Non-MALT marginal zone B-cell lymphomas: a description of clinical presentation and outcome in 124 patients

Marginal zone B-cell lymphoma (MZL) is a recently individualized lymphoma that encompasses mucosa-associated lymphoid tissue (MALT) lymphoma, splenic lymphoma with or without villous lymphocytes, and nodal lymphoma with or without monocytoid B-cells. If the clinical description and outcome of MALT lymphoma is well known, this is not the case for the other subtypes. We reviewed 124 patients presenting non-MALT MZL treated in our department to describe the morphologic and clinical presentation and the outcome of these lymphomas. Four clinical subtypes were observed: splenic, 59 patients; nodal, 37 patients; disseminated (splenic and nodal), 20 patients; and leukemic (not splenic nor nodal), 8 patients. These lymphomas were usually CD5-, CD10-, CD23-, and CD43-, but the detection of one or, rarely, two of these antigens may be observed. Bone marrow and blood infiltrations were frequent, except in the nodal subtype, but these locations were not associated with a poorer outcome. Splenic and leukemic subtypes were associated with a median time to progression (TTP) longer than 5 years, even in the absence of treatment or of complete response to therapy. Nodal and disseminated subtypes were associated with a median TTP of 1 year. However, in all these subtypes, survival was good with a median survival of 9 years, allowing these lymphomas to be classified as indolent. Because of the retrospective nature of this analysis, no conclusion may be drawn on the therapeutic aspects, but conservative treatments seem recommended for leukemic and splenic subtypes. (Blood. 2000;95:1950-1956)

The safety and clinical effectiveness of rapid infusion with CT-P10 in patients with non-Hodgkin's lymphoma or chronic lymphocytic leukemia: A retrospective non-interventional post-authorization safety study in Europe

Rapid infusion (RI) of the rituximab biosimilar CT-P10 is currently only an approved treatment regimen for the treatment of rheumatoid arthritis. Although both CT-P10 and reference rituximab are known to be frequently administered using a RI regimen (≤90 min) in clinical practice, published data on the safety of RI of CT-P10 in patients with NHL and CLL are limited. Hence, this study collected real-world safety and effectiveness data on RI-CT-P10 from the medical records of 196 patients with NHL or CLL in 10 European centers, 6 months after the date of the first RI (index date); the infusion-related reaction (IRR) rate was compared to previously published data. Ten percent (95% confidence interval 6%-15%; n = 20/196) of patients experienced an infusion-related reaction (IRR) on day 1-2 post-index, which was not significantly different (p = 0.45) to the IRR rate for rituximab described in a previous meta-analysis (8.8%). During the observation period, 2% of patients experienced grade 3-5 IRRs and 85% (n = 166) experienced an adverse event (non-IRR). The most common reason for discontinuation of first-line CT-P10 was planned treatment completion (81%; n = 158). Complete response and partial response to CT-P10 was observed in 74% (n = 142/192) and 22% (n = 42/192) of patients, respectively. The results of this real-world study demonstrate that the safety and effectiveness profile of RI-CT-P10 is similar to RI of reference rituximab and therefore support the current use of RI-CT-P10 in patients with NHL and CLL.

Efficacy of a short sandwich protocol, methotrexate, gemcitabine, L-asparaginase and dexamethasone chemotherapy combined with radiotherapy, in localised newly diagnosed NK/T-cell lymphoma: A French retrospective study

Extranodal NK/T-cell lymphoma, nasal type is a rare and aggressive form of lymphoma, historically associated with poor prognosis. We report here the results of a retrospective multi-centre study evaluating the efficacy of MGAD (methotrexate, gemcitabine, L-asparaginase and dexamethasone) regimen (two cycles) combined with 'sandwich' radiotherapy in 35 patients with localised newly diagnosed extranodal NK/T-cell lymphoma. Thirty-two patients (91%) reached complete remission. With a long median follow-up of 59.6 months, progression-free and overall survival at 2 and 5 years were 71%, 80% and 53%, 73%, respectively. Around one third of the patients experienced relapse within a median time of 14.5 months. Side-effects were manageable with grades 3-4 cytopenias, mucositis and infection in 50%, 24% and 21% of the cases, respectively. Monitoring of asparaginase activity was performed in 13 patients and showed inactivation of the drug in seven (54%) patients. Our results indicate that a short therapy by sandwich MGAD chemoradiotherapy is a tolerable and effective treatment option in localised newly diagnosed extranodal NK/T-cell lymphoma patients.

Treatment approaches to asymptomatic follicular lymphoma

Follicular lymphoma is a heterogeneous disease in which some patients present an indolent evolution for decades and others, a rather aggressive form of the disease requiring immediate therapy. While immunochemotherapy has emerged as a standard of care for symptomatic patients, treatment of the asymptomatic population remains controversial. Since the disease is still considered incurable, delayed initiation of therapy is an acceptable option. However, four single injections of rituximab can result in an acceptable clinical response and can improve the duration of the interval without cytotoxic therapy. With recent therapeutic approaches that enable substantial improvements in life expectancy for follicular lymphoma patients, limiting short- or long-term treatment toxicities appears as a new concern in the asymptomatic population. Based on these options, the challenge is to preserve patient quality of life and prolong survival: from the patient's perspective, his/her opinion is therefore of significant importance.

Rituximab in combination with adapted-dose of ifosfamide and etoposide as salvage treatment in elderly refractory/relapsed diffuse large B-cell lymphoma patients non-candidate for high dose therapy: a retrospective study

We retrospectively reviewed for 72 relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) patients ineligible for autologous stem-cell transplantation (ASCT) treated between 2004 and 2017, efficacy and safety profile of rituximab (375 mg/m²) in combination with etoposide (300 mg/m²) and ifosfamide (1500 mg/m²) at 2, 3, or 4-week intervals. Median age was 79 years (range, 64-92). The median number of previous line was 1 (range 1-8). Patients received a median of six cycles (1-12). Fourteen patients (19%) presented partial and 14 complete responses (19%). Among the 369 cycles, nine patients developed febrile neutropenia (13%), 14 a grade 3-4 neutropenia (19%), 7 a grade 3-4 thrombocytopenia (10%) without grade 3-4 non-hematological toxicity. With a median follow up of 7.8 months, the median progression-free survival, overall survival, and duration of response were 4.4 months, 9.4 months, and 12 months, respectively. This regimen represents a therapeutic option in R/R DLBCL patients ineligible to ASCT.

Clinical Practice Recommendations for Hematopoietic Cell Transplantation and Cellular Therapies in Follicular Lymphoma: A Collaborative Effort on Behalf of the American Society for Transplantation and Cellular Therapy and the European Society for Blood and Marrow Transplantation

Follicular lymphoma (FL) is the most common indolent B-cell non-Hodgkin lymphoma (NHL), accounting for nearly one-third of all NHL. The therapeutic landscape for patients with FL has significantly expanded over the past decade, but the disease continues to be considered incurable. Hematopoietic cell transplantation (HCT) is potentially curative in some cases. Recently, the emergence of chimeric antigen receptor T-cell therapy (CAR-T) for patients with relapsed/refractory (R/R) FL has yielded impressive response rates and long-term remissions, but definitive statement on the curative potential of CAR-T is currently not possible due to limited patient numbers and relatively short follow up. A consensus on the contemporary role, optimal timing, and sequencing of HCT (autologous or allogeneic) and cellular therapies in FL is needed. As a result, the American Society of Transplantation and Cellular Therapy (ASTCT) Committee on Practice Guidelines endorsed this effort to formulate consensus recommendations to address this unmet need. The RAND-modified Delphi method was used to generate 15 consensus statements/recommendations. These clinical practice recommendations will help guide clinicians managing patients with FL. Of note, the use of bispecific antibodies in R/R FL was not in the scope of this project.

Immunochemotherapy plus lenalidomide for high-risk mantle cell lymphoma with measurable residual disease evaluation

Chemoimmunotherapy followed by consolidative high-dose therapy with autologous stem cell rescue was a standard upfront treatment for fit patients with mantle cell lymphoma (MCL) in first remission; however, treatment paradigms are evolving in the era of novel therapies. Lenalidomide is an immunomodulatory agent with known efficacy in treating MCL. We conducted a single-center, investigator-initiated, phase II study of immunochemotherapy incorporating lenalidomide, without autologous stem cell transplant consolidation, enriching for patients with high-risk MCL (clinicaltrials gov. Identifier: NCT02633137). Patients received four cycles of lenalidomide-R-CHOP, two cycles of R-HiDAC, and six cycles of R-lenalidomide. The primary endpoint was rate of 3-year progression-free survival. We measured measurable residual disease (MRD) using a next-generation sequencing-based assay after each phase of treatment and at 6 months following end-oftreatment. We enrolled 49 patients of which 47 were response evaluable. By intent-to-treat, rates of overall and complete response were equivalent at 88% (43/49), one patient with stable disease, and two patients had disease progression during study; 3-year progression-free survival was 63% (primary endpoint not met) and differed by TP53 status (78% wild-type vs. 38% ALT; P=0.043). MRD status was prognostic and predicted long-term outcomes following R-HiDAC and at 6 months following end-of-treatment. In a high-dose therapy-sparing, intensive approach, we achieved favorable outcomes in TP53- wild-type MCL, including high-risk cases. We confirmed that sequential MRD assessment is a powerful prognostic tool in patients with MCL.

Atrial arrhythmias following CAR-chimeric antigen receptor T-cell therapy: Incidence, risk factors and biomarker profile

Recent reports have raised concerns about the association of chimeric antigen receptor T cell (CAR-T) with non-negligible cardiotoxicity, particularly atrial arrhythmias. First, we conducted a pharmacovigilance study to assess the reporting of atrial arrhythmias following CD19-directed CAR-T. Subsequently, to determine the incidence, risk factors and outcomes of atrial arrhythmias post-CAR-T, we compiled a retrospective single-centre cohort of non-Hodgkin lymphoma patients. Only commercial CAR-T products were considered. Atrial arrhythmias were nearly fourfold more likely to be reported after CAR-T therapy compared to all other cancer patients in the FAERS (adjusted ROR = 3.76 [95% CI 2.67-5.29]). Of the 236 patients in our institutional cohort, 23 (10%) developed atrial arrhythmias post-CAR-T, including 12 de novo arrhythmias, with most (83%) requiring medical intervention. Atrial arrhythmias frequently co-occurred with cytokine release syndrome and were associated with higher post-CAR-T infusion peak levels of IL-10, TNF-alpha and LDH, and lower trough levels of fibrinogen. In a multivariable analysis, risk factors for atrial arrhythmia were history of atrial arrhythmia (OR = 6.80 [2.39-19.6]) and using CAR-T product with a CD28-costimulatory domain (OR = 5.17 [1.72-18.6]). Atrial arrhythmias following CD19-CAR-T therapy are prevalent and associated with elevated inflammatory biomarkers, a history of atrial arrhythmia and the use of a CAR-T product with a CD28 costimulatory domain.

Deep immunophenotypic dissection and clinical impact of T cells in the follicular lymphoma microenvironment

Follicular lymphoma (FL) is an indolent B cell lymphoma with a heterogenous disease course, and patients may not require immediate treatment upon diagnosis. Scrutiny of its microenvironment may provide key insights into lymphomagenesis and enhancement of therapeutic options. We analyzed the T-cell composition of a large, well-annotated follicular hyperplasia (FH; n=43) cohort utilizing standardized high dimensionality flow cytometry (>150,000 cells analyzed/sample) and a novel reproducible analytical pipeline leading to identification of even minor T-cell subsets. This baseline reference set was compared to prospectively collected FL samples (n=91) from untreated patients (FL-UT) and patients with relapsed/refractory disease (FL-RR). Compared to FH, both FL-UT and FL-RR specimens exhibited depletion of CD4+ and CD8+ naive subsets and were characterized by an immune suppressive microenvironment enriched in specific inhibitory T-cells, along with exhausted memory T-cells overexpressing varying combinations of immune checkpoint receptors. FL specimens showed enrichment of T follicular regulatory cells (TFR) and two highly suppressive regulatory T-cell (Treg) populations expressing TIGIT and CTLA4 (TC) and PD1, TIGIT, CTLA4, and TIM3 (PTCTi). FL-UT cases with either increased T-reg TC or increased T follicular helper cells (TFH) showed reduced time to first treatment (.

Abstract 4921: Population pharmacokinetic modeling of ibrutinib administered in patients with relapsed or refractory B cell malignancies eligible for autologous stem cell transplantation

Background: Ibrutinib is a first-in-class selective, irreversible small molecule inhibitor of Bruton's tyrosine kinase (BTK). The present study's aim is to assess the feasibility and safety and pharmacokinetics (PK) of escalating doses of ibrutinib combined with rituximab (R), dexamethasone (D), ara-C (HA) and one of two platinum compounds (cisplatinum (P) or oxaliplatinum (Ox)) in patients with relapsed or refractory lymphoma. As part of this, Population PK (POPPK) modeling, PK parameters, and inter-individual and inter-occasion variabilities of oral ibrutinib in the presence of R-DHA(P/Ox) were assessed during the dose escalation part of this clinical trial.

Materials and methods: Dataset was obtained from an open label, multicenter, dose escalation, phase Ib study of ibrutinib in combination with R-DHA (P/Ox) in patients with B-cell malignancies. Patients received three doses (280, 420, 560 mg) of oral ibrutinib once a day D5 to D18. Blood samples were collected during cycles 1 and 2 on D5, Just before ibrutinib intake (T0) and at 1, 2 and 4 hours after ibrutinib intake and on D15 at T0 and 1 hour after ibrutinib intake. Ibrutinib plasma concentrations were measured using validated ultra-performance liquid chromatography with tandem mass spectrometry detection with a concentration range 1-400ng/mL. Analyses and POPPK modeling were performed with the nonlinear mixed effect modeling software program Monolix version 4.3.2. The following parameters were calculated Lagtime (Tlag), absorption constant (Ka); apparent distribution volumes (V1/F, V2); apparent clearances (CL/F, Q).

Results: 24 pts (18 male, 6 female), have validated PK data with 184 plasma concentrations. A 2-compartment model with linear elimination and lag time adequately described the total ibrutinib time-concentration curve. The main PK parameters (RSE%) estimated for ibrutinib were Tlag=0.6 (15), Ka=3.36 (36) h-1, CL/F= 699 (12) L/h, Q=182 (1) L/h, V1/F=5,060 (15) L, and V2=32,100 (49) L. The main covariate effect on ibrutinib CL was related to body weight (BW). The inter-individual and variabilities could be well estimated for CL and V1 and inter-occasion variabilities were well estimated for Tlag and V1.

Conclusions: The POPPK modeling satisfactorily described the plasma ibrutinib time-concentration curves in patients. Our data revealed the effect of BW on ibrutinib PK parameters. A large volume of the deep compartment suggest that ibrutinib has large tissue diffusion. The clinical data describes the toxicity and efficacy. This is an analysis of correlation between the PK and the clinical outcomes.

Citation Format: Keyvan Rezai, Olivier Madar, Christophe Bonnet, Jean Dupuis, Hervé Tilly, Thierry Lamy de la Chapelle, Steven Le Gouill, Ombeline Verite, Julie Assemat, Fanny Bret, Sophie Weill, François Lokiec, Gilles Salles. Population pharmacokinetic modeling of ibrutinib administered in patients with relapsed or refractory B cell malignancies eligible for autologous stem cell transplantation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4921.

[Contribution of dual CD13/CD14 markers in combination with CD34 for the collection of peripheral hematopoietic stem cells]

We evaluated the reliability of a flow cytometry technique for counting mononuclear cells (MNCs) in cytapheresis products. Eighty freshly-prepared samples of peripheral stem cells were studied using a dual immunolabeling technique with antibodies to CD13/CD14, and were also labeled with anti-CD34. Results of this immunophenotype determination were compared to those of the conventional method for counting MNCs under the microscope. Dual CD13/CD14 labeling was found to be a simple and reliable method for counting MNCs in the presence of immature and stimulated cells. When used in combination with CD34 labeling, the dual immunolabeling method helped improve the evaluation of the quality of peripheral stem cell grafts.

High CD34(+) cell counts decrease hematologic toxicity of autologous peripheral blood progenitor cell transplantation

Optimal numbers of CD34(+) cells to be reinfused in patients undergoing peripheral blood progenitor cell (PBPC) transplantation after high-dose chemotherapy are still unknown. Hematologic reconstitution of 168 transplantations performed in patients with lymphoproliferative diseases was analyzed according to the number of CD34(+) cells reinfused. The number of days from PBPC reinfusion until neutrophil recovery (>1.0 x 10(9)/L) and unsustained platelet recovery (>50 x 10(9)/L) were analyzed in three groups defined by the number of CD34(+) cells reinfused: a low group with less than or equal to 2.5 x 10(6) CD34(+) cells/kg, a high group with greater than 15 x 10(6) CD34(+) cells/kg, and an intermediate group to which the former two groups were compared. The 22 low-group patients had a significantly delayed neutrophil (P < .0001) and platelet recovery (P < .0001). The 41 high-group patients experienced significantly shorter engraftment compared with the intermediate group with a median of 11 (range, 8 to 16) versus 12 (range, 7 to 17) days for neutrophil recovery (P = .003), and a median of 11 (range, 7 to 24) versus 14 (range, 8 to 180+) days for platelet recovery (P < .0001). These patients required significantly less platelet transfusions (P = .002). In a multivariate analysis, the amount of CD34(+) cells reinfused was the only variable showing significance for neutrophil and platelet recovery. High-group patients had a shorter hospital stay (P = .01) and tended to need fewer days of antibotic administration (P = .12). In conclusion, these results suggest that reinfusion of greater than 15 x 10(6) CD34(+) cells/kg after high-dose chemotherapy for lymphoproliferative diseases further shortens hematopoietic reconstitution, reduces platelet requirements, and may improve patients' quality of life.

Mucosa-associated lymphoid tissue lymphoma is a disseminated disease in one third of 158 patients analyzed

Mucosa-associated lymphoid tissue-derived lymphoma (MALT lymphoma) is usually a very indolent lymphoma, described as localized at diagnosis and remaining localized for a prolonged period; dissemination occurs only after a long course of evolution. In our database, out of 158 patients with MALT lymphoma, 54 patients presented with a disseminated disease at diagnosis. Of these 54 patients, 17 patients (30%) presented with multiple involved mucosal sites; 37 patients (70%) presented with 1 involved mucosal site, but in 23 of these patients (44%), dissemination of the disease was due to bone marrow involvement; 12 patients (22%) had multiple lymph node involvement; and 2 patients (4%) had nonmucosal site involvement. No significant difference in clinical characteristics (sex, age, performance status, B symptoms) and biological parameters (hemoglobin [Hb] and lactate dehydrogenase levels) was observed between localized or disseminated MALT-lymphoma patients. Only beta2-microglobulin level was significantly more elevated in disseminated disease patients than in localized disease patients. Complete response after the first treatment was achieved in 74% of the patients, and there was no difference between the 2 groups. With a median follow-up of 4 years, the estimated 5- and 10-year overall survival rates were similar in the 2 groups, 86% and 80%, respectively. The median freedom-from-progression survival was 5.6 years for all patients, surprisingly without any difference between localized and disseminated MALT-lymphoma patients. In conclusion, MALT lymphoma is an indolent disease but presents as a disseminated disease in one-third of the cases at diagnosis. The dissemination does not change the outcome of the patients.

Tumor necrosis factor-alpha mRNA stability in human peripheral blood cells after lipopolysaccharide stimulation

TNF synthesis depends on many controls at transcriptional and post-transcriptional levels, including in particular mRNA stability and translational efficiency through the AU-rich elements (ARE) in the 3'untranslated region (3'UTR) of mRNA. We have previously reported that upon lipopolysaccharide (LPS) stimulation, TNF protein secreted by normal peripheral blood cells (PBC) from non-Hodgkin's lymphoma patients was slightly, but not significantly increased when compared to healthy control donors. In contrast, the relative amounts of TNF mRNA were significantly higher in lymphoma patients. Thus, the implication of TNF mRNA stability has been explored by investigating the decay rate of LPS-induced TNF mRNA and the expression of tristetraprolin (TTP), one of the factors involved in the destabilization of TNF mRNA. After LPS incubation, peak levels of TTP mRNA preceded those of TNF mRNA, supporting its implication in the control of TNF mRNA levels in human PBC. Furthermore, similar TTP expression in both groups correlated with an identical decay rate of TNF mRNA, which excludes this pathway for the higher LPS-induced TNF mRNA levels in PBC from lymphoma patients.