Subtype Of Large B-cell Lymphoma Research Articles

R-CHOP Versus R-EPOCH in Primary Mediastinal Large B-Cell Lymphoma: A Systematic Review and Meta-Analysis

Introduction: Primary mediastinal large B-cell lymphoma (PMBCL) is a rare B-cell lymphoma that is typically reported in young females. Although previously considered as a subtype of diffuse large B-cell lymphoma, PMBCL has unique clinical and molecular characteristics. The optimal treatment option for PMBCL remains to be elucidated. Two regimens that have been used as frontline therapy are rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine and prednisone (R-CHOP) and rituximab, etoposide phosphate, prednisone, vincristine, cyclophosphamide and doxorubicin hydrochloride (R-EPOCH). Our study compares the efficacy and safety of R-CHOP and R-EPOCH in PMBCL. Methods: A systematic literature search was conducted on PubMed, Embase, Cochrane and Clinicaltrials.gov using MeSH terms and relevant keywords for PMBCL, R-CHOP and R-EPOCH, including trade names and generic names, from inception to July 2022. The inclusion criteria were clinical trials and observational studies comparing the efficacy and safety of R-CHOP with R-EPOCH in PMBCL. Efficacy was assessed in terms of overall response rate (ORR), complete response (CR), overall survival (OS), progression-free survival (PFS) and relapse. Safety was assessed in terms of risk of occurrence of neutropenia and febrile neutropenia. Estimates of risk ratio (RR) with 95% confidence intervals (95% CI) for dichotomous outcomes were pooled using the random effects model with the Mantel-Haenszel method. Forest plots were constructed to visualize the pooled results. Heterogeneity was estimated using the I2 statistic. All statistical analyses were performed in Review Manager software (RevMan, version 5.4.1). Results: The initial search revealed 347 articles. After exclusion of duplicates, reviews and non-relevant articles, we included six articles (one prospective cohort and five retrospective cohorts) which compared outcomes following R-CHOP versus R-EPOCH in PMBCL. A total of 469 patients were included; R-CHOP and R-EPOCH were evaluated in 213 and 256 patients, respectively. The median age ranged from 27 to 35 years, and 318 (67.8%) patients were female. The median follow-up ranged from 23 to 60 months. R-CHOP and R-EPOCH were associated with an ORR of 84.9% and 91.8%, respectively. The difference between ORR of the two regimens was not statistically significant (RR 0.93, 95% CI 0.85-1.02; p = 0.11; I2 = 13%). However, R-CHOP was associated with significantly worse CR compared to R-EPOCH (65.5% versus 80.1%, RR 0.84, 95% CI 0.72-0.99; p = 0.04; I2 = 23%). OS was significantly lower with R-CHOP therapy (RR 0.84, 95% CI 0.72-0.97; p = 0.02; I2 = 36%). The two regimens had comparable PFS (RR 0.76, 95% CI 0.57-1.02; p = 0.06; I2 = 71%), and relapse rate (RR 0.91, 95% CI 0.26-3.16; p = 0.89; I2 = 56%). R-CHOP was associated with a lower risk of neutropenia (RR 0.67, 95% CI 0.54-0.83; p = 0.0004; I2 = 0%) and febrile neutropenia (RR 0.59, 95% CI 0.39-0.90; p = 0.01; I2 = 13%). Conclusion: R-EPOCH demonstrates superior CR and OS compared to R-CHOP. However, ORR, PFS and relapse rate were comparable for both regimens. R-CHOP was also associated with a lower risk of neutropenia and febrile neutropenia. Larger prospective studies and randomized controlled trials are required to establish the standard of care in PMBCL. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Elevated FDG Uptake in the Lung Is a Characteristic Finding of Intravascular Large B-Cell Lymphoma

[Introduction] Intravascular large B-cell lymphoma (IVBCL) is a rare subtype of extra-nodal diffuse large B-cell lymphoma (DLBCL), characterized by preferential growth of lymphoma cells within the lumina of small vessels. Clinical presentation of IVBCL is highly variable, and it often includes organ dysfunction related to obstruction of blood vessels. Up to 80% of IVBCL cases experienced hypoxemia at initial presentation, suggesting a high rate of respiratory involvement. In recent years, some IVBCL cases with diffuse pulmonary uptake on 18F-fluorodeoxyglucose (FDG) PET/CT have been reported from Asia and Western countries. It may also reflect the pulmonary infiltration of IVBCL; however, there are no reports of detailed studies with a large number of IVBCL cases. [Methods] We retrospectively evaluated patients with histopathologically proven newly diagnosed IVBCL according to the 2008 World Health Organization criteria between January 2010 through February 2022 from hospitals participating in the North Japan Hematology Study Group (NJHSG). PET/CT images were reviewed by an experienced nuclear medicine physician (S.W.). In addition to the general PET/CT evaluation, the ratio of the lung to mediastinum standardized uptake value (SUV) peaks (L/M ratio) was calculated to assess the degree of FDG accumulation in the lungs objectively. Lung SUV peaks were measured uniformly about 1 cm medial to the right lower lobe pleura, and mediastinum SUV peaks were measured in the left atrium. The L/M ratio of 226 advanced stage DLBCL cases diagnosed within the same periods was also calculated and compared with IVBCL cases. [Results] We identified fifty-one IVBCL patients (age 30-89 years, median 65 years; 56.9% male) who performed PET/CT at diagnosis, and 29 of whom also underwent after chemotherapy. IVBCL was diagnosed via skin biopsy in 31 (60.8%) cases, bone marrow biopsy in 15 (29.4%) cases, and lung biopsy in 8 (15.7%) cases. Hypoxemia were observed in 25 (49.0%) patients. Twenty-eight (54.9%) patients had poor performance status (ECOG score ≥2). Elevated LDH level was observed in 48 (94.1%) cases (median, 631 IU/L; range, 147-4907 IU/L). Diffusely elevated FDG uptake was seen at the lung in 28 (54.9%) patients, bone marrow in 40 (78.4%), and spleen in 32 (62.7%). Chest CT evaluation revealed that ground-glass opacity lesion corresponding to the areas of FDG accumulation on PET was observed in 14 of 28 patients. At diagnosis, the median L/M ratio was significantly higher in IVBCL patients than in DLBCL patients (IVBCL: median, 0.903; range, 0.22-2.583 vs. DLBCL: median, 0.421; range, 0.177-0.639, P < 0.0001, Fig.). ROC analysis revealed that the cutoff value of the L/M ratio of 0.649 predict IVBCL diagnosis. Area under curve was 0.916 (95% CI: 0.859-0.974). Thus, we classified patients with a threshold of 0.649 for the definition of "high” or "low” levels of the L/M ratio. At the time of diagnosis, 38 of 51 (74.5%) IVBCL cases were classified as having a high L/M ratio. The L/M ratio decreased to low levels in all patients who underwent FDG PET/CT after chemotherapy (median, 0.471; range, 0.269-0.647, Fig.). The high L/M ratio was significantly correlated with diffuse FDG uptake in the lung (P < 0.0001), bone marrow (P = 0.0507) and spleen (P < 0.001) and the presence of hypoxemia (P < 0.01). Surprisingly, 14 of 26 (53.8%) patients who did not present with hypoxemia showed high L/M ratio. Fifty (98%) patients received rituximab-containing chemotherapy. Of the patients treated, 13 (26%) patients experienced a relapse, and 9 (18%) patients eventually died. The 2-year overall survival (OS) was 84.6 % (range, 70.3-92.4 months). Median follow-up duration was 48.8 months (range, 4.7-140.5 months) in survivors. The L/M ratio did not stratify the prognosis significantly (L/M high: 2-year OS, 82.3%; 95% CI, 64.6-91.6 vs L/M low: 2-year OS, 90.9%; 95% CI, 64.6-91.6, P = 0.7). [Conclusion] To our knowledge, this is the largest study to assess pulmonary PET/CT findings in newly diagnosed IVBCL cases. A high L/M ratio was found in about 75% of patients with IVBCL while not in advanced stage DLBCL. Given that the L/M ratio decreased after treatment, the high L/M ratio reflects pulmonary infiltration of lymphoma cells. In cases of suspected IVBCL, FDG-PET can be a good indicator of whether to perform a lung biopsy, even in patients without hypoxemia. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Genetic Determinants of Isolated and Systemic Testicular Diffuse Large B-Cell Lymphoma Highlight a Disease Spectrum

Introduction Primary (diffuse) large B-cell lymphoma of the testis (PTL) is an aggressive extranodal B-cell lymphoma characterized by frequent relapses in the central nervous system (CNS) and other extranodal sites. While PTL has now been recognized as a distinct lymphoma in the latest classifications (International Consensus Classification and WHO HAEM5), however, the allowable extent of involvement outside of the testes is unclear from these publications. PTL are largely assigned to the MCD genetic subtype of diffuse large B-cell lymphoma (DLBCL) by LymphGen with frequent MYD88L265P mutations and have 6p loss associated with immune evasion. BCL6 rearrangements (BCL6-R), a feature of BN2, have been associated with an increased risk of CNS relapse (Twa et al., Blood 2021), though the mechanisms enabling tumor establishment in the CNS remain unclear. Here, we provide a characterization of the genomic landscape of DLBCL involving the testes, aiming to understand whether systemic disease is distinct from disease isolated to the testes and whether there are genetic features associated with patient outcomes. Methods Patients with DLBCL involving the testis, treated with R-CHOP immunochemotherapy, were identified in the BC Cancer Lymphoid Cancer database, yielding archival formalin-fixed paraffin-embedded orchidectomy samples from 65 patients. BCL6-R were identified by break-apart fluorescent in situ hybridization (FISH). High confidence simple somatic mutations (SSMs) from whole exome sequencing were selected using a voting approach of four variant callers (Strelka2, Lofreq, Mutect2, SAGE). Candidate copy number alterations (CNAs) were identified using CNVkit and PureCN and high confidence CNAs were determined using GISTIC2.0. LymphGen was run with SSMs to annotate genetic subgroups. Clinical endpoints included time to progression (TTP), disease-specific survival (DSS) and CNS relapse cumulative risk. Results The study cohort had a median age of 72 years (range 26-93) and median follow-up of living patients was 5.5 years. In 30 patients lymphoma was isolated to the testes (Stage IE), 27 had concurrent involvement outside of the testes (Stage II/E-IV), and eight had DLBCL isolated to the testes with low grade lymphoma in the bone marrow (herein labelled "BM" - excluded from isolated vs systemic comparisons). BCL6-R were detected in 29% of the tumors. The majority of the tumors (69%) were assigned to the MCD subgroup by LymphGen with 73% and 66% of tumors harboring MYD88L265P and PIM1 mutations, respectively, though 40% of BCL6-R tumors were assigned to BN2 or Other. To address whether there are biological differences between disease isolated to the testes versus those that also have systemic involvement, we compared tumors from patients with stage I vs II-IV disease. There were no significant differences in the proportions of BCL6-R or LymphGen subgroups. Similarly, there was no difference in CNAs and the mutational landscapes were largely the same, with the exception of two significant differences. There was a significant enrichment for CD58 truncating mutations in stage II-IV (31%; q < 0.1), with a missense mutation observed in one stage IE tumor. Secondly, BTG2 mutations were more frequently observed in stage I disease (37% vs 8%; q < 0.1). We observed significantly superior TTP (Hazard ratio (HR) = 0.46, P < 0.05) and DSS (HR = 0.34, P < 0.01) in patients with stage I vs stage II-IV diseases. In stage II-IV disease, the MCD (n=18) (vs non-MCD (n=9)) subgroup was associated with significantly superior TTP (2-year 72% vs 22% TTP; HR = 0.36, P < 0.05) and DSS (2-year 72% vs 22% DSS; HR = 0.37, P < 0.05) and lower frequency of CNS relapse (13% vs 55% cumulative relapse at 2 years; HR = 0.23, P < 0.05). In contrast, LymphGen subgroup was not prognostic in stage I disease. Conclusion Here, we show that there are very few genetic differences comparing testicular DLBCL isolated to the testes to those with stage II-IV disease. The novel observation of truncating mutations in CD58 exclusively in patients with systemic involvement suggests that these mutations contribute to immune evasion thereby promoting disease outside of the immune privileged site of the testes. Genetic subgroups appear to be associated with outcomes in patients with systemic involvement - an observation that requires validation in a larger cohort. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Preliminary Result of Lenalidomide Combined with R-CHOP(R2-CHOP) in Newly Diagnosed Double-Expressor Diffuse Large B-Cell Lymphoma: A Prospective Phase II Clinical Trial

Background: Double expressor lymphoma (DEL) is a subtype of diffuse large B-cell lymphoma (DLBCL) defined as having increased expression of MYC (≥40%) and BCL-2 (≥50%) by immunohistochemistry (IHC). Patients with DEL have inferior outcomes when treated with standard immunochemotherapy. Previous studies illustrated that lenalidomide showed a significant clinical response in non-GCB DLBCL, and well tolerated when combined with R-CHOP. This study aims to investigate the efficacy and safety of lenalidomide combined with R-CHOP (R2-CHOP) in newly diagnosed DEL patients. Methods: Histologic diagnosis of DLBCL and MYC/BCL-2 expression by IHC were confirmed by central pathology prior to study therapy. Treatment regimen included lenalidomide 25 mg/d orally days 1-10 per 21days, plus standard R-CHOP21 for 6 cycles. The primary end point was 2-year progression free survival (PFS) per independent central radiology review. Secondary end points included 2-year event-free survival (EFS), overall response rate (ORR), overall survival (OS), and safety. Results: Between Oct 2019 and Aug 2021, 67 eligible patients were enrolled in this study. Median age was 58 (range 27-75) years. Forty-one (61.2%) patients were stage III-IV, and 35.8% of patients were IPI score ≥3. Non-GCB subtype was determined in 44 (65.7%) patients. Three patients detected double-hit lymphoma withdrew from the study per investigator's decision. Sixty patients were evaluable for response. Fifty-seven patients responded to therapy, with overall response rate of 95% (57/60), and complete response rate of 80% (48/60). With a median follow-up of 17.8 months, the estimated 1-year PFS rate was 85.3% (95%CI 75.9%-95.2%). And the 1-year EFS rate was 79% (95%CI 68.8%-90.3%). Median OS was not reached, and 1-year OS rate was 90.9% (95%CI 84.1%-98.1%). Grade 3 or 4 hematologic toxicities included neutropenia (67.2%), thrombocytopenia (19.4%), and anemia (4.5%). The most common nonhematologic adverse events were grade 1 to 2, including nausea, vomiting, fatigue, diarrhea, and mucositis. Grade 3 pneumonia occurred in 5 patients. Dose modification of lenalidomide or R-CHOP due to AEs were noted in 43.3% and 20.9% patients. No treatment-related death occurred in the study. Conclusion: Our preliminary data indicate promising activity of lenalidomide combined with R-CHOP for newly diagnosed DEL patients. R2CHOP regimen was feasible, with predictable and manageable adverse events. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Plasma Extracellular Vesicle-Associated microRNAs for Early Response Prediction in Patients with High-Grade B-Cell Lymphoma

Background: Early and accurate outcome prediction is essential in the clinical management of high-grade B-cell lymphoma (HGBL). An early switch to salvage treatments for those patients who are likely to develop refractory/relapsed disease may improve overall survival. Unfortunately, the positive predictive value of an interim PET-CT is not high enough to guide treatment decisions. Extracellular vesicle-associated microRNAs (EV-miRNAs) are considered promising liquid biopsy-based biomarkers for lymphomas. We performed small RNA sequencing of plasma samples collected during treatment and applied machine learning to build EV-miRNA signatures for early response prediction in patients with HGBL with MYC and BCL2 and/or BCL6 rearrangements (HGBL-DH/TH). Methods: We analyzed PAXgene ccfDNA plasma samples, from 38 of the 97 patients included in the HOVON-152 trial (NCT03620578), a prospective, multicenter, non-randomized phase II trial. In this trial, patients with HGBL-DH/TH receive one cycle of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) followed by five cycles of dose adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (DA-EPOCH-R). Patients who achieve complete metabolic response (CMR) at the end-of-induction (EOI) receive one year of nivolumab consolidation. Response was assessed by an EOI PET-CT and classified as CMR (Deauville score 1-3) (responders) or no-CMR (non-responders). 20 responders and 18 non-responders (enrichment for non-responders), were selected for this analysis. We isolated plasma EVs with size exclusion chromatography as confirmed with transmission electron microscopy (TEM), tunable resistive pulse sensing (TRPS), and western blot (WB). Library preparation was done according to an unbiased, unique molecular identifier (UMI)-enhanced small RNA sequencing protocol (IsoSeek) (van Eijndhoven et al., 2021. bioRxiv) and sequenced on the NovaSeq 6000 (Illumina). We applied machine learning including the least absolute shrinkage and selection operator (LASSO), Elastic Net, and Ridge Regression to build models with EV-miRNAs for early EOI response prediction. We selected the most optimal model based on the lowest misclassification error. Then the model was internally validated and tested with bootstrapping (1000x) and over optimism estimate as well as the adjusted AUC was calculated. Results: TEM after one cycle of R-CHOP revealed abundant particles < 200 nm and TRPS measured significantly higher particle concentration in EV-enriched fractions. Plasma EVs were positive for CD63, CD81, flotillin-1, syntenin, HSP70, and negative for calnexin as determined by WB in accordance with the Minimal Information for Studies of EVs (MISEV) criteria 2018 for EV characterization. The most optimal model was an Elastic Net regression (a = 0.4) model consisting of 199 miRNAs with an area under the curve (AUC) of 0.95 (Confidence Interval (CI): 0.90 - 0.99) (Figure 1) [Sensitivity: 88%, Specificity: 90%; Positive Predictive Value (PPV): 90%, Negative Predictive Value (NPV): 87%]. We tested our model with bootstrapping (1,000x). After taking into account of over optimism estimate of 0.14, the adjusted AUC was 0.81 (CI: 0.64-0.96), which is higher than the performance of interim PET/CT [Sensitivity: 33-87%, Specificity: 49-94%; PPV: 20-74%, NPV: 64-95%] (Burggraaff 2019, PMID: 30141066). Conclusion: Machine learning models using plasma EV-miRNAs prepared with the IsoSeek small RNA sequencing protocol yielded a robust signature that can predict EOI response already after one cycle of R-CHOP with a NPV of 87% and a PPV of 90%. The next step is to validate this model in a large cohort of HGBL-DH/TH cases and explore its potential in all subtypes of diffuse large B-cell lymphoma. If validated in independent cohorts, this novel approach could potentially, in combination with other modalities such as cell-free DNA and interim PET-CT, guide early risk-adapted treatment strategies in aggressive high-grade B-cell lymphomas. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Preliminary Result of Phase 1 Trial of Orelabrutinib in Combination with Rituximab, Methotrexate, and Dexamethasone in Patients with Newly Diagnosed Primary CNS Lymphoma Implementing Bayesian Design for Dose-Seeking

Background: Primary central nervous system lymphoma (PCNSL) is an aggressive extranodal subtype of diffuse large B-cell lymphoma (DLBCL). High-dose methotrexate (HD-MTX)-based regimen is the first-line treatment of PCNSL, with or without the anti-CD20 antibody rituximab, remaining to be suboptimal due to unstable response and short effective remission time. Genetic alterations often occur in the chronic active B-cell receptor signaling featured by MYD88 and CD79B which mediate the response to BTK inhibition (BTKi) in PCNSL. Orelabrutinib is a novel, potent, highly selective BTK inhibitor with a high CSF concentration. This study aims to investigate optimal combination dose of Orelabrutinib in combination with Rituximab, Methotrexate, and Dexamethasone (ORMD) as well as safety and efficacy of the regimen. Methods: This was a phase 1, investigator-initiated, dose-escalation study of ORMD, being conducted at Huashan Hospital, Fudan University (ClinicalTrials.gov identifier: NCT05036577). It was planned to enroll 12-15 patients with newly diagnosed PCNSL to the regimen of orelabrutinib and MTX combined with the fixed dose of rituximab(R) and dexamethasone(D). Eligible patients must have histopathologically confirmed PCNSL-DLBCL by biopsy of brain lesions and be aged 18-75 years with adequate organ functions. Patients were treated for 6-8 cycles of induction therapy with 21 days per cycle, receiving rituximab (375mg/m2 on day 1), dexamethasone (10-15mg on d1-d4), MTX (d2, 3.5g/m2 or 5g/m2), and orelabrutinib (once daily, after MTX clearance, 150mg/d, or 200mg/d), followed by orelabrutinib maintenance up to one year among CR/CRu patients. The primary objective was to determine the maximum tolerated dose (MTD) of the combination of orelabrutinib and MTX with R and D and investigate the safety and tolerability of this regimen using Bayesian Optimal Interval (BOIN) waterfall design to determine rule of dose escalation and movement among dose combination matrix to identify MTD contour. DLT was defined by the occurrence of severe toxicities during the first cycle: any grade 4 hematologic toxicity, grade 3 febrile neutropenia and grade 3 thrombocytopenia with hemorrhage, or any grade 3 non-hematologic toxicity that failed to respond to supportive therapy and possibly related to orelabrutinib and/or MTX (assessed according to NCI CTCAE V5.0). The secondary objectives included ORR/CR(u) and PFS/OS. Baseline tissue/CSF samples and sequential CSF/plasma samples were collected for targeted NGS and pharmacokinetics evaluation as exploratory objectives. Results: Eight patients were enrolled from October 2021 to June 2022 as the preliminary analysis set. The median age was 62 year (range: 43-73) and six patients were male. All the patients with histologically confirmed DLBCL (6 non-GCB subtypes and 2 GCB subtypes) had completed at least one cycle of ORMD treatment and were evaluable for DLT. The median cycle of ORMD was one (range: 1-7). No DLT occurred among first three patients in cohort 1 (Orelabrutinib: 150mg/MTX: 3.5g/m2) and dose escalation was allowed to cohort 2 (Orelabrutinib: 200mg/MTX: 3.5g/m2). In cohort 2, 5 patients were dosed in total, and Gr 3 lung infection was observed in patient #4 during cycle 1, was deemed as a DLT. Another four patients were enrolled in the same cohort according to BOIN design algorithm and no DLT was identified, allowing to escalate to cohort 3 (Orelabrutinib:200mg/MTX:5g/m2). No Gr 4 AE had been observed. The most common adverse events were lymphopenia (Gr 3 in 4 case) and hyperglycemia (Gr 3 in 1 case). No atrial fibrillation, hypertension, or bleeding was observed by the cut-off date. The study is ongoing. Further results will be updated as data becomes mature. Conclusions: ORMD regimen preliminarily demonstrated predictable and manageable safety profile in newly diagnosed PCNSL patients with 200mg/d orelabrutinib and 3.5g/m2 MTX to date. MTD contour not reached and further evaluation continues. Longer follow-up is needed regarding efficacy, biomarker, and more safety data Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

115 (PB105) - New patient derived lymphoma xenograft (PDX) panel for drug development, immuno-oncology and translational research

Lymphomas represent a very heterogeneous group of hematological malignancies and, despite successful therapies, they are a major challenge in clinical practice. Lymphomas often develop resistance to treatment with standard of care drugs (SoC) and have a high relapse rate. Therefore, new therapies are needed to improve long-term remission and patient survival. Recent advances in high-throughput molecular profiling have helped to identify genetic factors and genetic subtypes of diffuse large B-cell lymphoma (DLBCL).

Challenges in the diagnosis and management of vitreoretinal lymphoma - Clinical and basic approaches.

Vitreoretinal lymphoma (VRL) is a subtype of diffuse large B-cell lymphoma and is sight- and life-threatening in the vast majority of patients. Lymphoma cells infiltrate the vitreous body and/or subretinal space and exhibit clinical signs of vitreous opacities and creamy white subretinal lesions. Although the intraocular signs can serve as clues to suspect VRL, they are nonspecific and may be misdiagnosed as uveitis. Histopathological evidence of malignant cells on vitreous biopsy, for instance, is the gold standard for diagnosis of VRL; however, cytological examination of the vitreous often results in a low success rate owing to the small quantity and poor quality of tissues and cells in the sample. Recent advancements in immunological, molecular, and gene analyses using intraocular samples have made it possible to accurately diagnose VRL. As for the management of VRL, local treatments with irradiation and/or intravitreal injections of anti-tumor agents (methotrexate or rituximab) are effective in suppressing intraocular VRL lesions. However, the effect of systemic chemotherapy, with or without brain irradiation, on preventing central nervous system involvements remains controversial. In this review article, we discuss the following concepts based on previous literature and our unpublished results: current ocular imaging examinations such as optical coherence tomography and fundus autofluorescence; immunological, molecular, and gene expression characterization of intraocular biopsies with special attention to flow cytometry; immunoglobulin gene rearrangement assays that use the polymerase chain reaction test; cytokine assays; gene mutations (MYD88, CD79B); and current local and systemic treatments of VRL.

Tumor immune contexture is a determinant of anti-CD19 CAR T cell efficacy in large B cell lymphoma

Axicabtagene ciloleucel (axi-cel) is an anti-CD19 chimeric antigen receptor (CAR) T cell therapy approved for relapsed/refractory large B cell lymphoma (LBCL) and has treatment with similar efficacy across conventional LBCL subtypes. Toward patient stratification, we assessed whether tumor immune contexture influenced clinical outcomes after axi-cel. We evaluated the tumor microenvironment (TME) of 135 pre-treatment and post-treatment tumor biopsies taken from 51 patients in the ZUMA-1 phase 2 trial. We uncovered dynamic patterns that occurred within 2 weeks after axi-cel. The biological associations among Immunoscore (quantification of tumor-infiltrating T cell density), Immunosign 21 (expression of pre-defined immune gene panel) and cell subsets were validated in three independent LBCL datasets. In the ZUMA-1 trial samples, clinical response and overall survival were associated with pre-treatment immune contexture as characterized by Immunoscore and Immunosign 21. Circulating CAR T cell levels were associated with post-treatment TME T cell exhaustion. TME enriched for chemokines (CCL5 and CCL22), γ-chain receptor cytokines (IL-15, IL-7 and IL-21) and interferon-regulated molecules were associated with T cell infiltration and markers of activity. Finally, high density of regulatory T cells in pre-treatment TME associated with reduced axi-cel–related neurologic toxicity. These findings advance the understanding of LBCL TME characteristics associated with clinical responses to anti-CD19 CAR T cell therapy and could foster biomarker development and treatment optimization for patients with LBCL.

Case report: Surgical repair of a large tracheo-esophageal fistula in a patient with post-transplant esophageal lymphoproliferative disorder

Introduction and importanceThe management of large malignant tracheo-esophageal fistulas (TEF) is not standardized. Herein, we report a case with a malignant TEF associated with esophageal post-transplant lymphoproliferative disorder (PTLD) for whom we successfully performed a surgical repair. This contributes to the knowledge on how to treat large acquired malignant TEFs.Case presentationA 69-year old male presented with a one-week history of fever, productive cough and bilateral coarse crackles. In addition, he described a weight loss of 10 kg during the past three months. The patient's history included a kidney transplantation twenty years ago. Esophagogastroduodenoscopy with a biopsy of the esophagus was performed nine days before. Histopathology showed a PTLD of diffuse large B-cell lymphoma subtype. Subsequent diagnostics revealed a progressive TEF (approx. 2.0 × 1.5 cm) 3.0 cm above the carina. PET-CT scan showed an esophagus with slight tracer uptake in the middle third (approx. 11.5 cm length, SUV max 7.4). After decision against stenting, transthoracic subtotal esophagectomy with closure of the tracheal mouth of the fistula by a pedicled flap was performed. PTLD was treated with prednisone and rituximab. Tumor progression (brain metastasis) led to death 95 days after surgery.Clinical discussionThe treatment of a malignant TEF is complex and personalized while both the consequences of the esophago-tracheal connection and those of the underlying responsible diagnosis have to be considered concurrently. In this case, we considered surgery as the best treatment option due to a relatively good prognosis of the underlying diagnosis (PTLD) and a large fistula. Esophageal or dual stenting, the treatment of choice for small malignant TEF, would have been associated with a high risk of failure due to the wide trachea, extensively dilated esophagus, proximal location and large diameter of the fistula.ConclusionSurgery can be considered for patients with a large acquired malignant TEF and positive long-term prognosis of the underlying diagnosis. Due to the complexity of TEF management, immediate pre-operative multidisciplinary discussion is advised.

Hemophagocytic lymphohistiocytosis as an onset of diffuse large B-cell lymphoma: A case report.

A 53-year-old male presented with a 1-month history of hyperpyrexia. The clinical manifestations revealed hemophagocytic lymphohistiocytosis (HLH). Although a lymph node biopsy could not be obtained, a bone marrow biopsy revealed the activated B-cell subtype of diffuse large B-cell lymphoma (DLBCL). After being treated with HLH-1994 (dexamethasone and etoposide), a rituximab-containing chemotherapy and target agents involving bortezomib, the patient achieved remission. To understand the molecular profile of patient, next-generation sequencing and MYD88 L265P mutation examinations were performed, and the patient was determined to be positive for the MYD88 L265P mutation. Reports of DLBCL with plasmacytic differentiation and a MYD88 innate immune signal transduction adaptor L265P mutation concurrent with HLH are rare. Early recognition, precise diagnosis and timely therapy are pivotal in improving patient prognosis. Furthermore, molecular profiling enables researchers to develop potential therapies aimed at the activated NF-κB and endoplasmic reticulum stress signaling pathways. The present study highlights this pathogenesis and provides suggestions for further individualized therapeutics.

P1234: REAL-WORLD EXPERIENCE OF OUTCOMES WITH GLOFITAMAB SALVAGE THERAPY FOR RELAPSE/REFRACTORY B-CELL LYMPHOMA IN TAIWAN: MINIMAL SAFETY CONCERN WITH HEPATITIS B REACTIVATION

Background: Glofitamab, a T-cell-engaging bispecific antibody (Ab) with a novel 2:1 configuration conferring robust bivalency for CD20 and monovalency for CD3, has recently shown promising activity in its phase I/II trial as a salvage therapy in various major subtypes of B-cell lymphoma. Few studies, however, have described the use of glofitamab in a real-world clinical setting. Aims: We aimed to depict the efficacy and safety profiles of glofitamab as a salvage therapy for patients with diffuse large B-cell lymphoma (DLBCL) and other subtype of B-cell lymphoma in the real-world setting with a special focus on the risk of hepatitis B virus (HBV) reactivation. Methods: The clinical data of patients with DLBCL or other B-cell lymphomas who had received ≥3 lines of prior therapies and received glofitamab salvage therapy in a compassionate use program in Nov. 2020 - Dec. 2021 were retrospectively analyzed. The treatment protocol included obinutuzumab pretreatment 1000mg given 7 days before the first glofitamab dose, followed by step-up dose of glofitamab administration: 2.5mg on Day 1 and 10mg on Day 8 of cycle 1, and then 30mg on Day 1 of cycle 2-12 (21-day cycles). Results: As of the end of 2021, 26 patients from two medical centers in Taiwan, 11(43%) of whom were females, were enrolled. Among them, 18 were diagnosed with de novo DLBCL, 3 with transformed large B-cell lymphoma, and 5 with other subtypes of B-cell lymphoma. The median age was 57 years (26-75). Among the 18 cases with de novo DLBCL, 10(56%) had non-germinal center subtype, and 9(50%), double-hit/triple-hit lymphoma. Extra-nodal lesions were observed in 12(46%) patients, and 7(27%), marrow involvement. Elevated LDH levels occurred in 15 (58%) patients. Median prior therapies were 5 (3–10) with 24(92%) patients having received ≥4 prior therapies. All patients had received prior rituximab therapy, 6(23%), autologous or allogeneic stem cell transplantation (SCT), and 9(35%), polatuzumab salvage. Nineteen (79%) patients were refractory to their most recent regimen. Median cycles of glofitamab treatment were 5 (1-12). With the median follow-up of 9 months, the median overall survival was 6 months. The overall response and complete response rates were 50% and 23%, respectively. The remissions are durable (Figure 1): among 13 responders, 8 are continuing the treatment, 1 finished the planned 12 cycles of therapy, 1 had consolidated autologous SCT in remission status, and 2 passed away because of infections in remission status; only one case had disease relapse after achieving remission. No case has had disease progression after achieving an initial response. Cytokine releasing syndrome (CRS) occurred in 15(58%) patients; most of them occurred in the initial two cycles and were mostly of grade 1/2 severity except two cases (8%) with grade 3 CRS, both resulted from transaminitis. No grade 4/5 CRS, neurological toxicity, or fatal toxicity was observed. In terms of HBV infection, 7 patients were HBs antigen(+) and 6 of them had concurrent prophylactic HBV therapy during glofitamab treatment, whereas 11 patients were anti-HBc antibody(+)/HBs antigen(-) and 2 of them received prophylactic HBV therapy. No HBV reactivation event was observed in this cohort of patients. Image:Summary/Conclusion: In the real-world setting, glofitamab remains an effective salvage treatment for patients with heavily pretreated relapse/refractory DLBCL and B-cell lymphomas. No new safety issues were observed. With optimal prophylaxis, the risk of HBV reactivation would not be of concern during glofitamab treatment.

Abstract 741: Evaluation of etiologic heterogeneity for risk of diffuse large B-cell lymphoma (DLBCL) subtype defined by cell-of-origin

Abstract Background: DLBCL is the most common non-Hodgkin lymphoma subtype in western countries and is clinically heterogeneous. Gene expression profiling has identified two major biologically distinctive DLBCL subtypes defined by their cell-of-origin (COO): germinal center B-cell (GCB) - characterized by BCL2 rearrangement and C-REL amplification, and activated B-cell (ABC) - characterized by constitutive activation of the NF-kB pathway. We evaluated putative DLBCL risk factors for etiologic heterogeneity as defined by COO. Methods: We used a clinic-based study of newly diagnosed NHL cases and frequency matched controls, enrolled from 2002-2014, with a total of 687 DLBCL cases and 2253 controls for this analysis. Using formalin-fixed, paraffin-embedded tumor tissue, we determined COO by either digital expression profiling (NanoString; classified as GCB, ABC, undetermined) or clinically using the Hans algorithm (immunohistochemical markers; classified as GCB, non-GCB, undetermined). Integrating these two sources of COO data, there were 271 GCB, 170 non-GCB, and 246 undetermined/missing (mainly due to lack of tissue) cases. Risk factor data were collected from self-administered questionnaires and included family history of hematologic malignancy; history of atopy, allergy, asthma, eczema, or autoimmune disease; blood transfusion; vaccination history; regular low-dose aspirin use; body mass index (BMI) 2 years prior diagnosis/enrollment; smoking history; alcohol consumption (never/current/former); leisure-time physical activity; and recreational sun exposure. Polytomous logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals for COO subtypes, adjusted for age, sex and residence. Results: The median age of cases was 64 years with 55% male; the median age of controls was 64 years and 53% male. The association with BMI (30+ vs. 18.5-24.9 kg/m2) was stronger for non-GCB (OR=2.21; 1.40-3.49) than for GCB (OR=1.70; 1.21-2.40) DLBCL (P-heterogeneity 0.02), while a family history of hematologic malignancy was associated with non-GCB (OR=2.27; 1.47-3.50) but not GCB (OR=1.30; 0.86-1.96) DLBCL, although the P-heterogeneity was not significant (P=0.13). For GCB, there was an inverse association with former (vs. never) alcohol use for GCB (OR=0.57; 0.39-0.83) but not for non-GCB (OR=0.98; 0.61-1.57) DLBCL (P-heterogeneity 0.007), and an inverse association with regular use of low-dose aspirin for GCB (OR=0.64; 0.47-0.87) but not for non-GCB (OR=0.88; 0.61-1.25) DLBCL (P-heterogeneity 0.05). No other risk factors evaluated showed important heterogeneity by COO. Conclusions: These initial results suggest most DLBCL risk factors do not show etiologic heterogeneity by DLBCL COO, although associations with BMI and family history with non-GCB DLBCL and alcohol and low-dose aspirin use with GCB DLBCL warrant follow-up. Citation Format: Geffen Kleinstern, Dennis P. Robinson, Lisa M. Rimsza, Melissa C. Larson, Rebecca L. King, Grzegorz S. Nowakowski, Carrie A. Thompson, Stephen M. Ansell, Matthew J. Maurer, Andrew L. Feldman, Susan L. Slager, Anne J. Novak, Thomas M. Habermann, James R. Cerhan. Evaluation of etiologic heterogeneity for risk of diffuse large B-cell lymphoma (DLBCL) subtype defined by cell-of-origin [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 741.

Brentuximab vedotin and nivolumab alone and then combined with rituximab, cyclophosphamide, doxorubicin, and prednisone for frontline therapy of patients with primary mediastinal large B-cell lymphoma.

TPS7589 Background: Primary mediastinal large B-cell lymphoma (PMBL) is a rare and distinct subtype of diffuse large B-cell lymphoma and affects primarily young adults. PMBL has a unique genomic profile that has similarities to classic Hodgkin lymphoma with CD30 expression and genomic alterations in the programmed T-cell death-ligand 1 (PD-L1) locus 9p24.1. The trial CheckMate-436, including relapsed/refractory PMBL patients treated with nivolumab (antibody that binds to immune checkpoint PD-1) and brentuximab vedotin ((BV) anti-CD30 antibody-drug conjugate) showed an overall response rate (ORR) of 73% and complete response rate (CRR) of 43% (Zinzani et al. JCO 2019). Although most PMBL patients can be cured with frontline chemoimmunotherapy with or without radiotherapy, the outcome of patients having rr-PMBL treated with intensive regimens is generally unfavorable. The discovery of new frontline regimens to decrease chemoresistance and toxicities represents an urgent unmet clinical need for PMBL patients. Methods: We are conducting a phase II, open-label, single-center clinical trial combining BV-Nivolumab alone and then combined with rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP) for patients with previously untreated PMBL Patients 18 years or older with previously untreated PMBL, stage I to stage IV disease are eligible. However, patients with an urgent need for cytoreductive treatment will be excluded. Patients will receive BV 1.8 mg/Kg IV and Nivolumab 240 mg flat dose IV day 1 for cycles 1 and 2, in a 21-day cycle. During cycles 3 and 4, R-CHP will be added to BV-Nivolumab. Patients who have achieved complete response (CR) at PET/CT before cycle 5 will receive 2 more cycles of BV-Nivolumab+R-CHP (cycle 5 and 6) and BV-Nivolumab only for cycles 7 and 8. In case of CR on PET/CT after cycle 8, therapy will be considered completed. Patients in PR on PET/CT before cycle 5 will receive 4 more cycles of BV-Nivolumab+R-CHP (cycles 5-8). The primary endpoint is CRR at the end of therapy (EOT). The maximum sample size for the PMBL cohort is 40 patients, with a target CRR at EOT of 70%. The null hypothesis is that the true CRR at EOT is 50%, and the alternative hypothesis is that the true CRR at EOT is 70%. The Simon’s optimal two-stage design controls the one-sided type I error rate at 0.06 and yields the power of 0.8. The secondary endpoints will include the response rate of BV-Nivolumab+R-CHP at the end of the immune lead-in, landmark survival outcomes, the safety of the combination, and patient-reported outcome. Exploratory analyses include assessing molecular response by sequencing cell-free DNA and Multiplexed ion beam imaging to analyze the tumor microenvironment. The trial is actively accruing at MD Anderson Cancer Center, and 2 out of 40 patients have been enrolled. Clinical trial information: NCT04745949.

Does ethnicity matter? A two-statewide population based analysis of outcomes of primary mediastinal B-cell lymphoma in Hispanics.

e19568 Background: Primary mediastinal B-cell lymphoma (PMBCL) is considered a rare distinct clinicopathological and molecular subtype of diffuse large B-cell lymphoma (DLBCL), mainly affecting females in their 4th and 5th decades [1,2,3]. Since the 1960s, there has been a significant increase in the number of immigrants to the US; and the states of Florida (FL) and Texas (TX) are well known for their Hispanic (HI) enriched population. Since there is scarce data of PMBCL in HI; we researched demographics, treatment patterns and outcomes in H compared to Non-Hispanics (NH) from FL and TX. Methods: This is a retrospective study of patients diagnosed with PMBCL from the Texas Cancer Registry (TCR) and the Florida Cancer Data System (FCDS), with years of analysis 2006-2017. Patients were identified by the International Classification of Diseases for Oncology Third Edition (ICD-O-3). Key variables collected included gender, race, ethnicity, dates at diagnosis and death, primary payer at diagnosis, stage, type of treatment, poverty index, and vitality status. The significance of variation in the distribution of categorical outcomes with ethnicity (H, NH) was assessed with Fisher’s Exact tests or Pearson’s Chi-square tests as appropriate. Survival distributions were described with Kaplan-Meier curves, and the significance of variation in median survival with ethnicity was assessed with log-rank testing. All statistical testing was two-sided with a significance level of 5%. Results: We had 2 cohorts; cohort A (A) includes 19 H vs. 89 NH from TX, cohort B (B), 27 H vs. 121 NH from FL. The median age at diagnosis in A was 33 years (y) in H vs 40 y in NH ( p-value = 0.091); while median age in B was 36 y in H vs 46 y in NH ( p-value = 0.005). Regarding poverty index; in A, most of H were in the 10-20% bracket, and most NH were in the 5-10% bracket. On the contrary, in B, most of H were in the 5-10%, and most NH were in the 10-20% bracket. Lack of insurance was more prevalent in H in A vs. NH, 42% vs. 12%, respectively, where it was less prevalent in H vs. NH in B, 8% vs. 5%. Multiple agents of chemotherapy were delivered to 74% of H, 70% of NH vs. 82% of H and 65% of NH with p-value = 0.292 and 0.635 in A and B, respectively. In A, the NH had better median survival (m) than H, not reached vs. 10.3 y, respectively. In B, H had better m than the NH, 10.7 y vs. not reached, respectively. The 5 y survival probability in A was even among H and NH; 0.702 [95% CI 0.49-1] and 0.732 [95% CI 0.578 - 0.9280], respectively. While 5 y survival probability in B was higher in H compared to NH, 0.923 [95% CI 0.675 -0.869] and 0.766 [95% CI 0.434 - 0.615], respectively. The overall survival (OS) difference in A and B, H vs. NH was not statistically significant. Conclusions: Despite some identified demographic differences in patients diagnosed with PMBCL, comparing H vs. NH on each cohort, there was no statistically significant difference in the overall survival probability.

Anticancer activity of IRAK-4 inhibitors against canine lymphoid malignancies.

The interleukin-1 receptor-related kinase 4 (IRAK4), downstream of myd88, plays an essential role in hyperactive TLR signalling seen in some B-cell lymphomas. In particular, efficient IRAK4 inhibitors of activated B-cell subtype of human diffuse large B-Cell lymphoma (DLBCL) are being developed. However, the anticancer effect of IRAK-4 inhibitors in veterinary medicine has not been elucidated. It is therefore explored in this study involving the GL-1 and CL-1 canine lymphoma cell lines in vitro. MyD88 expression was analysed using polymerase chain reaction. GL-1 and CL-1 cells were subjected to concentration- and time-dependent treatment with an IRAK-4 inhibitor and assessed for viability, TLR signalling association and apoptosis using a cell counting Kit-8 assay, Western blotting and flow cytometry. The GL-1 and CL-1 cells exhibited enhanced MyD88 expression, however, canine peripheral blood mononuclear cells (cPBMCs) did not. The IRAK-4 inhibitor reduced cell viability in a dose- and time-dependent manner, significantly reduced the phosphorylation of molecules associated with TLR signalling at IC50 such as IRAK1, IRAK4, NF-κB and STAT3, and induced apoptosis in GL-1 and CL-1 cells. The anticancer effect of the IRAK-4 inhibitor on canine lymphoma cells is mediated by apoptosis via downregulation of TLR signalling.

Treatment at high-volume facilities is associated with improved overall survival for patients with cutaneous B-cell lymphoma

To the Editor: Primary cutaneous B-cell lymphoma (CBCL), which comprises approximately 25% of cutaneous lymphomas, is much less common than cutaneous T-cell lymphoma. CBCLs require careful clinicopathologic correlation for accurate diagnosis and can range from more indolent (marginal zone lymphoma and follicle center lymphoma) to more aggressive (eg, diffuse large B-cell lymphoma) subtypes. Given the rarity and heterogeneity of CBCL, there is limited high-level data to guide management, with cases typically treated using a multidisciplinary approach using expert opinion and data from observational studies.

The prognostic significance of immune checkpoint receptor expression in patients with lymphoma: Association with disease status and clinical outcomes.

Little is known about the expression of immune checkpoint receptors in the peripheral blood of lymphoma patients. Herein, we assessed the expression of inhibitory checkpoint receptors, including CTLA-4, PD-1/PDL-1, LAG-3, and TIM-3 in the peripheral blood of lymphoma patients and its correlation with the clinical outcomes of patients. Therefore, 47 classical Hodgkin lymphoma (cHL), 48 non-Hodgkin lymphoma patients with diffuse large B-cell lymphoma (DLBCL) subtype, and 30 healthy controls were recruited. The expression of inhibitory receptors was evaluated using SYBR Green real-time PCR method. CTLA-4, LAG-3, and TIM-3 genes were significantly upregulated in both cHL and DLBCL patients compared to the healthy controls. In addition, the level of these molecules was differentially expressed in cHL and DLBCL patients at different disease phases compared to the healthy controls. The CTLA-4 gene was highly expressed in newly diagnosed (ND) cHL patients compared to the relapsed ones. Relapsed DLBCL patients had significantly increased LAG-3 expression compared to patients at remission, as well as ND patients. Regarding cHL patients, high CTLA-4 expression was correlated with low lactate dehydrogenase level and better performance status, whereas the level of LAG-3 was significantly elevated in patients with poor performance status. Lower initial PD-1 expression was associated with improved disease-free survival in cHL patients. Inhibitory immune checkpoint receptors are aberrantly expressed in the peripheral blood of cHL and DLBCL patients in which high LAG-3 in DLBCL patients and PD-1/LAG-3 in cHL patients are associated with relapse occurrence and worse prognosis, respectively.

Distinct clinical and genetic features of hepatitis B virus–associated follicular lymphoma in Chinese patients

AbstractHepatitis B virus (HBV) infection has been associated with an increased risk for B-cell lymphomas. We previously showed that 20% of diffuse large B-cell lymphoma (DLBCL) patients from China, an endemic area of HBV infection, have chronic HBV infection (surface antigen–positive, HBsAg+) and are characterized by distinct clinical and genetic features. Here, we showed that 24% of follicular lymphoma (FL) Chinese patients are HBsAg+. Compared with the HBsAg− FL patients, HBsAg+ patients are younger, have a higher histological grade at diagnosis, and have a higher incidence of disease progression within 24 months. Moreover, by sequencing the genomes of 109 FL tumors, we observed enhanced mutagenesis and distinct genetic profile in HBsAg+ FLs, with a unique set of preferentially mutated genes (TNFAIP3, FAS, HIST1H1C, KLF2, TP53, PIM1, TMSB4X, DUSP2, TAGAP, LYN, and SETD2) but lack of the hallmark of HBsAg− FLs (ie, IGH/BCL2 translocations and CREBBP mutations). Transcriptomic analyses further showed that HBsAg+ FLs displayed gene-expression signatures resembling the activated B-cell–like subtype of diffuse large B-cell lymphoma, involving IRF4-targeted genes and NF-κB/MYD88 signaling pathways. Finally, we identified an increased infiltration of CD8+ memory T cells, CD4+ Th1 cells, and M1 macrophages and higher T-cell exhaustion gene signature in HBsAg+ FL samples. Taken together, we present new genetic/epigenetic evidence that links chronic HBV infection to B-cell lymphomagenesis, and HBV-associated FL is likely to have a distinct cell-of-origin and represent as a separate subtype of FL. Targetable genetic/epigenetic alterations identified in tumors and their associated tumor microenvironment may provide potential novel therapeutic approaches for this subgroup of patients.

A Case Report of Plasmablastic Lymphoma with Unusual Presentation: How Do Socioeconomic Factors Contribute to Cancer Survival?

Plasmablastic lymphoma (PBL) is an uncommon but aggressive subtype of diffuse large B-cell lymphoma (DLBCL) that is mostly seen in HIV positive patients. This case report details an HIV-positive patient with two unusual sites of PBL manifestation, the pleural space and the rectum. The patient was initiated on treatment but subsequently developed complications leading to the inability to temporarily continue therapy. In addition to illustrating less common site manifestations of PBL as well as its therapeutic challenges, this case also exhibits how a patient’s socioeconomic and health insurance status can contribute to treatment delays, and hence their overall prognosis and survival.