Analysis Of Biological Features And Treatment Of Diffuse Large B-Cell Lymphoma With BCL-2/C-MYC Double Expression Status

PartⅠ Analysis of Clinical Impact and Up-front Treatment of Diffuse Large B-Cell Lymphoma with BCL-2/C-MYC Double Expression StatusObjective1.To explore the prognostic impact and interdependence of cell-of-origin(COO)classification and expression of BCL2,C-MYC proteins in patients with diffuse large B-cell lymphoma(DLBCL).2.To explore the prognostic survival of patients with BCL-2/C-MYC double expression(DE)undergo intensive induction and consolidative autologous stem cell transplantation(ASCT).MethodsWe retrieved cases of de novo DLBCL treated with R-CHOP like regimen at the department of Hematology in the First Affiliated Hospital of Soochow University from September,2015 through June,2019.Patients with transformed indolent B-cell NHL,primary mediastinal B-cell lymphoma,primary central nervous system(CNS)lymphoma,or Richter transformation of chronic lymphocytic leukemia were excluded.Confirmation of the histologic diagnosis and review of all immunohistochemistry(IHC)was performed by hematopathologists.Cases were subdivided into germinal center B cell-like(GCB)and non-GCB types according to the Hans algorithm.Cutoffs for positive expression of BCL2,BCL6 and C-MYC were defined as at least 50%,30%and 40%positive tumor cells,respectively.The clinicopathologic features and outcome of patients were compared between each group using Chi-quare test,t-test or Mann Whitney U-test.Overall survival(OS)and progression free survival(PFS)were calculated using the Kaplan-Meier method,and groups were compared using the log-rank test.Cox proportional hazard models were used to examine risk factors associated with OS and PFS events.The two-sided significance level was P<.05.All statistical analyses were performed using Statistical Package for Social Science(SPSS 22.0)software.Results1.Of the 280 de novo DLBCL patients identified.There were 144 men and 138 women with a median age of 57 years(range,16-82).Using the Hans algorithm,94(33.3%)cases were GCB,151(54.5%)cases were non-GCB,and 37(13.1%)cases were unclassified.Using IHC,BCL-2 expression was 190(67.3%)cases,C-MYC expression was 139(49.3%)cases and BCL-2/C-MYC double expression was 99(35.1%)cases.2.The study focused on the 245 de novo DLBCL patients,COO classification failed to predict OS and PFS in DLBCL patients(OS P=0.416;PFS P=0.531),and similar results were observed in BCL-2/C-MYC DE group(OS P=1.000)and Non-DE group(OS P=0.603)respectively.BCL-2 expression and C-MYC expression identified a subgroup with inferior survival among GCB-like DLBCL respectively(BCL-2+vs.BCL-2-OS P=0.013;C-MYC+vs.C-MYC-OS P=0.024),but not within Non-GCB-like DLBCL(BCL-2+vs.BCL-2-OS P=0.339;C-MYC+vs.C-MYC-OS P=0.164).3.Compared to Non-DE,significantly inferior OS and PFS was observed for patients with BCL-2/C-MYC DE in GCB-like DLBCL group and Non-GCB-like DLBCL group,respectively(GCB BCL-2/C-MYC DE vs.Non-DE 3 year OS 56.1%vs.76.2%P=0.005,3 year PFS 46.7%vs.65.2%P=0.042;Non-GCB BCL-2/C-MYC DE vs.Non-DE 3 year OS 51.9%vs.79.6%P=0.001,3 year PFS 42.3%vs.65.7%P=0.001).4.In multivariate analysis,BCL-2/C-MYC DE was still independent prognostic factor in DLBCL patients.5.In our study,97 patients with eligible DEL patients were treated with R-(DA)-EPOCH regimen and R-CHOP regimen.Of these,78 were treated with R-CHOP and 19 were treated with R-(DA)-EPOCH,the patients treated with R-(DA)-EPOCH regimen achieved higher complete remission(CR)rate and objective response rate(ORR)compared to patients treated with R-CHOP,but no significant statistical difference was observed(CR 68.4%vs.57.7%P=0.392;ORR 78.9%vs.71.8%P=0.528).In addition,No significant difference was observed between two groups in either 2-year OS(67.7%vs.58.2%,P=0.745)or 2-year PFS(51.0%vs.45.1%,P=0.536).6 patients who underwent consolidative ASCT did not show significant difference in 2-year OS and 2-year PFS compared to 12 matched patients who underwent observation(2-year OS 83.3%vs.82.5%P=0.870;2-year PFS(83.3%vs.65.6%P=0.340).Conclusions1.In this cohort,COO classification failed to stratify patient outcome.These data suggest that the prognostic role of COO defined by immunohistochemistry may be still controversial in DLBCL patients.In contrast,dual expression of MYC and BCL2 was predictive of poor survival and independent prognostic factors for DLBCL patients.BCL-2/C-MYC DE but not COO plays an important role in assessing the prognostic risk stratification in DLBCL.2.In our study,DEL patients may not benefit from R-(DA)-EPOCH or consolidative ASCT,though selection bias and limited sample size may have limited our ability to detect significant differences.Efforts are required to perform a larger,prospective and randomized clinical trials.Part Ⅱ Outcomes of CAR-T Therapy in Relapsed or Refractory Diffuse Large B-Cell Lymphoma with BCL-2/C-MYC Double Expression StatusObjectiveDouble-expressor lymphoma(DEL)is a subtype of diffuse large B-cell lymphoma(DLBCL)associated with poor outcomes after standard chemoimmunotherapy.More importantly,DEL is associated with inferior outcomes after autologous stem-cell transplantation(ASCT)or allogeneic hematopoietic cell transplantation(allo-SCT)in patients with relapsed or refractory(rel/ref)DLBCL.Chimeric antigen receptor T cell(CAR-T)is a newly emerging immunotherapy for rel/ref B-cell malignancy and has shown promising outcome.The aims of this study was to explore the efficacy and prognostic factors of CAR-T cells in patients with rel/ref double-expressor lymphoma.MethodsPatients with rel/ref DLBCL who underwent CAR-T therapy in our center and in whom archival tumor material was available were enrolled.The clinical features,therapeutic features and adverse events of patients with Non-DEL were compared to patients with DEL using Chi-quare test or t-test.Survival outcomes were calculated using the Kaplan-Meier method,and groups were compared using the log-rank test.The estimated cumulative incidence of relapse(CIR)was compared using Gray’s test with death in remission accounted for as a competing risk.Cox proportional hazard models were used to examine risk factors associated with OS and PFS events.The two-sided significance level was P<.05.Statistical analyses were performed using Statistical Package for Social Science(SPSS 22.0)and R 3.6.1 software.ResultsWe retrospectively studied the impact of DE status in our center of patients who underwent CAR-T therapy for relapsed/refractory(rel/ref)DLBCL.A total of 33 patients were included,51.5%had Non-DEL and 48.5%had DEL.There was no significant difference between Non-DEL and DEL groups in clinical features,therapeutic features and adverse events.Among the 24 patients who underwent CAR-T therapy alone,in the Non-DEL group,6(66.7%)of 9 evaluable patients who were in stable disease(SD)or progression disease(PD)had an objective response,and in the DEL group,3(42.9%)of 7 evaluable patients who were in SD or PD had an objective response,the Non-DEL patients achieved higher objective response compared to DEL patients,but no significant statistical difference was observed(ORR 66.7%vs.42.9%,P=0.615).With a median follow-up of 4.5(1-27)months,for the cohort,the 1-year OS and PFS were 47.3%(95%CI,26.0%-68.0%)and 39.6%(95%CI,20.0%-60.0%),respectively.There were no significant differences in 1-year PFS,OS or CIR between patients with DEL compared to patients without DEL(PFS 31.8%vs.46.2%,P=0.295;OS 38.4%vs.53.8%,P=0.499,CIR 50.0%vs.38.5%,P=0.970).For patients with rel/ref DLBCL who underwent CAR-T therapy,the lack of association between BCL-2/C-MYC DE status and outcome was confirmed.In addition,there were statistically significant differences in median OS and median PFS between CAR-T therapy alone group and Post-CAR-T therapy stem cell transplantation(SCT)group(CART vs.Post-CAR-T SCT OS 10m vs.Not reach P=0.043;PFS 5m vs.Not reach P=0.030).Among the DEL group,the median PFS in Post-CAR-T therapy SCT group was longer than in the CAR-T therapy alone(CART vs.Post-CAR-T SCT PFS 4m vs.Not reach P=0.038).In a multivariable analysis,achieving response status before CAR-T infusion was independently associated with improved survival.ConclusionsIn this cohort,the efficacy and safety of CAR-T cells in the treatment of rel/ref DLBCL were confirmed.Notely,unlike previous studie,the lack of association between DEL and efficacy and outcome was confirmed.In addition,with bridge to SCT after CAR-T therapy,better outcome for rel/ref DLBCL has been achieved in our study.Efforts are required to perform a larger,prospective and randomized clinical trials.