ALBERT

Beschreibung: Introduction Patients (pts) diagnosed with double hit lymphoma (DHL) are reported to experience poor survival outcomes following first-line treatment with R-CHOP, although survival may be improved with receipt of intensive front-line immunochemotherapy. These results may be altered by selection bias, as prior retrospective series of DHL pts did not report performing routine cytogenetic testing to identify those with DHL. We hypothesized that outcomes might differ for DHL pts identified after the implementation of routine testing at our institution. Methods In January of 2015, our institution began routine testing for MYC-rearrangement (R) by fluorescence in situ hybridization (FISH) for all newly-diagnosed cases of DLBCL and HGBL/BCLU, with reflex testing for BCL2-R and BCL6-R by FISH if positive for MYC-R. Prior to this, FISH for MYC-R, BCL2-R and/or BCL6-R was performed at the discretion of the treating physician or interpreting hematopathologist. Pts included in our analysis were diagnosed with DHL from May 2009 through July 2018. Inclusion criteria were adults treated with first-line curative-intent immunochemotherapy. Exclusion criteria were HIV-associated lymphoma, primary CNS or testicular lymphoma, post-transplant lymphoproliferative disorder, and incomplete clinicopathologic and outcomes data. Primary outcome measures were progression free survival (PFS) and overall survival (OS) in the pre-January 2015 selective testing (ST) and post-January 2015 routine testing (RT) cohorts. Data were censored on 5/31/19. Results Sixty-five pts were included in the analysis. The ST and RT cohorts did not differ significantly on the baseline characteristics of age, sex, stage, performance status, B symptoms, elevated LDH, extranodal disease, stage III/IV, blood or bone marrow involvement, International Prognostic Index score, Ki67, cell of origin, expression of MYC or BCL2 protein or the combination, time from diagnosis to treatment 〉14 days, disease bulk 〉 7.5 cm, transformation from an indolent lymphoma, or front-line treatment with R-CHOP vs intensive immunochemotherapy. Eighty percent (n=52) of pts received intensive front-line immunochemotherapy, most with R-EPOCH (n=42). Median length of follow-up was 32 months (61 months for ST and 24 months for RT). The RT group had a longer 2-year PFS 70% vs 43%, p=0.02; univariate hazard ratio (HR) for progression 2.4, 95% confidence interval (CI) 1.1-5.4, p=0.03, (Figure 1A). The only other variable associated with progression was presence of extranodal disease (HR 2.35, 95% CI 1.0-5.4, p=0.047). In a multivariate model, both ST and the presence of extra-nodal disease were independently associated with progression at 2 years (HR 2.84, 95% CI 1.3-6.4, p=0.012 and HR 2.79, 95% CI 1.2-6.5, p=0.018, respectively). Longer OS was observed with RT (median OS NR vs 16 months, 2-year OS 72% vs 41%, p=0.008; HR 2.97 95% CI 1.3-6.9, p=0.012, Figure 1B). No other factors were associated with longer OS. For pts who relapsed after first-line therapy, survival was poor with a median OS after relapse of 6 and 5 months in the RT and ST groups (p=0.11). When limiting the analysis to only those pts treated with intensive immunochemotherapy, median PFS and OS remained significantly longer for the RT group (2-year PFS 70% vs 38%, p=0.01; median OS NR vs 16 months and 2-year OS 74% vs 38%, p=0.007). Post-relapse survival was similarly poor for those treated with intensive induction regardless of RT vs ST (median post-relapse OS 6 vs 5 months, p=0.1). Conclusions Long-term survival may be improved for DHL pts identified through routine as opposed to selective FISH testing. These data could serve as a new baseline for outcomes of DHL pts identified in this manner. Survival outcomes for our cohort of pts treated with intensive immunochemotherapy are similar to those for DHL pts reported in a recent prospective multicenter study of front-line R-EPOCH (Lancet Haematol. 2018 Dec;5(12):e609-e617). While we suspected that the poorer outcomes experienced by ST pts may have been due to high-risk clinicopathologic factors that contributed to selection bias in testing, this does not seem to be the case for any measured factors. It may be that variation in additional molecular features within this high-risk cytogenetic population could explain differences in survival, and next generation sequencing analysis of DHL patient tissue specimens is planned. Disclosures Dwivedy Nasta: Celgene: Honoraria; ATARA: Research Funding; Pharmacyclics: Research Funding; Rafael: Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees; Roche: Research Funding; 47 (Forty Seven): Research Funding; Millenium/Takeda: Research Funding; Debiopharm: Research Funding; Aileron: Research Funding. Schuster:Merck: Honoraria, Research Funding; Novartis: Honoraria, Patents & Royalties: Combination Therapies of CAR and PD-1 Inhibitors with royalties paid to Novartis, Research Funding; Loxo Oncology: Honoraria; Pharmacyclics: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Genentech: Honoraria, Research Funding; Nordic Nanovector: Honoraria; AstraZeneca: Honoraria; Pfizer: Honoraria; Acerta: Honoraria, Research Funding; AbbVie: Honoraria, Research Funding; Gilead: Honoraria, Research Funding. Svoboda:AstraZeneca: Consultancy; Celgene: Research Funding; Incyte: Research Funding; Pharmacyclics: Consultancy, Research Funding; Kyowa: Consultancy; Merck: Research Funding; BMS: Consultancy, Research Funding; Seattle Genetics: Consultancy, Research Funding. Barta:Janssen: Membership on an entity's Board of Directors or advisory committees; Mundipharma: Honoraria; Celgene: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees; Takeda: Research Funding; Seattle Genetics: Honoraria, Research Funding; Bayer: Consultancy, Research Funding; Mundipharma: Honoraria; Merck: Research Funding; Celgene: Research Funding. Gerson:Abbvie: Consultancy; Seattle Genetics: Consultancy; Pharmacyclics: Consultancy. Chong:Merck: Research Funding; Tessa: Consultancy; Novartis: Consultancy. Rhodes:DAVA Oncology: Honoraria. Landsburg:Takeda: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Takeda: Research Funding; Curis, INC: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Curis, INC: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Seattle Genetics: Speakers Bureau; Seattle Genetics: Speakers Bureau; Triphase: Research Funding; Triphase: Research Funding.

Beschreibung: Introduction: Preclinical data have suggested that B-cell receptor-associated genes are upregulated in diffuse large B cell lymphoma (DLBCL) with increased expression of MYC protein, as well as MYC and BCL2 protein, also known as "double expressor" lymphoma (DEL) (Am J Surg Pathol. 2017 Apr;41(4):541-549 and PLoS One. 2017 Feb 17;12(2):e0172364). Patients (pts) with DEL respond poorly to cytotoxic chemotherapy; thus novel treatment approaches are needed for this disease. Here, we report outcomes of pts with relapsed/refractory (R/R) DLBCL and high grade B cell lymphoma (HGBL) treated with ibrutinib (ibr) monotherapy. Methods: Pts analyzed were those with R/R DLBCL or HGBL treated with ibr monotherapy at University of Pennsylvania, Ohio State University or Cleveland Clinic with immunohistochemical (IHC) stains for MYC and BCL2 from the tissue specimen obtained most recently prior to initiation of ibr available for hematopatholoigst (HP) review, and determined to have IHC scores of ≥40% for MYC and ≥50% for BCL2, meeting criteria for definition of DEL. Exclusion criteria were HIV positivity, post-transplant lymphoproliferative disorder, prior chronic lymphocytic leukemia and inadequate data. All available IHC stains for MYC and BCL2 were scored as positive or negative as per the aforementioned cutoffs by a HP at the treating center (HP1) as well as a second HP at one of the other centers (HP2) through review of digital slide images. In cases of disagreement, the score assigned in the clinical pathology report (CPR) was used as a tiebreaker. Progression free survival (PFS) was defined as the interval between time of initiation of ibr and documented disease progression, change in therapy (tx) if no disease response or last follow-up in remission, and overall survival (OS) between time of initiation of ibr and death or last follow-up while alive. Data were censored on 7/1/18. Results: Twenty-five cases with IHC stains for MYC and BCL2 were reviewed, with 19 meeting criteria for DEL which were included in the analysis. Clinicopathologic characteristics at time of ibr initiation were median age 69 years, 32% female, 63% stage III-IV, 74% elevated LDH, 11% bone marrow (BM) involvement, 11% B symptoms present, 21% extranodal (EN) disease at 〉1 site, 32% ECOG performance status (PS) 〉1, 58% with International Prognostic Index score (IPI)≥3, 26% HGBL, median Ki67 80% and 21% germinal center (GCB) cell of origin (COO) by Hans algorithm. Of pts with available fluorescence in situ hybridization (FISH) data, 50% (7/14), 25% (3/12) and 14% (1/7) demonstrated MYC, BCL2 and BCL6 rearrangements, respectively, and 3 pts were known to be double hit lymphoma. First-line tx was R-EPOCH in 26% and R-CHOP in 74%. Autologous stem cell transplantation was received by 42% prior to treatment with ibr. The proportion of pts receiving ibr as 2nd, 3rd, 4th and ≥5th line of tx was 21%, 37%, 21% and 21%, respectively. The time from initiation of the prior line of tx to initiation of ibr was 12 mo in 79%, 16% and 5%, respectively. Overall response to ibr was 47% (37% complete response and 10% partial response) and 5% with stable disease. All responses were seen in pts with non-GCB COO. The median PFS was 4.7 mo, median OS 5.5 mo and median duration of response 4.2 mo. For all cases reviewed (n=25), MYC IHC was scored by HP1 and HP2 and available in the CPR in 100%, 84% and 88%, respectively, and BCL2 IHC in 100%, 84% and 100%, respectively. Rates of concordance and kappa (κ) coefficient were as follows: HP1 and HP2 for MYC 85.7% (κ=0.49), BCL2 95.2% (κ=0.64) and DEL 84.0% (κ=0.61); HP1 and CPR for MYC 86.3% (κ=0.70), BCL2 96.0% (κ=0.78) and DEL 81.8% (κ=0.62); HP2 and CPR for MYC 66.7% (κ=0.18), BCL2 90.5% (κ=0.45) and DEL 68.2% (κ=0.34). In 4 cases with disagreement between HP1 and HP2 regarding DEL status, the CPR agreed with HP1, and 4 cases were identified as DEL by both HP1 and HP2 but not by CPR. Conclusion: An objective response to ibr was experienced by nearly half of pts with R/R DEL as defined by multicenter HP review in this series. Our data suggest a potential benefit to the use of ibr monotherapy as bridging tx to curative-intent cellular tx, as well as support the incorporation of ibr into clinical trials for the R/R DEL pt population. A relatively high rate of concordance between HP1 and CPR in identifying cases of DEL suggests that local review of MYC and BCL2 IHC may be a reasonable alternative for determining DEL status when central review is infeasible. Disclosures Landsburg: Curis, INC: Consultancy, Research Funding; Takeda: Research Funding. Maddocks:Novartis: Research Funding; Pharmacyclics/Janssen: Honoraria; BMS: Research Funding; Merck: Research Funding; Pharmacyclics: Research Funding; AstraZeneca: Honoraria; Teva: Honoraria. Hill:Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Genentech: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees. Dwivedy Nasta:Incyte: Research Funding; Merck: Other: DSMC; Pharmacyclics: Research Funding; Aileron: Research Funding; Roche: Research Funding; Takeda/Millenium: Research Funding; Rafael/WF: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Debiopharm: Research Funding. Svoboda:Regeneron: Research Funding; TG Therapeutics: Research Funding; Seattle Genetics: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Merck: Research Funding; Pharmacyclics: Consultancy, Research Funding; KITE: Consultancy; Kyowa: Consultancy. Schuster:Physician's Education Source, LLC: Honoraria; Dava Oncology: Consultancy, Honoraria; Merck: Consultancy, Honoraria, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; OncLive: Honoraria; Genentech: Honoraria, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees; Novartis Pharmaceuticals Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Nordic Nanovector: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.