Marchi, Enrica

Abstract Introduction: Primary central nervous system T-cell lymphoma (PCNSTL) is a rare form of PCNSL, comprising 2–8% of cases. Prognostic factors remain undefined, and no standard treatment protocol currently exists. Prior studies have been limited by small sample sizes, incomplete molecular profiling, and poor representation of novel treatment modalities. In this study, we aimed to identify clinicopathologic factors associated with patient (pt) outcomes and delineate the spectrum of treatment regimens used to inform future clinical practice. Methods A multicenter retrospective study was conducted across 15 North American academic institutions. Pts aged ≥18 years with biopsy-confirmed PCNSTL between 2009 and 2025 with no evidence of systemic disease were included. Cases with CNS relapse of systemic T-cell lymphoma were excluded. Baseline characteristics were analyzed using independent t-tests, Fisher's exact tests, or Pearson's chi-square tests. Primary endpoints were overall survival (OS) and progression-free survival (PFS), evaluated by Kaplan–Meier, log-rank tests, and Cox regression. Results: Forty-two pts met inclusion criteria. Median age was 57 (range 19–77), 69% were male, and 79% were white. Most (69%) had ECOG 0–1. No patients had HIV, hepatitis B or C, or a history of solid organ transplant. LDH was elevated at diagnosis in 38%, and 24% had B-symptoms. Mean absolute lymphocyte count at diagnosis was 1.82/µL. The most common histologic subtypes were PTCL-NOS (76%), followed by ALK-negative ALCL (12%) and γδ T-cell lymphoma (5%). All patients had parenchymal brain lesions with 57% having multifocal disease. Additionally, CSF involvement was seen in 21%, vitreoretinal involvement in 3%, and deep brain involvement in 34%. Next-generation sequencing was performed in seven pts (17%), with disease-associated variants identified in three cases. Among these, two pts had mutations in TP53, and one had a mutation in DNMT3A. Cytogenetics were obtained in 7 pts with only one exhibiting a complex karyotype. Only one pt was EBV positive by EBER-ISH. Overall, 79% received HD-MTX-based therapy. First-line treatments were mainly HD-MTX alone (38%), HD-MTX + temozolomide (17%), or vincristine + procarbazine (12%). No patients were treated on clinical trials. Median treatment duration was 78 days and median number of treatment cycles was 4 (range 1–9 cycles). One patient received radiation alone; 5% received radiation with systemic therapy. A steroid pre-phase was used in 60%, with 44% exhibiting a clinical response. Overall response rate to first-line treatment was 63% (13 CR, 12 PR). Imaging alone was used in determining response in all patients. Repeated biopsy was not performed. Twelve patients (29%) underwent consolidative autologous transplant, most commonly with thiotepa/carmustine (TT/BCNU, 69%) or BEAM conditioning (25%). Median duration of follow-up was 10.4 months. Sixty-two percent of pts progressed during the study period, with 7% experiencing extra-CNS relapse. Median PFS was 8.2 months. Improved PFS was associated with >3 cycles of therapy (p=0.03) and transplant with TT/BCNU (p=0.0004). At last follow-up, 43% were in remission and 52% were deceased, mostly due to disease progression (77%). Median OS was 17.6 months. One- and two-year OS rates were 58% and 42%, respectively. OS was associated with Nottingham/Barcelona score <2 (p=0.02), >3 treatment cycles (p=0.0008), response to first-line therapy (p=0.0007), and TT/BCNU-based transplant (p=0.0001). IELSG, Taipei, and MSKCC risk scores were not significantly associated with survival, though IELSG approached significance (p=0.09). Discussion: This study is among the largest cohorts of PCNSTL pts compiled to date. PCNSTL remains rare and heterogenous. Treatment across centers largely mirrors management of B-cell PCNSL with high utilization of HD-MTX regimens and TT/BCNU conditioning autologous transplant. Survival outcomes within our cohort are consistent with those previously reported within the literature. Receipt of >3 cycles of therapy, TT/BCNU conditioning and Nottingham/Barcelona scores were associated with longer survival within our cohort. Limitations of our study include its retrospective design and heterogeneity within pt disease characteristics, treatments utilized and disease assessment intervals. Further exploration into pathophysiology and optimal management of this unique entity is needed.

Abstract Introduction: T-PLL is a rare, aggressive leukemia with poor prognosis and limited therapies. Previous studies on T-PLL patients receiving an allogeneic stem cell transplant (alloSCT) are limited by small numbers with limited data on disease and transplant characteristics. Further, recent data from our large national cohort of patients demonstrated significant survival difference between TCL1A+ and TCL1A- T-PLL, and CD8+ T-PLL vs CD8- T-PLL. In this large multi-center series, utilizing comprehensive disease subtype and alloSCT clinical data, we evaluated prognostic and survival therapeutic outcomes in T-PLL patients that had an alloSCT with a particular focus on T-PLL disease subtypes. Methods: We retrospectively evaluated 572 diagnosed with T-PLL at 21 academic cancer centers throughout the USA between 2000-2023, of which we performed a further evaluation on the169 that proceeded with alloSCT. Overall survival (OS) and progression-free survival (PFS) were assessed using Kaplan-Meier methods and Cox proportional hazard models. Results: Among n=169 alloSCT recipients with T-PLL, the median follow-up time was 20.9 months post-alloSCT (range: 0.2-182.9), the median age at transplant was 59 years (range: 35-77) and 52% were male. In evaluated patients (n=109), TCL1A was positive by cytogenetics or FISH in 69%. As our recent analysis demonstrated significant differences in survival among specific subtypes of T-PLL, we evaluated outcomes in patients with CD4+CD8- T-PLL (n=90, 53%), CD4-CD8+ (n=17, 10%) T-PLL, and CD4+CD8+ T-PLL (n=52, 31%). 53% (87/164) had known nodal involvement at diagnosis identified by PET or CT scan and 45% (43/96) of known patients had minimal residual disease (MRD) at the time of transplant [defined as <5% T-PLL in marrow by flow, or +cytogenetics (e.g. TCL1A)] prior to alloSCT. At the time of alloSCT, 136 (80%) patients were in CR and 23 (14%) patients were in PR. Forty-nine (30%) had a myeloablative (MAC)conditioning regimen and 114 (70%) had a reduced intensity chemotherapy (RIC) conditioning regimen. Eighty (49%) patients had TBI as part of their regimen. The most common regimens were fludarabine (flu)/melphalan based regimens (n=44; 26.0%), flu/cyclophosphamide (cy) based regimens (n=33; 19.5%), flu/busulfan based regimens (n=22; 13.0%), flu/total body irradiation (TBI) (n=8; 4.7%), and cy/TBI (n=4; 2.4%). Across the whole cohort, the median OS and PFS post-alloSCT was 32.6 months (95% CI: 21.0-41.9) and 20.8 months (95% CI: 14.4-30.5) months while the 1-year cumulative incidences (CI) of NRM and relapse were 17% and 20%, respectively. The incidences of grade II-IV acute GVHD and cGVHD were 19% and 23%. There was no difference between patients with myeloablative conditioning (MAC) (n=49, 29%) when compared to patients that received reduced intensity conditioning (RIC) (n=114, 67%) in OS (33.1 vs 29.2; p=0.68) and PFS (20.2 vs 20.8; p=0.97). Patients that were MRD+ (n=31) had worse OS (22.2 vs 48.6; p=0.1) and PFS (14.1 vs 32.5; p=0.04) and higher rates of relapse (1-year relapse 20% vs 8%; p=0.08) than patients that were MRD- (n=50). PFS was improved in those who received alloSCT though only trended towards significance due to low numbers (HR 0.76, p=0.09). In subtype analysis, TCL1A+ T-PLL had significantly worse outcomes compared to TCL1A negative T-PLL. TCL1A+ disease had significantly worse OS (21.6 vs 63.1; p=0.01) and PFS (12.4 vs 50.7; p=0.01) compared to TCL1A-. Additionally, in TCL1A+ disease CI of NRM (24% vs 3%; p=0.02) and relapse (25% vs 12%; p=0.86) was higher vs TCL1A- PLL. CD4+CD8-, CD4-CD8+, and CD4+CD8+ disease had no difference in survival via either OS (28.0 vs 34.4 vs 21.0; p=0.17) or PFS (29.4 vs 23.5 vs 13.6; p=0.09) as well as no difference 1-year CI of NRM ( 11.6 vs 23.5 vs 26.2; p=0.35) and relapse (18.5 vs 23.5 vs 20.0; p=0.67).Conclusions: AlloSCT significantly improved outcomes for patients with T-PLL compared to those who did not proceed to alloSCT and remains he only curative therapy for those with T-PLL. OS, PFS, and CI relapse were significantly worse for patients with TCL1A+ subtype of T-PLL, or those with MRD positivity or PR prior to alloSCT. Novel strategies to decrease relapse such as post-alloSCT maintenance therapy to improve outcomes are urgently needed in these patients.

Abstract Background: Patients with relapsed or refractory (R/R) peripheral T-cell lymphoma (PTCL) have a poor prognosis with median overall survival of ~3-12 months with current therapies, highlighting an urgent unmet need for novel therapeutics. PTCL is uniquely sensitive to epigenetic modifiers. We have shown that DNMT3 inhibitors like 5-azacytidine have potent immunomodulatory effects, including upregulation of cancer testis antigens, in pre-clinical models of T-cell lymphoma. Similarly, we have shown that pralatrexate (PTX) is potentially synergistic with drugs targeting epigenetic regulation. These data suggest a role for combining the immune checkpoint inhibitor pembrolizumab (pembro) with epigenetic agents in patients with PTCL. Methods: PTCL-002 is a multicenter, multi-arm phase Ib study designed to evaluate the safety and efficacy of pembro in combination with PTX and/or decitabine (DAC) in patients with R/R PTCL and CTCL. The study included three arms: arm A (pembro+PTX), arm B (pembro+PTX+DAC), and arm C (pembro+DAC). All patients received pembro 200 mg by IV infusion every 21 days. Dose selection for DAC and PTX in arms A and C, respectively, was based on a continual reassessment method (CRM) while arm B used a partial order CRM. Primary endpoints included MTD, RP2D, dose-limiting toxicities (DLT) and clinical efficacy as assessed by overall response rate (ORR). Secondary endpoints included progression-free survival, duration of response, and overall survival. Select pharmacokinetic and pharmacodynamic endpoints were also included in order to assess immune modulation and identify potential predictors of response. Results: We enrolled 26 patients, including 9 patients in arm A, 7 in arm B, and 10 in arm C. Median age was 61 (range 27-77) with 13 males and 13 females. Racial demographics were as follows: White 62%, Black 23%, Asian 3%, and Hispanic 1%. Median number of prior treatments was 3 (range 1-6). Histologic subtypes included ATLL (n=1), AITL (n=4), PTCL-NOS (n=10), SS (n=1), MF (n=6), PCALCL (n=1), MEITL (n=1), PCAECTL (n=1), and TFh-PTCL (n=1). Twenty-four of 26 patients received at least one dose of study drug and were evaluable for toxicity. Twenty-one of 26 of patients received at least one full cycle of therapy and were evaluable for response. Reasons for early discontinuation included consent withdrawal (n=1), rapid disease progression during cycle 1 (n=2), adverse event (n=1), and investigator decision (n=1). One DLT was observed each in arms A and B for prolonged grade 3 thrombocytopenia and febrile neutropenia, respectively. Three DLTs were observed in arm C including one patient with grade 3 hyponatremia and rash; one patient with grade 4 thrombocytopenia, neutropenia, and anemia; and one patient with grade 4 neutropenia. There were no treatment related deaths. Based on the observed DLTs, the RP2D for DAC in combination with pembro is 20 mg/m2on days 1-3; the RP2D for PTX in combination with pembro is 30 mg/m2on days 1, 8, and 15; for the triplet combination, the RP2D for DAC is 10 mg/m2given on days 1-5 and the RP2D for PTX is 20 mg/m2given on days 1, 8, and 15. Among 21 evaluable patients, responses were as follows: ORR 19% (4/21), CR 10% (2/21), PR 10% (2/21), and disease control rate (defined as proportion of patients with stable disease or better) 38% (8/21). ORR among evaluable patients in arms A, B, and C were 40% (2/5), 29% (2/7), and 0% (0/9), respectively. Analysis of serum cytokine levels in select patients (4 in Arm A, 4 in Arm B, and 5 in Arm C) revealed significant changes in 5 cytokines when compared to healthy age- and sex-matched controls. Of the 5 cytokines, 3 pro-inflammatory cytokines, TNFα, MIP-3α and IL-10, measured at day 1 pre-treatment were significantly higher in trial patients (p= 0.0001, 0.0008 and 0.003 respectively) than in healthy controls. Trial patients who responded to treatment (PR/CR) in any arms demonstrated a decline in serum levels of TNFα and IL-10 by day 15 of cycle 1, whereas non-responders (PD/SD) showed stable to increased levels of both TNFα and IL-10. Conclusion: We successfully identified the RP2D for DAC and/or PTX in combination with pembro in patients with R/R PTCL and CTCL. We demonstrated that an epigenetic platform incorporating the immune checkpoint inhibitor pembrolizumab is safe in heavily pretreated disease. More work on changes in cytokine profiles is needed before drawing any conclusions on their relationship to response.

Introduction: T-PLL is a rare, aggressive malignancy with poor prognosis and limited therapies. Outside of prospective trials utilizing alemtuzumab, data is derived primarily from small retrospective series, and limited data on survival outcomes and therapeutic efficacy, particularly beyond frontline therapy are available. In this large multi-center series, with comprehensive clinical data, we evaluated survival and therapeutic outcomes in T-PLL patients, with a focus on identification of prognostic subgroups of T-PLL, that will inform future investigations into the biology and treatment of this disease. Methods: We retrospectively evaluated all patients diagnosed with T-PLL at 15 academic cancer centers throughout the USA between 2000-2023 using the recent TPLL-ISG staging and response criteria with overall response rate (ORR) defined as CR and PR. Overall survival (OS) and progression-free survival (PFS) were assessed using Kaplan-Meier methods and cox proportional hazard models. Single-cell RNA sequencing (scRNAseq) was performed using the standard 10X Genomics platform. Results: 377 patients, with a median follow-up time of 29 months (range: 0-196) were evaluated. The median age at diagnosis was 64 and 51% were male. In evaluated patients (n=223), TCL1A was positive by cytogenetics or FISH in 82%. 61% of patients had CD4+CD8- T-PLL, 11% of patients had CD4-CD8+ T-PLL, and 24% of patients had CD4+CD8+ T-PLL, with 4% unknown. 175 patients (46.4%) had known nodal involvement at diagnosis identified by PET or CT scan. Among treated patients (n=342, 91%), using TPLL-ISG criteria, the ORR to any frontline treatment was 67% (49% CR, 18% PR). Median OS and PFS was 19 months and 10 months in responding patients from the start of treatment initiation. For those treated with frontline alemtuzumab (n=250), the ORR was 74% (58% CR), with a median OS and PFS of 18 and 12 months. 20 patients (5%) were treated with a combination of alemtuzumab/pentostatin frontline with an ORR of 85% (70% CR), which was superior to alemtuzumab alone (ORR 74%, 58% CR). Patients that had frontline chemotherapy (excluding pentostatin, n=48) had a worse ORR of 35% (15% CR) (p<0.001), and a worse PFS of 4 months (p=0.002), when compared to those who received alemtuzumab. Among patients in 1st CR/PR (n=226), 44% (n=99) received an allograft and had an improved 3-year OS of 50% vs 17%, (HR=0.67, 95%CI 0.48-0.93), and 50% improvement in PFS (HR 0.48, 0.33-0.68) compared to those who did not receive an allograft. For patients that received second line treatment (n=176, 52%), re-treatment with alemtuzumab (n=33) produced a 46% ORR (21% CR). Other active second-line treatments included: pentostatin (n=23; 44% ORR, 17% CR), ruxolitinib-based regimens (n=4; 25% ORR, 0% CR), venetoclax-based regimens (n=13; 39% ORR, 8% CR), bendamustine (n=10; 30% ORR, 0% CR), and nelarabine (n=4; 75% ORR, 50% CR). In subgroup survival analysis, TCL1A+ patients had a worse OS and PFS when compared to TCL1A- patients (23 months vs 43 months; p=0.02), and (14 months vs 24 months; p=0.02) respectively, with HR 1.58 (1.08, 2.31) (p=0.02) for OS and HR 1.62 (1.09-2.40) (p=0.02) for PFS. Furthermore, CD4- T-PLL had worse OS (16 months vs 25 months) when compared to CD4+ patients [HR 1.57 (1.08, 2.27), p=0.02]. Single cell RNA seq in 13 patients, including 3 TCL1A- patients, with a total of 66,269 T-PLL cells, demonstrated a unique RNA signature between the CD4+/- and TCL1A+/- patients, suggesting these represent unique molecular subtypes of T-PLL. Conclusions: In this large, multi-center study of T-PLL, frontline treatment with a combination of alemtuzumab/pentostatin improved response rates and OS. Further, among patients who attained a CR, allograft improved OS & PFS vs no allograft. In relapsed T-PLL, retreatment with alemtuzumab had a high ORR, and we report significant activity of multiple novel/alternative agents with the largest reported numbers to date. Intriguingly, TCL1A+, and CD4- T- PLL had worse OS/PFS, and scRNAseq confirmed unique molecular signatures in these populations, suggesting these represent novel molecular subtypes of T-PLL with prognostic significance. These studies form the foundation for future, targeted, therapeutic studies in this rare, aggressive disease with few treatment options.

Lymphomatoid papulosis (LyP) has several histopathologic presentations. LyP featuring gamma-delta (γδ) T-cell receptor expression may masquerade as and may be misdiagnosed as aggressive cutaneous T-cell lymphoma, particularly primary cutaneous γδ T-cell lymphoma (PCGDTL) or γδ mycosis fungoides. We performed a clinicopathologic analysis of the largest series of LyP featuring γδ T-cell expression. We identified 26 patients with a diagnosis of LyP with γδ T cells from our institutions, as well as through a comprehensive review of the literature, and characterized these cases. Most cases were treated with topical steroids or not treated at all. The majority of cases showed a CD4-CD8+ phenotype and featured at least one cytotoxic marker. Histopathologic features included an intraepidermal or dermal infiltrate with large cells and frequent angiotropism. One case was initially misdiagnosed as PCGDTL, requiring further therapy. Our case series, the largest international cohort of γδ T cell predominant LyP cases, confirms marked clinicopathologic heterogeneity that may contribute to misdiagnosis, reasserting the need to identify classic clinical features, CD30+ T-cell components, and markers of cytotoxicity when dealing with this differential diagnosis. A limitation of this study includes somewhat limited follow-up, histologic, and immunophenotypic information for some cases.

Abstract Our group has demonstrated that combinations of epigenetic modifiers produce potent synergy in pre-clinical models of PTCL, and has confirmed this data in early phase clinical studies. We showed that the combination of romidepsin and hypomethylating agents, decitabine or azacytidine, uniquely induces the expression of genes, including cancer testis antigens, gamma interferon and endogenous retrovirus. We are conducting a phase 1 study of pembrolizumab combined with pralatrexate alone (Arm A), with pralatrexate + decitabine (Arm B), or decitabine alone (Arm C) in patients with peripheral T-cell lymphoma (PTCL) and cutaneous T-cell lymphoma. In addition, we are conducting a Phase 1/2A study of durvalumab combined with oral 5-azacitidine + romidepsin (Arm A), pralatrexate + romidepsin (Arm B), romidepsin (Arm C), or oral 5-azacitidine (Arm D) in patients with PTCL. Patient characteristics are listed in Table 1. We have treated a total of 12 patients across the 2 trials and 4 different Arms including pralatrexate plus pembrolizumab (3 patients), pralatrexate, decitabine and pembrolizumab (3 patients), decitabine and pembrolizumab (3 patients) and azacytidine, romidepsin and durvalumab (3 patients). Twelve patients out of 12 received at least one dose of drug and were evaluable for toxicity. There was a dose limiting toxicity (DLT) for each arm including prolonged grade 3 thrombocytopenia, febrile neutropenia, grade 3 hyponatremia and rash, and cytokine release syndrome, respectively. There were no treatment-related deaths. Eight patients out of 12 are evaluable for response at the time of this analysis. Three out of 8 patients achieved a complete remission, 3 out of 8 patients had a partial remission, and 2 out of 8 patients experienced progression of disease. Interestingly, all of the responses were seen in the triple combination of pralatrexate, decitabine, pembrolizumab and azacytidine, romidepsin and durvalumab. These preliminary clinical data suggest that the addition of immune-checkpoint inhibitors on an epigenetic backbone is safe and demonstrates encouraging responses in patient with PTCL and CTCL. These trials are registered at www.clinicaltrials.gov (NCT03240211, NCT03161223). Patient characteristics (n=12)Median age (range)68 (26-77)Sex, n (%) Male Female6 (50) 6 (50)Race, n (%)White/Non-Hispanic White/Hispanic Black Asian Unknown5 (42) 1 (8) 3 (25) 1 (8) 2 (17)Histology, n (%) PTCL, NOS AITL Mycosis Fungoides PTCL, NOS TFH ATLL Sezary Syndrome ALCL, ALK+2 (17) 2 (17) 2 (17) 1 (8) 1 (8) 1 (8) 1 (8)Stage at diagnosis IB II III IV Unknown1 (8) 2 (17) 3 (25) 4 (33) 2 (17)Median number of prior therapies (range) **2 unknown3 (0-5) Citation Format: Enrica Marchi, Helen Ma, Francesca Montanari, Ahmed Sawas, Jennifer K. Lue, Changchun Deng, Kareema T. Whitfield, Sandra Klein, Matthew V. Matthew, Freedy J. Loffredo, Luigi Scotto, Hyejung Lee, Hye A. Kim, Alice T. Jacobs, Aishling M. Rada, Karen A. Khan, Salvia Salvia, John Lister, Nora N. Benanni, Mark A. Francescone, Pier Luigi Zinzani, Wonseog Kim, Owen A. O'Connor. The integration of PD1 blockade with epigenetic therapy is highly active and safe in heavily treated patients with T-cell lymphoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT160.

8049 Background: Our group has demonstrated that combinations of epigenetic modifiers produce potent synergy in pre-clinical models of PTCL and induce the expression of cancer testis antigen, suggesting a role in the addition of the immune-checkpoint inhibitor, pembrolizumab. Methods: This is a phase 1b study of pembrolizumab combined with pralatrexate alone (Arm A), with pralatrexate + decitabine (Arm B), or decitabine alone (Arm C) in patients with relapsed and refractory PTCL and CTCL. A standard 3+3 dose-escalation is applied in the triplet Arm (Arm B) while in the doublet Arms (A and C) de-escalation is applied in case of toxicity. Pharmacokinetic and pharmacodynamic studies are ongoing. Results: We treated a total of 12 patients with 4 patients in each Arm. All patients that received at least one dose of drug were evaluable for toxicity. There was a dose limiting toxicity (DLT) in each arm including prolonged grade 3 thrombocytopenia (Arm A), febrile neutropenia (Arm B), grade 3 hyponatremia, and rash (Arm C). There were no treatment-related deaths. Six patients out of 12 were evaluable for response at the time of this analysis. One patient achieved a complete remission, 2 had partial remission, 1 had stable disease, and 2 experienced progression of disease. Interestingly, all of the responses were seen in the triple combination of pralatrexate, decitabine, and pembrolizumab. Table summarizes the patient characteristics, toxicities, and response rates. Conclusions: These preliminary clinical data suggest that the integration of pembrolizumab on an epigenetic backbone is safe and demonstrates encouraging responses in patient with PTCL and CTCL. Clinical trial information: 03240211 . [Table: see text]