Maja Bech Juul

A population-based study of prognosis in advanced stage follicular lymphoma managed by watch and wait

Watch and wait (WAW) is a common approach for asymptomatic, advanced stage follicular lymphoma (FL), but single‐agent rituximab is an alternative for these patients. In this nationwide study we describe the outcome of patients selected for WAW. A cohort of 286 out of 849 (34%) stage III‐IVA FL patients seen between 2000 and 2011, were managed expectantly and included. The 5‐year progression‐free survival (PFS) was 35% [95% confidence interval (CI) 29–42]. The 10‐year overall survival (OS) was 65% (95%CI 54–78), and the cumulative risk of dying from lymphoma within 10 years of diagnosis was 13% (95%CI 7–20). Elevated lactate dehydrogenase and > four nodal regions involved were associated with a higher risk of lymphoma treatment and death from lymphoma. The WAW patients and a matched background population had similar OS during the first 50 months after diagnosis (P = 0·7), but WAW patients had increased risk of death after 50 months (P < 0·001). The estimated loss of residual life after 10 years was 6·8 months. The 10‐year cumulative risk of histological transformation was 22% (95%CI 15–29) and the 3‐year OS after transformation was 71% (95%CI 58–87%). In conclusion, advanced stage FL managed by WAW had a favourable outcome and abandoning this strategy could lead to overtreatment in some patients.

Minimal Loss of Lifetime for Patients With Diffuse Large B-Cell Lymphoma in Remission and Event Free 24 Months After Treatment: A Danish Population-Based Study

Purpose The general outlook for patients with diffuse large B-cell lymphoma (DLBCL) in first remission is important information for patients and for planning post-treatment follow-up. The purpose of this study was to evaluate the survival of patients with DLBCL in remission compared with a matched general population. Methods A total of 1,621 patients from the Danish Lymphoma Registry who were newly diagnosed with DLBCL between 2003 and 2011 were included in this study. All patients were ≥ 16 years of age at diagnosis and had achieved complete remission or complete remission unconfirmed after first-line rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or R-CHOP-like therapy. Results The 5-year post-treatment DLBCL survival was inferior to survival in the matched general population (78%; 95% CI, 76 to 80; v 87%; standardized mortality ratio, 1.75; P < .001). Excess mortality was present but reduced for patients achieving post-treatment event-free survival for 24 months (pEFS24; standardized mortality ratio, 1.27; P < .001). In age-stratified analyses, the survival of patients < 50 years of age was normalized to the general population after achieving pEFS24 ( P = .99). During the first 8 years after pEFS24, the average loss of lifetime was 0.31 mo/y (95% CI, 0.11 to 0.50 mo/y). Excess mortality diminished when analyzing death from lymphoma as competing event to death from other causes, suggesting that early and late relapse is responsible for increased mortality in patients with DLBCL. Conclusion Although this population-based study does not support complete normalization of survival for patients with DLBCL achieving pEFS24, the estimated loss of residual lifetime was low for patients in continuous remission 2 years after ending treatment. Therefore, pEFS24 is an appealing and relevant milestone for patient counseling and could be a surrogate end point in clinical trials.

Uterine, but not ovarian, female reproductive organ involvement at presentation by diffuse large B-cell lymphoma is associated with poor outcomes and a high frequency of secondary CNS involvement

Involvement of the internal female reproductive organs by diffuse large B‐cell lymphoma (DLBCL) is uncommon, and there are sparse data describing the outcomes of such cases. In total, 678 female patients with DLBCL staged with positron emission tomography/computed tomography and treated with rituximab‐containing chemotherapy were identified from databases in Denmark, Great Britain, Australia, and Canada. Overall, 27/678 (4%) had internal reproductive organ involvement: uterus (n = 14), ovaries (n = 10) or both (n = 3). In multivariate analysis, women with uterine DLBCL experienced inferior progression‐free survival and overall survival compared to those without reproductive organ involvement, whereas ovarian DLBCL was not predictive of outcome. Secondary central nervous system (CNS) involvement (SCNS) occurred in 7/17 (41%) women with uterine DLBCL (two patients with concomitant ovarian DLBCL) and 0/10 women with ovarian DLBCL without concomitant uterine involvement. In multivariate analysis adjusted for other risk factors for SCNS, uterine involvement by DLBCL remained strongly associated with SCNS (Hazard ratio 14·13, 95% confidence interval 5·09–39·25, P < 0·001). Because involvement of the uterus by DLBCL appears to be associated with a high risk of SCNS, those patients should be considered for CNS staging and prophylaxis. However, more studies are needed to determine whether the increased risk of secondary CNS involvement also applies to women with localized reproductive organ DLBCL.

Validation of the German high-grade non-hodkin lymphoma study group (DSHNHL) prognostic model for CNS replapse in a large cohort of PET/CT staged patients

009 Table 1.

Thrombosis in Hb Taybe [codons 38/39 (-ACC) (α1)].

Hb Taybe is a highly unstable hemoglobin (Hb) variant caused by a 3 bp deletion at codons 38/39 (–ACC) on the α1-globin gene. We report for the first time, a patient with a compound heterozygosity for Hb Taybe and a 5 bp deletion at the splice donor site of IVS-I on the α2-globin gene and ischemic stroke and priapism. The patient, a male of Palestinian origin, suffered since childhood from moderate hemolytic anemia. Splenectomy was performed at the age of 19. Five years after the splenectomy, recurring attacks of priapism occurred and at the age of 28 the patient had a pontine infarction. A heterozygote prothrombin G20210A mutation was found. We assume that ongoing intravascular hemolysis, splenectomy and the prothrombin G20210A mutation may explain the thrombotic tendency in this case.

Female patients with DLBCL and involvement of the reproductive organs have poor outcomes and markedly increased risk of CNS relapse with R-chop(-like) therapy

151 Table CD3 P ≥ 50 CD4 P ≥ 50 CD8 P ≥ 50 CD3/B-cell P ≥ 50 CD4/CD8 P ≥ 50 CD4 TFH/CD4 + P ≥ 75 Age (%) <60 years 39 34 29 21 55 21 ≥60 years 59 56 57 43 43 39 Histological grade (%) 1–2 45 43 35 27 58 29 3 89 67 89 67 0 11 Bulky disease (%) No 57 53 46 60 46 23 Yes 22 17 33 11 56 29 Extranodal (%) ≤1 58 52 51 58 47 23 >1 21 21 21 26 53 29 Leukemic phase (%) No 56 50 48 32 60 22 Yes 10 10 10 0 46 25 182 Poster Presentations resistance. Immune cells in the lymphoma tumour microenvironment have been implicated in disease progression (Dave et al., NEJM 2004) and may play a role in transformation. We recently discovered that expression of the inhibitory receptor PD-1 was associated with suppressed cytokine signalling in FL tumour-infiltrating T cells (Myklebust et al., Blood 2013). Furthermore, it has been suggested that PD-1 int cells are the truly exhausted T cells and that PD-1 high cells are normal T follicular helper cells (TFH) (Yong et al., Blood Cancer J 2015). Antibody immunotherapy targeting PD-1 has shown significant promise in aggressive malignancies (Topalian et al., NEJM 2012), suggesting that exhausted T cells can regain functionality, including anti-tumour effects. Methods: Three mass cytometry (CyTOF) panels were designed to detect 30 markers per cell and used to characterize FL tumour biopsies (n = 9) and human tonsils. In the first panel, inhibitory and co-stimulatory receptors were quantified across 5 major T-cell subsets and maturation stages (Nicholas and Greenplate et al., manuscript in preparation). In the second panel, key surface markers were combined with antibodies to detect 12 phosphoproteins to correlate signalling responses with inhibitory receptor profiles. The last panel was designed to characterize healthy and malignant B cells. The dimensionality-reduction tool viSNE was used to analyse the high-dimensional mass cytometry data. Fluorescent flow panels were used in parallel to measure 9 inhibitory receptors in selected T-cell subsets. Results: viSNE analysis of 23 surface markers revealed a high degree of phenotypic similarity between T cells infiltrating FL and T cells in tonsils. In contrast, viSNE characterized the significant phenotypic differences between malignant B cells and healthy B cells within the same tumour. PD1 + T cells from FL samples displayed reduced cytokine signalling compared to PD1 cells, confirming previous results. TFH cells were identified as CXCR5 hi ICOS + CD4 memory T cells. Among the ICOS + cells in tonsils, a distinct CXCR5 population was identified with intermediate PD1 expression, suggesting an exhausted phenotype. These cells expressed less TIGIT, BTLA and LAIR1 than TFH but contained a subpopulation of TIM3 + cells that was not seen within the TFH population. Conclusions: Striking similarities in phenotype and signalling response of the T cells infiltrating FL tumours and T cells from healthy tonsil observed by mass cytometry suggest active immune responses in these tissues. These results provide further support for characterizing relationships between receptor signalling and T cell function and for researching into combination immunotherapies for FL focused on modulating adaptive immune responses. 151 T-CELL SUBPOPULATIONS QUANTIFIED BY FLOW CYTOMETRY IN LYMPH NODE CELL SUSPENSIONS IDENTIFY A GROUP OF PATIENTS WITH FOLLICULAR LYMPHOMA WITH FAVORABLE OUTCOME L. Magnano 1 , J. Carreras 2 , A. Martinez 2 , A. Martinez-Trillos 1 , J. Rovira 1 , I. Dlouhy 1 , E. Gine 1 , T. Bauman 1 , O. Balague 2 , E. Campo 2 , N. Villamor 3 , A. López-Guillermo 1 . 1 Hematología, Hospital Clinic de Barcelona, Barcelona, Spain, 2 Pathology Department, Hospital Clinic de Barcelona, Barcelona, Spain, 3 Hematopathology Unit, Hospital Clinic de Barcelona, Barcelona, Spain. Introduction: Tumour microenvironment plays an important role in the behaviour of follicular lymphoma (FL). By gene expression and immunohistochemistry, an increase in macrophages has been associated with poor outcome, while an increase in T cells is associated with good prognosis. The aim of the study was to explore the prognostic impact of subpopulations of T cells using flow cytometry and to identify different groups of risk in FL patients. Methods: Seventy-five patients (36 men/39 women, median age 60 years) diagnosed of FL (grades 1–2, 87%; grade 3, 13%) between 1984 and 2009 (median follow-up of 6.5 years) with sample at diagnosis were included in the present study. In 41 cases, T-cell staining were semiquantitatively analysed by immunohistochemical (IHC), including their distribution (intra, inter or perifollicular). T-cell populations from lymph node were quantified by multiparametric flow cytometry in cell suspensions in all cases. The percentage of B-cells, CD3 + , CD4 + , CD8 + , CD57 + , CD4TFH cells (double staining CD4 + CD57 + ), as well as the ratio T/B-cells, CD3 + /CD4 + , CD3 + /CD8 + , CD4 + /CD8 + and CD4TFH/CD4 + were analysed and correlated with initial features and outcome. Copyright

Validation of the German High-Grade Non-Hodgkin Lymphoma Study Group (DSHNHL) prognostic model for CNS relapse in a large cohort of PET/CT staged patients

009 Table 1.

TREATMENT STRATEGIES AND OUTCOMES IN DIFFUSE LARGE B-CELL LYMPHOMA OF THE ELDERLY: A DANISH POPULATION-BASED COHORT STUDY OF 1,011 PATIENTS

(n = 2), CLL9 (n = 9), and CLL10 (n = 2). Median age was 82 years (range 80‐90). Concomitant diseases were present in 99% of the pts and median cumulative illness rating scale (CIRS) score was 8 (0‐18). Median creatinine clearance was 46 mL/min (range 17‐99 mL/min). Distribution of CLL‐IPI risk groups was as follows: 6% low, 19% intermediate, 61% high, and 14% very high. Most pts had Binet stage B (36%) or C (43%).Chemoimmunotherapy with chlorambucil plus obinutuzumab (CLB‐OB) or chlorambucil plus rituximab (CLB‐R) was administered to 61 (40%) and 56 (37%) pts, respectively. Remaining pts received chlorambucil alone (CLB, n = 19), fludarabine (F, n = 10), F/cyclophosphamide (FC, n = 1), FC/rituximab (FCR, n = 2), or bendamustine/rituximab (BR, n = 3). Rates of grade 3 or 4 neutropenia and infections were 35% and 13%, respectively. Premature treatment discontinuations occurred in 15% of cases and were mostly due to adverse events. The total overall response rate was 92% with 13% complete remissions. Median observation time for all pts was 40.7 months. Median progression‐free survival (PFS) and treatment‐ free survival (TFS) were 17.2 and 32.3 months. A total of 47 pts (31%) received at least one further line of treatment. Median overall survival (OS) was 48.3 months, with adverse events (22%) and progressive CLL (15.8%) being the most frequent causes of death. Standardized mortality ratio was calculated and showed a 1.99 (CI 1.54‐2.53) increased risk of death as compared to an age‐ and sex‐matched general population. Independent prognostic factors for OS were 17p deletion and elevated serum thymidine kinase. Conclusion: Findings suggest that antileukemic therapy (incl. Chemoimmunotherapy) is feasible and efficacious in ≥80 year old pts with CLL. However, such pts are still highly underrepresented in clinical trials and even with modern treatment live shorter than age‐ matched controls of the general population.

Female patients with DLBCL and involvement of the reproductive organs have poor outcomes and markedly increased risk of central nervous system relapse with R-CHOP(-like) therapy

151 Table CD3 P ≥ 50 CD4 P ≥ 50 CD8 P ≥ 50 CD3/B-cell P ≥ 50 CD4/CD8 P ≥ 50 CD4 TFH/CD4 + P ≥ 75 Age (%) <60 years 39 34 29 21 55 21 ≥60 years 59 56 57 43 43 39 Histological grade (%) 1–2 45 43 35 27 58 29 3 89 67 89 67 0 11 Bulky disease (%) No 57 53 46 60 46 23 Yes 22 17 33 11 56 29 Extranodal (%) ≤1 58 52 51 58 47 23 >1 21 21 21 26 53 29 Leukemic phase (%) No 56 50 48 32 60 22 Yes 10 10 10 0 46 25 182 Poster Presentations resistance. Immune cells in the lymphoma tumour microenvironment have been implicated in disease progression (Dave et al., NEJM 2004) and may play a role in transformation. We recently discovered that expression of the inhibitory receptor PD-1 was associated with suppressed cytokine signalling in FL tumour-infiltrating T cells (Myklebust et al., Blood 2013). Furthermore, it has been suggested that PD-1 int cells are the truly exhausted T cells and that PD-1 high cells are normal T follicular helper cells (TFH) (Yong et al., Blood Cancer J 2015). Antibody immunotherapy targeting PD-1 has shown significant promise in aggressive malignancies (Topalian et al., NEJM 2012), suggesting that exhausted T cells can regain functionality, including anti-tumour effects. Methods: Three mass cytometry (CyTOF) panels were designed to detect 30 markers per cell and used to characterize FL tumour biopsies (n = 9) and human tonsils. In the first panel, inhibitory and co-stimulatory receptors were quantified across 5 major T-cell subsets and maturation stages (Nicholas and Greenplate et al., manuscript in preparation). In the second panel, key surface markers were combined with antibodies to detect 12 phosphoproteins to correlate signalling responses with inhibitory receptor profiles. The last panel was designed to characterize healthy and malignant B cells. The dimensionality-reduction tool viSNE was used to analyse the high-dimensional mass cytometry data. Fluorescent flow panels were used in parallel to measure 9 inhibitory receptors in selected T-cell subsets. Results: viSNE analysis of 23 surface markers revealed a high degree of phenotypic similarity between T cells infiltrating FL and T cells in tonsils. In contrast, viSNE characterized the significant phenotypic differences between malignant B cells and healthy B cells within the same tumour. PD1 + T cells from FL samples displayed reduced cytokine signalling compared to PD1 cells, confirming previous results. TFH cells were identified as CXCR5 hi ICOS + CD4 memory T cells. Among the ICOS + cells in tonsils, a distinct CXCR5 population was identified with intermediate PD1 expression, suggesting an exhausted phenotype. These cells expressed less TIGIT, BTLA and LAIR1 than TFH but contained a subpopulation of TIM3 + cells that was not seen within the TFH population. Conclusions: Striking similarities in phenotype and signalling response of the T cells infiltrating FL tumours and T cells from healthy tonsil observed by mass cytometry suggest active immune responses in these tissues. These results provide further support for characterizing relationships between receptor signalling and T cell function and for researching into combination immunotherapies for FL focused on modulating adaptive immune responses. 151 T-CELL SUBPOPULATIONS QUANTIFIED BY FLOW CYTOMETRY IN LYMPH NODE CELL SUSPENSIONS IDENTIFY A GROUP OF PATIENTS WITH FOLLICULAR LYMPHOMA WITH FAVORABLE OUTCOME L. Magnano 1 , J. Carreras 2 , A. Martinez 2 , A. Martinez-Trillos 1 , J. Rovira 1 , I. Dlouhy 1 , E. Gine 1 , T. Bauman 1 , O. Balague 2 , E. Campo 2 , N. Villamor 3 , A. López-Guillermo 1 . 1 Hematología, Hospital Clinic de Barcelona, Barcelona, Spain, 2 Pathology Department, Hospital Clinic de Barcelona, Barcelona, Spain, 3 Hematopathology Unit, Hospital Clinic de Barcelona, Barcelona, Spain. Introduction: Tumour microenvironment plays an important role in the behaviour of follicular lymphoma (FL). By gene expression and immunohistochemistry, an increase in macrophages has been associated with poor outcome, while an increase in T cells is associated with good prognosis. The aim of the study was to explore the prognostic impact of subpopulations of T cells using flow cytometry and to identify different groups of risk in FL patients. Methods: Seventy-five patients (36 men/39 women, median age 60 years) diagnosed of FL (grades 1–2, 87%; grade 3, 13%) between 1984 and 2009 (median follow-up of 6.5 years) with sample at diagnosis were included in the present study. In 41 cases, T-cell staining were semiquantitatively analysed by immunohistochemical (IHC), including their distribution (intra, inter or perifollicular). T-cell populations from lymph node were quantified by multiparametric flow cytometry in cell suspensions in all cases. The percentage of B-cells, CD3 + , CD4 + , CD8 + , CD57 + , CD4TFH cells (double staining CD4 + CD57 + ), as well as the ratio T/B-cells, CD3 + /CD4 + , CD3 + /CD8 + , CD4 + /CD8 + and CD4TFH/CD4 + were analysed and correlated with initial features and outcome. Copyright