双表达DLBCL相关临床试验

Abstract Double-expressor lymphoma (DEL) is a newly identified special subtype of diffuse large B-cell lymphoma (DLBCL), which is predominantly found in the activated B-cell-like (ABC) subtype of DLBCL. Characterized by concurrent overexpression of BCL2 and MYC, DEL is associated with poorer prognosis. Standard chemoimmunotherapy can achieve clinical cure in nearly 70% of DLBCL cases. DEL mainly presents with intermediate-to-high-risk international prognostic index scores, advanced stage at diagnosis, and may involve specific chromosomal rearrangements, mainly influencing older patients. These factors are interconnected and contribute to less favorable treatment outcomes. We review emerging drugs and clinical trial data potentially effective against DEL, formulating treatment recommendations based on evidence levels to provide a theoretical foundation for the clinical treatment of DEL.

Double‐expressor lymphoma (DEL) has a poorer prognosis than other subtypes of diffuse large B‐cell lymphoma (DLBCL). This study is a multicenter, prospective, single‐arm, phase 2 clinical study initiated by investigators to evaluate the efficacy and safety of combined zanubrutinib with R‐CHOP, which includes rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone for patients with DEL (stage II or more), as well as to explore factors related to efficacy preliminarily.

7012 Background: DLBCL with expression of MYC and BCL2 (double expressor lymphoma, DEL), has an adverse prognosis. Venetoclax, an inhibitor of BCL2, was previously studied in combination with R-CHOP. A051701 is a phase II/III randomized trial of chemoimmunotherapy +/- venetoclax in DEL and double hit lymphoma cohorts. Here we report initial phase II results from the DEL cohort. Methods: Patients (pts) age ≥ 18 years (y) with untreated DEL were randomized 1:1 to R-CHOP (Arm 1) or R-CHOP-venetoclax (Arm 2). DEL was defined as MYC expression ≥40% and BCL2 expression ≥50%, without double hit cytogenetics. Enrollment was based on local pathology results that were centrally confirmed. Venetoclax 800 mg was given orally days 4-8 of cycle 1 and days 1-5 of subsequent cycles for up to 6 cycles. All cycles were supported by GCSF or peg-GCSF. The primary endpoint was progression-free survival (PFS) with 84% power to detect a HR of 0.518 corresponding to 2y PFS rate of 65% in Arm 1 and 80% in Arm 2 (1-sided α=0.20). Results: 119 DEL pts were enrolled: 60 Arm 1; 59 Arm 2. Analyses were performed for the modified intent-to-treat population, defined as eligible pts with confirmed DEL histology (n=113; 56 Arm 1, 57 Arm 2). Median age was 64 y (range 22-85); baseline demographic factors were well balanced except for advanced stage (more common in Arm 1; (77% vs 60%, p=0.051). Most pts were non-germinal center B cell-like by immunohistochemistry (Arm 1 72%, Arm 2 58%), high-intermediate/high risk IPI (Arm 1 54%, Arm 2 51%) and ECOG performance status 0-1 (Arm 1 95%, Arm 2 86%). BCL2 rearrangements were detected in 25% and 33% of pts on Arm 1 and Arm 2, respectively. Most pts completed therapy per protocol (84% Arm 1, 75% Arm 2). Median follow up is 27 months (m). No difference in PFS was observed with 12-m PFS estimates of 77% in Arm 1, 76% in Arm 2 [HR = 0.98 (95% CI: 0.48 – 2.01), p=0.95]. The end of treatment (EOT) overall and complete response rates among patients with an EOT assessment were 87.5% and 70% in Arm 1, and 90% and 82% in Arm 2. Overall survival (OS) was not statistically significantly different with 12-mo OS estimates of 94% in Arm 1 and 79% in Arm 2 [HR = 1.27 (95% CI: 0.57 – 2.79), p=0.56]. Grade ≥3 adverse events (AEs) occurred more frequently in Arm 2 (42% vs 76%). The most commonly increased grade ≥3 AEs included neutropenia (20% vs 47%), anemia (4% vs 25.5%), thrombocytopenia (5.5% vs 24%), febrile neutropenia (7% vs 16%) and fatigue (0% vs 11%). No grade 5 AEs on treatment were reported on Arm 1, and 3 were reported on Arm 2 (lung infection and sudden death NOS, both possibly related; respiratory failure, unlikely related). Conclusions: Adding venetoclax to R-CHOP in DEL pts did not improve PFS and resulted in increased toxicity. The study did not meet its primary endpoint in phase II, and so did not proceed to phase III. Clinical trial information: NCT03984448 .

Dear editor, Diffuse large B-cell lymphoma (DLBCL) stands as the predominant subtype of non-Hodgkin ’ s lymphoma (NHL) among adults, accounting for 30 – 40% of cases globally. Apart from its marked invasiveness, DLBCL demonstrates signi fi cant heterogeneity across various parameters, including cellular origin, morphological characteristics, immunohistochemical phenotype, cellular molecular genetics, sites of occurrence within and outside lymph nodes, response to chemotherapy, and survival rates [1]. Double expressor diffuse large B-cell lymphoma (DE-DLBCL) is a distinct subtype characterized by heightened expression of MYC ( ≥ 40%) and BCL-2 (the cut-off varied considerably in the literature, but a fi gure of ≥ 50% is recommended) as determined by immunohistochemistry (IHC) [2]. DE-DLBCL currently lacks standardized treatment regimens. Compared to non-double-expressor DLBCL, DE-DLBCL patients exhibit inferior outcomes when treated with standard immunochemotherapy [3]. Notably, a review of outcomes revealed markedly lower 5-year overall survival rates (OS) and progression-free survival rates (PFS) for DE-DLBCL, at 36% and 32%, respectively, in stark contrast to those observed for non-double-expressor DLBCL (71% and 65%) [4]. Furthermore, investigations indicated that the application of the R-CHOP regimen in DE-DLBCL treatment resulted in a 2-year PFS rate of approximately 54% [5]. While more intensive chemotherapy regimens such as DA-EPOCH-R, R-hyperCVAD alternating with MTX/cytarabine, and cyclophosphamide,

Background Double-expressor lymphoma (DEL), defined by concurrent MYC and BCL2 protein overexpression in diffuse large B-cell lymphoma (DLBCL), is associated with poor prognosis, but precise risk quantification and optimal treatments remain unclear. Methods We conducted a two-stage evidence synthesis. First, a systematic review and meta-analysis quantified hazard ratios for progression-free survival (PFS) and overall survival (OS) comparing DEL with non-DEL and identified prognostic factors within DEL. Second, a network meta-analysis ranked the efficacy and safety of regimens including rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP); dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin plus rituximab (DA-EPOCH-R); R-CHOP plus lenalidomide (R2-CHOP); R-CHOP plus ibrutinib (I+R-CHOP); R-CHOP plus zanubrutinib (Z+R-CHOP); and R-CHOP plus venetoclax (Ven-R-CHOP). Results In 66 studies (9,808 patients), DEL was significantly associated with inferior PFS (hazard ratio 1.78, 95% confidence interval 1.50–2.10) and OS (1.90, 1.68–2.15). Within DEL, high International Prognostic Index, advanced age, elevated lactate dehydrogenase, B symptoms, and advanced stage predicted inferior PFS and OS; TP53 mutation and poor Eastern Cooperative Oncology Group performance status predicted inferior OS. In 13 treatment studies (1,803 patients), Z+R-CHOP and Ven-R-CHOP showed the highest efficacy. Z+R-CHOP demonstrated favorable hematological toxicity compared with other novel regimens. Conclusion DEL is a distinct high-risk subtype with quantifiable prognostic detriment. Z+R-CHOP emerges as a promising strategy requiring validation in prospective studies.

Emerging biologic subsets and new prognostic markers are significantly and adversely affecting curability after standard chemoimmunotherapy for aggressive B‐cell lymphomas. The identification of concurrent MYC and B‐cell CLL/lymphoma 2 (BCL2) deregulation, whether at a genomic or protein level, has opened a new era of investigation within the most common subtype of aggressive B‐cell lymphomas. Double‐hit lymphoma (DHL), defined as a dual rearrangement of MYC and BCL2 and/or B‐cell CLL/lymphoma 6 (BCL6) genes, is an uncommon subset accounting for 5% to 7% of all diffuse large B‐cell lymphomas (DLBCLs), and long‐term survivors are rare. Double‐expressor lymphoma (DEL), defined as overexpression of MYC and BCL2 proteins not related to underlying chromosomal rearrangements, is not a distinct entity in the current World Health Organization classification but accounts for 20% to 30% of DLBCL cases and also has poor outcomes. There are many practical considerations related to identifying, determining the prognosis of, and managing DHL and DEL.

Double-hit (DHL) and double expressor (DEL) DLBCL have poor prognosis with standard therapy but CART may overcome this poor prognostic impact. In this multicenter retrospective study, we sought to confirm this observation by evaluating survival outcomes among patients with relapsed/refractory DHL and DEL treated with CART and evaluate outcomes of relapse post-CART. A total of 408 adult patients with relapsed/refractory DLBCL from 13 academic centers were included based on the availability of DHL and DEL. All 408 patients were included in the DHL (n = 80) vs non-DHL (n = 328) analysis, while 333 patients were included in the analysis of DHL (n = 80) vs DEL (n = 74) vs non (n = 179). On MVA, there were no differences for PFS for DHL vs non-DHL (HR 0.8, 95%CI 0.5–1.3, p = 0.35) or DHL vs DEL vs other (three-way p value, p = 0.5). Response rates and toxicities were similar among groups. Patients with DEL had the highest relapse rates post-CART, while DHL had the worst overall survival after CART relapse. In sum, our data support the notion that CART cell therapy can overcome the poor prognostic impact of DHL and DEL DLBCL in the relapsed/refractory setting. Additionally, patients with DHL that relapse after CART have a very poor prognosis.

"Double-hit" and "double-expressor" lymphomas represent distinct but overlapping subsets of aggressive B-cell non-Hodgkin lymphoma. The high rates of bone marrow involvement by these lymphomas pose a major therapeutic challenge due to the chemotherapy-resistant nature of the bone marrow microenvironment and the limited utility of rituximab-based salvage regimens in patients with relapsed/refractory disease. Preclinical studies utilizing high-dose cyclophosphamide in combination with the anti-CD52 monoclonal antibody alemtuzumab have recently shown promise in the treatment of intramedullary disease, and a Phase I human trial is now underway. In support of such efforts, here we perform CD52 target validation on a series of double-hit (n = 40) and double-expressor (n = 58) lymphomas using immunohistochemistry. CD52 expression levels varied considerably across samples, however positive staining was observed in 75% of both double-hit and double-expressor lymphomas. Similarly, high levels of CD52 expression were seen in patients whose disease was associated with high-risk clinical features, including primary refractory status (73%), higher IPI score (76%), and bone marrow involvement (74%). CD52 expression was not significantly correlated with diagnostically relevant pathologic features such as morphology, cytogenetic findings or other immunophenotypic features, but was notably present in all cases lacking CD20 expression (n = 6). We propose that CD52 expression status be evaluated on a case-by-case basis to guide eligibility for clinical trial enrollment.

… Some cases that have a similar clinical course with concomitant overexpression of MYC or … double-hit lymphomas (ie, double-protein-expression lymphomas [DPLs]). The …

Simple Summary Diffuse large B-cell lymphoma (DLBCL) with co-expression of MYC and BCL2 proteins is referred to as double expressor lymphoma. Multiple studies have identified double expressor status to be an adverse predictive factor for response to standard chemotherapy regimens. The revised 2016 WHO classification recommends cutoff values of 40% for MYC and 50% for BCL2 protein expression; however, actual cutoff values have varied widely among published studies. Increasing recognition of the potential prognostic value of double expressor status prompted this systematic review and meta-analysis of the worldwide literature. Our findings indicate that approximately 23% of de novo DLBCL tumors express both MYC and BCL2 proteins above the indicated thresholds. Remarkably, different immunohistochemical cutoff values did not significantly affect the proportion of tumors attaining double expressor status. Cases lacking MYC/BCL2 co-expression were associated with a significantly higher probability of complete remission, thereby reaffirming the value of this predictive biomarker. Abstract MYC/BCL2 protein co-expression (i.e., double expressor) has been shown to be a negative predictor of outcome in diffuse large B-cell lymphoma (DLBCL). We aimed to establish the incidence of double expressor status in patients with de novo DLBCL and identify the predictive value of this biomarker on treatment response through systematic review and meta-analysis. PubMed and Embase were searched for studies published through December 2019 that reported proportions of double expressor DLBCL. The pooled proportions of MYC and BCL2 expression, both alone and in combination, were computed using the inverse variance method for calculating weights and by the DerSimonian–Laird method. The pooled odds ratios (ORs) of complete remission (CR) rate were calculated, and meta-regression analysis was conducted to explore heterogeneity. Forty-one studies (7054 patients) were included. The pooled incidence of double expressor status in DLBCL was 23% (95% confidence interval [CI], 20–26%), with an adjusted estimate of 31% (95% CI, 27–36%). Neither MYC/BCL2 protein cutoff values, race, mean, or median age of included patients, or overall study quality was a significant factor of heterogeneity (p ≥ 0.20). Cases without double expressor status demonstrated a higher probability of CR to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone treatment (OR, 2.69; 95% CI, 1.55–4.67). Our results reaffirm the predictive power of this important biomarker.

A 60-year-old female presented with abdominal pain and distension. Following computed tomography scans of the abdomen and pelvis, she was taken urgently to the operating room, with the belief that she had appendicitis with perforation. At laparotomy, the findings were consistent with an ovarian carcinoma; there was extensive infiltration of the ovary, bowel, and omental deposits. Cytoreductive surgery was performed including total abdominal hysterectomy and bilateral salpingo-oophorectomy. The final pathology, however, revealed infiltration with medium-sized atypical lymphoid cells positive for CD20, CD10, MYC, BLC2, and BCL6 by immunohistochemistry. MYC and BCL2 translocations were identified by fluorescence in situ hybridization consistent with a diagnosis of high-grade B-cell lymphoma with rearrangements of MYC and BCL2. With the current data available, what is the optimal treatment of this patient?

… Double-expressor lymphomas (DELs) are DLBCLs … study, we evaluated the prognostic impact of DEL and DHL status in patients with rel/ref aggressive B-cell non-Hodgkin lymphoma …

Background Double-expressor lymphoma (DEL) was found to account for 20–30% of DLBCL. We conducted this study to analyze the survival, the clinical presentation, and the factors associated with treatment outcomes in DEL-DLBCL. Methods A retrospective study of 291 patients diagnosed with DLBCL during January 2015 – December 2018 was conducted. Results Of the 291 patients, the median age was 63 years, germinal center B cell-like DLBCL (GCB) and non-GCB subtypes were found in 32% and 68%, respectively. DEL was found in 46% of 264 patients with available immunohistochemistry staining for MYC protein. Patients with DEL was significantly more common in elderly patients (p= 0.017) and non-GCB subtype (p= 0.006). High serum lactate dehydrogenase (LDH) levels and high Ki-67 index were significantly found in DEL patients than non-DEL patients (p= 0.024 and p= 0.04, respectively). The 3y-OS rate was shorter in the DEL group than in the non-DEL group, 58.7% versus 78.9% (p=0.026), whereas no significant difference in 3y-DFS was identified between these groups (58.4% versus 67.7%, p= 0.343). Independent factors affecting OS and DFS in DEL patients were ECOG 3–4, high LDH levels, extranodal involvement> 1 site, high IPI, and stage III-IV in univariate analysis. Conclusions High incidence of DEL was observed in this study, especially in patients aged 60 years or older and non-GCB subtype. Patients with DEL showed dismal DFS and OS.

Double-expressor lymphoma (DEL) is a diffuse large B cell lymphoma that exhibits co-expression of MYC and BCL2 proteins by immunohistochemistry. Patients with double-expressor lymphoma have a poor prognosis after standard chemoimmunotherapy or after high-dose chemotherapy with autologous transplantation, but the prognostic impact of DEL after allogeneic hematopoietic cell transplantation has not been well characterized. We retrospectively analyzed 60 consecutive patients with de novo diffuse large B cell lymphoma or transformed follicular lymphoma who underwent allogeneic transplantation at our center and had available immunohistochemistry data. Thirty-seven patients (62%) had DEL. The 2-year progression-free and overall survival rates were lower in patients with DEL than in those without DEL (20% versus 78%; overall P <.001 and 46% versus 77%; overall P = .016, respectively). The cumulative incidence of disease progression at 2 years was higher in patients with DEL (60% versus 13%; overall P = .005). The cumulative incidence of nonrelapse mortality did not differ statistically in the 2 groups. Even in patients with DEL and chemosensitive disease at transplantation, the 2-year progression-free survival rate was only 27% due to early disease progression. Multivariate analysis showed associations between DEL and increased risks of progression-free survival events (hazard ratio [HR], 4.58; 95% confidence interval [CI], 2.07-10.2; P <.001), overall mortality (HR, 2.29; 95% CI, 1.03-5.09; P = .042) and disease progression (HR, 3.60; 95% CI, 1.38-9.44; P = .009). Patients with DEL had poor outcomes after allogeneic transplantation. Innovative strategies are needed to improve outcomes in this population.

… A novel lymphoma-associated macrophage interaction signature (LAMIS) provides robust risk prognostication in diffuse large B-cell lymphoma clinical trial cohorts of the DSHNHL. …

… of this study were to apply the Lymph2Cx COO assay in two clinical trials and to correlate the results to DE status and clinical … This study, which tested the assay in two large prospective, …

Key Points • In the PHOENIX trial, the addition of ibrutinib to R-CHOP did not improve the survival of patients with previously untreated non-GCB DLBCL.• This study identified a patient subset with high BCL2/MYC coexpression using RNA sequencing, with improved EFS after R-CHOP with ibrutinib.

Introduction In the phase 3, double-blind, placebo (pbo)-controlled PHOENIX trial (NCT01855750), 838 patients (pts) with non-germinal center B-cell-like (non-GCB) diffuse large B-cell lymphoma (DLBCL) were randomized 1:1 to ibrutinib (IBR; 560 mg/day orally) + rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or pbo + R-CHOP. IBR + R-CHOP did not improve event-free survival (EFS) in the intent-to-treat (ITT) non-GCB population (hazard ratio [HR] 0.934; 95% confidence interval [CI], 0.726-1.200). However, in an exploratory analysis, pts < 60 years benefited from the addition of IBR (HR 0.579; 95% CI, 0.380-0.881 for EFS), whereas pts ≥ 60 years did not (HR 1.228; 95% CI, 0.887-1.699 for EFS) due to increased toxicity and reduced R-CHOP exposure. Based on evidence that co-expression of BCL2 and MYC by immunohistochemistry (IHC) have a worse outcome with R-CHOP, we examined their clinical prognostic effect in the 2 arms of the PHOENIX trial. Methods Pretreatment formalin-fixed paraffin-embedded biopsy samples were collected. RNA was extracted and profiled with Illumina RNAseq. Raw sequence reads were aligned to the hs37d5 genome build with STAR v2.5.1b, and gene-level quantification was conducted using RSEM v1.2.23. The median transcript per million mapped reads (TPM) values for BCL2 and MYC gene expression across all pts with RNAseq data (n = 766) were used as the cutoffs between high and low expression for each gene. BCL2 IHC data were available from 184 pts, and based on these, the threshold expression value from RNAseq data that could best approximate positive calls from IHC (≥ 50% lymphoma cells positive) was determined. This threshold value was very close to the median level calculated above and therefore supported the use of the median expression levels as the cutoffs to define high and low expressors in the subsequent analyses. The relationship between expression by RNAseq and survival (EFS, overall survival [OS]) in the 2 study arms was analyzed by Kaplan-Meier estimate with Cox regression to determine HRs and log-rank testing to assess significance. Results Based on a cutoff at the median TPM value, the percentage of non-GCB pts with BCL2-high + MYC-high (n = 234, 30.5%) was consistent with previous literature. In the IBR + R-CHOP (n = 386) and pbo + R-CHOP (n = 380) arms, respectively, 123 (31.9%) and 111 (29.2%) pts were MYC-high + BCL2-high by RNAseq. In the pbo + R-CHOP arm, pts with MYC-high + BCL-2-high had worse EFS (HR 1.820; 95% CI, 1.264-2.620; p = 0.0011) and OS (HR 1.662; 95% CI, 1.014-2.724; p = 0.0415) versus those with low expression of 1 or both markers in the ITT population (Figure), consistent with known poor outcomes associated with these genes. However, there was no difference in outcome for high versus low expression of these genes in the IBR + R-CHOP arm in the ITT population. In the ITT population, pts with MYC-high + BCL2-high had better EFS (HR 0.648; 95% CI, 0.423-0.993; p = 0.045) with IBR + R-CHOP versus pbo + R-CHOP, but there was no significant difference in OS (HR 0.783; 95% CI, 0.446-1.372; p = 0.39; Figure). We also examined the outcome of the 97 (30.6%) pts < 60 years of age (n = 317) with MYC-high + BCL2-high and observed an improved EFS and OS with IBR + R-CHOP versus pbo + R-CHOP (HR 0.393; 95% CI, 0.198-0.780; p = 0.0056 for EFS; HR 0.191; 95% CI, 0.055-0.666; p = 0.0037 for OS; Figure). There was no significant difference in EFS or OS in pts < 60 years with MYC-low + BCL2-low or in pts ≥ 60 years with MYC-high + BCL2-high in the 2 arms. Conclusions In this exploratory analysis, IBR was associated with improved EFS in combination with R-CHOP compared with pbo + R-CHOP in pts with MYC-high + BCL2-high expression in the ITT (non-GCB) population, without a significant improvement in OS. In pts aged < 60 years, both EFS and OS were significantly better with IBR, while there was no significant difference in older pts. These data suggest that IBR + R-CHOP may particularly benefit pts with MYC-high + BCL2-high-expressing lymphomas, a hypothesis warranting further testing in other DLBCL cohorts. Johnson: Novartis: Honoraria; Genmab: Honoraria; Kite: Honoraria; Celgene: Honoraria; Takeda: Honoraria; Bristol-Myers Squibb: Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Epizyme: Honoraria, Research Funding; Incyte: Honoraria; Boehringer Ingelheim: Honoraria. Balasubramanian:Janssen: Employment; Johnson & Johnson: Equity Ownership; Gilead Sciences: Equity Ownership; Celgene: Equity Ownership; Vertex: Equity Ownership; AbbVie: Equity Ownership. Hodkinson:Janssen: Employment. Schaffer:Johnson & Johnson: Equity Ownership; Janssen: Employment. Parisi:Janssen: Employment. Shreeve:Johnson & Johnson: Equity Ownership; Janssen: Employment. Sun:Janssen: Employment; Johnson & Johnson: Equity Ownership. Vermeulen:Johnson & Johnson: Equity Ownership; Janssen: Employment. Sehn:Abbvie: Consultancy, Honoraria; Merck: Consultancy, Honoraria; Merck: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; F. Hoffmann-La Roche/Genentech: Consultancy, Honoraria, Research Funding; F. Hoffmann-La Roche/Genentech: Consultancy, Honoraria, Research Funding; Seattle Genetics: Consultancy, Honoraria; TEVA Pharmaceuticals Industries: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Janssen-Ortho: Honoraria; TEVA Pharmaceuticals Industries: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; TG Therapeutics: Consultancy, Honoraria; TG Therapeutics: Consultancy, Honoraria; Kite Pharma: Consultancy, Honoraria; Lundbeck: Consultancy, Honoraria; Kite Pharma: Consultancy, Honoraria; Acerta: Consultancy, Honoraria; Astra Zeneca: Consultancy, Honoraria; Acerta: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Astra Zeneca: Consultancy, Honoraria; Janssen-Ortho: Honoraria; Lundbeck: Consultancy, Honoraria. Staudt:Nanostring: Patents & Royalties. Younes:AstraZeneca: Research Funding; Biopath: Consultancy; Genentech: Research Funding; Pharmacyclics: Research Funding; Syndax: Research Funding; BMS: Research Funding; HCM: Consultancy; Epizyme: Consultancy, Honoraria; Xynomics: Consultancy; Roche: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria; Janssen: Honoraria, Research Funding; Curis: Honoraria, Research Funding; Merck: Honoraria, Research Funding; Abbvie: Honoraria; Takeda: Honoraria.

… MYC and BCL2 rearrangements were more frequently observed in GCB-DLBCL and BCL6 … The number of ongoing clinical trials attests to the search for novel targeted agents tailored …

7517 Background: Overexpression of BCL2 and MYC, and translocation of MYC, BCL2, and BCL6, are associated with poorer outcomes in patients (pts) with DLBCL (Horn et al. Blood 2013). We previously reported progression-free survival (PFS) from POLARIX in subgroups of pts with DLBCL receiving Pola-R-CHP or R-CHOP, including pts with double expressor lymphoma (DEL; favoring Pola-R-CHP: hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.42–0.97), and double- or triple-hit lymphoma (DHL/THL; favoring R-CHOP: HR 3.81, 95% CI 0.82–17.64) (Tilly et al. NEJM 2022). In this prespecified exploratory analysis, we further analyzed immunohistochemistry (IHC) expression status of BCL2, MYC, and rearrangements (R) of BCL2, BCL6 and MYC as independent prognostic markers. We also explored the prognostic impact of DEL within treatment arms. Methods: BCL2 and MYC protein expression were assessed by IHC and identified as IHC+ (≥50% [BCL2]/≥40% [MYC]) or IHC−; MYC-R, BCL2-R, and BCL6-R were detected by fluorescence in situ hybridization (Tilly et al. NEJM, 2022). Exploratory multivariate Cox regression models were adjusted for treatment, stratification factors (IPI, bulky disease, geographic region), age >60 years, cell of origin, and biomarker evaluated, as appropriate. Results: The prevalence, univariate HR, and 2-year (yr) PFS estimates of BCL2+/MYC+ and BCL2-R/ MYC-R/ BCL6-R subgroups are presented (Table) except for BCL6-R, because all 4 PFS events in this subgroup were with Pola-R-CHP. Multivariate analyses results for Pola-R-CHP vs R-CHOP in pts with BCL2+ (HR 0.60, 95% CI 0.43–0.86) and in pts with MYC+ (HR 0.63, 95% CI 0.45–0.89) were similar to results of univariate analyses. Multivariate analyses of other subgroups were not performed due to the low pt number with BCL2-R/ MYC-R/ BCL6-R. While pts with DEL treated with Pola-R-CHP had improved PFS vs pts treated with R-CHOP (HR 0.64, 0.42–0.97), the prognostic impact of DEL vs non-DEL was more pronounced with R-CHOP (univariate HR 1.53, 95% CI 1.06–2.21; multivariate HR 1.29, 95% CI 0.88–1.91) vs Pola-R-CHP (univariate HR 1.10, 95% CI 0.72–1.69; multivariate HR 1.42, 95% CI 0.89–2.28). Conclusions: Multivariate analyses support the benefit of Pola-R-CHP in pts with BCL2+ and MYC+ DLBCL. The poor prognostic impact associated with DEL appears reduced in Pola-R-CHP- vs R-CHOP-treated pts. Clinical trial information: NCT03274492. [Table: see text]

The objective of this study was to create a bioclinical model, based on clinical and molecular predictors of event-free and overall survival for relapsed/refractory diffuse large B-cell lymphoma patients treated on the Canadian Cancer Trials Group (CCTG) LY12 prospective study. In 91 cases, sufficient histologic material was available to create tissue microarrays and perform immunohistochemistry staining for CD10, BCL6, MUM1/IRF4, FOXP1, LMO2, BCL2, MYC, P53 and phosphoSTAT3 (pySTAT3) expression. Sixty-seven cases had material sufficient for fluorescent in situ hybridization (FISH) for MYC and BCL2. In addition, 97 formalin-fixed, paraffin-embedded tissue samples underwent digital gene expression profiling (GEP) to evaluate BCL2, MYC, P53, and STAT3 expression, and to determine cell-of-origin (COO) using the Lymph2Cx assay. No method of determining COO predicted event-free survival (EFS) or overall survival (OS). Factors independently associated with survival outcomes in multivariate analysis included primary refractory disease, elevated serum lactate dehydrogenase (LDH) at relapse, and MYC or BCL2 protein or gene expression. A bioclinical score using these four factors predicted outcome with 3-year EFS for cases with 0–1 vs. 2–4 factors of 55% vs. 16% (P<0.0001), respectively, assessing MYC and BCL2 by immunohistochemistry, 46% vs. 5% (P<0.0001) assessing MYC and BCL2 messenger ribonucleic acid (mRNA) by digital gene expression, and 42% vs. 21% (P=0.079) assessing MYC and BCL2 by FISH. This proposed bioclinical model should be further studied and validated in other datasets, but may discriminate relapsed/refractory diffuse large B-cell lymphoma (DLBCL) patients who could benefit from conventional salvage therapy from others who require novel approaches. The LY12 study; clinicaltrials.gov Identifier: 00078949.

High-grade B-cell lymphomas (HGBLs) with MYC and BCL2 and/or BCL6 rearrangements, so-called “double-hit” lymphomas (HGBL-DH), are aggressive lymphomas that form a separate provisional entity in the 2016 revised World Health Organization Classification of Lymphoid Tumors. Fluorescence in situ hybridization (FISH) will be required to identify HGBL-DH and will reclassify a subset of diffuse large B-cell lymphomas (DLBCLs) and HGBLs with features intermediate between DLBCL and Burkitt lymphoma into this new category. Identifying patients with HGBL-DH is important because it may change clinical management. This poses a challenge for centers that may not be ready to handle the additional workload and financial burden associated with the increase in requests for FISH testing. Herein, we review the mechanisms of deregulation of these oncogenes. We identify the factors associated with a poor prognosis and those that can guide diagnostic testing. Restricting FISH analysis to the 10% of DLBCL patients who have a germinal center B-cell phenotype and coexpress MYC and BCL2 proteins would be cost-effective and would identify the subset of patients who are at highest risk of experiencing a relapse following conventional therapy. These patients may benefit from intensified chemotherapy regimens or, ideally, should enroll in clinical trials investigating novel regimens.

Diffuse large B-cell lymphomas with aberrations in MYC, BCL2 and/or BCL6 by genetic alterations or protein expression represent a group of high grade B-cell lymphomas with inferior outcomes when treated with standard RCHOP chemotherapy. As a result, intensified induction regimens have been suggested in an effort to improve outcomes. Conclusions to date have largely been drawn from retrospective data although prospective data is slowly starting to emerge. Chemoimmunotherapy refractoriness is problematic and relapse rates are high. Patients with double hit lymphoma appear to have increased risk of CNS involvement and prophylaxis is recommended. There is insufficient evidence available to date to strongly recommend for or against consolidative stem cell transplant in this population. Collaborative clinical trials will be needed to establish a preferred therapeutic regimen and an appropriate standard of care in this unique group of patients with DLBCL.

… high-risk patients with DLBCL who coexpress MYC and BCL2 proteins, a clinical scenario … represent relevant biomarkers that should be tested in the context of clinical trials such that …

Micro‐Abstract: We investigated the significance of BCL‐2 and BCL‐6 expression in MYC+ diffuse large B‐cell lymphoma. Immunohistochemistry was performed to evaluate the expression of BCL‐2, BCL‐6, and MYC. BCL‐2 played a more important role than MYC in patients with double‐expression lymphoma. Besides, BCL‐6− expression might also be a negative prognostic factor for such patients. Background: Double‐expression lymphoma (DEL) is a rare subgroup of diffuse large B‐cell lymphoma (DLBCL), which has coexpression of MYC and BCL‐2. Coexpression of MYC and BCL‐2 is considered a prognostic marker portending poor outcomes. However, the prognostic effect of BCL‐2 and BCL‐6 expression in DLBCL remains controversial. Materials and Methods: Immunohistochemical staining was performed to detect MYC, BCL‐2 and BCL‐6 expression in 212 patients with newly diagnosed DLBCL and assess the prognostic effects of BCL‐2 and BCL‐6 expression. The DLBCL patients were treated with R‐CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine [Oncovin], prednisone)–like regimens. Results: Retrospective analysis revealed that BCL‐2+ and BCL‐2+/MYC+ were prognostic factors indicative of poor outcomes. Patients with BCL‐2+ and/or MYC+ expression had a poorer prognosis than that of patients with BCL‐2− and/or MYC− expression. Patients with BCL‐2+/MYC− expression showed a trend toward poorer survival than those with BCL‐2−/MYC+ expression, suggesting that BCL‐2 plays a more important role than MYC. Also, patients with BCL‐6−/MYC+ expression had poorer progression‐free survival than those with BCL‐6+/MYC+ expression. In addition, patients with BCL‐2+/MYC+/BCL‐6− expression had the worst prognosis, suggesting that BCL‐6− is a prognostic factor for poor outcomes for MYC+ DLBCL patients. Altogether, our findings have shown that BCL‐2 is an independent prognostic factor and possibly plays a more important role than MYC in MYC+ DLBCL patients. Furthermore, we found that BCL‐6− expression could also be a prognostic factor portending poor outcomes for MYC+ DLBCL patients.

Double expression (DE) is a World Health Organization‐recognized adverse prognostic factor in diffuse large B‐cell lymphoma (DLBCL). However, the prognostic value of DE in the genetic subtyping era and potential mechanisms remain to be explored. We enrolled 246 DLBCL patients diagnosed between December 2021 and September 2023 in a Jiangsu Province Hospital cohort and included 930 DLBCL patients from three published studies in an external cohort. Double‐expression DLBCL (DEL) in the external cohort was mainly distributed in the OTHER subtype (42.0%), EZB subtype (28.3%), and MCD subtype (15.0%), whereas the MCD subtype exhibited the highest ratio of DEL. DEL was significantly related to unfavorable overall survival (OS) and progression‐free survival (PFS) in DLBCL, but only in EZB and OTHER subtypes that DEL retained remarkably adverse impacts on survivals compared to non‐DEL. We explored the prognostic value of clinical and genetic parameters in DEL patients and found only ST2 showed better OS than A53 in DEL patients, whereas the other subtypes showed no significant difference. DEL showed similarities with the MCD subtype in mutation profiles. Furthermore, RNA‐sequencing analyses exhibited upregulation in tumor proliferation‐related pathways in DEL patients, but downregulation in extracellular matrix organization, T‐cell activation and proliferation, type II interferon production, and pathways associated with cell death might contribute to the poor outcomes of DEL patients.

Key Points Dual expression of MYC and BCL2 is associated with an increased risk of CNS relapse in DLBCL treated with R-CHOP.

… when performed under optimized standardized conditions and that BCL2 expression may … -BCL2 targeted agents. In this prospective phase III trial, the coexpression of MYC and BCL2 …

Abstract We addressed the prognostic impact of cell-of-origin (COO), MYC and Bcl-2 overexpression as well as isolated MYC rearrangement among 111 patients with limited stage diffuse large B-cell lymphoma (DLBCL) treated with consolidative radiation therapy (RT) after a metabolic complete response to immunochemotherapy. With a median follow-up of 31.1 months (95% CI 27.4 − 34.8), 4 relapses occurred. The 3-year progression free survival (PFS), overall survival (OS), and loco-regional relapse free survival (LRFS) for the cohort were 95%, 96%, and 100%, respectively. There were no differences in OS, PFS, or LRFS based on COO or MYC/Bcl-2 dual expression (DE). Similarly, patients with MYC translocations without BCL2 or BCL6 rearrangements did not have worse outcomes. Consolidative RT produced excellent local control, regardless of DLBCL biology, with one late in-field failure.

… a higher number of cases with MYC and BCL2 protein coexpression in the GCB subtype (46… B-cell lymphomas treated within randomized trials of the german high-grade non-hodgkin’s …

… In conclusion, we demonstrate that patients with relapsed/refractory aggressive B-cell lymphoma and dual expression of MYC and BCL2 had particularly poor prognoses when treated …

PURPOSE: To evaluate whether the addition of two biological markers (MYC and BCL-2 protein overexpression) improves the stratification of high-risk patients with diffuse large B-cell lymphoma (DLBCL). METHOD: Seven risk factors were identified at diagnosis, and a maximum of 7 points were assigned to each patient. The patients were classified according to four risk groups: low (0-1), low-intermediate (2-3), high-intermediate (4), and high (5-7). Only high-risk patients with DLBCL were included in this analysis. We retrospectively examined 20 cases from 2008 to 2013 at the Nanjing Drum Tower Hospital. RESULTS: The median expression of MYC protein was 60%, and 17 of 20 (65%) evaluable cases overexpressed MYC. The median expression of BCL-2 protein was also 60%. Eighteen of 20 (90%) evaluable cases showed BCL-2 overexpression. Additionally, 12 out of 20 cases (60%) demonstrated coexpression of MYC and BCL-2 proteins. The percentages of overall survival and progression-free survival at the median follow-up time (36 months) were 33.3%±16.1% and 16.9%±13.5%, respectively. By comparison, nine, four, and 20 patients were classified as high risk based on the International Prognostic Index (IPI), National Comprehensive Cancer Network(NCCN)-IPI, and revised IPI criteria, respectively. According to the IPI and NCCN-IPI stratification, the risk groups demonstrated closely overlapping survival curves. In addition, four out of 20 cases were identified as low-intermediate risk according to the NCCN-IPI criteria. CONCLUSION: The addition of MYC and BCL-2 protein expression to the IPI could identify a subset of DLBCL patients with high-risk clinicopathological characteristics and poor clinical outcome.

… Recent advancements in double-expressor lymphoma: novel therapeutic approaches and … Double hit & double expressor lymphomas: a multicenter analysis of survival outcomes with …

BACKGROUND Double-expressor diffuse large B-cell lymphoma (DE-DLBCL) has a poor prognosis, and optimal treatment strategies remain unclear. This study evaluates the efficacy and safety of RCHOP, R2-CHOP (RCHOP plus lenalidomide), and RCHOP plus Bruton's Tyrosine Kinase inhibitors (BTKi) in DE-DLBCL treatment. METHODS Data from 213 DE-DLBCL patients treated from January 2019 and February 2024. Among them, 112 received R-CHOP, 65 received R2-CHOP, and 36 received R-CHOP plus BTKi. We evaluated clinical characteristics, overall response rate (ORR), complete response (CR) rate, progression-free survival (PFS), overall survival (OS), and adverse events (AEs) for each groups. RESULTS Baseline characteristics were comparable across groups. ORRs were 95.5 % for R-CHOP, 96.9 % for R2-CHOP, and 97.2 % for R-CHOP plus BTKi, with CR rates of 76.5 %, 80 %, and 75 %, respectively. BTKi significantly improved PFS (p=0.033) but not affect OS (p=0.165). Lenalidomide showed no benefit in PFS (p=0.153) or OS (p=0.351). With median follow-up times of 20.6 months for R-CHOP, 23.5 months for R2-CHOP, and 17.6 months for R-CHOP plus BTKi, the 1-year PFS rates were 73.6 %, 82.2 %, and 93.3 %, and the 1-year OS rates were 96.2 %, 93.2 %, and 100 %, respectively. Grade 3-4 adverse events included leukopenia, neutropenia, and anemia, and thrombocytopenia, with no significant differences among groups. CONCLUSION The addition of BTK inhibitor enhances progression-free survival in DE-DLBCL, especially in advanced-stage patients, without introducing new severe adverse reactions. In contract, adding lenalidomide does not offer additional efficacy or survival benefits.

Although MYC and BCL2 co-expression in diffuse large B cell lymphoma (DLBCL) is associated with inferior prognosis, it remains uncertain whether upfront autologous hematopoietic stem cell transplantation (ASCT) is beneficial in this lymphoma. This study aimed to investigate whether ASCT consolidation could have a positive role for patients with MYC and BCL2 co-expression (double-expressor lymphoma, DEL). We retrospectively evaluated 67 DLBCL patients who underwent upfront ASCT following rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy. The 5-year overall survival (OS) and progression-free survival (PFS) were 82.3% and 79.2%, respectively. There were 23 (34.3%) patients with DEL and 51 (76.1%) patients with non-germinal center B cell (GCB) subtype. The 5-year OS and PFS of patients with DEL were not different from those with non-DEL ( P  = 0.429 and P  = 0.614, respectively). No survival difference for OS and PFS was also observed between GCB and non-GCB subtypes ( P  = 0.950 and P  = 0.901, respectively). The OS and PFS were comparable for patients with DEL and non-DEL and both GCB and non-GCB subtypes. In conclusion, MYC and BCL2 co-expression did not have a poor prognostic impact among high-risk patients with DLBCL treated with upfront ASCT regardless of molecular classification. This preliminary study suggested that the role of consolidative ASCT is needed to be evaluated in a prospective randomized clinical trial.

The poor outcome of high-grade B-cell lymphoma, with rearrangements of MYC, BCL2 and/or BCL6, also known as double-hit lymphoma or triple-hit lymphoma (DHL or THL), has been well documented, while the clinical significance of extra copies of MYC, BCL2 or BCL6 are still less well known. In total, 130 cases of diffuse large B-cell lymphoma, not otherwise specified (DLBCL-NOS) were included in our study. Fluorescence in situ hybridization and immunohistochemistry were performed in all cases to evaluate the genetic status and protein expression levels of MYC, BCL2 and BCL6. Among the 130 cases of DLBCL, the prevalence rates of extra copies of MYC, BCL2 and BCL6 were 10.8, 20.0 and 14.6%, respectively, and the corresponding rates of gene rearrangement were 10.0, 14.6 and 16.9%, respectively. In total, 7.7% (10/130) of patients were DHL/THL; 9.2% (12/130) of patients were DLBCL with MYC and BCL2 and/or BCL6 gene abnormalities including rearrangements or extra copies, while excluded DHL/THL. The positive protein expression rates of MYC, BCL2 and BCL6 were 46.9% (61), 75.4% (98) and 70.0% (91), respectively. Among the 51 cases with MYC/BCL2 co-expression, 14 cases showed concurrence of MYC, BCL2 and/or BCL6 genetic abnormalities, and the remaining 37 cases were classified as double-expressor lymphoma (DEL). MYC and BCL2 rearrangement and BCL2 extra copies were all associated with upregulated protein expression. Cases with concurrence of MYC, BCL2 and/or BCL6 genetic abnormalities were both associated with MYC/BCL2 co-expression. Patients with concurrence of MYC, BCL2 and/or BCL6 genetic abnormalities excluded DHL/THL had shorter OS (P < 0.001) than patients with DLBCL with no genetic change, and showed no statistical different with patients with DHL/THL (P = 0.419). Extra copies of MYC was independent prognostic factors for DLBCL. Patients with MYC and BCL2 and/or BCL6 gene extra copies might show a trend towards poor prognosis, and the detection of extra copies of MYC, BCL2 and BCL6 might deserve more attention.

Introduction: High-grade B cell lymphoma (HGBCL) with rearrangements of MYC in addition to either BCL2 or BCL6 (DHL) generally has a poor prognosis for response to conventional therapies. Nevertheless, current studies of responses to anti-CD19 CAR-T cell therapies (CAR-T) have not demonstrated poorer overall response rates (ORR) in patients with DHL (Locke Lancet Oncol 2019, Schuster NEJM 2019). Double expressor diffuse large B-cell lymphoma (DEL), which lacks the chromosomal rearrangements of DHL but overexpresses MYC and BCL2 proteins by immunohistochemistry, has been similarly associated with poor outcomes, including after autologous and allogeneic stem cell transplantation (Herrera JCO 2017; Kawashima Biol Blood Marrow Transplant, 2018). DEL and DHL each have a different cell of origin and biology; DEL is typically activated B cell-like phenotype, whereas DHL typically have germinal center-like phenotype. To our knowledge, the association of DEL and outcomes with CAR-T has not been assessed. We aimed to assess whether DEL is associated with outcome after CAR-T. Methods: We retrospectively reviewed the records of 75 consecutive patients with aggressive B-cell lymphomas treated with commercial CAR-T therapy at the University of Pennsylvania between April 2018 and October 2019. We included all patients with either diffuse large B cell lymphoma or HGBCL who had both: a) fluorescence in situ hybridization testing for MYC, BCL2 and BCL6 chromosomal rearrangements, and b) immunohistochemical staining (IHC) for MYC and BCL2. Patients who had both MYC and BCL2 and/or BCL6 chromosomal rearrangements were classified as DHL; patients with IHC expression of both MYC in > 40% and BCL2 in > 50% of tumor cells without meeting criteria for DHL were classified as DEL. Patient characteristics were collected. Fisher's exact test was used to compare overall response rate (ORR) and log-rank test was used for comparison of progression-free survival (PFS). Results: Seventy-five eligible cases of aggressive B-cell lymphoma were identified; 9 were excluded due to non-DLBCL or HGBCL subtype and 16 were excluded due to insufficient characterization of tissue to assess DHL and DEL status. Fifty patients were eligible for analysis; 18 patients (36%) met criteria for DEL, 10 patients (20%) met criteria for DHL, and the remaining 44% of patients had neither DEL nor DHL (non-DEL/DHL). Tisagenlecleucel was administered to 39 patients, whereas axicabtagene ciloleucel was administered to 11 patients. Median age at leukapheresis was 65 years (range: 35-81). LDH, administration of bridging therapy, and ECOG performance status (PS) did not significantly differ between the three groups. Median follow-up for the entire cohort was 15.9 months. For all patients, best ORR was 54% (27/50 patients), median PFS was 3.7 months (95%CI: 2.8-NE), and median OS was not reached. Best ORR was 56% (10/18) for DEL patients, 50% (5/10) for DHL patients, and 55% (12/22) for patients with non-DEL/DHL. ORR did not differ between these groups (p=1.0). There was no difference in PFS (see Figure, p=0.90), OS (p=0.61), or RD (p=0.38) between the three groups. At 16 months, 69% of responding DEL continue in CR (95%CI: 30-89%), 72% of non-DEL/DHL (95%CI: 35-90%) continue in CR, and 100% of DHL (95%CI: NE) continue in CR. Conclusions: The proportion of patients with DEL in our study was similar to that reported for patients with diffuse large B-cell lymphoma in the literature. There were no significant differences between DEL, DHL, and non-DEL/DHL groups with regard to the proportion of patients with elevated LDH, bridging therapy, or ECOG PS. Although DHL and DEL have a negative prognostic impact on response to salvage therapies and hematopoietic stem cell transplant, neither DHL nor DEL status was associated with inferior response to anti-CD19 commercial CAR-T products. We demonstrate that patients with DEL can achieve prolonged responses after CAR-T. Moreover, neither DEL nor DHL status appeared to impact PFS, OS, or RD outcomes after commercial CAR-T. Figure Chong: BMS: Membership on an entity's Board of Directors or advisory committees; Tessa: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; KITE Pharma: Membership on an entity's Board of Directors or advisory committees. Landsburg:Curis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Triphase: Research Funding; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Morphosys: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Speakers Bureau; Takeda: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees. Gerson:Loxo: Research Funding; Genentech: Consultancy; Pharmacyclics: Consultancy; Abbvie: Consultancy. Svoboda:Atara: Consultancy; Genmab: Consultancy; TG: Research Funding; Adaptive: Consultancy; Astra-Zeneca: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Imbrium: Consultancy; Seattle Genetics: Consultancy, Research Funding; Pharmacyclics: Consultancy, Research Funding; Merck: Research Funding; Incyte: Research Funding. Dwivedy Nasta:Merck: Membership on an entity's Board of Directors or advisory committees; Roche: Research Funding; Debiopharm: Research Funding; Forty Seven: Research Funding; Incyte: Research Funding; Atara: Research Funding; Rafael Pharmaceuticals: Research Funding. Barta:Atara: Honoraria; Pfizer: Honoraria; Janssen: Honoraria; Seattle Genetics: Honoraria, Research Funding; Monsanto: Consultancy. Garfall:Novartis: Research Funding; Tmunity: Consultancy, Other: Personal fees, Research Funding; Amgen: Research Funding; Kite Pharma: Other: Personal fees; Janssen: Consultancy, Research Funding; GSK: Consultancy; Surface Oncology: Consultancy. Ruella:UPenn/Novartis: Patents & Royalties; Abclon, BMS, NanoString: Consultancy; Abclon: Consultancy, Research Funding. Frey:Amgen: Consultancy, Honoraria; Kite Pharma: Consultancy, Honoraria; Syntax: Consultancy, Honoraria. Porter:Incyte: Other: Advisory board; Novartis: Honoraria, Other: Advisory board, Patents & Royalties: CAR T cells for CD19+ malignancies, Research Funding; Janssen: Other: Advisory board; Genentech/Roche: Current equity holder in publicly-traded company, Other: Spouse employment (ended Sept 2020); her salary includes stock/options; Glenmark: Other: Advisory board; National Marrow Donor Program: Membership on an entity's Board of Directors or advisory committees; American Board of Internal Medicine: Other: Member, exam writing committee (end date Oct 2019); Tmunity: Patents & Royalties; Adicet bio: Other: Advisory board; Kite/Gilead: Other: Advisory board. Schuster:AlloGene, AstraZeneca, BeiGene, Genentech, Inc./ F. Hoffmann-La Roche, Juno/Celgene, Loxo Oncology, Nordic Nanovector, Novartis, Tessa Therapeutics: Consultancy, Honoraria; Novartis, Genentech, Inc./ F. Hoffmann-La Roche: Research Funding.

Primary cutaneous diffuse large B-cell lymphomas (pcDLBCL) are rare hematological neoplasms. pcDLBCL category includes primary cutaneous large B-cell lymphoma "leg type" (pcDLBCL-LT), characterized by a particularly unfavorable outcome, and primary cutaneous large B-cell lymphoma "not otherwise specified" (pcDLBCL-NOS), a widely debated sub-entity with a more indolent course. The negative prognostic impact of double expressor status (DE status, given by coexpression of MYC and BCL2) and double/triple hit status (DH/TH status, given by translocations of MYC and BCL2 and/or BCL6) in nodal DLBCL is well-known; however, no unanimous conclusions regarding relevance of DE and DH/TH status have been reached in pcDLBCL. Therefore, our purpose has been to investigate the presence and prognostic relevance of DE and DH/TH status among a retrospective multicentric cohort of 16 pcDLBCL-LT and 17 pcDLBCL-NOS. All cases were thoroughly re-evaluated, both on a morphological and immunoistochemical level, and tested by means of fluorescence hybridization in situ for MYC, BCL2 and BCL6 rearrangements. DE status was observed in 69% of pcDLBCL-LT and in 24% of pcDLBCL-NOS; however, it did not impact on prognosis in any of the groups examined. Combining molecular results, we highlighted a relevant fraction of DH pcDLBCL (three pcDLBCL-LT and one pcDLBCL-NOS) and the very first case of TH pcDLBCL-LT reported to date. All DH cases were characterized by MYC and BCL6 rearrangements. Overall, DH/TH cases represented 15% (5/33) of all pcDLBCLs and were mostly pcDLBCL-LTs. DH/TH status and DH status alone were associated with poorer OS and DSS (both p<0,05) among all pcDLBCLs, without reaching statistical significance in pcDLBCL-LT and pcDLBCL-NOS groups. In conclusion, MYC, BCL2 and BCL6 cytogenetical testing could be useful in identifying a putative subset of more aggressive pcDLBCLs, although this observation has to be confirmed by further studies.

… Most cases of double-hit lymphoma are of germinal center B-cell (GCB) origin whereas most cases of double-expresser lymphomas (without rearrangements) are of activated B-cell (…

… Introduction: High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements (double hit lymphoma [DHL]) and double expressor lymphoma (DEL; overexpression of …

… Lymphomas with MYC … double-hit (DHL) or double-expressor (DEL) lymphomas, respectively, are associated with poorer response to standard immunochemotherapy. Optimal therapy …

Background Approximately one-third of diffuse large B cell lymphoma (DLBCL) patients exhibit co-expression of MYC and BCL2 (double-expressor lymphoma, DEL) and have a dismal prognosis. Targeted inhibition of the anti-apoptotic protein BCL2 with venetoclax (ABT-199) has been approved in multiple B-cell malignancies and is currently being investigated in clinical trials for DLBCL. Whether BCL2 anti-apoptotic function represents a multifaceted vulnerability for DEL-DLBCL, affecting both lymphoma B cells and T cells within the tumor microenvironment, remains to be elucidated. Methods Here, we present novel genetically engineered mice that preclinically recapitulate DEL-DLBCL lymphomagenesis, and evaluate their sensitivity ex vivo and in vivo to the promising combination of venetoclax with anti-CD20-based standard immunotherapy. Results Venetoclax treatment demonstrated specific killing of MYC+/BCL2+ lymphoma cells by licensing their intrinsically primed apoptosis, and showed previously unrecognized immunomodulatory activity by specifically enriching antigen-activated effector CD8 T cells infiltrating the tumors. Whereas DEL-DLBCL mice were refractory to venetoclax alone, inhibition of BCL2 significantly extended overall survival of mice that were simultaneously treated with a murine surrogate for anti-CD20 rituximab. Conclusions These results suggest that the combination of anti-CD20-based immunotherapy and BCL2 inhibition leads to cooperative immunomodulatory effects and improved preclinical responses, which may offer promising therapeutic opportunities for DEL-DLBCL patients.

Standard chemotherapies for diffuse large B-cell lymphoma (DLBCL), based on the induction of exogenous DNA damage and oxidative stress, are often less effective in the presence of increased MYC and BCL-2 levels, especially in the case of double hit (DH) lymphomas harboring rearrangements of the MYC and BCL-2 oncogenes, which enrich for a patient’s population characterized by refractoriness to anthracycline-based chemotherapy. Here we hypothesized that adaptive mechanisms to MYC-induced replicative and oxidative stress, consisting in DNA damage response (DDR) activation and BCL-2 overexpression, could represent the biologic basis of the poor prognosis and chemoresistance observed in MYC/BCL-2 -positive lymphoma. We first integrated targeted gene expression profiling (T-GEP), fluorescence in situ hybridization (FISH) analysis, and characterization of replicative and oxidative stress biomarkers in two independent DLBCL cohorts. The presence of oxidative DNA damage biomarkers identified a poor prognosis double expresser (DE)-DLBCL subset, characterized by relatively higher BCL-2 gene expression levels and enrichment for DH lymphomas. Based on these findings, we tested therapeutic strategies based on combined DDR and BCL-2 inhibition, confirming efficacy and synergistic interactions in in vitro and in vivo DH-DLBCL models. These data provide the rationale for precision-therapy strategies based on combined DDR and BCL-2 inhibition in DH or DE-DLBCL.

… as double-hit lymphomas (DHL), constitute a subset of diffuse large B cell lymphoma (DLBCL… Additional cases of DLBCL, commonly referred to as double-expressors, show positivity for …

Although the MYC oncogenic network represents an attractive therapeutic target for lymphoma, MYC inhibitors have been difficult to develop. Alternatively, inhibitors of epigenetic/ transcriptional regulators, particularly the bromodomain and extraterminal (BET) family, have been used to modulate MYC. However, current benzodiazepine-derivative BET inhibitors (BETi) elicit disappointing responses and dose-limiting toxicity in relapsed/refractory lymphoma, potentially because of enrichment of high-risk molecular features and chemical backbone-associated toxicities. Consequently, novel nonbenzodiazepine BETi and improved mechanistic understanding are required. Here we characterize the responses of aggressive MYC-driven lymphomas to 2 nonbenzodiazepine BETi: PLX51107 and PLX2853. Both invoked BIM-dependent apoptosis and in vivo therapy, associated with miR-17∼92 repression, in murine Eµ-myc lymphomas, with PLX2853 exhibiting enhanced potency. Accordingly, exogenous BCL-2 expression abrogated these effects. Because high BCL-2 expression is common in diffuse large B-cell lymphoma (DLBCL), BETi were ineffective in driving apoptosis and in vivo therapy of DLBCL cell lines, mirroring clinical results. However, BETi-mediated BIM upregulation and miR-17∼92 repression remained intact. Consequently, coadministration of BETi and ABT199/venetoclax restored cell death and in vivo therapy. Collectively, these data identify BIM-dependent apoptosis as a critical mechanism of action for this class of BETi that, via coadministration of BH3 mimetics, can deliver effective tumor control in DLBCL.

… DLBCL cells [18]. Therefore, we firstly combined ibrutinib and venetoclax to treat R/R DLBCL … Moreover, a great many studies have demonstrated that double-expressor phenotype (C-…

Concomitant deregulation of MYC and BCL2 comprises clinically significant, yet poorly characterized biological high-risk feature in diffuse large B-cell lymphoma (DLBCL). To interrogate these lymphomas, we analyzed translocations and protein expression of BCL2, BCL6, and MYC; correlated the findings with comprehensive mutational, transcriptomic, and clinical data in 181 patients with primary DLBCL; and validated the key findings in independent data sets. Structural variations of BCL2 were subtype-specific and specifically increased BCL2 expression. Molecular dissection of MYC deregulation revealed associations with other lymphoma drivers, including loss of TP53, and distinctive gene expression profiles. Double protein expression (DPE) arose from heterogeneous molecular backgrounds that exhibited subtype-dependent patterns. In the germinal center B-cell (GCB) DLBCL, concurrent alterations of MYC and BCL2 loci gave rise to the majority of DPE DLBCLs, whereas among the activated B-cell (ABC) DLBCLs, concurrent alterations were infrequent. Clinically, DPE DLBCL defined a prognostic entity, which was independent of the International Prognostic Index (IPI) and cell of origin, and together with the loss of TP53 had a synergistic dismal impact on survival. In the DPE DLBCL, the loss of TP53 was associated with a chemorefractory disease, whereas among the other DLBCLs, no correlation with survival was seen. Importantly, BCL6 translocations identified non-GCB lymphomas with favorable BN2/C1-like survival independent of IPI and concurrent DPE status. Taken together, our findings define molecular characteristics of the DPE in DLBCL, and recognize clinically feasible predictors of outcome. Given the emerging taxonomical significance of BCL2, BCL6, MYC, and TP53, our findings provide further depth and validation to the genomic classification of DLBCL.

Double Expressor Lymphoma (DEL) refers to diffuse large B-cell lymphoma (DLBCL) with overexpression of the oncogenes MYC and BCL2 and carries a poor prognosis. However, the clinical utility of DEL is limited by variability in definitions for thresholds of positivity of these markers and a potential protective role of BCL6. We previously showed using multiplex imaging that the DEL phenomenon is explained at single cell resolution by a sub-population of cells co-expressing MYC and BCL2 in the absence of BCL6 (M+2+6−) (Hoppe et al., Cancer Discov 2023). Importantly, the precise extent of these M+2+6− cells for a given case can be derived from single marker information from routine IHC or bulk gene expression data through a simple probabilistic formula +2+6−% = ((%)/100 × (2%)/100 × ((100 − 6%))/100) × 100% using single marker values of MYC, BCL2, and BCL6, which we describe as the scDEL (single-cell DEL) score. In single-cell RNA sequencing data (Ye et al. Cell Rep 2022; n = 17), M+2+6− cells were strongly enriched for B-cell receptor (BCR) signalling, suggesting this subpopulation of cells driving relapse may depend on CD79B for survival, therefore use of polatuzumab vedotin in first line treatment may overcome the negative prognostic impact of DLBCL with a high scDEL score. We retrospectively analysed bulk RNA expression data from biomarker evaluable patients in the Phase III POLARIX trial for first-line treatment in DLBCL (NCT03274492; Tilly et al., N Engl J Med 2022; n = 668; POLA-R-CHP arm = 330; R-CHOP arm = 338) to derive a per-patient scDEL transcriptomic score, previously validated (Hoppe et al, Cancer Discov 2023) in the GOYA trial dataset (NCT01287741; Vitolo et al., J Clin Oncol 2017). Multivariable cox proportional hazards models in the POLARIX population with 3 year follow up outcomes were adjusted for cell-of-origin (COO) subtype and International Prognostic Index (IPI). Analyses were not adjusted for multiple testing. In the R-CHOP arm of POLARIX, higher scDEL scores were significantly associated with inferior progression-free survival (PFS) and overall survival (OS). When modelled as a continuous variable, each 1% increase in M+2+6− cells was associated with worse PFS (HR  1.04, p<0.0001) and OS (HR  1.05, p<0.0001). When dichotomised at a pre-specified 15% threshold based on prior studies, patients with high scDEL scores (M+2+6− ≥15%; 94/338 patients) had significantly poorer PFS (HR  2.10; 95% CI, 1.44–3.06) and OS (HR 2.63; 95% CI, 1.54–4.49). This adverse prognostic association remained significant in multivariable analyses adjusting for key clinical covariates, including COO and IPI, among patients receiving R-CHOP. In contrast, in the POLA-R-CHP arm, scDEL scores were not associated with outcome, either as a continuous variable (PFS: HR = 0.99, p = 0.39; OS: HR = 0.99, p = 0.51) or when dichotomised M+2+6− ≥15%; 107/330 patients (PFS: HR  0.76, p = 0.25; OS: HR   0.87, p = 0.65). Treatment-by–M+2+6− cell interactions were significant for both PFS and OS, even when adjusting for common prognostic factors (p<0.001 and 0.01 respectively), further suggesting an association between these clinical endpoints and the scDEL score in R-CHOP patients but not Pola-R-CHP patients. These findings validate the scDEL score as a clinically relevant biomarker associated with poor outcomes in DLBCL treated with R-CHOP. This study represents its first evaluation in the setting of frontline polatuzumab vedotin use in DLBCL and suggests that the risk conferred by a high scDEL score may be mitigated by the use of frontline polatuzumab vedotin, potentially through targeting of CD79B and BCR-addicted MYC-BCL2 co-expressing tumour cells. As the scDEL score can also be derived from routine clinical-grade IHC percentages for MYC, BCL2 and BCL6 (Hoppe at al, Cancer Discov 2023), these data suggest a potential biomarker with immediate clinical utility. Prospective validation is warranted, particularly using IHC derived scDEL scores, to guide future biomarker-enriched therapeutic strategies for front-line treatment of DLBCL.

received 20 Gy of irradiation for an intramedullary lesion at C3 of the cervical spinal cord. In addition, we initiated salvage therapy with polatuzumab vedotin (1.8 mg/kg) and bendamustine (90mg/m 2 ). After three cycles of Pola-B,

Background: Double-expressor lymphoma (DEL) is characterized by the overexpression of C-MYC and BCL2 proteins without underlying chromosomal rearrangements. Although it is not classified as a distinct entity in the current World Health Organization classification, DEL accounts for 20% to 30% of diffuse large B-cell lymphoma (DLBCL) patients. Currently, the prognosis for DEL patients remains poor despite receiving R-CHOP or R-EPOCH regimens as first-line chemotherapy. Aims: This study aimed to assess the clinical efficacy and treatment tolerance of the Pola-R-CHP regimen in DEL patients. Methods: In this study, newly diagnosed DEL patients were recruited from our hospital in China between June 2023 and April 2024. The cut-off values for C-MYC and BCL2 protein expression were defined as greater than 40% and 50%, respectively. Clinical information, overall response rates, and adverse events of all patients were collected. The Pola-R-CHP regimen consisted of polatuzumab vedotin (1.8 mg per kilogram of body weight), plus intravenous rituximab (375 mg per square meter), cyclophosphamide (750 mg per square meter), liposomal doxorubicin (30 mg per square meter) on day 1 of each cycle, and oral prednisone (100 mg once daily) on days 1 through 5 of the first six cycles. Results: Twenty-three newly diagnosed DEL patients were enrolled, with a median age of 68 years (range 37-79 years). The male-to-female ratio was 11:12. According to the Ann Arbor stage, 78.3% of patients were in stages III/IV, and 52.2% had an International Prognostic Index (IPI) score ≥3. Additionally, 69.6% had at least two extranodal lesions, commonly involving the spleen, gastrointestinal tract, kidneys, adrenal glands, uterus, and ovaries. White blood cell count, hemoglobin, and platelet levels were generally normal. Elevated levels of lactic dehydrogenase and β2 microglobulin were observed in 60.9% and 65.2% of patients, respectively. Based on Hans's algorithm, 82.6% of patients were classified as non-GCB. The median Ki-67 value was 80% (range 60%-95%), and three patients were CD5 positive. P53 protein expression greater than 50% was observed in 69.6% of patients. All patients completed at least three cycles of the Pola-R-CHP regimen. The overall response rate (ORR) was 91.3%, with a complete response rate (CRR) of 47.8% at the end of the third cycle. By the end of treatment, the ORR was 83.3%, and the CRR was 72.2%. The common adverse events of this Pola-R-CHP regimen were hematologic toxicities, and 43.5% of patients exhibited grade 3/4 granulocytopenia after three cycles. Conclusion: The Pola-R-CHP regimen demonstrated high response rates and good tolerability in patients with DEL, establishing it as an effective therapeutic option.

Background: Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous group of malignant tumors. Currently, the first-line R-CHOP chemotherapy regimen can cure approximately 60% of DLBCL patients, but about 40% still experience refractory or relapses. Further studies have found that patients with refractory or relapses often present with high-risk factors at initial diagnosis, such as high international prognostic index (IPI), extranodal involvement, double-expressor lymphoma (DEL), and double-hit lymphoma. Aims: This study aimed to evaluate the clinical efficacy and treatment tolerance of the Pola-R-CHP regimen for DLBCL patients with high-risk factors. Methods: We enrolled newly diagnosed DLBCL patients with high-risk factors who were treated with Pola-R-CHP as the first-line regimen at our hospital in China between April 2023 and May 2024. In this study, high-risk factors included an IPI >2, DEL, P53 protein overexpression (>50%), and extranodal involvement >2 at diagnosis. We collected clinical information, overall response rates, and adverse events for all patients. The Pola-R-CHP regimen included polatuzumab vedotin (1.8 mg/kg), rituximab (375 mg/m²), cyclophosphamide (750 mg/m²), liposomal doxorubicin (30 mg/m²) on day 1 of each cycle, and prednisone (100 mg orally, once daily) on days 1 through 5 of each of the first six cycles. Results: Forty-seven newly diagnosed DLBCL patients with high-risk factors were eventually enrolled, with a median age of 68 years (range 33-79). The male-to-female ratio was 1.1:1.0. Based on the Ann Arbor staging system, 78.7% of patients were classified as stage III/IV, and 61.7% had an IPI >2. Additionally, 48.9% of patients had at least three extranodal lesions, with the spleen, gastrointestinal tract, kidneys, adrenal glands, and bone marrow, being the most commonly involved organs. Furthermore, 66.0% of patients had B symptoms. White blood cell count, hemoglobin, and platelet count were nearly normal across all patients, while high levels of lactic dehydrogenase and β2 microglobulin were found in 63.8% and 61.7% of patients, respectively. According to the Hans algorithm, 76.6% of patients were in the non-GCB group, and the median Ki-67 value was 80% (range 60%-95%). Five patients were CD5 positive, and 48.9% were diagnosed with DEL. Among the cohort, 53.2% of patients exhibited expression greater than 50%. All patients completed at least three cycles of the Pola-R-CHP regimen. The overall response rate (ORR) was 93.6%, with a complete response rate (CRR) of 48.9% at the end of the third cycle. By the end of treatment, the ORR was 89.7%, and the CRR was 76.9%. The most common adverse events were hematologic toxicities, with 36.1% of patients experiencing grade 3/4 granulocytopenia after three cycles. Conclusion: The Pola-R-CHP regimen showed high response rates and good tolerability in DLBCL patients with high-risk factors, proving it to be an effective therapeutic option.

Polatuzumab vedotin (pola) is a CD79b‐targeted antibody‐drug conjugate delivering a potent antimitotic agent (monomethyl auristatin E) to B cells. This was an open‐label, single‐arm study of pola 1.8 mg/kg, bendamustine 90 mg/m2, rituximab 375 mg/m2 (pola + BR) Q3W for up to six cycles in patients with relapsed/refractory (R/R) diffuse large B‐cell lymphoma (DLBCL) who received ≥1 prior line of therapy and were ineligible for autologous stem cell transplantation (ASCT) or experienced treatment failure with prior ASCT. Primary endpoint was complete response rate (CRR) at the end of the treatment (EOT) by positron emission tomography–computed tomography (PET‐CT) using modified Lugano Response Criteria. Secondary endpoints included efficacy, safety, and pharmacokinetics. Thirty‐five patients (median age 71 [range 46‐86] years) were enrolled. Twenty‐three (66%) patients had refractory disease, and 23 (66%) had ≥2 prior lines of therapy. At a median follow‐up of 5.4 (0.7‐11.9) months, patients received a median of five treatment cycles. CRR was 34.3% (95% confidence interval [CI] 19.1‐52.2) at EOT. Overall response rate was 42.9% at EOT, and median progression‐free survival was 5.2 months (95% CI 3.6‐not evaluable). Median overall survival was not reached. No fatal adverse events (AEs) were observed. Grade 3‐4 AEs were mainly hematological: anemia (37%), neutropenia (31%), white blood cell count decreased (23%), thrombocytopenia/platelet count decreased/neutrophil count decreased (20% each), and febrile neutropenia (11%). Grade 1‐2 peripheral neuropathy (PN; sensory and/or motor) was reported in 14% of patients; there were no ≥grade 3 PN events. This study (JapicCTI‐184048) demonstrated the efficacy and safety of pola + BR in Japanese patients with R/R DLBCL who were ineligible for ASCT.

Background: Diffuse large B-cell lymphomas (DLBCL) are a heterogeneous group of aggressive lymphomas. Previous studies indicated that the prognosis of DLBCL patients with aberrant P53 expression was dismal, even though they received R-CHOP chemotherapy as the first-line regimen. Aims: This study aimed to evaluate the clinical efficacy and treatment tolerance of the Pola-R-CHP regimen in diffuse large B cell lymphoma (DLBCL) patients with aberrant P53 expression. Methods: We enrolled newly diagnosed DLBCL patients with aberrant P53 expression from our hospital in China between June 2023 and April 2024. Aberrant P53 expression was defined as greater than 50% or less than 5%. We collected clinical information, overall response rates, and adverse events for all patients. The Pola-R-CHP regimen included polatuzumab vedotin (1.8 mg/kg), rituximab (375 mg/m²), cyclophosphamide (750 mg/m²), liposomal doxorubicin (30 mg/m²) on day 1 of each cycle, and prednisone (100 mg orally, once daily on days 1 through 5 of each of the first six cycles). Results: Thirty newly diagnosed DLBCL patients with aberrant P53 expression were enrolled, with a median age of 66 years (range 33-79). The male-to-female ratio was 7:8. Based on the Ann Arbor staging system, 80% of patients were classified as stage III/IV, and 53.3% had an International Prognostic Index (IPI) score of ≥3. Seventy percent of patients had at least two extranodal lesions, with the spleen, gastrointestinal tract, kidneys, adrenal glands, uterus, and ovaries being the most commonly involved organs. The white blood cell count, hemoglobin, and platelet count were nearly normal across all patients. High levels of lactic dehydrogenase and β2 microglobulin were found in 60% and 56.7% of patients, respectively. According to the Hans algorithm, 73.3% of patients were in the non-GCB group, and the median Ki-67 value was 80% (range 60%-95%). Three patients were CD5 positive, and 50% were diagnosed with double- expressor lymphoma. Among the cohort, six patients had P53 protein expression less than 5%, while 24 patients exhibited expression greater than 50%. TP53 gene mutation analysis (exon 4-10) revealed that all patients with P53 expression less than 5% had TP53 mutations. Furthermore, 91.7% and 87.5% of patients with P53 expression greater than 80% and 50%, respectively, had TP53 mutations. Among these thirty patients, 86.7% of patients exhibited TP53 gene mutations, with the most common mutations occurring between exons 5 and 8. All patients completed at least three cycles of the Pola-R-CHP regimen. The overall response rate (ORR) was 96.7%, with a complete response rate (CRR) of 46.7% at the end of the third cycle. By the end of treatment, the ORR was 91.7%, and the CRR was 83.3%. The most common adverse events were hematologic toxicities, with 33.3% of patients experiencing grade 3/4 granulocytopenia after three cycles. Conclusion: Immunohistochemical analysis indicated a high TP53 gene mutation risk in patients with P53 expression patterns of less than 5% or greater than 80%. The Pola-R-CHP regimen demonstrated high response rates and good tolerability in DLBCL patients with aberrant P53 expression, making it an effective therapeutic option.

PURPOSE Patients with transplantation-ineligible relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) fare poorly, with limited treatment options. The antibody-drug conjugate polatuzumab vedotin targets CD79b, a B-cell receptor component. METHODS Safety and efficacy of polatuzumab vedotin with bendamustine and obinutuzumab (pola-BG) was evaluated in a single-arm cohort. Polatuzumab vedotin combined with bendamustine and rituximab (pola-BR) was compared with bendamustine and rituximab (BR) in a randomly assigned cohort of patients with transplantation-ineligible R/R DLBCL (primary end point: independent review committee [IRC] assessed complete response [CR] rate at the end of treatment). Duration of response, progression-free survival (PFS), and overall survival (OS) were analyzed using Kaplan–Meier and Cox regression methods. RESULTS Pola-BG and pola-BR had a tolerable safety profile. The phase Ib/II pola-BG cohort (n = 27) had a CR rate of 29.6% and a median OS of 10.8 months (median follow-up, 27.0 months). In the randomly assigned cohort (n = 80; 40 per arm), pola-BR patients had a significantly higher IRC-assessed CR rate (40.0% v 17.5%; P = .026) and longer IRC-assessed PFS (median, 9.5 v 3.7 months; hazard ratio [HR], 0.36, 95% CI, 0.21 to 0.63; P < .001) and OS (median, 12.4 v 4.7 months; HR, 0.42; 95% CI, 0.24 to 0.75; P = .002; median follow-up, 22.3 months). Pola-BR patients had higher rates of grade 3-4 neutropenia (46.2% v 33.3%), anemia (28.2% v 17.9%), and thrombocytopenia (41% v 23.1%), but similar grade 3-4 infections (23.1% v 20.5%), versus the BR group. Peripheral neuropathy associated with polatuzumab vedotin (43.6% of patients) was grade 1-2 and resolved in most patients. CONCLUSION Polatuzumab vedotin combined with BR resulted in a significantly higher CR rate and reduced the risk of death by 58% compared with BR in patients with transplantation-ineligible R/R DLBCL.

Key Points Consistent with previous results, pola + BR has a tolerable safety profile. The survival benefit of pola + BR vs BR persists with longer follow-up; efficacy in the pola + BR extension and randomized arms was similar.

Key Points • First-line Pola-M-CHP and Pola-R-CHP demonstrate similar response rates in previously untreated diffuse large B-cell lymphoma.• Pola-M-CHP did not demonstrate a clinical benefit over Pola-R-CHP in this small study and additional dose optimization may be required.

BACKGROUND Polatuzumab vedotin, an antibody-drug conjugate targeting the CD79b component of the B-cell receptor, has demonstrated activity as a single agent and in combination with rituximab in relapsed or refractory diffuse large B-cell lymphoma. In this study, we evaluated the safety and preliminary activity of polatuzumab vedotin in combination with rituximab or obinutuzumab and cyclophosphamide, doxorubicin, and prednisone (CHP) in patients with previously untreated diffuse large B-cell lymphoma. METHODS This was an open-label, non-randomised study composed of a phase 1b dose escalation and a phase 2 dose expansion at 11 hospitals and health centres in the USA and France. Patients aged 18 years or older with B-cell non-Hodgkin lymphoma were eligible. Exclusion criteria included peripheral neuropathy with grade greater than 1, major surgery within 4 weeks before enrolment, known CNS involvement of lymphoma, and uncontrolled heart disease. Phase 1b dose escalation had a three-plus-three design and established the recommended phase 2 dose. Phase 2 expansion evaluated the recommended phase 2 dose of polatuzumab vedotin in patients with newly diagnosed diffuse large B-cell lymphoma with an International Prognostic Index (IPI) of 2-5. Patients received cyclophosphamide 750 mg/m2 on day 1 intravenously, doxorubicin 50 mg/m2 on day 1 intravenously, and prednisone 100 mg once daily on days 1-5 of each 21-day cycle orally (CHP), plus either rituximab 375 mg/m2 intravenously on day 1 of each cycle (R-CHP) or obinutuzumab 1000 mg intravenously on days 1, 8, and 15 of cycle 1 and on day 1 of the following cycles (G-CHP). Polatuzumab vedotin was administered on day 2 of cycles 1 and 2, and on day 1 of the following cycles at 1·0-2·4 mg/kg during the escalation phase and at the recommended phase 2 dose during the expansion phase. Treatment could last six or eight cycles, depending on investigator preference. The primary endpoints of the study were safety and tolerability, and determination of the maximum tolerated dose (or recommended phase 2 dose) of polatuzumab vedotin. All endpoints were analysed per protocol in the safety evaluable population, defined as all patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT01992653. FINDINGS Between Dec 4, 2013, and July 26, 2016, 85 patients were enrolled. 82 patients were included in the safety and activity evaluable populations, 25 in phase 1b and 57 in phase 2. In light of information from other studies using polatuzumab vedotin reported during this study, in which the safety profile associated with exposure to polatuzumab vedotin at doses higher than 1·8 mg/kg every 3 weeks was not outweighed by any clinical benefit, the recommended phase 2 dose was set to 1·8 mg/kg in the R-CHP cohort and no higher doses were explored in this study. 66 patients with newly diagnosed diffuse large B-cell lymphoma received the polatuzumab vedotin recommended phase 2 dose (45 R-CHP; 21 G-CHP). In 66 patients with diffuse large B-cell lymphoma who received the recommended phase 2 dose, the most common adverse events of grade 3 or worse were neutropenia (20 [30%]), febrile neutropenia (12 [18%]), and thrombocytopenia (six [9%]). Among the 70 patients (any histology) who received the recommended phase 2 dose, 19 (27%) had grade 1 peripheral neuropathy, eight (11%) grade 2, and two (3%) grade 3. Four deaths were reported during follow-up: two treatment-related (one complication of atrial fibrillation and one septic shock) and two due to disease progression. As of the cutoff date of Dec 29, 2017, median follow-up time was 21·5 months (IQR 16·7-24·3) for the untreated diffuse large B-cell lymphoma cohort treated at the polatuzumab vedotin recommended phase 2 dose. 59 (89%) patients achieved an overall response at end of treatment (51 [77%] patients had a complete response, and eight [12%] patients had a partial response). INTERPRETATION The safety of incorporating polatuzumab vedotin to R-CHP or G-CHP was as expected and managable. Preliminary clinical activity in newly diagnosed diffuse large B-cell lymphoma seems promising and encouraged a phase 3 trial comparing polatuzumab vedotin with R-CHP to R-CHOP. FUNDING F Hoffmann-La Roche/Genentech.

OBJECT Autologous CD19 chimeric antigen receptor T-cell therapy (CAR-T) significantly modifies the natural course of chemorefractory diffuse large B-cell lymphoma (DLBCL). However, 25% to 50% of patients with relapsed/refractory DLBCL still do not achieve remission. Therefore, investigating new molecular prognostic indicators that affect the effectiveness of CAR-T for DLBCL and developing novel combination therapies are crucial. METHODS Data from 73 DLBCL patients who received CD19 CAR-T (Axi-cel or Relma-cel) were retrospectively collected from Shanghai Tongji Hospital of Tongji University, The Second Affiliated Hospital Zhejiang University School of Medicine, and The Affiliated People's Hospital of Ningbo University. Prior to CD19 CAR-T-cell transfusions, the patients received fludarabine and cyclophosphamide chemotherapy regimen. RESULTS Our study revealed that relapsed/refractory diffuse large B-cell lymphoma (r/r DLBCL) patients with both Double-expression (MYC > 40% and BCL2 > 50%) and TP53 alterations tend to have a poorer clinical prognosis after CAR-T therapy, even when CAR-T therapy is used in combination with other therapies. However, CAR-T therapy was found to be effective in patients with only TP53 alterations or DE status, suggesting that their prognosis is in line with that of patients without TP53 alterations or DE status. CONCLUSIONS Our study suggests that r/r DLBCL patients with both DE status and TP53 alterations treated with CAR-T therapy are more likely to have a poorer clinical prognosis. However, CAR-T therapy has the potential to improve the prognosis of patients with only TP53 alterations or DE status to be similar to that of patients without these abnormalities.

Background: Chimeric antigen receptor T-cell (CAR-T) therapy has revolutionized the treatment of relapsed or refractory diffuse large B-cell lymphoma (R/R LBCL), improving patients' progression-free survival (PFS) and overall survival (OS). However, CAR-T treatment failure remains a significant challenge in LBCL, with over 50% of patients experiencing disease relapse or progression within the first 6 months post-CAR-T therapy. There is an urgent clinical need for tools to identify patients at high risk of CAR-T failure prior to treatment initiation. Previously, we identified four serum miRNAs (miR-21, miR-28, miR-130b and miR-155) in patients with diffuse large B-cell lymphoma (DLBCL) predictive of disease outcome. Herein, we evaluated the clinical value of these four miRNAs in predicting CAR-T efficacy and prognosis using retrospective serum samples from patients with R/R LBCL. Methods: Here was a retrospective single-center study involving 22 patients with R/R LBCL, including 19 cases of DLBCL and 3 cases of primary mediastinal large B-cell lymphoma (PMBCL). All patients received CAR-T therapy, with 13 (59.1%) treated with CD28 CAR-T and 9 (40.9%) with 4-1BB CAR-T. Efficacy was assessed via PET/CT at 4 weeks, 3 months, 6 months, and 12 months (D28, M3, M6, and M12) post-CAR-T infusion, using criteria of complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). The median follow-up duration for relapse was 9.1 months (range: 3.2–36.5 months). PFS was defined as the time from CAR-T infusion to the first PD or death. We assayed the expression levels of the four miRNAs and an external reference in pretreatment serum samples by digital PCR (dPCR). The patients were stratified into CR vs. non-CR (PR+SD+PD) groups or response (CR+PR) vs. non-response (SD+PD) groups at each time point. We then optimized the predictive models through logistic regression and logit cutoff values for single or combined miRNAs and calculated the area under the receiver operating characteristic curve (AUC). Kaplan-Meier (KM) curves for PFS were generated to compare differences between groups stratified by miRNA expression, with hazard ratios (HR) calculated. A p-value < 0.05 was considered statistically significant. Results: Among the 22 patients before receiving CAR-T therapy, 63.6% had refractory disease, 36.4% had relapsed disease, and 36.4% had received ≥3 lines of prior therapy. Patient demographics and clinical characteristics included: 64.4% aged ≤60 years, 63.6% with Ann Arbor stage III–IV disease, 72.7% with elevated serum lactate dehydrogenase (LDH), 59.1% with maximum tumor size ≥5 cm, 45.4% with double-expressor/double-hit/triple-hit lymphoma and 47.4% with TP53 mutations. For the CR group vs. non-CR group, the AUC values of the 4-miRNA predictive model at D28, M3, M6 and M12 were 0.823 (p = 0.0016), 0.692 (p = 0.1034), 0.696 (p = 0.1208) and 0.769 (p = 0.0243), respectively. For the response (CR+PR) group vs. non-response group, the AUC values of the predictive model at M3, M6 and M12 were 0.924 (p < 0.0001), 0.883 (p < 0.0001), and 0.783 (p = 0.0111). Notably, the predictive model at M6 based solely on miR-28 also achieved an AUC of 0.792 (p = 0.0056). Kaplan-Meier curves stratified by the optimal logit cutoff values of the 4-miRNA model (for response vs. non-response at M3 or M6) showed significant differences in median PFS between groups. For the M3 model, median PFS was 843 days vs. 189 days (p < 0.0001, HR = 0.05254, 95%CI: 0.0135 – 0.2045); for the M6 model, median PFS was 850 days vs. 314 days (p = 0.0064, HR = 0.2083, 95%CI: 0.06745 – 0.6430). Conclusion This study demonstrates that a combined panel of 4 serum miRNAs (miR-21, miR-28, miR-130b, and miR-155) serves as a robust and clinically feasible predictive tool for assessing the efficacy and prognosis of CAR-T therapy in patients with R/R LBCL. Their integration into clinical practice has the potential to advance personalized medicine in lymphoma treatment, guiding pretreatment decision-making and ultimately improving the success rate of CAR-T therapy.