o Onkološki Institut Institute of Oncology Ljubljana gijo j Slovensko f Zdravniško Društvo Strokovni odbor: prof. dr. Barbara Jezeršek-Novakovic, dr.med. doc. dr. Lučka Boltežar, dr.med. doc. dr. Gorana Gašljevic, dr.med. prof. dr. Veronika Kloboves Prevodnik, dr.med. Organizacijski odbor: prof. dr. Barbara Jezeršek-Novakovic, dr.med. doc. dr. Lučka Boltežar, dr.med. doc. dr. Gorana Gašljevic, dr.med. prof. dr. Veronika Kloboves Prevodnik, dr.med. Lidija Kristan Urednik zbornika: Marko Boc, dr.med. Organizator in izdajatelj (založnik): Onkološki inštitut Ljubljana Sekcija za internistično onkologijo pri SZD Katedra za onkologijo Medicinske fakultete v Ljubljani Zborniki šol in ostale publikacije s strokovnih dogodkov so dosegljivi na spletnih straneh OI: www.onko-i.si/publikacije-strokovnih-dogodkov-oi Ljubljana, oktober 2023 PROGRAMME Thursday 19.10.2023 Chairman: prof. Veronika Kloboves Prevodnik, dr. Gorana Gašljevic 9.00 - 9.10: Opening speach (dr. Gašljevic, prof. Kloboves Prevodnik) 9.00 - 9.45: 5th WHO classification of Lymphoid malignanices (prof. Andrew Wotherspoon, The Royal Marsden, England) 9.45 -10.00: A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System (prof. Kloboves Prevodnik) 10.00 - 10.40: Treatment of ALL and flow cytometric analyses of MRD (prof. Michael Dworzak, St. Anna Kinderspital, Vienna, Austria) 10.40 - 11.00: Treatment of ALL - our centre experience (assist. prof.. Matevž Škerget, Dept. Of Hematology, University Clinical Centre Ljubljana, Slovenia) 11.00 - 11.30: Coffee break 11.30 - 12.30: Pathology and cytopathology workshops part I Case1. Gazic Barbara, Klopčič Ulrika: T-cell lymphoblastic lymphoma vs thymoma in effusion as well as in small biopsies Case 2. Gazic Barbara, Klopčič Ulrika: Nodal B-cell lymphoblastic lymphoma and its pitfalls in cytopathology Case 3: Grčar-Kuzmanov Biljana, Kloboves Prevodnik Veronika: Classical Hodgkin lymphoma vs Primary mediastinal large B-cell lymphoma Case 4. Grčar-Kuzmanov Biljana, Rode Aleš: Burkitt lymphoma vs diffuse large B-cell lymphoma 12.30 - 13.15: Lunch 13.15-14.15: Pathology and cytopathology workshops part II Case 5. Gašljevic Gorana, Jeričevic Anja: Nodular lymphocyte predominant Hodgkin lymphoma vs T-cell/histiocyte rich large B-cell lymphoma Case 6. Gašljevic Gorana, Jeričevič Anja: Classical Hodgkins lymphoma vs Nodular lymphocyte predominant Hodgkin lymphoma Case 7. Wotherspoon Andrew: Criteria for transformation of MZL into DLBCL ( Case 8. Car Milan, Rode Aleš: PEL versus PAL Flow cytometry workshop in flow lab (3hours, parallel to patho workshop) Friday 20.10.2023 Chairman: prof. Barbara Jezeršek Novakovic, assist. prof. Lučka Boltežar 9.00 - 09.30: Molecular pathogenesis of DLBCL (prof. Andrew Wotherspoon, The Royal Marsden, England) 09.30 - 10.00: Risk stratification in DLBCL - clinical prognostic factors, molecular prognostic factors (prof. Thomas Melchardt, SALK, Paracelsus Medical University Salzburg, Austria) 10.00 - 10.15: First line treatment of DLBCL in regard to molecular pathogenesis (Milica Miljkovic, Institute of Oncology Ljubljana, Slovenia) 10.15 - 10.45: Coffee break 10.45 - 11.05: Favorable and unfavorable subtypes of DLBCL (dr. Gorana Gašljevic, Urška Rugelj, Institute of Oncology Ljubljana, Slovenia) 11.05 - 11.25: Treatment of R&R DLBCL in regard to molecular pathogenesis (prof. Barbara Jezeršek Novakovic, Institute of Oncology Ljubljana, Slovenia) 11.25 - 11.45: Treatment of R&R DLBCL - our centre experience (Maria Cristina Pirosa, Institute of Southern Switzerland, Switzerland) 11.45 - 12.05: Treatment of R&R DLBCL - our centre experience (assist. prof. Lučka Boltežar, Institute of Oncology Ljubljana, Slovenia) 12.05 - 12.30: Discussion 12.30 - 13.30: Lunch 13.30 - 15.00: Difficult cases presentations and discussion (assist. prof. Lučka Boltežar, Maria Cristina Pirosa, Institute of Southern Switzerland, Switzerland, Aleš C. Mihelač, Tina Zupančič, Anja Žižek, Institute of oncology, Ljubljana, Slovenia) AVTORJI PRISPEVKOV V ZBORNIKU "3. LIMFOMSKA ŠOLA": prof. dr. Barbara Jezeršek-novakovic, dr.med., specialistka interne medicine in internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana prof. dr. Veronika Kloboves Prevodnik, dr.med., specialistka citopatologinja Oddelek za citopatologijo, Onkološki inštitut Ljubljana Aleš Christian Mihelač, dr.med., specialist hematologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana Milica Miljkovic, dr.med, specialistka internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana doc. dr. Lučka Boltežar, dr.med., specialistka internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana Urška Rugelj, dr.med., specialistka internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana Tina Zupančič, dr.med., specializantka internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana Anja Žižek, dr.med., specializantka internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana MODERATORJI NA SREČANJU: doc. dr. Lučka Boltežar, dr.med., specialistka internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana prof. dr. Barbara Jezeršek Novakovic, dr.med., specialistka interne medicine in internistične onkologije Sektor za internisti čno onkologijo, Onkološki inštitut Ljubljana prof. dr. Veronika Kloboves Prevodnik, dr.med., specialistka citopatologije Oddelek za citopatologijo, Onkološki inštitut Ljubljana doc. dr. Gorana Gašljevic, dr.med., specialistka citopatologinja Oddelek za citopatologijo, Onkološki inštitut Ljubljana KAZALO Jezeršek-Novakovic B.: Treatment of R&R DLBCL in regard to molecular pathogenesis_07 Miljkovic M.: First line treatment of DLBCL in regard to molecular pathogenesis_23 Boltežar L: Treatment of R&R DLBCL - our centre experience_37 Kloboves Prevodnik V.: A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System_43 Rugelj U.: Favorable and unfavorable subtypes of DLBCL_53 Mihelač A.C.: Clinical case of refractory DLBCL_61 Zupančič T.: Nine-years up-to-date treatment of follicular lymphoma transformed to DLBCL_65 Žižek A.: Clinical case presentation_70 Treatment of relapsed/refractory diffuse large B-cell lymphoma in regard to molecular classification Prof. Barbara Jezersek Novakovic, MD, PhD 3rd Lymphoma School October 2023 Introduction: an overview of the current status of DLBCL treatment DLBCL encompasses a wide variety of disease states to date characterized based on IHC methods "=> limited prognostic value to clinicians, no alteration in treatment regimen. The addition of R to CHOP last improvement in terms of treatment. When disease becomes refractory "=> regimens follow a standardized course with no individualization based on genotype. Guidelines direct standardized R-CHOP as first line treatment (regardless of presentation or cellular markers), and refractory cases are treated uniformly with second line therapy in combination with HCT, CAR T-cell therapy, clinical trials, or finally palliative care. 7 Treatments agnostic for genetic diversity of the DLBCL. Treatments agnostic for internal disease mechanisms (as opposed to outward morphology or presence of basic cell markers). Indiscriminate therapy based on patient response. FrontzekF et al. Current options and future perspectives inthe treatment of patients with relapsed/refractory diffuse large B-cell lymphoma. Ther Adv Hematol 2022, Vol. 13: 1-19. Introduction: current trends Research groups propose new strategies for categorizing DLBCL based on genetic abnormalities that are frequently found together to better predict disease course and to deliver targeted treatment. Identification of genetic markers that alter disease course is essential: ■ for implementation of effective treatment ■ to indicate which patients may require less potent treatment or less invasive surveillance in looking for relapse. Novel algorithms in combination with NGS have identified between 4 and 7 subgroups of DLBCL with potentially significant and actionable genetic alterations. 8 Subgroup by cell origin COO IHC in combination with various algorithms have allowed the basic classification of DLBCL into two groups, ABC and GCB type, which has provided some prognostic insight into disease course without yielding much into targeted therapies for these distinct subtypes. The heterogeneity of treatment outcomes, even among ABC and GCB subtypes, results from the specific pathways with altered regulation, expression, or end products that are not defined by classical subtyping. The current ABC and GCB subtypes provide relatively little utility because they do not take in account the numerous changes that can occur within the genome that are not observable with IHC staining techniques. Subgroup by cell origin COO Activated B-cell like type (ABC): Cells tend to express common mutations and translocations, such as PRDM1 truncations or homozygous deletions. These cells show increased incidence of "chronic active" BCR signaling which is characterized by BCR clustering and autoreactive selfantigens as opposed to tonic signaling which is antigen independent and exhibits a lack of BCR clustering, as seen in GCB. MYD88 mutations conferring extranodal involvement, TNFAIP3 inactivation leading to uncontrollable NF-kB expression, and NOTCH1 mutations are seen almost exclusively in this subtype. Germinal center B-cell like type (GCB): Cells are affected by the master regulator BCL6 similarly to ABC cells, but also are affected by more unique mutations. These possess an association with REL amplifications promoting lymphomagenesis, an almost exclusive presentation of t(14;18)(q32; q21) translocations leading to BCL2 activation and overexpression, and CREBBP mutation affecting the histone acetyltransferase domain leading to epigenetic dysregulation. 9 Subgroup by genetic alteration and signaling pathway Molecular classification Wright Schmitz Lacy Chapuy Genetic alteration (% prevalance*) BN2 BN2 NOTCH2 CI BCL6 (72.8%), NOTCH2 (41.8%), TNFA1P3 (51.6%), DTX1 (50.0%), CD70(41.3%), BCL10 (39.6%), UBE2A (30.4%), TMEM30A (26.7%), KLF2 (21.7%), SPEW (21.7%) A53 - C2 TP53 (86.8%),B2M(M2),TP53BP1 (27.0%), CNPY3 (23.7%),ING1 (15.8%),NTKBIZ (15.8%), »7.3(13.2%) EZB-MYC+ EZB-MYC- EZB BCL2 C3 BCL2 (68.4%), EZH2 (44.7%), TNFRSF14 (66.2%), KMT2D (53.9%), CREBBP (52.7%), REL (34.3%), FAS (30.1%), IRF8 (28.9%), EP30C (27.8%), MEF2B (26.3%), C11TA (25.0%), ARID1A (22.9%), GNA13 (22.5%), STAT6 (21.1%), PTEN (20.0%) ST2 TET2/SGK1 SOCS1/SGK1 C4 TET2 (48.1%), DUSP2 (44.4%), ZFP36L1 (40.7%), ACTG1 (37.0%), SGK1 (37.0%), JTPKB (33.3%), NFKBIA (33.3%), HF4A1 (29.6%), JUNB (29.6%), STAT3 (29.6%), BCL2L1 (25.9%), CDS3 (25.9%), DDX3X(25,9%), SOCS) (25.9%), CDS3 (25.9%), P2RY8 (22.2%), RFTN1 (22.2%) MCD 1 MYD8S C5 MYD88 (66.2%), CD79B (50.0%), PIM1 (92.5%), HLA-B (73.8%), BTGl (70.0%), CDKN2A (62.0%), ETV6 (55.0%), SPIB (51.9%), OSBPLIO (51.2%), TOX (48.1%), BCL2 (48.1%), BTG2 (43.8%), MPEG1 (43.8%), HLA-A (43.0%), HLA-C (42.5%), SETD1B (41.8%), KLHL14 (412%), TBL1XR1 (35.0%), GRHPR (33.8%), PRDM1 (32.5%), CD58 (31,6%), TAP] (26.6%), PIM2 (25.0%), FOXCI (21.2%), IRF4 (20.0%) N1 NI - - NOTCH1 (100%), ISF2BP2 (43.8%), 1D3 (25.0%), BCOR (25.0%), EPB41 (18.8%), IKBKB (18.8%), ALDH18A1 (18.8%) Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma.Front. Mol. Biosci. 10:1124360. Genetic alterations in DLBCL - major signaling pathway alteration in DLBCL Major signaling pathways affected by genetic alteration in DLBCL: ■ BCR signaling, ■ PI3K-AKT-mTOR signaling, ■ BCR dependent NF-kB activation, ■ NF-kB signaling, ■ TLR signaling, ■ and the BCL2 anti-apoptotic family. These pathways are related in their ability to evade apoptotic pathways, promote cell proliferation and gene expression, and confer lymphomagenesis. 10 Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma.Front. Mol. Biosci. 10:1124360. Alterations in epigenetic regulation that contribute to development of DLBCL Equally important as mutations within genes themselves are changes in epigenetic regulators that alter expression of these genes. Greater epigenetic heterogeneity is associated with poor clinical outcome and inhibitors of these mechanisms such as DNA methyltransferase and histone methyltransferase inhibitors may be a source of therapeutic intervention in DLBCL. 11 Alterations in other pathways Various other pathways are involved in the continued survival, proliferation, and immune evasion of malignant DLBCL cells. ■ Subtype N1 is based off alterations in NOTCH signaling. ■ Germinal center homing pathways and migration are disrupted in EZB type cases. ■ BCL6 signaling disruption is also found commonly in EZB subtype. ■ TP53 mutations prevent cell death. ■ MYC mutations are highly associated with MCD and BN2 type. ■ Evasion of immune surveillance is seen across numerous DLBCL subtypes. Targeted therapeutic strategies in DLBCL Different therapies may be needed to target not only different pathways, but also the same pathway in different ways depending on how it was altered along its mechanism. While these various subtyping methods may not be entirely clinically useful or relevant yet necessity to begin conceptually examining pharmaceuticals that could lead to outcomes superior to traditional R-CHOP when applied to these experimental subgroups. 12 Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma.Front. Mol. Biosci. 10:1124360 Targeted therapeutic strategies in DLBCL Targeting BCR signaling: Three targets of the BCR signaling pathway that are actionable by current drugs, are PKCP, SYK, and Bruton's tyrosine kinase (BTK). Enzastaurin is a selective PKCP inhibitor which inhibits signal transduction and ultimate pathway activation, but efficacy has yet to be shown with this drug, and clinical failures have been attributed to mutations further down the pathway than at PKCP. This drug may be of clinical use in patients with mutations specifically affecting PKCP, so being able to detect mutations here would be essential in utilizing this treatment. SYK inhibitor (SYKi) entospletinib has shown promise in clinical trials following BTK or PI3K5 inhibitors, with a response rate of 69%. Fostamatinib is another SYKi but has shown little clinical benefit, and likely caused side effects because it is a non- Shimkus G and Nonaka T (2023), Molecularclassification and therapeutics selective agent. in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 13 Targeted therapeutic strategies in DLBCL Targeting BCR signaling: Three targets of the BCR signaling pathway that are actionable by current drugs, are PKCP, SYK, and Bruton's tyrosine kinase (BTK). Another promising agent in this pathway is ibrutinib, a BTK inhibitor, and overall response rate in one monotherapy trial of refractory DLBCL with ibrutinib was 40% in ABC type and 5% in GBC type. MYD subtype in combination with CD79A and CD79B mutations increased susceptibility to ibrutinib, 80% of responses had MYD88 mutation with concomitant CD79B mutation, while the wild type CD79A/CD79B provided protection from this intervention. Shimkus G and Nonaka T (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 Targeted therapeutic strategies in DLBCL Targeting PI3K-AKT-mTOR: The PI3K-AKT-mTOR is another commonly active pathway in DLBCL with treatments that have shown promise in limited trials. CUDC-907 is a small molecule that inhibits PI3K and HDAC, that showed a response rate of 64% in patients with DLBCL concurrent with MYC alteration. Other drugs targeting PI3K are pilaralisib, buparlisib, and copanlisib. AKT inhibitor MK-2206 showed promise in preclinical models, but failed to show results in any of the patients treated in a phase II trial. Two drugs showing some clinical significance are the mTOR inhibitors everolimus and temsirolimus, with positive responses observed, and one patient achieved a durable and complete response to the everolimus for years. Shimkus G and Nonaka T (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 14 Targeted therapeutic strategies in DLBCL Targeting NF-kB signaling: Lenalidomide acts on the NF-kB pathway by targeting the E3 ubiquitin ligase component of cereblon, and shows substantial activity in patients with relapsed or refractory DLBCL alone or in combination with other regimens. The greatest effects have been seen in patients with ABC DLBCL, and the addition of lenalidomide to CHOP treatment in patients with novel DLBCL seems to negate the negative prognostic implications of ABC DLBCL. Lenalidomide has also been shown to be effective as a maintenance therapy and prolong PFS in patients who respond to R-CHOP. Another mechanism for the utility of lenalidomide may be realized, aside from acting as a sole inhibitor of the NF-kB pathway, is through synthetic lethality. Another drug acting on the NF-kB path is bortezomib which downregulates NF-kB through inhibition of proteasomal degradation of iKBa, but is has failed to show significant efficacy as a monotherapy or in addition to R-CHOP therapy. Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 Targeted therapeutic strategies in DLBCL Targeting BCL2 signaling: BCL2 expression is one of the most influential alterations in DLBCL and is already prognostically significant, as DLBCL with MYC and BCL2/BCL6 mutations are associated with a worse prognosis. Venetoclax is a BCL2 inhibitor that was shown to have a complete response in 12% of patients when used as a monotherapy, and an overall response rate of 41% when used in combination with bendamustine plus rituximab. In patients with confirmed BCL2 mutations, venetoclax had a superior overall response rate when compared to R-CHOP in the matched population, suggesting the potential of venetoclax to improve outcomes in patients receiving R-CHOP. Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 15 Targeted therapeutic strategies in DLBCL BCL6 signaling Cell Cell DNA Cell cycle differentiation Cell death migration damage (cdknia] ® ( TP53 ) ( S1PR2 ) ( ATR ) (cDKNIlf ( PRDM1 ) ( CHEW ) (KMT2D) I—* Epigenetic regulation Shimkus G and Nonaka T (2023), Molecular classification and therapeutics ir B-cell lymphoma. Front. Mol. Biosci. 10:1124360 Targeting epigenetic pathways: Gene regulation is another great target for manipulation since DLBCL displays frequent disruptions in histone-modifying enzymes and the general activity of genes. Tazemetostat is an EZH2 inhibitor with an encouraging safety profile and response in both EZH2 wild-type and mutant relapsed/refractory DLBCL, with responses up to 60% in R/R DLBCL. Histone deacetylase inhibitors (HDACi) such as vorinostat, panobinostat, mocetinostat, and abexinostat show potential benefit in certain patients with B-cell lymphoma when combined with other chemotherapies. Use of HDACi is proving useful especially in CREBBP-mutant cells, to restore acetylation of histones at transcriptional enhancer regions to enhance expression of tumor suppressor genes. HDACi's are also of interest in individuals with elevated MYC concurrent with elevated BCL2 levels, and can lead to induction of apoptosis through acetylated BCL6 accumulation. Targeted therapeutic strategies in DLBCL p53 signaling ( CDKN2A ) 1 ( MDM2 ) I— Idasanutlin 1 ( TP53 & t t ( CHK2 ^ ( CHK1 ^ _t t_ ( ATM ) ( ATR ) t t DNA damage Targeting p53 signaling: MDM2 antagonist, idasanutlin, showed potent anti-tumor activity in both ABC and GCB cell lines and idasanutlin could be used as a novel drug in the clinical setting of DLBCL. Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 16 Targeted therapeutic strategies in DLBCL MYC signaling ( BCL2 ) |— Venetoclax | AID (BCL2-MYC) (BCL6-MYC) (iGH-MYc) Birabresib 1 ( AID ) ( BRD2/3 ) Targeting MYC signaling: The ability to block overactive MYC transcription is of interest because of the genes' involvement in not only overall pathogenesis, but also its association with relapse and refractory DLBCL. The BET protein family enhance MYC transcription by binding acetylated histones. BET inhibitors (BETi) interfere with BET-mediated MYC transcription through disruption of bromodomain-containing proteins which normally organize transcriptional machinery. Birabresib specifically is a drug of interest, and functions through binding to the BRD2 and BRD3, limiting the transcription of MYC among other oncogenes. Shimkus G and Nonaka T (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 Targeted therapeutic strategies in DLBCL Targeting immune evasion: Evasion of DLBCL immune surveillance is accomplished through various mechanisms, but PD-L1 (CD274) and PD-L2 (PDCD1LG2) dysregulation is one of the most notable from a therapeutic standpoint. This pathway is targetable by antibodies that bind the PD-L1/2 ligand on the tumor cell, preventing it from binding PD-1/2 receptor and disabling immune escape. One such antibody is nivolumab, which has shown some promise in studies with ORR of 36% in patients with R/R DLBCL. Failure to respond has been attributed to the relatively small number of patients in the study who had 9p21.1 low level copy gains and amplifications. CD274 mutations may be predictive of response to anti-PD-L1 antibodies (pembrolizumab). Shimkus G and NonakaT (2023), Molecularclassification and therapeutics in diffuse large B-cell lymphoma. Front. Mol. Biosci. 10:1124360 17 F Morschhauser. Treating DLBCL: Where are we now? ICML 2023 Roche symposium. Lue et al. J Cancer Metastasis Treat 2022;8:11 18 GC- Tazemetostat1521'1221 EZH2 Inhibitor DLBCL Valemetostat1™1 c. . . .[129-130] Fimepinostai EZH1/2 Inhibitor HDAC/PI3K Inhibitor Venetodax"36,1371 BCL2 Inhibitor Phase 2 Phase lb/2 Phase 1 Phase 1-2 Fimepinostat Fimepinostat+Venetoclax Fimepinostat+Rituxan Fimepinostat+Venetoclax+Rituxarl Phase 1 CAVALLI Study Venetoclax+R-CHOP Phase! ALLIANCE51701 Venetoclax+DA-R-EPOCH Closed After Interim Assessment (NCT01897571) N/A (NCT02889523) ORR: 15% (R/R NHLXNCT02732274) ORR: 55% (5/9) ORR: 23.3% (14/60 MYC-altered DLBCL) (NCTQ17429B8) ORR: 87.5% (NCT02055820) ORR: 97% (NCT03036904) Lue et al. J Cancer Metastasis Treat 2022;8:11 Agnostic ^ojituHJambVedotin1 Antibody-Drug Conjugate against CD79b linked to MMAE Tafa»itamabIWH431 Anti-CD19 monoclonal Ab Phase lb/2 Polatuzumab+BR vs. BR Phase 3 Polatuzumab+R-CHP vs. R-CHOP Phase 1-2 L-MIND Tafasitamab+Lenalidorride Objectivé Response: 45.0% vs. 17.5% CR 40% vs, 17.5% OS 12.4 vs. 4.7 months (NCT02257567) ORR: 85.5% vs. 83.8% CR: 73.0% w, 74.0% Decrease risk in progression/relapse/death: HR: 0.73; 95%CI 0.57-0.95; P = 0.02 (NCT03274492) ORR: 54% CR: 32% NCTQ2399085 Loncastuximab tesirine Magrolimab Phase 3 FIRST-MIND Tafasitamb+Lenalidomide+R-CHOP Antibody-Drug conjugate Phase 2 against CD19 Anti-CD47 monoclonal Phase lb in R/R DLBCL and FL N/A NCTQ4134986 ORR: 48.3% CR: 24% PR: 24% (NCT03589469) Objective Response: 40% DLBCL) Lue et al. J Cancer Metastasis Treat 2022;8:11 19 (yjftsunetijíumab' CD3-CD20 BsAb Phase l/ib ORR: 37% CR: 19% (NCT02500407) Odronexatamabl:lfl9] CD3-CD20 BsAb Eplcoritamab Glofitamab'151-1523 2:1 CD20-C3 Bs Ab Phase lb/!l Mösunetuzumab+CHOP or Polatäizumab+CHP Phase I CD3-CD20 BsAb Phase l/ll Phase l/ib Trispecific Ab: CD19- Pending CD20-CD3 XPO-l Mediated Nuclear Phase 2 Transport Inhibitor N/A (NCT03677141) ORR: 60% (CART-cell NaiVe) CR: 60% (CART-cell NaTve) ORR: 33.3% {Refractory CAR T-cell) CR: 23.8% (Refractory CART-cell) (NCT02290951) ORR: 100% (DLBCU at 48mg CR: 28.6% (2/7) PR: 71.4% (5/7) (NCT03625037) ORR: 50% (aggressive NHL) CR: 29.2% (NCT03075696) N/A ORR: 28% CR:12% (NCT02227251) Lue et al. J Cancer Metastasis Treat 2022;8:11 Conclusion and future perspectives DLBCL encompasses a wide array of disease mechanisms/presentations that have historically been and are currently, grouped into essentially two prognostic groups all with the same therapeutic indication. Various novel ways to delineate cases of DLBCL have been proposed by groups such as Schmitz et al., Chapuy et al., Lacy et al., and Wright et al.. These systems have used various algorithms to group DLBCL by "constellations" of genetic alteration instead of examining and grouping each alteration individually, because it is the sum of the parts that leads to the specific disease state and that may point to specific treatment regimen. 20 Conclusion and future perspectives New therapies derived from NGS acquired data are aimed at disrupting signaling pathways or modulating immune response, however the impact of these therapies can only be fully realized when we are able to categorize DLBCL into subtypes based on internal disease mechanism and not on outward morphology or presence of basic cell markers. These internal mechanisms are the basis for future treatment modalities and the cessation of indiscriminate therapy based on patient response. Conclusion and future perspectives Mutations in pathways regulating BCR signaling, the PI3K-AKT-mTOR signaling pathway, BCR-dependent NF-kB signaling, NF-kB signaling, TLR signaling, and the BCL2 family are among the most influential when it comes to subdividing DLBCL cases into new subgroups. The end result of these pathways - either overstimulation of pro-growth factors or inhibition of apoptotic pathways, leads to the same phenotypic result of continued cell growth and survival. Even therapies directed specifically at these pathways may still fail if they treat steps further up the cascade than the mutation actually lies, so having the ability to identify and target multiple steps in these pathways will be a prerequisite to extend overall survival of these patients. 21 Conclusion and future perspectives Dysregulation of genes involved in epigenetic regulation may also result in aberrant pathway activation or inactivation in many DLBCL cases, so exploring treatments directed at regulation of these pathways may also impact the outcomes. Other pathways of interest with potential therapeutic interventions are the NOTCH signaling pathway, malignant cell migration, BCL6 signaling, p53 signaling, MYC signaling, and immune evasion through mutations in various receptors and ligands such as PD-L1 overexpression. Therapies currently showing promise include ibrutinib in targeting BCR signaling, everolimus in the PI3K-AKT-mTOR pathway, lenalidomide in targeting NF-kB signaling, venetoclax in BCL2 signaling, tazemetostat in EZH2 epigenetic regulation, birabresib in targeting MYC signaling, and nivolumab in targeting immune evasion. Conclusion and future perspectives To progress in the treatment of DLBCL, a new classification system must first be implemented as part of guidelines that will provide a better prognostic information, and that may indicate which second line therapies might be effective when first line R-CHOP fails. Availability of NGS for use in patients with DLBCL will also need to be increased in order to appropriately place a malignancy in its respective group applying novel algorithms. Larger quantities of data will also enable further differentiation which mutations are impactful on disease course, and which mutations may indicate a specific or targeted treatment. 22 First line treatment of DLBCL in regard to molecular pathogenesis Milica Miljkovic, medical oncologist Institute of Oncology Ljubljana 19th and 20th October, Ljubljana, Slovenia Classification by cell of origin (COO) • Activated B-cell like type (ABC) • Germinal center B-cell like type (GCB) • Unclassified 23 Outcomes after treatment with R-CHOP according to COO Scott DW. Prognostic Significance of Diffuse Large B-Cell Lymphoma Cell of Origin Determined by Digital Gene Expression in Formalin-Fixed Paraffin-Embedded Tissue Biopsies. J Clin Oncol 2015; 33: 2848. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) Outcomes after treatment with R-CHOP according to MYC and BCL-2 expression (IHC) Scott DW. Prognostic Significance of Diffuse Large B-Cell Lymphoma Cell of Origin Determined by Digital Gene Expression in Formalin-Fixed Paraffin-Embedded Tissue Biopsies. J Clin Oncol 2015; 33: 2848. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone), IHC-immunohistochemistry 24 Molecular classification of DLBCL Molecular classification Wright Schmitz Lacy Chapuy Genetic alteration {% prevalance*) BN 2 BN2 NOTCH2 Cl BCL6 (72.8%), N0TCH2 (41.8%), TNFAIP3 (51.6%), DTXi (50.0%), CD70 (41.3%), BCL10 (39.6%), UBE2A (30.4%), TMEM30A (26.7%), KLF2 (21.7%), SPEN (21.7%) A53 _ _ C2 TP53 (86.8%), B2M (34.2), TPS3BP1 (27.0%), CNPY3 (23.7%), 1NGI (15.8%), NFKB1Z (15.8%), TP73 (13.2%) EZB-MYC+ EZB-MYC- EZB BCL2 C3 BCL2 (68.4%), E7.H2 (44.7%), TNFRSF14 (66.2%), KMT2D (53.9%), CREBBP (52.7%), REL (34.3%), FAS (30.1%), IRF8 (28.9%), EP300 (27,8%), MEF2B (26.3%), CUT A (25.0%), AR/D1A (22.9%), GNA13 (22.5%), STAT6 (21.1%), PTEN (20.0%) ST2 TET2/SGK1 SOCSl/SGKl C4 TET2 (48.1%), DUSP2 (44.4%), ZFP36L1 (40.7%), ACTGI (37.0%), SGKl (37.0%), ITPKB (33.3%), NFKBIA (33.3%), E1F4A2 (29.6%), JUNB (29.6%), STAT3 (29.6%), BCL2U (25.9%), CDS3 (25.9%), DDX3X (25.9%), S0CS1 (25.9%), CDS? (25.9%), P2RY8 (22.2%), RFTNI (22.2%) MCD MCD MYD88 C5 MYDS8 (66.2%), CD79B (50.0%), PIM1 (92.5%), HLA-B (73.8%), BTG1 (70.0%), CDKN2A (62.0%), ETV6 (55.0%), SPIB (51.9%), OSBPL10 (51.2%), TOX (48.1%), BCL2 (48.1%), BTG2 (43.8%), MPEGl (43.8%), HLA-A (43.0%), HLA-C (42.5%), SETDIB (41.8%), KLHL14 (41.2%), TBL1XR1 (35.0%), GRHPR (33.8%), PRDM1 (32.5%), CD5S (31.6%), TAP1 (26.6%), PIM2 (25,0%), FOXCl (21.2%), IRF4 (20.0%) NI NI - - NOTCH/ (100%), IRF2BP2 (43.8%), ID3 (25.0%), BCOR (25.0%), EPB41 (18.8%), IKBKB (18.8%), ALDH18A1 (18.8%) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9936827/ First line therapy - NCCN I comprehensive NCCN Guidelines Version 5.2023 | Network™ Diffuse Large B-Cell Lymphoma NCCN Guidelines Index Table of Contents Discussion SUGGESTED TREATMENT REGIMENS3 An FDA-approved biosimilar is an appropriate substitute for rituximab.b FIRST-LINE THERAPY Stage l-ll (excluding stage II with extensive mesenteric disease) Stage II (with extensive mesenteric disease) or Stage lll-IV Patients with Poor Left Ventricular Functiond,e'f (All Stages) Very Frail Patients and Patients >80 Years of age with comorbidities®'' (All Stages) • RCHOP (rituximab,c cyclophosphamide, doxorubicin, vincristine, prednisone) Preferred regimens Other recommended regimens Other recommended regimens • RCHOP (rituximab,c cyclophosphamide, doxorubicin, vincristine, prednisone) (category 1) • Pola-R-CHP (polatuzumab vedotin-piiq, rituximab, cyclophosphamide, doxorubicin, prednisone) (IPI &2) (category 1) Other recommended regimens • Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) + rituximab (in alphabetical order by category) • DA-EPOCH9 (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) + rituximab • RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, prednisone) • RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, prednisone) • RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, prednisone) • RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, procarbazine) (category 2B) (in alphabetical order by category) •RCDOP * R-mini-CHOP •RGCVP • RCEPP (category 2B) FIRST-LINE CONSOLIDATION (OPTIONAL) • Lenalidomide maintenance (category 2B) for patients 60—80 y of age CONCURRENT PRESENTATION WITH CNS PISEASEh • Parenchymal: systemic high-dose methotrexate (23 g/m2 or more given with RCHOP cycle that has been supported by growth factors). Different schedules have been used for the integration of high-dose methotrexate with RCHOP (early- or mid-cycle or day 15 of a 21-day cycle) • Leptomeningeal: IT methotrexate/cytarabine, consider Ommaya reservoir placement. Systemic high-dose methotrexate (3-3.5 g/m2) can be given in combination with RCHOP or as consolidation after RCHOP ♦ IT methotrexate/cytarabine_ https://www.nccn.org/guidelines/categorv 1 25 First line therapy - our practice • R-CHOP or R-mini-CHOP or R-C(X)OP • R-DA-EPOCH (high IPI score, ABC subtype or double hit) • Polatuzumab-R-CHP (IPI score 3-5) • HD MTX (3-5g/m2) • Prophylactic intrathecal chemotherapy (IT): MTX+ARA-C+Dexamethason *R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone); R-C(X)OP (X= gemcitabine or etoposide); R-DA-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin); Polatuzumab - R- CHP (rituximab, cyclophosphamide, doxorubicin, prednisone); HD MTX - high dose of methotrexate; IPI - international prognostic index; ABC-activated B cell like subtype; double hit - mutation of MYC and BCL-2 POLARIX (GO39942) Primary analysis - global population A Phase III, multicenter, randomized, double-blind, placebo-controlled trial comparing the efficacy and safety of polatuzumab vedotin in combination with R-CHP vs R-CHOP in previously untreated patients with DLBCL 26 Study design overview • Double-blind, randomized controlled • Collaboration with LYSA NCT03274492 Patients • Previously untreated DLBCL • Age 18-80 years • IPI 2-5 • ECOG PS 0-2 N=879 Stratification factors • IPI score (2 vs 3-5) • Bulky disease (>7.5cm vs absence) • Geographic region* ARM A Polatuzumab vedotin 1.8mg/kg R-CHP + vincristine placebo Q21D x 6 cycles 1 Cycle=21 days ARM B R-CHOP + polatuzumab vedotin placebo Q21D x 6 cycles Rituximab 375mg/m2 Cycles 7 & 8 Rituximab 375mg/m2 Cycles 7 & 8 Primary endpoint PFS by INV Key secondary endpoints EFSefficacy by INV, PET CR at EOT by BICR, OS, and safety "Western Europe, United States, Canada and Australia vs Asia vs Rest of World. BICR, blinded independent central review, CR, complete response, ECOG PS, Eastern Cooperative Oncology Group performance status, EFSefficacy, event-free survival for efficacy causes (time from randomization to the earliest occurrence of disease progression/relapse, death due to any cause, initiation of any non-protocol specified anti-lymphoma treatment, or biopsy-confirmed residual disease after treatment completion) Tilly H, et al. New Engl J Med 2022;386:351-63. Demographics and baseline characteristics were generally well balanced between arms-global ITT (1 of 3) Pola-R-CHP R-CHOP (N=440) (N=439) Age, n (%) >60 years 300 (68.2) 308 (70.2) Age, years Median (Min-Max) 65.0 (19-80) 66.0 (19-80) Sex, n (%) Male 239 (54.3) 234 (53.3) ECOG PS, n (%) 0-1 374 (85.0) 363 (82.7) 2 66 (15.0) 75 (17.1) Unknown 0 1 (0.2) Geographic region, n (%) Asia 81 (18.4) 79 (18.0) Rest of World 57 (13.0) 59 (13.4) Western Europe, United States, Canada, and Australia 302 (68.6) 301 (68.6) IPI at screening, n (%) 2 167 (38.0) 167 (38.0) 3-5 273 (62.0) 272 (62.0) Bulky disease, n (%) Absent 247 (56.1) 247 (56.3) Present 193 (43.9) 192 (43.7) Baseline LDH, n (%) <1 x ULN 146 (33.2) 154 (35.1) >1 x ULN 291 (66.1) 284 (64.7) Unknown 3 (0.7) 1 (0.2) Tilly H, et al. New Engl J Med 2022;386:351-63. 27 Demographics and baseline characteristics were generally well balanced between arms-global ITT (2 of 3) Pola-R-CHP R-CHOP (N=440) (N=439) Bone marrow involvement Unknown 22 (5.0) 18 (4.1) at diagnosis, n (%) Negative 342 (77.7) 349 (79.5) Positive 76 (17.3) 72 (16.4) Ann Arbor Stage, n (%) I or II 47 (10.7) 52 (11.8) III or IV 393 (89.3) 387 (88.2) No. of extranodal sites, n (%) 0-1 227 (51.6) 226 (51.5) >2 213 (48.4) 213 (48.5) Tilly H, et al. New Engl J Med 2022;386:351-63. Demographics and baseline characteristics were generally well balanced between arms - global ITT (3 of 3) Pola-R-CHP R-CHOP (N=440) (N=439) NHL histologic diagnosis DLBCL NOS (including ABC and GCB) 373 (84.8) 367 (83.6) (local diagnosis), n (%) HGBL, (including NOS and DHL/THL) 43 (9.8) 50 (11.4) Other large B-cell* 24 (5.5) 22 (5.0) COO/ n (%) N=330 N=338 ABC 102 (30.9) 119 (35.2) GCB 184 (55.8) 168 (49.7) Unclassified 44 (13.3) 51 (15.1) Double-expressor lymphoma/ N=362 N=366 n (%) DEL 139 (38.4) 151 (41.3) Non DEL 223 (61.6) 215 (58.7) Double/triple-hit lymphoma/ N=331 N=334 n (%) DH/TH+ 26 (7.9) 19 (5.7) DH/TH- 305 (92.1) 315 (94.3) *Other large B-cell lymphomas by local diagnosis included EBV+ DLBCL NOS, and T-cell/histiocyte rich large B-cell lymphoma. "•"Based on central review, and percentages are based on biomarker evaluable population (i.e. by excluding patients with unknown status). Tilly H, et al. New Engl J Med 2022;386:351-63. 28 Overall safety profile AE, n (%) Pola-R-CHP R-CHOP (N=435) (N=438) Any-grade AEs 426 (97.9) 431 (98.4) Grade 3-4 AEs 251 (57.7) 252 (57.5) SAEs 148 (34.0) 134 (30.6) Grade 5 AEs 13 (3.0) 10 (2.3) AEs leading to treatment discontinuation Any treatment 27 (6.2) 29 (6.6) Polatuzumab vedotin/vincristine 19 (4.4) 22 (5.0) AEs leading to dose reduction (any treatment) 40 (9.2) 57 (13.0) • The safety profile of Pola-R-CHP was similar to that of R-CHOP • Fewer AEs leading to dose reductions were observed in the Pola-R-CHP arm Tilly H, et al. New Engl J Med 2022;386:351-63. Most common adverse events (1 of 3) All-grade incidence rate of >12% in any treatment arm Pola-R-CHP R-CHOP AE, n (%) (N=435) (N=438) Any grade Grade 3-4 Any grade Grade 3-4 Gastrointestinal disorders Nausea 181 (41.6) 5 (1.1)* 161 (36.8) 2 (0.5) Vomiting 65 (14.9) 5 (1.1)* 63 (14.4) 3 (0.7) Diarrhea 134 (30.8) 17 (3.9) 88 (20.1) 8 (1.8) Constipation 125 (28.7) 5 (1.1)* 127 (29.0) 1 (0.2) Blood and lymphatic system disorders Anemia 125 (28.7) 52 (12.0) 114 (26.0) i 37 (8.4) Neutropenia 134 (30.8) 123 (28.3) 143 (32.6) 135 (30.8) Febrile neutropenia* 62 (14.3) 60 (13.8) 35 (8.0) 35 (8.0) I • The most common AEs were consistent with R-CHOP therapy | • Grade 3-4 AEs were comparable between treatment arms and most were associated with myelosuppression *Granulocyte-colony stimulating factor (G-CSF) administration was required during the first six cycles as primary prophylaxis of neutropenia: G-CSF prophylaxis was reported in 93.2% and 90.1% of patients in the R-CHOP and Pola-R-CHP arms, respectively; With the exception of diarrhea, Grade 3-4 events for all gastrointestinal disorders were less than 2% in the Pola-R-CHP arm. Tilly H, et al. New Engl J Med 2022;386:351-63. 29 Most common adverse events (2 of 3) All-grade incidence rate of >12% in any treatment arm AE, n (%) Pola-R-CHP (N=435) R-CHOP (N=438) Any grade Grade 3-4 Any grade Grade 3-4 Nervous system disorders 1 Peripheral neuropathy* 230 (52.9) 7(1.6)* 236 (53.9) 5(1.1) Headache 56 (12.9) 1 (0.2)* 57 (13.0) 4 (0.9) Dysgeusia 49 (11.3) 0* 57 (13.0) 0 General disorders and administration site conditions Fatigue 112 (25.7) 4 (0.9)* 116 (26.5) 11 (2.5) Pyrexia 68 (15.6) 6 (1.4)* 55 (12.6) 0 Asthenia 53 (12.2) 7 (1.6)* 53 (12.1) 2 (0.5) Skin and subcutaneous tissue disorders Alopecia | 106 (24.4) 0* | 105 (24.0) 1 (0.2) *Grade 3-4 events for all nervous system, general and skin disorders were less than 2% in the Pola-R-CHP arm; fData presented here refer to grouped term peripheral neuropathy, which included preferred terms: peripheral neuropathy, peripheral sensory neuropathy, paresthesia, hypoesthesia, polyneuropathy, peripheral motor neuropathy, dysesthesia, neuralgia, peripheral sensorimotor neuropathy, hypotonia, hyporeflexia, neuromyopathy, ear paresthesia, peroneal nerve palsy, skin burning sensation. Tilly H, et al. New Engl J Med 2022;386:351-63. Most common adverse events (3 of 3) All-grade incidence rate of >12% in any treatment arm AE, n (%) Pola-R-CHP (N=435) R-CHOP (N=438) Any grade Grade 3-4 Any grade Grade 3-4 Respiratory, thoracic and mediastinal disorders Cough 56 (12.9) 0 53 (12.1) 0 Metabolism and nutrition disorders Decreased appetite 71 (16.3) 5 (1.1)* 62 (14.2) 3 (0.7) Investigations Decreased weight 55 (12.6) 4 (0.9)* 52 (11.9) 1 (0.2) *Grade 3-4 events for all metabolism, musculoskeletal disorders and investigations were less than 2% in the Pola-R-CHP arm. Tilly H, et al. New Engl J Med 2022;386:351-63. 30 Safety summary (1 of 2) Overall safety profile of Pola-R-CHP is similar to that of R-CHOP and consistent with the known risk of the individual study drugs1 Drug deliverability favors Pola-R-CHP vs R-CHOP1 • Lower incidence of AEs leading to any dose reduction in Pola-R-CHP (9.2% vs 13.0%) • More patients received all planned doses of polatuzumab vedotin/vincristine in the Pola-R-CHP arm vs R-CHOP (91.7% vs 88.5%) Rates of febrile neutropenia were higher with Pola-R-CHP vs R-CHOP (14.3% vs 8.0%) but this did not translate into greater overall rates of infection: Grade >3 infections were comparable (15.2% vs. 12.6%, respectively)1 • Similar FN rates reported in recent R-CHOP studies (9.0% to 15.2%)2-4 • Drug discontinuations (2.1% vs 2.3%), dose reductions due to infections/neutropenia (1.8% vs 2.5%) and G-CSF prophylaxis (90.1% vs 93.2%) were also comparable • Grade 5 AEs were comparable between treatment arms 1. Tilly H, et al. New Engl J Med 2022;386:351-63; 2. Vitolo U, et al. J Clin Oncol 2017;35:3529-37; 3. Nowakowski GS, et al. J Clin Oncol 2021 ;39:1329-38; 4. Younes A, et al. J Clin Oncol 2019;37:1285-95. Safety summary (2 of 2) No significant differences in rates or severity of PN were observed in patients receiving Pola-R-CHP vs R-CHOP; most PN events were Grade 112 • Fewer dose modifications as a result of PN were required for patients who received Pola-R-CHP than for those who received R-CHOP • According to ClinRO and PRO data, PN appeared to occur later after initial exposure to Pola-R-CHP than to R-CHOP; however, the duration of neuropathy events was comparable in both treatment arms • Patient and clinician assessments similarly demonstrated the temporal relationship between PN symptoms and their resolution No new safety signals were detected1 1. Tilly H, et al. New Engl J Med 2022;386:351-63; 2. Trneny M, et al. ASCO 2022. Poster P7561. 31 Pola-R-CHP R-CHOP HR 0.73 (p=0.02) Pola-R-CHP ^ 27% reduction in risk of progression, relapse or death1 Relapsing or being refractory to 1L treatment remain the main causes of morbidity and mortality in DLBCL2 1 .Tilly H, et al. New Engl J Med 2022;386:351-63; 2. Maurer MJ, et al. Ann Oncol 2018;29:1822-27. Pola-R-CHP R-CHOP 6.5% improvement1 76.7% 24 months Progression-free survival 70.2% 24 months Progression-free survival Most relapses in patients with previously untreated DLBCL occur in the first 2 years, and outcomes with salvage therapy remain poor for a variety of patients2 Landmark analysis at 24 months showed a clinically meaningful improvement in the number of patients avoiding relapse with Pola-R-CHP vs R-CHOP 1. Tilly H, et al. New Engl J Med 2022;386:351-63; 2. Maurer MJ, et al. J Clin Oncol 2014;32:1066-73. * 32 Investigator-assessed PFS (global ITT population) Pola-R-CHP (N=440) R-CHOP (N=439) No. of events, n (%) 107 (24.3) 134 (30.5) Earliest contributing event, n Death 19 20 Disease progression or relapse 88 114 Stratified analysis* P-value (Log-rank) 0.02 Hazard ratio (95% CI) 0.73 (0.57-0.95) 12-month PFS rate* (95% CI) 83.9 (80.4-87.4) 79.8 (75.9-83.6) 24-month PFS rate* (95% CI) 76.7 (72.7-80.8) 70.2 (65.8-74.6) 'Stratified for IPI score (IPI 2 vs IPI 3-5), bulky disease (present vs absent), and geographical region (Western Europe, United States, Canada and Australia vs Asia vs Rest of World [remaining countries]); +Kaplan-Meier estimate. Tilly H, et al. New Engl J Med 2022;386:351-63. Investigator-assessed PFS (global ITT population) 100 Pola-R-CHP (N=440) R-CHOP (N=439) Censored 18 24 Time (months) 36 42 Number at risk 'ola-R-CHP 440 404 353 327 246 78 NE NE R-CHOP 439 389 330 296 220 78 NE Till« H et al New Engl .1 Med 2022386 351-63 3 33 Investigator-assessed PFS by subgroup (global ITT, unstratified) Baseline risk factors Total N Pola-R-CH P (N=440) R-CHOP N=439) HR 95% Wald CI Pola-R-CHP better R-CHOP better M 608 300 777 308 695 ; 9 (0 5,.0 9: -1 ■■I 5445 753 651 07 1 ■1 s 3.T ^ 75 3 09 6to15: _ - 9 mH 575 % 754 ä 67 2 07 (0 6,01 1: i; Z 738 07 (: ■ 0: _ '- ■-■ ■pSSHS S 5 »5 36 ((00 4,01 5: =-> 0.25 1 5 Tilly H, et al. New Engl J Med 2022;386:351-63. Overall survival (global ITT population) 100 ■Q ro ■Q o 60 40 20 Number at ris Pola-R-CHP (N=440) R-CHOP (N=439) Censored Pola-R-CHP vs R-CHOP: Number of events: 53 (12%) vs 57 (13%) HR (95% CI): 0.94 (0.65-1.37); p=0.75 6 12 18 24 30 Time (months) 36 -1 42 Pola-R-CHP R-CHOP (N=440) (N=439) No. of events, n (%) 53 (12.0) 57 (13.0) Earliest contributing event, n Death 53 57 Stratified analysis* p-value (Log-rank) Hazard ratio (95% CI) 24 months OS rate* (95% CI) _J The final OS analysis will be performed (two-sided alpha boundary = 0.04) in the 2nd half of 2022. OS analysis was time-driven. 'Stratified for IPI score (IPI 2 vs IPI 3-5), bulky disease (present vs absent), and geographical region (Western Europe, United States, Canada and Australia vs Asia vs Rest of World [remaining countries]); +Kaplan-Meier estimate. 0.94 (0.65-1.37) 88.7 (85.7-91.6) 88.6 (85.6-91.6) Tilly H, et al. New Engl J Med 2022;386:351-63. 0.75 0 0 Pola-R-CHP R-CHOP 34 Updated survival data June 15th 2022 data cut-off PFS with additional follow-up (global ITT population) Primary analysis (CCOD: June 28, 2021)1 Median follow-up: 28.2 months No. of patients at risk Pola-R-CHP 440 R-CHOP 439 ~l-118 24 Time (months) Updated results (CCOD: June 15, 2022)2 Median follow-up: 39.7 months Pola-R-CHP _ (N=440) — R-CHOP (N=439) + Censored No. of patients at risk Pola-R-CHP 440 R-CHOP 439 Time (months) PFS benefit with Pola-R-CHP vs R-CHOP was maintained with longer follow-up (HR 0.76, 95% CI: 0.60-0.97)2 'Descriptive analysis only. 1. Tilly H, et al. New Engl J Med 2022;386:351-63; 2. Herrera AF, et al. ASH 2022. Oral presentation 542. 35 OS with additional follow-up (global ITT population) O 40 ■ 0 Primary analysis (CCOD: June 28, 2021)1 Median follow-up: 28.2 months HR 0.94 (p=0.75) 95% CI: 0.65-1.37 Pola-R-CHP (N=440) R-CHOP (N=439) Censored 0 No. of patients at risk Pola-R-CHP 440 R-CHOP 439 —I— 12 -1-1- 18 24 "Time (months) T" "I _ 60 W o 40 0 Updated results (CCOD: June 15, 2022)*2 Median follow-up: 39.7 months HR 0.94 (p=0.73) 95% CI: 0.67-1.33 0 No. of patients at risk Pola-R-CHP 440 R-CHOP 439 Pola-R-CHP -(N=440) - R-CHOP (N=439) + Censored 24 36 "Time (months) OS remained similar between treatment arms with longer follow-up2 No new safety signals have been identified with longer follow-up compared with the primary analysis2 *Final analysis of OS at 3 years, prespecified per the study protocol. 1. Tilly H, et al. New Engl J Med 2022;386:351-63; 2. Herrera AF, et al. ASH 2022. Oral presentation 542. 12 * The impact of POLARIX POLARIX is the first trial in over 20 years to show a meaningful improvement in the benefit-risk profile over R-CHOP in an international Phase III double-blind, randomized controlled trial POLARIX demonstrated a positive benefit-risk profile that was sustained with longer follow-up. The risk of progressive disease or death was reduced at 2 years (HR 0.73, 95% CI: 0.57-0.95) and at longer follow-up (median follow-up: 39.7 months; HR 0.76, 95% CI: 0.60-0.97) This global collaboration with LYSA and sites all over the world has led to a significant advancement for patients and the field of DLBCL, and supports the use of Pola-R-CHP in the initial management of DLBCL Tilly H, et al. New Engl J Med 2022;386:351-63. 36 Treatment of DLBCL -our experience ASSIST. PROF. LUCKA BOLTEZAR, MD, PHD INSTITUTE OF ONCOLOGY LJUBLJANA OCTOBER 2023 Our institutional recommendations 1st line: R-CHOP, R-mini-CHOP, R-COEP, R-DA-EPOCH 2nd line: R-polatuzumab vedotin-bendamustin 3nd line: R-CBVPP, R-GemOx, R-IGEV...*CAR-T* 4th line:.......... 37 Polatuzumab vedotin Available (and reimbursed) in Slovenia since 30.12.2020 So far we treated 74 patients with polatuzumab vedotin Year Number of patients 2020 1 2021 19 2022 33 2023 23 Number of Number of cycles patients 6 25 5 7 4 6 3 6 2 5 1 12 Therapeutic regimen Number of patients Rituximab-polatuzumab- 71 bendamustin Rituximab-polatuzumab 2 Rituximab-polatuzumab- 1 CHP Analyses 2015 -2018 2015: 99 patients 2016: 103 patients 2017: 73 patients 2018: 76 patients 2019: *COVID* 2020: *COVID* + in the middle of 2020 ^ CAR-T 2021: 91 patients 38 Before CAR-T period 2015: 99 patients with DLBCL (8f), (26) 21 are treated with 2nd line treatment, 11 are treated with 3rd line treatment ^ 6 potential CAR-T patients (aged 56,65,67,67,70,74) 2016: 103 patients with DLBCL (9f), (18) 14 are treated with 2nd line treatment, 7 are treated with 3rd line treatment ^ 5 potential CAR-T patients (aged40,69,69,72,74) 2017 : 73 patients with DLBCL (6f), (7) 5 are treated with 2nd line treatment, 1 is treated with 3rd line treatment ^ 1 potential CAR-T patient (aged 61) 2018: 76 patients with DLBCL (6f), (15) 8 are treated with 2nd line treatment, 6 are treated with 3rd line treatment ^ 2 potential CAR-T patients (aged 57 in 59) 39 Department of Hematology of University Clinical Centre of Ljubljana established Center of excellency with Novartis's help in the middle of 2020 — product: Kymriah CAR-T period In 2021 we analyzed 91 patients with DLBCL: 14 are treated with 2nd line treatment, 2 are treated with 3rd line treatment -> 1 potential CAR-T candidate, who died due to progressive disease before CAR-T administration Department of Hematology of University Clinical Centre of Ljubljana established Center of excellency with Novartis's help in 2020 -> product: Kymriah CAR-T period Since 2020 we had 17 potential patients for CAR-T treatment, presented at University Clinical Center tumor board — 4 were rejected by the hematologists, 13 were approved — Out of those 4 rejected, two were offered autologous transplantation, but none of them recieved it 40 9 patients with successfull CAR-T administration: aged 29 - 71 years Median number of prior treatment lines: 2 (range 2-3) 7 patients with PS 0 and 2 with PS 1 Histology Number of patients Transformed 5 follicular lymphoma DLBCL 2 Primary mediastinal 1 B lymphoma Richter's 1 transformation *DLBCL* *3* *LPHL^DLBCL* *1* Bridging therapy regimen Number of patients IGEV 2 GemOx 1 R-DHAP 1 Brentuximab-R-IGEV 1 R-IGEV 1 R-CBVPP 1 Venetoclax + 1 radiotherapy GemOx + radiotherapy 1 41 Prognostic factors prior to CAR-T Patient PS 2 or Resistance to Bulky number more bridging disease therapy 2 or more CRP above LDH Progressed extranodal normal level above after CAR-T localisations normal level # i - - - - - + + # 2 - + - - - - - # 3 - - - - + - - # 4 - + - - - - + # 5 - + - + + - + # 6 - - - - + + + # 7 - + - + - - - # 8 - + - - + - + # 9 - + - + + + - # 10 - + + + + + # 11 - + - + + + # 12 - - + + + + # 13 - - - - + - Survival curves 42 O* Onkološki Inštitut > Institute of Oncology Ljubljana Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System Veronika Kloboves Prevodnik Dept. of Cytopathology, Institute of Oncology Ljubljana 3rd Scool of Malignant Lymphomas, Institute of Oncology Ljubljana, 19th -20th October, 2023 Standardization in cytopathology ? Amazon.com • Amazon.com S Amazon.com Û Springer Link ■ Amazon.com Vasiliadis Medical Boo... fi SpringerLink «i Bisturi - Livras Técnicos WHO Reporting Syste... The International Sys... The Bethesda System... The Papanicolaou So... The Papanicolaou So.. The Bethesda System... The Paris System for... Book The Internationa... * Amazon.com 4) Springer B Eason V AbeBooks B Rakuten Kobo WHO Reporting Syste... Genitourinary System... Buy The Yokohama S... The Milan System for... The Bethesda System. Classification of the disease and uniform reporting system are the basis for their multidisciplinary comprehension and treatment (prof. Pio Zeppa at the European Congress of cytology, Budapest 2023) 43 What about lymph nodes? • Evaluation of lymph nodes by FNAB is used in many institutions but it is not uniformly accepted mainly because of the lack of guidelines and a cytopathological diagnostic classification. • Its role in lymphoma diagnostic is controversial and not widely accepted among clinicians and pathologists. Standardization in lymph nodes cytopathology A steering committee of international cytopathologists involved in LN-FNAC met at the International Cytology Congress on May 2019 in Sydney, Australia, and decided to develop a system for reporting LN-FNAC. The project has received the endorsement and patronage of the International Academy of Cytology and the European Federation of the Cytology Societies. |||jjj| A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System (Acta Cytologica 2020;64:306-322) O Orr P. Zeppa at ECC in Budapest 44 The main aims of the proposed lymph nodes consensus system • Provide consensus guidelines and a framework of reference to facilitate communication among cytopathologists, hematopathologists, clinicians, surgeons, and other healthcare providers. • Define and identify lymph node FNAB • indications, • preferred operators, • recommended performance, • analytical and preanalytical issues, • technical issues • basic diagnostic reporting categories and additional diagnostic information that can produce specific disease subtyping when possible. O^ Provide the key diagnostic cytopathological features of lesions that occur commonly in the various categories. • Provide recommendations on the components of standardized diagnostic reports with the aim to improve reporting and communication between cytopathologists and clinicians. • Provide management recommendations linked to the reporting categories with possible options that include the use of clinical and imaging follow-up, ancillary testing, and possible need of LN excision. • Encourage cytohistopathological correlations, cell storage, and research on neoplastic and non-neoplastic LN specimens. • Increase lymph node-FNAC reliability O 45 Main goals of lymph nodes FNAB • Lymph node identification (i.e. intramammary) • Lymph node diagnosis (malignant/reactive) and avoid excisional biopsy for benign/reactive process • Diagnosis and staging metastases and lymphomas • Diagnosis and microbial culture material for infectious etiology • Relieve anxiety for benign/ reactive processes • Cell collection for prognostic and predictive tests • Cell collection for clinical trials or other research tests O Diagnostic approach in lymphadenopathy • Two levels 1. Clinical, imaging, serological 2. FNAB, core needle biopsy or excissional biopsy o 46 Clinical, imaging, and serological evaluation of lymphadenopathy • Clinical evaluation of patients with lymphadenopathy may be a complex task for clinicians. • Medical history and physical examination often suggest the cause of lymphadenopathy and, in most cases with a clear clinical context, the diagnosis and management of reactive lymphadenopathy is quite straightforward and FNAB, core needle biopsy or excisional biopsy are not indicated. • Age • Clinical history • The size (> 1 cm and for specific sites (SCL, popliteal, iliac, epitrochlear region > 0,5 cm), consistency and/or image findings (US). • Basic laboratory test (CBC, DBC, biochemical blood analytes: LDH, IP, SR... rology (Toxoplasma, CMV...) (• Se Indications for lymph node FNAB • When the clinical and US presentation is less clear and serological data do not explain or do not match the clinical context, diagnostic imaging (CT...) and/or pathological evaluation are required (FNAB, core needle biopsy or excisional biopsy). • For the most frequent causes of lymphaedenopathy, such as benign reactive hyperplasia, specific infections or a metastasis from a known or unknown primary tumour, FNAB is an accurate, quick, and cost-effective procedure, often making excisional biopsy an unnecessary and costly alternative. • FNAB can distinguish a benign from malignant entity, or a haematolymphoid from a non-haematolymphoid process. • FNAB can be the first-choice procedure for patients who are poor candidates for surgical biopsy or with abnormal lymph nodes in deep or inaccessible locations. 47 Indications for core needle biopsy or excisional biopsy after FNAB • Primary lymphomas/leukemia • Inconclusive cytopathological diagnosis • Prognostic and predictive markers which cannot be asses by cytopathological examination o Lymph node FNAB techniques and procedural considerations • Informed consent • Based on the guidelines of the Internal Review Board or Ethics Committee of the involved institution • Operator • Cytopathologist, radiologist, clinician • FNAB • US guide recommended • Manual, CT, EUS, EBUS guide • Rapid on site evaluation (ROSE) O^ Accurate triage of material for ancillary studies I (immunophenotypic and molecular) 48 Lymph node FNAB request Table 1. LN-FNAC: clinical assessment and indications LN-FNAC issues Significant data Course of action Clinical context for requesting LN-FNAC Single or multiple LN with no relevant history Single or multiple LN in known pathology Mandatory Mandatory Clinical data to review when interpreting LN-FNAC Age, symptoms, site, size, time of onset, imaging (US) Remote and current medical history Basic serology (ESR, LDH, ToRCH complex, ANA, others) Specific serology (known or suspected disease) ^ Generally not available! Mandatory Mandatory Recommended Recommended LN, lymph node; US, ultrasound; ESR, erythrocyte sedimentation rate; LDH, lactate dehydrogenase; ToRCH, toxoplasmosis rubella Acta Cytologica 2020;64:306-322 o Cytopathological examination • Microscopic evaluation of MGG and Papanicolaou stained smears • Ancillary techniques • Flow cytometry • Reactive hypoplasia/lymphoma/leukemia • ICC on cytospins and cell blocks • Metastases, Hodgkin lymphoma • Gene rearrangement studies (Biomed II) • Especially for T-cell lymphomas • FISH, CISH • Specific translocations Infections • Special stains, cell culture, PCR O 49 Proposed diagnostic reporting categories for lymph nodes FNAB Recommendations Post-LN-FNAC management recommendations Inadequate/non-diagnostic LN-FNAC repetition and/or CNB or excision Benign Clinical follow-up/specific treatment (depending on diagnosis, e.g., antibiotics for bacterial infection) Atypical undetermined significance/atypical lymphoid uncertain significance (AUS/ALUS) LN-FNAC repetition with acquisition of material for ancillary studies and/or CNB or excision Suspicious Malignant Repeat FNAB/CNB LN-FNAC repetition with acquisition of material for appropriate ancillary studies and/or CNB or excision Histological biopsy requested (note: histological for HL and NHL relapses or wn or clearly indicated primary particular sites, or in case of 3r specific clinical settings) Acta Cytologica 2020;64:306-322 50 FNAB report LN-FNAC issues Procedures I Clinical data, site, imaging (US/CT) features Course of action } For external patients LN-FNAC report elements Recommended |procedure description: G-needle, guide, number of passes, ROSE,|method, sample type(s), processing, staining Suggested Basic diagnostic class (L1-L5) Recommended Microscopic description, ancillary technique/s used Suggested Secondary diagnosis or specific subtyping (if any) Suggested Sample suitable (or not) for further studies (ICC, molecular) for predictive markers (possibly % content of the tumor) Recommended ¡Recommendations (follow-up for reactive, repetition-biopsy for undetermined/suspicious, Ijioosv for first dssnosis îi L Nri_.. arc onCtieroniiK'o :"j£ta;tasis! OccasionaNy, Suggested Notes general If necessary Acta Cytologica 2020;64:306-322 practitioner's o Risk of malignancy (ROM) • Many publications in last 3 years: Gupta (2012), Vigliar (2021), Torres Rivas (2021), Ahuja 2022, Caputo 2022, Uzun 2022, Makarenko 2022, Shanmugasudaram 2023, Juanita 2023, Kanhe 2023) ROM (data from the literature), % ROM (OIL) Nondiagnostic 0.55-10.7 Benign 0.2-9.38 Atypical 37.5-100 Suspicious 82.3-100 Malignant 98.8-100 O 51 Conclusions • Implementation of A Proposalfor the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System in daily practice worldwide will improve accuracy of lymph node FNAB results and its acceptance among clinicians and pathologists. • At institute of Oncology Ljubljana the recommendations of the Sydney system has been part of our daily routine work long before their publishing and are also incorporated in The guidelines for diagnostic and treatment of malignant lymphomas of our hospital. Conclusions Clinical data Cytopathology (flow cytometry) Pathology CONSENSUS DIAGNOSIS (EMR data base) Multidisciplinary lymphoma bord at the Institute of Oncology Ljubljana O Thank you! 52 o Onkološki institut Institute of Oncology Ljubljana Favorable and unfavorable subtypes of DLBCL Urška Rugelj, MD Gorana Gašljevic, MD, PhD Institute of oncology Ljubljana 3rd School of Malignant Lymphomas, Ljubljana, 20.10.2023 53 ...now What are the locations of lymphoma? Does this patient have immunodefitiency? And what co-morbidities he has? Any previous treatment? Ok, it's DLBCL. What about COO? Imunochistochemistry results? Any rearrangements? Any other co-expressions? DLBCL - heterogeneus family • Different prognostic and predictive factors in DLBCL are already know. • The current standard of care - ChT with R-CHOP will not cure approx. 30%-40% of patient. • IPI score does not include any biological features. • Need to identify biomarkers to direct the treatment selections. • Many biomarkers have been investigated, but few show suffitient prognostic power. o 54 Cell Of Origin » Two main biologically distinct molecular subgroups of DLBCL based on GEP. germinal center B-cell like (GCB) activated B-cell like (ABC) or non-GCB • IHC expression of CD10, MUM1 and BCL-6 (Hans algorithm) • ABC subtype associated with worse prognoses compared to GCB Lu, T.-X. et al.. Sci. Rep. 6, 20465; doi: 10.1038/srep20465 (2016). o CD10 o BCL6 MUM - 1 55 GEP o IHC Scott et al. J Clin Oncol. 2015, Sept. 10;33:2848-2856. What about double positive GCB (CD10+, MUM1+) and triple negative non-GCB (CD10-, MUM1-, BCL6-) subtypes o Lu, T.-X. et al. The distinct clinical features and prognosis ofthe CD10+ MUM1+ and CD10-Bcl6-MUM1- diffuse large B-cell lymphoma. Sci. Rep. 6, 20465; doi: 10.1038/srep20465 (2016) 56 Double Hit/Double Expression Lymphomas 5-10% of DLBCL over-express MYC and BCL-2 • BCL-2 over-expression plays a role in resistence to chemotherapy ■ 47%-58% of DLBCL • MYC over-expression is associated with increased proliferation. ■ 20-30% of DLBCL 5y OS and PFS when treated with R-CHOP <30% o 57 o DLBCL with CD5/CD43 co-expression CD5 expressed in 5-10% de novo DLBCL CD43 expressed in approx. 25% of DLBCL Co-expression CD5/CD43 in approx. 5% The expression in studies correlates with higher I PI, higher Ki-67% and non-GCB phenotype All three variants predict poorer prognosis with (R)CHOP CD5+RREFS: 3,30;OS 3,69 CD43+ RR EFS: 3,18; OS 2,89 CD5+/CD43+ RR EFS: 7,71; OS 6,25 Ma X-B et all. Coexpression of CD5 and CD43 predicts worse prognosis in DLBCL. Cancer Med.2018 O DLBCL with CD56 expression • Reported incidence 0,5 - 7% of DLBCL NOS • Data are limited as it is not part of standard testing in B cell lymphoma • A predictive marker in myeloma, AML and ALL • More frequent with GCB subtype expressing CD10 and BCL-6 • May be related to more frequent extranodal involvement • The reports suggest favorable prognostic value A series from our Institution showed EFS and OS 100% G.Gasljevicetal.. Radiol Oncol. 2023 58 DLBCL with TP53 mutation • Mutation of TP53 detected in 18% to 30% of LBCL • Present in both GCB and non-GCB subtype • Associated with lower response to R-CHOP (CR 62%) and lower 3y EFS (42%) and OS (50%) o Zenz et al. Int. J. Cancer:141, 1381 -1388 (2017) EBV+/EBER DLBCL • EBV infection is correlated to several types of lymphoma • Associated with advanced stage, male patients, B simp., higher IPI, elevated LDH, extranodal involvement and non-GCB subtype • Predicts poor EFS and shorter survival. 59 T-cell-rich/histiocyte-rich BCL • 10% atypical B cells in a background rich in polyclonal T-cells • 1 -3% of DLBCL • Aggressive clinical course, high risk of bone marrow involvement, hepatosplenomegaly, high rates of extranodal involvement Instead of conclusion... There are many more subtypes andsubgroups according to molecular testing, NGS... Due to its speed, good reliability, and widespread applicability, IHC will remain the gold standard for additionaldiagnosis of DLBCL for some time. It is our task to further research and discover treatment modalities that will transform unfavorable lymphomas into favorable ones. o 60 Clinical case of refractory DLBCL Ales Christian Mihelac, MD Institute of Oncology Ljubljana, Slovenia Initial presentation Patient Presentation of disease T-i-i-fi-iTr,TnrrirnriTmrrffmrrTirni rrm t mm.............. Diagnosis y Laboratory 61 . and III. Line of Treatment R-DHAP (rituximab, dexamethasone, high dose cytarabine and cisplatine), started in june 2022 Favorable response, collection of stem cells for autologous bone marrow transplantation Prolonged Covid infections, 3rd cycle delayed for 2 months Confirmed relapse R-IGEV (rituximab, ifosfamide, gemcitabine, vinorelbine), started in September 2022 Very good response achieved 2nd relapse, patient already received several myelosupressive regimens Hematologists were consulted and an agreement was made, that she is a suitable candidate for CAR-T cell therapy, which she received in november 2022 • In february 2023, 3rd relapse was confirmed • Relapse in the right ureter, the only site of relapse according to all diagnostic studies • Radical irradiation of single relapse site with a dose of 40 Gy in april 2023 • Despite all interventions 4th relapse was confirmed with large tumor retroperitoneal and mesenterial masses after 2 months • R-pola-benda (rituximab, polatuzumab and bendamustine) with addition of prophylactic intrathecal chemotherapies was introduced • After 1st cycle progress of disease, chemotherapy with R-IGEV was reintroduced • PET-CT after 4 cycles showed complete metabolic remission. 63 Future considerations Current status HlliH^ ■iiflliMilHtti^r r k Plan of treatment ■QgSBBHfli^ V Overview of treatments 64 20.10.2023, Institute of Oncology Ljubljana 3rd school of malignant lymphomas Clinical case presentation Anja Žižek, dr.med CASE PRESENTATION 36-year-old female □ Pharmacist with 2 children (2,5-year-old, 6-month-old) □ Family history: mother had breast cancer □ Past history: eczema skin changes last 2 years on both arms(unkown cause) □ December 2020: COVID-19 disease ^ negative test after 1 week, but still persisting dyspnea, new onset of pain under right scapula, in pelvis and in left lower part of chest □ Coughing, night sweats, loss of 4 kg in 1,5 month □ Examination: palpable lymph nodes in bothSCL region (1,5 cm), right axila (4cm infiltrate), left axila (3 cm) □ RTG p.c. (january 2021): widened mediastinum (15 cm), small left sided pleural effusion □ CT of thorax, abdomen with contrast (January 2021): large solid formation in mediastinum, pressing on VCS, numerous enlarged lymph nodes □ LDH 4,67 Diagnosis: histopathological examination (right axillary lymph node, 29.1.2021) and other investigations: primary mediastinal large-B cell lymphoma • MIB-1 80% • without bcl-2, bcl-6 and myc translocation - Bone marrow biopsy and aspiration: no lymphoma infiltration - PET-CT (2.2.2021): widened mediastinum (X=15 cm, SUV max 19,4), infiltration of lymph nodes: both SCL regions, axillae, intercostal, abdomen; infiltrates in lungs?, clear infiltrations in left pleura, pleural effusion and bones (skull, mandibula, iliac bone, femur) • Primary clinical stage: IV.B.X, IPI 3 2 65 Treatment 3 Treatment □ 1st line treatment: 6 x R- DA- EPOCH □ 2nd line treatment: 3 x DHAP ^ after 1 (4x level 1, 2xlevel 2, finished by the end cycle collection of stem cells for ASCT of May 2021), 5 x zoledronic acid, 2x IT, - November 2021 -PET-CT: disease □ January 2022 - PET-CT: disease CSF negative progression: 2 formations in anterior Droaression in anterior □ CT of neck, thorax, abdomen with mediastinum (7 cm, SUV max 18), new mediastinum, new infiltrate in right contrast before 6th cycle: 5,9 x 2,1 x 8,5 infiltrate in 5th left rib (SUV max 25) paratracheal lymph node(DS 5) cm formation in anterior mediastinum - US-guided cytological puncture of tumor ■ Refractory large B cell lymphoma, CD 19+ □ PET-CT: CR (DS 3 only in upper in anterior mediatinum: large-B-cell retrosternal mediastinum). lymphoma, high expression of □ Bridging therapy : 2 x R-IGEV □ Lymphoma council: no further CD20+, MIB-1 70% □ March 2022 - PET-CT: PR in treatment, repeat PET-CT after 3 anterior mediastinum, retrosternal months and parasternal space (DS 4) Continuation of treatment June 2022 - biopsy of lymph node in right SCL region: mature highly malignant B cell lymphoma, morphological and immunophenotypically similar to primary biopsy. Immunohistochemical features: CD19+, CD23+, p63+, p53+, bcl-2+, bcl-6+, CD30 < 1% Negative: CD20, CD3, CD5. EBV-. MIB-1 at least 70% February 2023 - biopsy of lesion in liver: large-B-cell lymphoma, CD19+, partial CD23+, 30% of cells is CD30+ Negative: CD20, CD10, Cyclin D1 and CD5. ^ MIB-1 > 90%. ^ PD-L1 clone 142: 1% ^ PD-L1 clone 22C3: 70%. 3rd line: CAR-T cell therapy (23.3.2022) - Fever, occasional chest pain, night sweats - May 2022 - PET-CT: severe progression of -disease: infiltrated whole mediastinum (9,9 x 16 cm, SUV max 18), new infiltrates in liver hilus, at head of pancreas, aortocaval (SUV max 17) 4th line: 2 x CBVPP July 2022 - PET-CT: new, <1cm in diameter, hypodense lesions in liver (SUV max 5,8), other localisations: PR • MR of liver: diffuse lesions, ~ 10mm ^ characteristics of malignant growth 5th line: 3 x polatuzumab-bendamustin (+ venetoclax 200mg in 2nd and 3rd cycle) - After 2nd cycle - PET-CT in September 2022: CR - Prolonged pancytopenia + parainfluenza infection - November 2022: allogenic SCT, conditioning with TBF protocol, imunosupression: ATG, mycophenolat, cyclosporine. 4 66 ^ January 2023 - PET-CT: hypermetabolic, 1-2 cm large lesions in liver (SUV max 10,5), hypermetabolic lymph nodes in mediastinum, retroperitoneal lymph nodes ^ relapse of disease ^ Reducing immunosupression! February 2023 - biopsy of lesion in liver: large-B-cell lymphoma, CD19+, partial CD23+, 30% of cells are CD30+ Negative: CD20, CD10, Cyclin D1 and CD5. ^ MIB-1 > 90%. ^ PD-L1 clone 142: 1% ^ PD-L1 clone 22C3: 70%. Hematology and Lymphoma council: -> 6th line therapy (16.3.2023 -1.8.2023) Day 1: brentuximab-vedotin 1,8 mg/kg IV (7x) Day 8: nivolumab 240 mg IV (6x) Repeat every 21 days. Adverse effects - After 2nd dose of brentuximab vedotin —small fiber sensory neuropathy: severe burning pain in feet— i dose of brentuximab to 1,2 mg/kg - Itching skin eczema on elbow, clavicula, neck — corticosteroid creme - After 6th cycle: TSH 112 MIU/L, FT4 3,1 pmol/L, FT3 3,8, asymptomatic — Levothyroxine 50 mcg - — ICI induced hypothyroidism PET-CT after 4th cycle: CR 5 Clinical Case Report Name - 6 Avgust 2023: severe pancytopenia (TO - Fever, severe fatigue, respiratory infection V azythromicin and AMX/SMX - Numerous blood and platelets transfusions - Platelet antibodies: + - Ineffective platelet transfusions- > ITP? - Tranexamic acid - increasing LDH Leukocytes 0,39 Hemoglobin 66 MCV 98 Trombocytes 2 LDH 37 TSH 15, pT3 3,7, pT4 12,6 feritin 21341 TAG 2,51 CRP 55, PCT 0,48 Bilirubin 19 67 Diagnostic evaluation of pancytopenia PET-CT - end of August 2023 Microbiology results: - new diffuse accumulation of 18F-FDG in enlarged spleen (SUV max 6,6) and liver (SUV max 3,8), bone marrow (SUV max 3-4) - no pathological accumulation in lymph nodes (DS 2) - PCR - CMV, EBV: negative - Parvovirus B19: IgG positive (16), IgM negative - PCR - RV panel: negative - Induced sputum - Pneumocystis jirovecii: negative - Beta-D-glukan, Aspergillus galactomanan: negative - Populations of T-lymphocytes: decreased all values BONE MARROW EXAMINATION - 30.8.2023: including NK cells - sIL-2r: 5470 U/ml - Citology: no lymphoma cells. - Histology: toxic mielopathy due to specific oncology - Sputum: normal bacterial microbiota - Blood cultures: negative treatment, no hemophagocytosis. Few individual (max 3- - Coombs test-direct: + 4) transformed B cells - etiology? Minimal infiltration of - Coombs test-indirect: - large B-cell lymphoma? - 4.9. ^ Blood transfusion center: new anti-E antibodies against donor erythrocytes - 2 units of blood transfusions without E antigen, tocilizumab 440 mg ^ appropriate tHb: 90 HLH - 2004 criteria (at least 5 out of 8 criteria) 4. 5. 6. 7. 8. Fever Splenomegaly Cytopenia (in at least 2 of the 3 cell lines a. Hb < 90mg/dl b. Platelet counts < 100 c. neutrophils count < 1 ■fTAG or ^fibrinogen Low or absent NK-cell activity Ferritin level >500 ug/L sCD25r level >2400 U/ml Hemophagocytosis in bone marrow, spleen, or lymph nodes Haemophagocytic lymphohistocytosis secondary to immune checkpoint inhibitor therapy —> Therapy: 31.8.2023 - start of Dexamethasone 16 mg p.o. ^ slowly tapering of dose During hospitalization: 4 units of blood transfusions, 2 units of blood transfusion without E antigens, 5 units of platelet transfusion Sent application for compassionate use of loncastuximab tesirine ^ rejected due to pancytopenia 8 68 1.9.2023 31.8. - 25.10.: Dexamethasone 16 mg/day (2 weeks) ^ 8 mg/day (2 weeks) ^ 4 mg/day (2 weeks) ^ 2 mg/day (1 week) ^ 2 mg every second day 11.9.2023 Leukocytes 1,84 Leukocytes 2,93 Date S-IL2-R (158 -623 U/ml) Hemoglobin 88 Hemoglobin 76 29.8.2023 5470 MCV 92 MCV 90 4.9.2023 5313 Platelets 8- Platelets 3 25.9.2023 1398 Neutrophils 1,4 x 10A9/L Neutrophils 2,38 x 10"9/L Lymphocyte 0,29 x 10A9/L Lymphocyte 0,32 x 10A9/L Reticulocytes 4,7 x 10A9/L Reticulocytes LDH 45 ukat/L LDH 15 ukat/L TSH 15, pT3 3,7, pT4 12,6 TSH 0,927, pT3 3,2, pT4 21 feritin 35043 feritin 11358 CRP 64 PCT 0,756 CRP 1,2 Bilirubin 19 Bilirubin 19 Last visit- 9.10.2023 History: - well-being, going for a walk, good appetite - no fatigue - active at home and around the house - no B-symptoms, bleeding, dispnea or cough - Muscle cramps at night - dull pain in lumbar region, which is spreading to chest in last two days • Future: PET-CT after completion of treatment with dexamethasone Leukocytes 2,35 Hemoglobin 100 MCV 104,4 Platelets 14 Neutrophils 1,49 x 10A9/L Lymphocytes 0,42 x 10A9/L Bilirubin 9 LDH 5,71 TAG 4,03 Feritin 3773 CRP < 0,6 TSH 1,65 mlU/L FT3 3 pmol/L FT4 19,6 pmol/L 69 Onkološki Inštitut institute of oncology Nine-years up-to-date treatment of follicular lymphoma transformed to diffuse large B-cell lymphoma Tina Zupančič Prof. Barbara Jezeršek Novakovic, PhD Third school of malignant lymphomas, Institute of Oncology Ljubljana October, 2023 Patient presentation • November 2014 • 42-year-old male • Familly history negative for heamatological diseases • No commorbidities, PS 0 • No B symptoms • Axillar lymphadenopathy - lymph node biopsy confirmed low grade follicular lymphoma (FL) • IV A.X. (lymph nodes of the neck, axilla, large retroperitoneal mass (X) causing obstruction of the right kidney, bone marrow positive for FL) • FLIPI low risk • Interested in alternative medicine WBC: 4,97 x 109/L (normal 4,0 —10,0) HB: 159 g/L(normal 130 -170) PLT: 188 x 109 /L (normal 150 — 410) Creat: 98 |imol/L (normal 59 —104) LDH: 2,71 |kat/L (normal < 4,13) 70 First and second line • December 2014 • Radiotherapy to the retroperitoneal mass 2x2 Gy ❖April - October 2015 • Transformation to diffuse large B-cell lymphoma (DLBCL) in abdominal mass • 8 cycles of R-CHOP (cyclophosphamide, doxorubicine, vincristine, metilprednisolone) • Partial remission on PET CT reached • Consolidation radiotherapy indicated, but patient DECLINED • Rituximab maintenance for 6 cycles • November 2016 • Lymph node on neck - cytological relapse of FL confirmed • Multiple cytological punctions were suggested, but he DECLINED • Radiotherapy on multiple sites was suggested, again he DECLINED WBC: 4,82 x 109/L (normal 4,0 —10,0) HB: 100 g/L (normal 130 -170) PLT: 125 x 109 /L (normal 150 — 410) LDH: 10,34 |kat/L (normal < 4,13) PS: 0 WBC: 3,13 x 109/L (normal 4,0 —10,0) HB: 161 g/L (normal 130 — 170) PLT: 183 x 109 /L (normal 150 —410) LDH:2,39 |kat/L (normal < 4,13) PS:0 Third line ❖February- April 2020 • Massive clinical progression on right side of scalp and neck and other sites • Citology confirmed DLBCL, CD 20 positive • 3 cycles R-DHAP (rituximab, cisplatin, cytarabine, dexamethasone; after 2 cycles hearing immparement and cisplatin switch for oxaliplatin) and planned for autologous TX • Just before cytoreduction chemotherapy for autologous TX clinical progression at jugulum - confirmed DLBCL, CD 20 negative! WBC: 6,63 x 109/L (normal 4,0 —10,0) HB: 136 g/L (normal 130 — 170) PLT: 210 x 109 /L (normal 150 —410) LDH: 2,68 |kat/L (normal < 4,13) PS: 0 71 Fourth line ❖April 2020 • First cycle of IGEV (ifosfamide, gemcitabine, vinorelbine) • Presented forCAR-T therapy • 14. 5. 2020 leukapheresis for CAR-T performed • Totally 3 cycles of IGEV and complete response confirmed on PET CT • 1. - 7. 7. 2020 Lymphodepletion (cyclophosphamide, fludarabine) and CAR-T (2,6 x 10A9) infussion • No major complications • Remission for 8 months! • First patient in Slovenia! WBC: 3,39 x 109/L (normal 4,0 -10,0) HB: 98 g/L (normal 130 -170) PLT: 158 x 109 /L (normal 150 -410) LDH: 3,71 |kat/L (normal < 4,13) ps: 0 Fifth line WBC: 4,40 x 109/L (normal 4,0 -10,0) HB: 147 g/L (normal 130 -170) PLT: 150 x 109/L (normal 150 -410) LDH: 4,14 |kat/L (normal < 4,13) PS: 0 ❖February - april 2021 • Right-sided Horner's syndome, no B symptoms • PET CT: higher SUV on right apical pleura (6,4) • VATS biopsy of apical pleura confirmed DLBCL, GCB phenotype, double expressor, CD 20 negative, CD 19 40% ❖May 2021 • Polatuzumab-bendamustine was started and he was presented for allogenic TX • All necessary procedures for allogenic TX were performed and brother was a suitable donor • After 2 cycles (patient missed one cycle due to cellulitis and personal preferences) complete response on PET CT (july) confirmed • DECLINED further treatment • Declinded COVID-19 vaccination 72 Follow up ❖September 2021 ❖February 2022 • No B symptoms, PS 0 • PET/CT: Higher SUV in skin and fat • No lymphadenopathy tissue of right side of scalp • LDH: 4,1 ukat/L (normal < 4,13) ❖April 2022 • No B symptoms, PS 0 • Clinically not suspicious for progression • LDH 3,55 ukat/L (normal < 4,13) Sixth line ❖September/november 2022 • Clinically evident progression on right side of neck and scalp (10 cm large induration of skin and lymph nodes) • Denied B symptoms • Citology of infiltrât and node confirmed DLBCL, CD 20 weakly positive • PET CT: massive progression - including mass in pericard, infiltration of stomach, multiple sites in lungs and bones, many sites of lymph nodes • Polatuzumab-rituximab-bendamustine, intratecal application (mtx, AraC, Dexa) and zolendronic acid for 3 cycles • According to PET CT mixed response (progression and stable disease) WBC: 4,38 x 109/L (normal 4,0 —10,0) HB: 151 g/L (normal 130 -170) TBC: 226 x 109 /L (normal 150 -410) LDH: 11,36 |kat/L (normal < 4,13) PS: 0-1 73 Seventh line ♦♦♦A request was made for compassionate use of glofitamab (available in Slovenia at that time) - it was denied due to newly confirmed negative CD 20 status ♦February - april 2023 • CBVPP (carmustine, cyclophosphamide, vinblastine, procarbazine, prednisone) for 4 cycles and 3 intratecal applications (complication - Klebsiella pneumoniae sepsis) • PET CT again showed mixed response (progression and stable disease) • Radiotherapy of the progressed sites with continuity of CBVPP proposed - DECLINED radiotherapy ( but performed CT simulations) • Turned to alternative medicine • Patient died (at home) in june 2023 WBC: 3,45 x 109/L (normal 4,0 —10,0) HB: 100 g/L (normal 130 -170) TBC: 185 x 109 /L (normal 150 -410) LDH: 14,81 |kat/L (normal < 4,13) PS: 1-2 Conclusions • In 9 years 7 lines used according to up-to-date treatment, although not all possibilities were used • Non-compliant patient, prone to alternative treatment • Despite all, patient remained in good performance status and enjoyed high quality of life • First patient to receive CAR-T therapy in Slovenia 74 v v DOGODEK "3. LIMFOMSKA SOLA" SO PODPRLE NASLEDNJE DRUŽBE: Genesis Novartis Roche Astra Zeneca Takeda Eli Lilly Sobi Amgen Swixx Biopharma Abbvie O; Onkološki Inštitut | Institute of Oncology Ljubljana Strokovna knjižnica za onkologijo 8 čitalniških mest 5.300 knjig 6.000