes, only partially overlapping with what achieved by single BTK inhibition

Abstract Background. Nemtabrutinib is a reversible, ATP competitive tyrosine kinase inhibitor of BTK and of several other kinases, including LYN and MEK1 (Reiff et al, Cancer Discov 2018). Nemtabrutinib has shown preclinical and clinical activity in chronic lymphocytic leukemia (CLL), also against tumors bearing mutations affecting the C481 amino acid of BTK (Reiff et al, Cancer Discov 2018; Eradat et al, ICML 2023), which is commonly mutated in patients treated with 1st and 2nd generation inhibitors such as ibrutinib, acalabrutinib, zanubrutinib (Thompson & Tam, Blood 2023). Based on these data, a phase 3 trial is comparing the drug against chemo-immunotherapy in untreated-CLL patients (NCT05624554). Phase 1/2 studies are currently exploring nemtabrutinib in various B-cell lymphomas as single-agent (NCT05673460, NCT04728893) and combined with the ROR1-targeting antibody drug conjugate zilovertamab vedotin (NCT05458297). Due to the ability of nemtabrutinib to block multiple kinases, we exposed a large series of lymphoma cell lines to nemtabrutinib to understand the lymphomas that might most benefit. Methods. Nemtabrutinib (MedChemExpress) was assessed for its anti-proliferative activity at 72h across 54 cell lines, comprising germinal-center B-cell like (GCB) DLBCL (n.=18), activated B-cell like (ABC) DLBCL (n.=8), mantle cell lymphoma (MCL) (n.=10), marginal zone lymphoma (MZL) (n.=6), CLL (n.=2), plus other two derived from B- and eight from T-cell (n.=8) lymphomas. Results. The median IC50 for nemtabrutinib was 1.4 µM (95%CI, 0.8-2.3 µM) across all 54 lymphoma cell lines tested. Higher activity was found in B (median-IC50, 1.1 µM) compared to T (median IC50, 22.6 µM) cell lymphomas. Strong anti-lymphoma activity was observed in CLL cell lines (median IC50, 389 nM), MCL (median IC50, 627 nM), in one primary mediastinal B cell lymphoma (815 nM) and one canine diffuse large B-cell lymphoma cell line (389 nM). No difference was seen between ABC (median IC50, 1 µM) and GCB (median IC50, 1.2 µM) DLBCL. In DLBCL, nemtabrutinib anti-tumor activity was not affected by the presence of inactive TP53, BCL2 and/or MYC translocations. Taking advantage of publicly available ibrutinib data, we observed that nemtabrutinib and the 1st generation BTK inhibitor behaved similarly across 45 lymphoma cell lines (Pearson correlation r=0.5, P=0.001), especially in MCL (r=0.8, P=0.005) and ABC-DLBCL (r=0.75, P=0.039), but not in GCB-DLBCL, in which only nemtabrutinib was active. Further analyses integrating baseline transcriptome and mutational data are underway. Conclusions. Nemtabrutinib showed anti-tumor activity across B-cell lymphomas, higher in some histotypes (including MCL, CLL). The pattern of anti-tumor activity was only partially overlapping by what achieved by the BTK inhibitor ibrutinib: while MCL and ABC-DLBCL responded similarly, activity in GCB-DLBCL was seen only with nemtabrutinib. Citation Format: Giulio Sartori, Filippo Spriano, Luciano Cascione, Chiara Tarantelli, Alberto J. Arribas, Luca Aresu, Davide Rossi, Giovanna Damia, Massimo Broggini, Francesco Bertoni. The in vitro anti-tumor activity of the multi-kinase inhibitor nemtabrutinib (ARQ-531, MK-1026) is seen across multiple B-cell lymphoma subtypes, only partially overlapping with what achieved by single BTK inhibition [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr B170.

Diagnostic peculiarities of lymphomas in the cervical region in children

Thisarticle discusses various aspects of pediatric lymphadenopathy, focusing on Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). It outlines common etiologies, diagnostic techniques, and key characteristics of differ- ent lymphoma subtypes. HL is classified into classical HL (CHL) and nodular lymphocytic predominant HL (NLPHL), while NHL includes Burkitt lymphoma (BL), lymphoblastic lymphoma (LBL), diffuse large B-cell lymphoma (DLBCL), and anaplastic large cell lymphoma (ALCL). The text emphasizes the importance of accurate diagnosis through various tests, including imaging modalities such as positron emission tomography (PET) and computed tomography (CT). It also discusses the potential use of ctDNA as a prognostic marker and highlights genetic alterations contributing to lymphoma development. The relevance of these findings for pediatric patients and their impact on treatment strategies is emphasized throughout the text.

A Case of Diffuse Large B-cell Lymphoma Transformed from Primary Thyroid MALT Lymphoma

Diffuse large B cell lymphoma (DLBCL) is main subtype of primary thyroid lymphoma and can be histologically transformed from a low-grade B-cell lymphoma. The characteristics and treatment guidelines of these particular DLBCL have not been fully established. The mainstay of treatment of primary thyroid DLBCL is multimodality treatment with chemotherapy and radiotherapy. Meanwhile, surgery can be considered only for diagnosis or alleviation of airway compressive symptoms.A 57-year-old female visited our outpatient clinic for recently enlarged long-held anterior neck mass. A thyroid mass compressing the airway and esophagus was identified on imaging, which was diagnosed as MALT lymphoma by excisional biopsy. After staging, the patient underwent total thyroidectomy with regional lymph node dissection for treatment of stage IIE MALT lymphoma and relieving airway compromise symptoms. The final diagnosis was DLBCL transformed from MALT Lymphoma, and chemotherapy was additionally performed. We report this rare experience with a review of literature.

Spectrum of Lymphomas involving Gastrointestinal tract in a Single Institution: A Retrospective Analysis

Abstract Introduction/Objective Lymphomas affecting the gastrointestinal (GI) tract are relatively uncommon occurrences. Given that GI biopsies are primarily evaluated by pathologists specializing in GI pathology, a comprehensive understanding of GI lymphomas is essential for accurate diagnosis and appropriate referral. However, there is limited updated studies of the prevalence and distribution of GI lymphoma subtypes in diverse patient populations. Therefore, the objective of this study was to address this knowledge gap by characterizing the prevalence and distribution patterns of GI lymphoma subtypes in a diverse patient population residing in the west coast region. Methods/Case Report A comprehensive retrospective review was conducted on patients diagnosed with lymphomas involving GI tract between 2015 and 2023 at a single institution over 8 years. Clinical and pathological data, including age, gender, tumor locations, and histological diagnoses, were collected and analyzed. Results (if a Case Study enter NA) A total of 32 cases diagnosed with lymphomas involving GI tract were included in this study. The patient population consisted of 44% female and 56% male, with an average age of 61 years (range: 35 to 93 years). The most common tumor locations (figure 1) were the stomach (53%), followed by the duodenum (16%), ileum and colon (8%). The other less frequent locations such as the pancreas, jejunum, and rectum and esophagus (each 3%). Notably, 38% (12 cases) of the total cases exhibited involvement of two or more anatomical sites. Conclusion Our study findings are consistent with previous literature, confirming that Diffuse Large B-cell Lymphoma (DLBCL) remains the most prevalent subtype of gastrointestinal (GI) lymphoma. The high frequency of stomach involvement aligns with the recognized association between Helicobacter pylori infection and lymphomagenesis. However, it is worth noting that the prevalence of MALT lymphoma has decreased, potentially indicating improved eradication efforts through antibiotic treatment. The observed proportion of cases with involvement of multiple anatomical sites highlights the diagnostic challenge of GI lymphomas and emphasizes the need for comprehensive evaluation.

Prephase Cyclophosphamide: An Advantageous Bridge to Definitive Therapy

Background Classic Hodgkin lymphoma (cHL) and aggressive non-Hodgkin lymphoma (NHL) account for an estimated 0.5% and 4.1% of all new cancer diagnosis in the US in 2023, respectively. At time of diagnosis, approximately 43% of cHL and 53% of NHL are staged as advanced disease (stage III-IV). While these diseases are considered curable, standard treatments involve intensive combination chemotherapy that may preclude certain patients from receiving optimal therapy. One option to minimize risks is to use prephase cyclophosphamide (pCy) as an initial treatment in aggressive lymphomas. There is however limited data on the utility, adverse effects, and outcomes of this approach. Here we present data on our institutional experience of employing pCy for patients ineligible for intensive chemotherapy. Methods We performed a single institution, retrospective chart review of patients with history of cHL and NHL that received cyclophosphamide (Cy) as an initial chemotherapy during hospitalization. Lymphoma subtype, medical history, baseline bloodwork at time of treatment initiation, outcomes including transplant, relapse data and overall survival were collected. Fifty patients received pCy at 200 mg/m2 with the remaining four receiving 100 mg/m2, 150 mg/m2, or 300 mg/m2 based on provider preference. Corticosteroids, including prednisone, dexamethasone or methylprednisolone, were administered simultaneously with varying duration and dosage. We analyzed hepatic and kidney injury at the time of diagnosis, after initiation of pCy and time to recovery. Acute kidney injury (AKI) was defined as an increase in creatine more than 30% from baseline and hepatic injury was defined based on Common Terminology Criteria for Adverse Events (CTCEA) version 5. Charlson scores for all patients were collected. Results Fifty-four patients received pCy as a bridge to possible definitive therapy. The most common diagnosis was diffuse large B-cell lymphoma (DLBCL) and cHL, with 29 (53.7%) and seven (13%) patients, respectively (Figure 1). The median age was 56 years (18-84) with 21 (39%) patients >65 years. Advanced stage was observed in 49 (90.7%) patients. Four patients required treatment for tumor lysis syndrome (TLS) prior to initiation of pCy. Nineteen (35%) patients had AKI and 15 (28%) patients had hepatic injury at the time of initial presentation. Five patients experienced AKI from pCy with an average time to recovery of 11.2 days. Six patients, with only two having concurrent AKI, had hepatic injury from pCy with an average time to recovery of 8.5 days. PCy allowed 42 (78%) patients to undergo definitive treatment in respect to their lymphoma subtype. Eight (14.8%) patients went on to receive a consolidative autologous transplantation (HSCT) after reaching a remission from definitive therapy. At the time of our analysis, 30 (55%) patients are deceased which includes four patients that underwent HSCT. Of the 30 deceased, 10 patients were transitioned to comfort care during the admission after receiving pCy. Median overall survival is 370.5 days. Conclusion Based on our institutional experience, pCy is a reliable method to salvage patients with aggressive lymphomas that are not candidates for intensive chemotherapy. In our analysis, pCy allowed 78% of patients to receive definitive therapy for their respective lymphoma. In general, patients receiving pCy required hospitalization related to disease burden and pCy represents an effective and cost-efficient bridging strategy to outpatient treatment. Cyclophosphamide has a broad indication across hematologic malignancies and is a well-tolerated chemotherapy with a limited side effect profile. The modest dosing in combination with corticosteroids allows initial disease control and provides the ability to start definitive therapy in a timely manner. Additionally, we feel that pCy should be considered when designing clinical trials in an effort to promote enrollment of the “real-world” patient.

Decoding the DIC-Lymphoma Relationship: A Nationwide Analysis of Increased Risk in Adult Patients

Background: Disseminated intravascular coagulation (DIC) is a severe, often fatal condition characterized by systemic coagulation activation leading to both widespread microvascular thrombosis and profuse hemorrhaging. Frequently associated with malignancies, DIC represents a serious clinical challenge. Lymphomas, characterized by their clinical diversity and varying prognoses, may present differing DIC risks across their subtypes. Aim of the study The study aims to understand how various lymphoma subtypes influence the development of DIC in hospitalized individuals, utilizing data from a national inpatient sample. Methods and Materials This study retrospectively examines a cohort of adult patients in the United States, hospitalized with DIC, both with and without lymphoma, utilizing the 2020 National Inpatient Sample (NIS). Patients were identified using the International Classification of Diseases (ICD-10) codes. Patients who were younger than age 18 years were excluded from the study. We used STATA for our analyses. Fisher's exact test was utilized for comparing proportions, while Student's t-test was employed for the comparison of continuous variables. We performed a multivariate logistic regression analysis, taking into consideration various patient, and hospital characteristics including age, gender, race, median zip income, insurance status, hospital geographical region and location, bed size, urban or rural setting, teaching status to identify the adjusted odds ratio for the development of DIC in different lymphoma subtypes. The Charlson comorbidity index was utilized to account for the burden of comorbidities in the analysis. Results Among 48,310 adult DIC patients in the 2020 NIS dataset, 2.48% concurrently had lymphoma. A significant disparity was noted in gender distribution, with fewer females in the lymphoma group (40% vs 49%, p=0.0135). Patients with lymphoma were, on average, older with a mean age of 62.72 years. The racial composition between the two groups was not significantly different (p=0.651). The odds of developing DIC were significantly increased overall in lymphoma patients (aOR=2.14, p <0.001). Of the lymphoma subtypes, other specified types of T/NK- cell lymphoma (natural killer) (grouped under the ICD-10 code: C86, and further sub-categorized into extra-nodal NK/T cell lymphoma, hepatosplenic, intestinal, subcutaneous, angioimmunoblastic, primary cutaneous T cell lymphoma, and blastic NK-cell lymphoma) exhibited the highest risk of DIC development (aOR=16.85, p <0.001). Non-follicular, mature T-NK-cell, other specified and unspecified types of Non-Hodgkin, and Hodgkin lymphomas also showed significant DIC risks (p<0.05), whereas no statistically significant risks were found in follicular lymphoma (p=0.753) and malignant immunoproliferative diseases and certain other B-cell lymphomas (p=0.726). See Table 1 for further details. Conclusion: This study underlines a significant association between lymphoma and elevated risk of DIC, with the highest odds observed in other specified types of T/NK- cell lymphoma. Clinical diversity within lymphoma subtypes influenced DIC risks differently, underlining the importance of individualized care. In clinical practice, increased vigilance for DIC is suggested in lymphoma patients. Prompt identification and management of DIC in this patient population could potentially improve outcomes in healthcare optimization. Further studies are warranted to elucidate the underlying mechanisms and to explore potential targeted interventions.

No Discernable Dysfunction of Peripheral T-Cells and NK-Cells Despite Distinct Phenotypes in MYC Rearranged Versus Non Rearranged B-Cell Lymphoma Patients

Background: Patients with diffuse large B-cell lymphoma/high-grade B-cell lymphoma with MYC and BCL2 rearrangements (DLBCL/HGBL- MYC/BCL2, hereafter HGBL- MYC/BCL2) respond poorly to standard immunochemotherapy treatment compared with DLBCL not otherwise specified (LBCL-NOS) patients without a MYC rearrangement. This suggests a negative interaction between MYC and the immune system. As novel T-cell and NK-cell based immunotherapeutic approaches emerge as potential treatment options for aggressive lymphomas, we conducted comprehensive immune profiling to compare peripheral blood T-cells and NK-cells of HGBL- MYC/BCL2 with LBCL NOS patients. Methods: Peripheral blood mononuclear cells (PBMCs) were prospectively collected from HGBL- MYC/BCL2 patients (registered in the HOVON-152 trial, NCT03620578), LBCL-NOS (registered in the HOVON-902 cohort, NCT04139252) and age-matched healthy donors (HDs). Flow-cytometry-based immune profiling of T-cells and NK-cells was performed on baseline samples available from n=66 HGBL- MYC/BCL2 patients (median age 62 years), n=67 LBCL NOS patients (median age 69 years) and n=17 HDs (median age 64 years). The flow cytometry data were computationally analyzed using FlowSOM and UMAP. T-cells were also functionally assessed for intracellular cytokine secretion (ICS) after stimulation with PMA/ionomycin (4h) and proliferation after stimulation with CD3/CD28 beads (5 days) using CellTrace Violet. NK-cells were assessed for cytotoxicity against K562 and degranulation (CD107a/b upregulation) after 4h. Mann-Whitney's U tests were used to compare HGBL-MYC/BCL2 patients with LBCL-NOS patients (primary comparison), and for pairwise comparisons of the lymphoma groups with HDs. To correct for baseline characteristics (age), linear regression analysis was performed. Results: CD4 + helper T-cells did not significantly between the lymphoma subgroups, but were decreased in LBCL-NOS patients as compared to HDs. Frequencies of cytotoxic CD8 + and CD4 +CD8 + T-cells did not significantly between the lymphoma subgroups and were similar as in HDs. Regulatory T-cell (Treg) frequencies of HGBL- MYC/BCL2 patients were similar to that of HDs, but were decreased in LBCL NOS patients. The frequency of CD4 -CD8 - T-cells was increased in LBCL NOS patients. Previously activated (HLA-DR +) CD4 + and CD8 + T-cells, as well as recently activated CD25 +, CD38 + or CD127 + CD4 + T-cells (Figure 1A) or activated/exhausted (PD-1 +) CD4 + T-cells and PD1 + Tregs were increased in both lymphoma subtypes (Figure 1B), but only HGBL- MYC/BCL2 displayed an increase in PD1 + CD8 + T-cells (Figure 1B). Conversely, recently activated CD8 + T-cells were decreased exclusively in LBCL NOS. HGBL- MYC/BCL2 patients and HDs had similar percentages of T-cells with a senescent phenotype (CD28 -CD57 +KLRG1 +), but the frequency of T-cells with this senescent phenotype was increased in LBCL NOS patients (Figure 1A), also after adjustment for age. Despite all these phenotypic differences, functional in vitro assays detected no differences in proliferation or cytokine secretion of peripheral T-cells from HGBL- MYC/BCL2 patients, LBCL NOS patients and HDs. In the NK-cell compartment, both lymphoma subtypes contained lower frequencies of CD56 brightTim3 +, CD56 bright/dimDNAM-1 + NK-cells, but LBCL NOS patients expressed a higher amount of NK-cells expressing inhibitory receptor NKG2A compared with HDs. NK-cells of HGBL- MYC/BCL2 patients, LBCL NOS patients and HDs displayed similar cytotoxic activity, suggesting no apparent functional impairment. Conclusions: HGBL- MYC/BCL2 patients have a distinct peripheral T-cell and NK-cell phenotype from LBCL NOS patients without a MYC rearrangement, but show no apparent functional deficiencies in terms of proliferation, cytokine secretion or cytotoxic activity. These results are not contradicting the application of T-cell and NK-cell based immunotherapeutic approaches for patients with aggressive B-cell lymphoma. Simultaneously, it emphasize the need to investigate the potential immunomodulatory impact of lymphoma intrinsic MYC in the tumor microenvironment.

Phase 1 Study of Autologous Sirpα-Low Macrophages (SIRPant-M) Administered By Intratumoral Injection Alone or in Combination with External-Beam Radiotherapy in Patients with Relapsed or Refractory Non-Hodgkin Lymphoma (NCT05967416)

Background and Significance. While a sentinel role of macrophages in channeling immune responses has long been recognized, the opportunity to harvest, harness and deploy macrophages for therapeutic potential has been underappreciated clinically. Most currently marketed and development-stage cell therapies target a single tumor-associated antigen, permitting activation of resistance and tumor escape mechanisms that frequently lead to relapse. High rates of CRS and neurotoxicity (ICANS) associated with CAR-T therapies complicate usage, with associated product labeling that includes a Risk Evaluation and Mitigation Strategy (REMS), mandating hospitalization and post-therapy monitoring with attendant administrative burden that precludes widespread use in community-based settings. Moreover, many subtypes of lymphoma (NHL) lack a readily druggable target. The current first-in-human Phase 1 study advances a novel paradigm in cell-therapy, deploying SIRPα-depleted activated macrophages, manufactured from an autologous mononuclear apheresis (SIRPant-M). In the context of macrophages, SIRPα acts as a strong negative regulator of (i) phagocytosis and (ii) productive pro-inflammatory T cell stimulation; therefore abrogation of SIRPα-activity serves as a necessary precondition for robust neo-antigen-specific anti-tumor responses. Requiring no genetic modification, in pre-clinical models these SIRPα-depleted macrophages orchestrated an immune response that targets multiple individual-specific and tumor-unique neo-antigens in parallel. SIRPant-M elicits a multi-pronged polyclonal immune response that transforms the tumor microenvironment (TME) by fostering a pro-inflammatory milieu that provides for unencumbered and orchestrated targeting of cancer cells via both cellular and humoral effector mechanisms. Manufactured and subsequently frozen as 3 aliquots from a single apheresis, activation of macrophages is brought about by conditioning the macrophages during ex vivo culture with a proprietary cytokine cocktail (PhagoAct™) with the added effect of modulating activity of SIRPα. This combination of product attributes permits the same cell product to have potential clinical applications in both solid tumor and hematologic malignancies. While this initial Phase 1 study administers the macrophages by intra-tumoral injection (ITI), subsequent studies aim to explore IV-dosing. Study design, methods and patients. This is a multicenter open-label Phase 1 study of SIRPant-M monotherapy, with sequential cohorts receiving low [90×10 6] and high [300×10 6] ITI cell doses. Cell product is administered alone or combined with focal external-beam radiotherapy (XRT). Each cell dose is administered in 3 ITI-fractions on days 1, 3, and 5 over 1 cycle. Upon confirmation of safety as a single agent, subsequent cohorts receive cell product concurrent with focally directed radiation in three 2.5 Gy fractions (7.5 Gy total). The primary end point, Dose Limiting Toxicity, is assessed over 30 days and dose escalation is gated by a standard 3+3 dose escalation design, overseen by a Safety Monitoring Committee. The enrollment target is 12-24 DLT-evaluable patients. The study enrolls an “all comers” B- and T-cell NHL population, including systemic and cutaneous histologies (CTCL), with relapsed or progressive disease following a minimum of 2- but no maximum number of prior therapies. Minimum age is 18, with no upper age limit. Prior CAR-T, bi-specific antibody and/or autologous/allogeneic transplant is allowed after recovery from treatment-related AEs. Patients must not receive immuno-suppression for GVHD and must have at least 1 target lesion that is 1.5 to 5 cm in diameter and accessible for safe ITI, ECOG ≤ 2, life expectancy > 3 months, renal/hepatic/coagulation parameters and blood counts that are standard for Phase 1 studies at baseline. Secondary and Exploratory Endpoints. Tumor response, including abscopal response, is evaluated by Lugano criteria or other Workgroup criteria as appropriate for the tumor type at the end of the DLT-period (Day 30), Week 12 and per SOC thereafter. Serial blood samples and a tumor biopsy before and 16 days after treatment are collected for multi-parameter analyte detection including pro-inflammatory cytokines, multiplex flow cytometry, scRNA sequencing, and ctDNA analysis to investigate pharmacodynamics and mechanism of action.

Targeting Aberrantly Activated Glycolysis in Natural Killer T Cell Lymphomas

Background and aims: With advances in the diagnosis and treatment of malignant lymphoma, improvements in long-term survival have been achieved for most common lymphoma types. However, natural killer/T-cell lymphoma (NKTL), which is rare in Europe and North America (0.3%) but relatively common in Asia and Latin America, has been left behind as a subtype of lymphoma with a high relapse rate and a poor prognosis. In particular, the outcome of patients with advanced or recurrent NKTL is dismal, with an overall survival of only a few months. This is mainly attributed to the intrinsic resistance of NKTL cells to anthracycline due to the high expression of P-glycoprotein. Molecular-targeted drugs used for other hematological malignancies, such as anti-CD30 and anti-CD52 monoclonal antibodies, have only limited effects on NKTL, and conversely, these drugs can cause severe immunodeficiency and severe autoimmune diseases, often with a fatal course. The development of NKTL-specific and effective molecular-target therapies is expected to improve the prognosis of NKTL. Methods: We performed a gene expression array targeting genes involved in glucose cell metabolism to compare the gene signatures of NK cell lines (NKL, NK92, YT, and KYHG1) and freshly isolated NK cells from three healthy donors (FNK). Results: The expression of various glucose metabolism genes was higher in NK cell lines than in FNK cells, and in particular, the PKM gene was highly enriched in NK cell lines. The PKM gene encodes the pyruvate kinase muscle isozyme 2 (PKM2), which is responsible for ATP production within the glycolytic sequence and plays an essential role in aerobic glycolysis (the Warburg effect), a dominant metabolic pathway used by cancer cells. Immunohistochemistry studies revealed high PKM2 protein expression in 17 out of 20 tumor tissues derived from patients with extranodal NK/T cell lymphoma. Treatment of NKL, NK92, YT, and KYHG1 cells with Benserazide or Shikonin, two known PKM2 inhibitors, robustly induced cell apoptosis in a time- and dose-dependent manner and inhibited colony formation in in vitro clonogenic assays. Western blotting studies showed a dose-dependent inhibition of STAT1 and STAT3 in NK cell lines exposed to PKM2 inhibitors. A colorimetric assay showed that PKM2 glycolytic activity correlated with the PKM2 gene expression in NK cells, with significantly higher glycolytic activity in malignant NK cell lines than in normal FNK cells. Further mechanistic studies showed that in normal FNK cells, PKM2 is mainly in the tetrameric form, where glucose is converted to pyruvate to generate ATP. In contrast, in malignant NK cell lines, PKM2 is mainly expressed in its dimeric form, with a low affinity for pyruvate and a higher affinity for glycolytic intermediates that promote the synthetic processes and thereby lead to persistent cell proliferation. Conclusions: These results substantiate the importance of aerobic glycolysis in malignat NK cells and indicate that targeting this pathway by blocking PKM2 activity has therapeutic potential for NKTL.

Inferred Gene Expression By Cell-Free DNA Profiling Allows Noninvasive Lymphoma Classification

Background : Current diagnostic criteria for mature B-cell tumors require a combination of histopathological, immunophenotypic, cytogenetic, and genetic evaluations on tissue biopsy specimens (Campo, Blood 2022; Alaggio, Leuk 2022). Despite this battery of techniques, substantial heterogeneity remains in specific subgroups that can be further resolved using additional molecular diagnostic methods, including gene expression profiling (GEP). For example, among aggressive B-cell tumors, a subset recognized as high-grade B-cell lymphomas can be identified as harboring MYC+BCL2 lesions by FISH (HGBCL-DH-BCL2). However, a significant remaining high-risk subset also have a characteristic tumor gene expression “double-hit signature” or “dark zone signature” (DZsig) (Ennishi, JCO 2018; Alduaij, Blood 2023). Yet, inadequate tissue specimens can limit the application of these techniques for some patients. Separately, the invasive nature of tissue biopsies and their attendant risks can preclude adequate diagnostic evaluations in some patients, and logistical barriers for obtaining surgical tissue specimens can result in diagnostic delays. To address these unmet needs, we tested the performance of a novel noninvasive strategy to detect and classify mature B-cell tumors using plasma cfDNA, with special attention to HGBCL-DH-BCL2 and DZsig. Methods : We used EPIC-Seq to infer expression levels for genes of interest, using cfDNA fragmentomic signals at their transcription start sites (Esfahani, Nat Biotech 2022). We first curated and catalogued genes from prior GEP studies (n=56) of >10k diverse lymphoid tumors profiled by various RNA techniques. We systematically prioritized genes recurrently identified in multiple studies of tumor-specific expression profiles as compared with other tumor types and normal tissues. We included canonical markers used for immunodiagnosis by IHC and FACS, as well as key lineage and differentiation markers of normal B and T cells, and other leukocyte subsets. Finally, we also included recurrently mutated genomic regions and fusion hotspots for quantifying ctDNA levels using variant allelic fractions (VAF). To validate performance of DZsig in FFPE for HGBCL-DH-BCL2, we analyzed 95 FFPE biopsies by FISH (20% HGBCL-DH-BCL2), IHC, and RNA-seq. We then analyzed 36 corresponding pretreatment cfDNA samples (28% HGBCL-DH-BCL2) and used EPIC-Seq to infer gene expression. Results: Starting from our curated catalogue, we designed a targeted lymphoid EPIC-Seq panel (1676 genes; 2.6 MB) to resolve 11 major mature lymphoid malignancies and their clinically relevant molecular subtypes (cHL, DLBCL, HGBCL, FL, MCL, BL, MZL, PMBCL, SLL/CLL, PTCL, and MM). We next applied this EPIC-Seq panel to profile cfDNA samples from 207 lymphoma patients, including cHL (n=113), DLBCL (n=66), FL (n=15), and MCL (n=13) as well as healthy adults to assess specificity. We tested histology specific signatures derived from several existing RNA GEP datasets for cHL from sorted HRS cells (~85k by scRNA-Seq) and for DLBCL (n=959), FL (n=635), and MCL (n=100) from bulk RNA-Seq. Using this approach, we found high correlations between EPIC-Seq signature scores from cfDNA and corresponding circulating tumor VAFs in each histology [cHL (R p=0.83), DLBCL (R p=0.83), FL (R p=0.87), MCL (R p=0.81); Fig A]. In addition, when measuring these tumor derived signatures in cfDNA, each histology was significantly distinguishable from healthy controls (AUCs: cHL 0.94, DLBCL 0.91, FL 0.77, MCL 0.96). We next evaluated the DZsig when measured in LBCL patients and comparing paired tumor and cfDNA samples. We first confirmed the performance of the DZsig for detection of HGBCL-DH-BCL2 in 95 FFPE tumors by RNA-Seq (p<0.0001, AUC 0.85). We then noninvasively measured the DZsig in plasma cfDNA by EPIC-Seq (cfDZsig) and found significant discrimination of HGBCL-DH-BCL2 and DLBCL (p=0.0088, AUC 0.78, Fig B). Conclusions: These results confirm that inferred gene expression by cfDNA profiling allows noninvasive diagnosis of multiple lymphoma subtypes, including classification of challenging diagnostic entities such as HGBCL and DZsig+ tumors. Our ability to design and validate a pan-lymphoid gene panel for detection and classification of several lymphoma subtypes suggests the promise of this approach for other diverse tumors as well as the refinement of cfDZsig using a larger cohort.

Impact of Progression-Free Survival at 24 Months on Subsequent Survival in Patients with Diffuse Large B-Cell Lymphoma Treated with R-CHOP Therapy: A Supplementary Analysis of JCOG0601

Introduction The impact of progression-free survival status at 24 months (PFS24) or event-free survival status at 24 months (EFS24) on subsequent survival has been evaluated in patients with various lymphoma subtypes. Patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) who achieve PFS24 or EFS24 generally have excellent outcomes. It has been observed that the overall survival (OS) after achieving EFS24 was not significantly different from that of the general population (M.J. Maurer. J Clin Oncol, 2014). However, the OS after achieving PFS24 was significantly worse than that of the general population (M.J. Maurer. Ann Oncol, 2018). Consequently, the impact of achieving PFS24 for DLBCL patients remains controversial. In this supplementary analysis, we evaluated the impact of achieving PFS24 on the subsequent survival of untreated DLBCL patients by using data from JCOG0601, a randomized phase2/3 study assessing the schedule of rituximab administration in combination with tri-weekly CHOP (Ohmachi K. Blood Adv, 2021). Methods Among 422 patients enrolled between Dec 2007 and Dec 2014 in JCOG0601, 409 patients were eligible for this analysis (Data cutoff date: Dec 19, 2017). PFS24 was defined as being alive without progression or relapse for 24 months from randomization. The protocol treatment was initiated within 7 days after randomization. OS from PFS24 was defined as the time from achieving PFS24 or the date of progression or relapse to death from any cause. We compared OS from PFS24 with that of age-, sex-, and calendar period-matched Japanese general population using standardized mortality ratios (SMRs). Similarly, PFS12 and PFS60, as well as OS from PFS12 and PFS60, were defined in the same manner as PFS24 and OS from PFS24. The log-rank P-values for OS were calculated. Results The baseline characteristics of the 409 patients were as follows: a median age of 62 years (range, 20-79), with males accounting for 56% (n=227) of the patients. At diagnosis, 46% (n=188) of the patients were Ann Arbor stage III or IV. The majority of patients (82%; n=335) were classified as international prognostic index low or low-intermediate risk. Based on the Hans algorithm for cell-of-origin, 51% (n=210) of the patients were categorized as non-germinal center B-cell type (non-GCB). At a median follow-up of 5.3 years among all patients, a total of 334 patients (82%) achieved PFS24, while 66 patients (16%) failed to achieve PFS24. Five patients died without progression within 24 months, and four patients were lost to follow-up within 24 months. Multivariable analysis revealed that risk factors for failing to achieve PFS24 included serum LDH levels higher than the upper normal limit and two or more extranodal lesions. Patients who achieved PFS24 had a significantly better OS than those who failed to achieve PFS24 (median OS, not reached vs. 1.3 years; P < 0.001). Similar results were observed when using PFS12 and PFS60, regardless of the cell-of-origin. Among the patients who failed to achieve PFS24, non-GCB type patients more frequently had relapsed or refractory diseases in extranodal sites (72%: n=26/36) compared to GCB type patients (43%; n=6/14). The OS after achieving PFS24 or PFS60 was not remarkably different from that of the general population (PFS24: SMR 1.29, 95% confidence interval [CI] 0.72-2.12, P = 0.39; PFS60: SMR 1.43, 95% CI 0.47-3.33, P = 0.55). However, the OS after achieving PFS12 was significantly worse than that of the general population (SMR 2.30, 95%CI 1.59-3.22, P < 0.001). The primary cause of death for patients achieving PFS12 was DLBCL with the cumulative incidence of more than 5% at 5 years, while the incidence of death due to DLBCL was less than 5% for those achieving PFS24. The primary cause of death for the patients achieving PFS24 was other diseases except for DLBCL and treatment-related toxicity, including secondary malignancies (n=4/7) and pneumonia (n=3/7). Conclusion Newly diagnosed DLBCL patients treated with R-CHOP who achieved PFS24 exhibited an excellent subsequent outcome, which did not differ from those of age-, sex-, calendar-period matched individuals in the general population. Our findings suggest that PFS24 achievement could serve as a surrogate endpoint for OS in DLBCL patients. Further research is warranted to establish the utility of PFS24 achievement as a reliable milestone in clinical practice.

Disparities in Clinical Outcomes of B-Lymphoblastic Lymphoma: A National Cancer Database Study with Focus on Hispanic Populations in the United States

BACKGROUND Lymphoblastic lymphoma, a rare non-Hodgkin's lymphoma subtype, exhibits striking cytological and histological parallels with acute lymphoblastic leukemia (ALL). Such similarities have led to its classification as precursor B and T lymphoblastic lymphoma/leukemia by the World Health Organization. Exhibiting a modest global incidence of 1 to 5 cases per 100,000 population, it is notable that two-thirds of cases of ALL cases are of B-cell phenotype (PMID 15698386). To deepen our comprehension of this rare disease, it becomes essential to understand its behavior across various demographics, particularly among Hispanic (HI) and Non-Hispanic (NH) populations in the United States (US). To bridge this knowledge gap, this pioneering nationwide study endeavors to unravel how demographic, clinical, and survival outcomes vary between HI and NH patients with this disease. METHODS: Data were analyzed on B-Lymphoblastic lymphoma patients in the US reported to the National Cancer Database (NCDB) between 2004 and 2019. Demographic and treatment characteristics were compared between ethnic groups. Kaplan-Meier and Cox regression analyses were used to compare OS between Hispanic and Non-Hispanic populations. Multivariate analysis and propensity score matching was performed with adjustment for age, stage, co-morbidity score, and insurance status, type of facility and great circle distance. RESULTS Of 989 B-Lymphoblastic Lymphoma patients, 16 were HI, and 81% NH. 53% of HI were male, compared to 57% of NH. At diagnosis, HI patients were younger (40 years vs. 56 years) (p=<0.001); the majority of HI 84% and NH 68% were diagnosed in the age bracket of < 65 (p=<0.001). With respect to race, most of both HI and NH were whites (87% vs 85%), followed by blacks (1% vs 10%). Examining the stage, most of both HI 45% and NH 47% were stage IV (p= 0.260). When looking at insurance type; private insurance was the most prevalent type in HI vs NH (42% vs 51%), followed by government-sponsored (40% vs 44%). The most uninsured group was HI 16% vs NH 3%. Considering Census Median Income (2008-2012), the most prevalent bracket for HI was Less than $38,000 (29%) and NH was $63,000+ (34%). When it comes to median income of less than $38,000, HI were 29% vs NH 16%. As for Charlson-Deyo Score (comorbidities score), HI had 10% =/> 2 scores, vs NH 8%. In terms of Academic/Research Programs, including NCI-designated comprehensive cancer centers, it was the most prevalent type of facility providing care for both HI 55% and NH 50%. Regarding the median distance in miles between the patient's residence and the hospital that reported the case (Great Circle Distance), HI lived at a median of 9.3 miles, vs NH at a median of 12.4 miles. On survival analysis; the survival probability at 2, 5, and 10 years of HI vs NH were (0.624 vs 0.552), (0.516 vs 0.435), and (0.458 vs 0.362), respectively. The median survival time (MS) was 10.0 years for HI, vs 3.1 years for NH; and there was an overall survival (OS) difference favoring HI with (p=0.017). On multivariate analysis, there were no independent variables associated with better or worse OS; however, the propensity matched analysis showed a striking MS difference between HI vs NH (3.02 y vs. 1.43 y). CONCLUSION This groundbreaking study provides crucial insights into the distinct demographic and clinical characteristics of HI and NH patients with B-Lymphoblastic Lymphoma in the US. Importantly, we found that HI patients were significantly younger at diagnosis, and despite having a higher percentage of uninsured individuals and lower median income, showed better survival outcomes compared to NH. These findings highlight the critical role ethnicity plays in disease presentation and prognosis, thus emphasizing the importance of culturally sensitive, tailored healthcare approaches. This study underscores the urgent need for further research to understand intrinsic biologic factors contributing to these disparities and enhance health equity in lymphoma care.

Red Cell Distribution Width-to-Albumin Ratio Is a Simple but Robust Prognostic Biomarker in Peripheral T-Cell Lymphoma

Background: Red cell distribution width (RDW) is the difference in the volume and size of erythrocytes. High RDW has been identified as a worse prognostic factor in various diseases, including sepsis, cerebrovascular accidents, and diverse cancers. More recently, RDW-to-albumin ratio (RAR) is a comprehensive biomarker combining inflammation and nutrition status that better reflects a patient's frailty. However, little is known about its prognostic relevance in peripheral T-cell lymphoma (PTCL), with only one publication focusing on RDW (Castro et al.). Methods: This retrospective analysis included consecutive patients with newly diagnosed PTCL between 2007 and 2023 at Kameda Medical Center. Extranodal NK/T-cell lymphoma, adult T-cell leukemia/lymphoma, and ALK-positive anaplastic large cell lymphoma were excluded due to distinct prognosis and treatment strategies. The RDW coefficient of variation (RDW-CV) was assessed prior to treatment and calculated using the following formula: 1 standard deviation of mean corpuscular volume (MCV) divided by MCV, multiplied by 100. Receiver operating curve (ROC) analysis was used to determine the optimal cutoff value of RDW-CV and RAR for 2-year outcomes. Survival analyses were conducted using Kaplan-Meier curves with log-rank tests, and Cox proportional hazard models were used for univariate and multivariate analyses. Results: In total, 115 patients were included in this analysis. The median age was 74 years (range 45-93), with male predominance (60.8%). Sixty-five patients (56.5%) were initially treated with the CHOP regimen, while 29 patients (25.2%) received more intensive chemotherapy. The most common disease subtype was PTCL-not otherwise specified (49.5%), followed by angioimmunoblastic lymphoma (40.0%). The median RDW-CV and RAR were 14.8 (range 12.2-21.5) and 4.61 (range 2.6-9.8), respectively. The RDW-CV was significantly correlated with levels of hemoglobin (R = -0.4), albumin (R = - 0.59), and lactate dehydrogenase (R = 0.27) (all P < 0.05). ROC curve analysis for 2-year survival revealed a higher area under the curve (AUC) for RAR (0.79) compared to RDW (0.74), with cutoff values of 4.4 and 14.1, respectively (Figure 1). Using this cutoff value, patients with high RAR had significantly worse overall survival (OS) and progression free survival (PFS) than those without (2-year OS rate: 82.5% vs. 35.1%, Figure 2; 2-year PFS rate: 54.8% vs. 27.9%, P <0.001). On multivariate analysis, high RAR was associated with a significantly worse PFS (hazard ratio [HR] =1.89 [95% confidence interval 1.15-3.11], P =0.01) and OS (HR=3.02 [1.66-5.50], P <0.001) independent of the international prognostic index (IPI), dose reduction of chemotherapy and lymphoma subtype. Conclusion: We demonstrated that RAR improved the prognostic stratification compared to RDW-CV alone. Additionally, baseline high RAR was identified as a simple but robust prognostic factor independently associated with IPI category and treatment intensity in PTCL patients.

Clinical Features and Outcomes of Hemophagocytic Lymphohistiocytosis Secondary to Lymphoma: Insights from a Tertiary Center in Saudi Arabia

Introduction: Lymphoma encompasses a prominent cause of secondary hemophagocytic lymphohistiocytosis (HLH), an aggressive hyperinflammatory syndrome characterized by immune dysregulation. The concurrence of lymphoma and HLH represents a challenging entity due to the ambiguity of clinical features and paucity of standardized treatment regimens. Limited data exists regarding the characteristics and outcomes of secondary HLH within the Middle East and Saudi Arabia. Moreover, the structure of the population within our region, characterized by a predominance of males and young adults, offers a unique perspective to the literature regarding secondary HLH. Herein, we evaluate the clinical features and outcomes of patients presenting with HLH secondary to lymphoma at a tertiary center in Saudi Arabia. Methods: We retrospectively reviewed the electronic medical records of patients diagnosed with lymphoma over the past ten years at our center to identify patients who developed secondary HLH. The Kaplan-Meier method was used to estimate median overall survival (OS). OS was defined as the incidence of death from any cause from the onset of HLH diagnosis until the end of follow-up. The Cox proportional hazards model was used to identify demographic, clinical, and treatment associated prognostic indicators which had a significant impact on OS. Results: A total of 1484 patients with lymphoma were identified, of which seventeen (1.1%) patients had concurrent HLH. Of the seventeen patients, the median age was 42 years (range 17-64) with 5 (29.4%) patients aged 50 and over. Interestingly, all 17 (100.0%) patients within our cohort were male. Regarding lymphoma subtypes, 10 (58.8%) patients had T and NK-cell lymphoma, 5 (29.4%) had B -cell lymphoma, and 2 (11.7%) had Hodgkin lymphoma. The median HScore was 272.0 (range 182-337) whereas the median HLH-2004 diagnostic criteria score was 6 out of 8 points (range 4-8). Hemophagocytic features in the bone marrow were present in 13 (76.5%) patients. Epstein-Barr virus infection was detected in 9 (52.9%) patients with a median quantitative PCR level of 37347.5 IU/mL (range 1960.0-402847.0). HLH therapy utilized in our patient sample included corticosteroids in 15 (88.2%) patients, etoposide in 8 (47.1%) patients, and intravenous immunoglobulin in 3 (17.6%) patients. Death occurred in 7 (41.2%) patients whilst the median OS of the cohort was 13.0 months (95% CI 0.0-27.4). Using the cox proportional hazards model, both age ≤50 years (P=0.04, hazard ratio=0.186) and etoposide administration (P=0.002, hazard ratio=0.011) were associated with significantly improved survival. Conclusions: To our knowledge, this is the first cohort study reporting the clinical features and outcomes of HLH secondary to lymphoma within our region. Our study highlights the significant disparities between our population and other countries across the globe as our cohort demonstrated a significant male predominance as well as a relatively young median age at diagnosis. Nonetheless, the survival outcomes of secondary HLH remain poor despite the advances in the diagnostication and recognition of the disease. Future efforts ought to explore both the pathophysiological mechanisms underlying lymphoma-associated HLH and the efficacy of different targeted therapeutic modalities.

Lymphoma Treatment Alterations in the Context of Autoimmune Disease

Background: Autoimmune disease (AD) confers an increased risk for lymphoma. Several studies have shown that pre-existing AD portends a worse prognosis for lymphoma patients, but the reasons for this are unknown. 1,2,3 We hypothesize that one reason may be poor treatment tolerance in AD patients due to concurrent risk for cytopenias, infections, and immune-related adverse events. Methods: We conducted a retrospective cohort study to understand whether AD is associated with higher risk for treatment alterations, hospitalizations, and transfusions among lymphoma patients. The study population consisted of adult patients (aged 18-74 at lymphoma diagnosis) who underwent lymphoma treatment at one tertiary care center from 2017-2022. Patients who developed AD after or within the 12 months before lymphoma diagnosis were excluded to avoid including patients whose AD was paraneoplastic or a treatment side effect. Subjects were found by using cohort builder in electronic medical record then reviewing records for eligibility. The primary exposure of interest was pre-existing diagnosis of AD and the primary outcome was treatment alteration, such as dose reduction, delay, or discontinuation. The secondary outcomes were hospitalization, and transfusion. Outcomes were compared between groups with non-parametric tests. Logistic regression was used to estimate the association of AD with any treatment alteration. Results: We reviewed 357 records, with 30 eligible for inclusion in AD cohort and 65 eligible for non-AD cohort. There were 17 different lymphoma types with diffuse large B cell lymphoma as the most common (10 in AD cohort, 20 in non-AD). In the AD cohort, there were 12 distinct autoimmune diagnoses and rheumatoid arthritis was the most common (n=11). Baseline patient characteristics did not differ between the AD and non-AD cohorts in age, sex, diagnosis, stage, renal function, hemoglobin or type of treatment received. However, patients in the AD cohort were more likely to be Black or Asian compared to the non-AD cohort (Table 1). There were no differences in frequency of treatment alterations, unplanned hospitalizations, or incidence of transfusion between the AD and non-AD groups. Logistic regression showed no association of study group with incidence of any treatment alteration, even after controlling for baseline characteristics. Discussion: This study examines whether autoimmune disease impacts treatment tolerance among lymphoma patients. In a Swedish retrospective study of lymphoma, worse outcomes were seen among patients with AD due to increased non-lymphoma risk of death, suggesting that AD patients may have more frequent serious and life-threatening complications from lymphoma therapy. 1 In our study, there were no differences in treatment tolerance between the AD and non-AD groups. However, sample size is a limitation, and chart review is ongoing. Notably, treatment alterations were common in both groups, and no increase in unplanned hospitalizations was seen in the AD group. Clinical decisions to dose reduce, delay or discontinue therapy may mitigate against hospitalization from serious treatment related complications even in lymphoma patients with concurrent AD. Future directions include examining interactions between treatment alterations, autoimmune disease, and prognosis in specific lymphoma subtypes. 1. Simard JF, Baecklund F, Chang ET, Baecklund E, Hjalgrim H, et al. Lifestyle factors, autoimmune disease and family history in prognosis of non-hodgkin lymphoma overall and subtypes. Int J Cancer. 2013 Jun 1;132(11):2659-66. doi: 10.1002/ijc.27944. Epub 2012 Dec 3. PMID: 23160780. 2. Jachiet V, Mekinian A, Carrat F, Grignano E, Retbi A, Boffa JJ, et al. Autoimmune manifestations associated with lymphoma: Characteristics and outcome in a multicenter retrospective cohort study. Leuk. Lymphoma. 2018;59:1399-1405 3. Kleinstern G, Averbuch M, Abu Seir R, Perlman R, Ben Yehuda D, Paltiel O. Presence of autoimmune disease affects not only risk but also survival in patients with B-cell non-Hodgkin lymphoma. Hematol. Oncol. 2018;36:457-462.

Longitudinal Patient-Reported Outcomes and Clinical Outcomes By VES-13 and Comprehensive Geriatric Assessment in Older Adults with Aggressive Non-Hodgkin Lymphomas

Background: Older adults with aggressive non-Hodgkin lymphoma (NHL) can experience durable remissions with therapy but also substantial toxicities and healthcare utilization. The Vulnerable Elders Survey (VES-13) is a 13-item tool assessing age, self-rated health, and ability to perform physical and functional activities (score of 3+ indicates vulnerability). The Fondazione Italiana Linfomi comprehensive geriatric assessment (CGA) assesses age, comorbidities, and ability to perform physical and functional activities and classifies patients as fit, unfit, or frail. Both the VES-13 and CGA hold promise to risk stratify older adults for poor outcomes. Few data are available comparing these tools in assessing risk for poor survival and healthcare utilization, and prior studies have not examined the impact of therapy on longitudinal patient-reported outcomes (PROs). Methods: We conducted a longitudinal prospective study of 105 older adults with aggressive NHL at Massachusetts General Hospital or the Dana-Farber Cancer Institute between 9/2020 and 1/2023. Eligible patients were age >= 65 years at time of treatment initiation receiving combination chemoimmunotherapy. Patients could enroll up until cycle 1 day 8 of therapy. Patients completed questionnaires at baseline and 6 weeks, 12 weeks, 18 weeks, and 6 months post therapy initiation assessing demographics, quality of life (QOL-Functional Assessment of Cancer Therapy-Lymphoma [FACT-Lym]), depression and anxiety (Hospital Depression and Anxiety Scale [HADS]), and physical symptoms (Edmonton Symptom Assessment Scale-revised [ESAS-r]). At baseline patients also completed the VES-13 and underwent CGA evaluated by an oncologist. We utilized linear mixed models to examine longitudinal QOL, depression, anxiety, and physical symptoms. We assessed univariate factors associated with longitudinal QOL. Using Cox regression models controlling for gender, age-adjusted International Prognostic Index (IPI), hypoalbuminemia, Charlson comorbidity index (CCI), and lymphoma subtype, we assessed the relationship of VES-13 and CGA in separate models with overall survival (OS). We also examined factors associated with unplanned hospitalization within 6 months of therapy start using logistic regression. Results: We enrolled 106/163 (65.0%) patients. 1 patient was excluded due to treatment with an ineligible therapy. Patients had a median age of 73 years (range: 65-99, 38.1% >75, 21.9% >=80); most were male gender (64.8%), White race (96.2%), and married/with a life partner (72.4%). The most common lymphoma subtypes were DLBCL (73.0%), DLBCL/high grade B-cell lymphoma with MYC and BCL2 translocations (12.4%), and mantle cell lymphoma (10.5%). The majority (56/104, 53.8%) had an age-adjusted IPI of 2 or 3, over a third (34.3%) had a CCI score of 2+, and 82.9% had an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-1. 45.7% (48/105) had a VES-13 score of 3+. 40.0%, 9.5%, and 50.5% were fit, unfit, and frail, respectively, on CGA. QOL, depression, anxiety, and physical symptoms all improved over time (Figure 1). QOL improved regardless of age group, VES-13 category (<3 vs 3+), or CGA result (Figure 1). Compared to other patients, those 80+ years with either VES-13 score 3+ (β= -2.90, p=0.045) or frail on CGA (β= -3.68, p=0.007) had a worse QOL trajectory. Income > $50,000 annually (β=2.41; p=0.041) was associated with better QOL trajectory. VES-13 score of 3+ (HR=6.08; p=0.014) and frail on CGA (HR=5.20; p=0.028) were both associated with worse survival. Of those with follow up (N=66), 8 died within 1 year (1-year OS=87.9%), all of whom were both frail on CGA and had VES-13 score 3+. 25.8% (8/31) of the CGA frail patients and 28.6% (8/28) of those with VES-13 3+ died within 1 year. VES-13 score (OR=1.16, p=0.028) was associated with greater likelihood of unplanned hospitalization. Conclusion: Older adults with aggressive NHL often experience improvement in QOL and other PROs with treatment, even across age and frailty categories. VES-13 score and CGA identify patient groups at high risk for early death and poor QOL trajectory, for whom novel therapies and supportive care interventions are warranted. Higher VES-13 score is also associated with higher risk of unplanned hospitalization. Routine assessment of VES-13 and CGA has high potential for early identification of high risk patients and implementation of appropriate interventions.

Risk of Transformation By Frontline Management in Follicular Lymphoma and Marginal Zone Lymphoma: A US Population-Based Analysis

INTRODUCTION Follicular lymphoma (FL) and marginal zone lymphoma (MZL) are commonly characterized by an indolent nature and favorable overall survival (OS). However, patients (pts) may experience high-grade transformation (HGT) into DLBCL, with an estimated annual risk of 1%-3% and cumulative incidence of HGT are 8% for FL and 10% for MZL at 10 and 12 years, respectively. The impact of treatment and surveillance strategies on the incidence of HGT remains uncertain, with some studies indicating reduced risk in treated pts without significant OS difference post-HGT. This study uses population-based data to assess the cumulative incidence and risk factors associated with HGT, post-HGT OS and lymphoma-specific survival (LSS) across lymphoma subtypes, with either treatment or surveillance as initial strategies. METHODS We extracted data for pts diagnosed with grades 1-2 FL, splenic MZL (SMZL), nodal MZL (NMZL), and extranodal MZL (MALT) from SEER database (period 2000-2015 with follow-up through 2018). We only included pts with histologic confirmed lymphoma as first malignancy, complete survival and treatment data, and a minimum of 3 months from FL and MZL diagnosis to HGT. Competing risk methods were used to estimate HGT cumulative incidence rates, with time to first event (HGT or death) defined from lymphoma diagnosis to date of first event; event-free pts were censored at date of last contact. Gray's test and Fine-Gray (FG) proportional subdistribution hazard modelling was employed to identify variables associated with risk of HGT. Post-HGT OS and LSS analyses utilized Cox and FG regression models, respectively. RESULTS 26827 pts met inclusion criteria. FL comprised 14229 pts (53%) while MZL types were SMZL 1182 (4.4%), NMZL 3916 (14.6 %) and MALT 7500 (28%). Treatment was given at diagnoses in 60.2%, 33.7%, 53.8% and 49.8% of pts with FL, SMZL, NMZL, MALT, respectively. 864 (3.2%) pts developed HGT to DLBCL, 553 (3.9%) in FL and 311 (2.5%) in MZL pts. After a median follow-up of 84 months (range 1-227), the 10-year cumulative incidence of HGT were for FL 4.24% (95%CI 3.88%-4.62%), SMZL 6.46% (95%CI 4.98%-8.20%), NMZL 3.28% (95%CI 2.70%-3.95%) and MALT 1.73% (95%CI 1.42%-2.09%). In FL, the 10-year cumulative incidence of HGT was 3.83% (95%CI 3.40-4.31%) in treated pts and 4.88% (95%CI 4.26%-5.54%) for those under surveillance (SHR=0.80, 95%CI 0.68-0.94; p=0.009) (Figure 1). This finding was confirmed in a multivariable analysis (p=0.001) that conversely identified female gender (p<0.001) and advanced stage at diagnosis (p<0.001) with higher risk of HGT (Figure 1). In MZL, the 10-year cumulative incidence rate of HGT in treated pts versus those managed with surveillance depicted by subtypes were as follows: SMZL 6.93% (95%CI 4.40%-10.2%) vs 6.29% (95%CI 4.53%-8.43%); NMZL 3.71% (95%CI 2.87%-4.70%) vs 2.78% (95%CI 2.03%-3.71%); MALT 2.01% (95%CI 1.54%-2.57%) vs 1.45% (95%CI 1.07%-1.93%). No significant difference between treatment versus surveillance were detected in univariable and multivariable analyses for SMZL (p=0.72 and 0.54) and NMZL (p=0.07 and 0.07), whereas surveillance pts had lower risk of HGT in MALT (p=0.02 and 0.01) (Figure 2). There were 429 (49.7%) deaths, including 337 (39%) lymphoma-specific deaths recorded in 864 pts with HGT in the entire cohort; and the median OS after HGT was 3.67 years (95%CI 2.5-6.25). Frontline therapy for FL was associated with higher risk of overall and lymphoma-specific deaths post-HGT (HR=1.32, 95%CI 1.03-1.69, p=0.02; and SHR=1.33, 95%CI 1.02-1.75, p=0.03); however, there was no significant difference in OS between frontline therapy and surveillance approach in SMZL (p=0.11), NMZL (p=0.73) and MALT (p=0.70). Interestingly, in SMZL worse LSS post-HGT was observed in those managed with frontline therapy (SHR=2.68, 95%CI 1.32-5.45, p=0.006). CONCLUSIONS Frontline treatment was associated to reduced HGT risk in FL, with advanced stage and female gender identified as risk factors for HGT. Contrarily, for SMZL, NMZL, and MALT, initial treatment neither diminished HGT risk nor improved overall survival post-HGT. Interestingly, in MALT initial treatment exhibits a higher HGT risk, likely due to selection bias, even though HGT cumulative incidence in MALT was lower compared to other subtypes. SMZL displayed a particularly high cumulative incidence of HGT and poorer LSS.

Real-World Impact of Differences in the World Health Organization (WHO) Classification and International Consensus Classification (ICC) Systems on the Diagnosis of Non-Hodgkin Lymphoma: An Analysis from the LEO Cohort Study

Introduction: The use of standardized, evidence-based classification systems is crucial for the accurate diagnosis and treatment of diseases. Moreover, standardized classification facilitates research and epidemiologic studies and promotes consistency in communication among healthcare professionals. Since 2016, the revised 4 th edition of the World Health Organization classification (WHO-HAEM4R) has been the global standard for diagnosis of lymphoid malignancies. With the emergence of new data, 2 new classification systems were developed and published in 2022: the 5 th edition of the WHO Classification (WHO-HAEM5) and the International Consensus Classification (ICC). Both WHO-HAEM5 and ICC maintain a shared fundamental concept of disease classification that integrates clinical, pathologic, and molecular data. However, they differ on nomenclature, establishment of new entities, and/or diagnostic criteria for some disease categories. To evaluate the impact of these differences on real-world diagnosis of non-Hodgkin lymphoma (NHL), we examined the diagnostic classification of NHL in the Lymphoma Epidemiology of Outcomes (LEO) Cohort Study (NCT02736357). Methods: Initiated in 2015, LEO is an ongoing prospective observational study of patients aged ≥18 years with newly diagnosed NHL. Patients are enrolled at 8 major U.S. medical centers. Clinical, epidemiologic, pathologic, and treatment data are abstracted at baseline and active follow-up is conducted for all patients. Lymphoma subtype is coded for each case based on expert hematopathology re-review of the diagnostic pathology slides, the pathology report, biomarker data, and clinical data. Of note, NHL subtype distribution is similar to SEER data. We studied all patients enrolled in LEO between 7/1/2016 (the date LEO pathology review started using WHO-HAEM4R diagnostic codes) and 5/31/2020. WHO-HAEM4R diagnoses and additional clinicopathologic data, when relevant, were used to map cases into the corresponding WHO-HAEM5 and ICC diagnoses. Differences between WHO-HAEM5 and ICC were annotated for each case as: None - same disease entity; Minor - difference in nomenclature with similar diagnostic criteria; Major - difference in disease category and/or diagnostic criteria; or Unevaluable - insufficient data to assign WHO-HAEM5 and/or ICC diagnosis. Results: LEO enrolled 6143 patients during the study period. Of these, comparison between WHO-HAEM5 and ICC was evaluable in 5730 (93.3%). Unevaluable cases included those without a specific WHO-HAEM4R diagnosis at enrollment (N=384; e.g., patients with a low-grade B-cell lymphoma that could not be definitively sub-classified) and those with a specific WHO-HAEM4R diagnosis, but with insufficient clinicopathologic data to assign a specific WHO-HAEM5 and/or ICC diagnosis (N=29). Of the 5730 evaluable cases, 5376 (93.8%) showed no difference between WHO-HAEM5 and/or ICC diagnosis, 311 (5.4%) showed minor differences (nomenclature only), and 43 (0.8%) showed major differences (Table 1). The 43 major differences all involved B-cell NHLs; 20 (46.5%) were attributable to different approaches to classifying double-hit lymphomas, 21 (48.9%) to classification of splenic/leukemic B-cell lymphomas, and 2 (4.6%) to classification of B-cell lymphomas occurring at specific anatomic sites (Table 2). Conclusion: In a large, prospective lymphoma cohort reflecting real-world clinical practice at 8 major U.S. medical centers, major diagnostic differences in the classification of NHL using WHO-HAEM5 or ICC classification criteria were seen in 0.8%, whereas the remaining 99.2% of diagnoses were either the same or showed differences in nomenclature only. The existence of 2 concurrent classification systems presents potential for discrepancies in pathologic diagnosis, clinical practice, clinical trials, and other lymphoma research. Furthermore, some of the differences between WHO-HAEM5 and ICC are clinically and potentially therapeutically significant, and their resolution requires further study. Nevertheless, our findings argue that the proportion of patients affected would be small in real-world practice settings. This appears largely related to incidence rates of specific lymphoma subtypes, with major differences between the 2 classifications predominantly affecting rare entities, while there is general concordance on the most common forms of NHL.