Bartlett, Nancy L.

ABSTRACT One quarter of patients with diffuse large B‐cell lymphoma (DLBCL) who achieve a complete response following front‐line therapy will eventually experience disease relapse. Existing prognostic models use baseline factors to predict outcomes from the start of initial therapy and are not intended for use following completion of treatment. We developed a conditional event‐free survival (cEFS) tool that predicts a patient's risk of lymphoma recurrence after completing front‐line therapy taking into consideration baseline risk characteristics plus the time the patient has been in remission. Model development used pooled and harmonized data from two observational cohorts and four randomized trials of patients with newly diagnosed DLBCL treated with immunochemotherapy and either achieving a complete response or not experiencing an event within 12 weeks of end of therapy. Cox proportional‐hazards regression modeling with backwards stepwise selection was utilized for model development. External validation was performed using a large independent data registry. In total, data from 2757 patients were used for model development. The risk of experiencing an event at a time point after having survived a period of time could be computed parsimoniously using four basic predictors: age, ECOG performance status grade, Ann Arbor stage, and lactate dehydrogenase level. C‐index in the model development cohort was 0.65 (95% CI, 0.63–0.68), compared to 0.64 (95% CI, 0.62–0.66) in the external validation cohort. We believe that this dynamic risk prediction tool will not only aid clinicians in providing data‐driven recommendations for surveillance, but also assist patients themselves with key decisions, such as family planning.

Abstract The phase 1/2 Intergroup study E4412 investigated checkpoint blockade with nivolumab (Nivo) and ipilimumab (Ipi) combined with the CD30 targeting antibody-drug conjugate brentuximab vedotin (BV) in relapsed/refractory classic Hodgkin lymphoma. A total of 147 patients aged ≥12 years were randomized between BV/Nivo and BV/Ipi/Nivo; 132 patients were included in the primary efficacy analysis. The complete response (CR) rate, was 64.7% (52.2, 75.9) for BV/Nivo and 70.3% (57.6, 81.1) for BV/Ipi/Nivo (1-sided P = .29). The median survival follow-up was 38.0 months (interquartile range, 32.6-48.1). Progression-free survival (PFS) did not significantly differ between the 2 arms (hazard ratio [HR], 0.78, confidence interval [CI], 0.39-1.57; 1-sided P = .24). Treatment-related grade 3+ toxicities in the adult cohort, excluding rash, were similar between both arms (38.5% BV/Nivo and 39.3% BV/Ipi/Nivo); there was a higher frequency of grade 3 rash with BV/Ipi/Nivo (24.6%) compared with BV/Nivo (9.2%). We compared PFS by stem cell transplantation (SCT) status in a planned before hoc comparison; 58 patients received SCT, and 36-month PFS (from SCT) was >90% for both arms. Sixty-six patients were progression free after the first scan and did not undergo SCT. The 36-month PFS was 73.0% (54.5, 85.0) for BV/Ipi/Nivo compared with 45.8% (26.3, 63.4) for BV/Nivo (HR, 0.45; CI, 0.19-1.08; 1-sided P = .03). The study did not meet its primary end point of superior CR rate for the triplet, but it supports the use of checkpoint antibody-drug conjugate induction prior to auto SCT, and there is an intriguing signal of disease control for patients wishing to defer or avoid SCT with the triplet of BV/Ipi/Nivo. This trial was registered at www.clinicaltrials.gov as NCT01896999.

Abstract Introduction Diffuse large B-cell lymphoma (DLBCL) is a heterogenous disease with varied expressions of CD30. Brentuximab vedotin (BV) is a CD30-directed antibody-drug conjugate approved for treatment of patients with relapsed or refractory DLBCL in combination with lenalidomide (Len) and rituximab (R). In the phase 3 ECHELON-3 study (NCT04404283), BV + Len + R showed significant overall survival (OS) benefit compared with placebo + Len + R in patients with relapsed or refractory DLBCL. Subgroup analysis from this study showed that BV + Len + R provided clinical benefit regardless of CD30 expression level. We hypothesized that even sub-threshold levels of CD30 expression, below the detection limits of immunohistochemistry (IHC), may be sufficient to elicit the antitumor activity of BV. Here, we further investigated whether trace amounts of CD30 staining are required for patients to benefit from BV + Len + R. Methods In the ECHELON-3 study, patients with relapsed or refractory DLBCL were randomized 1:1 to receive BV + Len + R or placebo + Len + R. The primary endpoint was OS, with progression-free survival (PFS) and objective response rate (ORR), per Lugano 2014, as key secondary endpoints. CD30 expression was assessed by IHC by central and/or local testing. CD30 positivity was scored as the percentage of CD30 positive cells out of neoplastic cells or out of total lymphocytes, when neoplastic cells could not be distinguished. In this updated analysis, patients with CD30 <1% staining by central laboratory IHC were further grouped into CD30 <1% with trace staining and CD30 <1% with no staining. Results Overall, 60 patients in the BV + Len + R group had CD30 <1% expression; of these, 34 had CD30 <1% with trace staining and 26 had CD30 <1% with no staining. In the placebo + Len + R group, 63 patients had CD30 <1% expression; of these, 36 had CD30 <1% with trace staining and 27 had CD30 <1% with no staining. In the overall CD30 <1% groups, numerically greater OS and PFS benefits were observed with BV + Len + R vs placebo + Len + R (HR for OS, 0.57; 95% CI, 0.36-0.89 and HR for PFS, 0.53; 95% CI, 0.34-0.82). In patients with CD30 <1% with trace staining, BV + Len + R showed a numerically higher OS compared with placebo + Len + R, with HR of 0.48 (95% CI, 0.26-0.90); median OS was 15.6 vs 5.2 months. In patients with CD30 <1% with no staining, there was a trend toward higher OS with BV + Len + R vs placebo + Len + R, with HR of 0.66 (95% CI, 0.34-1.28); median OS was 14.8 vs 11.8 months. Similarly, in patients with CD30 <1% with trace staining, BV + Len + R showed a trend toward longer PFS compared with placebo + Len + R, with HR of 0.60 (95% CI, 0.33-1.11); median PFS was 2.8 vs 1.5 months. In patients with CD30 <1% with no staining, a numerically longer PFS benefit was observed with BV + Len + R vs placebo + Len + R, with HR of 0.41 (95% CI, 0.21-0.79); median PFS was 4.2 vs 2.7 months. In the overall groups, ORR was 60.0% with BV + Len + R and 34.9% with placebo + Len + R. Higher ORR was observed with BV + Len + R compared with placebo + Len + R in both CD30 <1% with trace staining (55.9% vs 25.0%) and CD30 <1% with no staining (65.4% vs 48.1%) groups. Conclusions Results from this updated analysis indicate that visible CD30 detection by IHC is not required for response to BV + Len + R in patients with relapsed or refractory DLBCL. Treatment with BV + Len + R showed efficacy benefit compared with placebo + Len + R regardless of CD30 expression level, including in patients with no visible CD30 IHC staining. These results are consistent with those from the overall ECHELON-3 study population, in which significant improvement in OS was demonstrated with BV + Len + R compared with placebo + Len + R.

The treatment landscape of B-cell lymphomas has significantly evolved in recent years with approval of novel targeted therapies. CD3 × CD20 bispecific antibodies and CD19-directed monoclonal antibodies and antibody–drug conjugates have demonstrated efficacy in relapsed/refractory follicular lymphoma (FL). Bruton tyrosine kinase (BTK) inhibitor–based regimens are emerging as effective treatment options for patients with TP53-mutated classical mantle cell lymphoma (MCL). Results from ongoing clinical trials suggest that the addition of CD3 × CD20 bispecific antibodies to chemoimmunotherapy improves outcomes in patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL). These NCCN Guideline Insights highlight significant updates to the NCCN Guidelines for B-Cell Lymphomas for the treatment of FL, MCL, and DLBCL.

Abstract Outcomes in classic Hodgkin lymphoma (cHL) have steadily improved; however, additional therapies are needed for patients who relapse or do not respond to novel agents. Here, we report the efficacy and safety of camidanlumab tesirine (Cami), an anti-CD25 antibody-drug conjugate, in patients with relapsed/refractory cHL after brentuximab vedotin/programmed cell death protein 1 inhibitor therapies from the phase 2 ADCT-301-201 study. Eligible patients were adults with cHL who had received ≥3 previous lines of systemic therapy (or ≥2 if ineligible for hematopoietic stem cell transplant). Patients received 45 μg/kg Cami (IV, once every 3 weeks) in cycles 1 to 2, followed by 30 μg/kg IV once every 3 weeks for ≤1 year. The primary end point was overall response rate (ORR) per 2014 Lugano classification. Secondary end points included complete response rate (CRR), progression-free survival (PFS), and overall survival (OS). In total, 117 patients were enrolled with a median age of 37.0 years (range, 19-87). The ORR was 70.1% (95% confidence interval [CI], 60.9-78.2), with a CRR of 33.3% (95% CI, 24.9-42.6). The median PFS was 9.13 months (95% CI, 5.3-15.0); median OS was not reached. Thirty-three (28.2%) patients discontinued treatment because of treatment-emergent adverse events; the most common reasons were skin and subcutaneous tissue disorders (n = 10 [8.5%] patients), infections and infestations (n = 5 [4.3%]), and nervous systems disorders (n = 5 [4.3%]). Guillain-Barré–type or polyradiculopathy-type events occurred in 8 (6.8%) patients. Cami was efficacious in this heavily pretreated population; however, the efficacy was overshadowed by substantial issues with the safety profile. This trial was registered at www.clinicaltrials.gov as #NCT04052997.