The Absolute Number of Extranodal Sites Detected By PET-CT Is a Powerful Predictor of Secondary Central Nervous System Involvement in Patients with Diffuse Large B-Cell Lymphoma Treated with R-CHOP

Abstract Background Central nervous system (CNS) relapse in patients with diffuse large B-cell lymphoma (DLBCL) is an infrequent but devastating complication. The German Risk model which includes the 5 IPI risk factors plus involvement of the kidneys has been validated in 2 large independent cohorts (Schmitz, ICML 2013; Savage, ASH 2014; El-Galaly, ICML 2015). In this model, the presence of >1 extranodal site of involvement contributes only 1 point. However, the precise impact of the extent of extranodal disease in PET-CT staged patients is unknown. Patients and Methods We identified patients with newly diagnosed DLBCL presenting to hospitals in Denmark, Canada, the United Kingdom and Australia through systematic searches of national/local lymphoma registries. Inclusion criteria were: staging included PET-CT, primary treatment with R-CHOP or similar regimen ± CNS prophylaxis. Patients treated with high-dose regimens (such as R-HyperCVAD) and those with CNS involvement at diagnosis were excluded. Medical records and PET-CT reports were reviewed for clinical information and outcome. Multiple lesions in one organ or set of paired organs/ tissue were counted as a single extranodal site, and the spleen and Waldeyer's ring were not included as extranodal sites. Time to CNS relapse was determined using the method of Kaplan and Meier, with univariate analysis of absolute number of extranodal sites associated with CNS relapse performed using competing risk regression with death before CNS relapse as competing risk. Multivariate analyses (adjusted for elevated LDH, age>60 y and performance status>1) were performed using Cox proportional hazards to identify the specific increase in risk attributable to the absolute number of extranodal sites of involvement. Involvement of the kidney/adrenals and advanced disease stage were not included in the adjustment because of their intrinsic relationship to number of extranodal sites. Results 1,536 patients meeting the above criteria were included, with the following characteristics: median age 65 y (range 17-92), 63% stage III/IV, 39% B symptoms, 50% elevated LDH, 15% performance status >1 and 39%, 36%, 15%, 6% and 3% had 0, 1, 2, 3 and 4+ extranodal sites of involvement, respectively. 79% received no specific CNS-directed prophylaxis; 8% received intrathecal chemotherapy alone, 5% received systemic high-dose anti-metabolites and 8% received both intrathecal and systemic. After a median follow-up of 41 (interquartile range 28-61) months, 62 (4%) patients developed CNS relapse at a median of 9 (range 4-78) months from initial diagnosis. The 3-y incidence of CNS relapse, unadjusted and adjusted hazard ratios for CNS relapse according to number of extranodal sites of involvement are presented in Table 1. The competing risk regression analysis for CNS relapse using absolute number of extranodal sites of involvement is displayed in Figure 1; >2 vs 2 or fewer extranodal sites was associated with markedly increased risk of CNS progression (P <0.0001). Conclusions In patients with newly diagnosed DLBCL staged with PET-CT and treated with R-CHOP, the presence of 3 or more extranodal sites of involvement is associated with markedly increased CNS relapse risk, even when adjusting for other variables. This finding may reflect the greater sensitivity of PET-CT for detection of extranodal disease compared with CT alone. This population would be suitable for prospective studies evaluating the efficacy of prophylaxis strategies and predictive biomarker studies. Table 1. Risk of CNS relapse according to number of extranodal sites at initial diagnosis. *adjusted for LDH, age>60 y and performance status >1 Number of extranodal sites n (%) 3-year incidence % (95%CI) Unadjusted hazard ratio HR (95% CI) Adjusted hazard ratio* HR (95% CI) 0 602 (39) 1.7 (0.9-3.5) 1.0 (ref) 1.0 (ref) 1 559 (36) 4.0 (2.5-6.4) 3.0 (1.3-6.7) 3.1 (1.3-7.2) 2 230 (15) 4.8 (2.4-9.4) 3.4 (1.3-8.5) 2.8 (1.0-7.5) 3 92 (6) 12.8 (6.6-24.0) 8.1 (3.1-20.9) 6.3 (2.2-17.6) 4+ 53 (3) 32.1 (20.1-48.8) 22.0 (9.0-53.6) 17.2 (6.5-45.8) Figure 1. Competing risk regression analysis depicting cumulative incidence of CNS relapse according to absolute number of extranodal sites of involvement. Figure 1. Competing risk regression analysis depicting cumulative incidence of CNS relapse according to absolute number of extranodal sites of involvement. Disclosures Hutchings: Takeda: Research Funding. Connors:Roche: Research Funding; Seattle Genetics: Research Funding. Seymour:Incyte: Honoraria, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support, Research Funding, Speakers Bureau; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support, Research Funding; Phebra: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Infinity: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support, Speakers Bureau; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees; Genentech, Inc.: Membership on an entity's Board of Directors or advisory committees. Villa:Roche: Research Funding.

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Combining PET Radiomic Features with MYC Gene Rearrangement Results in High Prediction of Outcome in Diffuse Large B-Cell Lymphoma

Blood ◽

10.1182/blood-2021-145855 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 451-451

Author(s):

Jakoba J Eertink ◽

Gerben J.C Zwezerijnen ◽

Sanne E Wiegers ◽

Martine E.D Chamuleau ◽

Pieternella Lugtenburg ◽

...

Keyword(s):

Board Of Directors ◽

Predictive Value ◽

Research Funding ◽

Performance Status ◽

Model Performance ◽

B Cell Lymphoma ◽

Advisory Committees ◽

Predictive Values ◽

Clinical Model ◽

Pet Ct

Abstract Introduction Genetic abnormalities, such as MYC oncogene rearrangements, contribute to the outcome heterogeneity in diffuse large B-cell lymphoma (DLBCL) patients. These rearrangements occur in 10-15% of DLBCL patients and have been associated with a poor prognosis. Recently, radiomics features extracted from PET/CT scans have shown to be predictive of outcome. The aim of this study was to investigate if the ability to predict outcome in DLBCL can be improved by combining different clinical, radiomics and genetic features. Methods 323 DLBCL patients from the HOVON-84, HOVON-130, and PETAL trials with a baseline PET/CT scan and a minimum follow-up of two years were included. MYC status was assessed using Fluorescence in situ hybridization (FISH). 245 patients were MYC negative, whereas 25 patients had a MYC rearrangement and 57 patients had MYC and BCL2 and/or BCL6 rearrangements. Lesions were delineated using a semi-automated preselection of 18F-FDG avid structures defined by a SUV4.0 threshold using the ACCURATE tool. Next, 5 conventional PET features (maximum standardized uptake value (SUV max), SUV peak, SUV mean, metabolic tumor volume (MTV) and total lesion glycolysis and 18 dissemination features were extracted. Dissemination features were pertaining to distance between lesions, differences in uptake between lesions and differences in volume between lesions. Logistic regression with backward feature selection was used to predict 2-year time to progression, defined as time from baseline PET/CT to progression. We tested the predictive value of 4 models. 1) a clinical model using individual components of the international prognostic index (IPI): Ann Arbor stage (categorical), WHO performance status (categorical), lactate dehydrogenase (LDH) levels (dichotomous) and age (continuous), 2) a model that included clinical and genetic predictors: MYC status (categorical) and IPI components, 3) a model that included radiomics features: 5 conventional PET and 18 dissemination features and 4) a model that combined clinical and genetic predictors with radiomics features. Model performance was assessed using repeated cross-validation (5-fold, 1000 repeats) yielding the cross-validated area under the curve of the receiver-operator-characteristics curve (CV-AUC). To match prevalence of MYC-positive patients with real-world prevalence (Rosenwald et al, JCO 2019) all 245 MYC-negative patients were used for each repeat, and 10 MYC-FISH_positive DLBCL patients and 20 patients with MYC and BCL2 and/or BCL6 rearrangements were selected using random stratified sampling. Regression coefficients were averaged over all folds to calculate the probability of progression for all patients. High- and low-risk groups were defined based on prevalence of events and the diagnostic performance was assessed using positive- and negative predictive values. Results The highest model performance for the clinical model was observed when combining Ann Arbor stage, LDH and extranodal involvement and yielded in a CV-AUC of 0.69 (95% confidence interval (CI): 0.52-0.83). MYC status combined with WHO performance status, LDH and extranodal involvement yielded an improved CV-AUC of 0.71 (95% CI: 0.52-0.86). The highest model performance for the radiomics model was observed for MTV combined with the maximum distance between the largest lesion and any other lesions (Dmax bulk), the maximum difference in SUV peak between two lesions (DSUVpeak patient) and the maximum difference in volume between two lesions (DVol patient) yielding a CV-AUC of 0.77 (95% CI: 0.62-0.90). The optimal combined model included MYC status, WHO performance status, LDH, MTV, Dmax patient, DSUVpeak patient and DVol patient after backward feature selection and yielded a CV-AUC of 0.77 (95% CI: 0.60 - 0.90). The positive predictive value was highest for the combined model (53.0%) and increased by 20% compared to the optimal clinical model (33.1%). Negative predictive values were comparable between models and ranged between 85.8-88.1%. Conclusions Prediction models using 18F-FDG PET/CT radiomics features at baseline aids in identifying DLBCL patients at high risk for relapse. The positive predictive value increased when radiomics features were added to the clinical and genetic parameters. Therefore, radiomics features can increase the efficiency of clinical trials by only selecting poor prognosis patients. Figure 1 Figure 1. Disclosures Chamuleau: Gilead: Research Funding; Genmab: Research Funding; Celgene: Research Funding. Lugtenburg: Incyte: Honoraria; Regeneron: Honoraria; Genmab: Honoraria; Servier: Honoraria, Research Funding; Takeda: Honoraria, Research Funding; Celgene: Honoraria, Other: Non-financial support; Travel support; Roche: Honoraria, Research Funding. Dührsen: CPT Cellex Patient Treatment: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Hüttmann: Celgene: Honoraria; Gilead: Honoraria; Lead Discovery Center GmbH: Consultancy; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees. Richter: HTG Molecular Diagnostics, Inc.: Current Employment, Research Funding. Klapper: Regeneron: Consultancy, Research Funding; Amgen: Research Funding; Roche: Consultancy, Research Funding; Takeda: Consultancy, Research Funding. Zijlstra: Takeda: Research Funding.

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An International Collaborative Study of Outcome and Prognostic Factors in Patients with Secondary CNS Involvement By Diffuse Large B-Cell Lymphoma

Blood ◽

10.1182/blood.v128.22.1874.1874 ◽

2016 ◽

Vol 128 (22) ◽

pp. 1874-1874 ◽

Cited By ~ 1

Author(s):

Tarec Christoffer El-Galaly ◽

Chan Yoon Cheah ◽

Mette Dahl Bendtsen ◽

Gita Thanarasjasingam ◽

Roopesh Kansara ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Cell Lymphoma ◽

Systemic Disease ◽

Performance Status ◽

B Cell Lymphoma ◽

Cns Involvement ◽

First Line ◽

Advisory Committees ◽

Large B Cell Lymphoma

Abstract Background: Secondary CNS involvement (SCNS) is a detrimental complication seen in ~5% of patients with diffuse large B-cell lymphoma (DLBCL) treated with modern immunochemotherapy. Data from older series report short survival following SCNS, typically <6 months. However, data in patients that develop SCNS following primary therapy that contains a rituximab-based-regimen as well as the impact of more intensified treatment for SCNS are limited. Aims: The aims of this study were to i) describe the natural history of SCNS in a large cohort of patients treated with immunochemotherapy, and ii) determine prognostic factors after SCNS. Patients and methods: We performed a retrospective study of patients diagnosed with SCNS during or after frontline immunochemotherapy (R-CHOP or equivalently effective regimens). SCNS was defined as new involvement of the CNS (parenchymal, leptomeningeal, and/or eye) in patients without known CNS involvement at the time of first pathologic diagnosis of DLBCL. Patients were identified from local databases and/or regional/national registries in Denmark, Canada (British Columbia), Australia, Israel, US (University of Iowa/Mayo Clinic SPORE), and England (Guy's and St. Thomas' Hospital, London). Clinico-pathologic and treatment characteristics at the time of SCNS were collected from medical records. Results: In total, 281 patients with SCNS diagnosed between 2001 and 2016 were included. Median age at SCNS was 64 (range 20-93) years and male:female ratio was 1.3. SCNS occurred as part of first relapse in 244 (87%) patients and 112 (40%) had documented concurrent systemic disease at the time of SCNS. The median time from initial DLBCL diagnosis to SCNS was 9 months, which was similar for patients treated with (N=76, 27%) or without upfront CNS prophylaxis (N=205, 73%) (10 vs 9 Mo; P=0.3). The median post-SCNS OS was 4 months (interquartile range 2-13) and the 2yr survival rate was 20% (95% CI 15-25) for the entire cohort. Associations between clinicopathologic features, management strategy, and post-SCNS survival are shown in Table 1, which excludes patients who did not receive any treatment against SCNS, patients treated with steroids alone, and a patient with unavailable treatment information (n=43, 15%). In multivariable analysis, performance status >1, concurrent leptomeningeal and parenchymal involvement, SCNS developing before completion of 1st line treatment, and combined systemic and CNS involvement by DLBCL were associated with inferior outcomes. Upfront CNS prophylaxis did not influence post-SCNS OS. High-dose methotrexate (HDMTX) and/or platinum based treatment regimens (i.e. ICE, DHAP, or GDP [+/- IT treatment and/or radiotherapy], N=163) for SCNS were associated with reduced risk of death (HR 0.45 [0.32-0.62, P<0.01]). The 2yr post-SCNS survival for patients treated with HDMTX and/or platinum-based regimens (N=163) was 29% (95% CI 22-37). For patients with isolated parenchymal SCNS, single modality treatment with radiotherapy resulted in 2-yr OS of 19% (95% CI 8-35). For the subgroup of 49 patients treated with HDMTX- and/or platinum-based regimens for isolated SCNS after 1st line DLBCL treatment and with performance status 0 or 1, the 2yr post-SCNS survival was 46% (95% CI 31-59). Overall, 9% of the patients received HDT with ASCT as part of salvage therapy at the time of SCNS. Amongst 36 SCNS patients without systemic involvement and in CR following intensive treatment (HDMTX and/or platinum-based treatments), 11 patients consolidated with HDT had similar outcomes to 25 patients treated without consolidating HDT (P=0.9, Fig 1) Conclusions: Outcomes for patients with SCNS remain poor in this large international cohort of patients from the immunochemotherapy era. Combined parenchymal and leptomeningeal disease, presence of systemic disease concurrent with SCNS, performance status >1, and SCNS developing during first line treatment were independently associated with inferior OS. However, a significant fraction of patients with isolated SCNS after first line DLBCL treatment and with good performance status may achieve long-term remissions after intensive regimens for SCNS. Disclosures El-Galaly: Roche: Consultancy, Other: travel funding. Cheah:Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Gilead Sciences: Membership on an entity's Board of Directors or advisory committees; Janssen-Cilag: Membership on an entity's Board of Directors or advisory committees, Other: Speaker's Bureau. Kansara:Celgene: Honoraria. Connors:Bristol Myers Squib: Research Funding; NanoString Technologies: Research Funding; F Hoffmann-La Roche: Research Funding; Millennium Takeda: Research Funding; Seattle Genetics: Research Funding. Sehn:roche/genentech: Consultancy, Honoraria; amgen: Consultancy, Honoraria; seattle genetics: Consultancy, Honoraria; abbvie: Consultancy, Honoraria; TG therapeutics: Consultancy, Honoraria; celgene: Consultancy, Honoraria; lundbeck: Consultancy, Honoraria; janssen: Consultancy, Honoraria. Opat:Roche: Consultancy, Honoraria, Other: Provision of subsidised drugs, Research Funding. Seymour:Genentech: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie Inc.: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Gilead: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Villa:Celgene: Honoraria; Lundbeck: Honoraria; Roche: Honoraria, Research Funding.

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Incidence and Risk Factors for Central Nervous System Relapse in Very Elderly Patients over 80 with Diffuse Large B-Cell Lymphoma: A Retrospective Analysis of Two Lysa Studies

Blood ◽

10.1182/blood.v128.22.927.927 ◽

2016 ◽

Vol 128 (22) ◽

pp. 927-927

Author(s):

Aurelie Cabannes-Hamy ◽

Frederic Peyrade ◽

Fabrice Jardin ◽

Jean-Francois Emile ◽

Sylvie Castaigne ◽

...

Keyword(s):

Risk Factors ◽

Elderly Patients ◽

Board Of Directors ◽

Research Funding ◽

Risk Group ◽

B Cell Lymphoma ◽

Very Elderly ◽

Advisory Committees ◽

Large B Cell Lymphoma ◽

Cns Relapse

Abstract Background. The prevalence of diffuse large B-cell lymphoma (DLBCL) in patients aged over 80 years is reported to have tripled compared to patients in their sixties. Treating very elderly patients is particularly challenging given the likelihood of comorbidities and concerns over risks of toxicity. One of the most devastating and rapidly fatal complications in DLBCL is central nervous system (CNS) relapse. Most studies reporting incidence and risk factors of CNS relapse concern DLBCL patients under the age of 80 years, and little is known about CNS recurrence in the very elderly, aged over 80 years. CNS prophylaxis is rarely implemented in this population due to the burden of comorbidities, frequent antiplatelet or anticoagulant treatment along with renal failure and hypoalbuminemia, as well as potential prophylaxis toxicity of IV high dose methotrexate and/or the invasiveness of IT therapy. Aim. We retrospectively evaluated the incidence of CNS relapse, risk factors and specific survival in very elderly DLBCL patients aged 80 years Patients and Methods. Data were collected retrospectively from two multicentre, open-label, single arm phase II LYSA trials (LNH 03-7B (NCT01087424) between 2004 and 2007, LNH09-7B (NCT01195714) between 2009 and 2013) evaluating the addition of rituximab or ofatumumab to miniCHOP as front-line therapy. Results. A total of 270 elderly patients were included in the two trials, 150 treated with R-miniCHOP and 120 with O-miniCHOP. Median age was 83 years (range 79-95) and none received CNS prophylaxis. At inclusion, most patients (76%) presented with disseminated disease (Ann Arbor stage III or IV), and 37% had at least two extra-nodal sites. Overall 18% of patients had bone marrow involvement, while renal, adrenal, testis or cavum involvement was rare (4%, 2%, 3%, and 2%, respectively). After a median follow-up of 28.7 months (range 0.1-72.1), 8 (3%) cases of CNS relapse were reported. Median time between inclusion and CNS relapse was 19.2 months (range 3.2 - 32.6). Cumulative 1 and 2-year incidence of CNS relapse was 1.4% (95% CI 3.2-25.4) and 2.5% (95% CI 6.9-9.2), respectively. At inclusion, clinical characteristics of the CNS relapse patients were not significantly different from patients without relapse. At CNS relapse, all patients except one present a performance status ECOG > 2. neurological symptoms were either mild with loss of autonomy, asthenia, hearing impairment, urinary incontinence, or more prominent with delirium, aphasia, intracranial hypertension, or consciousness disorder. Treatment of CNS relapse was a supportive care based- treatment with corticosteroid only in 5 patients, radiation therapy in one patient, and chemotherapy for 2 patients including rituximab-temodal (5 cycles) in one patient and rituximab -aracytine-vepeside (2 cycles) for the other one. Patients survived for a median of 1.5 months after CNS relapse diagnosis (range, 0.4 to 4). The CNS international prognostic index (CNS-IPI) classified 33 (12%) patients in the low-risk group, 164 (62%) in the intermediate-risk group, and 71 (26%) in the high-risk group. The low-risk and intermediate-risk CNS-IPI groups showed 2-year rate of CNS disease of 3%, and the high-risk of 2.8% (p=0.9483). Conclusion. Incidence of CNS relapse in very elderly previously untreated patients is approximately 3% and is associated with a very poor survival. The absence of prophylaxis in this population did not appear to have a strong impact on CNS relapse incidence. Higher number of patients is warranted to identify risk factors for CNS relapse in this population Disclosures Coiffier: Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celltrion: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; MorphoSys: Consultancy, Membership on an entity's Board of Directors or advisory committees. Salles:Celgene: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Janssen: Honoraria; Roche: Consultancy, Honoraria, Research Funding; Amgen: Consultancy. Thieblemont:Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Research Funding; Bayer: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Safety and Efficacy of Induction and Maintenance Avelumab Plus R-CHOP in Patients with Diffuse Large B-Cell Lymphoma (DLBCL): Analysis of the Phase II Avr-CHOP Study

Blood ◽

10.1182/blood-2020-136024 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 43-44

Author(s):

Eliza A Hawkes ◽

Geoffrey Chong ◽

Charmaine Smith ◽

Sze-Ting Lee ◽

Leonid Churilov ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Progressive Disease ◽

Cell Lymphoma ◽

Genomic Analysis ◽

B Cell Lymphoma ◽

Advisory Committees ◽

Pet Ct ◽

Variant Detection ◽

Grade 3

Background: Novel strategies are needed to improve upon the 60% cure rate of upfront R-CHOP in advanced DLBCL. Single-agent immune checkpoint inhibition (ICI) has limited efficacy in heavily pre-treated DLBCL (response rate <10%, Ansell JCO 2019), potentially due to residual immunocompromise from prior therapy. Frontline ICI, given when host immunity is relatively intact, may improve these outcomes. Concurrent ICI with R-CHOP is safe (Smith BJH 2020) but corticosteroid-related immunosuppression may negate ICI efficacy. These factors, along with evidence that ICI sensitises non-Hodgkin lymphoma to subsequent chemotherapy (Carreau BJH 2020), support a sequential treatment strategy. Avelumab (Av) is an anti-PDL1 monoclonal antibody with antibody dependent cell cytotoxicity (ADCC) activity which acts synergistically with rituximab (R) in vitro. We report the results of a phase II single arm study assessing safety of 1st line sequential AvR induction, R-CHOP & Av maintenance for DLBCL. Methods: Patients aged ≥18 years, ECOG 0-2 with untreated stage II-IV DLBCL and no active autoimmune disease were treated with AvR induction x2 cycles q2-weekly (Av 10mg/kg IV + R 375mg/m2 IV), followed by R-CHOP21 x 6 cycles then Av 10mg/kg x 6 cycles q2-weekly if in complete metabolic response (CMR) post R-CHOP. The primary endpoint was the rate of grade 3/4 immune-related adverse events (irAE). Secondary endpoints included overall response rate (ORR), failure free survival (FFS), overall survival (OS) and overall toxicity. Response was determined centrally by PET-CT (Lugano 2014 criteria). CMR rates by PET-CT post AvR induction and post C2 R-CHOP were exploratory endpoints. Genomic analysis was performed including next generation sequencing (NGS) based sequence variant detection, copy number analysis and structural variant detection. Results: 28 pts were enrolled from Dec 2017 to Oct 2019. Key baseline characteristics included median age 54 yrs (range 20-79); stage III/IV disease 68%; elevated LDH 61%; IPI ≥2 25%. Histology included 21 DLBCL NOS (75%; 14 GCB, 7 non-GCB by Hans algorithm), 6 primary mediastinal B-cell lymphoma (PMBCL; 21%) and 1 EBV positive DLBCL (4%). The study met its pre-specified primary endpoint of G3/4 irAE <30%. Grade 3/4 irAEs included hepatitis (n=1) and rash (n=2). G1/2 irAEs occurred in 71% (20/28) as follows: rash 53%, liver dysfunction 26%, hyper/hypothyroidism 29% and diarrhoea 21%. 79% had G3/4 toxicity, predominantly haematological, related to RCHOP with febrile neutropenia/infection in 28% of pts. ORR post R-CHOP was 89% (all CR) (Figure 1). The ORR to 2 cycles of induction AvR was 60%, including 6 CMR (21%) across all diagnostic/histologic subgroups (n=1 PMBCL, n=2 non-GCB DLBCL, n=3 GCB DLBCL; Figures 1 and 2). Six pts (21%) progressed during AvR induction (with 1 pt completing only 1 x AvR cycle); all subsequently responded to R-CHOP. With a median follow-up of 16 months, 1-year FFS was 76% and OS 89%. Treatment was discontinued early in 5 pts; 2 during R-CHOP due to progressive disease and 3 during Av maintenance (n=1 immune hepatitis; n=1 pulmonary embolism initially reported as pneumonitis; n=1 progressive disease). Alterations in the CD274/PDCDLG2 locus were identified by NGS in 3 of 27 evaluable pts (n=2 PMBCL, n=1 EBV+ DLBCL). Full genomic analysis to identify factors associated with response will be presented. Conclusion: Sequential AvR induction, R-CHOP and Av maintenance in pts with newly diagnosed DLBCL is feasible with a manageable toxicity profile and a high CR rate. Responses to AvR alone were higher than expected based on the relapsed/refractory population and may suggest superior efficacy of ICI in the frontline setting. These results support ongoing sequential studies of immune priming with PD1/PDL1 inhibition prior to R-CHOP in DLBCL. Acknowledgements: Merck KgA for avelumab plus funding. Tour de Cure Scott Canning Early Career Grant (E Hawkes) and Wilson Centre for Lymphoma Genomics for biomarker testing. Disclosures Hawkes: Astra Zeneca: Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees, Other: Travel, Research Funding, Speakers Bureau; BMS celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen-Cilag: Membership on an entity's Board of Directors or advisory committees, Other: Travel, Speakers Bureau; Merck Sharpe &Dohme: Membership on an entity's Board of Directors or advisory committees, Research Funding; takeda: Speakers Bureau; Merck KgA: Research Funding. Chong:Merck Serono: Research Funding; Bristol-Myers Squibb: Research Funding; Hutchison Medipharma: Research Funding; Bayer: Research Funding; Pharmacyclics LLC, an AbbVie Company: Research Funding; Servier: Research Funding; Isofol: Research Funding. Blombery:Novartis: Consultancy; Janssen: Honoraria; Amgen: Consultancy; Invivoscribe: Honoraria. Barraclough:Roche: Other: Conference sponsorship. Keane:Celgene: Honoraria, Other: Travel; BMS: Research Funding; Roche: Honoraria, Other: Travel, Speakers Bureau; MSD Oncology: Honoraria, Other: Travel; Gilead: Honoraria, Other: Travel, Speakers Bureau. Fong:Pfizer: Honoraria; Astellas: Honoraria; Amgen: Honoraria, Research Funding, Speakers Bureau; Novartis: Honoraria; AbbVie: Honoraria. Manos:Bristol-Myers Squibb: Other: Conference sponsorship. OffLabel Disclosure: Avelumab is an anti-PDL1 monoclonal antibody. Inhibition of the PD1/PDL1 pathway stimulates anti-tumour immunity.

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Lenalidomide Plus R-CHOP (R2CHOP) in Patients with DLBCL Is Associated with a Lower Risk of CNS Relapse: Combined Analysis from Two Phase 2 Studies

Blood ◽

10.1182/blood.v128.22.3033.3033 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3033-3033 ◽

Cited By ~ 2

Author(s):

Ayed O. Ayed ◽

Annalisa Chiappella ◽

Grzegorz S. Nowakowski ◽

Federica Cavallo ◽

Angela Giovanna Congiu ◽

...

Keyword(s):

High Risk ◽

B Cell ◽

Board Of Directors ◽

Research Funding ◽

Performance Status ◽

Phase 2 ◽

Cell Of Origin ◽

Ecog Performance Status ◽

Advisory Committees ◽

Cns Relapse

Abstract Background Central nervous system (CNS) relapse of diffuse large B-cell lymphoma (DLBCL) is a devastating event occurring in approximately 5% of patients treated with standard R-CHOP (Thanarajasingam et al, ASH 2015, abs 1456). Isolated CNS relapse is associated with significant morbidity and mortality. New treatment regimens with agents that cross the blood-brain barrier (BBB) are needed. The combination of lenalidomide with R-CHOP (R2CHOP) has shown promising results in activated B-cell (ABC) type DLBCL in phase 2 studies and is currently being evaluated in randomized trials. Lenalidomide crosses the BBB and has been demonstrated to have single-agent activity in relapsed CNS lymphoma. Accordingly, the addition of lenalidomide to R-CHOP may decrease the risk of CNS relapse. Here we characterize the combined incidence of isolated CNS relapse in a population of DLBCL patients who received R2CHOP for induction therapy in two independent phase 2 studies. Methods We analyzed the incidence of isolated CNS relapse in patients with histologically-confirmed DLBCL enrolled in two R2CHOP phase 2 trials - one conducted by Mayo Clinic (MC) and the other by Italian Lymphoma Foundation (FIL) - in the context of clinical variables that included age, gender, disease stage, cell of origin, and administration of CNS prophylaxis. We assessed CNS-International Prognostic Index (CNS-IPI) factors (age, stage, lactate dehydrogenase level, ECOG performance status, extranodal sites, adrenal/kidney involvement) and classified patients into groups of low, intermediate, and high risk of CNS relapse. The risk of CNS relapse in R2CHOP-treated patients was then estimated and compared against published rates in RCHOP-treated patients based on CNS-IPI score. Results One hundred thirty-six patients with DLBCL from both cohorts (87 MC patients, 49 FIL patients) were included in this analysis. Mean age was 65 and median follow-up in 104 patients still alive was 48.2 months (range: 2.1-88.5). 61.8% of patients were male; 86.0% had stage III disease or higher; 44.1% had ECOG performance status of 0; cell of origin phenotype by immunohistochemistry according to Hans algorithm was germinal center B-cell (GCB), non-GCB (ABC), and not available in 43.4%, 36.8%, and 19.8%, respectively; 14.7% received intrathecal (IT) methotrexate for CNS prophylaxis per local practice. No patients received intravenous methotrexate. 10.3%, 71.3%, and 18.4% of patients were classified into low, intermediate, and high-risk CNS-IPI groups, respectively. Only one of 136 patients developed isolated CNS relapse, corresponding to an estimated incidence of CNS relapse of 0.007 (0.7%). Conclusions Despite a large proportion of patients with intermediate and high risk of CNS relapse treated in both phase 2 studies, induction therapy with R2CHOP in patients with DLBCL is associated with a lower-than-expected rate of isolated CNS relapse. The latter is unlikely to be explained by use of IT chemotherapy, which is considered to be marginally effective in this setting and was implemented only in a small proportion of patients. This suggests that addition of CNS-penetrating small molecules, such as lenalidomide, to R-CHOP may decrease the risk of CNS relapse. Disclosures Chiappella: Celgene: Speakers Bureau; Teva: Speakers Bureau; Roche: Speakers Bureau; Pfizer: Speakers Bureau; Janssen-Cilag: Speakers Bureau; Amgen: Speakers Bureau. Nowakowski:Morphosys: Research Funding; Celgene: Research Funding; Bayer: Consultancy, Research Funding. Cavallo:Janssen-Cilag: Honoraria; Onyx: Honoraria; Celgene: Honoraria. Gaidano:Roche: Consultancy, Honoraria, Speakers Bureau; Karyopharm: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Gilead: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau. Spina:Mundipharma: Membership on an entity's Board of Directors or advisory committees, Other: Speaker Fee; Teva Pharmaceuticals Industries: Membership on an entity's Board of Directors or advisory committees, Other: Speaker Fee. Vitolo:Takeda: Other: Honoraria for lectures; Gilead: Other: Honoraria for lectures; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: Honoraria for lectures; Roche: Membership on an entity's Board of Directors or advisory committees, Other: Honoraria for lectures.

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AvR-CHOP: Feasibility Study of Induction and Maintenance Avelumab Plus R-CHOP in Patients with Diffuse Large B-Cell Lymphoma (DLBCL)

Blood ◽

10.1182/blood-2019-127858 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5332-5332

Author(s):

Eliza A Hawkes ◽

Kate Manos ◽

Charmaine Smith ◽

Joanne Hawking ◽

Stephanie O'Brien ◽

...

Keyword(s):

B Cell ◽

Board Of Directors ◽

Phase Ii ◽

Research Funding ◽

Metabolic Response ◽

B Cell Lymphoma ◽

Advisory Committees ◽

Complete Metabolic Response ◽

Pet Ct ◽

Large B Cell

Background: Whilst up to 60% of DLBCL patients (pts) are cured with frontline R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone), outcomes remain poor for those with relapsed or refractory disease. 1 New strategies to improve frontline cure rates are needed. Tumour cells exploit immune checkpoint pathways, including the PD1/PDL1 axis, to evade the host immune system. PD1/PDL1 over-expression and cytogenetic 9p24 alterations in some DLBCL subtypes provide additional rationale for immune checkpoint inhibition (ICI) in this disease. Although single agent PD1 inhibition yields an overall response rate (ORR) of only 10%-30% in heavily pre-treated unselected DLBCL, many responses are durable.2 Immunosuppressive effects of prior therapy may contribute to the modest response to ICI in relapsed disease. A number of considerations influence the incorporation of ICI into upfront DLBCL treatment. Although concurrent PD1/PDL1 inhibition and R-CHOP is safe,3 corticosteroid-related immunosuppression may negate PDL1-inhibitor efficacy. Evidence supporting host immune priming with ICI prior to chemotherapy is promising,4 and maintenance ICI post chemotherapy may assist with immune reconstitution and enhance the anti-tumour immune response. Additionally, avelumab (Av, an anti-PDL1 monoclonal antibody with antibody dependent cellular cytotoxicity activity) acts synergistically with rituximab (R) in vitro (unpublished data, Pfizer 2016). Thus, we present our phase II study assessing the safety of sequential Av+R induction, R-CHOP and Av maintenance as upfront therapy for DLBCL. Methods: AvR-CHOP (NCT03244176) is a phase II multicentre single-arm trial of Av induction + maintenance with R-CHOP in newly-diagnosed adult pts with DLBCL. Pts aged >18 years, ECOG 0-2, stage II-IV and with no active autoimmune disease are eligible. Exclusion criteria include the necessity for urgent cytoreduction, grade 3B or transformed follicular lymphoma, CNS involvement, chronic steroid use, prior transplantation or pneumonitis. Treatment (Fig 1) comprises R (375mg/m2 IV) + Av (10mg/kg IV) x 2 cycles q2-weekly, followed by R-CHOP21 x 6 cycles. Maintenance Av x 6 cycles q2-weekly is given to patients achieving a complete metabolic response by PET/CT at the end of R-CHOP. PET/CT is performed after R+Av 2 cycles, cycle 2 R-CHOP, end of R-CHOP and end of Av maintenance. The primary endpoint is immune-related toxicity within 30 days post-treatment. Secondary endpoints include ORR, failure free survival (FFS), overall survival (OS) and toxicity of treatment. Complete metabolic response rates by PET-CT after R-Av induction and after C2 R-CHOP are exploratory endpoints. Biomarker sample collection is synchronised with PET response assessment. A comprehensive translational substudy will apply high throughput technologies to tissue and sequential blood samples to characterise the tumour-immune system interaction and correlate novel host, tumour and tumour microenvironment factors with treatment responses and toxicity. Planned enrolment is 28 pts across 3 sites in Australia. The study follows a Simon 1 stage design, with an 80% power and a 1-sided alpha of 0.05 to rule out an Av-related toxicity rate of 30% (p0=70%), assuming an expected immune related toxicity rate of 10% [p1=90%]. 23 pts are enrolled to date. Acknowledgements: Merck KgA (avelumab and funding) References: 1. Cunningham D et al. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone in patients with newly diagnosed diffuse large B-cell non-Hodgkin lymphoma: a phase 3 comparison of dose intensification with 14-day versus 21-day cycles. Lancet (London, England). 2013;381(9880):1817-26. 2. Ansell SM et al. Nivolumab for Relapsed/Refractory Diffuse Large B-Cell Lymphoma in Patients Ineligible for or Having Failed Autologous Transplantation: A Single-Arm, Phase II Study. J Clin Oncol. 2019;37(6):481-9. 3. Nowakowski GS et al. Safety and efficacy of PD-L1 inhibitor durvalumab with R-CHOP or R2-CHOP in subjects with previously untreated, high-risk DLBCL. Journal of Clinical Oncology. 2019;37(15_suppl):7520-. 4. Park SE et al. Increased Response Rates to Salvage Chemotherapy Administered after PD-1/PD-L1 Inhibitors in Patients with Non-Small Cell Lung Cancer. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2018;13(1):106-11. Disclosures Hawkes: Roche/Genentech: Membership on an entity's Board of Directors or advisory committees, Other: Travel expenses, Speakers Bureau; Bristol-Myers Squibb: Research Funding, Speakers Bureau; Astra Zeneca: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck KgA: Research Funding; Janssen-Cilag: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Mundi pharma: Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Research Funding; Takeda: Speakers Bureau; Merck Sharp & Dohme: Membership on an entity's Board of Directors or advisory committees. Manos:NovoNordisk Pharmaceuticals: Other: Travel; Janssen: Honoraria. Renwick:Celgene: Consultancy; Roche: Honoraria. Grigg:MSD: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Roche: Other: Travel. Scott:Medimmune: Consultancy; Abbvie: Consultancy, Patents & Royalties; IBA: Consultancy; Avipep: Consultancy; Life Science Pharmaceuticals: Equity Ownership; Paracrine Therapeutics: Equity Ownership, Patents & Royalties; NHMRC: Research Funding; Cancer Australia: Research Funding; Cancer Council Victoria: Research Funding; Cure Brain Cancer: Research Funding; Humanigen: Patents & Royalties. Lee:Australian Nuclear Science and Technology Organisation: Membership on an entity's Board of Directors or advisory committees. Fong:Astellas: Consultancy; Amgen: Consultancy, Research Funding, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau; Novartis: Speakers Bureau. Rooney:GenesisCare: Employment. Wight:Janssen: Honoraria; Takeda: Honoraria; Abbvie: Honoraria; BMS: Other: Travel; Amgen: Other: Travel. Chong:BMS: Research Funding; Merck Serono: Research Funding; Bayer: Research Funding; Novartis: Research Funding; Hutchison Medipharma: Research Funding; Pharmacyclics: Research Funding. OffLabel Disclosure: Avelumab is an anti-PDL1 monoclonal antibody.

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Response to Bridging Therapy As a Predictor of Outcomes for Chimeric Antigen Receptor Therapy in Large B-Cell Lymphoma

Blood ◽

10.1182/blood-2021-154186 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3841-3841

Author(s):

Arushi Khurana ◽

Matthew Hathcock ◽

Radhika Bansal ◽

Yucai Wang ◽

Jonas Paludo ◽

...

Keyword(s):

B Cell ◽

Board Of Directors ◽

Research Funding ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Advisory Board ◽

Bridging Therapy ◽

Advisory Committees ◽

Pet Ct ◽

Car T

Abstract Background: Bridging therapy (BT) was not allowed in the ZUMA-1 pivotal trial for axicabtagene ciloleucel (axi-cel) chimeric antigen receptor T-cell therapy (CAR-T) . Since then, several real-world studies have shown the use of bridging therapy to be associated with worse overall survival, duration of response, and complete remission rates. In addition, patients requiring BT during CAR-T manufacturing have a more aggressive and higher tumor burden of disease, also factors associated with poor outcomes. Therefore, factors that can predict outcomes in this high-risk patient cohort are required. We herein examine the impact of response to BT on CAR-T outcomes in large B-cell lymphoma (LBCL). Methods: A retrospective review of patients who received axi-cel for NHL from June 2016 - July 2020 at Mayo Clinic, Rochester, was performed. BT was defined as any lymphoma-directed therapy given between leukapheresis and CAR-T infusion. Patients received BT if there were concerns for symptomatic progression of disease during CAR-T manufacturing, reducing the likelihood of eligibility to receive CAR-T. The decision and choice of BT were at the discretion of the treating physician. Response to all lymphoma-directed therapy was evaluated using the 2014 Lugano criteria. Response to BT included patients with a partial response (PR) or stable disease (SD) on PET-CT before initiating lymphodepletion chemotherapy. Event-free survival (EFS) was defined as the time from axi-cel infusion to progression, next treatment, or death. Overall survival (OS) was defined as the time from axi-cel infusion to death. Survival curves were calculated using Kaplan-Meier estimates and were compared between subgroups using the log-rank test. Cox regression was used for univariate and multivariate analysis (MVA). Results: A total of 73 patients underwent car T therapy during this period. Of these, 67% (49/73) received BT therapy. Table 1 shows baseline characteristics of the total BT cohort (n = 49). The median age at CAR-T infusion was 59 years (IQR 46-64); 57% were males and comprised of 47% (23/49) DLBCL followed by 31% (15/49) high-grade B-cell lymphoma types. Based on the Lugano criteria on PET-CT, 22/49 (45%) patients responded to BT. The baseline characteristics were comparable between the responders and non-responders to BT except for a higher proportion (73%) of patients receiving systemic chemotherapy as BT in the responders (Table 1). At a median follow-up of 24 months, 75% had either progressed, died, or started the next treatment (event), and 59% (29/49) had died. The median EFS was significantly longer in the responders as compared to the non-responders to BT, figure 1 (13.04 months (95%CI, 3.54-not reached [NR]) vs. 2.56 months (95%CI, 1.18-3.02), p = 0.002). The OS also trended in favor of the responders (median OS 18.4 months (95% CI, 13.44-NR) vs. 11.84 months (95% CI, 5.05-NR), p = 0.092). The responder group also had a higher 6-month CR rate of 50% than 11.1% in the non-responder group (p = 0.004). There were no differences in any grade or grade ≥ 3 cytokine release syndrome and neurotoxicity rates in the two groups. On univariate analysis within the bridging group (n = 49), type of bridge (non-chemo) and response to bridge (PR+SD) were associated with a better EFS. In the MVA, only response to BT maintained significance for EFS (HR 0.34, p = 0.025). Conclusions: Having some control of lymphoma after BT was associated with better EFS and 6-month CR rate. Future studies need to prospectively evaluate the type and response to BT as a prognostic factor for improving outcomes in patients receiving CAR-T. Figure 1 Figure 1. Disclosures Wang: InnoCare: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees, Research Funding; LOXO Oncology: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding; Genentech: Research Funding; MorphoSys: Research Funding; Eli Lilly: Membership on an entity's Board of Directors or advisory committees; TG Therapeutics: Membership on an entity's Board of Directors or advisory committees. Paludo: Karyopharm: Research Funding. Bennani: Kymera: Other: Advisory Board; Vividion: Other: Advisory Board; Kyowa Kirin: Other: Advisory Board; Daichii Sankyo Inc: Other: Advisory Board; Purdue Pharma: Other: Advisory Board; Verastem: Other: Advisory Board. Ansell: Bristol Myers Squibb, ADC Therapeutics, Seattle Genetics, Regeneron, Affimed, AI Therapeutics, Pfizer, Trillium and Takeda: Research Funding. Lin: Kite, a Gilead Company: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Novartis: Consultancy; Celgene: Consultancy, Research Funding; Bluebird Bio: Consultancy, Research Funding; Juno: Consultancy; Legend: Consultancy; Sorrento: Consultancy; Gamida Cell: Consultancy; Vineti: Consultancy; Merck: Research Funding; Takeda: Research Funding.

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Blinatumomab Consolidation Post Autologous Hematopoietic Stem Cell Transplantation in Patients with Diffuse Large B Cell Lymphoma

Blood ◽

10.1182/blood-2020-142464 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 3-4

Author(s):

Armin Ghobadi ◽

Michael P. Rettig ◽

Amanda F Cashen ◽

Leah Gehrs ◽

Stephanie Christ ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Board Of Directors ◽

Research Funding ◽

B Cell Lymphoma ◽

Advisory Committees ◽

Hematopoietic Stem ◽

Large B Cell Lymphoma ◽

Pet Ct

Introduction: Autologous hematopoietic stem cell transplantation (auto-HCT) is the standard treatment for patients with chemo-sensitive relapsed/refractory diffuse large B cell lymphoma (DLBCL). However, post-auto-HCT outcomes are still poor in this population, with 5-year progression free survival (PFS) of 40%. We hypothesize that in patients with DLBCL, blinatumomab consolidation post auto-HCT will eradicate remaining tumor cells, leading to decreased relapse and increased overall survival. Therefore we conducted a pilot study to test blinatumomab as consolidation therapy post auto-HCT for patients with DLBCL. Methods: Adult patients with chemosensitive DLBCL or transformed FL who underwent auto-HCT were included. All patients received one cycle of blinatumomab consolidation starting 42 days post auto-HCT (9 mcg daily as continuous infusion for 7 days, followed by 28 mcg daily for 21 days). Response evaluation was done at day 100 post auto-HCT. Minimal residual disease (MRD) was quantified by immunoglobulin high-throughput sequencing (Ig-HTS) of plasma cell-free DNA on days 42 post auto-HCT (pre-blinatumomab) and on day 100 post auto-HSCT (one month post completion of blinatumomab). Immunophenotyping of T cells in cryopreserved peripheral blood mononuclear cells collected on day 42 (pre-blinatumomab), day 56 (midpoint of blinatumomab treatment cycle), and day 100 (1 month post blinatumomab) was performed using 18-color flow cytometry panels for extracellular and intracellular antigens. Results: As of August 2020, ten patients have been treated with at least 100 days follow up. Patient characteristics and outcomes are summarized in Table 1. Three out of 10 patients (30%) were in partial remission (PR) as determined by CT or PET/CT imaging before auto-HCT. All subjects completed the planned cycle of blinatumomab consolidation. Blinatumomab was well tolerated. Two patients developed grade 1 CRS, with no grade 2 and higher CRS. Immune effector cell-associated neurotoxicity syndrome (ICANS) was not observed. Six patients developed transient tremor (four grade 1, one grade 2, and one grade 3). One subjects developed BCNU pneumonitis and CMV viremia that resolved with steroid and ganciclovir. One hundred days post auto-HCT (one month post blinatumomab consolidation) 10/10 (100%) of patient were in complete remission (CR) as determined by both MRD testing and by CT or PET/CT imaging. Plasma cell free based MRD was positive on day 42 (post auto-HCT and pre-blinatumomab), in two out of ten patients (20%). These two patients achieved MRD negative status after receiving blinatumomab consolidation. With median follow up of 14.5 months (range: 7-34 months), all 10 patients are alive and 6/10 remain in remission.. Interestingly, the 4 patients with disease relapse had lower CD8/CD4 T cell ratio before starting blinatumomab compared with patients who remained in remission (Figure 1A). However, there were no significant differences in the distribution of the major T cell subtypes (naïve, memory, effector and Treg), and expression of markers of T cell activation, proliferation, or exhaustion (Figure 1B-1E). High dimensional analysis with t-stochastic neighbor embedding (tSNE) revealed a cluster of CD8+ and CD4+ T cells characterized by high expression of granzyme B (GB) and perforin that was present in the DLBCL patients before and after blinatumomab treatment but not in a healthy untreated control (Figure 1F-1H). Although further analysis of healthy untreated controls and pre-transplant samples is needed, CD8+ T cells from these DLBCL patients pre-blinatumomab contained very few naïve cells and were enriched for terminally differentiated effector cells. Conclusion: This pilot study shows that blinatumomab consolidation post auto-HCT is safe and well tolerated. MRD response to blinatumomab in all patients with MRD positive disease post auto-HCT is encouraging. Strategies to increase CD8/CD4 ratio and more cycles of consolidation in a larger randomized trial are needed to confirm the efficacy of consolidation with blinatumomab post auto-HCT. Finally, the unusually "high activation" immunophenotype (Teff/GB+) seen in CD8 T cells of DLBCL patients after auto-HCT (compared to those seen in resting peripheral blood) may both impact the response to blinatumomab and provide key insights into optimal timing for administration after auto-HCT. Disclosures Ghobadi: WuGen: Consultancy; Bristol Myers Squibb: Consultancy; Kite: Consultancy, Research Funding; EUSA: Consultancy; Amgen: Consultancy, Research Funding. Mehta-Shah:Bristol Myers-Squibb: Research Funding; Karyopharm Therapeutics: Consultancy; Corvus: Research Funding; Genetech/Roche: Research Funding; Innate Pharmaceuticals: Research Funding; Kyowa Hakko Kirin: Consultancy; Celgene: Research Funding; Verastem: Research Funding; C4 Therapeutics: Consultancy. Kahl:Celgene Corporation: Consultancy; AstraZeneca Pharmaceuticals LP: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics LLC: Consultancy; Roche Laboratories Inc: Consultancy; BeiGene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Acerta: Consultancy, Research Funding; ADC Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Consultancy; AbbVie: Consultancy. DiPersio:Magenta Therapeutics: Membership on an entity's Board of Directors or advisory committees.

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Phase I Trial of Carfilzomib + R-CHOP (CarR-CHOP) for Frontline Treatment of Patients with Diffuse Large B-Cell Lymphoma (DLBCL)

Blood ◽

10.1182/blood-2018-99-113381 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1692-1692 ◽

Cited By ~ 1

Author(s):

Brian T. Hill ◽

Robert M. Dean ◽

Deepa Jagadeesh ◽

Alex V. Mejia Garcia ◽

Brad Pohlman ◽

...

Keyword(s):

Phase I ◽

B Cell ◽

Board Of Directors ◽

Research Funding ◽

Performance Status ◽

B Cell Lymphoma ◽

Advisory Committees ◽

Large B Cell Lymphoma ◽

End Of Treatment ◽

Grade 3

Abstract INTRODUCTION: R-CHOP is effective for diffuse large B-cell Lymphoma (DLBCL), but many patients (Pts) relapse or have refractory disease, likely due to inherent biologic differences in DLBCL subtype. Activated B-Cell (ABC) subtype DLBCL signals through Nuclear Factor-κ-B (NF-κB) and is more likely to display treatment failure than DLBCL arising from the germinal center (GC). Proteasome inhibitors disrupt NF-κB signaling, but randomized trials have failed to demonstrate clinical benefit of adding bortezomib to R-CHOP for the treatment of non-GC DLBCL. Carfilzomib (Car) displays superior clinical activity relative to bortezomib in plasma cell neoplasms and, while occasionally associated with cardiac events, does not have dose-limiting neuropathy. To explore the safety and efficacy of Car in upfront treatment of DLBCL, we initiated a phase I/II clinical trial of Car + R-CHOP and report the phase I results. METHODS: 24 adult (age ≥ 18) Pts with untreated de novo or transformed DLBCL, adequate organ function and performance status were enrolled. During 3 x 3 dose escalation, Car was given at 20 mg/m2 on days 1 and 2, with R-CHOP on day 2 for 6 cycles (n = 6). Due to grade 4 thrombocytopenia, the protocol was amended to administer Car at a dose (in mg/m2) of 20 on days 1 and 2 of cycle 1 with rituximab (R) on day 2 and CHOP on day 3, followed by a Car dose of 20 (n=3), 27 (n=3), 36 (n=3), 45 (n=3) and 54 (n = 6) on days 1 and 2 of cycles 2-6. All Pts received pegfilgrastim the day after CHOP and zoster prophylaxis with acyclovir x 6 months post treatment. Echocardiograms were obtained at baseline and at conclusion of therapy to assess the cardiac safety of combining Car with anthracycline. Interim response assessments with CT +/- PET were performed after cycle 3 and end-of-treatment response assessments were uniformly captured with PET. RESULTS: The median age was 57 (range 24-77) years old. 63% of patients were female. Stage at diagnosis was I-II (58%) or III-IV (32%). The majority of Pts had ECOG performance status of 0-1 (88%). B symptoms were present in 21% of Pts and 54% had an increased LDH at diagnosis. 29% had >1 extranodal site. IPI score was 0-1 (50%), 2 (21%) or 3-4 (39%). For this phase I dose escalation study, eligible Pts included primary mediastinal lymphoma (n = 1) and DLBCL of GC (n = 9), non-GC (n = 13) and unknown (n = 1) Hans algorithm subtypes. Hematologic adverse events (AEs) included 60 grade 1/2, 27 grade 3 and 16 grade 4 AEs. Grade 3/4 hematologic toxicities included neutropenia (n=14), thrombocytopenia (n = 6) anemia (n = 6), with only 4 cases of grade 3 febrile neutropenia. Grade 3/4 non-hematologic AEs were generally consistent with known R-CHOP toxicity were notable for: hypertension (n = 2), decreased ejection fraction (n =2), GI hemorrhage (n = 2) dizziness, headache, and syncope (n = 1 each), thromboembolic event (n=1), hyperglycemia (n=2), increased ALT (n=1) and nausea/vomiting (n=2). Compared to age-matched controls, end-of-treatment echocardiograms of CarR-CHOP treated Pts showed no statistically significant additional effect on ejection fraction (EF) [94.8% vs. 90.0% of pre-treatment value, respectively (P = 0.19)] after 6 cycles of treatment and there was no association of change in EF with Car dose (P = 0.61). There were no dose limiting toxicities. As of June 2018, median follow-up among surviving Pts was 16 months. There were 3 deaths during the study period, 2 from lymphoma and 1 from lung cancer. The overall response rate was 92% [75% complete remission (CR), 17% partial remission]. 18-month Kaplan Meier estimates of PFS and overall survival were 77% and 88%, respectively (Figure). There was no significant difference in CR rates or PFS for patients with GC vs. non-GC subtype (P = 0.65 and 0.61, respectively). CONCLUSION: CarR-CHOP is safe at a recommended phase II dose of 20 mg/m2 on day 1 & 2 for cycle 1 followed by 56 mg/m2 for cycles 2-6, without significant excess cardiac effects. Within the limitations of a prospective phase I clinical trial with potential patient selection bias, preliminary efficacy data suggest a high complete metabolic response rate and equivalent outcomes for patients with GC and non-GC subtype. Phase II accrual is ongoing for non-GC DLBCL only and additional correlative studies of the molecular subtype of DLBCL will be incorporated into future analysis. Disclosures Hill: Amgen: Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Genentech: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees. Tomlinson:Foundation Medicine: Consultancy. Caimi:Genentech: Membership on an entity's Board of Directors or advisory committees; ADC Therapeutics: Research Funding; Celgene: Speakers Bureau; Kite Pharma: Membership on an entity's Board of Directors or advisory committees.

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Predictors and Outcomes of Flares in Chronic Graft-Versus-Host Disease

Blood ◽

10.1182/blood-2020-136479 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 47-48

Author(s):

Grigori Okoev ◽

Daniel J. Weisdorf ◽

John E Wagner ◽

Bruce R. Blazar ◽

Margaret L. MacMillan ◽

...

Keyword(s):

Regression Analysis ◽

Board Of Directors ◽

Graft Versus Host Disease ◽

Research Funding ◽

Time Dependent ◽

Advisory Committees ◽

Graft Versus Host ◽

Day Range ◽

Similar Risk ◽

Fund Research

Introduction: Chronic Graft-versus-Host Disease (cGvHD) frequently requires prolonged immune suppressive therapy (IST) with > 50% still on IST at 5 years. The IST typically involves a slow taper of steroids often with flare of cGvHD, necessitating augmentation of previous therapy or addition of new IST. Studies describing cGvHD flares are limited. We analyzed patients with cGvHD who flared during the treatment with systemic IST, their overall survival (OS) and non-relapse mortality (NRM). Methods: This study included all adult patients with cGvHD (n=145) following an allogeneic transplant (2010 - 2017) from a matched sibling donor peripheral blood stem cell transplant (MSD, n=104 (72%) or double/single umbilical cord blood transplant (UCBT, n=41 (28%). The 2014 NIH Consensus Criteria were used to classify organ/overall cGvHD severity. Flare of cGvHD was defined as progression in cGvHD manifestations (after initial response), which was less severe than at diagnosis. Multivariate regression of flares was based on the Prentice, Williams and Peterson model for ordered multiple events (flares). Time-dependent effects on OS and NRM were analyzed by Cox and Fine and Gray regression with propensity scoring to control for confounding. Results: Flares occurred in 87 patients; the cumulative incidence of flares was 60% (95% CI: 51-70%) at a median of 188 days (range 16-751) after diagnosis of cGvHD. The median dose of prednisone was 1 mg/kg/day (range 0-4.2) at diagnosis of cGvHD. At the diagnosis of flare, 36 (41%) of the patients were off prednisone, 50 (57%) were receiving 0.1-0.5 mg/kg /day, and 2 patients > 0.5 mg/kg /day. Thirty two of the 87 (36%) patients experienced multiple flares (2 to 4). The most common organs involved at cGvHD flare were skin (n=45; 51%), mouth (n=27; 31%), GI tract (n=22; 25%) and liver (n=12; 14%); often in combinations of skin/mouth in 11 cases (13%), skin/GI in 6 (7%) and liver/mouth in 4 (5%) cases. Treatment for flare was mostly increase in dose of prednisone to 0.5 mg/kg/day (range 0.3-1.0) in 77 patients (88%) plus the addition of another line of IST in 48 patients (55%). In multiple regression analysis, only donor type was significant predictor of flare in cGvHD. UCBT was associated with 2-fold lower probability of flaring (HR 0.5; 95% CI: 0.3-0.9; p=0.03) compared to MSD. cGvHD severity, organ involvement, platelet count at diagnosis and type of onset were not significant predictors of cGvHD flares. At 2 years after the initial flare, the OS was 77% (95% CI: 66-84%) and NRM 19% (95% CI: 11-28%). Multiple regression analysis evaluating OS and NRM from onset of cGvHD comparing flare to non-flare were performed using flare as a time dependent variable. Compared to cGvHD patients without flare at 2 years, those with flare of cGvHD had a similar risk of NRM (HR 1.2; 95% CI: 0.2-6.1, p=0.86) and OS (HR 0.9; 95% CI: 0.4-2.3, p=0.85). At 2 years from cGvHD onset, the cumulative incidence of resolved cGvHD (durable discontinuation of steroids for ≥ 6 consecutive months) was 31% (95% CI: 21-41%) in those who flared vs. 86% (95% CI: 75-96%) in those without flare. Conclusions: Though cGvHD patients with flare had similar risk of NRM and OS as those without a flare, patients with flare required extended steroids, along with clinical monitoring and intensified IST. cGvHD after UCBT was associated with significantly lower risk of flaring compared to MSD. The ongoing burden of IST, risk of infection and morbidity of cGvHD is substantial and needs better approaches than chronic slow taper of steroids. Disclosures Weisdorf: Incyte: Research Funding; FATE Therapeutics: Consultancy. Wagner:Novartis: Research Funding; Rocket Pharmaceuticals, Inc.: Consultancy, Current equity holder in publicly-traded company; Magenta Therapeutics: Consultancy, Research Funding; BlueRock: Research Funding; Gadeta: Membership on an entity's Board of Directors or advisory committees. Blazar:Fate Therapeutics Inc.: Research Funding; Childrens' Cancer Research Fund: Research Funding; BlueRock Therapeutics: Research Funding; BlueRock Therapeuetic: Consultancy; Magenta Therapeutics: Consultancy; KidsFirst Fund: Research Funding; Tmunity: Other: Co-founder. MacMillan:Mesoblast: Consultancy; Angiocrine Biosciences, Inc.: Consultancy; Equillium, Inc.: Consultancy; Talaris Therapeutics, Inc: Consultancy; Fate Therapeutics, Inc.: Consultancy. Holtan:Generon: Consultancy; BMS: Consultancy; CSL Behring: Other: Clinical trial data adjudication; Incyte: Consultancy. Brunstein:AlloVir: Other: Advisory board; Gamida: Research Funding; Astex: Research Funding; Magenta: Research Funding. Betts:Patent Pending: Patents & Royalties: Dr. Betts has a pending patent WO2017058950A1: Methods of treating transplant rejection. This includes the use of JAK inhibitors. Neither he nor his institution have received payment related to claims described in the patent.. Bachanova:FATE: Research Funding; Karyopharma: Membership on an entity's Board of Directors or advisory committees; Incyte: Research Funding; Gamida Cell: Membership on an entity's Board of Directors or advisory committees, Research Funding; Kite: Membership on an entity's Board of Directors or advisory committees; BMS: Research Funding. Rashidi:Synthetic Biologics: Other: DSMC member (1 trial) and related honorarium. Arora:Fate Therapeutics: Consultancy; Kadmon: Research Funding; Pharmacyclics: Research Funding; Syndax: Research Funding.

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