Grzegorz S. Nowakowski

Treatment strategies for relapsed/refractory large B-cell lymphoma (R/R LBCL) have evolved rapidly, yet relationships between therapy selection and outcomes remain poorly defined. The LEO CReWE study evaluated disease characteristics, patterns of care, and outcomes in 1504 patients with R/R LBCL from 2002 to 2022. Of these, 64% received chemoimmunotherapy at second-line (2L). Autologous stem cell transplant (ASCT) and/or chimeric antigen receptor T-cell therapy (CAR-T) were planned at 2L for 984 patients (65%), with 471 (31%) ultimately receiving ASCT and 94 (6%) receiving CAR-T. Complete response (CR) rates at 2L ranged from 24% for lenalidomide-based regimens to 49% for CAR-T; salvage chemotherapy achieved a 44% CR rate overall and 60% among patients who eventually underwent ASCT. Median event-free and overall survival from 2L were 4.3 months and 18.3 months, respectively; survival improved in eras during which CAR-T was available. Patients intended for but unable to receive ASCT or CAR-T experienced poor outcomes comparable to those never intended for curative therapy at 2L. The LEO CReWE study represents the first large-scale depiction of 2L treatment patterns and outcomes for LBCL in the modern era, inclusive of all treatment approaches, and underscores the ongoing need for more effective therapies despite the advent of CAR-T.

Therapeutic options for Waldenström macroglobulinemia (WM) have expanded but improvements in overall-survival (OS) are difficult to interpret due to competing non–WM mortality. We conducted a large single-center retrospective study of 1,020 patients with WM to evaluate survival trends. Patients were stratified by era of active WM diagnosis using a two-era model (1996–2005 and post-2005) and a four-era model (pre-2001, 2001–2007, 2008–2013, and post-2013). OS did not differ significantly across eras in the overall cohort (p = 0.64 and p = 0.86 for the two- and four-era models). However, among patients aged < 65 years at the time of active WM diagnosis in the 2-era model, OS improved in the post-2006 era (median 18.8 vs 14.1 years, p = 0.018). Cause-specific-survival (CSS) improved across all eras, increasing from 15.6 years in 1996–2005 to 18.9 years post-2006 (p < 0.0001), and from 13.7 years pre-2001 to not reached in later periods in the four-era model (p < 0.0001). Competing-risk-analysis (CRA) demonstrated a reduction in WM-related mortality over time (p < 0.001). However, excess mortality persisted, with a standardized mortality ratio (SMR) of 2.79 (p < 0.001) among patients < 65 years compared with a matched U.S. population. Our findings highlight improvements in WM-specific survival, while gains in OS are observed in younger patients.

The phase III AUGMENT trial (ClinicalTrials.gov identifier: NCT01938001 ) demonstrated improved efficacy for lenalidomide plus rituximab (R ² ) versus rituximab with placebo (R-placebo) in patients with relapsed or refractory (R/R) indolent non-Hodgkin lymphoma (iNHL). Here, we present the long-term follow-up results and prespecified subgroup analyses of patients with follicular lymphoma (FL), including those 70 years and older. Patients with R/R grade 1 to 3a iNHL were randomly assigned 1:1 to receive R ² or R-placebo. In this long-term follow-up report, progression-free survival (PFS) was assessed per the investigator. Secondary end points included overall survival (OS) and safety. Of the 358 randomly assigned patients (intent-to-treat [ITT] population), 295 had FL (≥70 years, n = 66). At long-term follow-up (median, 65.9 months), in the ITT iNHL population, PFS (hazard ratio [HR], 0.50 [95% CI, 0.38 to 0.66]) and OS (HR, 0.59 [95% CI, 0.37 to 0.95]) were improved with R ² versus R-placebo. Safety findings were consistent with the primary analysis. Improved long-term efficacy with R ² versus R-placebo and manageable safety with R ² were observed in patients with FL, including those 70 years and older. With a follow-up of >5 years, data from the AUGMENT trial continue to support the use of R ² as a standard of care for patients with R/R iNHL.

Diffuse large B-cell lymphoma (DLBCL) is an aggressive B-cell malignancy and is the most common subtype of lymphoma. Treatment is administered with curative intent and approximately two thirds of patients are expected to have durable long-term survival. To achieve this, anthracycline-based chemotherapy in combination with rituximab is typically administered as initial therapy. Management is optimized based on the disease stage, prognostic clinical features, and histological or molecular subclassification. In patients with the activated B-cell subtype of DLBCL, polatuzumab vedotin is commonly included in the combination. For those with Myc and BCL-2 rearrangements, a more treatment intense approach is used. Despite this risk-adapted approach, at least one third of patients relapse. Those who relapse within 1 year, or are resistant to initial therapy typically receive chimeric antigen receptor (CAR) T-cell therapy. For those relapsing more than a year post initial treatment, salvage chemotherapy followed by an autologous stem cell transplant is offered. In patients ineligible for cellular therapy, or those who progress after CAR T-cell treatment, management is palliative and includes administration of bispecific antibodies or antibody drug conjugate combinations. To further improve the outcome of DLBCL patients, incorporation of cellular and bispecific therapies into front-line treatment is currently being tested.

Purpose:Polatuzumab vedotin (polatuzumab) was approved for up-front treatment of diffuse large B-cell lymphoma in combination with chemoimmunotherapy (Pola-R-CHP) based on the POLARIX trial. However, when stratified by cell of origin (COO), polatuzumab seems to have greater efficacy in activated B-cell than germinal center B-cell (GCB) subtype disease. Most studies of polatuzumab used RNA expression to assess COO, whereas in routine clinical practice, the immunohistochemistry-based Hans algorithm is used.Experimental Design:To assess the impact of COO by immunohistochemistry on polatuzumab efficacy, we conducted a multicenter real-world study of adults with large B-cell lymphoma (LBCL) receiving polatuzumab from 2015 to 2024, split by receipt of polatuzumab in first-line versus relapsed/refractory settings. The primary endpoint was overall response rate (ORR) to polatuzumab-based treatment in GCB versus non-GCB relapsed/refractory LBCL.Results:Of 740 patients, 305 received polatuzumab in the first-line setting and 435 in the relapsed/refractory setting. In the relapsed/refractory cohort, the ORR in non-GCB versus GCB LBCL was 59.7% versus 36.3% [OR, 2.6; 95% confidence interval (CI), 1.77–3.84; P < 0.0001], with a complete response rate of 35.7% versus 17.7% (OR, 2.6; 95% CI, 1.66–4.02; P < 0.0001). Progression-free survival was longer for patients with non-GCB versus GCB COO (HR, 0.64; 95% CI, 0.5–0.83; P = 0.0006). In the first-line cohort, ORR, complete response rate, and progression-free survival were similar in non-GCB versus GCB LBCL, as hypothesized based on outcomes in the Pola-R-CHP arm of POLARIX, suggesting that the addition of polatuzumab overcomes the adverse risk of non-GCB COO in patients receiving R-CHOP.Conclusions:Based on these data, COO classification by the Hans algorithm is a strong predictor of polatuzumab efficacy in LBCL, informing real-world treatment decisions.