CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma

Racial disparity in Non-Hodgkin Lymphoma: Parallel survival analysis with data from the DoD central cancer registry and SEER

PURPOSE

Barriers to health care access may contribute to the poorer survival of Black patients with Non-Hodgkin Lymphoma (NHL) than their White counterparts in the U.S. general population. The Department of Defense's (DoD) Military Health System (MHS) provides universal or equal health care access to all its beneficiaries. This study compared overall survival of NHL patients by race in the MHS and U.S. general population, respectively, and aimed to provide evidence on the role of universal health care in reducing racial disparity.

METHODS

The MHS Patients were identified from the DoD's Central Cancer Registry (CCR) and the patients from the U.S. general population were identified from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program. A retrospective cohort study was conducted comparing survival of major NHL subtypes by race in the CCR and the SEER cohorts, respectively.

RESULTS

Non-Hispanic Black patients and Non-Hispanic White patients in the CCR cohort had similar survival in Cox regression models sequentially adjusted for different sets of confounders. The hazard ratios (HRs) and 95 % confidence intervals (CIs) comparing Black to White patients for diffuse large B-cell lymphoma (DLBCL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), and other NHLs were 1.25 (0.89-1.78), 0.74 (0.39-1.42), and 1.25 (0.89-1.77) in the full models, respectively. In contrast, Black patients in the SEER cohort exhibited significantly worse survival than White patients in all models adjusting for the same sets of confounders. The HRs were 1.46 (95 % CI= 1.40-1.52), 1.57 (95 % CI=1.48-1.67), and 1.61 (95 % CI=1.54-1.68) in the full models for DLBCL, CLL/SLL and other NHL, respectively.

CONCLUSIONS

Our study supported universal access to health care as an important factor in reducing survival racial disparity among NHL patients.

Phase II Trial of Hypofractionated Radiotherapy and Immunochemotherapy in Primary Refractory Diffuse Large B-Cell Lymphoma: Preliminary Results and Insights from Digital Spatial Profiling

This open-label, single-arm phase II study assessed the safety and efficacy of sequential hypofractionated radiotherapy (RT) followed by zimberelimab and R-GemOx (rituximab, gemcitabine, oxaliplatin) in patients with primary refractory diffuse large B-cell lymphoma (DLBCL). Fourteen patients were enrolled between June 2022 and December 2023, with 13 included in the analysis. RT doses of 36 and 24 Gy were delivered to the gross and target volumes in 12 fractions, followed by zimberelimab and R-GemOx. The overall response rate within the irradiated field was 92.3%, and a complete response (CR) was achieved by 61.5% of patients; however, 38.5% experienced disease progression. Treatment-related toxicities were manageable, primarily comprising mild leukocytopenia. Digital spatial profiling revealed 53 differentially expressed genes in CD20-rich lymphoma regions and 93 in CD3-rich T cell regions in non-CR patients. Reactome analysis identified key immune system pathways. T cell infiltration correlated with treatment efficacy, and multiplex immunohistochemistry validated immune pathways as potential therapeutic targets. This study demonstrated the promising role of RT combined with immunochemotherapy in refractory DLBCL and suggests immune pathways as critical targets to improve treatment outcomes.

The Improving Outcomes in Relapsed-Refractory Diffuse Large B Cell Lymphoma: The Role of CAR T-Cell Therapy

OPINION STATEMENT

Diffuse large B cell lymphoma, not otherwise specified (DLBCL-NOS) is the most common aggressive lymphoma and can be cured with CHOP-R immunochemotherapy in 60% of cases. The second-line therapy includes salvage regimens followed by autologous stem cell transplantation (ASCT), which offers a cure to a minority of patients due to limitations in efficacy and eligibility. These data present the unmet need in the field, and this review article focuses on how second-generation chimeric antigen receptor T (CAR T) cell therapy targeting CD19 antigen may improve the outcomes with relapsed/refractory DLBCL. In heavily pretreated patients, who have dismal outcomes with conventional therapy, all three approved products-tisangenlecleucel (tisa-cel), axicabtagene ciloleucel (axi-cel), and lisocabtagene maraleucel (liso-cel) have shown durable, unprecedented complete responses with the potential for cure. When compared to salvage regimens and ASCT as the standard of care, axi-cel and liso-cel, unlike tisa-cel, have demonstrated superiority in long-term control. In ASCT-ineligible r/r DLBCL, liso-cel has shown a favourable benefit-risk ratio. Regarding safety, two adverse events of interest have emerged: cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, both of which are manageable. Real-world evidence reflects the results of pivotal trials while favouring axi-cel in heavily pretreated patients, albeit with higher toxicity. The main barrier to the implementation of this treatment modality is the cost associated with the process of CAR T therapy, along with complications and reimbursement issues. However, the barriers can be overcome, and CAR T therapy has the potential to become the standard of care in relapsed/refractory DLBCL. Furthermore, with advances in the scientific engineering of CAR products and the understanding of novel treatment modalities currently being tested in clinical trials, we believe that targeted cellular therapy will become the future of relapsed/refractory DLBCL treatment.

Inextricable association of connective tissue disease with B‑cell lymphoma (Review)

Connective tissue disease (CTD) is a kind of autoimmune disease with multisystem damage that mainly involves the bone, muscle and the vascular system. Patients with CTD have an increased incidence of malignant tumors, particularly hematological malignancies, compared to the general population. This association of autoimmune diseases with lymphoproliferative diseases is bidirectional. There is a heightened risk of B-cell lymphoma development among patients with CTD, and patients with autoimmune disease display a higher prevalence of non-Hodgkin lymphoma compared to the general population. More than 80% of malignant tumours occur after or at the same time as CTD develops. Among secondary lymphomas, the most common aggressive type of lymphoma is diffuse large B-cell lymphoma, while the most common indolent type is marginal zone lymphoma. Novel targets in patients with B-cell lymphoma are BCL2, the NF-κB pathway, components of the BCR activator of RhoGEF and GTPase signalling pathway and the PI3K-mTOR pathway. In this review, information is provided on the common types of B-cell lymphoma in CTD, the pathogenic factors implicated in lymphoma development and recent advancements in therapies effective for both autoimmune conditions and malignant lymphoproliferative diseases.

Phase 2 study of alemtuzumab and dose-adjusted EPOCH-R in relapsed or refractory aggressive B-cell lymphomas

Immune cells within the lymphoma tumor microenvironment promote immune evasion and are rational therapeutic targets. Alemtuzumab targets CD52 expressed on malignant B-cells and infiltrating nonmalignant T-cells. We evaluated the safety and efficacy of alemtuzumab with DA-EPOCH-R in 48 patients with relapsed/refractory aggressive B-cell lymphoma. Febrile neutropenia occurred in 18% of cycles and serious infections in 21% of patients. Responses were observed in 30 (62%) patients, including 12 (80%) patients with classical HL and 3 (75%) patients with T-cell/histiocyte-rich large B-cell lymphoma (THRLCL). Seventeen (35%) patients achieved complete responses, and 12 (25%) were bridged to consolidation. The 2-year progression-free survival (PFS) and overall survival were 22.1% (95% CI, 11.5-34.7%) and 45.2% (95% CI, 34.3-58.9%), respectively. The 2-year PFS for HL and THRLCL patients was 35% and 50%, respectively. Alemtuzumab can be safely combined with DA-EPOCH-R in relapsed/refractory aggressive B-cell lymphomas and can induce durable responses in patients with T-cell-rich microenvironments.

SOHO State of the Art Updates and Next Questions | Diffuse Large B-Cell Lymphoma in Older Adults: A Comprehensive Review

Older adults (OA) with DLBCL are a heterogenous population with suboptimal outcomes. In this review, we identify and address the unique challenges encountered in the care of OA with DLBCL. We elaborate on the role and limitations of current geriatric assessment (GA) tools and ways to incorporate fitness in therapeutic decision making. We suggest best practices to implement GA in routine practice and clinical trials. The most widely used tool is simplified GA (sGA) which categorizes patients into fit, unfit and frail groups. Patients who are fit benefit from full dose/curative approach, whereas consideration should be made to reduce the intensity of chemotherapy for unfit patients. Frail patients with DLBCL are a major unmet need without any satisfactory treatment options. Ongoing investigations combining novel therapies into chemotherapy-free regimens are underway with promising early results. In the relapsed/refractory (R/R) setting, anti-CD19 CAR-T cell therapy (CART) is now the standard of care for primary refractory disease or relapse within 12 months of completing therapy. Autologous stem cell transplant is still a consideration for fit OA with relapse >12 months after completing therapy. The recent approval of bispecific antibodies is a welcome advance that will greatly benefit OA not eligible for CART. Other regimens available for patients ineligible for CART or for those who experience progression post-CART include polatuzumab-rituximab±bendamustine, tafasitamab-lenalidomide, loncastuximab or chemotherapy-based approaches such as rituximab-gemcitabine-oxaliplatin. We discuss the changing paradigm in R/R DLBCL and spotlight emerging data from recent congresses that can improve outcomes in this vulnerable population.

Mosunetuzumab plus Pola-CHP compared with Pola-R-CHP in previously untreated DLBCL: final results from a phase 2 study

ABSTRACT

This phase 2 study evaluated mosunetuzumab plus cyclophosphamide, doxorubicin, prednisone, and polatuzumab vedotin (Pola-M-CHP) vs Pola-rituximab (R)-CHP for first-line treatment of diffuse large B-cell lymphoma. Patients were randomized 2:1 to receive 6 cycles of Pola-M-CHP or Pola-R-CHP on day 1 of each 21-day cycle. Mosunetuzumab was administered intravenously via step-up dosing during cycle 1 and at 30 mg on day 1 of subsequent cycles. The primary end point was independent review committee-assessed complete response (CR) rate by positron emission tomography-computed tomography. Overall, 62 patients were enrolled and received Pola-M-CHP (n = 40) or Pola-R-CHP (n = 22). CR rates were similar in both arms (72.5% with Pola-M-CHP vs 77.3% with Pola-R-CHP); the 24-month investigator-assessed progression-free survival rate was 70.8% (95% confidence interval [CI], 55.6-86.1) with Pola-M-CHP vs 81.8% (95% CI, 65.7-97.9) with Pola-R-CHP. The most common adverse event (AE) was cytokine release syndrome (68.4%; mostly grade 1 [52.6%], and primarily confined to cycle 1) with Pola-M-CHP and neutropenia/neutrophil count decreased (54.5%) with Pola-R-CHP. Neutropenia/neutrophil count decreased was the most frequently observed grade ≥3 AE in both arms (Pola-M-CHP, 36.8%; Pola-R-CHP, 22.7%). Rates of grade ≥3 AEs (86.8% vs 59.1%), serious AEs (63.2% vs 13.6%), and AEs leading to treatment discontinuation (13.2% vs 0%) were higher with Pola-M-CHP than Pola-R-CHP, respectively. Pharmacodynamic changes were supportive of mosunetuzumab's mechanism of action and its addition to the Pola-CHP combination. Pola-M-CHP, although an active combination, did not demonstrate a clinical benefit over Pola-R-CHP in this small study. This trial was registered at www.clinicaltrials.gov as #NCT03677141.

Carfilzomib in combination with R-CHOP for initial treatment of patients with non-germinal center diffuse large B-cell lymphoma: a multicenter, single arm, phase 1/2 study

We performed a phase I/II trial to explore the safety and efficacy of carfilzomib (K) in combination with R-CHOP (KR-CHOP) in patients with diffuse large B cell lymphoma (DLBCL). A total of 48 patients were enrolled and 47 were treated. The overall response rate (ORR) was 89% (70% complete response). At a median follow-up of 31 months, 3-year Kaplan-Meier estimates of PFS and OS were 79% and 87%, respectively. Treatment with KR-CHOP for non-GC DLBCL was associated with a decreased risk of disease progression and death relative to standard of care treatment with R-CHOP with hazard ratios (HR) of 0.16 [95% confidence interval (CI) 0.04-0.58, p = 0.002] and 0.31 [(95% CI, 0.09 - 0.99), p = 0.02], respectively. The most common grade 3 or 4 adverse events (AEs) were anemia (13%), thrombocytopenia (9%) and febrile neutropenia (9%). KR-CHOP is safe and may have preferential activity in non-GC DLBCL.

Next-generation immunotherapeutic approaches for blood cancers: Exploring the efficacy of CAR-T and cancer vaccines

Recent advancements in immunotherapy, particularly Chimeric antigen receptor (CAR)-T cell therapy and cancer vaccines, have significantly transformed the treatment landscape for leukemia. CAR-T cell therapy, initially promising in hematologic cancers, faces notable obstacles in solid tumors due to the complex and immunosuppressive tumor microenvironment. Challenges include the heterogeneous immune profiles of tumors, variability in antigen expression, difficulties in therapeutic delivery, T cell exhaustion, and reduced cytotoxic activity at the tumor site. Additionally, the physical barriers within tumors and the immunological camouflage used by cancer cells further complicate treatment efficacy. To overcome these hurdles, ongoing research explores the synergistic potential of combining CAR-T cell therapy with cancer vaccines and other therapeutic strategies such as checkpoint inhibitors and cytokine therapy. This review describes the various immunotherapeutic approaches targeting leukemia, emphasizing the roles and interplay of cancer vaccines and CAR-T cell therapy. In addition, by discussing how these therapies individually and collectively contribute to tumor regression, this article aims to highlight innovative treatment paradigms that could enhance clinical outcomes for leukemia patients. This integrative approach promises to pave the way for more effective and durable treatment strategies in the oncology field. These combined immunotherapeutic strategies hold great promise for achieving more complete and lasting remissions in leukemia patients. Future research should prioritize optimizing treatment sequencing, personalizing therapeutic combinations based on individual patient and tumor characteristics, and developing novel strategies to enhance T cell persistence and function within the tumor microenvironment. Ultimately, these efforts will advance the development of more effective and less toxic immunotherapeutic interventions, offering new hope for patients battling this challenging disease.

Efficacy and safety of selinexor-based regimens as first-line treatments for elderly patients with diffuse large B-cell lymphoma: a real-world study

PURPOSE

This study aimed to evaluate the efficacy and safety of selinexor-based regimens as first-line treatments for elderly patients with diffuse large B-cell lymphoma (DLBCL).

METHODS

A retrospective analysis of 16 elderly patients with DLBCL who received selinexor-based regimens as first-line treatments at Sun Yat-sen University Cancer Center from November 2021 to September 2023 was conducted. The primary endpoint was the objective response rate (ORR), while the secondary endpoints included progression-free survival (PFS), duration of response (DOR), and safety.

RESULTS

Among the 16 elderly patients, 7 were male (43.8%), and 9 were female (56.2%). The median age was 70.5 years (range, 60-80). The ORR was 93.8%, and 13 patients (81.3%) achieved a complete response (CR), 2 patients (12.5%) achieved a partial response (PR) and 1 patient had progressive disease (PD). It is noteworthy that all 5 patients who received chemotherapy-free regimens achieved CR. The median follow-up was 8.5 months (range, 2.7-22.9). The median PFS was not reached, and the 1-year PFS rate was 79.6%. A total of 81.3% of the patients maintained a response for at least 6 months, and 25% maintained a response for at least 12 months. All 3 patients aged ≥ 75 years achieved CR (100%). Haematologic AEs, including leukopenia (n = 15, 93.8%), neutropenia (n = 13, 81.3%), anaemia (n = 8, 50.0%) and thrombocytopenia (n = 4, 25.0%), were common. The most common nonhaematologic AEs were nausea and vomiting (n = 6, 37.5%), fatigue (n = 5, 31.3%) and decreased appetite (n = 5, 31.3%), most of which were limited in severity to grades 1 or 2 and improved with standard supportive care.

CONCLUSIONS

In the real world, selinexor-based regimens demonstrate good efficacy and controllable safety as first-line treatments for elderly patients with DLBCL.

Clinical and imaging features of primary thyroid MALT lymphoma

Primary thyroid lymphoma is a rare hematologic malignancy of the thyroid gland, accounting for approximately 5% of all malignant thyroid tumors. The most common pathological type is B-cell-derived non-Hodgkin's lymphoma, mainly diffuse large B-cell lymphoma, followed by mucosa-associated lymphoid tissue lymphoma and mixed types. The clinical and radiographic characteristics of primary thyroid lymphoma are non-specific, often leading to misdiagnosis as thyroiditis and a delay in treatment. A 60-year-old woman was referred to our hospital with neck swelling that had persisted for a week. Histopathological findings of a thyroid biopsy revealed mucosa-associated lymphoid tissue lymphoma. Bone marrow examination revealed atypical lymphocytes on myelograms. [18F]FDG PET/CT images showed increased [18F]FDG uptake in both lobes of the thyroid gland and the cervical lymph nodes. The patient was diagnosed with stage IV primary thyroid mucosa-associated lymphoid tissue lymphoma. The patient subsequently received four cycles of R-CEOP chemotherapy and remained under follow-up. Due to the rarity of this case, we conducted a systematic literature review to better understand the disease and improve timely diagnosis and treatment.

A Model of Intratumor and Interpatient Heterogeneity Explains Clinical Trials of Curative Combination Therapy for Lymphoma

SIGNIFICANCE

A new model of intratumor and interpatient heterogeneity in response to drug combinations explains and predicts the results of clinical trials of curative-intent treatments for DLBCL. This model can be used to understand and inform optimal design of curative drug combinations and clinical trials. See related commentary by Goldstein et al., p. 153.

Targeting Myc through BET-PROTAC elicits potent anti-lymphoma activity in diffuse large B cell lymphoma

Diffuse large B cell lymphoma (DLBCL) presents a great challenge in the clinic due to its poor prognosis. Prior research has identified c-Myc as a promising therapeutic target in DLBCL; however, direct targeting of c-Myc protein has proven challenging. The bromodomain and extraterminal (BET) protein family, which acts as transcriptional and epigenetic regulators, plays a crucial role in super-enhancer organization and transcriptional regulation of oncogenic drivers like c-Myc, offering an alternative approach. Recently developed BET proteolysis targeting chimera (PROTAC) compounds can rapidly and effectively degrade BET proteins and potentially offer a more durable effect than traditional BET inhibitors. In this work, we compared the anti-tumor activity of a BET PROTAC, ARV-825, with a BET inhibitor, JQ1, in DLBCL. Cell proliferation was assessed by CCK-8 assay, apoptosis was evaluated by Annexin V/PI staining, and the cell cycle was analyzed by staining DNA with propidium iodide (PI). Western blotting was used to determine the expression levels of BET family proteins and its downstream regulatory gene c-Myc, and the in vivo SCID mouse model implanted with SU-DHL-4 cells was used to analyze the in vivo drug efficacy. Our results showed that ARV-825 was superior to JQ1 in inhibiting DLBCL cell proliferation, inducing apoptosis, promoting cell cycle arrest, and prolonging survival. Notably, ARV-825 was more effective at downregulating c-Myc and BET protein levels than JQ1 in both in vitro and in vivo experiments. These evidences suggest that BET-PROTACs may offer a promising novel strategy for the clinical treatment of DLBCL.

IRF4 contributes to chemoresistance in IGH::BCL2-positive diffuse large B-cell lymphomas by mediating BCL2-induced SOX9 expression

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL), an aggressive type of non-Hodgkin's lymphoma, has a high relapse/refractory rate. We previously identified sex-determining region Y (SRY)-box transcription factor (SOX9) as a transcription factor that serves as a prognostic biomarker, particularly in BCL2-overexpressing DLBCL, and plays a vital role in lymphomagenesis. However, the molecular mechanisms that modulate the aberrant expression of SOX9 in this DLBCL subset remain unknown.

METHODS

Cell viability, apoptosis and cell cycle assays were performed to determine whether SOX9 contributes to DLBCL chemoresistance and rescues silencing IRF4-induced phenotypes. Protein‒protein interactions and protein ubiquitination were elucidated using immunoprecipitation, immunohistochemistry, immunofluorescence and immunoblotting. Chromatin immunoprecipitation sequencing (ChIP-seq), ChIP and dual-luciferase reporter assays were used to investigate IRF4 binding to the SOX9 promoter. The therapeutic potential of IRF4 inhibition was evaluated in vitro and in a mouse model of DLBCL xenografts.

RESULTS

SOX9 enhanced the resistance of the BCL2-overexpressing DLBCL subset to chemotherapy or a BCL2 inhibitor. Moreover, BCL2 inhibition downregulated SOX9 in an immunoglobulin heavy chain/BCL2-positive DLBCL subset. We further identified IRF4 as a key regulator of BCL2-induced SOX9 expression, and ChIP-seq confirmed that IRF4 is a key transcription factor for SOX9 in DLBCL. In addition, BCL2 promotes IRF4 entry into the nucleus by enhancing protein stability and downregulating proteasomal ubiquitination, thereby enforcing SOX9-mediated phenotypes. Finally, in a DLBCL cell line and xenografted mouse model, in vivo inhibition of IRF4 with an hIRF4 antisense oligonucleotide repressed lymphomagenesis and DLBCL chemoresistance.

CONCLUSIONS

Our data support the conclusion that IRF4 plays an essential role in BCL2-induced upregulation of SOX9 expression, and targeting IRF4 may represent a promising therapeutic strategy to cure relapsed and refractory DLBCL.

KEYPOINTS/HIGHLIGHTS

BCL2 activated IRF4 by enhancing its nuclear activity to induce sex-determining region Y (SRY)-box 9 protein (SOX9) aberrant expression, which is a critical pathway for drug resistance in BCL2-overexpressing diffuse large B-cell lymphoma (DLBCL). Targeting IRF4 may be worth investigating further regarding its potential to overcome the chemoresistance of BCL2-overexpressing DLBCL to standard therapies.

Tumor Lesion Uptake of [ 177 Lu]Lu-DOTA-Rituximab in Skeletal and Splenic Disease in Diffuse Large B-Cell Lymphoma

ABSTRACT

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma, and a sizable fraction of the DLBCL patients presents with advanced, relapsed, and refractory disease, demonstrating poor response to standard chemotherapy regimens. Radioimmunotherapy (RIT) has shown to be clinically effective in refractory DLBCL. We present the case of a patient with DLBCL with [ 18 F]FDG-avid widespread skeletal as well as splenic involvement as poor prognostic extranodal disease on FDG PET/CT. RIT based on [ 177 Lu]Lu-DOTA-rituximab was explored to study the biodistribution and dosimetry of [ 177 Lu]Lu-DOTA-rituximab in CD20-positive lymphoma. An exceptionally high tracer concentration in skeletal and splenic disease was observed, supporting its potential RIT application in relapsed and refractory DLBCL patients in the future.

Factors and Considerations in No-Treatment Decisions in Patients With Key Hematological Malignancies: A Nationwide, Population-Based Study in the Netherlands

Comprehensive insights are lacking into why patients with hematological malignancies (HMs) receive no cancer-directed treatment. We evaluated socio-demographic and cancer-related characteristics, decision-making rationales, and overall survival in patients with three common HMs-diffuse large B-cell lymphoma (DLBCL), symptomatic multiple myeloma (MM), and acute myeloid leukemia (AML)-who do not receive cancer-directed treatment, using the nationwide Netherlands Cancer Registry. A total of 26 945 patients diagnosed with DLBCL (47%), symptomatic MM (29%), or AML (25%) between 2014 and 2021 were included. About 16% of the patients did not receive cancer-directed treatment, ranging from 26% in AML to 15% in DLBCL and 10% in MM. The primary reason for not receiving cancer-directed treatment in all three HMs was related to physical condition. The second main reason was patient/family choice in DLBCL and MM, whereas in AML it was rapid disease progression. In female patients, patient/family choice was a more prevalent reason for not receiving cancer-directed treatment than in male patients. Patients with a lower socio-economic position more often did not receive cancer-directed treatment. Median OS varied by reason for not receiving cancer-directed treatment, with the shortest OS in patients experiencing rapid disease progression or death before treatment initiation (0·4 to 0·6 months).

Nanotechnology in Hematology: Enhancing Therapeutic Efficacy With Nanoparticles

Background and Aims

Hematological malignancies, such as leukemia, lymphoma, and multiple myeloma, contribute significantly to global cancer diagnoses. Despite progress in conventional therapies, such as chemotherapy and immunotherapy, these treatments face limitations, including nonspecific targeting, side effects, and drug resistance. The aim of this review is to explore the potential of nanotechnology, particularly nanoparticles (NPs), to improve therapeutic outcomes for these cancers by enhancing drug delivery and reducing toxicity.

Methods

This review examines recent advancements in NP-based therapies, focusing on their application in hematological malignancies. We discuss different types of NPs, including liposomes, polymeric, and inorganic NPs, for their potential in targeted drug delivery. The review also evaluates the current state of clinical trials and highlights challenges in the translation of nanomedicines from preclinical research to clinical practice.

Results

Nanoparticles, with their unique properties, offer significant advantages in drug delivery systems, such as enhanced stability, extended circulation time, and targeted tumor delivery. Various NP formulations have shown promise in clinical trials, including liposomal formulations like Vyxeos for acute myeloid leukemia and Marqibo for Ph-negative acute lymphoblastic leukemia. However, challenges in toxicity, regulatory hurdles, and large-scale production still remain.

Conclusion

Nanomedicine holds transformative potential in the treatment of hematological malignancies, offering more effective and specific therapies compared to conventional treatments. Continued research is necessary to overcome the clinical challenges and maximize the benefits of NP-based therapies for patients with blood cancers.

Efficacy and Safety of Rituximab plus Modified EPOCH (Etoposide, Vincristine, Doxorubicin, Carboplatin, and Prednisolone) for Transplant-ineligible Relapsed/Refractory Diffuse Large B-cell Lymphoma

Objective Despite the recent development of various novel therapeutic approaches for relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL), optimal management of patients with R/R DLBCL who are elderly and/or unfit has not yet been established. Methods and Patients We retrospectively analyzed the efficacy and safety of the R-mEPOCH regimen comprising rituximab, etoposide, vincristine, doxorubicin, carboplatin, and prednisolone in transplant-ineligible patients with R/R DLBCL. Results In total, 22 patients were included in this study. The median patient age was 75 years old. The median number of prior lines of therapy was one (range, 1-5). The overall response rate was 68%, with 45% achieving complete response (CR) or unconfirmed CR and 23% achieving partial response. With a median follow-up of 27.8 months, the median progression-free survival and overall survival (OS) were 17.1 and 27.4 months, respectively. The 2- and 5-year OS rates were 50% and 28%, respectively. The most common grade ≥3 adverse events were neutropenia (n=18 [82%]), febrile neutropenia (n=16 [73%]), anemia (n=12 [55%]), and thrombocytopenia (n=8 [36%]). The median total lifetime cumulative dose of anthracyclines was 281 mg/m2 (range, 69-536 mg/m2) in doxorubicin equivalents. One case of grade 1 bradycardia occurred, leading to the discontinuation of R-mEPOCH. No other cardiac adverse events of grade ≥3 and/or discontinuation of treatment were observed. Conclusion Our study suggests that the R-mEPOCH regimen may be an effective and tolerable salvage regimen for transplant-ineligible R/R DLBCL patients.

Immunotherapy in chronic lymphocytic leukemia: advances and challenges

Chronic lymphocytic leukemia (CLL) is characterized as a clonal proliferation of mature B lymphocytes with distinct immunophenotypic traits, predominantly affecting the middle-aged and elderly population. This condition is marked by an accumulation of lymphocytes within the peripheral blood, bone marrow, spleen, and lymph nodes. The associated immune dysregulation predisposes CLL patients to a higher risk of secondary malignancies and infections, which significantly contribute to morbidity and mortality rates. The advent of immunotherapy has revolutionized the prognosis of CLL, advancing treatment modalities and offering substantial benefits to patient outcomes. This review endeavors to synthesize and scrutinize the efficacy, merits, and limitations of the current immunotherapeutic strategies for CLL. The aim is to inform the selection of optimal treatment regimens tailored to individual patient needs. Furthermore, the review juxtaposes various therapeutic combinations to elucidate the comparative advantages of each approach, with the ultimate objective of enhancing patient prognosis and quality of life.

Single-cell RNA sequencing in diffuse large B-cell lymphoma: tumor heterogeneity, microenvironment, resistance, and prognostic markers

Diffuse large B-cell lymphoma (DLBCL) is a highly heterogeneous malignancy with challenges in treatment resistance and relapse. Single-cell RNA sequencing (scRNA-seq) has provided important insights into tumor heterogeneity, microenvironment interactions, resistance mechanisms, and prognostic biomarkers. This review summarizes key findings from scRNA-seq studies, which have deepened our understanding of DLBCL and contributed to the development of precision therapeutic strategies. Integrating scRNA-seq with spatial transcriptomics and single-cell multi-omics may further elucidate disease mechanisms and identify novel therapeutic targets, supporting the advancement of precision medicine in DLBCL.

Efficacy of tazemetostat in combination with R-CHOP in elderly patients newly diagnosed with diffuse large B cell lymphoma: results of the EpiRCHOP phase II study of the LYSA

Background

In the phase I Epi-RCHOP study (NCT02889523), we reported that R-CHOP-tazemetostat was well tolerated with the recommended phase II dose, consistent with monotherapy.

Methods

Phase II included newly diagnosed diffuse large B cell lymphoma patients aged 60-80 years who received six cycles of rituximab-CHOP (R-CHOP) with continuous tazemetostat (800 mg BID), plus two cycles of tazemetostat and rituximab (cycles 7 and 8), from July 31, 2020 to July 18, 2022. Primary endpoint was positron emission tomography complete metabolic response (CMR). Sample size was calculated with H0 of 70% and H1 assumption of 80%.

Findings

The trial enrolled 122 patients: median age 70 (60-80), 90.2% with stage III-IV, and 73.8% with International Prognostic Index 3-5. Overall, 100 patients (82%) received eight cycles, while 22 had premature treatment discontinuation (PTD), including 12 during the first two cycles. Reasons for PTD were consent withdrawal (N = 10), adverse events (N = 6), death (N = 2), protocol deviation (N = 2), progressive disease (N = 1), and physician decision (N = 1). The median percentage of relative dose intensity of tazemetostat and R-CHOP exceeded 90%, but required a protocol amendment and reduction in vincristine dosage at 1 mg full dose. At the end of treatment or PTD, 92/122 patients (75.4%) achieved CMR, eight (6.6%) partial metabolic response, five (4.1%) progressive disease, two (1.6%) died (septic shock), and 15 (12.3%) were not evaluated. Sensitivity analysis, excluding ten non-evaluated patients who withdrew consent, showed CMR in 82.1%. After a median follow-up of 18.5 months (IQR: 15.4-21), estimated progression-free and overall survival at 18 months were 77.7% (95% CI: 67.5-85.1%) and 88.8% (95% CI: 79.9-93.9%), respectively.

Interpretation

R-CHOP plus tazemetostat is feasible with a promising CMR in elderly DLBCL patients. Complementary biomarker studies are needed for a more personalized approach.

Funding

This study was sponsored under a grant from Ipsen.

Pharmacokinetics, efficacy, and safety of subcutaneous versus intravenous rituximab in previously untreated Chinese patients with CD20+ diffuse large B-cell lymphoma: a phase II randomized controlled trial

Subcutaneous (SC) rituximab has demonstrated advantages over intravenous (IV) administration; however, insufficient data exist on its use with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in Chinese patients with diffuse large B-cell lymphoma (DLBCL). This multicenter, phase II, randomized, controlled study was conducted across China between February 2021 and October 2022. Fifty adult patients with previously untreated CD20-positive DLBCL were randomized to receive one cycle of IV rituximab and seven cycles of SC rituximab (RSC-CHOP; n = 26), or eight cycles of IV rituximab (RIV-CHOP; n = 24), combined with six or eight cycles of CHOP. Geometric mean ratio of trough rituximab serum concentration of SC to that of IV rituximab (Ctrough,SC/Ctrough,IV) at cycle 7 was 1.52 (90% CI: 1.28-1.79), demonstrating non-inferiority of Ctrough,SC. The complete response rate was similar in both treatment arms. SC rituximab is a viable option in Chinese patients with untreated CD20-positive DLBCL, potentially reducing administration burden (ClinicalTrials.gov identifier: NCT04660799).

Phase I Study of Subcutaneous Rituximab Hyaluronidase Combined With CHOP Chemotherapy for the Treatment of Diffuse Large B-Cell Lymphoma in Uganda

PURPOSE

Patients with diffuse large B-cell lymphoma (DLBCL) who are treated in low-resource settings have inferior outcomes compared with those in high-resource settings. Rituximab, an anti-CD20 monoclonal antibody, when combined with chemotherapy, improves overall survival (OS) for DLBCL. However, in part due to the limited availability of infusion centers in low-resource countries, rituximab is rarely used. Subcutaneous rituximab (sqR) is a potential solution; however, its safety and efficacy have not been tested in low-income countries.

METHODS

This open-label phase I study enrolled patients 18 years or older with newly diagnosed DLBCL. The first cohort (n = 6) received intravenous rituximab plus CHOP. This cohort received sqR for subsequent cycles. The second cohort (n = 12) received sqR plus CHOP for all cycles. Safety and tolerability were evaluated; secondary outcomes included response rates and treatment completion.

RESULTS

Between October 25, 2019, and October 7, 2022, 18 patients, with a median age of 36.5 years, were enrolled; 10 were male, and 10 presented with advanced-stage disease. The most common hematologic toxicity was neutropenia (n = 9, 50%). Fifteen of the 18 participants completed treatment; 14 (93.3%) patients achieved a complete response, and one patient (6.7%) had a partial response. The OS and progression-free survival (PFS) at 12 months were 83% (95% CI, 68 to 100) and 67% (95% CI, 48 to 92), respectively. The OS and PFS at 24 months were 66% (95% CI, 47 to 92) and 67% (95% CI, 48 to 92), respectively.

CONCLUSION

As demonstrated in other parts of the world, sqR together with CHOP was safe, well-tolerated, and efficacious among Ugandan patients with DLBCL. The very high OS rates are nearly double those of historical controls and comparable with outcomes expected in resource-rich settings. This study demonstrated the feasibility, safety, and efficacy of sqR-CHOP, increased the research infrastructure in Uganda, and will improve care in other resource-limited settings.

Real-World Effectiveness of Chemoimmunotherapy and Novel Therapies for Patients With Relapsed/Refractory Aggressive Large B-Cell Lymphoma

INTRODUCTION

Clinical trials provide meaningful data regarding the safety and efficacy of novel therapies but there is often a lag between the time of new drug approval and information on posttreatment clinical outcomes in real-world practice. This study evaluated clinical outcomes in a large real-world population of patients with relapsed and/or refractory large B-cell lymphoma (r/r LBCL) treated with chemoimmunotherapy or novel therapies in second or later lines of therapy (2L+).

MATERIALS AND METHODS

Data from the Lymphoma Epidemiology of Outcomes (LEO) Consortium of Real-World Evidence (CReWE) cohort (1/1/2015-2/15/2023) were analyzed. Patients' demographic and clinical characteristics were described and response rates, duration of response, progression-free survival, and overall survival were evaluated. Multivariable Cox proportional hazards regression models were used to assess associations between patient clinical characteristics and outcomes.

RESULTS

The 2L+ cohort included patients treated with chemoimmunotherapy (N = 593), lenalidomide-based therapy (n = 60), polatuzumab vedotin-based therapy (N = 116), tafasitamab-based therapy (N = 55), and loncastuximab tesirine (N = 42). Most patients who received prior chimeric antigen receptor T-cell therapy (CAR-T) were refractory to the treatment. Across all patients, overall response rates were <50%, with one-quarter achieving complete response and median duration of response and overall survival were short (<6 and <10 months, respectively) among patients treated with chemoimmunotherapy or novel therapies. The prognosis was worse for patients who had previously received CAR-T. Primary refractory status, high-risk disease, and failing 3 or more lines of therapy were significantly associated with worse outcomes.

CONCLUSION

Patients with r/r LBCL have unfavorable outcomes and need more effective treatment alternatives.

The current understanding of chimeric antigen receptor (CAR) T-cell therapy for older patients with relapsed or refractory large B-cell lymphoma

Chimeric antigen receptor (CAR) T-cell therapy has changed treatment landscape of relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) and more older patients have been treated with curative intent for R/R disease, including patients previously deemed unfit for autologous stem-cell transplant with a broader application of CAR T-cell therapy. Due to the unique CAR T-cell-related toxicity and special attention needed in treating older patients, optimal patient selection and management of CAR T-cell therapy in older patients are becoming more critical. More data are emerging in the field; multiple approaches, such as geriatric and frailty assessment and multi-disciplinary work with geriatrics, are being studied for CAR T-cell therapy application. Studies support the safe use of CAR T-cell therapy in older patients, however, application of geriatric assessment tools and maximizing multi-disciplinary approach to tailor supportive care are critical to reduce morbidity and improve outcomes in older patients.

The Current State of Bispecific Antibodies and T-Cell Directed Therapy in NHL

Relapsed/refractory non-Hodgkin lymphoma (r/r/NHL) is an aggressive disease with overall poor response rates to chemo-immunotherapy and autologous stem-cell transplant, especially in patients with diffuse large B-cell lymphoma. Major improvements in this disease space have come through the incorporation of novel immune therapies, including CD19/CD20 directed CAR-T cells and bispecific antibodies. These exciting new therapies continue to change the landscape of treatment for r/r NHL and have been incorporated in earlier lines of therapy with demonstrated efficacy and patient safety. In this review, the role of these treatments in the management of relapsed/refractory NHL is discussed in detail along with future directions of research.

Real-world treatment patterns, healthcare resource use, and costs among patients with diffuse large B-cell lymphoma: a retrospective analysis of US claims data

Treatment patterns and all-cause and diffuse large B-cell lymphoma (DLBCL)-related healthcare resource use (monthly incidence) and costs (per patient per month [PPPM]) were estimated among patients with incident DLBCL in US Optum's de-identified Clinformatics® Data Mart Database (October 2015-December 2020). Among 3664 patients, 2279 (62%) had ≥1 line (1 L), 409 (18%) had 2 L, and 99 (4%) had 3 L treatment. Rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine, and prednisone were most common in 1 L (75%) and 2 L (23%), although multiple regimens were used in 2 L and 3 L. With increasing lines of therapy, treatment duration decreased while hospitalization rates increased. Mean DLBCL-related hospitalization costs PPPM increased with each line (1 L: $6028; 2 L: $10,708; 3 L+: $20,483), accounting for increasing proportions of total all-cause costs (1 L: 30%; 2 L: 38%; 3 L+: 56%). Thus, DLBCL poses a substantial economic burden with fewer therapeutic alternatives, especially during later lines, highlighting the need for more effective treatment options.

Measurable Residual Disease Testing During Treatment with Bispecific Antibodies for Lymphoma

The introduction of bispecific antibodies (BsAbs) has led to significant improvements in survival for patients with relapsed and refractory B-cell lymphomas. Despite these advances, there remains a significant number of patients who experience disease progression after these novel therapies. Predicting which patients may respond to certain treatments and the durability of their responses remains challenging. Measurable residual disease (MRD) has become easier to detect and quantify through the use of genomic next-generation sequencing tools and has been studied as a possible biomarker to predict long-term outcomes and risk-stratify patients after BsAb therapy in several lymphoma subtypes. Here, we review recent data demonstrating that MRD negativity is associated with radiographic response and improved progression-free survival. Because of heterogeneity in assay choice, assessment timing, and technical parameters, further work is needed before MRD testing is ready to be incorporated into clinical practice in the context of BsAb treatment for B-cell lymphomas.

Prognostic predictors of newly diagnosed Diffuse large B-cell lymphoma treated with R-THP-COP regimen

The prognostic value of models such as the international prognostic index (IPI) in patients with malignant lymphomas treated with a combination of rituximab, doxorubicin, cyclophosphamide, vincristine, and prednisolone is well established. However, whether these prognostic models apply to patients treated with a combination of tetrahydropyranyl adriamycin, rituximab, cyclophosphamide, vincristine, and prednisolone (R-THP-COP) is unclear. This retrospective analysis included 101 patients with Diffuse large B-cell lymphoma (DLBCL) treated with R-THP-COP. The primary endpoint was overall survival (OS). The secondary endpoints were progression-free survival (PFS), complete response rate (CRR), and effectiveness of risk prediction in the IPI, revised international prognostic index (R-IPI), and National Comprehensive Cancer Network (NCCN)-IPI groups. OS and PFS at 5 years were 67% and 58.9%. CRR was 63.5%. The IPI, R-IPI, and NCCN-IPI predicted the outcomes of patients treated with R-THP-COP. According to the NCCN-IPI, OS and PFS could distinguish four risk groups. In conclusion, the NCCN-IPI is the most effective prognostic tool for identifying patients with poor prognosis, even those treated with R-THP-COP.

Prolonged Cytopenia with CAR-T Cell Therapy and Management Recommendations

Chimeric antigen receptor T-cell (CAR T-cell) therapy has revolutionized the treatment of lymphoid malignancies. Prolonged cytopenias, though poorly understood, have emerged as important considerations in the treatment process. In this review, we classified cytopenias into early (< 30 days post CAR T infusion), and late-occurring (after day 30 post infusion). We identified previous chemotherapy and lymphodepletion chemotherapy as the major risk factors contributing to early cytopenia. Product characteristics, such as costimulatory domains, and side effects of therapy such as cytokine release syndrome (CRS) and immune effector cell associated neurotoxicity syndrome (ICANS) were identified as contributing factors to prolonged cytopenias occurring more than 30 days post CAR-T infusion. We recommend close monitoring with frequent checks, enhanced care with granulocyte colony stimulating factor (GCSF) support for grade 3-4 neutropenia, blood transfusion for severe anemia (Hb < 7g/dL), platelets for severe thrombocytopenia (< 10,000/µL) and thrombopoietin (TPO) mimetics such as eltrombopag or romiplostim for prolonged severe thrombocytopenia in patients at high-risk of hemorrhagic complications.

Temporal trends in time toxicity of R-CHOP: a nationwide hospital-based database analysis in Japan

PURPOSE

While the prognosis of patients with cancer has improved, the time burden of treatment has recently been recognized as time toxicity; although, the actual clinical situation remains largely unexplored. This retrospective study aimed to elucidate the time toxicity of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in patients with B-cell lymphoma and the factors influencing it.

METHODS

We used a nationwide hospital-based database between January 2010 and November 2021 in Japan. We extracted the claims data of patients with diffuse large B-cell lymphoma and follicular lymphoma who were hospitalized and/or visited hospitals for chemotherapy.

RESULTS

Among the 7760 R-CHOP administered to 2006 patients, the rate of outpatient therapy increased over time (2010-2015: 17.9%; 2016-2021: 31.8%). In 2016, the median length of hospitalization was the shortest at 13 days (IQR 8-19), which coincided with the peak use of pegylated granulocyte colony-stimulating factor (Peg-G-CSF) during hospitalization in 2015-2016, likely driven by changes in the insurance system. In multivariate analysis, the factors associated with longer hospital stays were older age and poor activities of daily living, whereas the use of Peg-G-CSF, a reduced-dose regimen, and treatment at cancer-designated hospitals were associated with shorter stays.

CONCLUSION

The time toxicity of R-CHOP has improved and may be influenced by the patient's condition, adequate supportive care, changes in the insurance system, and center-specific treatment proficiency.

CYP3A5 Polymorphism in Circulating Tumor Cells Confers an Increased Disease-Free Survival in DLBCL Patients Treated with R-CHOP

Purpose

Diffuse Large B-Cell Lymphoma (DLBCL) is a heterogeneous aggressive lymphoid neoplasm. Cases of refractoriness and relapse persist in approximately 40% of patients treated with first-line R-CHOP regimen, thus, the identification of factors associated with disease progression have become a necessity. Diverse polymorphisms in genes encoding proteins involved in the metabolism and elimination of chemotherapeutic drugs have been studied as potential causes of treatment failure. In oncology, liquid biopsies have emerged as a non-invasive method for detecting circulating biomarkers, thereby strengthening both diagnosis and prognosis for patients. Therefore, the purpose of this study was to determine polymorphisms in Circulating Tumor Cells (CTCs) to describe the relevance of liquid biopsy in the clinical outcomes of patients with DLBCL.

Patients and Methods

We analyzed 102 liquid biopsies of peripheral blood from DLBCL patients, of which CTCs were isolated by density gradient and CD20 immunomagnetic antibodies. Allelic discrimination assays were performed to analyze ABCB1 C3435T, ABCG2 C421A and CYP3A5 A6986G polymorphisms. Overall survival (OS) and disease-free survival (DFS) analysis were performed using Kaplan-Meier curves and risk analysis was performed using Cox regression.

Results

We found that GG genotype of CYP3A5 A6986G was associated with a longer DFS (68.6% vs 49%, p=0.019) and lower risk of course with adverse event related to disease (progression, relapse and death) (OR 0.374, CI 0.187-0.745, p=0.011). No significant associations were found between ABCB1 C3435T and ABCG2 C421A genotype with the clinical outcome.

Conclusion

In this study, we demonstrated that in CTCs derived from liquid biopsies, the GG genotype in the CYP3A5 A6986G, which is related to the metabolism and elimination of chemotherapy drugs, impacts in longer DFS. These findings confirm the relevance of circulating biomarkers in non-invasive biological samples for strengthening the prognosis of DLBCL.

Fatty Acid Metabolism Provides an Essential Survival Signal in OxPhos and BCR DLBCL Cells

Backgroung/objectives: Diffuse large B-cell lymphoma (DLBCL) is the most frequent subtype of malignant lymphoma and is a heterogeneous disease with various gene and chromosomal abnormalities. The development of novel therapeutic treatments has improved DLBCL prognosis, but patients with early relapse or refractory disease have a poor outcome (with a mortality of around 40%). Metabolic reprogramming is a hallmark of cancer cells. Fatty acid (FA) metabolism is frequently altered in cancer cells and recently emerged as a critical survival path for cancer cell survival. Methods: We first performed the metabolic characterization of an extended panel of DLBCL cell lines, including lipid droplet content. Then, we investigated the effect of drugs targeting FA metabolism on DLBCL cell survival. Further, we studied how the combination of drugs targeting FA and either mitochondrial metabolism or mTOR pathway impacts on DLBCL cell death. Results: Here, we reveal, using a large panel of DLBCL cell lines characterized by their metabolic status, that targeting of FA metabolism induces massive DLBCL cell death regardless of their OxPhos or BCR/glycolytic subtype. Further, FA drives resistance of DLBCL cell death induced by mitochondrial stress upon treatment with either metformin or L-asparaginase, two FDA-approved antimetabolic drugs. Interestingly, combining inhibition of FA metabolism with that of the mTOR oncogenic pathway strongly potentiates DLBCL cell death. Conclusion: Altogether, our data highlight the central role played by FA metabolism in DLBCL cell survival, independently of their metabolic subtype, and provide the framework for the use of drugs targeting this metabolic vulnerability to overcome resistance in DLBCL patients.

Design and Synthesis of Novel Deazapurine DNMT 1 Inhibitors with In Vivo Efficacy in DLBCL

The application of drugs to regulate abnormal epigenetic changes has become an important means of tumor treatment. In this study, we employed computer-aided design methods to develop a novel deazapurine compound targeting DNA methyltransferase 1 (DNMT1). Through screening for enzyme activity, selectivity, and cellular efficacy, we optimized three structural skeletons, ultimately yielding compound 55, exhibiting an IC50 of 2.42 μM for DNMT1. Compound 55 displayed excellent in vitro inhibitory effects on various hematological tumor and solid tumor cell lines, especially lymphoma cells, with IC50 values in the nanomolar range. In vitro studies confirmed compound 55 selectively inhibited DNMT1 and exhibited demethylation ability. In vivo mouse model validated the DNA methylation inhibition of compound 55. Compound 55 demonstrated good antitumor activity in vivo. Specifically, compound 55 combined with chidamide demonstrated a superior therapeutic effect over the first-line therapy RTX-CHOP in both the DEL and TP53 mutant DLBCL PDX tumor models.

Zanubrutinib plus R-CHOP improves the treatment effect of newly diagnosed diffuse large B cell lymphoma with double expression of MYC and BCL-2

Background

Relevant studies have demonstrated the poor treatment outcomes and prognosis for double-expressor diffuse large B cell lymphoma (DE-DLBCL) in the rituximab era. Zanubrutinib plus R-CHOP (rituximab, cyclophosphamide, doxorubicin/liposomal doxorubicin, vincristine, prednisone; ZR-CHOP) has shown efficacy in untreated non-GCB DLBCL patients with extranodal involvement. However, its efficacy in newly diagnosed DE-DLBCL remains uncertain.

Objective

This retrospective study sought to assess the efficacy and safety of ZR-CHOP in comparison to R-CHOP in treatment-naïve patients with DE-DLBCL.

Method

This study assessed 78 patients with newly diagnosed DE-DLBCL who were admitted between June 2017 and January 2024. Among them, 55 patients received the R-CHOP regimen, while 23 patients were treated with the ZR-CHOP regimen. The clinical characteristics were well balanced between the two groups.

Results

The complete response rates (CRR) were higher in the ZR-CHOP group than the R-CHOP group, regardless of whether patients completed 4 or 6 treatment cycles (P= 0.019; P= 0.025). ORR in the ZR-CHOP group showed a higher trend than that in the R-CHOP group (P= 0.624; P= 0.219). The median follow-up period was 23.3 months, and the predicted median progression free survival (PFS) in the R-CHOP group was 22.8 months, whereas the median PFS in the ZR-CHOP group was not reached. The 1-, 2-, and 3-year PFS rates in the ZR-CHOP group showed a beneficial trend compared with the R-CHOP group, but there was no statistical difference (P= 0.072). However, the PFS of the ZR-CHOP group was longer than that of the R-CHOP group in patients with Ki67 index >75% (P= 0.034) and p53 expression >50% (P= 0.0033). The predicted median overall survival (OS) in the ZR-CHOP and R-CHOP groups were not reached. The 1-, 2- and 3-year OS rates were not significantly different between the two groups (P= 0.29). The most common adverse event in both groups was hematotoxicity, but there was no significant difference in the incidence of all adverse events between the two groups.

Conclusion

First-line treatment with the ZR-CHOP regimen improved CRR in the untreated patients with DE-DLBCL and prolonged PFS in the Ki67 index >75% subgroup and the p53 expression >50% subgroup.

Mastering the complexities of cancer nanomedicine with text mining, AI and automation

In this contribution to the Orations - New Horizons of the Journal of Controlled Release, I present a personal perspective on the complexities of cancer nanomedicine and the approaches to master them. This oration draws mainly from my lab's journey to explore three transformative approaches to master complexities in the field: (1) leveraging text mining to construct dynamic knowledge bases for hypothesis generation in cell-specific drug delivery, (2) introducing the concept of meta-synergy to further optimize and classify multi-drug combinations across dimensions such as chemical loading, pharmacodynamics, and pharmacokinetics (3) utilizing automation to accelerate nanoparticle discovery with advanced screening methodologies such as aggregation-induced emission (AIE). I argue that by embracing complexity in nanomedicine, we can manifest new therapeutic possibilities, paving the way for more effective, precise, and adaptive treatment strategies.

Multilevel Analysis of MYC and BCL2 Aberrations in Diffuse Large B-Cell Lymphoma: Identifying a High-Risk Patient Subgroup Across Cell-of-Origin Using Targeted Sequencing

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) exhibits striking clinical and biological heterogeneity. Recent studies have identified new subgroups within germinal center B-cell like (GCB) DLBCL, associated with inferior prognosis, irrespective of MYC and BCL2 translocations. We explored the existence of such a DLBCL high-risk subgroup, based on multilevel aberrations, especially focusing on MYC and BCL2.

METHODS

Tissue samples from 111 DLBCL patients were sequenced with a 90-gene lymphoma panel, followed by integrative analyses combining sequencing data, immunohistochemistry, fluorescent in situ hybridization, and clinical data.

RESULTS

We identified a high-risk subgroup in DLBCL defined by: dual immunohistochemical MYC and BCL2 expression (DEL), concurrent MYC and BCL2 translocations (DHL-BCL2), mutations in MYC, CXCR4, or both, and/or BCL2 amplification. The high-risk subgroup constituted 41% of the cohort and included DHL-BCL2, DEL, a GCB subgroup likely representing the recently described GCB subgroups, and a subset of non-GCB patients. In multivariate analysis, high-risk features provided independent predictive value from age and IPI. The 5-year overall survival was 36% in high-risk patients, compared to 76% in non-high-risk patients.

CONCLUSION

We identified a distinct high-risk DLBCL subgroup, characterized by MYC and BCL2 aberrations, beyond conventional DHL-BCL2 and DEL, and irrespective of cell-of-origin, thereby expanding the poor-prognosis group.

Current treatment approach and future perspectives in B cell lymphoma

Diffuse large B cell lymphoma (DLBCL) and follicular lymphoma (FL) represent the two major subtypes of mature B cell lymphoma. A deeper understanding of tumor biology, as well as molecular classification characterized by targetable gene alterations, and the introduction of novel treatment options, including targeted drugs (e.g., antibody-drug conjugates and small molecules [e.g., Bruton tyrosine kinase inhibitor]) and immune therapies (e.g., chimeric antigen receptor [CAR] T cell therapy and bispecific antibody [BsAb]), has changed the treatment paradigms for DLBCL and FL. In clinical practice, however, treatment regimens are determined mainly based on prior treatment history, duration of response after previous treatment, patient age, and patient frailty because there have been few randomized trials to inform treatment selection for patients with relapsed or refractory disease and because there is no single prognostic index that guides suitable treatment for each patient. In this review, we summarize the treatment options for DLBCL and FL and discuss the treatment strategies for these two subtypes. We also discuss future perspectives for the treatment of these subtypes.

Usefulness of the 3-hydroxykynurenine/kynurenic acid ratio as a diagnostic biomarker for diffuse larger B-cell lymphoma

ObjectivesReports have shown that the kynurenine pathway, one of the pathways by which tryptophan is metabolized, is activated in patients with diffuse large B-cell lymphoma (DLBCL). Activation of the kynurenine pathway triggers the production of various metabolites, such as kynurenine (Kyn), 3-hydroxykynurenine (3-HK), 3-hydroxyanthranilic acid (3-HAA), kynurenic acid (KA), and anthranilic acid (AA), which contribute to immune tolerance. The current study aimed to investigate the changes in metabolites of kynurenine pathway in DLBCL patients and evaluate their performance predicting DLBCL.MethodsChanges in metabolites of kynurenine pathway were examined using high-performance liquid chromatography in 35 DLBCL patients (age 61.2 ± 13.5 years) and 44 healthy controls (age 58.5 ± 12.5 years).ResultsDLBCL patients had significantly higher levels of 3-HK, AA, and 3-HAA but lower levels of tryptophan (Trp) and KA compared to healthy controls. Given that the ratio of each metabolite represents the change in the Kyn pathway, the 3-HK/KA ratio was examined. Notably, DLBCL patients had a significantly higher 3-HK/KA ratio compared to healthy controls. In DLBCL, the area under the receiver operative characteristic (ROC) curve for 3-HK/KA (0.999) was higher than that for lactate dehydrogenase (0.885) and comparable to that for soluble interleukin-2 receptor (sIL-2R) (0.997). Based on ROC curve analysis, the 3-HK/KA ratio was found to be useful biomarker for the diagnosis of DLBCL.ConclusionOur results suggest that the 3-HK/KA ratio is a clinically useful biomarker of DLBCL. Moreover, its combination with existing markers, such as sIL-2R, can improve its effectiveness of diagnosing DLBCL.

Efficacy and safety of polatuzumab-vedotin plus bendamustine and rituximab in patients with relapsed/refractory diffuse large B-cell lymphoma: A systematic review and meta-analysis

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL), the most common non-Hodgkin's lymphoma subtype, relapses or becomes refractory (R/R) in 40 % of cases after initial treatment. Among the second-line treatments for these patients is CAR T-cell therapy, which is considered the gold standard and treatment better than SCT. For these patients, polatuzumab vedotin in combination with bendamustine and rituximab (Pola-BR) is a novel treatment. The main goal of our research is to evaluate Pola-BR's efficacy in R/R DLBCL patients.

METHODS

We followed PRISMA criteria for conducting this systematic review and meta-analysis. A search was conducted from the start until May 2024 using the Cochrane Library, PubMed, and clinicaltrials.gov. Studies included randomized-controlled trials, observational studies, and single-arm studies assessing Pola-BR efficacy in R/R DLBCL patients. The overall response rate (ORR), partial response (PR), and complete response (CR) were the main outcomes. Using random-effect models, statistical analysis was carried out on OpenMeta[Analyst] software leading to pooled risk ratios with 95 % confidence intervals (CIs).

RESULTS

Eight studies with 398 patients were present in our study. The studies were of high quality, with pooled analysis showing a significant ORR of 52.6 % (95 % CI: 43.6 - 61.6 %), CR of 34.3 % (95 % CI: 23.5 - 45.0 %), and PR of 15.5 % (95 % CI: 8.7 - 22.3 %). Significant hematologic toxicities were observed, the most common being, neutropenia, thrombocytopenia, neuropathy, and anemia.

CONCLUSION

Pola-BR is an effective option for advanced R/R DLBCL but poses significant hematologic toxicity, requiring careful management. Further high-quality randomized trials are needed to better understand and evaluate Pola-BR's success. To fully assess its effectiveness, comparisons with non-cell therapies are essential.

Limited Benefit of Routine Clinical Follow-Up for Relapse Detection in Diffuse Large B-Cell Lymphoma Patients in Complete Remission Following First-Line Treatment

Despite advances in treatment, approximately 15% of patients with diffuse large B-cell lymphoma (DLBCL) who achieve complete remission (CR) after first-line therapy will experience a relapse. However, there is no consensus on the optimal follow-up strategies for detecting relapse after achieving CR. This population-based study, based on the Danish Lymphoma Registry (LYFO), identified a total of 1634 patients diagnosed with DLBCL between 2010 and 2017, including 105 patients who achieved CR following first-line R-CHOP-like therapy and subsequently relapsed. The median follow-up time was 6 years (range 3-8 years). Most cases of relapse were symptomatic (83%), with B symptoms and peripheral lymphadenopathy being the most common. Asymptomatic relapses were identified through physical examination (1%), blood tests (3%), or imaging findings (13%). The proportion of relapses identified outside routine visits was 70%. Only 5% of scheduled routine visits led to a relapse diagnosis, whereas 74% of unscheduled visits initiated by the patient outside routine follow-up resulted in relapse detection. Our findings highlight that systematic, scheduled monitoring of patients in remission after first-line treatment contributes only modestly to the early detection of disease recurrence. Future studies should explore alternative methods of relapse surveillance rather than relying solely on pre-scheduled clinical follow-up.

Association of age and performance status with adverse events in older adults with diffuse large B-cell lymphoma receiving frontline R-CHOP therapy: Alliance 151930, a secondary analysis of the phase III trial CALGB 50303

INTRODUCTION

Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) therapy is the standard of care for patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). However, detailed delineation of toxicity data is limited and has not been examined by age. We sought to examine adverse event data in patients receiving R-CHOP from the Cancer and Leukemia Group B (CALGB) 50303 trial to determine if there were differences in grade 3+ toxicities by age cohort or ECOG performance status (PS), and if outcome was impacted by age cohort or toxicity occurrence.

MATERIALS AND METHODS

CALGB 50303 was an intergroup phase III study for previously untreated patients with DLBCL that included R-CHOP as one of the trial arms. In the subset of 235 evaluable, seemingly fit patients receiving R-CHOP on this trial, data regarding the occurrence of grade 3+ hematologic and non-hematologic toxicities by treatment arm, as well as completion of protocol therapy, overall response rate (ORR), and survival outcome parameters were collected and analyzed for Alliance A151930.

RESULTS

Data were available for further analysis from 235 of 243 patients evaluable for safety, i.e., those who received R-CHOP therapy on this trial, with 165 being <65 years of age, and 70 ≥ 65 years of age. There was an increased rate of grade 3+ non-hematologic (but not hematologic) toxicities in the older age cohorts, after controlling for disease stage and performance status (p < 0.001). One-year and three-year overall survival (OS) were inferior in patients ≥65 years of age, compared to those <65 years of age; there was no difference in one-year or in three-year progression-free survival (PFS) between the age cohorts.

DISCUSSION

Standard frontline therapy with R-CHOP can be effectively administered to an older age cohort. We found more grade 3+ non-hematologic, but not hematologic, toxicities in older patients. These data can be used in clinical trial and real-world settings to identify at-risk DLBCL subgroups for which pro-active measures can be utilized to ensure completion of therapy and optimization of clinical outcomes.

CLINICALTRIALS

gov Identifier: NCT00118209 (CALGB 50303).

Recent progress in cancer vaccines and nanovaccines

Vaccine science, nanotechnology, and immunotherapy are at the forefront of cancer treatment strategies, each offering significant potential for enhancing tumor-specific immunity and establishing long-lasting immune memory to prevent tumor recurrence. Despite the promise of these personalized and precision-based anti-cancer approaches, challenges such as immunosuppression, suboptimal immune activation, and T-cell exhaustion continue to hinder their effectiveness. The limited clinical success of cancer vaccines often stems from difficulties in identifying effective antigens, efficiently targeting immune cells, lymphoid organs, and the tumor microenvironment, overcoming immune evasion, enhancing immunogenicity, and avoiding lysosomal degradation. However, numerous studies have demonstrated that integrating nanotechnology with immunotherapeutic strategies in vaccine development can overcome these challenges, leading to potent antitumor immune responses and significant progress in the field. This review highlights the critical components of cancer vaccine and nanovaccine strategies for immunomodulatory antitumor therapy. It covers general vaccine strategies, types of vaccines, antigen forms, nanovaccine platforms, challenges faced, potential solutions, and key findings from preclinical and clinical studies, along with future perspectives. To fully unlock the potential of cancer vaccines and nanovaccines, precise immunological monitoring during early-phase trials is essential. This approach will help identify and address obstacles, ultimately expanding the available options for patients who are resistant to conventional cancer immunotherapies.

Maplirpacept: a CD47 decoy receptor with minimal red blood cell binding and robust anti-tumor efficacy

Introduction

CD47 is highly expressed on cancer cells and triggers an anti-phagocytic "don't eat me" signal when bound by the inhibitory signal regulatory protein α (SIRPα) expressed on macrophages. While CD47 blockade can mitigate tumor growth, many CD47 blockers also bind to red blood cells (RBCs), leading to anemia. Maplirpacept (TTI-622, PF-07901801) is a CD47 blocking fusion protein consisting of a human SIRPα fused to an IgG4 Fc region and designed to limit binding to RBCs.

Methods

To determine maplirpacept binding to RBCs and interference with blood tests, human blood samples were used. The ability of maplirpacept to promote macrophage-mediated phagocytosis of human tumor cells was assessed using both confocal microscopy and flow cytometry. In vivo antitumor efficacy as a monotherapy and in combination with other therapeutic agents was evaluated in xenograft models.

Results

In the current study, we demonstrate that maplirpacept has limited binding to RBCs while driving enhanced macrophage-mediated phagocytosis of hematological tumor cells in vitro and reducing tumor burden in human xenograft models. Moreover, phagocytosis of neoplastic cells can be enhanced when maplirpacept is combined with other therapeutic agents, including antibodies or chemotherapeutic agents.

Conclusion

These preclinical results establish maplirpacept as an effective CD47 blocker that mitigates the potential for anemia in patients.

Population based registry study on large B-cell lymphoma mortality and morbidity in Finland

BACKGROUND

Large B-cell lymphomas (LBCLs) form a notable subgroup of lymphomas; however, their associated long-term comorbidities and mortality rates remain under-researched in real-world settings.

MATERIAL AND METHODS

This nationwide Finnish population-based matched cohort study included virtually all LBCL patients (N = 7,019) diagnosed from 2008 to 2019, alongside age, sex, and region-matched controls (1:1 ratio) without lymphoma. Diagnoses of LBCLs were obtained from the Finnish Cancer Registry, with data linked to additional nationwide registries. Baseline characteristics were summarised using descriptive statistics. Overall survival (OS) was estimated using the Kaplan-Meier method, while Cox regression was used to analyse factors associated with OS and evaluate the risk and associated factors of comorbidities considering the competing risk of death.

RESULTS

The 5-year survival rate for LBCL patients, median age 70.7 years and 52.7% male, was 50.0% (95% Confidence Interval [CI] 48.7% - 51.3%), compared to 82.6% (95% CI 81.5% - 83.6%) for controls. Among LBCL patients, older age and a higher Charlson comorbidity index were associated with increased mortality. Conversely, female sex, later diagnosis year, and radiation therapy were associated with improved survival. Patients with LBCL exhibited an elevated risk of long-term comorbidities, including solid tumours, hematological and skin cancers, lung and thyroid diseases, mental and behavioral disorders, and cardiovascular diseases. After 12 years of follow-up, lymphoma accounted for the primary cause of death in approximately 43% of LBCL patients.

INTERPRETATION

Large B-cell lymphomas are linked with significant long-term comorbidities and elevated mortality rates.

Primary subdural lymphoma mimicking chronic subdural hematoma: a case report and a narrative review of some recent similar cases in the literature

BACKGROUND

Chronic subdural hematoma (CSDH) is a common condition in elderly patients, typically diagnosed through neuroimaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI). Cases of subdural lymphoma mimicking chronic subdural hematoma are exceedingly rare and present significant diagnostic challenges for emergency physicians.

CASE PRESENTATION

A 71-year-old female patient with subdural lymphoma was initially diagnosed with CSDH based on her medical history, clinical presentation, and neuroimaging findings. However, postoperative pathology revealed diffuse subdural lymphoma. Although the patient's symptoms initially improved following standard lymphoma treatment, the disease recurred within 14 months of follow-up. The patient ultimately succumbed to malignant intracranial hypertension 15 months after discharge.

CONCLUSIONS

This article discusses the neuroimaging findings, histological features, and treatment strategies of this case, while reviewing the limited number of similar cases reported since 2000. Based on the diagnostic and therapeutic experience of this case, it is recommended that when a patient's clinical presentation deviates from that of typical chronic subdural hematoma, supplementary MRI with diffusion-weighted imaging (DWI) should be considered to aid in differential diagnosis.

Analysis of temporal survival trends: considerations and best practice

Monitoring quality of healthcare is vital to ensure that changes made to clinical practice achieve the intended goals. Assessing temporal trends due to the accumulated effect of all changes in clinical practice in a given period is essential in quality monitoring. However, this assesment is compplicated by the fact that numerous of changes might occour over time unrelated to the clinical practice. Furthermore, the methods used to assess temporal trends in patient outcomes in the medical literature are heterogeneous, making it difficult to compare results between studies. In this paper, we describe methods that enable researchers to investigate temporal trends in survival data and we discuss their pros and cons. Numerous unrelated changes may occur over time which must be taken into account and disentangled when assessing the improvement in clinical management. The methods and interpretation thereof are exemplified on patients with diffuse large B-cell lymphoma from the Danish lymphoma registry.