Received CAR T-cell Therapy Research Articles

Cytokine Release Syndrome Associated With Immune-Modulating Chemotherapy: Potential Mitigating Role of Intravenous Omega-3 Fatty Acid Triglycerides.

Patient susceptibility to cytokine release syndrome (CRS) resulting from immune-modulating chemotherapy has profound implications for clinical outcome. This is particularly true for patients receiving CAR T-cell therapy. First-line pharmacotherapy for CRS includes the administration of the IL-6 receptor-binding monoclonal antibody tocilizumab, or tocilizumab and corticosteroids. Other agents, such as siltuximab, anakinra, and dasatinab are also being explored for refractory cases of CRS. This review summarizes the potential role of omega-3 fatty acids, that is, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) at ameliorating CRS in cancer patients receiving immune-modulating chemotherapy, and is compared with current treatment strategies to reduce the severity of the inflammatory response. Selective blockade of specific proinflammatory mediators (e.g., IL-6) is effective, but carries a significant risk of serious opportunistic infections. In contrast, omega-3 fatty acids affect multiple triggers underlying the inflammatory response (i.e., prostaglandins, leukotrienes, transcription factors, and specialized proresolving molecules), and its major limitation is avoidance of hypertriglyceridemia, which can be managed by reducing the rate of intravenous administration. This discussion proposes a novel approach by continuous infusion of omega-3 fatty acids to modulate the intensity of the severe systemic inflammatory response from CRS. The purpose of this review is to highlight the potential clinical benefits of a specialized omega-3 fatty acids dosage form to mitigate the severity of CRS as a hypothetical alternative to current treatment. Optimizing the formulation, for example, enriched fish oil that meets drug concentration standards for EPA and DHA, a continuous infusion rate, reductions in long-chain saturated fatty acids concentrations, and addition of medium-chain triglycerides to improve EPA + DHA utilization and physical stability are key pharmaceutical factors. This may result in a safer and more effective option than targeted abrogation of cytokines and consequent risks of adverse drug reactions, but will require formal study in randomized control trials in humans.

False-positive HIV NAT results in patients receiving CAR T-cell therapy

False-positive HIV NAT results in patients receiving CAR T-cell therapy

Chimeric Antigen Receptor T-Cell Postinfusion Fever: Infection Profile, Clinical Parameters, and Biomarkers Trends to Assist Antibiotic Stewardship.

This study aimed to describe documented infections associated with postinfusion fever after CAR T-cell therapy and to evaluate daily changes in vital signs, laboratory results, and the National Early Warning Score (NEWS) in patients with and without confirmed bacterial infections following fever onset, with the objective of assisting in antibiotic stewardship. This was a retrospective, observational study including all consecutive adult patients who received CAR T-cell therapy. Documented infection in the first fever episode after infusion, and clinical and analytic trend comparison of patients with bacterial documented infections and those without documented infections, are described. Among 152 patients treated with CAR T-cell therapy, 87 (57.2%) had fever within 30 days of infusion, with a median time from infusion to fever of 3 (interquartile range, 2-5) days. Of these 87 patients, 82 (94.3%) received broad-spectrum antibiotics. Infection was documented in 9 (10.3%) patients and only 4 (4.6%) had bacterial infections. Clinical signs and biomarkers were similar in patients with bacterial documented infection and in those without documented infection at fever onset. Fever, tachycardia, and high C-reactive protein levels remained high during the first 3 days after CAR T-cell infusion, even when no infection was documented. Fever is a common symptom following CAR T-cell infusion and is largely treated with broad-spectrum antibiotics. However, confirmed bacterial documented infections after the first fever post-CAR T-cell infusion are very unusual. Because clinical parameters and biomarkers are not useful for identifying infectious fever, other methods should be assessed to ensure the proper use of antibiotics.

Glofitamab (Columvi)

CADTH reimbursement reviews are comprehensive assessments of the clinical effectiveness and cost-effectiveness, as well as patient and clinician perspectives, of a drug or drug class. The assessments inform non-binding recommendations that help guide the reimbursement decisions of Canada's federal, provincial, and territorial governments, with the exception of Quebec. This review assesses glofitamab (Columvi), concentrate for solution for infusion, 2.5 mg/2.5 mL vial and 10 mg/10 mL vial, IV infusion. Indication: For the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified, arising from follicular lymphoma (trFL), or primary mediastinal B-cell lymphoma (PMBCL), who have received two or more lines of systemic therapy and are ineligible to receive or cannot receive CAR-T cell therapy or have previously received CAR-T cell therapy.

A meta-analysis to assess the risk of bleeding and thrombosis following chimeric antigen receptor T-cell therapy: Communication from the ISTH SSC Subcommittee on Hemostasis and Malignancy

BackgroundChimeric antigen receptor T-cell (CAR T-cell) therapy is increasingly utilized for treatment of hematologic malignancies. Hematologic toxicities including thrombosis and bleeding complications have been reported. Accurate estimates for thrombotic and bleeding outcomes are lacking. ObjectivesWe performed a systematic review and meta-analysis in patients who received CAR T-cell therapy for an underlying hematologic malignancy with the objective to: a) assess the thrombosis and bleeding risk associated with CAR T-cell therapy, b) assess the impact of CRS and ICANS on the risks of thrombosis and bleeding, and c) assess the safety of anticoagulant or antiplatelet use in the period following treatment with CAR T-cell therapy. MethodsWe searched MEDLINE, EMBASE, and Cochrane CENTRAL up to February 2022 for studies reporting thrombotic or bleeding outcomes in patients receiving CAR T-cell therapy. Pooled event rates were calculated using a random-effects model. We performed subgroup analyses stratified by follow-up duration, CAR T-cell target antigen, and underlying hematologic malignancy. ResultsWe included 47 studies with a total of 7040 patients. High heterogeneity between studies precluded reporting of overall pooled rates of thrombotic and bleeding events. In studies with follow-up duration of ≤6 months, the pooled incidence of venous thrombotic events was 2.4% (95% CI, 1.4%-3.4%; I2 = 0%) per patient-month, whereas the rate was 0.1% (95% CI, 0%-0.1%; I2 = 0%) per patient-month for studies with longer follow-up periods (>6 months). The pooled incidences of any bleeding events per patient-month in studies with follow-up duration of ≤6 months and >6 months were 1.9% (95% CI, 0.6%-3.1%; I2 = 78%) and 0.3% (95% CI: 0%-0.8%, I2 = 40%), respectively. Secondary analyses by CAR T-cell target antigen, underlying malignancy, and primary outcome of the studies did not reveal significant differences in the rates of thromboembolism, any bleeding events, or major bleeding events. ConclusionThe risk of both thrombosis and bleeding following CAR T-cell therapy appears to be highest in the initial months following infusion.

388 Prototyping a mobile phone application for Chimeric Antigen Receptor (CAR) T-cell therapy patient monitoring and data collection post-discharge

OBJECTIVES/GOALS: Research objectives include prototyping a mobile phone application that allows physicians to monitor CD19-directed CAR T-cell therapy patients remotely after discharge. This app will also enable standardized data collection across different centers that provide CAR-T cell therapy and allow for the harmonization of follow-up protocols. METHODS/STUDY POPULATION: Literature review and semi-structured interviews with patients, clinical coordinators, and other experts in the field will be used to determine what parameters must be included in the mobile application prototype to effectively monitor the side effects of CD19-directed CAR T-cell therapy. The mobile phone application will be designed using process mapping to integrate data from self-reporting and wearable technologies, including the Garmin smart watch. Figma will then be used to develop new screens based on an existing patient monitoring app for Allogeneic Stem Cell Transplant follow-up. Finally, a preliminary feasibility study will be conducted to collect feedback on the app prototype from CAR T-cell therapy patients, providers, and stakeholders. RESULTS/ANTICIPATED RESULTS: The anticipated results of this study include an app prototype that will include the functionalities required to monitor patients for adverse effects of CD19-directed CAR T-cell therapy. This will include the parameters that will be recorded or measured using a combination of self-reporting, a reliable body temperature sensor, and the Garmin watch which monitors basic vitals, activity, and sleep. Additional parameters may be added during the stakeholder co-design process. The app prototype will include a physician interface where doctors can monitor their patients and will be alerted if they require further physician assessment. It is expected that the app will provide standardized monitoring of patients when they are discharged from the hospital after receiving CAR T-cell therapy. DISCUSSION/SIGNIFICANCE: This app will allow physicians to monitor patients for general follow-up and adverse effects, including cytokine release syndrome and neurotoxicity. Future studies may utilize this app to develop best practices for harmonizing CAR-T follow-up protocols across Canada.

Dynamic monitoring of circulating tumor DNA reveals outcomes and genomic alterations in patients with relapsed or refractory large B-cell lymphoma undergoing CAR T-cell therapy

BackgroundOver 50% of patients with relapsed or refractory large B-cell lymphoma (r/r LBCL) receiving CD19-targeted chimeric antigen receptor (CAR19) T-cell therapy fail to achieve durable remission. Early identification of relapse...

Glofitamab (Columvi)


 CADTH recommends that Columvi be reimbursed by public drug plans for the treatment of adult patients with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) not otherwise specified, DLBCL arising from follicular lymphoma (trFL), or primary mediastinal B-cell lymphoma (PMBCL), who have received 2 or more lines of systemic therapy and are ineligible to receive or cannot receive CAR-T cell therapy or have previously received CAR-T cell therapy if certain conditions are met.
 Columvi should only be covered to treat adult patients who have DLBCL not otherwise specified, trFL, or PMBCL that has come back or that did not respond to 2 or more previous treatments for their cancer, and who have also previously received CAR-T cell therapy, declined CAR-T cell therapy, or cannot receive CAR-T cell therapy.
 Columvi should only be reimbursed for a maximum of 12 treatment cycles, after a single dose of obinutuzumab to reduce the risk of cytokine release syndrome (CRS) and should not be given in combination with other anticancer drugs. Reimbursement of Columvi should be discontinued if a patient’s cancer grows or spreads or if treatment is unacceptably toxic to the patient. Columvi should only be reimbursed when prescribed by specialists with experience managing DLBCL, and if its cost is reduced.

High Incidence of Cytomegalovirus (CMV) Reactivation in Patients Receiving CAR T-Cell Therapy.

High Incidence of Cytomegalovirus (CMV) Reactivation in Patients Receiving CAR T-Cell Therapy.

‘The last bridge’- How patients experience the CAR T-cell therapy. A qualitative study

PurposeCAR T-cell therapy gives patients new hope, who are diagnosed with relapsed or refractory B-cell lymphoma or B-cell leukaemia. To date, there is no scientific knowledge about the experiences of patients with CAR T-cell therapy, their process of treatment decision making or how they handle potential side effects. The study aims at deepening the understanding of the patient's experiences, indicating how to improve nursing care for this patient population. MethodA qualitative study was carried out. Episodic guideline-based interviews were conducted with 14 patients who had received CAR T-cell therapy. The data analysis was performed according to the Grounded Theory. The study took place at a German university hospital. ResultsData analysis showed five sequential phases including the following concepts: ‘living with cancer recurrence’, ‘deciding on CAR T-cell therapy’, ‘waiting for the reinfusion of the CAR T-cells’, ‘experiencing CAR T-cell therapy’ and ‘recovering and staying healthy’. The decision for CAR T-cell therapy was characterised by the lack of alternatives and uncertainty about the outcome and side effects. ConclusionsBefore, during and after CAR T-cell therapy, patients are faced with major challenges for which they need nursing support and guidance. These include preparation for CAR T-cell therapy, handling of side effects and preparation for discharge home.

Digital PCR Assay for Evaluation of CD19-CAR-T Cells In Vivo Expansion in Aggressive B-Cell Lymphoma: Impact on Clinical Outcome

Background: Chimeric antigen receptor (CAR)-T cells therapy has revolutionized hematological treatment mainly in non-Hodgkin lymphoma (NHL) demonstrating unprecedented clinical responses when directed against CD19 combining the antigen-binding properties of antibodies with the effector functions of T cells. In particular, CAR-T cell peak concentrations and area under the curve in the first 28 days after Axicabtagene Ciloleucel (Axi-cel) infusion have been associated with long-term efficacy. Based on a digital PCR assay for sensitive CAR-T cells detection, we aimed to detect the CAR-T product in patients (pts) and associate its kinetics with patient outcome. Methods: A retrospective analysis was conducted involving 28 patients diagnosed with NHL treated with Axi-cel CAR-T products (2019-2023) in the Department of Hematology of the Clinical University Hospital of Valencia, Spain according to the Declaration of Helsinki ethical criteria. 97 peripheral blood mononuclear cell (PBMC) DNA samples were extracted from 3-12 ml EDTA tubes. We performed serial measurements of CAR-T-cell blood levels (7,14, 28 days post-infusion) using a newly developed axi-cel-specific dPCR assay (Bio-Rad,USA) with QIAcuity Digital PCR System and QIAcuitySoftware for data analysis (QIAGEN, Germany). The peak CAR-T-cell blood concentrations (CAR-T-Cmax) and the cumulative CAR-T-cell levels over the first 28 days in PB by area under the curve (AUC CAR-T) were calculated based on CAR-T dPCR values (copies/μL). Response assessment was performed per institutional practice and based on Lugano Criteria. Statistical analyses were performed using SPSS Software (IBM, Germany, v.22). Logistic regression was used to evaluate the relationship between covariate and outcome. Kruskal-Wallis and Dunn's tests were used when 3 subgroups were involved. Survival analyses were conducted according to CAR-T dPCR values. Results: A total of 28 pts (16 [57.1%] females) who received CAR-T cell therapy were included [25 (89%) DLBCL; 3 (11%) PMBCL]. The patient's best overall response assignment (partial or complete) were observed in twenty-two (78,4%) named as responders (R), otherwise six (21,4%) nonresponders (NR) around day 30 of evaluation. CAR-T-CMax ranged from 2.30 to 176.10 (median, 40.16) CAR-T copies/μL, 7 days later of majority expansion day post infusion: R pts had a higher peak expansion of 66.38 copies/µL compared to 32.43 copies/µL although this difference did not reach statistical significance ( p=018). Expansión was faster in R pts (median 7.64 days pot-infusion) versus NR pts (median 12.83, p=0,10) . Quantitative 7-d CAR-T copies/μL, and AUC value from days 0 to 7, showed statistical significance differences post-infusion between R and NR (52.08±32.48 vs 15.51±20.51, p<0.005; 3603.88±2520.02 vs 1291.74±1948.77, p<0.037). As for response assessment, 7-d CAR-T values were able to successfully predict the development of NR pts with an area under the curve of 0.841 (CI 95% 0.66-1.00), a sensitivity of 0.950 and a specificity of 0.625 (Fig 1.). Eleven pts (39.3%) died at a median of 3.6 months (1.7-6.1 months) post-infusion. For survival analyses, a cut-off value of 18.35 7-d CAR-T copies/μL that maximized the Log-Rank statistic, was selected to divide pts into R and NR categories. Median overall survival (OS) was 23.9 [16.3-NA, 95% CI] months and 13.2 [3.30-3.96, 95% CI] months for R and NR according to CAR-T copies/μL 7 days, respectively (Fig.2). Conclusions: Digital PCR for CAR-T evaluation shows that quantitative CAR-T copies/μL could be a potential predictor of short-term response and survival at first 7 days post-infusion value in pts with DLBCL or PMBCL treated with CAR-T cell therapy.

Patterns of Care and Prognostic Modeling Following Follicular Lymphoma Transformation to Aggressive B-Cell Lymphoma: An Analysis from the LEO Consortium

Introduction: Histologic transformation (HT) from follicular lymphoma (FL) to an aggressive lymphoma is infrequent but has unfavorable outcomes. Sarkozy et al. (J Clin Oncol, 2019) reported that approximately half of FL-related deaths within the first decade of diagnosis occurred following HT. Our recent analysis showed heterogeneous outcomes with median overall survival (OS) of 61 months (Day et al., ASH, 2022). Prognostic tools post HT would be clinically useful but development has been limited by small cohort sizes. Factors previously associated with outcomes following HT have included age, time to progression, prior therapy, anthracycline exposure, and early HT. Utilizing the Lymphoma Epidemiology of Outcomes (LEO) Consortium of Real World Evidence (CReWE), we describe patterns of care and evaluate other prognostic factors following HT. Methods: This multicenter observational cohort consists of prospectively enrolled patients in the LEO Cohort, and patients with HT retrospectively identified at LEO centers. Patients diagnosed with biopsy proven grade 1-3A FL at diagnosis, and a subsequent biopsy showing HT to an aggressive lymphoma (FL grade 3B, diffuse large B cell lymphoma [DLBCL], or high-grade B cell lymphoma [HGBCL]) between 2002-2022, were eligible for the study. Patients with a component of FL grade 3B, DLBCL, or HGBCL at diagnosis were excluded. HGBCL was defined as double or triple hit or another aggressive subtype. OS was defined as the time from HT until death from any cause and calculated via Kaplan-Meier. Associations between clinical factors at time of HT and/or diagnosis and OS were evaluated using Cox models. Cause of death was evaluated using a competing risk approach. Results: Overall, 328 patients were confirmed with HT during the study period, 41% were female, and the median age at HT was 63 years (interquartile range [IQR] 56-70). The median time from diagnosis to transformation (TDT) was 35 months (IQR 12-66). At HT, 88% had advanced stage disease (III-IV) and LDH was elevated in 49%, while few patients exhibited B symptoms (5%) and ECOG performance status was >2 in 9%. 23% did not receive systemic therapy prior to HT. For those with prior therapy, the median time from prior therapy to HT was 15 months (IQR 7-39). The most frequent treatment regimens following HT were CD20-CHOP (42%), followed by platinum-based salvage therapy (20%), R-EPOCH (10%), CD20-Benda (8%), R-Mono (4%), and R-Gem-Ox (3%). 50 (15%) patients underwent consolidation with autologous stem cell transplant, 3 underwent allogeneic transplant (30 platinum-based, 15 CD20-CHOP, 5 R-EPOCH, 3 Other), and 2 received CAR T-cell therapy (Figure 1). After median follow-up of 85 months from HT, 170 patients had died; 5-year OS was 52% and median OS was 65 months (95% CI: 55-107). Among 160 patient deaths, cause was most often lymphoma-related (progression, n=107 [63%]; therapy-related, n=14 [7%]) compared to non-lymphoma (n=20, 13%) or missing/unknown causes (n=29, 17%). Clinical factors at the time of HT that were associated with worse OS include: ECOG PS >2, age ≥70, IPI 3-5, and shorter TDT (<24 months), hemoglobin <10 g/dl and elevated LDH. A transformation to HGBCL was also associated with inferior OS (Table 1). OS did not significantly differ by gender, BMI, stage, presence of B-symptoms, absolute lymphocyte count, number of extranodal groups, presence of bulky disease at HT, or response to prior FL treatment. Factors at the time of FL diagnosis that were associated with decreased OS after HT included FLIPI score 3-5 (high risk), FLIPI 2 (moderate risk), and FL grade 3A at diagnosis. Exposure to any systemic therapy for FL prior to HT was associated with shorter OS, with the worst outcomes in patients receiving an anthracycline prior to HT. POD24 to frontline immunochemotherapy was associated with inferior OS after HT (Table 1). Conclusions: Patterns of care in Transformed FL are heterogeneous and vary greatly in intensity. These data confirm previous reports that age, early HT, and any systemic therapies prior to HT are negative prognostic indicators for OS. At HT elevated LDH, low hemoglobin, POD24 status, poor performance status, and HT to HGBCL were associated with poor outcomes following HT. These data provide a basis for future prognostic indices to identify patients with highest risk of lymphoma related mortality for whom study of novel treatments is greatly needed.

CART-AI-Radiomics: Survival and Neurotoxicity Prediction in B-Cell Lymphoma Patients Treated with CAR-T Cells through an Imaging Features-Based Model

Background: Despite clinical outcome improvements observed in relapsed/refractory (R/R) B-cell lymphoma patients (pts) treated with antigen receptor modified T-cells (CAR-T cells), a sizeable proportion still progress or relapse after infusion. Besides, this procedure is associated with significant morbidity primarily due to the immune effector cell-associated neurotoxicity syndrome (ICANS). The main goal of the CART-AI-Radiomics study is to apply artificial intelligence to develop new imaging-based prognostic and predictive models that integrate molecular and imaging biomarkers towards improved stratification of pts at high risk of R/R. In this sub-study, we retrospectively assessed the ability of imaging features and clinical data to predict survival and neurotoxicity. Methods: Consecutive pts diagnosed of diffuse large B-cell lymphoma (DLBCL) and primary mediastinal B-cell lymphoma (PMBCL) treated with anti-CD19 CAR-T cells from 2019-2022 in Valencia Clinic Hospital and La Fe Hospital were included (cut-off date: July 2023). All the pre-infusion flourine18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18F-FDG PET/CT) scans and clinical data were collected. The volume of interest (VOI) was manually contoured for all visible lesions in the PET/CT imaging exams. A subsequent imaging features extraction was performed. Features included PET conventional parameters-maximum standardized uptake value (SUV max), metabolic tumor volume (MTV; defined as the volume of voxels with SUVs higher than the threshold of 41% × SUV max) and total lesion glycolysis (TLG)-and radiomic features. Imaging parameters were calculated for all lesions (total) and for the dominant lesion (DL), whereas clinical variables were measured before lymphodepletion (LD). Univariate and multivariate analyses were carried out using Cox proportional-hazards models for survival prediction and logistic regression for neurotoxicity assessment. Survival analyses were conducted according to MTV total values. Results: A total of 29 pts (median age 63.2 [range 21.8-79.3] years; 18 [62.1%] females) who received CAR-T cell therapy were included. Twenty-six (89.7%) pts had DLBCL and 3 (10.3%) had PMBCL. At the time of pre-LD, 22 (75.9%) pts had increased lactate dehydrogenase (LDH) levels 18 (62.1%), presented with stage IV disease, 16 (55.17%) with an International Prognostic Index (IPI) score of 3-5, 8 (27.6%) had bulky disease. Median number of prior treatment lines was 2 (range 2-6). Twenty-three (79.3%) pts were treated with axicabtagene ciloleucel and 6 (20.7%) with tisagenlecleucel. Bridging therapy before LD was required by 26 (89.6%) pts. For survival analyses, a cut-off MTV total value of 236.03 mL that maximized the Log-Rank statistic was selected to divide pts into high MTV total and low MTV total categories. Median overall survival (OS) was 5.7 [3.2-NA, 95% CI] months and 36.2 [13.9-NA, 95% CI] months for the high and low MTV total, respectively (Fig. 1). In multivariate analyses, a model including MTV total, SUV max and TLG total as imaging feature, and ICANS, C-reactive protein LD (CRP LD), LDH LD, lymphocytes count LD (Li LD) as clinical variables was able to successfully predict OS ( p = 0.019). Median progression-free survival (PFS) was 3 [1.31-NA, 95% CI] months and 11.06 [5.81-NA, 95% CI] months for the high and low MTV total, respectively. In multivariate analysis, a successful prediction of PFS ( p = 0.007) was achieved with a model including the same predictors that were used for OS. For the neurotoxicity assessment, a logistic regression model including six conventional PET parameters-MTV total, MTV DL,TLG total, TLG DL, median SUV DL, SUV max-two radiomic features,-entropy and entropy DL-and four clinical variables-CRP LD, LDH LD, Li LD and type of CAR-T cell treatment-was able to successfully predict the development of ICANS with an area under the curve of 0.971, a sensitivity of 0.813, a specificity of 0.846 and an accuracy of 0.828 (Fig. 2). Conclusions: Imaging features extracted from pre-infusion 18F-FDG PET/CT images in combination with several clinical features could predict survival and neurotoxicity in pts with DLBCL or PMBCL treated with CAR-T cell therapy. Quantitative features extracted from the PET/CT imaging exams may be useful for patient risk stratification and neurotoxicity prediction. Validation of these classifiers in independent datasets is warranted.

Application of cfDNA-NGS Test in MRD Monitoring of Acute Leukemia Patients with CAR-T Cell Therapy

Background: The minimal residual disease (MRD) plays an important role in the comprehensive management of CAR-T cell therapy. However, some reasons hinder the application of MRD monitoring in CAR-T cell therapy. Dynamic monitoring of cfDNA in solid tumors and hematological malignancies can effectively evaluate the efficacy of treatment and predict long-term prognosis. However, there is no relevant researches on whether cfDNA can replace bone marrow for MRD monitoring after CAR-T cell therapy for acute leukemia. Methods: 23 patients with acute leukemia who received CAR-T cell therapy from January 2021 to October 2022 in the First Affiliated Hospital of Suzhou University were collected retrospectively, including 14 AML patients and 9 ALL patients. The CAR-T cell targets included CD38, CD7, CLL-1 and CD19/CD22. Bone marrow and peripheral blood samples were collected before CAR-T cell therapy, +28d and every month after CAR-T cell therapy. We used QIAamp Circulating Nucleic Acid Kit to extract cfDNA, and then conducted high-throughput sequencing through Nextseq550 sequencing platform. We compared the test results of cfDNA-NGS and BM-NGS in terms of gene mutation types and variant allele frequency (VAF), and analyzed the efficacy of cfDNA-NGS, BM-NGS and FCM on the prediction of remission and replase of CAR-T cell therapy by the receiver operating characteristic curve (ROC curve). Results: In this study, a total of 123 peripheral blood samples were collected and cfDNA was extracted from all samples. The results of 121 cfDNA-NGS and BM-NGS test were consistent, with a consistency rate of 98.4% (121/123), and the consistency rate with bone marrow FCM detection was 85.4% (105/123). cfDNA-NGS test was a good indicator for predicting the efficacy and replase after CAR-T cell therapy: compared with BM-NGS and FCM, cfDNA-NGS test before CAR-T cell therapy had the highest prediction efficiency for CR (AUC=0.767, 95%CI: 0.576-0.958, P=0.039). Survival analysis showed no difference in 1-year OS and LFS between cfDNA-NGS (+), BM-NGS (+) , FCM (+) patients at +28 days after CAR-T cell therapy (OS: 27.3% vs 33.3% vs 30%, P=0.949; LFS: 27.3% vs 33.3% vs 30%, P=0.970). At +28 days after CAR T treatment, there was no difference in 1-year OS and LFS between patients with cfDNA-NGS (-), BM-NGS (-), FCM (-) (OS: 91.7% vs 76.2% vs 83.3%, P=0.671; LFS: 73.3% vs 76.2% vs 82.1%, P=0.726). Then we assessed the long-term prognosis by cfDNA-NGS combined with traditional MRD detection methods after CAR-T cell therapy: Survival analysis showed that 1-year OS and LFS of patients with cfDNA (-), BM-MRD (-) and cfDNA1 (-), BM-MRD (+) were significantly better than those with cfDNA (+), BM-MRD (-) and cfDNA1 (+), BM-MRD (+) (OS: 90.9% vs 100% vs 50% vs 22.2%, P=0.008: LFS：68.2% vs 100% vs 50% vs 22.2%, P=0.017). Conclusions: The cfDNA-NGS test was a good indicator for predicting the efficacy and replase after CAR-T cell therapy, and was not inferior to BM-NGS and FCM detection in evaluating efficacy, replase and long-term prognosis. Combination cfDNA-NGS test with traditional MRD detection methods could evaluate the long-term prognosis of CAR-T cell therapy more comprehensively.

Economic Burden Associated with ASCT in Patients with Relapsed/Refractory Diffuse Large B-Cell Lymphoma: A Nationwide Health Insurance Claims Database Study in Japan during 2012-2022

Introduction: Autologous stem-cell transplantation (ASCT) is a standard of care for transplant-eligible patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL). ASCT-related costs and cost drivers remain unknown in Japan, thus restricting economic evaluation comparisons of newer innovative therapies with ASCT. Japan has universal health insurance coverage with a copayment system, which provides a nationwide snapshot of the current treatment landscape in Japan through health insurance database analysis. To capture continuous follow-up data of DLBCL patients who received stem-cell transplantation (SCT) in Japan, we conducted this study using a Japanese health insurance association (HIA) claims database. Methods: This is a retrospective observational study of patients with DLBCL who received SCT using the Medical Data Vision, Co. Ltd. (MDV; Tokyo, Japan) HIA claims database. The MDV HIA database contains inpatient, outpatient, and pharmacy claims from 149 health insurance societies in Japan. The database comprises approximately 7.84 million unique patient identifiers and covers about 3.0% of the Japanese population (as of August 2022). Patients who received treatment during the identification period from October 2012 to February 2022, inclusive, were selected using the DLBCL ICD-10 codes C83.3, C83.8, C85.1, and C85.2. Patients were required to have data for at least 6 months before and after the index date, which is the date of the first recorded ASCT procedure. The total cost included the costs of SCT-related lab tests, stem cell harvests, conditioning regimens during the lookback period, and all costs during the follow-up period including SCT-related hospitalization. Structural Equation Modelling (SEM) is ongoing to estimate the relationships of observed and latent variables having direct and indirect effects on pre-assumed causal relationships. Results: A total of 108 patients (3.8%) among all DLBCL patients who received SCT met the eligibility criteria, and all were ASCT patients. Of those patients, 41.67% were female and 97.22% were aged between 18 to 65 years old with a median age of 55. Subsequent therapy after the index date was received by 13.89% of the 108 patients, of which 2 (1.85%) patients received CAR-T cell therapy. Among the 108 ASCT patients, the median (Q1-Q3) length of SCT-related hospitalization was 34 days (28.50-42.00 days). During SCT-related hospitalization, CT scan was the most common test (22, 50.93%) among all ASCT patients, followed by MRI (12, 11.11%) and PET (3, 2.78%); and no patients were admitted to the ICU or emergency room during SCT-related hospitalization. There was 1 (0.93%) patient who received radiation therapy during SCT-related hospitalization. The median (Q1, Q3) of the total cost for ASCT patients during the lookback and follow-up period (index date inclusive) was $78,718.63 ($57,175.90, $141,108.38). Conclusions: This is the first study to examine the total cost and healthcare resource use of ASCT among patients with DLBCL in the Japan nationwide setting with a follow-up period of up to 24 months. While it is not directly comparable to our study, the median of the total cost for ASCT with a 6-month follow-up period in the US, as reported by Cui et al. (2022), was more than $86,408. The data presented in this study will be a benchmark when considering new innovative therapies for patients with DLBCL. Identifying the cost drivers of ASCT-related costs for DLBCL patients may provide insights for optimizing clinical practice for patients with DLBCL undergoing ASCT and for delivering better care for patients.

Early Autologous Hematopoietic Stem Cells (AHSC) Boost (HCB) to Overcome Immune Effector Cell-Associated Hematotoxicity (ICAHT) after CAR T-Cell Therapy for Lymphoma: A Single Center Experience

Sustained cytopenias designed as Immune Effector Cell-Associated Hematotoxicity (ICAHT) represent one of the most frequent side effect of CAR-T-cell therapy (30 to 90 % patients in recent real life studies) resulting in significant morbidity, mortality and resources consumption. We report single center experience of early reinjection of previously cryopreserved AHSC (HCB) in that setting. From July 2021 until January 2023, 27 patients received CAR T-cell therapy (25 Axi-Cel, 2 Brexu-Cel) after Fludarabine and Cyclophosphamide lymphodepletion for relapsed/refractory large B-cell lymphomas (24), mantle lymphoma (2), or follicular lymphoma (1). Median age was 62 years (19-75). CAR-HEMATOTOX score was ≥ 2 for 46% of patients. All patients received Filgrastim from D0. Hematopoietic recovery was longitudinally evaluated until D90 or censoring for relapse and/or subsequent cytotoxic treatment: severe (CTAE grade ≥ 3) neutropenia, anemia or thrombopenia occurred respectively for 88, 44 and 76% of patients until D28, and 60, 24 and 60% until D90. Median duration of severe neutropenia was 7 days (0-39) and 28 days for severe thrombocytopenia (0-118). Prolonged neutropenia occurred in 18/25 evaluable patients, mostly with a biphasic course (intermittent recovery and aplastic phenotype for 14 and 4 patients respectively). CAR-HEMATOTOX score was significantly correlated with sustained thrombopenia (p = 0,005) but only marginally with ICAHT (p = 0,054) and not with severe neutropenia (p = 0,44) . We observed significant correlation of severe ICAHT with progressive disease at CAR T-cell infusion (p = 0,015), platelets nadir < 30 giga/l before D28 (p < 0,005) and CAR T-cell expansion (> 200/µl) at D7 (p = 0,023). 7 patients received HCB (no conditioning) at a median D24 (15-41) post CAR T-cell infusion: after D14 for patients with aplastic phenotype, or for cytopenic recurrence for patients with biphasic course. Filgrastim was pursued or reintroduced until neutrophil recovery (> 1 giga/l) which occurred after a median of 10 days (4-16); platelet recovery (> 20 giga/l and > 50 giga/l) occurred after a median of respectively 12 (8-14) and 17 (11-22) days. If we consider D0 as CAR T-cell infusion, neutrophil recovery occurred at median D37 (22-49) and platelet recovery (> 50 giga/l) at median D37 (26-63). Median complete hematopoietic reconstitution (defined as PMNC > 1 giga/l, and Hb > 100 g/l, and PLT > 100 giga/l) was significantly shorter (median 23 days, 14-30) for patients receiving HCB compared with patients with prolonged cytopenia (> 28 days) who do not receive HCB (60 days, p = 0,018). Transfusion and hematopoietic growth factors (HGF) consumption was significantly reduced after HCB but we observe no difference between 2 groups considering hospitalization, EFS or OS. 2 patients receiving HCB experienced late recurrence of cytopenia (after D90) requiring intermittent HGF support but no transfusion or hospitalization. Discussion - Perspectives Recent case series highlighted clinical feasibility and safety and of this approach across a broad population of pediatric and adult patients: we validate this strategy in a more homogeneous and systematic practice. As study population is small, we failed to demonstrate that earlier application of an HCB is associated with superior survival outcomes as shown by others. We agree with recent updated recommendation of experts panel considering application of HCB without prior conditioning chemotherapy for grade ≥ 3 ICAHT beyond D14 (so considered early) if AHSC graft is readily available. Prophylactic AHSC harvest in high-risk candidates has been proposed but collection process may add to already high logistic burden and costs of CAR T-cell therapy in the lymphoma setting. Conversely, cryopreserved ASHC is mainly available for patients with myeloma and this approach would be readily proposed and useful for around 20% patients as recently described. Gagelmann N et al. Hematopoietic stem cell boost for persistent neutropenia after CAR T-cell therapy: a GLA/DRST study. Blood Adv. 2023;7(4):555 Rejeski K et al, Immune Effector Cell-Associated Hematotoxicity (ICAHT): EHA/EBMT Consensus Grading and Best Practice Recommendations. Blood. 2023 doi: 10.1182/blood.2023020578 Davis JA et al. Efficacy and safety of CD34+ Stem Cell Boost for Delayed hematopoietic Recovery After BCMA Directed CAR T-cell Therapy. Transplant Cell Ther. 2023 doi: 10.1016/j.jtct.2023.05.012

Improved Survival of R/R Double Hit/Triple Hit Lymphoma in the Era of CD19 Chimeric Antigen T Cell (CART) Therapy

Introduction: DH/THL also classified as high-grade B cell lymphomas (HGBCL) with MYC and BCL2 and/or BCL6 rearrangements have higher risk of progression after initial treatment and poor response to salvage therapies compared to diffuse large B cell lymphoma (DLBCL), NOS. Recently, CART cell therapy has shown encouraging responses in treatment of relapsed refractory (R/R) DLBCL. In this retrospective study, we evaluated whether survival of (R/R) DH/THL is improved in the CART era. Methods: In this multicenter retrospective study, adult pts (pts) with R/R DH/THL after anthracycline-based therapy were included. Demographic and clinical variables were obtained from electronic health records. Study objectives was overall survival (OS) at 2 year landmark. We utilized full propensity score matching to compare progression free survival (PFS) and OS of CART with 2 nd line chemoimmunotherapy. Results: 278 DH/THL pts treated between 2010-2020 were included. Median age was 63 years (range 52-74), 163 (58%) were male, 119 (43%) were classified as DLBCL and 116 (42%) as HGBCL; 40 (14%) were transformed from follicular lymphoma. 225 (82%) had advanced stage, 161 (67%) had elevated LDH, 85 (33%) had bulky disease, 74 (59%) had B symptoms. 105 (38%) pts treated for relapsed disease before 2018 were included in the pre-CART era cohort. 168 (60%) pts treated from 2018 onwards were included in the CART era cohort. 102 (60%) pts in CART cell era received CART cells, 40 (14%) received polatuzumab vedotin (pola), 10 (3.5%) received loncastuximab tesirine, tafasitamab and bispecific antibody each. Characteristics at relapse were similar in both groups. Median follow up was 8.9 (0.2-146) months. 2-year OS estimate was 36% (CI 95: 30-42%) in entire population. Patients treated in CART cell era had significantly higher OS (2 yr OS: 43% [CI 95: 35-53]) compared to pts treated in pre-CART cells era (2-year OS: 24% [CI 95: 16-34], p=0.0006) (Figure 1). In multivariable analyses, increasing age (HR = 1.02 (CI 95: 1.01, 1.04), p=0.003), extranodal disease (HR = 1.41 (CI 95: 1.00, 1.99), p<0.001), elevated LDH (HR = 1.57 (CI 95: 1.11, 2.24), p=0.01) were associated with inferior OS. Increasing time to relapse (HR = 0.98 (CI 95: 0.97, 0.99), p<0.001) was associated with superior OS. BCL6 rearrangement did not affect OS. When adjusted for these factors, treatment with CART cells was associated with higher 2 yr OS (HR = 0.33 (CI 95: 0.22, 0.49), p<0.001). Treatment with polatuzumab (HR = 1.07 (CI 95: 0.71, 1.6), p=0.07) was not significantly associated with OS in univariable analysis. 102 pts underwent CART cell therapy at any point for relapse; 94 (93%) were refractory to prior chemotherapy. 62 (60%) responded and 52 (50%) had CR after CART cells. 2-year PFS and OS after CART cell therapy were 28% (CI 95: 19-40) and 40% (CI 95: 30-53), respectively. Increasing time to CART was associated with inferior OS (HR: 1.02 (CI 95: 1.0-1.03, p=0.03) but not PFS (HR: 1.02 (CI 95: 0.99-1.04), p=0.2). 219 (79%) pts received curative intent salvage chemotherapy for 2 nd line. 2-year PFS and OS were 15% (CI 95: 11-20) and 38% (CI 95: 31-45), respectively. 21 pts received CART cell therapy for 2 nd line. 2 year PFS and OS in this small number of pts were 52% (CI 95: 35-79) and 70% (CI 95: 52-94), respectively. Due in part to the small number of pts who received CART cells in 2 nd line, we utilized full propensity score matched analysis to compare each patient in CART cell group to all possible matched controls in salvage chemotherapy group. Variables matched were age, LDH, extra nodal disease and time to relapse. In propensity score matched analysis, pts who received CART cells had significantly higher 2 year PFS (HR: 10.5 (CI 95: 3.4-17.5), p=002) and 2 year OS (HR: 7.5 (CI 95: 1.4-13), p=0.01). Conclusions: Survival of r/r DH/THL appears to have improved in the era of CART cell therapy. About 2/3 of pts refractory to chemotherapy respond to CART cells, and in multivariable analysis, receipt of CART cells was associated with improved OS. Increasing time to CART cells was associated with inferior survival. In a propensity score matched analysis utilizing full matching, CART cell therapy in 2 nd line was associated with significantly higher 2 year PFS and OS compared to curative intent salvage therapy. Other CD 19 and CD 20 targeting agents approved after CART cell therapy might contribute to favorable survival, effect of these agents could not be assessed because of small numbers.

Beyond Mitigating Immune-Related Adverse Events: Glucocorticoids Ameliorate Bispecific Antibody-Mediated T-Cell Exhaustion I n Vitro

Following the approval of blinatumomab in 2015 T-cell recruiting bispecific antibodies (BsAbs) became the established standard-of-care for relapsed or refractory (r/r) and minimal residual disease positive B-cell precursor acute lymphoblastic leukemia. More recently, there has been a notable increase in the approval of additional BsAb constructs for malignancies such as r/r follicular lymphoma, r/r large B-cell lymphoma, and advanced multiple myeloma (MM), with further approvals anticipated. Despite the clinical success, administration of BsAbs is commonly linked to dose-limiting immune-related adverse events (IrAEs), such as cytokine release syndrome, possibly compromising treatment efficacy. Hence, current BsAb as well as CAR T approvals integrate prophylactic and acute glucocorticoid (GC) application upon occurrence of IrAEs. Surprisingly, despite their immunosuppressive nature, GC administration had no negative impact on response or survival of MM patients receiving CAR T-cell therapy (Wang 2022). Based on these data, we hypothesize that the GC-mediated downregulation of BsAb-induced T-cell function has a dual effect: mitigating IrAEs and ameliorating T-cell exhaustion. Here we tested the effect of simultaneous administration of the GC dexamethasone (dexa) and a CD3xCD19 targeting BsAb on T-cell function and exhaustion. We first evaluated the short-term effect of dexa exposure on BsAb-mediated cytotoxicity by co-culturing healthy donor (HD) T cells with CD19 + cell lines and stimulating with a CD3xCD19 BsAb alone or in combination with 300nM dexa for 3-5 days. In fact, the addition of dexa decreased BsAb-mediated tumor cell lysis against OCI-Ly1 cells after 3 days, but not after 5 days. Surprisingly, however, T-cells showed a significantly increased expansion upon dexa exposure after 3 and 5 days (day 3: Ki-67 MFI ratio BsAb=337.2, +dexa=676.0, p=0.008; day 5: CD2 +-fold change to day 0 BsAb only=7.1; +dexa=11.6; p=0.01). In cytotoxicity assays against murine Ba/F3 cells transduced with human CD19 with or without the co-stimulatory molecule CD86, T cells showed significantly reduced BsAb-mediated cytotoxicity and proliferation upon dexa exposure in the absence of CD86. Intriguingly, however, T-cell function was rescued upon CD86 co-expression. To evaluate long-term effects of GCs on T-cell function and exhaustion, we next used our established long-term in vitro model system to mimic continuous stimulation of T cells with a BsAb ± GCs. HD T cells were co-cultured with CD19 + OCI-Ly1 cells for 28 days and continuously stimulated with a CD3xCD19 BsAb alone or in combination with dexa. T-cell fitness was assessed longitudinally. Surprisingly, but in line with our short-term data, we found increased CD8 + T-cell expansion upon BsAb +dexa co-exposure in long-term cultures (abs. CD8 + cell count day 21 BsAb=1.613, +dexa=34.583). Furthermore, immunophenotyping revealed similar upregulation of the checkpoint inhibitors PD-1, Tim-3, Lag-3 after 7 days. On day 21, however, Lag-3 expression on dexa exposed CD4 + and CD8 + T cells was decreased (MFI ratio BsAb=10.5, +dexa=1.7, p=0.02). Inflammatory cytokine (IL-2, IFN-γ, TNF-α) levels were decreased in the supernatant of dexa-exposed vs BsAb only co-cultures. However, low levels of IFN-γ were maintained in the dexa co-exposed condition over 24 days (mean level IFN-γ day 24 BsAb=53pg/ml, +dexa=1756 pg/ml). Finally, T cells were isolated from cultures every 7 days and tested in 72h cytotoxicity assays, without further exposure to dexa. Intriguingly, T cells previously exposed to dexa maintained a significantly higher cytotoxicity over 28 days (mean % specific lysis day 21 BsAb=34.2, +dexa=90.3, p=0.004). Taken together, our data demonstrate a positive impact of GCs on BsAb-mediated T-cell expansion in short- and long-term setting. Characterization of T cells upon long term BsAb exposure demonstrated an ameliorating effect of GCs on BsAb-induced T-cell exhaustion. Our data suggest that dampening of T-cell activity by GC administration in BsAb-treated patients could serve two purposes: managing IrAEs while simultaneously ameliorating T-cell exhaustion and improving T-cell persistence. In future studies we will further dissect the effect of dexa on the transcriptional landscape of BsAb-stimulated T cells by performing RNA sequencing and also explore the effect of GCs on CAR T-cell function.

Pirtobrutinib, a Highly Selective, Non-Covalent (Reversible) BTK Inhibitor in Relapsed/Refractory Follicular Lymphoma: Results from the Phase 1/2 BRUIN Study

Background: Follicular lymphoma (FL) is a chronic and incurable disease requiring multiple lines of therapy for patients (pts) with relapsed/refractory (R/R) disease. Covalent Bruton tyrosine kinase inhibitors (cBTKi) have transformed the management of select B-cell malignancies, in particular chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL). However, despite the transformative impact in CLL and MCL, the efficacy of single-agent cBTKi has been limited in pts with R/R FL, with an overall response rate (ORR) of 20.9% to 37.5% (Gopal et al, J Clin Oncol, 2018; Bartlett et al, Blood, 2018). Pirtobrutinib, a highly selective, non-covalent (reversible) BTKi, inhibits both wildtype and C481-mutant BTK with equal low nM potency and has a favorable oral pharmacology that enables continuous BTK inhibition throughout the once-daily dosing interval. Pirtobrutinib has demonstrated promising efficacy and tolerability in pts with poor-prognosis B-cell malignancies following prior therapy, including cBTKi. Here, we report the safety and efficacy of pirtobrutinib in a cohort of pts with R/R FL from the BRUIN study (NCT03740529). Methods: Pts with previously treated B-cell malignancies were eligible for treatment with pirtobrutinib monotherapy in either the dose escalation or expansion portion of the multicenter phase 1/2 BRUIN study. FL diagnosis required pathologic review of an adequate biopsy. Key endpoints included investigator-assessed ORR per Lugano 2014 criteria, duration of response (DoR), progression-free survival (PFS), overall survival (OS), and safety. A data cutoff date of 05 May 2023 was utilized. Results: Among the 48 pts with FL, 45 (94%) pts received the recommended phase 2 dose of pirtobrutinib (200 mg once daily) as their starting dose. Pts had a median age of 64.5 years (range, 37.0-85.0), were mostly male (60%, n=29), and had a median of 3 (range, 1-12) prior lines of therapy. Most pts (81%, n=39) had Ann Arbor stage III/IV disease. The Follicular Lymphoma International Prognostic Index (FLIPI) risk was low (0-1) in 9 (19%) pts, intermediate (2) in 13 (27%) pts, high (3-5) in 23 (48%) pts, and missing in 3 (6%) pts. Overall, 43 (90%) pts had received chemotherapy plus an anti-CD20 antibody, 17 (35%) pts had received a PI3K inhibitor, 14 (29%) pts had received lenalidomide, 6 (13%) pts had received an autologous stem cell transplant, and 4 (8%) pts had received CAR T-cell therapy. Of the 4 (8%) pts who had received a prior cBTKi, 3 discontinued due to disease progression and 1 discontinued for intolerance. The ORR was 50.0% (95% confidence interval [CI], 35.2-64.8), including 7 (14.6%) complete responses and 17 (35.4%) partial responses (Figure). An additional 12 (25.0%) pts had stable disease. Among 4 pts who had received prior cBTKi, 3 achieved partial response and 1 had stable disease. With a median follow-up of 18.4 months (interquartile range, 10.1-21.0) among 24 responding pts, median DoR was 5.5 months (95% CI, 3.7-not estimable [NE]), and the 18-month estimated DoR rate was 41.0% (95% CI, 20.1-60.9). Median PFS was 5.8 months (95% CI, 3.8-8.1), and the 18-month estimated PFS rate was 32.3% (95% CI, 19.1-46.2). Median OS was NE, and the 18-month estimated OS rate was 78.3% (95% CI, 62.1-88.1). The efficacy outcomes by FLIPI risk category are presented in the Table. The median time on treatment was 7.6 months (range, 0.6-42.2), with 14 (29.2%) pts still receiving pirtobrutinib. The most frequent treatment-emergent adverse events (TEAEs), regardless of attribution, were diarrhea (29.2%, n=14), fatigue (25.0%, n=12), and nausea (22.9%, n=11). TEAEs of hemorrhage/hematoma (6.3%, n=3), hypertension (4.2%, n=2), and atrial fibrillation/flutter (2.1%, n=1) were infrequent. The most frequent grade ≥3 TEAEs were infection (18.8%, n=9) and neutropenia/neutrophil count decreased (14.6%, n=7). Only 1 (2.1%) pt had a treatment-related adverse event (rash) that led to pirtobrutinib discontinuation. Conclusions: In this cohort of heavily pre-treated pts with R/R FL, pirtobrutinib showed potential efficacy and was well tolerated, including in pts with high risk FLIPI.

Outcomes of High-Grade B-Cell Lymphoma As Compared to Other Large B-Cell Lymphoma Subtypes in Patients Treated with CD19-Directed CAR-T Cells at 3 rd Line or More. a Lysa Study Based on the French Descart-Registry.

Introduction : High-Grade-B-cell Lymphoma with MYC and BCL2 and/or BCL6 rearrangements (HGBL double hit [HGBL-DH] or HGBL triple hit [HGBL-TH]), or not otherwise specified (HGBL NOS), are distinct subtypes among Large B-Cell lymphoma (LBCL) considered to be more aggressive diseases. These entities are often resistant to standard chemotherapy (Landsburg, JCO, 2017). CAR-T cell therapy (CAR-T) have changed the treatment landscape of LBCL in chemo resistant LBCL in 3 rd line, and more recently in 2 nd line of treatment. Prognosis with CAR-T seems to be as good in HGBL as in other LBCL subtypes. (Neelapu, NEJM, 2017; Schuster, NEJM, 2019; Zurko, ASH 2022). However, Fluorescence In Situ Hybridation (FISH) study isn't systematically done at diagnosis leading to an underestimation of the diagnosis of HGBL. The aim of this study was to compare the prognosis of a large cohort of patients with HGBL versus other LBCL subtypes, characterized with FISH at diagnosis, in a real life setting, based on the French DESCAR-T registry (NCT04328298). Methods : We collected clinical and pathological data of patients treated for relapsed/refractory LBCL or HGBL in third line or more. Data were collected both at the time of the decision of treatment in multidisciplinary meeting (MDM) and at the time of CAR-T cell infusion. Histology other than de-novo LBCL were excluded. All patients should have been studied with FISH at least with MYC probe. If a MYC rearrangement was identified, a BCL2 and/or BCL6 rearrangement should have been characterized. A p-value <0.05 was significant. Results : Between January 2018 and November 2022, 228 patients meeting the inclusion criteria were included across 14 centers, 73 with HGBL (28 HGBL-DH with MYC- BCL2 rearrangement, 8 HGBL-DH with BCL6 rearrangement, 14 HGBL-TH, 23 HGBL NOS) and 155 with non-HGBL (LBCL with [n=19] or without [n=136] MYC rearrangement). Characteristics of patients with HGBL vs non-HGBL at eligibility for CAR-T and at infusion of CAR-T cells were similar with no statistical difference. At the time of CAR-T treatment decision, median age was 62 years and the others characteristics were as follows in patients with HGBL vs patients with non-HGBL : ECOG>=2: 9 (12 %) vs 23 (15%), LDH > 1N : 52 (71%) vs 119 (77%) and Ann Arbor stage III-IV : 63 (86%) vs 125 (81%). Median number of prior lines of treatment was 2 (maximum 7 in HGBL vs maximum 9 in non-HGBL). Among the population, 60 (82%) HGBL and 135 (87%) non-HGBL patients received CAR-T cell therapy. In non-treated patients : 5 (39%) vs 8 (40%) had a disease progression and 3 (23%) vs 7 (35%) died. In treated patients, 55 (92%) HGBL vs 126 (93%) non-HGBL received at least one bridging therapy before CAR-T infusion ; and response to bridging therapy was similar among them : 19 (35%) patients with HGBL were in complete or partial response vs 46 (37%) with non-HGBL. Characteristics of treated patients at time of infusion were also similar and as follows in HGBL patients vs non-HGBL patients : 16 (27%) vs 34 (25%) had bulky disease and 16 (27%) vs 31 (23%) had an elevated CRP. 23 (38%) vs 45 (33%) were treated with Tisa-cel and 90 (67%) vs 37 (62%) were treated with Axi-cel. The frequency of Cytokine Release Syndrome (CRS) and Immune effector-Cell Cytotoxicity Syndrome (ICANS) (including grade >=3) did not significantly differ : 56 (93%) patients with HGBL vs 114 (84%) patients with non-HGBL presented CRS and 23 (38%) vs 55 (41%) presented ICANS. Interestingly, more patients were admitted in ICU in the HGBL cohort : 21 (35%) vs 23 (17%) (p=0.009). Macrophage Activation Syndromes was reported for 2 HGBL patients (3%). Median follow-up was 20.5 [95 CI, 19.2-25.5] months from eligibility decided in MDM and 18.5 m [95CI, 14.3-23.4] from infusion. Progression free survival (PFS) and Overall survival (OS) were similar in both groups. Since eligibility, median OS was 7.6 m [95 CI, 6.4-18.3] for HGBL patients vs 11.8 m [95 CI, 9.5-22] for non-HGBL (p = 0.062). Since infusion, median PFS was 3.2 m [95CI, 2.8-6.0] for HGBL patients vs 4.5 m [95CI, 3.1-8.7] for non-HGBL (p = 0.103) Figure 1 and median OS was 15.4 m [95CI, 5.6-32.4] for HGBL patients vs 18.3 m [95CI, 8.5-not reached] for non-HGBL (p = 0.214). Figure 2 Conclusion : CAR-T cell therapy used in third line or more seems to overcome the poor prognosis of HGBL subtypes as compared to other LBCL subtypes, all characterized with FISH. This observation supports the interest to evaluate the potential benefit of CAR-T earlier in the course of the disease.