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Davies AJ, Barrans S, Stanton L, Caddy J, Wilding S, Saunders G, Mamot C, Novak U, McMillan A, Fields P, Collins GP, Stephens R, Cucco F, Sha C, van Hoppe M, Tooze R, Davies JR, Griffiths G, Schuh A, Burton C, Westhead DR, Du MQ, Johnson PW. Differential Efficacy From the Addition of Bortezomib to R-CHOP in Diffuse Large B-Cell Lymphoma According to the Molecular Subgroup in the REMoDL-B Study With a 5-Year Follow-Up. J Clin Oncol 2023; 41:2718-2723. [PMID: 36972491 PMCID: PMC10414744 DOI: 10.1200/jco.23.00033] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/10/2023] [Indexed: 03/29/2023] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The REMoDL-B phase III adaptive trial compared rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) versus R-CHOP + bortezomib (RB-CHOP) in patients with diffuse large B-cell lymphoma (DLBCL), stratified by molecular subtype. Primary analysis at a median follow-up of 30 months found no effect of bortezomib on progression-free survival (PFS) or overall survival (OS). Retrospective analysis using a gene expression-based classifier identified a molecular high-grade (MHG) group with worse outcomes. We present an updated analysis for patients successfully classified by the gene expression profile (GEP). Eligible patients were age older than 18 years with untreated DLBCL, fit enough for full-dose chemotherapy, and with adequate biopsies for GEP. Of 1,077 patients registered, 801 were identified with Activated B-Cell (ABC), Germinal Center B-cell, or MHG lymphoma. At a median follow-up of 64 months, there was no overall benefit of bortezomib on PFS or OS (5-year PFS hazard ratio [HR], 0.81; P = .085; OS HR, 0.86; P = .32). However, improved PFS and OS were seen in ABC lymphomas after RB-CHOP: 5-year OS 67% with R-CHOP versus 80% with RB-CHOP (HR, 0.58; 95% CI, 0.35 to 0.95; P = .032). Five-year PFS was higher in MHG lymphomas: 29% versus 55% (HR, 0.46; 95% CI, 0.26 to 0.84). Patients with ABC and MHG DLBCL may benefit from the addition of bortezomib to R-CHOP in initial therapy.
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Affiliation(s)
- Andrew J. Davies
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Sharon Barrans
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Louise Stanton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Josh Caddy
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Sam Wilding
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Geoff Saunders
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | | | - Urban Novak
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrew McMillan
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Paul Fields
- Department of Haematology, Guy's and St Thomas's Hospitals NHS Trust, Kings Health Partners, London, United Kingdom
| | - Graham P. Collins
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford, United Kingdom
| | - Richard Stephens
- National Cancer Research Institute Consumer Forum, London, United Kingdom
| | - Francesco Cucco
- Department of Pathology, University of Cambridge, Cambridge, United Kingdom
| | - Chulin Sha
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Moniek van Hoppe
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Reuben Tooze
- Section of Experimental Haematology, University of Leeds, Leeds, United Kingdom
| | - John R. Davies
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Anna Schuh
- Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Catherine Burton
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - David R. Westhead
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Ming-Qing Du
- Department of Pathology, University of Cambridge, Cambridge, United Kingdom
| | - Peter W.M. Johnson
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Sha C, Barrans S, Cucco F, Bentley MA, Care MA, Cummin T, Kennedy H, Thompson JS, Uddin R, Worrillow L, Chalkley R, van Hoppe M, Ahmed S, Maishman T, Caddy J, Schuh A, Mamot C, Burton C, Tooze R, Davies A, Du MQ, Johnson PW, Westhead DR. Molecular High-Grade B-Cell Lymphoma: Defining a Poor-Risk Group That Requires Different Approaches to Therapy. J Clin Oncol 2019; 37:202-212. [PMID: 30523719 PMCID: PMC6338391 DOI: 10.1200/jco.18.01314] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2018] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Biologic heterogeneity is a feature of diffuse large B-cell lymphoma (DLBCL), and the existence of a subgroup with poor prognosis and phenotypic proximity to Burkitt lymphoma is well known. Conventional cytogenetics identifies some patients with rearrangements of MYC and BCL2 and/or BCL6 (double-hit lymphomas) who are increasingly treated with more intensive chemotherapy, but a more biologically coherent and clinically useful definition of this group is required. PATIENTS AND METHODS We defined a molecular high-grade (MHG) group by applying a gene expression-based classifier to 928 patients with DLBCL from a clinical trial that investigated the addition of bortezomib to standard rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) therapy. The prognostic significance of MHG was compared with existing biomarkers. We performed targeted sequencing of 70 genes in 400 patients and explored molecular pathology using gene expression signature databases. Findings were validated in an independent data set. RESULTS The MHG group comprised 83 patients (9%), with 75 in the cell-of-origin germinal center B-cell-like group. MYC rearranged and double-hit groups were strongly over-represented in MHG but comprised only one half of the total. Gene expression analysis revealed a proliferative phenotype with a relationship to centroblasts. Progression-free survival rate at 36 months after R-CHOP in the MHG group was 37% (95% CI, 24% to 55%) compared with 72% (95% CI, 68% to 77%) for others, and an analysis of treatment effects suggested a possible positive effect of bortezomib. Double-hit lymphomas lacking the MHG signature showed no evidence of worse outcome than other germinal center B-cell-like cases. CONCLUSION MHG defines a biologically coherent high-grade B-cell lymphoma group with distinct molecular features and clinical outcomes that effectively doubles the size of the poor-prognosis, double-hit group. Patients with MHG may benefit from intensified chemotherapy or novel targeted therapies.
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MESH Headings
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Bortezomib/administration & dosage
- Cyclophosphamide/administration & dosage
- Databases, Genetic
- Doxorubicin/administration & dosage
- Female
- Humans
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Middle Aged
- Neoplasm Grading
- Prednisone/administration & dosage
- Proportional Hazards Models
- Randomized Controlled Trials as Topic
- Retrospective Studies
- Rituximab/administration & dosage
- Transcriptome
- Vincristine/administration & dosage
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Affiliation(s)
- Chulin Sha
- University of Leeds, Leeds, United Kingdom
| | | | | | | | | | - Thomas Cummin
- Cancer Research UK Centre and Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | | | | | | | | | | | | | | | - Tom Maishman
- Cancer Research UK Centre and Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Josh Caddy
- Cancer Research UK Centre and Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Anna Schuh
- University of Oxford, Oxford, United Kingdom
| | - Christoph Mamot
- Cantonal Hospital Aarau, Aarau/Swiss Group for Clinical Cancer Research, Switzerland
| | | | | | - Andrew Davies
- Cancer Research UK Centre and Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Ming-Qing Du
- University of Cambridge, Cambridge, United Kingdom
| | - Peter W.M. Johnson
- Cancer Research UK Centre and Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
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Cucco F, Clipson A, Kennedy H, Sneath Thompson J, Wang M, Barrans S, van Hoppe M, Ochoa Ruiz E, Caddy J, Hamid D, Cummin T, Burton C, Davies AJ, Johnson P, Du MQ. Mutation screening using formalin-fixed paraffin-embedded tissues: a stratified approach according to DNA quality. J Transl Med 2018; 98:1084-1092. [PMID: 29769698 DOI: 10.1038/s41374-018-0066-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/30/2022] Open
Abstract
DNA samples from formalin-fixed paraffin-embedded tissues are highly degraded with variable quality, and this imposes a big challenge for targeted sequencing due to false positives, largely caused by PCR errors and cytosine deamination. To eliminate false positives, a common practice is to validate the detected variants by Sanger sequencing or perform targeted sequencing in duplicate. Technically, PCR errors could be removed by molecular barcoding of template DNA prior to amplification as in the HaloPlexHS design. Nonetheless, it is uncertain to what extent variants detected using this approach should be further validated. Here, we addressed this question by correlating variant reproducibility with DNA quality using HaloPlexHS target enrichment and Illumina HiSeq4000, together with an in-house validated variant calling algorithm. The overall sequencing coverage, as shown by analyses of 70 genes in 266 cases of large B-cell lymphoma, was excellent (98%) in DNA samples amenable for PCR of ≥400 bp, but suboptimal (92%) and poor (80%) in those amenable for PCR of 300 bp and 200 bp respectively. By mutation analysis in duplicate in 93 cases, we demonstrated that 20 alternative allele depth (AAD) was an optimal cut-off value for separating reproducible from non-reproducible variants in DNA samples amenable for PCR of ≥300 bp, with 97% sensitivity and 100% specificity. By cross validation with a previously established targeted sequencing protocol by Fluidigm-PCR and Illumina MiSeq, the HaloPlexHS protocol was shown to be highly sensitive and specific in mutation screening. To conclude, we proposed a stratified approach for mutation screening by HaloplexHS and Illumina HiSeq4000 according to DNA quality. DNA samples with good quality (≥400 bp) are amenable for mutation analysis with a single replicate, with only variants at 15-20 AAD requiring for further validation, while those with suboptimal quality (300 bp) are better analysed in duplicate with reproducible variants at >15 AAD regarded as true genetic changes.
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Affiliation(s)
- Francesco Cucco
- Department of Pathology, University of Cambridge, Cambridge, UK
| | | | - Hannah Kennedy
- Department of Pathology, University of Cambridge, Cambridge, UK
| | | | - Ming Wang
- Department of Pathology, University of Cambridge, Cambridge, UK
| | - Sharon Barrans
- HMDS, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Moniek van Hoppe
- HMDS, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Josh Caddy
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Debbie Hamid
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Thomas Cummin
- Cancer Research UK Clinical Centre, University of Southampton, Southampton, UK
| | - Cathy Burton
- HMDS, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew J Davies
- Cancer Research UK Clinical Centre, University of Southampton, Southampton, UK
| | - Peter Johnson
- Cancer Research UK Clinical Centre, University of Southampton, Southampton, UK
| | - Ming-Qing Du
- Department of Pathology, University of Cambridge, Cambridge, UK.
- Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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