non-GCB Diffuse Large B-cell Lymphoma Research Articles

Polatuzumab vedotin in diffuse large B-cell lymphoma therapy: Literature review and experience of the Oncohematology Division of the Lapino Clinical Hospital

Study of molecular and genetic features of diffuse large B-cell lymphoma (DLBCL) suggests differential approach to treatment of this aggressive B-cell disorder characterized by short remission after each subsequent therapy line. Therefore, more effective regimens should be used at earlier stages. Identification of biological markers and their integration into prognostic scales can help to personalize therapy, especially in patients with high risk of quick progression and increase survival.Our own experience of using immunoconjugate polatuzumab vedotin in therapy of patients with DLBCL. The use of Pola-BR combination in a patient with refractory non-GCB DLBCL allowed to achieve full remission alongside satisfactory tolerability and absence of significant adverse events. An evaluation of the Pola-R-CHP regimen in treatment of a patient with newly diagnosed generalized GCB DLBCL is presented.

Prognostic Significance of Bcl-2 Expression in Non-germinal Center B-cell-Like Diffuse Large B-cell Lymphoma.

Diffuse large B-cell lymphomas (DLBCLs) are a group of malignant neoplasms with extensive clinical and molecular heterogeneity. Several key genetic aberrations have been identified, such as those involving the MYC, BCL6, and BCL2 genes. Prior studies on the prognostic significance of Bcl-2 protein expression in DLBCL have been contradictory, with some suggesting it has an adverse effect, while others have shown no such association. Bcl-2 is known to be more highly expressed in the non-germinal centerB-cell-like (non-GCB) subtype compared to germinal centerB-cell-like (GCB) DLBCL. Non-GCB status is associated with a less favorable prognosis. This study aimed to investigate whether the expression of Bcl-2 protein in non-GCB DLBCL influences response to treatment, progression-free survival, or overall survival. In this retrospective study, we investigated whether there was a difference in the clinical outcomes of non-GCB DLBCL cases (n = 97) that were confirmed by immunochemistry to demonstrate high levels of Bcl-2 protein expression (>50% neoplastic cells stained) when compared to those who were deemed negative based on this criterion. Response to rituximab-based induction immunochemotherapy, five-year progression-freesurvival, and five-year overall survival were assessed. There was no statistically significant difference in response to treatment, five-year progression-freesurvival, or five-year overall survival between the patients who were positive for Bcl-2 (n = 70) compared to those who were considered Bcl-2 negative (n = 27). High levels of Bcl-2 protein expression do not appear to be of prognostic significance in non-GCB DLBCL and therefore Bcl-2 may not be a key therapeutic target in the treatment and improvement of clinical outcome in such cases.

Carfilzomib plus rituximab, ifosfamide, carboplatin and etoposide (C-RICE) led to higher response, OS, and PFS in patients with transplant-eligible relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL).

7042 Background: The CORAL study highlighted the need to develop novel salvage regimens for R/Rr/r DLBCL previously treated with R+CHOP. Overall response rate (ORR) to second line immuno-chemotherapy was 51% with a 3-year progression free survival (PFS) of 30% following high-dose chemotherapy and autologous stem cell support (HDC-ASCS). Optimal disease control (complete remission [CR] or partial remission [PR]) prior to HDC-ADCS and more recently to chimeric antigen receptor T-cell therapy (CAR T), correlates with improved outcomes. Dysregulation of Bcl-2 family members has been associated with acquired resistance to rituximab and chemotherapy which we have previously shown may be mitigated by co-treatment with proteasome inhibition in pre-clinical model. Subsequently, we conducted a Phase I/II clinical trial evaluating the safety and efficacy of CRICE as salvage therapy for R/R DLBCL (Blood Adv. 2023 7:1146-1155). Methods: Here we retrospectively compared the clinical outcomes of R/R DLBCL patients treated with CRICE (N=28) versus RICE (N=38) on our prior clinical trial (NCT01959698). Demographic, clinical, and pathological characteristics were collected for both groups (Table). Study endpoints consisted of differences in overall response rate (ORR), CR/PR rates, median progression free survival (PFS) and overall survival (OS) between the two cohorts. Results: The addition of Carfilzomib to RICE resulted in improved clinical outcomes. A higher ORR (92.9 vs 76.3, P=0.073) and CR rates (82.1 vs. 44.7, P=0.002) were observed in CRICE vs. RICE treated patients. Multivariate analysis confirmed the higher CR rates in CRICE vs. RICE when adjusted by DLBCL subtype (GCB vs. nNon-GCB, P=0.003). More CRICE patients proceeded to HDC-ASCS (52.6% vs. 47.4%, P=0.618). The 3yr PFS rate was higher in CRICE (54%, 32-72%) vs. RICE treated patients (35%, 19-51%). While the median PFS was longer in CRICE treated patients 36.8m (0.8, 73.2) vs. 3.2m (0.5, 54.2) (RICE), it did not reach statistical significance (P=0.714). No differences in OS were observed between CRICE & RICE patients, median OS 67.3m vs. 71.8m. Conclusions: The CRICE outcomes were more striking in patients with non-GCB r/r DLBCL (ORR 85%, mPFS and OS not reached). CRICE led to high CR rates and longer PFS among r/r DLBCL patients, especially in non-GCB DLBCL patients. CRICE could be an attractive regimen to achieve disease control in r/r DLBCL patients undergoing consolidation therapy with HDC-ASCT or CAR T-cell therapy. [Table: see text]

Matched control analysis suggests that R-CHOP followed by (R)-ICE may improve outcome in non-GCB DLBCL compared with R-CHOP

AbstractRituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is considered the standard-of-care for patients with advanced-stage diffuse large B-cell lymphoma (DLBCL), despite findings that patients with nongerminal center B-cell like (non-GCB) have significantly worse outcome with this regimen. We evaluated the prognostic significance of baseline risk factors, including cell of origin (COO) classified by the Hans algorithm, within an alternative chemoimmunotherapy program. At Memorial Sloan Kettering Cancer Center (MSK), 151 patients with DLBCL received sequential R-CHOP induction and (R)-ICE (rituximab, ifosfamide, carboplatin, and etoposide) consolidation. Outcome analysis based on COO was validated with a propensity score–matched cohort treated with R-CHOP from the Mayo Clinic component of the Molecular Epidemiology Resource (MER). Among the patients with GCB (n = 69) and non-GCB (n = 69) at MSK, event-free survival (EFS) of non-GCB was superior to that of GCB (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.29-0.98). Overall survival (OS) demonstrated an association in the same direction but was not statistically significant (HR, 0.68; 95% CI, 0.33-1.42). Propensity score–matched patients from MSK (n = 108) demonstrated a small attenuation in the HRs for EFS (HR, 0.57; 95% CI, 0.27-1.18) and OS (HR, 0.76; 95% CI, 0.33-1.79) and were no longer statistically significant. In contrast, the matched MER cohort (n = 108) demonstrated an EFS association (HR, 1.17; 95% CI, 0.70-1.95) and OS association (HR, 1.13; 95% CI, 0.64-2.00) in the opposite direction, but were also not statistically significant. R-CHOP induction and (R)-ICE consolidation may overcome the negative prognostic impact of the non-GCB phenotype, per the Hans algorithm, and can be preferentially selected for this population. This trial was registered at www.ClinicalTrials.gov as #NCT00039195 and #NCT00712582.

CD5 Gene Signature Identifies Diffuse Large B-Cell Lymphomas Sensitive to Bruton's Tyrosine Kinase Inhibition.

A genetic classifier termed LymphGen accurately identifies diffuse large B-cell lymphoma (DLBCL) subtypes vulnerable to Bruton's tyrosine kinase inhibitors (BTKis), but is challenging to implement in the clinic and fails to capture all DLBCLs that benefit from BTKi-based therapy. Here, we developed a novel CD5 gene expression signature as a biomarker of response to BTKi-based therapy in DLBCL. CD5 immunohistochemistry (IHC) was performed on 404 DLBCLs to identify CD5 IHC+ and CD5 IHC- cases, which were subsequently characterized at the molecular level through mutational and transcriptional analyses. A 60-gene CD5 gene expression signature (CD5sig) was constructed using genes differentially expressed between CD5 IHC+ and CD5 IHC- non-germinal center B-cell-like (non-GCB DLBCL) DLBCLs. This CD5sig was applied to external DLBCL data sets, including pretreatment biopsies from patients enrolled in the PHOENIX study (n = 584) to define the extent to which the CD5sig could identify non-GCB DLBCLs that benefited from the addition of ibrutinib to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). CD5 expression was observed in 12% of non-GCB DLBCLs. CD5+ DLBCLs displayed transcriptional features of B-cell receptor (BCR) activation and were enriched for BCR-activating mutations known to correlate with BTKi sensitivity. However, most CD5+ DLBCLs lacked canonical BCR-activating mutations or were LymphGen-unclassifiable (LymphGen-Other). The CD5sig recapitulated these findings in multiple independent data sets, indicating its utility in identifying DLBCLs with genetic and nongenetic bases for BCR dependence. Supporting this notion, CD5sig+ DLBCLs derived a selective survival advantage from the addition of ibrutinib to R-CHOP in the PHOENIX study, independent of LymphGen classification. CD5sig is a useful biomarker to identify DLBCLs vulnerable to BTKi-based therapies and complements current biomarker approaches by identifying DLBCLs with genetic and nongenetic bases for BTKi sensitivity.

Zanubrutinib Combined with R-CHOP in Previously Untreated Non-Germinal Center B-Cell (GCB) Diffuse Large B-Cell Lymphoma (DLBCL) Patients with BCL2 and MYC Protein Co-Expression: A Multicenter, Phase II Study

Introduction DLBCL is the most common subtype of lymphoma, accounting for up to 40% of lymphoma cases worldwide and can be classified into GCB and non-GCB by immunohistochemistry (IHC). Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy is the standard first-line treatment of DLBCL. Patients with non-GCB DLBCL or co-expression of BCL2 and MYC have a worse outcome with R-CHOP treatment. Previous study has showed that ibrutinib combined with R-CHOP had improved event free survival (EFS) compared with placebo plus R-CHOP in non-GCB DLBCL patients with BCL2 and MYC co-expression (Johnson et al., Blood 2019). This study aimed to investigate the efficacy and safety of the new-generation BTKi zanubrutinib combined with R-CHOP in previously untreated non-GCB DLBCL patients with BCL2 and MYC protein co-expression. Here, we report the preliminary results of this study. Methods Eligible patients were previously untreated non-GCB DLBCL confirmed by Hans' algorithm age 18 years or older, MYC positive (defined as ≥40% of tumor cells showed any level of MYC nuclear staining above background) and BCL-2 positive (defined as ≥50% of tumor cells showed a cytoplasmic intensity score of 2+ or 3+) determined by IHC, and Eastern Cooperative Oncology Group performance status of 0-2.Patients were treated with R-CHOP combined with zanubrutinib (160 mg oral BID per day) of each 21-day cycle for six cycles. After 4 cycles, response was assessed by CT per Lugano 2014 criteria. Patients who were progression disease (PD) would discontinue the treatment. After completion of 6 cycles treatment, patients who were assessed with complete response (CR) (by PET-CT) would proceed to zanubrutinib (160 mg oral BID) maintenance treatment for one year, or until PD, intolerance of toxicity, loss of follow-up, withdrawal of informed consent, or death. Patients who were not CR would receive subsequent anti-tumor therapies determined by investigator. The primary endpoint was 3-year EFS rate assessed by investigator, Secondary endpoints included overall response rate (ORR), CR rate, 3-year progression free survival rate, 3-year overall survival rate and safety. Results From Jan 2022 to Jun 2023, 27 patients were enrolled with a median age of 58, and 40.7% (11/27) were with IPI ≥3. At the data cut-off date of 30 Jun 2023, all 27 patients received at least one cycle of R-CHOP plus zanubrutinib and included in safety evaluation. Seventeen patients have received 4 cycles treatment and were assessed by CT with CR (n=1) or partial response (n=16); 2 patients withdrew the study before the first assessment. Among the 17 patients, 11 patients completed 6 cycles of treatment and achieved a response (11/11), with a CR (CR and complete metabolic response) of 10/11 ( Table). Two patients discontinued after 4 cycles treatment (1 due to outbreak of COVID 19 and 1 due to AE, infectious pneumonia). Ten patients with CR are in the zanubrutinib maintenance treatment, while 1 patient with PR had received salvage therapy decided by the investigator. The most common hematologic TEAEs were neutropenia (33.3% in Grade 1-2, 18.5% in Grade ≥3) and thrombocytopenia (7.4% in Grade 1-2, 11.1% in Grade ≥3), and non-hematologic TEAE includes alanine aminotransferase increased, aspartate aminotransferase increased, rash, hypokalemia, anemia, diarrhea, infectious pneumonia and hemorrhage (Figure). Hypertension and atrial fibrillation/flutter were not observed during the treatment. Four patients experienced SAE of infectious pneumonia (n=1), neutropenia (n=1), and thrombocytopenia (n=2, Grade 3), and were recovered. Conclusions At the time of data cut-off 30 Jun 2023, 6 cycles of zanubrutinib combined with R-CHOP regimen was well tolerated and showed a promising response result in untreated non-GCB double-expression DLBCL patients. The study is ongoing and further results will be continuously released.

A CD5 Gene Signature Identifies Diffuse Large B-Cell Lymphomas Sensitive to Brutonʼs Tyrosine Kinase Inhibition

Introduction: Diffuse large B-cell lymphomas (DLBCLs) with a non-germinal center B cell-like (non-GCB) cell-of-origin are frequently driven by genetic alterations that culminate in constitutive B-cell receptor (BCR) signaling, which has inspired the exploration of Bruton's tyrosine kinase inhibitors (BTKi) in these lymphomas. However, the phase III PHOENIX study that randomized untreated, non-GCB DLBCL patients to R-CHOP plus placebo or ibrutinib failed to meet its primary endpoint of event-free survival (Younes et al. 2019), which suggests that cell-of-origin alone is an insufficient biomarker to predict BTKi sensitivity in DLBCL. More recently, a DLBCL genetic classifier termed LymphGen has identified distinct subtypes (MCD and N1) of non-GCB DLBCL that benefit from the addition of BTKi to R-CHOP (Wilson et al. 2021). However, genetic classifiers are complex and difficult to implement in routine clinical settings and may fail to capture all DLBCLs that benefit from BTKi. Therefore, we sought to identify a straightforward biomarker of BTKi responsiveness in DLBCL with greater precision than cell-of-origin but with broader inclusivity than current genomic platforms, such as LymphGen. We hypothesized that CD5 - a surrogate marker of BCR activation - may effectively identify BCR-driven, non-GCB DLBCLs that are sensitive to BTKi therapy, and evaluated the extent to which CD5 protein expression and a transcriptionally defined CD5 gene signature could accurately identify BCR-activated DLBCLs with potential susceptibility to BTKi-based therapies. Methods: CD5 immunohistochemistry (IHC) was performed on a cohort of 406 diagnostic DLBCL samples, which were considered CD5+ if >=30% of lymphoma cells exhibited unequivocal membranous staining. A majority of DLBCL samples had available RNA-sequencing and targeted mutational sequencing data. A comparison of differentially expressed genes between CD5+ and CD5- DLBCLs was performed in order to construct a 60-gene CD5 signature (CD5sig), which was applied to large genomic DLBCL datasets, including pre-treatment biopsies from patients enrolled on PHOENIX (n = 584) to evaluate the utility of the CD5sig in identifying DLBCLs that benefitted from the addition of ibrutinib to R-CHOP. Results: Twenty-six of 406 DLBCLs were identified as CD5+ by IHC (6% of all DLBCLs; 12% of non-GCB DLBCLs). CD5 IHC+ DLBCLs were majority non-GCB cell-of-origin and were associated with inferior progression-free survival (PFS) to R-CHOP (50% 3-year PFS), compared with CD5 IHC- DLBCLs, consistent with previous reports. Gene set enrichment analysis revealed that CD5 IHC+ DLBCLs exhibited transcriptional features of BCR activation, and mutational analysis demonstrated that CD5 IHC+ DLBCLs were enriched for CD79B BCR-activating mutations known to correlate with BTKi sensitivity. Many CD5 IHC+ DLBCLs, however, lacked canonical BCR-activating mutations or were classified as “Other” by LymphGen. A CD5 gene signature (CD5sig; Figure 1A) was developed that recapitulated these findings in independent DLBCL datasets (NCI, Duke), where ~13% of non-GCB DLBCLs were classified as CD5sig+. Together, these results suggest that CD5 signature expression captures DLBCLs with both a genetic and non-genetic basis for BCR dependence. Supporting this notion, CD5sig+ DLBCL patients (< 60 years) derived a selective and striking event-free and overall survival advantage from the addition of ibrutinib to R-CHOP in the PHOENIX study ( Figure 1B), independent of LymphGen classification. Conclusions: We demonstrate that CD5 IHC and a novel CD5 gene signature identify high-risk, BCR-driven DLBCLs. Importantly, the CD5 signature also identifies DLBCL patients with a selective survival advantage to BTK inhibitor-based therapy, independent of LymphGen classification. In conclusion, the CD5 signature expands upon LymphGen classification as a biomarker of BTKi response by accurately identifying DLBCLs with both genetic and non-genetic bases for BTKi response. The CD5 signature and/or CD5 IHC should be prospectively evaluated in BTKi-based clinical trials for non-GCB DLBCLs.

The ZR2-Minichop Study：Zanubrutinib, Lenalidomide, Rituximab, Cyclophosphamide, Vincristine, Epirubicin and Prednisone in Elderly Patients with Previously Untreated Diffuse Large B-Cell Lymphoma

Background: Diffuse large B cell lymphoma (DLBCL) is common in the elderly group. New schedules are required due to the toxicity in classic chemotherapy regimens. Previous studies reported that non-germinal center B cell (non-GCB) subtype aggregates in elderly patients with abnormality in the activated B cell receptor signal and nuclear factor kappa-B pathway. We conducted a prospective trial to investigate the efficacy and safety of the ZR2-miniCHOP schedule (zanubrutinib, lenalidomide, rituximab, cyclophosphamide, vincristine, epirubicin and prednisone) in elder patients newly diagnosed with non-GCB DLBCL. Methods: This multicenter, single-arm, phase II clinical study started in June 2021 at 6 centers in China. Eligible patients were newly diagnosed non-GCB DLBCL, aged 60 to 80 with Eastern Cooperation Oncology Group (ECOG) performance status over 2, or patients aged over 80 with ECOG status of 0-4. The purpose of this study is to discuss the response, safety and long-term survival with the primary endpoint of objective response rate (ORR) and the secondary endpoint of overall survival (OS) and progression free survival (PFS). Patients would receive 2 cycles induction period with zanubrutinib 160mg twice per day on d1-28, lenalidomide 25mg d1-10 and rituximab 375mg/m 2 d1, after then combine 4-6 cycles miniCHOP schedule as: cyclophosphamide 400mg/m 2 d2, vincristine 1.4mg/m 2 d2, epirubicin 35mg/m 2 d2 and prednisone 45mg/m 2 d2-6. Evaluation is conducted after 6 cycles of treatment including the ORR and CR rate by positron emission tomography-computed tomography (PET-CT) and 2-years OS and PFS. Results: At the data collection duration from June 2021 to June 2023, 45 patients were recruited in this trial. 34 patients were considered for result analysis as 2 withdrawals and 1 drop-out. 6 patients are still in the process of treatment. The median age of the 45 patients enrolled was 79 (range 65-90) years, with 34 (75.6%) patients over 75 years old. The ORR was 91.2% (31/34). Among the 34 assessable patients, 61.8% (21/34) of them reached CR after 6 cycles routine therapy. Besides, 29.4% (10/34) patients just achieved PR, and for these patients we then continued administered more 2 cycles with ZR2+miniCHOP. Later 5 of these 10 patients achieved CR. One patient stayed SD and 3 patients appeared disease progressing. The most common hematology-relevant adverse events (AEs) were neutropenia (13/34) and thrombocytopenia (10/34). Eleven patients appeared AEs over grade 3 occurred during therapy with neutropenia, thrombocytopenia, infectious pneumonia events. All these patients have been administrated the normal dose as the treatment resistance and the toxicity did not affect therapy. Two patients died of progressive disease. No treatment-associated death was observed. Generally analyzing, this trial achieved acceptable response and safety. Conclusion: The ZR2-miniCHOP schedule represented satisfactory efficacy and safety in elderly non-GCB DLBCL.

MALT1 Protease Inhibition Overcomes BTK Inhibitor Resistance and Shows Synergistic Activity with Venetoclax in Models of B Cell Lymphoma and Leukemia

Background Specific B cell malignancies, including the aggressive non-germinal center B cell-like (GCB) subtype of diffuse large B cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL), are driven by constitutive activation of the transcription factor NF-kB. Chronic signaling resulting from mutations or antigen-induced activation of the B cell receptor (BCR) pathway drives NF-kB activity in these tumors resulting in sustained proliferation and survival pathways. Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) represents a key mediator of the BCR/NF-kB signal transduction pathway responsible for maintaining survival and driving proliferation of NF-kB-addicted B cell tumors by proteolytically cleaving NF-kB antagonists. Aims Pharmacological inhibition of MALT1 protease activity may provide an attractive treatment option for patients with these cancers. Further, as combination therapy is often required for the treatment of aggressive B cell malignancies, the identification of therapies that synergistically combine with MALT1 inhibitors could afford additional and promising treatment options. Methods A highly potent and orally bioavailable MALT1 protease inhibitor (ABBV-MALT1) was used to test the hypothesis that MALT1 inhibition will abrogate the proliferation of preclinical models of B cell malignancies in vitro and in vivo. Tumors treated with ABBV-MALT1 were subjected to transcriptomic and functional proteomic assays to elucidate molecular mechanisms of action and rational combination partners. Results ABBV-MALT1 potently inhibits MALT1 activity in vitro while showing high selectivity against a panel of proteases, kinases and other types of receptors and enzymes. Mechanistic studies reveal that ABBV-MALT1 effectively inhibits signal transduction of the BCR pathway and reduces NF-kB gene activation in non-GCB DLBCL cell lines resulting in cell cycle arrest and diminished viability. In vivo, oral administration of this compound demonstrates robust tumor growth inhibition in several models of B cell tumors, including non-GCB DLBCL models that are resistant to Bruton's tyrosine kinase (BTK) inhibitors. NF-kB target genes include the pro-survival family members BCL-XL and BCL2-A1, which aid in regulation of the intrinsic apoptosis pathway. As ABBV-MALT1-induced inhibition of the NF-kB pathway resulted in downregulation of these genes, we hypothesized that the associated tumor models would become increasingly dependent on the pro-survival family member BCL-2. To test this hypothesis, combination studies of ABBV-MALT1 and the selective BCL-2 inhibitor venetoclax were performed in both cell line and patient-derived xenograft models of DLBCL. Herein we show that concomitant administration of ABBV-MALT1 and venetoclax results in dramatic antitumor activity in all models tested in vivo. This efficacy also translates to primary patient CLL cells in vitro where the combination confers greater levels of apoptosis compared to either agent alone. Summary/Conclusion: ABBV-MALT1 demonstrates robust single agent anti-tumor activity in malignant B cell models that are resistant to BTK inhibitors. Moreover, combination of ABBV-MALT1 with the BCL-2 inhibitor venetoclax shows synergistic cell killing of B cell tumors in vitro and dramatic tumor regression in vivo. Together, these data indicate that MALT1 inhibition may overcome BTK inhibitor resistance and combine with venetoclax to effectively treat patients with DLBCL, CLL and other B cell malignancies. Disclosures All authors are employees of AbbVie. The design, study conduct, and financial support for this research were provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the publication.

Clinical Outcomes of Patients with Newly Diagnosed Diffuse Large B-Cell Lymphoma in a County Hospital System

Introduction: Advances in the treatment of diffuse large B-cell lymphoma (DLBCL) have improved survival, with Surveillance, Epidemiology, and End Results (SEER) Program data showing 5-year overall survival (OS) of 64.7% (SEER*Explorer, 2023). However, insurance status in the US is related to DLBCL survival (Han et al., Cancer 2014), and real-world data for patients who are uninsured or who may have socioeconomic barriers to care remain limited. We performed a retrospective cohort study to examine outcomes for patients with newly diagnosed DLBCL treated in a large safety-net hospital system in the third most populous county in the US. Methods: Patients aged 18 years and older diagnosed with DLBCL between January 2011 and June 2022 and treated at Harris Health System, Houston, TX, were included in the analysis. Demographic, disease, treatment, response, and follow-up data were abstracted from the electronic medical record. US Census Block Group FIPS codes derived from geocoded home address at the time of initial diagnosis were used to compute the Area Deprivation Index (ADI). Eligibility for cellular therapies including hematopoietic stem cell transplantation (HSCT) and chimeric antigen receptor T-cell therapy (CAR-T) was determined by the abstractors. Time-to-event analysis was performed using the Kaplan-Meier method, and Cox proportional hazards regression was used to examine factors associated with event-free survival (EFS) and OS. Results: Among 461 patients with newly diagnosed DLBCL (Table 1), the median age was 53 years (range, 18-93), 75% were uninsured, and 80% were in the most disadvantaged ADI national quartiles, defined as at or above the fiftieth percentile. Most patients had stage III or IV disease and an Eastern Cooperative Oncology Group Performance Status (ECOG) of 0 to 1 at the time of diagnosis. One hundred ninety-eight patients (44%) had poor-risk disease by the Revised International Prognostic Index (R-IPI). Seventy-five (16%) had a history of HIV infection. Common first-line treatments included R-CHOP ( n = 210, 46%) and R-EPOCH ( n = 183, 40%); 18 received no therapy (3.9%). The median time from diagnosis to treatment initiation (DTI) was 18 days (range, 0-246); 76% completed therapy. Of 425 evaluable patients, 288 (68%) achieved a complete response (CR) and 44 (10%) had a partial response (PR); of these, 74 (22%) relapsed. Twenty-five (58%) of 43 patients eligible for cellular therapies at relapse received them: 14 (56%) underwent autologous HSCT, 8 (32%) received CAR-T, and 3 (12%) had both. Median follow-up time for the cohort was 48.8 months (range, 0.2-147). By the time of analysis, 167 patients (36%) had developed refractory/relapsed disease, and 148 (32%) had died. At 1, 2, and 5 years, EFS was 72%, 64%, and 58%, and OS was 82%, 76%, and 69% (Figure 1). At 1, 2 and 5 years, EFS was 77%, 69%, and 64% and OS was 85%, 79%, and 75% for patients with germinal center B-cell-like (GCB) DLBCL, whereas EFS was 68%, 56%, and 50% and OS was 80%, 73%, and 62% for those with non-GCB DLBCL. In multivariable Cox regression models, predictors of OS were poor-risk disease by R-IPI (HR 6.08 compared to very-good-risk disease, 95% CI 1.02-36.09), ECOG (HR 2.10 for ECOG ≥2 compared to 0-1, 95% CI 1.12-3.95), and normalized LDH (HR 1.07 per fold increase, 95% CI 1.03-1.11). Race/ethnicity, insurance status, and DTI were not associated with significant differences in OS. However, receiving fewer than planned cycles of first-line therapy was associated with higher mortality (HR 2.00, 95% CI 1.12-3.56), as was not attaining CR by the end of first-line therapy (HR 7.90, 95% CI 3.65-17.12). Conclusion: This is one of the largest real-world studies to date examining outcomes of patients with newly diagnosed DLBCL at a safety-net hospital system. Overall, patients had shorter EFS and OS compared to historical clinical trials but had similar OS to SEER estimates. In this health system with robust financial assistance programs and access to cellular therapies for some patients, uninsured status was not associated with inferior outcomes. Addressing barriers to care may improve outcomes for uninsured patients in other settings.

Characterization of Hemophagocytic Lymphohistio(HLH）in Relapsed Diffuse Large B-Cell Lymphoma Patients after CAR-T Therapy

Background: Patients with chemotherapy-refractory diffuse large B-cell lymphoma (DLBCL) have poor prognoses. The objective response rate of patients with standard salvage regimens is 26%, while CART therapy have complete remission (CR) rates of 40%- 54% against DLBCL. Half of DLBCL patients relapsed or progressed after chimeric CAR-T cell therapy, but only a few of them were accompanied by HLH. Its clinical characteristics are unclear. This study aimed to investigate the clinical characteristics of these patients. Methods: We retrospectively analyzed the clinical data of 8 patients with relapsed DLBCL lymphoma accompany by HLH after CAR-T therapy between May 2019 and July 2023(NCT02537977 and NCT04036019). We investigate the clinical characteristics of these patients, compare the survival between patients with and without CR after CAR-T therapy, compare the survival between patients with and without CRS after CAR-T therapy. Results: 8 R/R DLBCL patients were enrolled. Median age was 59.5 years (range, 37-69), and 6(75%) patients had non-germinal center B-cell-like (non-GCB) DLBCL, one had GCB DLBCL, one had transformed DLBCL. 2 patients (25.0%) had HLH before CAR-T treatment previously. Among them, 3 patients (37.5%) achieved CR after CART therapy, while 3 patients (37.5%) achieved partial remission. ALL of the patients (100%) relapsed or progressed, and all of them died because of disease progression. With a median follow-up of 7 months, the median overall survival (OS) was 206.0 days (95%CI 106.2-305.8) and progress-free survival (PFS) was 125.0 days (95%CI 40.5-210.0). Particularly，the median time from HLH to death was only 45.0 days (95%CI: 22.8-67.2). 6 patients (75.0%) occurred grade 1-2 CRS, no patient occurred ≥grade 3 CRS, and 2 patients (25.0%) did not occurred any CRS. The median OS was 328.0 days and 142.0 days (95%CI 60.4-223.6) for patients without CRS and with CRS1-2, respectively. There is significantly different in OS for patients with and without CRS ( P=0.03). The median OS was 328.0 days (95%CI 217.6-438.4) and 142.0 days (95%CI 133.4-150.6) for patients with CR and without CR, respectively. The median PFS was 257.0 days (95%CI 103.4-410.6) and 77.0 days (95%CI 8.3-145.7) for patients with CR and without CR. There is significantly different in OS and PFS for patients with CR and other patients ( P=0.01 and P=0.01). Conclusion: Hemophagocytic lymphohistiocytosis (HLH) is a rare and life threatening disorder. The prognosis of patients with relapsed DLBCL lymphoma accompany by HLH after CAR-T therapy is very poor. Patients with CRS during CART therapy may more likely have HLH when DLBCL relapse. The patients without CRS have better survival time than those with CRS during CART therapy. We hypothesis that because both HLH and CRS is inflammatory syndrome resulting from T-cell activation.

BTK Inhibitors and Chidamide-Combined Therapy in Relapsed or Refractory Diffuse Large B-Cell Lymphoma

Background: Relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) shows poor clinical outcomes, particularly in patients ineligible for stem cell transplantation or who failed induction therapy or salvage therapy. Monotherapy Bruton tyrosine kinase inhibitors (BTKi) have established modest antitumor effect in R/R DLBCL by targeting B-cell receptor signaling, with median progression-free survival (PFS) and overall survival (OS) of 1.64-2.8 months and 6.4-8.4 months, respectively. Chidamide is a selective oral histone deacetylase inhibitors (HDACi) that shows promising treatment for DLBCL and may overcome BTKi resistance. So, we evaluated the efficacy and safety of BTKis and chidamide-combined therapy in R/R DLBCL. Methods: This retrospective study consists of 11 R/R DLBCL who received combination therapy of chidamide and BTK inhibitors between September 2021 and July 2023. Chidamide was orally administered at a dose of 20 mg twice a week, while the BTK inhibitor was administered daily. Patient clinical characteristics were collected upon patient enrollment. Efficacy outcomes included overall response rate (ORR), PFS and OS, whereas safety outcomes included incidence of adverse events. Results: 11 R/R DLBCL patients were enrolled. Median age was 61 years (range, 56-73), and 81.82% of the patients had non-germinal center B-cell-like (non-GCB) DLBCL, one had GCB DLBCL, one had transformed DLBCL. The median number of previous treatment lines was 3 (range, 3-8). 10 patients (90.91%) received treatment with BTK inhibitors before. Four patients（36.36%）failed to chimeric antigen receptor T-cell/NK-cell(CAR-T/CAR-NK) therapy. The best ORR was 81.82%, with 9 patients acquired objective disease remission after 1-2 cycles. Among them, 3 patients (27.27%) achieved complete response, and6 patients (54.55%) achieved partial remission. With a median follow-up of 5 months, the median PFS was 6.0 months (95%CI 3.14-8.86) and median OS was not yet reached. In terms of adverse events, the most common hematologic toxicities observed were grade ≥3 neutropenia (36.36%, 4/11) and grade ≥3 thrombocytopenia (36.36%, 4/11). Two patients (18.18%) had pneumonia, and one patient (9.09%) had herpes zosters. Due to the positive real-world outcomes observed in the retrospective study, prospective clinical studies of chidamide in combination with BTK inhibitors for the treatment of R/R DLBCL are underway (ChiCTR2300073233). Conclusion: This real-world study revealed promising results. Despite the majority of patients had been treated with BTK inhibitors and experienced relapse and resistance, the addition of chidamide brought patients back into remission, suggesting that chidamide can enhance the efficacy of BTK inhibitors and overcome acquired resistance. Notably, chidamide combined with BTK inhibitors showed high efficacy and manageable tolerability, making it a promising treatment option for patients with R/R DLBCL. Keywords: BTK inhibitors, Chidamide, R/R DLBCL, efficacy and safety

The Activation Status of RSK2, but Not PDPK1 and AKT, Associates with the Prognosis of Diffuse Large B Cell Lymphoma

B-cell lymphoma (BCL) is the most common hematologic malignancy with various genetically and molecularly distinct subtypes. Although the prognosis of most BCL subtypes has been dramatically improved by the advances of disease subtype-directed, molecularly targeted therapies, some patients remain incurable with currently available therapeutics. We previously identified that a serine/threonine kinase 3-phosphoinositide-dependent kinase-1 (PDPK1) and its major downstream substrate serine/threonine kinases, AKT and RSK2, play pivotal roles in the pathophysiology of multiple myeloma and mantle cell lymphoma (MCL) (Chinen Y, Cancer Res 2014; Shimura Y, Mol Cancer Ther 2012; Matsumura-Kimoto Y, Cancer Med 2020). In particular, we found the crucial roles of the constitutive activation of the N-terminal kinase domain (NTKD) of RSK2 in cell survival, resistance to apoptosis, and cell proliferation of myeloma cells and MCL cells. However, the activation status of PDPK1, AKT, and RSK2-NTKD and their impacts on prognosis have yet to be comprehensively investigated in various subtypes of BCLs. To answer this, we here investigated the activation status of PDPK1, AKT, and RSK2-NTKD and their prognostic impacts in two major subtypes of BCLs, diffuse large B cell lymphoma (DLBCL) and follicular lymphoma (FL). To evaluate the activation status of the three kinases in DLBCL and FL, we performed the immunohistochemical analyses to characterize the expression profiles of phosphorylated (p)-PDPK1, p-AKT, and p-RSK2-NTKD in tumor-biopsied samples from 277 pts with DLBCL and 121 patients (pts) with FL diagnosed between 2010 and 2022 at our institution, and the expression levels of three target kinases were classified into four categories; negative (0), weak (1), moderate (2), and strong (3). As a result, in DLBCL, p-PDPK1, p-AKT, and p-RSK2 were positive in 98%, 68%, and 100%, respectively. More precisely, p-PDPK1 was 0-1 in 160 (59%) and 2-3 in 111 (41%). p-AKT was 0-1 in 225 (82%), and 2-3 in 48 (18%). p-RSK2 was 1 in 177 (65%), and 2-3 in 96 (35%). OS was significantly shorter in patients with moderate/strong expression (2-3) of p-RSK2 than those with weak expression (1) of p-RSK2 (5-year OS rate 52% vs. 73%, P<0.01), and, importantly, p-RSK2 status was identified as the independent prognostic factor by the multivariate analysis evaluating p-RSK2 expression and elements included in the International Prognostic Index as variables (HR 1.6, P=0.03). In addition, the prognostic relevance of RSK2 activity was evident in non-GCB type DLBCL but not GCB type DLBCL. In FL, p-PDPK1, p-AKT, and p-RSK2 were positive in 76%, 53%, and 69%, respectively. More precisely, p-PDPK1 status was 0-1 in 94 (89%) and 2-3 in 11 (10%), p-AKT status was 0-1 in 81 (77%) and 2-3 in 24 (23%)), and p-RSK2 was 0-1 in 67 (64%), and 2-3 in 38 (36%). In contrast to the case with DLBCL, the OS of FL was not associated with the activation status of p-PDPK1, p-AKT, and p-RSK2. In conclusion, the present analysis suggests the functional involvement of p-RSK2 activity and the role of future therapeutic targeting, especially in DLBCL, especially in high-risk non-GCB subtype.

Abbv-101, a Highly Potent and Selective Clinical Stage Bruton Tyrosine Kinase Degrader for the Treatment of B-Cell Malignancies

Bruton tyrosine kinase (BTK), a clinically validated target for various B-cell malignancies, plays a critical role in regulating cell growth, adhesion and homing to key lymphoid tissues that provide a microenvironment favorable to cancer cells. Despite the success of approved covalent BTK inhibitors in diseases such as CLL, most patients do not achieve complete response with monotherapy and eventually relapse, often via the emergence of the BTK-C481S mutation. Additionally, covalent BTK inhibitors have not shown sufficient differentiation from standard-of-care (SoC) in B-cell malignancies such as diffuse large B cell lymphoma (DLBCL) to warrant approval to date. To address these unmet needs, a next-generation orally bioavailable BTK degrader ABBV-101 has been developed. Unlike BTK inhibitors that solely bind to and impede the catalytic domain of BTK, ABBV-101 eliminates the protein in a highly selective fashion. This degradation mechanism targets both the catalytic and scaffolding functions of BTK, and thus may enable deeper and more durable responses in patients with B-cell malignancies. In preclinical studies, the BTK degrader ABBV-101 has shown potent in vitro and in vivo efficacy in BCR pathway-dependent leukemia/lymphoma models, including covalent BTK inhibitor resistant BTK-C481S systemic mouse CLL and human DLBCL models. ABBV-101 degrades BTK-WT and BTK-C481S with similar sub-nanomolar potency in the human DLBCL cell line TMD8 which translates to potent cellular growth inhibition. In addition to the BTK-C481S mutation, ABBV-101 demonstrates similar potent activity against novel BTK mutations associated with resistance to reversible BTK inhibitors in the clinic, an emerging unmet need. ABBV-101 induces complete tumor regression in the BTK-C481S TMD8 DLBCL xenograft model. A spontaneous mouse CLL model carrying BTK-C481S mutation was developed through crossing BTK-C481S knock-in mice with the Emu-TCL1 transgenic mice in the C57BL/6 background. ABBV-101 completely inhibits BTK-C481S Emu-TCL1 CLL burden increase in the blood compartment and reduces CLL burden in the spleen and lymph nodes, whereas covalent BTK inhibitors show no activity. Further, ABBV-101 induces complete tumor regressions in multiple non-GCB DLBCL PDX models, demonstrating deeper and more durable response than covalent and reversible inhibitors. Combination with a BCL-2 inhibitor enhances the efficacy of ABBV-101 in CLL and DLBCL models. Kinome and global proteomics profiling showed ABBV-101 to be highly selective, a designed feature that may enable favorable tolerability in patients. ABBV-101 is currently in phase 1 clinical trial for a variety of B-cell malignancies. ClinicalTrials.gov identifier: NCT05753501

High Level of IL-16 Secreted By Non-GCB DLBCL Facilitates Tumor Growth Though the Tumor-Promoting and Immunosuppressive Tumor Microenvironment

Introduction: Diffuse Large B-Cell Lymphoma (DLBCL) is a highly heterogeneous non-Hodgkin's lymphoma. Based on cell origin, DLBCL is classified into two main molecular subtypes: the germinal center B-cell-like (GCB) subtype and the activated B-cell-like (ABC) subtype. ABC subtype is more aggressive and associated with a worse prognosis than GCB subtype. Previous studies have shown that cytokines play an important role in the growth of ABC subtypes, and IL-16 was supposed to be highly expressed in ABC-DLBCL, however it has not been explored in depth in DLBCL. In this study, we broadly assessed the expression and role of IL-16 on DLBCL. Method: Serum and tissues samples from patients with DLBCL and whole blood from healthy donors were collected. The characterization of protein expression, mRNA expression, and levels of cytokines in cells and tissues was detected by Western blotting, IHC/IHF, PCR, ELISA, RNA-seq, and Flow cytometry. Cells experiments such as cell proliferation, cell apoptosis, cell cycle, cell migration, and ADPC were detected by CCK-8, Flow cytometry, and Transwells. Gene knockdown or overexpression was conducted by lentiviruses and then verified by Western blotting and ELISA. We established subcutaneous tumors (human DLBCL cells and murine DLBCL cells) in BALB/c mice, BALC/c nude mice, and NOD SCID mice for the tumor size or the therapeutic evaluation. Results: First, we found that IL-16, secreted by the cleavage of active caspase-3 from the lymphoma cells under tumor burden, was highly expressed in ABC-DLBCL compared to GCB-DLBCL. The serum IL-16 levels were positively correlated with unfavorable prognosis in DLBCL patients. The dynamic change of serum IL-16 levels accurately predicted the treatment response in patients with DLBCL who received R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone) or anti-CD19 Chimeric Antigen Receptor (CAR) T cells. Interestingly, bioactive IL-16 showed rare effect on DLBCL cells in vitro, but significantly promoted their growth in vivo. Mechanically, tumor-derived bioactive IL-16 promoted the migration of monocytes via CD4+ receptor, thereby inducing the enrichment of monocytes-derived tumor-associated macrophages in the tumor microenvironment (TME) of DLBCL, which accelerated the tumor growth primarily by expressing cytokines such as IL-6, inducing angiogenesis, and exerting immunosuppressive effects through the expression of cytokines like IL-10; thus, conferring growth advantage to the ABC- DLBCL. To translate the findings into clinical application, we design a novel treatment strategy to overcome the poor outcomes in ABC-DLBCL patients with high IL-16 expression by combination of high-dose cyclophosphamide (CTX) and the bispecific antibody targeting CD20 and CD47 (IMM0306). IMM0306 effectively reversed the tumor-promoting effects of macrophages in subsets of ABC-DLBCL, while CTX induced IL-16 and increased the infiltration of macrophages in the TME. The increasing effector cells/tumor cells ratio further improved the antitumor effect of IMM0306. The combination of high-dose CTX and IMM0306 was confirmed to significantly inhibit the growth of ABC-DLBCL with high IL-16 expression. A clinical trial is being designed to evaluate the potential for clinical applications. Conclusion: In conclusion, this study provides insight into the expression and role of IL-16 in DLBCL. IL-16 is proposed to be highly expressed in ABC-DLBCL, and serum IL-16 indicate the tumor burden, treatment response, and clinical prognosis of DLBCL patients. IL-16 may be a key driver of the TME of DLBCL, which can confer growth advantage to the ABC-DLBCL. Our data provides a theoretical basis for future clinical treatment. A novel treatment regimen (IMM0306 and CTX) could attenuate the pro-oncogenic roles of IL-16 to prevent ABC-DLBCL progression.

A Phase Ib Study of Linperlisib Monotherapy in Patients with Relapsed or Refractory B-Cell Malignancies

Background: B-cell malignancies, a diverse and complex spectrum of lymphoproliferative disorders, are marked by a gradient of severity, ranging from indolent non-Hodgkin lymphomas (NHLs) such as follicular lymphoma (FL) and chronic lymphocytic leukemia (CLL), to more aggressive variants of NHL like diffuse large B-cell lymphoma (DLBCL). This wide array of disorders brings unique challenges in treatment, particularly for relapsed or refractory (r/r) cases where there is a significant dearth of effective therapeutic options. The PI3K pathway, a vital regulator of cellular functions such as cell growth, survival, and differentiation, has increasingly been recognized as a promising therapeutic target in the context of B-cell lymphomas. Accumulating evidence points towards its role in the pathogenesis of these disorders, underlining the potential of PI3K inhibitors in their treatment. Linperlisib, an orally administered PI3Kδ inhibitor, has emerged as a potential candidate for the management of r/r B-cell malignancies, with a previous phase I study demonstrating its safety and suggesting preliminary clinical activity. In this light, our phase Ib study aimed to further assess the safety and efficacy of linperlisib in a broader cohort of patients with r/r B-cell malignancies. Methods: Patients with histologically or cytologically confirmed B-cell malignancies, relapsed, refractory, or lacking standard-of-care systemic therapies, were enrolled. The study encompassed several subtypes of the disease, including DLBCL, mantle cell lymphoma (MCL), FL, marginal zone lymphomas (MZL), and CLL/small-cell lymphocytic leukemia (SLL). Linperlisib was administered orally at a dose of 80 mg daily in a 28-day cycle until disease progression, onset of unacceptable toxicity, or patient withdrawal. The primary endpoint of the study was the objective response rate (ORR), as per the 2007 International Working Group Criteria for lymphomas. Secondary endpoints included safety, disease control rate (DCR), duration of response (DOR), progression-free survival (PFS), and overall survival (OS). Results: A total of 43 patients with r/r B-cell malignancies were enrolled between Jun 15, 2020, and Apr 02, 2021, and subsequently received linperlisib. At the data cutoff point of Jan 10, 2023, the median follow-up was 24.7 (range: 0.8, 30.6) months. The ORR was recorded at 46.5% (95%CI, 31.2% to 62.3%), and the DCR at 72.1% (95%CI, 56.3% to 84.7%) across all patients. More specifically, the ORR for individual diseases were as follows: 30.8% (4/13) for GCB DLBCL, 27.3% (3/11) for non-GCB DLBCL, 55.6% (5/9) for MCL, 100.0% (4/4) for FL, 66.7% (2/3) for CLL/SLL, and 66.7% (2/3) for MZL. The median DOR for the entire patient cohort was 9.3 months (95% CI: 5.4 to not reached), and the median PFS was 8.3 months (95% CI: 3.7 to not reached). The median OS was not reached, with 1-year and 2-year OS rates of 79.1% (95% CI: 63.6% to 88.5%) and 76.7% (95% CI: 61.1% to 86.8%), respectively. In terms of safety, the most common adverse events of grade 3 or higher were decreased neutrophil count, infectious pneumonia, and decreased white blood cell count (Table 1). Conclusion: In summary, our study underscores the significant potential of linperlisib in providing broad anti-tumor activity across a range of r/r B-cell malignancies, including DLBCL, MCL, MZL, FL, and SLL/CLL. These encouraging results justify further investigation of linperlisib, both as a monotherapy and in combination with other therapeutic agents. It is hoped that these findings will help evolve and enhance our treatment strategies for B-cell malignancies and ultimately improve patient outcomes.

Linperlisib in Conjunction with Gemcitabine and Oxaliplatin in Relapsed/Refractory Diffuse Large B-Cell Lymphoma: A Multicenter, Single-Arm Phase Ib/II Study

Background: Diffuse large B-cell lymphoma (DLBCL) represents the most common subtype of non-Hodgkin lymphoma (NHL), comprising approximately 30-40% of new NHL cases. Although immunochemotherapy is the current front-line treatment for DLBCL, nearly 40% of patients will face disease relapse or refractoriness to the initial therapy, with a suboptimal prognosis. Gemcitabine in combination with oxaliplatin (GEMOX) offers an established treatment regimen with a manageable side-effect profile, thus providing a viable backbone for innovative treatment combinations. Linperlisib, a selective PI3Kδ inhibitor, has demonstrated its ability to inhibit the growth of PI3Kδ-expressing human tumor cells, as evidenced by both in vitro and in vivo studies. The tolerability, pharmacokinetics, and preliminary efficacy of linperlisib were affirmed in a preceding phase I study, laying the groundwork for its further exploration in patients with relapsed or refractory (r/r) DLBCL. This study aimed to investigate the efficacy and safety of combining linperlisib with GEMOX in treating r/r DLBCL patients. Methods: In this multicenter, single-arm phase Ib/II trial (NCT04500561), histologically confirmed r/r DLBCL patients across six Chinese centers were enrolled and received oral linperlisib (80 mg/day) alongside intravenous GEMOX (gemcitabine 1000 mg/m 2 on day 1, and oxaliplatin 100 mg/m 2 on day 2) every three weeks, with GEMOX administered for a maximum of six cycles. The primary endpoint was the objective response rate (ORR), with secondary outcomes including disease control rate (DCR), time to response (TTR), duration of response (DOR), progression-free survival (PFS), and overall survival (OS). Results: Between September 2020 and June 2021, 39 patients were enrolled and received the study treatment, all of whom were included in the efficacy and safety analysis. By the data cutoff in February 2023, and after a median follow-up of 24.1 months, three patients were still on treatment. The ORR reached 53.8% (95%CI: 37.2, 69.9), and the DCR was recorded at 64.1% (95%CI: 47.2, 78.8) (Figure 1). The median TTR was 1.3 months (range: 1.2-4.0). The median DOR stood at 5.7 months (95%CI: 4.3-9.1), and the median PFS was 5.4 months (95%CI: 1.8-6.7). The median OS had not yet been reached by the cutoff, with the one-year OS rate standing at 65.5% (95%CI: 48.1-78.3). Stratification by subtype revealed an ORR of 66.7% (6/9) among germinal center B-cell like (GCB) DLBCL patients compared to 40% (10/25) among non-GCB DLBCL patients. Median PFS was reported at 3.0 and 3.4 months for GCB and non-GCB DLBCL patients, respectively. The most prevalent grade 3 or higher treatment-related adverse events included decreases in neutrophil count (46.2%), platelet count (41.0%), and white blood cell count (28.2%). Conclusion: The combination of linperlisib with GEMOX exhibits a favorable safety profile and promising clinical efficacy in patients with r/r DLBCL who have received a median of two prior systemic therapies. These findings support the potential role of linperlisib combined with GEMOX as an active and safe therapeutic option for patients with r/r DLBCL, and set a foundation for further research into linperlisib's potential in combination with other treatment regimens.

Efficacy and safety of zanubrutinib plus R-CHOP in treatment of non-GCB DLBCL with extranodal involvement.

Treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) shows poor response rates in non-germinal center B cell-like (non-GCB) diffuse large B-cell lymphoma (DLBCL) patients with multiple extranodal involvement. This study aims to evaluate anti-tumor activity and safety of zanubrutinib with R-CHOP (ZR-CHOP) in treatment naïve non-GCB DLBCL with extranodal involvement. In this single-arm, phase 2, prospective, single-center study, patients with newly diagnosed non-GCB DLBCL with extranodal involvement enrolled between October 2020 to March 2022 received ZR-CHOP for 6 cycles followed by 2 cycles of maintenance treatment with rituximab and zanubrutinib. The primary endpoint included progression-free survival (PFS) in the intent-to-treat (ITT) population whereas the secondary endpoints included overall response rate (ORR), complete response (CR), and duration of response. Further, next-generation sequencing (NGS) was used for detection of different oncogenic mutations closely related to DLBCL pathogenesis. From October 2020 to March 2022, 26 patients were enrolled, and 23 of them were evaluated for efficacy after receiving 3 cycles of ZR-CHOP treatment. 1-year PFS and OS were 80.8% and 88.5% respectively while expected PFS and OS for 2-years are 74.0% and 88.5% respectively with median follow-up of 16.7 months and ORR was 91.3% (CR: 82.61%; PR: 8.70%). Oncogenic mutations closely related to DLBCL pathogenesis were assessed in 20 patients using NGS. B-cell receptor and NF-κB pathway gene mutations were detected in 10 patients, which occurred in MYD88 (7/19), CD79B (4/19), CARD11 (5/19), and TNFAIP3 (2/19). Hematological adverse events (AEs) ≥ grade 3 included neutropenia (50%), thrombocytopenia (23.1%), and anemia (7.7%) whereas non-hematological AEs ≥ grade 3 included pulmonary infection (19.2%). ZR-CHOP is safe and effective for treating treatment naïve non-GCB DLBCL patients with extranodal involvement. Clinicaltrials.gov, NCT04835870.

EXPLORING DIFFERENTIAL MUTATIONAL DISTRIBUTION BY TARGETED SEQUENCING IN A R‐CHOP TREATED COHORT OF DIFFUSE LARGE B‐CELL LYMPHOMA PATIENTS

Background: Diffuse large B-cell lymphoma (DLBCL) harbors striking clinical and molecular heterogeneity, which continues to encumber risk stratification with a consequently high rate of refractory/relapsed patients (pts). Though the genomic landscape of DLBCL has been comprehensively uncovered, the search for eligible molecular biomarkers continues. Exploratively, we set out to retrospectively evaluate differential mutational distributions in a DLBCL cohort using targeted sequencing. Patients and method: A cohort of 105 de novo DLBCL pts, uniformly treated with first-line R-CHOP, were studied. Thirty pts relapsed, of which 70% had early relapses (<2 years after completing therapy), while 30% had late relapses (≥2 years). Targeted next-generation sequencing (90 gene panel) was applied on archival paraffin-embedded diagnostic samples and, if available, first relapse samples. Results: In total, 118 samples were sequenced, each displaying a median of 12 (range 1–46) putative somatic protein-coding mutations. Germinal center B-cell (GCB) DLBCL (n = 60) displayed a differential somatic signature with enrichment of EZH2, TNFRSF14, BCL2, ACTB, SOCS1, and FAS mutations (Fisher's Exact, p < 10-4), whereas mutations in CDKN2A, PRDM1, MYD88, and CD79B were significantly enriched in non-GCB pts (p < 10-4, n = 44). Survival analysis confirmed inferior overall survival (OS) in non-GCB DLBCL (5-year OS, log-rank (Mantel-Cox), p = 0.01, hazard ratio (HR) 1.7). Pts with double-hit biology (DHB), defined as either MYC and BCL2 and/or BCL6 fluorescent in situ hybridized positive and/or with MYC and BCL2 immunohistochemical double expression (n = 32), did not display a significant mutational signature or differential OS. However, a subgroup of DHB pts characterized by mutations in MYC, PRDM1, or IRF4 (n = 15) had markedly inferior OS (5-year OS, log-rank, p = 0.0003, HR 3.34) compared to negative non-DHB pts (n = 55) or negative non-DHB/DHB pts (p = 0.0017, HR 2.7, n = 72). Noticeably, ACTB mutations were only present in non-DHB pts. The mutational distribution at diagnosis did not differ between pts with relapse and in sustained remission. However, in the relapse group, GNA13 mutation at diagnosis was more frequent in early relapses than late relapses (43% vs. 0%, Fisher’s Exact without correction, p = 0.03). The presence of GNA13 in the entire cohort showed a trend towards inferior survival. Conclusion: Differential distribution with significant mutational signatures were expectedly found in GCB versus non-GCB, but not in subgroups with DHB or relapse. Interestingly, mutations in MYC, PRDM1 or IRF4 identified a distinct subset of DHB pts with inferior survival. Furthermore, GNA13 mutations were significantly enriched in early relapse pts. These preliminary findings call for validation of GNA13 as a potential marker of early relapse as well as the prognostic value of MYC, PRDM1 and IRF4 mutations in DHB DLBCL. The research was funded by: The Danish Cancer Society and The Vissing Foundation Keywords: aggressive B-cell non-Hodgkin lymphoma, genomics, epigenomics, and other -omics, tumor biology and heterogeneity Conflicts of interests pertinent to the abstract T. S. Larsen Consultant or advisory role Roche, Gilead, Novartis, Celgene/BMS Research funding: Genentech

Clinical impact of ibrutinib plus R-CHOP in untreated DLBCL coexpressing BCL2 and MYC in the phase 3 PHOENIX trial.

Diffuse large B-cell lymphoma (DLBCL), with high coexpression of BCL2 and MYC proteins (DE lymphoma), is considered an adverse prognostic indicator associated mostly with non-germinal center B-cell-like (non-GCB) DLBCL. BCL2/MYC overexpression is associated with B-cell receptor (BCR) pathway activation; consequently, DE DLBCL may be sensitive to BCR inhibitors. We assessed whether high BCL2/MYC coexpression by RNA sequencing could identify a patient subset responsive to ibrutinib using baseline biopsies from the PHOENIX trial, which evaluated the addition of ibrutinib to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in untreated non-GCB DLBCL. BCL2/MYC RNA expression was correlated with lower event-free survival (EFS) and overall survival (OS) using Kaplan-Meier estimates with Cox regression and log-rank testing. In total, 234 of 766 (30.5%) patients had high BCL2/MYC coexpression: 123 of 386 (31.9%) received ibrutinib plus R-CHOP and 111 of 380 (29.2%) received R-CHOP. EFS was superior with ibrutinib plus R-CHOP compared with R-CHOP alone in patients with high BCL2/MYC coexpression, but there was no significant impact on OS. However, EFS and OS showed clinically meaningful improvement with ibrutinib plus R-CHOP over R-CHOP alone in patients aged <60 years with high BCL2/MYC coexpression. We observed a significant association between high BCL2/MYC coexpression and activated B-cell-like and MYD88L265P/CD79B-mutated subtypes of DLBCL. Consequently, high BCL2/MYC coexpression identified a subset of non-GCB DLBCL that may be preferentially responsive to ibrutinib and warrants further investigation. This trial was registered at www.clinicaltrials.gov as #NCT01855750.