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Abstract BACKGROUND Whilst the broad clonal architecture of naturally progressing chronic lymphocytic leukemia (CLL) has been described, a comprehensive picture of how chemotherapy and targeted agents reshape that landscape is lacking. Here we integrate clone-specific growth kinetics with mutational profiles, transcriptomic subtypes, and CpG-methylation-based epigenetic classes to capture the multidimensional evolutionary responses of CLL under native conditions and during treatment. METHODS We previously reported a systematic whole-exome sequencing (WES) analysis of 417 leukemia–germline pairs from 169 treatment-naïve patients ≥ 65 y (Karisani et al., Blood 2024). The treatment arm comprised 83 patients who received ibrutinib and 39 who received chlorambucil in the RESONATE-2 trial (NCT01722487). Forty-seven age-matched “watch-and-wait” patients from the CLL Research Consortium served as untreated controls. Peripheral-blood samples were collected at baseline and again ~300 d and ~600 d after therapy initiation (or diagnosis in the watch-and-wait cohort), enabling longitudinal clonal tracking. WES data were processed with PhylogicNDT to reconstruct clonal architectures, define phylogenies, and identify significant clonal shifts. MutSig tools identified mutations enriched in expanding or contracting clones. Pretreatment RNA-sequencing profiles were grouped into transcriptional subtypes by consensus clustering based on the Louvain algorithm. Differentially methylated regions plus epitypes were called from reduced representation bisulfite sequencing data. RESULTS Across the 169 patients with WES, we resolved 579 subclonal clusters. Significant clonal shifts (defined as a distribution shift of cancer cell fraction in a subclone of >95% between two timepoints) were uncommon during watch-and-wait (36%) but markedly higher after therapy — chlorambucil 67% (q = 0.01), and ibrutinib 77% (q < 10-4). In ibrutinib-treated CLL, regressing subclones were enriched for KRAS (q<10-3) and SF3B1 mutations (q<10-3), whereas expanding subclones preferentially harboured mutations in BIRC3 (q<10-4), NOTCH1 (q <10-3), TP53 (q=0.02), and POT1 (q=0.098). In chlorambucil-treated patients, no specific mutations were found to be enriched in expanding or regressing subclones. Using the recently defined CLL expression clusters (ECs) in patients treated with chemoimmunotherapy as defined by Knisbacher et al. (Nat Genet 2022), we were unable to identify any relationship between ECs and outcomes. We therefore sought to identify de novo ECs with prognostic relevance in the context of BTK-inhibition (BTKi-ECs). We identified a transcriptionally defined patient subgroup (C4, n=20) associated with inferior progression-free survival (median PFS = 63 months, log-rank q=0.05), independent of known prognostic clinical and molecular features, including epitypes, in multivariate analysis (Cox HR=3.7, 95% CI: 1.6-8.6, q=0.02). Gene-set enrichment in this cluster highlighted TNF-ɑ signalling via NF-κB (REL, TNFAIP3, NFKB2) and G2M checkpoint pathways (SMC4, EZH2). We also identified a distinct transcriptionally defined patient subgroup (C3, n=18) that was enriched for patients harboring at least one contracting subclone and no expanding subclones (q=0.005). This cluster showed a relative depletion of mutations within the chromatin modification pathway (6% vs 50%, q<0.01). Gene-set enrichment in this cluster highlighted a downregulation of genes in the TNF-ɑ signalling via NF-κB pathway (SOCS3, ICOSLG, NFKB2). CONCLUSION BTK inhibition and chemotherapy drive distinct evolutionary trajectories in CLL. Multi-omics profiling reveals mutation-defined subclones with divergent sensitivity to targeted therapy and delineates two informative expression states: a high-risk NF-κB/inflammatory cluster (C4; poor PFS) and a cluster enriched with contracting subclones with depleted TNF-ɑ signalling via NF-κB (C3). Integrating clonal growth kinetics with genomic, transcriptomic, and methylation data can potentially identify patients likely to progress on BTK inhibitors and identify actionable pathways for adaptive or combination therapy.

Abstract Introduction: Graft Failure (GF) is a rare but devastating outcome of HCT. Primary GF (PGF), defined as a failure of neutrophil recovery by Day+28, is straightforward to diagnose. Diagnosing secondary GF (SGF) is more challenging, with its broad time-range, multiple confounding diagnoses, and lack of predictive biomarkers. In BMT CTN1703/1801, we analyzed patients receiving RIC HCT for heme malignancies with either Tac/MTX (n=159) or PT-Cy (n=165) GVHD prophylaxis. SGF was defined as donor chimerism <5% after initial donor engraftment. With Tac/MTX, there were 3 PGF and 1 SGF diagnoses. With PT-Cy, there were 4 PGF and 6 SGF. Median SGF diagnosis was Day +64 (range: Day+28-215). There were too few Tac/MTX patients to analyze SGF, but sufficient events with PT-Cy. To identify PT-Cy SGF predictors, we leveraged lymphocyte, T, B, and NK cell reconstitution analysis. In SGF we found an early, profound deficit in the reconstitution of all major lymphocyte populations, including total lymphocytes, T, B, and NK cells, as early as Day+28. This enabled the modeling of a SGF risk classifier based on the Absolute Lymphocyte Count (ALC). Methods: Clinical ALC measurements were performed on all SGF patients (n=6) and on non-GF controls with ALCs available (146 of 155 non-GF patients). Flow cytometry was performed on all PT-Cy SGF patients (n = 6) and from a subset of non-GF controls (n = 18: controls were chosen as patients without relapse or severe GVHD, to reduce confounders introduced by immunologic interventions, and for whom all samples, including from the graft infusion, were available). T, B, and NK counts, as well as T cell subsets, were compared (using Welch's T test) on Days 7, 14, 21, 28, 42, 63, 98, 180, 270, 365, 730, with SGF patients censored on the day of GF diagnosis. To interrogate the optimal ALC cutoff, the cumulative incidence of SGF was computed at Days +28 and +42, with death without GF as a competing risk. Results: We have previously demonstrated that, compared to Tac/MTX, PT-Cy patients exhibited an early decrease in reconstitution of all T cell populations (with normal NK and B cell reconstitution). Here we focused specifically on PT-Cy patients with or without SGF. Graft CD34 counts/kg were not different between SGF patients and non-GF patients (mean CD34/kg = 1.38 x10e6 (SGF) vs 0.67 x10e6 (non-GF, p = 0.61) However, even amidst the overarching early suppression in T cell reconstitution with PT-Cy, SGF patients could be easily distinguished from the larger PT-Cy cohort, based on more profound deficits in ALC, T, B and NK cells reconstitution, measured using 2 strategies: (1) SGF patients demonstrated significant early (Day +28) quantitative defects in the reconstitution of the ALC (mean +/- SEM 262+/-32 cells/µL (non-GF) vs 60 +/- 25 (SGF, p<0.0001), CD4 T cells (62 +/- 12 cells/µL vs 19+/-15, p=0.048), CD8 T cells (15 +/-3 cells/µL vs 3.5 +/-1 p=0.0009), all CD8 T cell subpopulations, as well as NK cells (116+/-31 cells/µL vs 2.9+/-1.4 cells/µL, p= 0.002) and B cells (3.5 +/-1.4 cells/µL vs 0.16+/-0.07 p =0.03). (2) In SGF, there was a significant deficit in the rate of rise of all major lymphocyte populations between Days 28-42-60 vs non-GF, including CD4 T cells (p<0.0001), CD8 T cells (p = 0.0002), B cells (p<0.0001), and NK cells (p =0.048). These discoveries suggested that a classifier could be identified to risk-stratify patients for SGF. We explored an ALC cutpoint, amenable to standard clinical lab analysis. A statistically significant threshold was identified at both Days+28 and +42, with Day+42 being most predictive: A threshold of 120 cells/µL was identified as optimal, with landmark analysis documenting a SGF rate of 34.7% below the cutpoint, and SGF of 1% above it (HR = 45.9, 95% CI 5.7 - 366). Conclusions: Despite the small number of events, PT-Cy patients with SGF demonstrated a distinctive reconstitution trajectory that encompassed an early, substantial, and sustained deficit in all lymphocyte counts, as well as a lack of their longitudinal expansion. This enabled the discovery of a candidate ALC biomarker cutpoint at Day+42 that could distinguish patients who were more likely to develop SGF. If confirmed, these data could generate a predictive biomarker for SGF, which would enable the design of trials evaluating early interventions (e.g. CD34+ boosts, DLI, modification of immunosuppression) to improve outcomes for these patients.

Abstract Background Neurolymphomatosis (NL) is a rare and frequently underrecognized manifestation of lymphoma, characterized by infiltration of peripheral or cranial nerves by malignant lymphocytes. Limited data exist to guide optimal management. We present the largest single-enterprise (included the 3 Mayo Clinic sites) cohort to date, evaluating disease characteristics, treatment patterns, and outcomes in patients (pts) with NL. Methods We conducted a retrospective analysis of pts ≥18 years (yrs) diagnosed with clinical, radiographic, or biopsy-confirmed NL at Mayo Clinic between January 2002 and December 2024. Baseline characteristics were compared using independent t-tests for continuous variables and Fisher's exact or Pearson's chi-square tests for categorical variables. Primary endpoints were overall survival (OS) and progression-free survival (PFS). Objective response rate (ORR) was a secondary endpoint. Kaplan–Meier methods, log-rank tests, and Cox proportional hazards regression were used to assess survival outcomes and associated factors. Results We included 149 pts. Median age at diagnosis was 64 yrs (range 22–83), and 23% were female. Most presented with stage IV disease (89%), and NL was part of the initial lymphoma presentation in 42% (primary NL). Diagnostic confirmation was based on histopathology and imaging in 55%, imaging alone in 26%, histopathology alone in 16%, and clinical features in 4%. Diffuse large B-cell lymphoma was the most common histology (61%), followed by marginal zone lymphoma (7%), and T-cell lymphoma (7%). Clinical presentation included painful neuropathy (65%), concurrent CNS involvement (37%), systemic disease (43%), elevated LDH (46.9%), and ECOG ≥2 (38%). Pattern of involvement included cranial nerves (29%), peripheral nerves (28%), and spinal nerve roots (27%). Median follow-up was 92 months (95% CI, 63–119). Among 137 treatment-evaluable pts, first-line regimens included methotrexate-based (MTX) (62%), bendamustine-based (B) (11%), cytarabine-based (Ara-C) (4%), and rituximab-based (R) (excluding MTX, B, or Ara-C) (15%) therapies. Radiation was used in 18%, and 21% underwent autologous stem cell transplant (ASCT). Among 103 response-evaluable pts, the ORR was 67% (52% complete response [CR], 16% partial response [PR]). ORRs by regimen were 78% (MTX), 92% (B), and 86% (R). On univariate analysis, primary NL (OR 4.3) and frontline ASCT (OR 8.47) were associated with higher odds of response (p<0.05), while ECOG ≥2 (OR 0.24) and localized disease (OR 0.33) were associated with lower odds. On multivariable analysis (MVA), primary NL (OR 5.0 [1.5–12.1], p=0.02) and ECOG >1 (OR 0.2 [0.06–0.79], p=0.018) remained significant predictors of response. Median PFS was 13 months (95% CI, 9–36), with a 2-yr PFS of 43% (95% CI, 35–53). On MVA, concurrent CNS involvement (HR 2.4, p=0.05), systemic disease (HR 2.7, p=0.02), and ECOG >1 (HR 2.4, p=0.02) were associated with inferior PFS, while primary NL was associated with improved PFS (HR 0.3, p=0.002). Patients undergoing frontline ASCT had a median PFS of 108 months (95% CI, 58–not reached) with a 7-yr PFS of 62% (95% CI, 46–84). Among those receiving second line and beyond (2+) therapy, 24 received MTX-based regimens, 10 received CAR-T, and 8 received tyrosine kinase inhibitors. Post-ASCT median PFS was 30 months (95% CI, 15–NR). Among CAR-T recipients, evaluable responses (n=8) included 4 CR, 1 PR, and 3 PD. Median OS was 56 months (95% CI, 29–133), with a 5-yr OS of 50% (95% CI, 41–60). On MVA, ECOG ≥2 (HR 2.5, p=0.02) predicted worse OS, while receipt of ASCT (HR 0.4, p=0.04) and primary NL (HR 0.5, p=0.04) were associated with improved OS. Conclusion This study represents the largest single-enterprise cohort of pts with NL, providing comprehensive insight into its clinical presentation, treatment patterns, and outcomes. Primary NL and preserved PS were independently associated with improved response rates and survival, while CNS and systemic involvement at diagnosis portended poorer PFS. MTX and bendamustine-based regimens achieved high ORR, and frontline ASCT was associated with significantly prolonged remission duration and OS. These findings highlight the prognostic importance of baseline disease burden and functional status, support the early incorporation of high-intensity regimens in eligible patients, and underscore the urgent need for prospective studies to guide evidence-based management in this rare and understudied population.

Abstract Background Antiphospholipid syndrome (APS) is diagnosed when vascular thrombosis or pregnancy morbidity occurs in the presence of persistent antiphospholipid antibodies (aPL). Although IgM-isotype antibodies are part of the laboratory criteria, their clinical value remains uncertain. We evaluated real-world aPL testing patterns to quantify the prevalence of isolated IgM positivity. Methods We analyzed aPL testing data across the Mayo Clinic sites between January 2006 and July 2025, lined up with the publication of the revised Sapporo (Sydney) classification criteria. For each patient, we identified the first time in which any aPL test was performed. We assessed available results for Lupus anticoagulant (LA), anticardiolipin (aCL) isotypes IgG and IgM, and anti–beta 2 glycoprotein (B2GP1) isotypes IgG and IgM. Positivity rates were calculated for each marker, and a subgroup of patients who had results for all three test categories at the initial workup was identified. In this cohort, we assessed the distribution of single, double, and triple positivity. We also quantified the number and percentage of patients who were positive only for IgM isotypes (aCL or B2GP1), with negative LA and IgG at initial testing. Antibodies were considered positive based on international criteria and internal standards. aCL and B2GP1 were positive if ≥40 units. LA positivity followed ISTH SSC guidelines, requiring demonstration of a phospholipid-dependent inhibitor in the following assays: screening, mixing, and confirmatory steps in DRVVT or aPTT-based platelet neutralization procedure (PNP), Staclot LA delta and HEX LA delta assays. Criteria for a positive result was as follows: DRVVT: prolonged screen and inhibited mix with screen/confirm ratio >1.2; Staclot LA delta: >7 seconds; PNP: shortening of the APTT clotting time with PNP by ≥5 seconds before 2023 and ≥2 seconds thereafter; HEX LA delta >13 seconds. Results A total of 99,814 unique patients underwent testing for at least one aPL marker. The most frequently tested was LA (n = 75,085), with a positivity rate of 10.29% (7,730/75,085). Among antibody isotypes, positivity rates were 1.2% (846/69,539) for aCL IgG, 1.7% (1,198/69,640) for aCL IgM, 1.9% (732/37,791) for B2GP1 IgG, and 2.0% (762/37,601) for B2GP1 IgM. Among the 30,274 patients who underwent simultaneous testing for LA, aCL IgG/IgM, and B2GP1 IgG/IgM, 1.3% (n = 407) were triple-positive, 1.4% (n = 427) were double-positive, and 9.9% (n = 3,009) had a single positive marker. The remaining 87.3% (n = 26,431) tested negative for all three. Of the 3,009 patients with only one positive marker, 9.8% (n = 296) were positive exclusively for aCL IgM, and 7.4% (n = 224) were positive exclusively for B2GP1 IgM. Among all fully tested patients, 2.2% (668/30,274) were positive for only IgM isotypes (either aCL or B2GP1) in the absence of IgG and LA positivity. Specifically, 0.9% (n = 296) were exclusively positive for aCL IgM and 0.7% (n = 224) for B2GP1 IgM. Additionally, 0.5% (n = 148) were simultaneously positive for both aCL IgM and B2GP1 IgM, without associated IgG or LA markers. Had only IgG and LA been assayed, 17.4 % (668/3843) of initially positive patients—and one-third of those classified as triple-positive—would have been missed. Conclusion Within this large-scale analysis of real-world APS test ordering practice, less than one-third of orders included a comprehensive characterization. Isolated IgM positivity, defined as aCL or B2GP1 IgM in the absence of IgG and LA, was infrequent yet represents a sizable proportion of initial positive aPL testing. How these results impact APS diagnosis and management of APS requires further study.

Abstract Background: Glofit, a CD20/CD3 bispecific antibody, has shown efficacy in prospective trials, including the Phase III STARGLO study evaluating glofit plus gemcitabine/oxaliplatin (GemOx) in transplant-ineligible patients (pts) with R/R large B-cell lymphoma (BCL). However, concerns raised by the FDA's Oncology Drug Advisory Committee regarding the generalizability of the STARGLO data to U.S. pts underscore the need for real-world evidence. We report real-world outcomes of Glofit-GemOx in U.S. pts with R/R aggressive BCL. Methods: We conducted a multicenter retrospective review across 8 U.S. academic centers, identifying 31 pts with R/R aggressive BCL treated with Glofit-GemOx outside clinical trials. Baseline characteristics, treatment history, and outcomes were abstracted from medical records. Results: At Glofit-GemOx initiation: median age was 72 years (range, 34–88); 90% had stage III/IV disease. Histologic subtypes included DLBCL in 58% (n=18), high-grade BCL in 29% (n=9), PTLD/DLBCL in 6.5% (n=2), follicular lymphoma (FL) grade 3B in 3.2% (n=1), and Burkitt lymphoma (BL) in 3.2% (n=1). Germinal center B-cell phenotype was seen in 80% of evaluable cases. Double- (n=8) or triple-hit (n=1) cytogenetics were observed in 31% (n=9). Elevated LDH was present in 74%, and 16% had B symptoms. Median ECOG performance status was 1 (range, 0–3), and 23% (n=7) had received prior CAR T-cell therapy. Pre-treatment biopsy was performed in 77% (n=24) with CD20 expression tested in 74% (n=23). CD20 expression was negative in 3 pts by flow cytometry and/or immunohistochemistry. Pts received a median 1 prior line of therapy (range, 0-6); Glofit-GemOx was administered as 1L in 7% (n=2), and 2L in 58% (n=18). Median 4 cycles (range, 1-11); both 1L pts had prior FL (1 and 3 prior lines for FL). Twelve pts remain on therapy, 2 on Glofit monotherapy. Four pts were unevaluable (2 death pre-assessment; 2 pending evaluation). Among 27 evaluable pts, ORR was 78% (21/27) and CR rate was 41% (11/27). Among CD20- negative cases on pre- Glofit-GemOx biopsy (n=3), ORR was 33% (1/3), with 1 CR lasting 3.5 months. Of 11 pts who progressed on Glofit-GemOx, 6 were rebiopsied; 1 showed CD20 loss, 1 was previously CD20-negative. Among the 24 pts who received Glofit-GemOx as destination therapy, ORR of 75% (15/20 evaluable). Among pts with prior CAR T (n=7), the ORR and CR rate were both 43% (3/7). None received Glofit-GemOx within 30 days of CAR T-cell infusion; 4 received within 6 mo; 2 of whom achieved CR. Seven pts (24%) received Glofit-GemOx as bridging to CAR T. ORR pre-CAR T was 86% (6/7); 4 pt successfully proceeded to CAR T, 2 are pending infusion, and 1 progressed after 2 cycles and transitioned to alternate therapy. Three pts were evaluable post-CAR T with an ORR of 100% (3/3) and CR rate of 67% (2/3). At data cutoff, 23/31 pts were alive. Full PFS and OS data will be presented at ASH. Notable individual responses included a patient with relapsed BL post–DA-EPOCH-R who received Glofit-GemOx as 2L therapy and achieved a 6 mo CR without consolidation before progression. Another patient treated with Glofit-GemOx in the 7L setting after prior allogeneic transplant achieved a 3 mo CR prior to progression. CRS occurred in 58% (18/31), with grade ≥3 in 13% (4/31), including 2 possible treatment-related deaths. One occurred in a frail patient after the 1st dose, though neutropenic fever was present prior to Glofit administration. The second followed influenza A infection, respiratory failure, and possible grade 4 ICANS after the 2nd dose; attribution to CRS vs. infection was unclear. ICANS occurred in 10% (3/31), with one possible grade ≥3 case. Conclusions: This is the first U.S.-based real-world analysis of Glofit-GemOx, including more U.S. pts than the STARGLO trial, appear to demonstrate comparable response rates, potentially supporting its use as both bridging and destination therapy. Notable toxicities, including CRS, were observed, with 2 possible treatment-related deaths, with plausible alternate non-treatment related causes. Favorable responses were seen in bridging therapy and high-risk subgroups (transformed, HGBCL) which were excluded in the STARGLO trial. These findings support the real-world utility of Glofit-GemOx in the management of R/R aggressive BCL but underscore the need for caution due to associated toxicities. Further real-world and prospective evaluation are warranted, particularly in rare subgroups and as bridging therapy.

Abstract While the use of NCCN guidelines is essential in lymphoma care, adherence among oncologists remains highly variable. Real-world concordance ranges from 65–80% overall, dropping to as low as 11–46% for certain lymphoma subtypes. Although 88% of clinicians report using NCCN guidelines for Hodgkin lymphoma, adherence to PET-adapted approaches is inconsistent. This gap highlights a critical need for tools that support guideline-concordant care.Large language models (LLMs) such as GPT–4 promise decision support, yet hallucinations and divergence from evidence-based care remain obstacles. We assessed whether retrieval-augmented generation (RAG) with National Comprehensive Cancer Network (NCCN) guidelines improves GPT–4 performance in lymphoma treatment recommendation tasks. To address this, we developed a RAG-enhanced GPT-4 agent (RAG-GPT) by indexing the 2025 NCCN Lymphoma Guidelines into a vector database. Fifty clinical vignettes spanning diverse lymphoma subtypes were compiled from published case reports; this sample provides 80 % power (α = 0.05) to detect a mean score difference of ≥ 0.18 on the modified Generative AI Performance Score (mG-PS). Guideline concordance was assessed based on NCCN guidelines and clinical judgment reflecting real-world oncological decision-making. Scores were normalized between -1.0 and 1.0 for consistent evaluation. Readability and rationale clarity were rated on a 5-point Likert scale. Baseline GPT-4 and RAG-GPT generated treatment plans via standardized prompts. An oncologist scored all outputs with mG-PS, which rates NCCN concordance (0.0–1.0) and penalizes hallucinations (-0.25 to –1.0). RAG-GPT achieved a higher mean mG-PS (0.32) than baseline GPT–4 (0.10) (t(98)=-2.11, p=0.038; mean score difference ΔmG-PS=0.22). Importantly, RAG-GPT eliminated severe hallucinations, reinforcing confidence in the safety of its treatment reccomendations. Fully concordant “gold-standard” plans were produced in 46 % of vignettes with RAG-GPT versus 22 % with baseline. Readability scores favored RAG-GPT modestly without statistical significance. Lymphoma's bimodal age distribution, heterogeneity, and lack of standardized treatment algorithms, coupled with regimen toxicity and the need to account for patient frailty and comorbidities, create complex clinical scenarios that constrain LLM applicability for nuanced decision-making. Non-Hodgkin lymphoma, particularly relapsed/refractory, transformed disease, or rare subtypes, lacks a defined standard of care, leading reviewers to rely on clinical judgment or published case series beyond NCCN guidelines. This underscores a key limitation of LLM-supported tools: their performance is highly dependent on the presence of clear algorithmic consensus within a given disease. Linking GPT-4 to NCCN guidelines via RAG significantly improved treatment accuracy and reduced hallucination severity in lymphoma, though performance remained lower than prior RAG studies in cancers like breast and CNS suggesting a greater impact on hallucination reduction than on retrieval of a consistent gold standard regimen. These findings support continued development and prospective validation of guideline-anchored LLMs for clinical use.

Abstract Background Measurable residual disease (MRD) negativity post- autologous stem cell transplantation (ASCT) in newly diagnosed multiple myeloma (MM) is associated with favorable outcomes and may overcome the adverse impact of high-risk cytogenetic abnormalities (HRCAs). However, as the definition of high risk evolves and MRD emerges as a key endpoint, understanding its prognostic value within individual HRCAs is critical for treatment guidance. Methods We retrospectively included patients with NDMM that underwent an ASCT between September 19, 2016, and October 19, 2023, and achieved MRD negativity on Day 100 post ASCT. The MRD testing was conducted using multiparameter flow cytometry with a sensitivity of 2x10. HRCAs were defined as del(17p), 1q21+ gain or amplification (1q21+), t(4;14), t(14;16), t(14;20) and del(1p) and rest were considered standard risk (SRCA). Patients were grouped by the number of HRCAs (0, 1, ≥2). An adaptation of the recently proposed International Myeloma Society (IMS)/International Myeloma Working Group (IMWG) classification for high-risk disease (TP53 mutation unavailable) was also used. Progression-free survival (PFS), measured from stem-cell infusion to progression or death, was estimated using Kaplan–Meier methodology and compared using log-rank test. Results We identified 386 patients with MRD negativity post ASCT, of which 381 had cytogenetic data available for analysis. The median follow-up for the study cohort was 47.3 months (95% CI: 43.2-50). The median age at the time of ASCT was 65.7 (25.4-79.2) years and 58.3% patients were males. A total of 49% (n=189) patients had standard-risk cytogenetics, 31.4 % (n=121) harbored 1 HRCA, 15.3% (n=59) patients had two HRCAs and 3.1% (n=12) had 3 HRCAs. The individual HRCA by their prevalence were: 1q21+ in 35.5%(n=137), del(17p) in 14.3% (n=55), t(4;14) in 10.9% (n=42), t(14;16) in 5.4% (n=21), del(1p) in 4.2% (n=16), and t(14;20) in 1.04% (n=4) of patients. The most common double-hit lesions were1q21+ gain and/or amplification co-occurring with t(4;14) (33.9%, n=20) and del(17p) with 1q21+ (18.6%, n=11). Despite universal MRD negativity at Day 100, several HRCAs remained prognostically significant for PFS. Patients with del(17p) had worse 3-year PFS (71%) than those without (81%) [hazard ratio (HR)=1.85, 95% CI 1.11–3.07, p = 0.0172], though 3-year OS did not significantly differ at data cutoff (80% vs. 92%, p=0.1176). Presence of 1q21+ was associated with an inferior 3-year PFS (73%) compared to those without [84%, HR: 1.96 (95% CI: 1.25–3.06), p=0.0026], while 3-year OS was similar (88% vs. 91%, HR:1.33 p=0.36). Isolated 1q21+ had inferior PFS with comparable OS when compared to SRCA [3-year PFS of 82% vs. 88% respectively (HR:1.97, p=0.0177)]; 3-year OS was 91% vs. 94% (HR:1.38, p=0.44)]. Among 1q21+ patients, those with co-occurring HRCAs had a 3-year PFS of 66% vs. 81% for isolated 1q21+ (HR: 1.47, p=0.21). Patients with t(4;14) had worse 3-year PFS (64%) vs. 82% in non t(4;14) [HR 2.11(95% CI: 1.21-3.67) p=0.0064], and 3-year OS of 82% compared to 91% [HR 2.14 (95% CI: 1.02–4.49), p=0.038]. Isolated t(4;14) showed a 3-year PFS of 59% vs. 87% in standard-risk (p=0.06), and 3-year OS of 90% vs. 93% [HR 3.29, 95% CI 0.95–11.33, p = 0.06]. The presence of t(14;16), t(14;20), and del(1p) did not significantly affect 3-year PFS (all p>0.1), likely due to small subsets. When patients were grouped by the number of HRCAs, PFS declined with increasing cytogenetic complexity. Compared to standard risk, the 3-year PFS was 77% for 1 HRCA vs [HR = 2.11 (95% CI: 1.29–3.46), p = 0.0027], 67% for ≥2 HRCA [HR = 2.64 (95% CI: 1.53–4.57), p = 0.0005]. Maintenance therapy was used in 98% of patients. Patients with HRCAs received a doublet maintenance compared to SRCA (p<0.0001), even in MRD negative disease post ASCT. Conclusion In patients with certain HRCA, achievement of MRD negativity post-ASCT does not overcome the adverse impact of HRCA on PFS. In our cohort, patients with del(17p), t(4;14), or 1q21+ continued to exhibit significantly shorter PFS despite achieving MRD-negative status. These findings underscore the need for ongoing risk-adapted strategies even in patients with MM who attain MRD-negative state. The OS estimates are immature at this time.

Abstract Background and Significance: Waldenström's Macroglobulinemia (WM) is an indolent B cell disorder characterized by proliferation of clonal lymphoplasmacytic lymphocytes in the bone marrow, lymph nodes, as well as liver and spleen, and secreting a monoclonal IgM Protein. WM is a rare disorder with about 1,700 cases diagnosed in the U.S. each year. There have been significant advances in the management of patients with WM in the last decade, with Bruton's tyrosine kinase (BTK) inhibitors (ibrutinib and zanubrutinib) emerging as a major treatment advancement in this disease. Currently, both BTK inhibitors are approved for the treatment of WM patients with newly diagnosed as well as relapsed/refractory (R/R) disease. BTK inhibitors are effective for the therapy of WM, especially among patients with MYD88 mutation, although the response rates are lower in patients with CXCR4 mutations. In addition, these drugs can cause cardiac side effects such as atrial and ventricular arrhythmias as well as an increased risk of bleeding/bruising. Thus, these drugs can be difficult to use in patients who are older and have cardiac comorbidities. BCL-2 overexpression is well described in a number of B cell malignancies, including WM, leading to inhibition of apoptosis of malignant cells. BCL-2 inhibition with venetoclax has been tested in patients with R/R WM and showed excellent activity with an overall response rate (ORR) of 85% and very good partial response (VGPR) rate of 19%. The therapy was overall well tolerated with no evidence of cardiac toxicity. Given the excellent activity and tolerability of Venetoclax in WM, we are conducting a national cooperative group randomized phase 2 trial comparing ibrutinib+rituximab (IR) vs. venetoclax+rituximab (VR) in patients with newly diagnosed WM. Our hypothesis is that with this trial, we have the potential to develop a more effective therapy targeting BCL-2 for patients with untreated WM, that does not have cardiac or hemostatic toxicity. In addition, we are testing use of a fixed duration therapy with these regimens. Study design and methods: The ongoing clinical trial () is being conducted through the Southwest Oncology Group (SWOG) and is enrolling at multiple SWOG, ECOG, and ALLIANCE centers throughout the US. Major inclusion criteria include 1) newly diagnosed WM confirmed by biopsy and measurable disease (≥0.5 g/dl IgM type paraprotein), 2) meeting WM-related clinical criteria to initiate therapy (cytopenias, B symptoms, bulky lymphadenopathy, neuropathy, hyperviscosity) 3) adequate blood counts (ANC >1000, HGB ≥7.5, PLT ≥50,000), 4) eGFR ≥30 ml/min, 5) adequate liver function tests (total bilirubin ≤1.5 x ULN and AST, ALT and alkaline phosphatase ≤3 x ULN), 6) Zubrod performance status ≤2, 7)prior treatment with single-agent R allowed as long as >6 months prior to registration. Once enrolled the patients will be randomized 1:1 to IR vs. VR. I will be started at 420 mg daily at start of therapy while V will be given at 400mg daily during cycle 1 week 1 and then increased to 800 mg daily from cycle 1 day 8 onwards. R will be given weekly x 4 in cycles 2 and 5. Dose adjustments for both I and V can be done depending on toxicity. Therapy will be given for 2 years and then the patients will be observed off treatment. Patients with disease progression during these 2 years of therapy can cross-over to the other arm. The primary endpoint of the study is rate of VGPR or better. With 41 eligible participants per arm (total N=82), this design has 80% power to reject the null hypothesis of a 25% VGPR rate, given the alternative of a 50% VGPR rate, with a one-sided alpha of 10%. To account for an anticipated 10% ineligibility rate, approximately 46 participants will be accrued per arm (92 total). Current enrollment stands at 15 patients. The secondary end points include ORR, complete response rate, major response rate, progression free and overall survival rates.

Abstract Background: For LS-DLBCL, clinical trials (FLYER, LYSA/GOELAMS 02-03, LYSA LNH09-1B, S1001) have shown that 4 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (RCHOP4) without radiation (RT) leads to durable remissions in >90% of cases. However, only patients (pts) with non-bulky disease and/or international prognostic index (IPI) of 0 and complete metabolic response (CMR) on interim positron emission tomography (PET) scan, if performed, were eligible for RCHOP4 alone in these studies. Outcomes in trial-ineligible LS-DLBCL and the appropriate real-world candidates for RCHOP4 are still undefined. Methods: We conducted a multicenter retrospective study of adult pts with stage I/II DLBCL of any tumor bulk, IPI and with or without B-symptoms diagnosed after 2011 and treated with RCHOP4 +/- 2 cycles R from 21 U.S. centers. Pts with PMBCL, PTLD or receiving non-standard dose RCHOP for cycle (C) 1 or planned consolidative RT were excluded. The primary endpoint was PFS from C1 by Kaplan-Meier method, not counting indolent lymphoma relapse. Event free survival (EFS) was time to next therapy without progression (including unplanned RT for non-CR), progression or death. A competing risks analysis of non-relapse mortality (NRM) vs. DLBCL progression was performed. Results: The characteristics of the 428 pts were: median age 60 (18-88), 60% male, 11% Hispanic and 4% non-Hispanic Black, 62% stage I, 15% elevated LDH, 3% ECOG PS>1, 5% tumor bulk >7cm, 9% had B-symptoms and median Charlson Comorbidity Index (CCI) was 4 (2-12). IPI was 0, 1 and 2-3 in 42%, 46% and 12% and stage-modified IPI (smIPI) was 0, 1, 2 and 3-4 in 25%, 48%, 21% and 6% of pts. 66% had nodal (59% head/neck, 11% pelvic, 9% multiple above diaphragm, 7% abdominal) and 46% extranodal sites (37% head/neck, 20% gastric/intestinal, 9% spleen, 8% skin/soft tissue); 6% had transformed/concurrent FL/MZL or grade 3B FL, 33% (138/408) were non-GCB cell of origin (COO), 25% (90/357) double expressor (DEL) and 0.5% (2/379) double-hit. 13% had completely resected disease, 97% staging PET and 47% bone marrow biopsy. Median diagnosis to treatment interval was 30 days (IQR 20-43), 6% had dose reductions after C1, 77% had an interim PET (iPET) after C2 (33%) or C3 (67%), 15% received 2 additional cycles R and 4% CNS prophylaxis. CMR rates by iPET were 83% after C2 and 94% after C3, and 95% by end-of-treatment PET. iPET PMR was more likely if smIPI>2 or bulky disease. Median follow-up time was 2.7 years. There were 32 progression events: 14 occurred at the primary site and 17 at distant sites (1 unknown), and 12 occurred after 2 years. Another 11 pts received unplanned RT after RCHOP4 for non-CR. There were 24 deaths, 12 without prior progression. Cause of death was DLBCL in 7 and non-DLBCL in 17 cases (6 infection, 2 ILD, 2 heart failure, 2 second cancer, 1 seizure, 4 unknown). EFS, PFS and OS rates were 88%, 90% and 96% at 3 years. By univariable Cox regression, Black race, elevated LDH, smIPI>2, DEL, increasing CCI, multiple subdiaphragmatic nodal sites and iPET PMR were associated with worse PFS. Non-significant variables of note included COO, extranodal sites, complete resection, missing bone marrow biopsy, missing iPET and additional cycles R. By multivariable analysis (including age>60, stage, ECOG PS>1, elevated LDH, bulky disease, CCI, B-symptoms and DEL), ECOG PS>1 (HR 3.95 p=0.050), CCI (HR 1.29 p=0.003) and DEL (HR 2.02 p=0.069) were associated with worse PFS. Cumulative incidence of DLBCL progression and NRM were 8% and 2% at 3 years. Competing risk analysis by univariable models found that age>60, ECOG PS>1, smIPI>2, elevated LDH, CCI and bulky disease were associated with NRM, while DEL and B-symptoms were associated with DLBCL progression.Conclusion: Presented is the largest retrospective cohort of LS-DLBCL treated uniformly with RCHOP4 to date. Despite modest follow-up time and lack of an “intention-to-treat“ population, this study shows that abbreviated RCHOP4 leads to excellent outcomes in the real-world, albeit with continuous risk of late relapse. smIPI risk factors were associated with worse PFS, though this may in part be driven by risk of non-lymphoma death. As pts with advanced age, poor performance status or comorbidities may benefit from reduced treatment exposure, RCHOP4 should still be considered for these and other “trial-ineligible” pts, particularly if other high-risk features (iPET PMR, DEL or B-symptoms) are absent.

Abstract Background Chimeric antigen receptor T-cell (CAR-T) and bispecific antibody (BsAb) therapies are both effective for patients with relapsed/refractory (R/R) follicular lymphoma (FL), but differ in treatment schedules and associated “time toxicity,” or contact days spent physically interacting with the healthcare system. While contact days can be estimated from clinical trials, real-world data provides a more nuanced depiction of treatment-related time burden, which may guide treatment decision-making. The comparative time toxicity of CAR-T vs BsAb in R/R FL is not defined. Methods We conducted a multicenter retrospective study of adults with R/R grade 1-3A FL who received standard-of-care CAR-T (axi-cel, tisa-cel, liso-cel) or BsAb (mosunetuzumab, epcoritamab) in the third-line or later setting before Jan 1, 2025. Time toxicity was defined as outpatient or inpatient days with physical health care system contact, counting multiple visits on the same day as only one day. All days after treatment initiation were counted, regardless of disease progression, therapy completion, or relation to FL therapy. Median contact days over 1-year time horizon were compared, stratified by CAR-T vs BsAb, prior lines of therapy (LOT, 2 vs 3+), and time intervals (0-1, 1-3, 3-6, 6-9, and 9-12 months). Progression-free survival (PFS) and overall survival (OS) were calculated from day of CAR-T infusion or day 1, cycle 1 for BsAb. Cox regression and propensity matching (by age, ECOG, refractory to prior LOT, POD24) were used to assess predictors and survival associations with contact days. Results Among 209 patients from 15 U.S. academic centers, median age was 64, 37% were female, 61% received CAR-T (80% axi-cel, 7% liso-cel, 13% tisa-cel) and 39% BsAb (93% mosun, 7% epcor). Most had Grade 1-2 FL (72%), advanced stage (84%), and extranodal disease (51%). Median prior LOT was 3 (range 2-15), 41% were refractory to prior LOT, and 52% had POD24. Median number of BsAb doses was 10 (range 1-36). Patients receiving BsAb were significantly older (p<.01) and had higher CIRS comorbidity scores (p<.02) in both 2 and 3+ prior LOT cohorts, and had higher ECOG scores (p=.01) and were less likely to be refractory to prior LOT (p=.029) in 3+ LOT cohort. There were no differences in POD24 rates between CAR-T and BsAb. Median PFS for the entire cohort was 3.6 yrs; median OS was not reached. In the 2 prior LOT cohort (N=75), 60% received CAR-T and 40% BsAb. With median follow-up of 1.5 years, median PFS was not reached for CAR-T and 1.6 yrs for BsAb (p<.0001). In the 3+ prior LOT cohort (N=134), 62% received CAR-T and 38% BsAb. With median follow-up of 2 yrs, median PFS was 3.6 yrs for CAR-T and 1.6 yrs for BsAb (p=.0044). In propensity matched analysis, PFS was shorter for BsAb in both 2 LOT (HR 9.0, 95% CI 1.14-71.04, p=.037) and 3+ LOT (HR 3.25, 95% CI 1.06-9.97, p=.039) cohorts as compared to CAR-T. There were no significant differences in OS between CAR-T and BsAb. Median contact days were significantly higher for CAR-T vs BsAb in the 0-1 month interval: 19 vs 8 days in 2 LOT (p<.0001) and 18 vs 7 days in 3+ LOT (p<.0001) cohorts. There were no differences in contact days between CAR-T vs BsAb in subsequent time intervals. Over 1 year, CAR-T had significantly more time toxicity than BsAb: median 51 vs 36 contact days in 2 LOT (p<.0001) and 64 vs 38 days in 3L+ LOT (p<.0001) cohorts; these remained significant in the matched analysis. B symptoms (p=.04) and Grade ≥3 cytopenias (p=.007) were associated with higher contact days in 3+ LOT cohort in univariable analysis. Higher contact days were associated with inferior PFS (HR 1.01, 95% CI 1.00-1.02, p=.032) and OS (HR 1.01, 95% CI 1.00-1.02, p=.038) in 3+ LOT cohort regardless of treatment type. Discussion In this large real-world cohort of patients with R/R FL, CAR-T therapy resulted in better PFS but more time toxicity over the first year as compared to BsAb therapy. Excess time toxicity from CAR-T was driven by more contact days in the first month of treatment. This study provides benchmark data for counseling patients about expected time burden of CAR-T (51-64 days) and BsAb (36-38 days) over the first year of these therapies. Further, with superior PFS of CAR-T in this study and minimal impact of time toxicity on survival outcomes, these data can be used to better support shared decision-making in R/R FL by addressing patient preferences regarding both contact days as well as duration of disease control.