Systemic Diffuse Large B-cell Lymphoma Research Articles

The genomic and transcriptional landscape of primary central nervous system lymphoma

Primary lymphomas of the central nervous system (PCNSL) are mainly diffuse large B-cell lymphomas (DLBCLs) confined to the central nervous system (CNS). Molecular drivers of PCNSL have not been fully elucidated. Here, we profile and compare the whole-genome and transcriptome landscape of 51 CNS lymphomas (CNSL) to 39 follicular lymphoma and 36 DLBCL cases outside the CNS. We find recurrent mutations in JAK-STAT, NFkB, and B-cell receptor signaling pathways, including hallmark mutations in MYD88 L265P (67%) and CD79B (63%), and CDKN2A deletions (83%). PCNSLs exhibit significantly more focal deletions of HLA-D (6p21) locus as a potential mechanism of immune evasion. Mutational signatures correlating with DNA replication and mitosis are significantly enriched in PCNSL. TERT gene expression is significantly higher in PCNSL compared to activated B-cell (ABC)-DLBCL. Transcriptome analysis clearly distinguishes PCNSL and systemic DLBCL into distinct molecular subtypes. Epstein-Barr virus (EBV)+ CNSL cases lack recurrent mutational hotspots apart from IG and HLA-DRB loci. We show that PCNSL can be clearly distinguished from DLBCL, having distinct expression profiles, IG expression and translocation patterns, as well as specific combinations of genetic alterations.

Masquerade versus masquerade

This is an atypical uniocular presentation of systemic diffuse large B-cell lymphoma. An 80-year-old Caucasian female presented with acute left visual loss, anorexia, headache, and jaw pain with disk swelling. Systemic steroids for giant cell arteritis were started despite negative temporal artery biopsy. Later, an inferior exudative retinal detachment developed. Lytic skull lesions were eventually seen on magnetic resonance imaging. Diffuse large B-cell lymphoma was diagnosed postmortem. This is the second documented case of unilateral serous retinal detachment with no uveitis/pseudouveitis or choroidal infiltrate due to lymphoma. It demonstrates pitfalls of pattern recognition when pieces of the jigsaw do not fit.

Hidden in the Eyes-Recurrence of Systemic Hemopathies Reportedly "In Remission": Six Cases and Review of Literature.

Background and Objectives: Secondary ocular localizations of hematological malignancies are blinding conditions with a poor prognosis, and often result in a delay in the diagnosis. Materials and Methods: We describe a series of rare cases of ocular involvement in six patients with hematological malignancies, reportedly in remission, who presented secondary ocular localizations, challenging to diagnose. Two patients had an acute lymphoblastic leukemia (ALL) and developed either a posterior scleritis or a pseudo-panuveitis with ciliary process infiltration. One patient had iris plasmacytoma and developed an anterior uveitis as a secondary presentation. Two patients had a current systemic diffuse large B-cell lymphoma (DLBCL) and were referred either for intermediate uveitis or for papilledema and vitritis with secondary retinitis. Finally, one patient with an acute myeloid leukemia (AML) presented a conjunctival localization of a myeloid sarcoma. We herein summarize the current knowledge of ophthalmologic manifestations of extramedullary hematopathies. Results: Inflammatory signs were associated with symptomatic infiltrative lesions well displayed in either the iris, the retina, the choroid, or the cavernous sinus, from the admission of the patients in the ophthalmological department. These findings suggest that patients with ALL, AML, systemic DLBCL, and myeloma can present with ophthalmic involvement, even after having been reported as in remission following an effective systemic treatment and/or allograft. Conclusions: Early detection of hidden recurrence in the eyes may permit effective treatment. Furthermore, oncologists and ophthalmologists should be aware of those rare ocular malignant locations when monitoring patient’s progression after initial treatment, and close ophthalmologic examinations should be recommended when detecting patient’s ocular symptoms after treatment.

Efficacy and Safety of Cyclophosphamide Low-Dose Pre-Phase Chemotherapy in Diffuse Large B Cell Lymphoma with Gastrointestinal Involvement.

BackgroundGastric Diffuse large B-cell lymphoma (DLBCL) is the most common extranodal site of lymphoma’s involvement (30%–40% of all extranodal lymphomas and 55%–65% of all gastrointestinal lymphomas). However, gastric localizations are also sometimes found in systemic DLBCL. Gastric complications such as bleeding, perforation, and stenosis under chemotherapy are well documented.MethodsWe retrospectively analyzed 15 patients with newly diagnosed DLBCL with gastrointestinal involvement. Endoscopies were performed in these patients before and after treatment. Treatment consisted of cyclophosphamide low-dose pre-phase chemotherapy before conventional-dose chemotherapy.ResultsEndoscopy at staging detected ulcers in 12 patients (80%). After low-dose pre-phase chemotherapy, GI ulcers healed in 91.6% of cases (1 ulcer detected). After the whole treatment (Low-dose pre-phase + chemotherapy) 9 patients (60%) achieved complete response, 4 patients (26.6%) partial response, 2 (13,3%) patients presented disease progression. The most frequent adverse event was neutropenia (73.3%); the most frequent non-hematological adverse event was transaminases elevation (20%).ConclusionCyclophosphamide low-dose pre-phase chemotherapy resulted in a safe and effective way to prevent adverse events in systemic DLBCL with gastrointestinal involvement.

Cell-of-origin classification using the Hans and Lymph2Cx algorithms in primary cutaneous large B-cell lymphomas

Primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT) and primary cutaneous follicle center lymphoma with a diffuse population of large cells (PCFCL-LC) are both primary cutaneous B-cell lymphomas with large-cell morphology (CLBCL) but with different clinical characteristics and behavior. In systemic diffuse large B-cell lymphoma, not otherwise specified (DLBCL-NOS), gene-expression profiling (GEP) revealed two molecular subgroups based on their cell-of-origin (COO) with prognostic significance: the germinal center B-cell-like (GCB) subtype and the activated B-cell-like (ABC) subtype. This study investigated whether COO classification is a useful tool for classification of CLBCL. For this retrospective study, 51 patients with PCDLBCL-LT and 15 patients with PCFCL-LC were analyzed for their COO according to the immunohistochemistry-based Hans algorithm and the NanoString GEP-based Lymph2Cx algorithm. In PCFCL-LC, all cases (100%) classified as GCB by both Hans and Lymph2Cx. In contrast, COO classification in PCDLBCL-LT was heterogeneous. Using Hans, 75% of the PCDLBCL-LT patients classified as non-GCB and 25% as GCB, while Lymph2Cx classified only 18% as ABC, 43% as unclassified/intermediate, and 39% as GCB. These COO subgroups did not differ in the expression of BCL2 and IgM, mutations in MYD88 and/or CD79B, loss of CDKN2A, or survival. In conclusion, PCFCL-LC uniformly classified as GCB, while PCDLBCL-LT classified along the COO spectrum of DLBCL-NOS using the Hans and Lymph2Cx algorithms. In contrast to DLBCL-NOS, the clinical relevance of COO classification in CLBCL using these algorithms has limitations and cannot be used as an alternative for the current multiparameter approach in differentiation of PCDLBCL-LT and PCFCL-LC.

Clinical utility of brain biopsy for presumed CNS relapse of systemic lymphoma.

The objective of this study was to determine the frequency with which brain biopsy for presumed CNS relapse of systemic hematological malignancies yields new, actionable diagnostic information. Hematological malignancies represent a disparate group of genetic and histopathological disorders. Proclivity for brain involvement is dependent on the unique entity and may occur synchronously or metasynchronously with the systemic lesion. Diffuse large B-cell lymphomas (DLBCLs) have a high propensity for brain involvement. Patients in remission from systemic DLBCL may present with a lesion suspicious for brain relapse. These patients often undergo brain biopsy. The authors' a priori hypothesis was that brain biopsy in patients with a history of systemic DLBCL and a new brain MRI lesion would have lower diagnostic utility compared with patients with non-DLBCL systemic malignancies. The authors performed a retrospective review of patients who underwent brain biopsy between 2000 and 2019. Inclusion criteria were patients ≥ 18 years of age with a prior systemic hematological malignancy in remission presenting with a new brain MRI lesion concerning for CNS relapse. Patients with a history of any CNS neoplasms, demyelinating disorders, or active systemic disease were excluded. The main outcome was the proportion of patients with a distinct histopathological brain diagnosis compared with the systemic malignancy. The authors secondarily assessed overall survival, procedure-related morbidity, and 30-day mortality. Sixty patients met inclusion criteria (40 males and 20 females); the median age at brain biopsy was 67 years (range 23-88 years). The median follow-up was 8.5 months (range 0.1-231 months). Thirty-nine (65.0%) patients had DLBCL and 21 (35%) had non-DLBCL malignancies. Thirty-five of 36 (97.2%) patients with prior systemic DLBCL and a diagnostic biopsy had histopathological confirmation of the original systemic disease versus 0 of 21 patients with non-DLBCL systemic malignancies (p < 0.001). Morbidity and 30-day mortality were 8.3% and 10.0%, respectively; 2 of 6 30-day mortalities were directly attributable to the biopsy. The median overall survival following brain biopsy was 10.8 months. Patients with a history of systemic DLBCL and presumed CNS relapse gained minimal clinical benefit from brain biopsy but were at high risk of morbidity and mortality. In patients with a history of non-DLBCL systemic malignancies, brain biopsy remained critical given the high likelihood for discovery of distinct diagnostic entities. It was determined that patients with a prior systemic DLBCL and presumed brain relapse should likely receive empirical therapy obviating treatment delay and the risks of brain biopsy.

Поражение центральной нервной системы при диффузной В-клеточной крупноклеточной лимфоме

Introduction. Current approaches used to predict the recurrence of diffuse large B-cell lymphoma (DLBCL) with involvement of the central nervous system (CNS) need to be improved. Data from national studies on the incidence and clinical and laboratory characteristics of primary CNS DLBCL and secondary CNS involvement in systemic DLBCL are fragmentary and do not allow us to assess the overall picture. Aim. An assessment on the territory of the Siberian metropolis of data on the incidence and clinical and laboratory characteristics of DLBCL patients with primary CNS lymphoma (PCNSL) and secondary CNS involvement, as well as validation of the CNS-International Prognostic Index (CNS-IPI) on this sample. Materials and methods. The study group consisted of 47 patients with PCNSL and 35 with secondary CNS involvement in systemic DLBCL, the comparison group consisted of 202 patients with DLBCL without CNS involvement. Results. All patients with secondary CNS involvement in DLBCL belonged to the medium and high risk groups (p = 0.007) according to the CNS-IPI, which confirms its prognostic value. The risk factors for secondary CNS involvement in DLBCL were ECOG performance status ≥ 2, HIV infection, age over 60 years, a history of chronic kidney disease, ≥ 2 extranodal sites, and high expression of Ki-67 (&gt;75% positive tumor cells), non-GCB subtype of lymphoma, and presence of anemia. When assessing the characteristics of the clinical course of the disease, a number of peculiarities of the primary and secondary CNS involvement in DLBCL were identified. In particular, in terms of overall survival, the PCNSL group had a more favorable prognosis (p = 0.051). Conclusion. The results of the study confirm the importance of the CNS-IPI as a tool of a hematologist to determine the group of patients needing prevention of recurrence of DLBCL in the CNS. New data on a higher incidence of chronic kidney disease, arterial hypertension and thyroid disorders in the group of patients with PCNSL require further study.

Perspectives on Precision Medicine in Primary Central Nervous System Lymphoma

Primary central nervous system lymphoma(PCNSL)is an aggressive, extranodal non-Hodgkin lymphoma that arises from the central nervous system, eyes, leptomeninges, and the spinal cord. Most PCNSLs are a type of diffuse large B-cell lymphoma(DLBCL), and the majority are categorized as a non-germinal center B-cell(GCB)subtype. Recent genetic studies have revealed several common genetic abnormalities in PCNSL, such as MYD88 and CD79B mutations, suggesting dependence on the B-cell receptor/Toll-like receptor signaling pathway. These genetic findings have rationalized targeted therapy targeting Bruton's tyrosine kinase(BTK), a key molecule of the B-cell receptor pathway in PCNSL and systemic non-GCB DLBCL. The first-generation BTK inhibitor ibrutinib has been widely studied in clinical trials for PCNSL and systemic non-GCB DLBCL. In Japan, a second-generation BTK inhibitor tirabrutinib was studied in a phase I/II trial and approved by the Japanese Ministry of Health and Welfare in March 2020 for relapsed and refractory PCNSL. While the current standard-of-care therapy for PCNSL is methotrexate(MTX)-based multi-agent induction immunochemotherapy like R-MPV(rituximab, MTX, procarbazine, and vincristine)followed by consolidation chemotherapy and/or radiation therapy, further investigation into the optimal use of BTK inhibitors in the standard-of-care therapy of PCNSL is warranted.

Outcomes of patients with diffuse large B-cell and high-grade B-cell lymphomas with synchronous CNS and systemic involvement at diagnosis treated with high-dose methotrexate and R-CHOP: a single-center retrospective study.

Background:The optimal treatment of patients with systemic diffuse large B-cell (DLBCL) or high-grade B-cell (HGBL) lymphomas with synchronous central nervous system (CNS) involvement at diagnosis is not well defined. High-dose methotrexate administered concurrently with R-CHOP (RM-CHOP) is a commonly used regimen, but data on outcomes achieved with this regimen are limited.Objective:To report our experience with RM-CHOP in patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis.Design:A single-center retrospective analysis.Methods:We identified consecutive patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis who were treated with RM-CHOP from January 2012 to January 2021.Results:Fifty patients were included with a median age of 62 years; 82% had DLBCL (n = 41) and 18% had HGBL (n = 9). Treatment with RM-CHOP was followed by consolidative autologous hematopoietic cell transplantation in 14 patients (28%). The complete response (CR) rate following RM-CHOP was 62%. With a median follow-up of 40 months, the median progression-free (PFS) and overall (OS) survivals were 16 and 58 months, and the 2-year PFS and OS were 41% and 57%, respectively. The 2-year cumulative incidence of CNS progression/relapse was 29%. Outcomes were particularly poor in HGBL, with median PFS and OS of 6 and 7 months, compared with median PFS and OS of 22 months and not reached in DLBCL, respectively. The outcomes of patients with relapsed/progressive disease were poor, with only 63% of patients receiving subsequent treatments and only 21% achieving CR to next subsequent treatment. Most patients (58%) with disease relapse/progression had CNS involvement which was associated with very poor outcomes (median OS of 2 months).Conclusion:CNS involvement in aggressive B-cell non-Hodgkin lymphoma at diagnosis dictates clinical outcomes and requires more effective treatment options.

Preliminary Evaluation of Zanubrutinib-Containing Regimens in DLBCL and the Cerebrospinal Fluid Distribution of Zanubrutinib: A 13-Case Series

Zanubrutinib is a second-generation Bruton’s tyrosine kinase inhibitor. Its safety and effectiveness in central nervous system (CNS) lymphoma along with its distribution in the brain and ability to cross the blood–brain barrier (BBB) remain unknown. This retrospective case series involved patients with diffuse large B-cell lymphoma (DLBCL) treated with zanubrutinib-containing regimens from August to December 2020 in PUMCH. The amounts of zanubrutinib in the plasma and brain were assessed by liquid chromatography–tandem mass spectrometry in paired plasma and cerebrospinal fluid (CSF) samples. In total, 13 patients were included: eight primary CNS lymphoma cases and five systemic DLBCL cases with 61.5% (8/13) refractory/relapsed and 84.6% (11/13) showing CNS involvement. The overall response rates were 84.5% in the entire population and 81.8% in the CNS-involved cases. A total of 23 time-matched plasma-CSF sample pairs were collected. The mean peak concentration of zanubrutinib in CSF was 2941.1 pg/ml (range, 466–9032.0 pg/ml). The corrected mean CSF/plasma ratio determined based on 94% protein binding was 42.7% ± 27.7% (range, 8.6%–106.3%). This preliminary study revealed the effectiveness of zanubrutinib-containing regimens in DLBLC, especially CNS-involved cases, for the first time. The excellent BBB penetration of zanubrutinib supports its further investigation for the treatment of CNS lymphoma.

Prognostic implications of the tumor immune microenvironment and immune checkpoint pathway in primary central nervous system diffuse large B-cell lymphoma in the North Indian population.

Primary central nervous system-diffuse large B-cell lymphoma (PCNS-DLBCL) is a rare, extranodal malignant lymphoma carrying poor prognosis. The prognostic impact of tumor microenvironment (TME) composition and the PD-1/PD-L1 immune checkpoint pathway are still undetermined in PCNS-DLBCL. We aimed to quantify the tumor-infiltrating lymphocytes (TILs), tumor-associated macrophages (TAMs), and PD-L1 expression in the PCNSL and evaluated their prognostic significance. All patients with histopathologically diagnosed PCNS-DLBCL over a period of 7 years were recruited. Immunohistochemistry for CD3, CD4, CD8, FOXP3, CD68, CD163, PD-1, and PD-L1 was performed on the tissue microarray. Forty-four cases of PCNS-DLBCL, who satisfied the selection criteria, were included with mean age of 55 ± 12.3 years and male-to-female ratio of 0.91:1. The mean overall survival (OS) and disease-free survival (DFS) was 531.6 days and 409.8 days, respectively. Among TILs, an increased number of CD3+ T cells showed better OS and DFS, without achieving statistical significance. CD4 positive T-cells were significantly associated with the longer OS (p = 0.037) and DFS (p = 0.023). TAMs (68CD and CD163 positive) showed an inverse relationship with OS and DFS but did not reach statistical significance (p > 0.05). Increased PD-L1 expression in immune cells, but not in tumor cells, was associated with significantly better DFS (p = 0.037). The TME plays a significant role in the prognosis of PCNS-DLBCL. Increased number of CD4+ T cells and PD-L1-expressing immune cells is associated with better prognosis in PCNS-DLBCL. Further studies with larger sample size are required to evaluate the role of targeted therapy against the TME and immune check point inhibitors in this disease.

Profiling of Circulating Tumor DNA for Noninvasive Disease Detection, Risk Stratification, and MRD Monitoring in Patients with CNS Lymphoma

Abstract Introduction: Clinical outcomes for patients with central nervous system lymphoma (CNSL) are remarkably heterogeneous, yet identification of patients at high risk for treatment failure remains challenging with existing methods. In addition, diagnosis of CNSL requires invasive neurosurgical biopsies that carry procedural risks and often cannot be performed in frail or elderly patients. Circulating tumor DNA (ctDNA) has shown great potential as a noninvasive biomarker in systemic lymphomas. Yet, previous studies revealed low ctDNA detection rates in blood plasma of CNSL patients. In this study, we utilized ultrasensitive targeted high-throughput sequencing technologies to explore the role of ctDNA for disease classification, MRD detection, and early prediction of clinical outcomes in patients with CNSL. Methods: We applied Cancer Personalized Profiling by Deep Sequencing (CAPP-Seq) and Phased Variant Enrichment and Detection Sequencing (PhasED-Seq, Kurtz et al, Nat Biotech 2021) to 85 tumor biopsies, 131 plasma samples, and 62 CSF specimens from 92 CNSL patients and 44 patients with other brain cancers or inflammatory cerebral diseases, targeting 794 distinct genetic regions. Concentrations of ctDNA were correlated with radiological measures of tumor burden and tested for associations with clinical outcomes at distinct clinical time points. We further developed a novel classifier to noninvasively distinguish CNS lymphomas from other CNS tumors based on their mutational landscapes in plasma and CSF, using supervised training of a machine learning approach from tumor whole genome sequencing data and own genotyping analyses, followed by its independent validation. Results: We identified genetic aberrations in 100% of CNSL tumor biopsies (n=63), with a median of 262 mutations per patient. Pretreatment plasma ctDNA was detectable in 78% of plasma samples and in 100% of CSF specimens (Fig. 1a), with ctDNA concentrations ranging from 0.0004 - 5.94% allele frequency (AF, median: 0.01%) in plasma and 0.0049 - 50.47% AF (median: 0.62%) in CSF (Fig. 1b). Compared to ctDNA concentrations in patients with systemic diffuse large B-cell lymphoma (DLBCL, data from Kurtz et al., J Clin Oncol, 2018), plasma ctDNA levels in CNSL were in median more than 200-fold lower (Fig. 1b). We observed a significant correlation of ctDNA concentrations with total radiographic tumor volumes (TRTV) measured by MRI (Fig. 1c,d), but no association with clinical risk scores (i.e., MSKCC score) or concurrent steroid treatment. Assessment of ctDNA at pretreatment time points predicted progression-free survival (PFS) and overall survival (OS), both as continuous and binary variable (Fig. 1e,f). Notably, patients could be stratified into risk groups with particularly favorable or poor prognoses by combining ctDNA and TRTV as pretreatment biomarkers (Fig. 1g). Furthermore, ctDNA positivity during curative-intent induction therapy was significantly associated with clinical outcomes, both PFS and OS (Fig. 1h). Finally, we applied our novel machine learning classifier to 207 specimens from an independent validation cohort of CNSL and Non-CNSL patients. We observed high specificity (100%) and positive predictive value (100%) for noninvasive diagnosis of CNSL, with a sensitivity of 57% for CSF and 21% for plasma, suggesting that a significant subset of CNSL patients might be able to forego invasive surgical biopsies. Conclusions: We demonstrate robust and ultrasensitive detection of ctDNA at various disease milestones in CNSL. Our findings suggest that ctDNA accurately mirrors tumor burden and serves as a valuable clinical biomarker for risk stratification, outcome prediction, and surgery-free lymphoma classification in CNSL. We foresee an important potential future role of ctDNA as a decision-making tool to guide treatment in patients with CNSL. Figure 1 Figure 1. Disclosures Esfahani: Foresight Diagnostics: Current holder of stock options in a privately-held company. Kurtz: Genentech: Consultancy; Roche: Consultancy; Foresight Diagnostics: Consultancy, Current holder of stock options in a privately-held company. Schorb: Riemser Pharma GmbH: Honoraria, Research Funding; Roche: Research Funding; AbbVie: Research Funding. Diehn: BioNTech: Consultancy; RefleXion: Consultancy; Roche: Consultancy; AstraZeneca: Consultancy; Foresight Diagnostics: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; CiberMed: Current holder of stock options in a privately-held company, Patents &amp; Royalties; Illumina: Research Funding; Varian Medical Systems: Research Funding. Alizadeh: Foresight Diagnostics: Consultancy, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Gilead: Consultancy; Roche: Consultancy, Honoraria; Celgene: Consultancy, Research Funding; Janssen Oncology: Honoraria; CAPP Medical: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Forty Seven: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Cibermed: Consultancy, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Bristol Myers Squibb: Research Funding.

A Multicenter, Real World Analysis of Primary Central Nervous System Lymphoma in Those with and without Human Immunodeficiency Virus

Introduction: Representing 4% of central nervous system (CNS) tumors, primary CNS lymphoma (PCNSL) is a rare type of extranodal non-Hodgkin lymphoma (NHL) that involves the brain, leptomeninges, eyes, spinal cord or cerebrospinal fluid without evidence of systemic disease. High-dose methotrexate (HD-MTX)-based regimens that incorporate consolidation with reduced dose whole brain radiation therapy (WBRT) or autologous stem cell transplant have shown 2-year overall survival (OS) rates ranging from 69% to 81% (Morris, JCO, 2013; Omuro, Blood, 2015).Although these data are encouraging, patients whose CNS deficits are too severe to receive treatment will die within the first months of diagnosis. HIV PCNSL has been associated with a poorer performance status and worse OS compared to non-HIV PCNSL. With the advent of combination antiretroviral therapy (ART), HIV PCNSL has become less common and by incorporating HD-MTX into HIV PCNSL treatment, outcomes have improved (Gupta, Neuro Oncol, 2017).In this study, we report the real world survival of PCNSL at 3 large academic centers, including those who received HD-MTX versus those who did not. We also compare survival of HIV PCNSL relative to non-HIV PCNSL.Methods: Adult patients (>18 years of age) with PCNSL at 3 medical centers (UNC Chapel Hill, Vanderbilt Medical Center, Emory University) were included in this analysis. Patients were diagnosed between January 2004 and July 2020. Only the diffuse large B-cell lymphoma (DLBCL) histology was included. Cases were excluded if there was any disease outside of the CNS or if they previously had systemic DLBCL. Demographic information was collected from the medical record, as well as disease-related information, HIV status, HD-MTX treatment (defined as >3g/m2) with or without other chemotherapeutic agents, imaging to determine progression, and survival data. Data were analyzed for the entire cohort as well as compared between HIV and non-HIV subjects. Demographic variables were summarized using appropriate statistics (frequencies, mean and standard deviation) and compared between HIV and non-HIV patients using Fisher's exact tests or Wilcoxon rank sum tests. Progression free survival (PFS) and OS were also compared between HIV and non-HIV patients using log-rank tests.Results: We identified 158 cases of PCNSL. The median PFS for the entire cohort was 1.17y and the median OS was 3.24y. Patients who received HD-MTX had an improved PFS (1.69y vs 0.25y; p=0.0016) and an improved OS (4.01y vs 1.05y; p=0.00075) over those who did not receive HD-MTX.Twenty-six of the 158 cases were HIV positive. Table 1 reports clinical features in HIV versus non-HIV PCNSL patients. Patients with HIV PCNSL were significantly younger than those with non-HIV PCNSL (44y vs 75y), and had a worse performance status (PS>2: 57.7% vs 26.8%). Notably, patients with HIV were less likely to receive HD-MTX compared to patients without HIV (53.8% vs 83.3%). Receiving frontline WBRT trended towards significance in favor of the HIV PCNSL group. Other factors such as gender, deep structure involvement, elevated cerebrospinal fluid protein, and elevated lactose dehydrogenase (LDH) were not significantly different between groups.When comparing HIV to non-HIV PCNSL, there was not a statistically significant difference in PFS (0.30y vs 1.34y; p=0.34), but there was a statistically significant difference in OS (0.30y vs 3.65y; p=0.0023) (Figure 1). When comparing those who received HD-MTX in the HIV group vs non-HIV group, there was not a statistically significant difference in PFS (3.39y vs 1.66y; p=0.45) or OS (3.6y vs 4.0y; p=0.43) (Figure 2).Conclusions: Our analysis shows that real-world survival for PCNSL is modest compared to reported outcomes from clinical trials. Patients who are able to receive treatment with HD-MTX had a significantly improved outcome. HIV PCNSL has worse OS than non-HIV PCNSL, and the median PFS and OS were both several months in the HIV PCNSL group, suggesting an unmet need for both frontline and salvage therapies. The survival difference between HIV PCNSL and non-HIV PCNSL decreased when evaluating only those patients who received HD-MTX. Importantly, fewer patients received HD-MTX in the HIV PCNSL group; and these patients had worse PS. These real-world data may serve as the benchmark for survival outcomes in PCNSL and provide valuable information for designing future trials in patients with PCNSL. [Display omitted] DisclosuresDittus: Genentech: Research Funding; AstraZeneca: Research Funding; Seattle Genetics: Research Funding; BeiGene: Other: Advisory Board. Grover: Kite: Other: Advisory Board; ADC: Other: Advisory Board; Novartis: Consultancy; Tessa: Consultancy; Genentech: Research Funding. Cohen: Janssen, Adicet, Astra Zeneca, Genentech, Aptitude Health, Cellectar, Kite/Gilead, Loxo, BeiGene, Adaptive: Consultancy; Genentech, BMS/Celgene, LAM, BioINvent, LOXO, Astra Zeneca, Novartis, M2Gen, Takeda: Research Funding. Park: G1 Therapeutics: Consultancy; Takeda: Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding; Teva: Consultancy, Membership on an entity's Board of Directors or advisory committees; Morphosys: Membership on an entity's Board of Directors or advisory committees; Rafael Pharma: Membership on an entity's Board of Directors or advisory committees, Other: Advisory Board; Seattle Genetics: Research Funding, Speakers Bureau; Gilead: Speakers Bureau.

Clinical characteristics and prognosis of 49 newly diagnosed primary central nervous system diffuse large B-cell lymphoma

目的回顾性分析原发中枢神经系统淋巴瘤中弥漫大B细胞淋巴瘤（PCNSL-DLBCL）患者的临床特征及不同治疗方案对患者生存及预后的影响。方法回顾性分析天津医科大学总医院自2014年7月至2020年12月收治的49例PCNSL-DLBCL患者的临床资料，根据治疗方案分为MTX组、R-CDOP组、BTKi-R-MTX组和RLZT组，计算各组中位总生存（OS）与无进展生存（PFS）时间，并进行单因素、多因素预后分析，比较各组患者的生存预后。结果MTX组、R-CDOP组、BTKi-R-MTX组和RLZT组的中位OS时间分别为16.5个月、4.5个月、42个月和未达到（P<0.001），中位PFS时间分别为7个月、1.5个月、20个月和5个月（P＝0.005）。多因素预后分析表明是否双表达、IESLG评分和治疗方案是PCNSL-DLBCL患者的预后影响因素。结论PCNSL-DLBCL患者的生存预后受治疗方案影响，CD20单抗在PCNSL-DLBCL 治疗中的作用尚有争议，含BTKi的治疗方案有巨大潜力，RLZT方案对于高龄、不耐受大剂量化疗及放疗患者有良好前景。

Multifocal Primary Central Nervous System (CNS) Diffuse Large B-Cell Lymphoma (DLBCL) in a Patient with Aquired Immunodeficiency Syndrome (AIDS)

Abstract Introduction/Objective Primary CNS DLBCL is a rare entity, with an incidence of less than 0.47 per 100,000, however, in immunocompromised patients, especially those with Human Immunodeficiency Virus (HIV-1) infection, the incidence increases dramatically to 2-6 percent. Here we present a case of multifocal DLBCL in a young 28-year-old homeless male with untreated AIDS and polysubstance abuse. Methods/Case Report He presented to the hospital with altered state of consciousness; a Computerized Tomography (CT) scan showed three ring-enhancing masses; one in the left fronto-temporal region, the largest in the left basal ganglia and the third in the cerebellum. The main lesion was biopsied and diagnosed as DLBCL. The patient developed aspiration pneumonia and demised from respiratory failure Results (if a Case Study enter NA) NA Conclusion Coronal sections of the brain revealed a large grey-tan, soft lesion of poorly defined, irregular borders located in the left basal ganglia that measured 5 x 4 x 4 cm, extended dorsally and laterally. A similar lesion was observed in the deep left cerebral hemisphere, affecting the temporal lobe and extending rostrally into the frontal lobe, but completely separate from the tumor in the basal ganglia. A third, much smaller lesion was found in the right cerebellar hemisphere. Histologically, the tumor was composed of sheets of atypical lymphoid cells with increased nuclear to cytoplasmic ratio, increased mitotic activity, and showed scattered areas of necrosis. In the peripheral areas, tumor cells were located in the Virchow Robin space, and in more central areas they have broken into the brain parenchyma. Tumor cells were positive for CD20 and CD79a, indicating their B-cell origin. Other markers positive by immunohistochemistry were PAX5, MUM1 and BCL6 and the Epstein-Barr Virus (EBV) latent membrane protein (LMP). Fluorescence In situ hybridization (FISH) corroborated the presence of Eptein-Barr encoded RNAs.

Targeting Bruton's tyrosine kinase in primary central nervous system lymphoma.

We review the preclinical and clinical experience with first and subsequent generation Bruton's tyrosine kinase inhibitors in B-cell lymphoproliferative diseases, highlighting the rationale for their clinical use in primary central nervous system diffuse large B-cell lymphoma (PCNSL). Growing knowledge on the molecular and genetic profile of PCNSL has provided the basis for new drug development targeting aberrantly activated oncogenic signal transduction pathways. PCNSL exhibits frequent genetic alterations of components of the B-cell and Toll-like receptor signalling pathways. On the basis of these discoveries and the limited efficacy obtained with chemotherapy in refractory and relapsed PCNSL, activity of new targeted agents, such as Bruton's tyrosine kinase inhibitors, has been explored with promising results. Innovative therapeutic strategies, applied in first line, have contributed to improved outcomes in patients with PCNSL, making this disease potentially curable in young and fit patients. However, response to induction therapies remains suboptimal and the best consolidative therapy has yet to be defined. In this regard, given the activity of Bruton's tyrosine kinase inhibitors in the refractory and relapsed PCNSL setting, these agents are currently being explored as part of combination regimens for induction therapy of newly diagnosed PCNSL.

Primary Mediastinal Large B-cell Lymphoma: Diagnostic Challenges and Recent Advances

Primary mediastinal (thymic) large B-cell lymphoma (PMBL) is a subtype of uncommon aggressive large B-cell lymphomas primarily occurring in mediastinum although rare cases with non-thymic type of PMBL have been reported. Typical PMBL has characteristic clinical, morphological, and immunophenotypic features which the pathologists use as diagnostic paradigm in routine practice. However, the diagnosis can be occasionally challenging due to the overlapping clinicopathologic features with other lymphomas, among which are nodular sclerosis classic Hodgkin lymphoma, systemic diffuse large B-cell lymphoma (DLBCL) involving mediastinum, and B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classic Hodgkin lymphoma (gray zone lymphoma). Recent depictions of the characteristic genetic/ molecular aberrations and unique gene expression profiling in PMBL have provided a robust tool to significantly improve the diagnostic accuracy. In addition, the progresses in understanding the pathogenesis of PMBL have paved the way discovering novel therapeutic agents for patients with refractory/relapsed disease.

Primary central nervous system lymphoma in older adults and the rationale for maintenance strategies: a narrative review.

Objective:To provide a summary and analysis of the evidence for various agents applied as maintenance therapy and highlight ongoing trials or trials in development that evaluate the efficacy of maintenance therapy strategies in older patients with primary central nervous system lymphoma (PCNSL).Background:PCNSL are rare neoplasms that can have an aggressive course with short-lived remissions when compared to systemic diffuse large B-cell lymphoma (DLBCL). There is currently a paucity of evidence on treatment in older adults with PCNSL, who may be unfit to tolerate effective therapies for PCNSL. Those who can tolerate these therapies and survive PCNSL are at increased risk from developing treatment-related toxicity, functional decline, and debilitating neurotoxicity. While there is no clearly defined role for maintenance therapy after treatment of systemic DLBCL, it should be considered in PCNSL because central nervous system (CNS) recurrence often has a devastating and irreversible impact on neurologic function. Therefore, at least theoretically, use of effective maintenance therapy in older adults with PCNSL, either in lieu of consolidation or after consolidation therapy, may be better tolerated and help delay tumor progression, resulting in an improved overall global neurologic function and quality of life.Methods:We systematically searched MEDLINE (via PubMed) for all studies of drug treatments for maintenance therapy in PCNSL and also relied on expert opinion. We provide a summary and analysis of the evidence for various maintenance therapy agents, including methotrexate, rituximab, lenalidomide, temozolomide, ibrutinib, and procarbazine. We also highlight ongoing trials or trials in development that evaluate the efficacy of maintenance therapy in PCNSL.Conclusions:Prospective clinical studies focusing on PCNSL patients who are not candidates for intensive post-induction therapy are scarce. To date, there are no studies that clarify whether maintenance therapy can be used in lieu of consolidation therapy with autologous stem cell transplant or radiation. Prospective studies may provide critical data regarding the identification of optimal agents, whether consolidation therapy could be replaced by maintenance therapy, and the overall role of maintenance therapy as a means to potentially improve survival and preserve quality of life and function in a vulnerable, older patient population.

Cell of Origin and Genomic Profile of Primary Central Nervous System Lymphoma Determined Using the Nanostring Lst Assay and Ultra Deep Targeted Next Generation Sequencing

Introduction: Primary central nervous system lymphoma (PCNSL) is characterized by a consistently inferior outcome compared to systemic diffuse large B-cell lymphoma (DLBCL) with a median overall survival of 2-4 years. Therefore, PCNSL represents a significant clinical challenge with an urgent need for better biomarkers and novel therapeutic targets. The distinction of DLBCL into cell of origin (COO) categories based on patterns of gene expression reminiscent of germinal center B-cell (GC-) type, activated B-cell (ABC-) type, with a small number of “unclassified” cases, has profound prognostic and potential therapeutic implications with many novel therapies displaying differential efficacy between the GC and ABC groups. Therefore, the precise determination of COO is becoming increasingly important for the appropriate patient stratification for novel targeted therapies. The NanoString LST assay is a digital gene-expression based test for COO assignment, representing a more accurate means of COO determination compared to standard immunohistochemistry (IHC) based algorithms, and was recently successfully applied in nodal DLBCLs. In the present study, we tested the LST assay on a cohort of PCNSL patients and performed a complementary targeted genomic profiling on a subset of these patients.Methods: The COO of 77 PCNSL patients was determined with the NanoString LST assay using RNAs extracted from FFPE samples and compared with the results obtained by the Hans IHC algorithm. The genomic profiles of 62 PCNSL cases were determined using ultra-deep targeted next generation sequencing (NGS) of 13 recurrently mutated target genes, including CARD11, CCND3, CD79B, CSMD2, CSMD3, IRF4, C-MYC, MYD88, PAX5, PIM1, PRDM1, PTPRD and TP53 using the TruSeq Custom Amplicon approach (dual strand workflow) on a HiSeq4000 Instrument (Illumina) to an average depth of 30.000x. Only variants supported by more than 100 mutant reads with an allele frequency (VAF) of >5% were considered.Results: The LST assay resulted in the following subtype calls: 80.5% ABC, 12.9% GC and 6.5% unclassified (UC). Using the Hans IHC algorithm, 94.8% (73/77) of the PCNSL cases were classified as ABC subtype with 5.2% (4/77) representing the GC subtype. Interestingly, the COO classification obtained using the LST assay showed a different outcome in 16.9% (13/77) of the cases: Out of the 12 cases classified as ABC subtype with the IHC algorithm, 7 cases presented as GC subtype and 5 showed an UC profile using the LST assay. On the other hand, one case characterized as GC subtype with the IHC assay was classified as ABC when analyzed using the LST assay. As for the mutation analysis, we detected a total of 402 somatic mutations in the 62 PCNSL cases across the 13 genes analyzed with individual cases harboring mutations in 4 genes on average (range: 1-11). The most frequently mutated genes were MYD88 (76%), PIM1 (55%) and PRMD1 (50%). The mutation frequencies in the remaining genes were as follows: CD79B (40%), PTPRD (32%), MYC (31%), PAX-5 (31%), CARD11 (26%), TP53 (26%), IRF4 (23%), CCND3 (19%), CSMD2 (19%) and CSMD3 (18%). Analyzing the mutation profiles of the ABC and GC subtypes, we observed an enrichment of CD79B (47% vs 20%) and PIM1 (59% vs 20%) in cases with ABC subtype, with IRF4 mutations being present in ABC cases only (29% vs 0%). None of the other genes demonstrated a considerable difference between the GC and ABC subtypes with regards to the mutation frequency.Conclusions: We successfully applied, for the first time, the NanoString LST assay for COO determination using FFPE derived RNA samples from a cohort of 77 PCNSL patients. Interestingly, the LST assay revealed a lower proportion of patients with ABC subtype compared our IHC findings (80.5% vs 94.8%). This may reflect the genuine biology of these cases, as the NanoString LST assay represents the most reliable COO determination approach compared to the original gold standard GEP method. The frequent mutations revealed in components of different actionable pathways including the BCR pathway, cell cycle regulation and CNS development highlights the role of these variants in the pathogenesis of PCNSL. Considering the emergence of novel therapies with selective activity in the GC and ABC patient groups the precise assignment of COO and the complementary mutation analysis will most likely have an important role in guiding the appropriate patient management in PCNSL. DisclosuresStorhoff:NanoString Technologies: Employment, Equity Ownership. Ghali:NanoString Technoliges: Employment.

The Impact of EBV upon the Tumor Microenvironment and Mutational Profile of Primary CNS Lymphoma in PTLD

Primary CNS Lymphoma (PCNSL) with diffuse large B-cell lymphoma (DLBCL) histology occurring after organ transplantation (EBV+ PCNSL-PTLD) is characterized by extremely poor outcome, almost universal EBV-positivity and late presentation relative to systemic PTLD (Fink, AJT 2012; Evens, AJT 2013). However, as the incidence is low and biopsy material limited, characterization of its immunobiology is minimal. Furthermore, there is no comparative data with EBV+ DLBCL occurring as systemic PTLD (EBV+ syDLBCL-PTLD), or with EBV-ve DLBCL in the non-PTLD setting occurring either as PCNSL (EBV-ve PCSNL) or systemically (EBV-ve syDLBCL).Here, we outline results of a detailed comparison of the genetic landscape and tumor microenvironment (TME) between PCSNL and systemic DLBCL (syDLBCL), stratified by EBV and PTLD status. A combination of targeted sequencing (involving NFk-B, immune response, cell cycle and epigenetic genes), CNV analysis, nanoString gene expression (for macrophage, immune checkpoint and effector molecules), and in-vitro assays was employed. 191 adult patients with DLBCL (13 EBV+ PCNSL-PTLD; 27 EBV-ve PCNSL; 11 EBV+ syDLBCL-PTLD; and 140 EBV-ve syDLBCL) were included, with 16 non-malignant lymph nodes as controls.EBV+ PCNSL-PTLD was typically viral latency III. In EBV-ve PCNSL, in broad agreement with previous studies (Gonzalez-Aguilar, CCR 2012; Chapuy, Blood 2015; Fukumura, Acta Neuropath 2016; Nakamura, Neuropath Appl Neurobiol 2016), common nonsynonymous mutations in known cancer drivers were PIM1 (76%), MYD88 (72%), CD79B (68%), TBL1XR1 (48%), KMT2D (44%), TOX (28%), PRDM 1 (24%), EP300, CREBBP1 and CIITA (all 20%). Interestingly, the mutation rate in EBV-ve PCNSL was considerably higher than in EBV+ PCNSL-PTLD, and was also higher than EBV-ve syDLBCL and EBV+ syDLBCL-PTLD.In line with previous reports, there was high occurrence of CN loss at the HLA-class I/II loci (Riemersma, Blood 2000) in EBV-ve PCNSL. However, this was relatively infrequent in EBV+ PCNSL-PTLD and EBV+ syDLBCL-PTLD, and intermediate in EBV-ve syDLBCL. To investigate the TME gene expression profile, a selection of immune effector and checkpoint genes were quantified in combined PCNSL cases and compared to syDLBCL i.e. irrespective of viral status. CD4 and CD8 levels were similar in PCNSL vs. sysDLBCL, whereas the NK cell marker CD56 was 9-fold higher in PCNSL (p<0.0001). A key feature was that the immune activation marker CD137 was 2-fold higher in syDLBCL than PCNSL (p<0.0001), indicative of reduced immune effector function in PCNSL. Consistent with this, there was a 6-fold increase in the M2 immunosuppressive tumor-associated macrophage marker CD163 in PCNSL vs. syDLBCL (p<0.0001). Furthermore, CD4 and CD8 correlated with CD163, suggesting an adaptive immune response in which the malignant B-cell up-regulates M2 macrophages to evade immune surveillance. To test this, healthy monocytes were co-incubated with a PCNSL cell-line. This resulted in the elevated expression of CD163+, PD-L1+ and PD-L2+ M2 polarized monocyte/macrophages in PCNSL relative to a syDLBCL control cell-line (all ≥7-fold, p<0.0001), confirming the differential impact of PCNSL to upregulate immunosuppressive monocyte/macrophages.Next, differences between the TME in EBV-ve PCNSL and EBV+ PCNSL-PTLD were examined. PD-1 levels were similar. However, consistent with our previous findings in EBV+/-ve Hodgkin Lymphoma, levels of CD163 (Jones, CCR 2012) and LAG3 (Gandhi, Blood 2006) genes were both 4-fold higher in EBV+ PCNSL-PTLD biopsies than EBV-ve PCNSL (both p≤0.005). Furthermore, both PD-L1 and PD-L2 were 7-fold and 3-fold higher in EBV+ PCNSL-PTLD than EBV-ve PCNSL respectively (both p<0.005). These data implicate EBV as a major determinant of the TME within the CNS.Combined, these results indicate that ‘immune privilege’ occurring in the context of lymphoma within the CNS is more accurately described as an adaptive immune response in which the malignant B-cell actively utilizes a variety of mechanisms to evade immune surveillance (Fig 1). For EBV+ PCNSL-PTLD this involves up-regulation of PD-L1+/PD-L2+ M2 monocyte/macrophages and LAG3, whereas with EBV-ve PCNSL the emphasis is on genetically mediated immune evasion including loss of HLA-I/II loci. The findings will help guide the rational design of novel immunotherapeutic strategies for EBV+ PCNSL-PTLD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.