Call, Timothy G.

e19507 Background: Patients (pts) with CLL are at elevated risk of developing non-hematologic malignancies. Radiation therapy (RT) is a critical component of management in localized solid organ malignancies. Novel agents (NA) are widely used in CLL treatment; however, safety data are lacking to guide treatment of pts requiring concurrent RT and NA. Methods: We identified pts treated concurrently with NA for CLL and RT for second primary malignancy (SPM) at Mayo Clinic from 2014-2022. Adverse events within 3 months of RT were evaluated using the International Workshop on Chronic Lymphocytic Leukemia (iwCLL) criteria for hematological toxicity and the Common Terminology Criteria for Adverse Events (CTCAE) version 5 for non-hematological toxicity. Patients without seamless, concurrent treatment with NA and RT were excluded. Results: Twenty-six pts were included. NA therapy consisted of ibrutinib (n = 23), acalabrutinib (n = 2), and venetoclax (n = 1). Median follow up time since RT completion was 1.5 years. The median age at NA initiation was 67 years (range:46-85) and at RT start was 68 years (range: 51-85); 92% of pts were male. NA was first treatment in 23% of pts; the median number of prior lines of therapy was 1 (range: 0-4). IGHV was unmutated in 82% and TP53 aberration was present in 24% of evaluable patients. SPM sites included prostate (n = 9), head/neck (n = 8), lung (n = 3), and brain, breast, bone, skin, kidney, and thymus (n = 1 each). The most common conventionally fractionated prescriptions (cGy/fx) were 6000/30 (n = 6) and > 6000-7020/20-33 (n = 7). SBRT ranged from 3300/5 to 5400/3 (n = 8). Five pts received other, varied RT prescriptions. Overall, 3 (12%) pts experienced at least one grade 3/4 toxicity. Grade 3/4 thrombocytopenia was observed in 2 (8%) pts and grade 3/4 neutropenia was observed in 2 pts per iwCLL criteria. Grade ≥3 non-hematological toxicities occurred in two pts that required hospitalization for critical illness, including 1 pt with grade 5 respiratory failure within 6 weeks after RT. Dose de-escalation of ibrutinib was reported in one case for pancytopenia attributed to use of a radiosensitizing agent. There were no cases of RT dose modification. Conclusions: Continuing NA CLL therapy during RT did not result in unexpected toxicities. This approach may maintain CLL disease control without compromising management of the SPM. [Table: see text]

Abstract TP53 aberrations, including mutations and deletion of 17p13, are important adverse prognostic markers in chronic lymphocytic leukemia (CLL) but are less studied in high count monoclonal B-cell lymphocytosis (HCMBL), an asymptomatic pre-malignant stage of CLL. Here we estimated the prevalence and impact of TP53 aberrations in 1,230 newly diagnosed treatment-naïve individuals (849 CLL, 381 HCMBL). We defined TP53 state as: wild-type (no TP53 mutations and normal 17p), single-hit (del(17p) or one TP53 mutation), or multi-hit (TP53 mutation and del(17p), TP53 mutation and loss of heterozygosity, or multiple TP53 mutations). Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for time to first treatment and overall survival by TP53 state. We found 64 (7.5%) CLL patients and 17 (4.5%) HCMBL individuals had TP53 mutations with variant allele fraction >10%. Del(17p) was present in 58 (6.8%) of CLL and 11 (2.9%) of HCMBL cases. Most individuals had wild-type (N=1,128, 91.7%) TP53 state, followed by multi-hit (N=55, 4.5%) and then single-hit (N=47, 3.8%) TP53 state. The risk of shorter time to therapy and death increased with the number of TP53 abnormalities. Compared to wild-type patients, multi-hit patients had 3-fold and single-hit patients had 1.5-fold increased risk of requiring therapy. Multi-hit patients also had 2.9-fold increased risk of death compared to wild-type. These results remained stable after accounting for other known poor prognostic factors. Both TP53 mutations and del(17p) may provide important prognostic information for HCMBL and CLL that would be missed if only one were measured.

Abstract Monoclonal B-cell lymphocytosis (MBL) is a common hematological premalignant condition that is understudied in screening cohorts. MBL can be classified into low-count (LC) and high-count (HC) types based on the size of the B-cell clone. Using the Mayo Clinic Biobank, we screened for MBL and evaluated its association with future hematologic malignancy and overall survival (OS). We had a two-stage study design including discovery and validation cohorts. We screened for MBL using an eight-color flow-cytometry assay. Medical records were abstracted for hematological cancers and death. We used Cox regression to evaluate associations and estimate hazard ratios and 95% confidence intervals (CIs), adjusting for age and sex. We identified 1712 (17%) individuals with MBL (95% LC-MBL), and the median follow-up time for OS was 34.4 months with 621 individuals who died. We did not observe an association with OS among individuals with LC-MBL (P = .78) but did among HC-MBL (hazard ratio, 1.8; 95% CI, 1.1-3.1; P = .03). Among the discovery cohort with a median of 10.0 years follow-up, 31 individuals developed hematological cancers with two-thirds being lymphoid malignancies. MBL was associated with 3.6-fold risk of hematological cancer compared to controls (95% CI, 1.7-7.7; P < .001) and 7.7-fold increased risk for lymphoid malignancies (95% CI:3.1-19.2; P < .001). LC-MBL was associated with 4.3-fold risk of lymphoid malignancies (95% CI, 1.4-12.7; P = .009); HC-MBL had a 74-fold increased risk (95% CI, 22-246; P < .001). In this large screening cohort, we observed similar survival among individuals with and without LC-MBL, yet individuals with LC-MBL have a fourfold increased risk of lymphoid malignancies. Accumulating evidence indicates that there are clinical consequences to LC-MBL, a condition that affects 8 to 10 million adults in the United States.

SummaryPatients with chronic lymphocytic leukaemia (CLL) disease progression on ibrutinib or after sequential ibrutinib and venetoclax‐based treatments (double‐refractory) have poor outcomes. In this retrospective study, we analysed outcomes with combined ibrutinib and venetoclax treatment in these groups of patients. The median treatment‐free and overall survival for 22 patients with prior progression on ibrutinib (venetoclax‐naïve) were 23.7 and 47.1 months respectively. In 11 patients with double‐refractory CLL, the median treatment‐free and overall survival were 11.2 and 27.0 months respectively. The combination of ibrutinib and venetoclax may help bridge the current gap in options for patients with disease refractory to the most commonly used novel agents.

Abstract Monoclonal B-cell lymphocytosis (MBL) is one of the most common pre-malignant conditions and is characterized by a circulating population of clonal B-cells with an absolute clonal B-cell count < 5x10 9/L and no evidence of lymphadenopathy, organomegaly, or cytopenias. MBL can be classified by the immunophenotype: CLL-like MBL (CD5+, CD20dim), atypical MBL (CD5+, CD20+), or non-CLL-like MBL (CD5-, CD20+), as well as by the size of the clone (low-count or high-count) with low-count MBL (LC-MBL) defined as clonal B-cell <0.5x10 9/L or percent clonal B-cell count <85% out of total B-cell count. The prevalence of MBL varies depending on detection methods and population tested. In a Spanish screening study of 608 individuals, they identified 73 MBLs (12%) with CLL-like MBL; moreover, these authors also evaluated overall survival (OS) compared to 290 individuals without MBL and found a significantly shorter OS among these predominantly LC-MBLs. Here, we evaluate the prevalence and OS of LC-MBL in a large screening cohort of 8,297 individuals. Study participants from the Mayo Clinic Biobank, a large-scale biorepository of adult patients, who had no prior history of hematologic malignancy, provided blood samples between 7/2009 to 4/2021. Stored peripheral blood mononuclear cells were screened for MBL with an eight-color flow cytometry assay capable of detecting clonal B-cell event to the 0.005% level. We classified each MBL by immunophenotype as CLL-like MBL, atypical MBL, and non-CLL-like MBL. Individuals with more than one immunophenotype were classified into one immunophenotype based on the following hierarchy: CLL-like MBL, then atypical MBL, then non-CLL like MBL. Based on previously published evidence, individuals were also classified by clonal counts using the percent clonal B-cell count <85% out of the total B-cell count to define LC-MBL. Individuals were followed from sample date to the earliest of death, loss to follow-up, or 5/31/2021. OS for LC-MBL and controls (individuals who screened negative for MBL) was assessed by Kaplan-Meier method. Age- and sex-adjusted OS was analyzed using inverse weights methods. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CIs), adjusted for age and sex. We screened 8,297 individuals 40 years or older (median age 67 years, 39% male) and identified 1,326 (16%) with LC-MBL and 6,651 (80%) controls. Those individuals detected with high-count MBL (N=90, 1%) or individuals who had insufficient cells for flow cytometry interpretation (N=230, 3%) were excluded from subsequent analyses. The prevalence of LC-MBL was higher in males (21%) than females (14%; p<0.01) and significantly increased with age (p<0.01) ranging from 3% among those 40-49 years, 10% among those 50-59 years, 15% among those 60-69 years, 23% among those 70-79 years, and 29% for those 80+ years. Sixty-one individuals had clones with more than one type of immunophenotype. Based on our hierarchy, CLL-like MBL was the most common (N=1,155), followed by non-CLL-like (N=168) and atypical MBL (N=67). The median follow-up time in our cohort was 26 months (range 0-142), and 432 individuals had subsequently died. The 5-year and 10-year OS adjusted for age and sex among LC-MBLs was 95% and 87%, respectively; control estimates were 95% and 84%, respectively. We did not observe a significant difference in OS between those individuals with LC-MBL versus controls (HR=0.98, CI=0.77-1.24, P=0.84, Fig 1a), nor when we stratified individuals by age <65 (P=0.77) or age >= 65 (P=0.68). Among females, OS was longer among LC-MBL compared to controls (HR=0.61, CI=0.38-0.97, P=0.04); but no evidence of a difference in OS among males was observed (HR=1.22, CI=0.92-1.62, P=0.17). When we evaluated OS by MBL immunophenotype, we observed no statistically significant difference (Fig 1b, log rank P=0.44). When we stratified the MBLs by immunophenotype versus controls, we also did not observe a difference: CLL-like (HR=0.91, CI=0.71-1.18, P=0.5), atypical (HR=1.73, CI=0.92-3.27, P=0.09), non-CLL like (HR=0.98, CI=0.58-1.66, P=0.95). In the largest MBL screening cohort to date, LC-MBL was a common condition among adults 40 years or older reaching a prevalence as high as 29% among individuals 80 years of age or older. OS among those with and without LC-MBL was similar, regardless of immunophenotype and age. The longer survival in females with MBL versus controls requires further evaluation. Figure 1 Figure 1. Disclosures Parikh: Pharmacyclics, AstraZeneca, Genentech, Gilead, GlaxoSmithKline, Verastem Oncology, and AbbVie: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics, MorphoSys, Janssen, AstraZeneca, TG Therapeutics, Bristol Myers Squibb, Merck, AbbVie, and Ascentage Pharma: Research Funding. Kay: Juno Therapeutics: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol Meyer Squib: Membership on an entity's Board of Directors or advisory committees, Research Funding; Targeted Oncology: Membership on an entity's Board of Directors or advisory committees; TG Therapeutics: Research Funding; Sunesis: Research Funding; Dava Oncology: Membership on an entity's Board of Directors or advisory committees; Genentech: Research Funding; Behring: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Acerta Pharma: Research Funding; MEI Pharma: Research Funding; Tolero Pharmaceuticals: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees; CytomX Therapeutics: Membership on an entity's Board of Directors or advisory committees; Oncotracker: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios Pharm: Membership on an entity's Board of Directors or advisory committees; Morpho-sys: Membership on an entity's Board of Directors or advisory committees; Rigel: Membership on an entity's Board of Directors or advisory committees. Shanafelt: Genentech, Pharmacyclics: Research Funding.

Abstract Introduction: TP53 aberrations, including mutations and deletion of 17p (del17p), are important adverse prognostic markers in chronic lymphocytic leukemia (CLL). Prevalence of TP53 aberrations ranges from 7-11% in untreated CLL and increases with disease progression and treatment. Among CLL patients with TP53 aberrations, co-occurrence of TP53 mutations with del(17p) is common. CLL patients with TP53 mutations or del(17p) have significantly worse outcomes when compared to wild-type patients. Previous studies, focusing on CLL patients at time of treatment, are mixed as to whether a single or more than one TP53 aberration impacts outcomes. TP53 is less well studied in monoclonal B-cell lymphocytosis (MBL), an asymptomatic pre-malignant state of CLL. Del(17p) occurs in 3-4% of MBL individuals, and a study of 54 MBL individuals reported a 2% mutation frequency in TP53. Here we estimated prevalence and evaluated the impact of TP53 aberrations in a large cohort MBL or untreated CLL individuals. Methods : Patients with CLL or MBL diagnosed between 2000 and 2019 from the Mayo Clinic CLL Resource with pre-treatment peripheral blood mononuclear cells (PBMC) collected within two years of diagnosis were considered. DNA was extracted from PBMCs with purity >80% or with sorted CD5+/CD19+ clonal cells. The entire coding regions of 59 CLL driver genes were paired end sequenced. Median coverage depth was >1000x per nucleotide, allowing for detection of mutations with variant allelic fraction (VAF) as low as 1%. Somatic mutations were called using MuTect2 in tumor-only mode, and high impact mutations (frameshift, nonsense, and splicing variants) and missense mutations in CLL hot spots were selected. Somatic mutations and FISH del(17p) were used to define TP53 state for each patient: 1) wild-type [no TP53 mutations and normal del(17p)], 2) single-hit [one TP53 mutation or del(17p)], or 3) multi-hit [multiple TP53 mutations or TP53 mutation and del(17p)]. Time to first treatment (TTFT) and overall survival (OS) were analyzed by TP53 state. TTFT and OS were defined as time from sample collection to first treatment or death, respectively, or last follow-up date. Median TTFT and OS was estimated by the Kaplan-Meier method. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals for TTFT and OS associations. The models were adjusted for known adverse prognostic factors including clinical diagnosis (CLL or MBL), age at diagnosis, Rai stage, b2 microglobulin, and IGHV mutation status. Results: Individuals with CLL (N=597) or MBL (N=285) were analyzed for prevalence of TP53 mutations and del(17p). We found 58 CLL patients (9.7%) and 15 MBL individuals (5.3%) had TP53 mutations. The median VAF in CLL was 30.9% (<10% VAF, n=21) and in MBL was 13.5% (<10% VAF, n=7). Del(17p) was present in 37 patients with CLL (6.2%) and 7 individuals with MBL (2.7%). In total, 86 CLL/MBL patients had a TP53 mutation and/or del(17p): 56.8% (48 patients) were single-hit and 44.2% (38 patients) were multi-hit (Fig. 1a). Patients with any TP53 aberration had shorter TTFT than wild-type patients (median 2.3 vs 9.4 years). Among patients with TP53 aberrations, median TTFT was shorter in multi-hit patients (20 events, 1.8 years) compared to single-hit patients (24 events, 3.2 years) (Fig. 1b). In Cox regression, single-hit (HR = 1.7 [1.1-2.6]) and multi-hit (HR = 1.8 [1.1-2.9]) patients had shorter TTFT compared to wild-type patients after adjusting for covariates (Fig. 1c). Multi-hit patients also had shorter OS compared to wild-type patients, while OS in single-hit patients did not significantly differ from wild-type patients (Fig. 1d). Median OS was 5.5 years in multi-hit patients (22 deaths) compared to 15.1 years in wild-type patients (196 deaths) and 14.3 years in single-hit patients (15 deaths). In the OS model adjusted for covariates, multi-hit patients had a significant increased risk (HR = 2.6 [1.6-4.1]), but single-hit patients did not (HR = 1.4 [0.8-2.5]) compared with wild-type patients (Fig. 1e). OS HRs remained stable after censoring at time of treatment. Both TTFT and OS HRs were consistent when mutations with VAF < 10% were excluded. Conclusions: This study suggests single versus multi-hit TP53 aberrations may be important for prognostic outcomes in untreated CLL and MBL patients. Prognostic metrics may need to consider single versus multi-hit TP53 aberrations and include TP53 mutations with low VAF. Figure 1 Figure 1. Disclosures Cerhan: Regeneron Genetics Center: Other: Research Collaboration; Celgene/BMS: Other: Connect Lymphoma Scientific Steering Committee, Research Funding; NanoString: Research Funding; Genentech: Research Funding. Parikh: Pharmacyclics, MorphoSys, Janssen, AstraZeneca, TG Therapeutics, Bristol Myers Squibb, Merck, AbbVie, and Ascentage Pharma: Research Funding; Pharmacyclics, AstraZeneca, Genentech, Gilead, GlaxoSmithKline, Verastem Oncology, and AbbVie: Membership on an entity's Board of Directors or advisory committees. Kay: MEI Pharma: Research Funding; Bristol Meyer Squib: Membership on an entity's Board of Directors or advisory committees, Research Funding; TG Therapeutics: Research Funding; AstraZeneca: Membership on an entity's Board of Directors or advisory committees; Dava Oncology: Membership on an entity's Board of Directors or advisory committees; Genentech: Research Funding; Juno Therapeutics: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Tolero Pharmaceuticals: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees; Agios Pharm: Membership on an entity's Board of Directors or advisory committees; Targeted Oncology: Membership on an entity's Board of Directors or advisory committees; CytomX Therapeutics: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Behring: Membership on an entity's Board of Directors or advisory committees; Sunesis: Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Acerta Pharma: Research Funding; Oncotracker: Membership on an entity's Board of Directors or advisory committees; Morpho-sys: Membership on an entity's Board of Directors or advisory committees; Rigel: Membership on an entity's Board of Directors or advisory committees.