Relapsed/Refractory Diffuse Large B-Cell Lymphoma
Prospects for Improving Outcomes in High-Risk Diffuse Large B-Cell Lymphoma
The classification of high-risk diffuse large B-cell lymphoma (DLBCL) is evolving to include more biologic and genetic markers. The treatment of patients with high-risk DLBCL remains challenging, but several different strategies appear promising.
What is the current paradigm for high-risk DLBCL, and what investigational avenues are being explored at each line of therapy for these patients?
Associate Member, Lymphoma Service
“The management of double-hit lymphoma with MYC translocated to an immunoglobulin partner is an area of ongoing debate. To date, prospective randomized data to help guide decision making have been very limited.”
Defining high-risk disease has been a bit of a moving target. We have traditional classifiers such as the International Prognostic Index (IPI) and cell of origin, and now we have molecular and genetic classifiers that indicate double-hit biology (ie, translocations of MYC and either BCL-2 or BCL-6). When MYC is translocated with an immunoglobulin gene partner, a worse prognosis is conferred. Some patients have a double-hit gene signature without the classically identified translocations by fluorescence in situ hybridization (FISH), and the use of double-hit genetic signatures may offer more precision than using translocation data from FISH alone. There are various classification schemata that are in development that move away from cell of origin, and these may also help inform the development of precision-targeted therapy in the treatment of either newly diagnosed or relapsed/refractory high-risk disease.
The management of double-hit lymphoma with MYC translocated to an immunoglobulin partner is an area of ongoing debate. To date, prospective randomized data to help guide decision making have been very limited. Some retrospective data have suggested that intensified induction strategies such as dose-adjusted etoposide, prednisone, vincristine sulfate, cyclophosphamide, doxorubicin hydrochloride, and rituximab (EPOCH-R regimen) may improve outcomes compared to rituximab plus cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone (R-CHOP regimen), but a recent abstract using data from the Flatiron Health electronic health record database found no difference in survival between these regimens in patients with MYC-rearranged double- or triple-hit DLBCL.
There are several clinical trials that have been completed, are currently accruing, or are in development, each of which focuses on a different way to improve outcomes in patients with higher-risk DLBCL. These often use the IPI to create a high-risk disease category and may incorporate biologically agnostic treatments. Early nonresponse to treatment is another indicator of high-risk disease, but identifying those early nonresponders is a challenge. However, we may be able to use the rate of disappearance of cell-free DNA or circulating tumor DNA after treatment initiation to predict prognosis and to help guide response-adaptive approaches in the future.
Professor of Medicine, Division of Oncology
“If positive, POLARIX and ESCALADE would both be practice-changing clinical trials.”
Risk can be assessed by clinical features or by biologic markers. We know that patients with higher IPI scores are less likely to be cured with standard chemoimmunotherapy, whereas those with an IPI of 0 or 1 have very high cure rates with R-CHOP. Thus, some of the ongoing trials are looking to make improvements in the treatment of high-risk populations.
For example, the ongoing POLARIX trial (NCT03274492) is comparing polatuzumab vedotin with rituximab, cyclophosphamide, doxorubicin hydrochloride, and prednisone (R-CHP) vs standard R-CHOP in patients with an IPI score of 2 or higher. Polatuzumab vedotin plus R-CHP is a modified version of R-CHOP, where polatuzumab vedotin is added and vincristine is removed from the regimen. Early data are expected soon.
Another ongoing global study is the ESCALADE trial (NCT04529772), which uses cell of origin and clinical features (IPI ≥2) to create a high-risk category. The trial is limited to patients with nongerminal center B-cell–like (NGCB) disease, who generally have higher risk than patients with GCB disease. Additionally, it appears that Bruton tyrosine kinase inhibitors have activity in NGCB disease but very little activity in GCB disease. So, the ESCALADE trial is evaluating the use of R-CHOP plus the Bruton tyrosine kinase inhibitor acalabrutinib in these patients. If positive, POLARIX and ESCALADE would both be practice-changing clinical trials.
For future trials, we will likely be more sophisticated in our approach. For instance, we now know that classifications such as cell of origin may not be sufficiently precise, as there are distinct molecular subtypes within these categories that may respond differently to therapy. Dr Abramson is involved in another interesting trial that is using molecular markers to assess risk, looking at either the double-hit or double-expressor population. These patients generally overexpress the BCL-2 protein and they are known to have inferior outcomes, and the trial is evaluating the addition of venetoclax to standard chemoimmunotherapy in an effort to improve outcomes (NCT03984448).
Director, Jon and JoAnn Hagler Center for Lymphoma
“R-CHOP remains the standard of care for double-expressor lymphomas, and there is no evidence that a more intensified induction regimen is better; however, that does beg the question of whether a more biologically driven strategy might be more successful.”
Biological factors beyond cell of origin include the double-hit and double-expression populations. In patients with double-hit high-grade BCL, the prognosis has traditionally been seen as very poor with conventional therapy, whereas double expressors seemed to have intermediate outcomes, falling between double-hit and other DLBCL patients. However, the prognosis in both groups may not be as grave as initially described, and I think that this is an important point to raise when counseling our patients.
R-CHOP remains the standard of care for double-expressor lymphomas, and there is no evidence that a more intensified induction regimen is better; however, that does beg the question of whether a more biologically driven strategy might be more successful. Double-hit DLBCL is a heterogeneous group, with some patients having highly kinetic disease, presenting with leukemic phase disease and lactate dehydrogenase levels in the thousands, whereas others present with relatively typical-appearing DLBCL. Thus, there are a lot of biological differences beyond just those cytogenetic changes. However, a biologically driven strategy might improve outcomes in double-hit patients and in double-expressor patients, in whom BCL-2 is uniformly expressed. This is currently being investigated in the clinical trial that was mentioned by Dr Kahl (NCT03984448), which is looking at venetoclax plus chemoimmunotherapy for MYC/BCL-2 double-hit and double-expressing lymphomas.
We are eagerly awaiting the results of the ESCALADE trial incorporating acalabrutinib, and we are also interested in potentially seeing more data with lenalidomide to know whether we should be incorporating that into our treatment of selected patients. POLARIX is an appealing concept across the board, since CD79b is a ubiquitously expressed target, and it appears poised to change our upfront standard of care. Another intriguing strategy is being employed in the ZUMA-12 trial (NCT03761056), which is a nonrandomized study evaluating patients with high-risk LBCL (double or triple hit, or IPI ≥3) as a component of first-line treatment. Patients receive 2 initial cycles of an anti-CD20 monoclonal antibody and an anthracycline-containing regimen, and those with a persistently positive positron emission tomography scan after 2 cycles then receive chimeric antigen receptor T-cell therapy with axicabtagene ciloleucel. And we will continue to see bispecific antibodies getting into the mix as well, to examine whether dialing in additional immunotherapy for both relapsed and upfront therapy might cure more patients with high-risk disease.
Chong LC, Ben-Neriah S, Slack GW, et al. High-resolution architecture and partner genes of MYC rearrangements in lymphoma with DLBCL morphology. Blood Adv. 2018;2(20):2755-2765. doi:10.1182/bloodadvances.2018023572
ClinicalTrials.gov. A combination of acalabrutinib with R-CHOP in subjects with previously untreated non-GCB subtype DLBCL (ACE-LY-312) (ESCALADE). Updated October 21, 2021. Accessed October 25, 2021. https://clinicaltrials.gov/ct2/show/NCT04529772
ClinicalTrials.gov. A study comparing the efficacy and safety of polatuzumab vedotin with rituximab-cyclophosphamide, doxorubicin, and prednisone (R-CHP) versus rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in participants with diffuse large B-cell lymphoma (POLARIX). Updated August 30, 2021. Accessed October 25, 2021. https://clinicaltrials.gov/ct2/show/NCT03274492
ClinicalTrials.gov. Efficacy and safety of axicabtagene ciloleucel as first-line therapy in participants with high-risk large B-cell lymphoma (ZUMA-12). Updated August 18, 2021. Accessed October 25, 2021. https://clinicaltrials.gov/ct2/show/NCT03761056
ClinicalTrials.gov. Testing the addition of a new anti-cancer drug, venetoclax, to usual chemotherapy for high grade B-cell lymphomas. Updated October 20, 2021. Accessed October 25, 2021. https://clinicaltrials.gov/ct2/show/NCT03984448
Hartert KT, Wenzl K, Krull JE, et al. Targeting of inflammatory pathways with R2CHOP in high-risk DLBCL. Leukemia. 2021;35(2):522-533. doi:10.1038/s41375-020-0766-4
Magnusson T, Narkhede M, Mehta A, Goyal G. No difference in overall survival between R-CHOP and R-EPOCH among patients with advanced stage MYC-rearranged, double hit, or triple hit diffuse large B-cell lymphoma [abstract S224]. Abstract presented at: EHA2021 Virtual Congress; June 9-17, 2021.
Morschhauser F, Feugier P, Flinn IW, et al. A phase 2 study of venetoclax plus R-CHOP as first-line treatment for patients with diffuse large B-cell lymphoma [published correction appears in Blood. 2021;137(13):1844]. Blood. 2021;137(5):600-609. doi:10.1182/blood.2020006578
Neelapu SS, Dickinson M, Ulrickson ML, et al. Interim analysis of ZUMA-12: a phase 2 study of axicabtagene ciloleucel (axi-cel) as first-line therapy in patients (pts) with high-risk large B cell lymphoma (LBCL). Blood. 2020;136(suppl 1):49. doi:https://doi.org/10.1182/blood-2020-134449
Raval A, Tracy S, Ray J, et al. Risk profiling of de novo DLBCL patients by measuring circulating tumor DNA [abstract 1208]. Abstract presented at: 62nd American Society of Hematology Annual Meeting and Exposition; December 5-8, 2020.
Sehn LH, Kahl BS, Matasar MJ, et al. ESCALADE: a phase 3 study of acalabrutinib in combination with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) for patients ≤65y with untreated non-germinal center B-cell–like (non-GCB) diffuse large B-cell lymphoma (DLBCL). J Clin Oncol. 2021;39(suppl 15):TPS7572. doi:10.1200/JCO.2021.39.15_suppl.TPS7572
Tilly H, Flowers C, Friedberg J, et al. POLARIX: a phase 3 study of polatuzumab vedotin (pola) plus R-CHP versus R-CHOP in patients (pts) with untreated DLBCL. J Clin Oncol. 2019;37(suppl 15):TPS7571. doi:10.1200/JCO.2019.37.15_suppl.TPS7571
Tucci A, Re A, Pagani C, et al. Rituximab with dose-adjusted EPOCH (R-DA-EPOCH) with or without autologous stem cell transplantation (ASCT) as first line treatment in patients with aggressive B-cell lymphoma with MYC and BCL-2 and/or BCL-6 gene rearrangements or increase copy number. Blood. 2020;136(suppl 1):38-39. doi:https://doi.org/10.1182/blood-2020-139977