This document discusses treatment of diffuse large B-cell lymphoma (DLBCL). It notes that DLBCL is a heterogeneous disease with genetic subgroups that have different prognoses and responses to treatment. The addition of the antibody rituximab to chemotherapy improves outcomes for DLBCL compared to chemotherapy alone. Strategies discussed to improve outcomes include increasing chemotherapy dose intensity and the potential role of the drug bortezomib for the activated B-cell subtype.

1. Treatment of Diffuse Large B-Cell Lymphoma : Trying to do a better job Hamdy A.Azim Professor of Clinical Oncology Cairo University

3. Frequency of NHL Subtypes in Adults NHLClassification Project 1403 cases of NHL at 9 study sites worldwide. Indolent (35%) Diffuse large B-cell (31%) Armitage et al. J Clin Oncol. 1998;16:2780 – 2795. Mantle cell (6%) Peripheral T-cell (6%) Other subtypes with a frequency  2% (9%) Composite lymphomas (13%)

4. Frequency of NHL Subtypes in Adults Is it equally common throughout the world An EGYPTIAN large study (1009 cases) Frequency of Diffuse Large B-Cell Lymphoma is 48% Frequency of Low Grade B cell Lymphoma : 8% Follicular subtypes : 5% Azim et al. Proc ASCO; abs#72, 1998 Diffuse Large B-Cell Lymphoma

7. Rosenwald A et al. N Engl J Med . 2002;346:1937-1947. Activated B-cell–like Type 3 Germinal-center B-cell–like Overall survival (years) Probability 0 2 4 6 8 10 1.0 0.5 0.0 High Level of gene expression Low Genetic Subgroups in DLBCL Classification Germinal-center B-cell–like Type 3 Activated B-cell–like Genes GEP : DNA microarray analysis Their gene expression profiles suggest that they arise from B cells at different stages of differentiation.

8. Evolution of DLBCL Pre-B Early B Mature B Centroblast B Immunoblast Plasmablast ±CD5 CD19 CD20 CD22 CD52 Plasmacytic Intermediate B ? ? ? Stem cell Burkitt’s, FL, DLCL, HCL ALL CLL, PLL WM MM Changes in morphology and antigen expression during B-cell differentiation are reflected in the malignant counterparts of individual B cells

10. If you do not have DNA microarray analysis How can you determine the Genetic Subgroups in DLBCL ?

11. Genetic Subgroups in DLBCL Role of IHC : Hans Classification Hans et al , Blood 2004 Nebraska Group

13. . Prognosis of ABC subgroup still remains poor in the Post-Rituximab era ©2008 by American Society of Clinical Oncology Fu K et al. JCO 2008;26:4587-4594 Prognostic significance of Genetic Classification in DLBCL Post-Rituximab

17. bcl-2 BCL-2 overexpression in GCB DLBCL Courtesy to N Mokhtar

23. Efficacy of bortezomib + chemo ( DA-EPOCH) in relapsing DLBCL [ABC-DLBCL vs GCB-DLBCL] Dunleavy et al, Blood 2009; 113:6069 3.4 months 10.8 months P = .003 improved response rates for ABC compared with GCB. (83% ORR with 41,5% CR vs. 13% %; P < .001 )

33. Adverse Features in the International Prognostic Factors Index A AGE > 60 P PERFORMANCE STATUS E EXTRANODAL >1 L LDH >NL S STAGE III-IV International non-Hodgkin’s lymphoma prognostic factors project. N Engl J Med. 1993;329:987.

34. NHL: prognostic index for aggressive lymphomas 5-year overall survival by IPI risk grouping in 2031 patients with complete data necessary for risk stratification Risk Group Features CR (%) Survival (%) Low 0 - 1 87 73 Low-Intermediate 2 67 51 High-Intermediate 3 55 43 High 4-5 44 26 Shipp et al., NEJM 1993;329:987

35. IPI is an extemely valid prognostic index : GELA data base 6696 patients included in GELA randomized studies Overall survival Progression-free survival

41. Try to give more dose intensity /density of doxorubicin over the classic standard CHOP

43. Complete response rate analysis Hamdy A. Azim et al , Annals of Oncology,2009

44. Event free survival Hamdy A. Azim et al , Annals of Oncology,2009

45. Overall survival analysis. Hamdy A. Azim et al , Annals of Oncology,2009

46. A Point To Discuss This analysis by no means questions the need for “R” This analysis aims at providing a better alternative to CHOP for patients in countries with limited resources who are frequently not offered “R” Hamdy A. Azim et al , Annals of Oncology,2009

47. Treatment of DLBCL Post-Rituximab Era

48. Potential effects of Rituximab on CD20 + tumor cells Synergy with chemotherapy Complement fixation CD20 on malignant cell surface Active signaling (apoptosis induction) ADCC Fc  R CR3

49. DLCL : Rituximab improves outcomes compared with CHOP-like chemotherapy alone R-Chemo Chemo MInT 2 Overall survival British Columbia 3 Overall survival p = 0.0001 p < 0.0001 Overall survival GELA 1 p = 0.0004 Failure-free survival ECOG 4 p = 0.003 1. J Clin Oncol 2007; 25:Abstract 8009; 2. Lancet Oncol 2006; 7:379–391;3. J Clin Oncol 2005; 23:5027–5033; 4. J Clin Oncol 2006; 24:3121–3127; 5. Lancet Oncol 2008; 9:105–116.

52. GELA LNH 98.5: Rituximab improved survival in all IPI subgroups PFS: high risk OS: high risk PFS: low risk OS: low risk 1.0 0.8 0.6 0.4 0.2 0 Survival probability CHOP R-CHOP 1.0 0.8 0.6 0.4 0.2 0 Survival probability 1.0 0.8 0.6 0.4 0.2 0 Survival probability 1.0 0.8 0.6 0.4 0.2 0 Survival probability CHOP R-CHOP CHOP R-CHOP CHOP R-CHOP p=0.0051 p=0.0030 p=0.0022 p=0.0213 0 1 2 3 4 5 6 7 8 9 Years 0 1 2 3 4 5 6 7 8 9 Years 0 1 2 3 4 5 6 7 8 9 Years 0 1 2 3 4 5 6 7 8 9 Years Coiffier B, et al. J Clin Oncol 2007;25(Suppl. 18):443s (Abstract 8009)

53. R-CHOP: a consistent clinical benefit in all studies TTF Years 0 1 2 3 4 5 ECOG study 3 Maintenance Observation CHOP R-CHOP R-CHOP-14 p=0.000025 FFS 0 5 10 15 20 25 30 35 40 45 Months RiCOVER study 4 CHOP-14 British Columbia 2 Years Survival Post-rituximab Pre-rituximab p=0.0001 1 Pfreundschuh M, et al. Lancet Oncol 2006;7:379–91 2 Sehn LH, et al. J Clin Oncol 2005;23:5027 –33 3 Habermann T, et al. J Clin Oncol 2006;24:3121–7 4 Pfreundschuh M, et al. Lancet Oncol 2008;Jan 14:Epub ahead of print MInT = MabThera International Trial ECOG = Eastern Cooperative Oncology Group TTF = time-to-treatment failure FFS = failure-free survival 1.0 0.8 0.6 0.4 0.2 0 1.0 0.8 0.6 0.4 0.2 0 1.0 0.8 0.6 0.4 0.2 0 0 1 2 3 4

54. RICOVER 60 interim analysis: freedom from treatment failure (FFTF) Pfreundschuh M, et al. Blood 2005;106 (Abstract 13) * Median 26 months follow-up R- CHOP-14 X 6 = R- CHOP-14X8 i.e. If R is given more chemo is not essentially better 70 203 8 x CHOP-14 + 8 x R 58 210 8 x CHOP-14 70 211 6 x CHOP-14 + 8 x R 53 203 6 x CHOP-14 FFTF* (%) No. of patients Regimen

56. CD20 + DLBCL 18–60 years IPI 0,1 Stages II–IV, I with bulk 6 x CHOP-like + 30–40 Gy (Bulk, E) 6 x CHOP-like + MabThera + 30–40 Gy (Bulk, E) Randomisation MInT: trial design Pfreundschuh M, et al., Lancet Oncol. 2006

57. 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Probability 0 12 24 36 48 60 72 84 96 108 120 M o n t h s 89.8 % 80.0 % Overall Survival R-CHEMO (n=413) CHEMO (n=410) p=0.001 Pfreundschuh M, et al., Lancet Oncol. 2006 MInT

58. MInT trial: 3-year EFS by treatment group and prognostic factors Pfreundschuh M, et al. Lancet Oncology 2006;7:379–91

59. FLYER (6-6/6-4) STUDY DESIGN Patients with IPI = 0 and &quot;no bulk&quot; d 106 Interim Analysis (200 pts): 2-y-EFS = 98%, 2-y-OS = 99.5% C H O P C H O P C H O P C H O P C H O P C H O P R R R R R R C H O P R C H O P C H O P R R R R C H O P R R Stage I/II aaIPI=0 no Bulk 18-60 years d 1 d 64

60. ACVBP versus ACVBP plus rituximab for young patients with localized low-risk diffuse large B-cell lymphoma: A study by the Groupe d’Etude des Lymphomes de l’Adulte Ketterer N, et al . ICML 2011; Abstract 030

62. R-ACVBP vs ACVBP: Efficacy Ketterer N, et al . ICML 2011; Abstract 030. Endpoint R-ACVBP (n = 110) ACVBP (n = 113) p- value Hazard ratio 3-year EFS, % 93.4 82.1 0.0487 0.459 3-year PFS, % 92.5 83.0 0.0205 0.371 3-year overall survival, % 98.0 97.0 0.6857 –

65. A phase III trial comparing R-CHOP 14 and R-CHOP 21 for the treatment of newly diagnosed diffuse large B cell lymphoma Results from a trial by the UK NCRI Lymphoma Clinical Study Group (CRUKE/03/019) D. Cunningham , P. Smith, P. Mouncey, W. Qian, C. Pocock, K. M. Ardeshna, J. Radford, J. Davies, A. McMillan, D. Linch on behalf of the NCRI trial collaborators ASCO 2011, ABS# 8000

67. Patient characteristics Central review confirmed DLBCL in 96% R-CHOP21 (n=540) % R-CHOP14 (n=540) % Age ≤ 60 yrs median 47 61yrs (19-88) 48 61yrs (19-85) Gender male 54 54 WHO PS 0-1 2 87 13 87 13 B symptoms yes 44 47 Stage I-II III-IV 37 63 38 62 Bulky disease yes 51 48 IPI score 0-1 2-3 4-5 27 54 19 27 56 16

70. Toxicity during treatment *p < 0.01 (considered significant due to multiple testing) <1 <1 Other grade 5 toxicities 11 8 Neurological 2.6 (14) <1 (5) Cardiac 19 25 Infection Grade ≥ 3 Non- Haematological Toxicity 5 11 * Febrile neutropenia 3 1 Anaemia 9 * 5 Thrombocytopenia 37 77 * Neutropenia Grade ≥ 3 Haematological Toxicity R-CHOP 21 % R-CHOP 14 %

72. R-CHOP-14 compared to R-CHOP-21 in elderly patients with diffuse large B-cell lymphoma (DLBCL): Results of the second interim analysis of the LNH03-6B GELA study Delarue R, et al . ICML 2011; Abstract 106

78. Récher V, et al. Blood . 2010;116: Abstract 109. GELA study group (LNH 03-2B trial) youg population and an Age-Adjusted IPI of 1 GELA:

80. GELA study group (LNH 03-2B trial)

81. GELA study group (LNH 03-2B trial)

85. Randomized phase III US / Canadian Intergroup trial (SWOG S9704) comparing CHOP±R x 8 vs CHOP±R x 6 followed by high dose therapy and auto transplant for patients with diffuse aggressive non-Hodgkin’s lymphoma (NHL) in high-intermediate (H-Int) or high IPI risk groups . P.J. Stiff 1 , J.M. Unger 2 J.R. Cook 3 , L.S. Constine 4 , S. Couban 5 , T.C. Shea 6 , J.N. Winter 7 , T.P. Miller 8 , R.R. Tubbs 3 , D.C. Marcellus 9 , J. Friedberg 4 , K. Barton 1 , G. Mills 10 , M. LeBlanc 2 , L. Rimsza 8 , S.J. Forman 11 , R.I. Fisher 4 1 Loyola University Medical Center, Maywood, IL; 2 SWOG Statistical Center, Seattle, WA; 3 Cleveland Clinic Foundation, Cleveland, OH; 4 University of Rochester, Rochester, NY; 5 Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, CAN; 6 University of North Carolina at Chapel Hill, Chapel Hill, NC; 7 Northwestern University, Chicago, IL; 8 University of Arizona, Tucson, AZ; 9 Margaret and Charles Juravinski Cancer Centre, Hamilton, Ontario, CAN; 10 Louisiana State University Medical Center, Shreveport, LA; 11 City of Hope Medical Center, Duarte, CA

88. Overall Outcome : PFS HR: 1.72 (95% CI: 1.18-2.51)

89. Overall Outcome: Survival HR 1.24 (95% CI: 0.81-1.91)

90. Outcome of All Randomized Patients Based on IPI: PFS/OS (interaction p value = 0.02) (interaction p value = 0.01)

92. A randomised multicentre Phase III study for first-line treatment of young patients with high-risk (AAIPI 2-3) diffuse large B-cell lymphoma (DLBCL): Rituximab (R) plus dose-dense chemotherapy CHOP14/MegaCHOP14 with or without intensified high-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT). Results of DLCL04 trial of Italian Lymphoma Foundation (FIL) Vitolo U, et al . ICML 2011; Abstract 072

94. R-(Mega)CHOP-14 with or without HDT/ASCT: Efficacy 2-year PFS (%) by ASCT (R-CHOP-14 and R-MegaCHOP-14 combined) 2-year PFS (%) by induction regimen (HDT/ASCT and no HDT/ASCT combined) Vitolo U, et al . ICML 2011; Abstract 072. HDT/ASCT (n = 192) No HDT/ASCT (n = 200) p- value 71 59 0.0128 R-CHOP-14 (n = 199) R-MegaCHOP-14 (n = 193) p-value 65 64 0.7088

99. Dose-dense rituximab with CHOP-14 increases CR rates in DLBCL patients with high IPI score p = 0.037 Dose-dense R-CHOP-14 R-CHOP-14 82% 82% 78% 68% 0 20 40 60 80 100 All patients IPI 3–5 Patients in CR (%) Pfreundschuh M, et al. J Clin Oncol 2008; 26:Abstract 8508.

100. Optimal use of rituximab C H O P C H O P C H O P C H O P C H O P C H O P DENSE-R-CHOP-14 12 14 C H O P C H O P C H O P C H O P C H O P C H O P 12 14 R-CHOP-14

103. PARMA Trial : OS 53 % 32 % Philip T, et al. NEJM 1995;333:1540-5 (BEAC) (DHAP) Patients who received transplants in CR had a significantly better OS and EFS than those in PR.

104. PARMA Trial OS according to IPI at relapse IPI = 1-3 IPI = 0 Blay J. et al.Blood.1998;92(10):3562-3568 Overall survival was significantly better in the BMT group compared to the salvage chemotherapy group in patients with an IPI > 0 only.

106. CORAL : Collaborative Trial in Relapsed Aggressive Lymphoma (GELA and others) R-ICE vs R-DHAP R A N D O M I S E D ARM 1: Rituximab maintenance ARM 2: Monitoring C1 C2 C3 C1 C2 C3 S0 S3 S6 S0 S3 S6 Evaluation ARM B: R-DHAP Collect PSC ARM A: R-ICE Collect PSC S9 S9 4–6 weeks After C3 BEAM + autograft = (D0) Evaluation +M1 +M3 +M5 +M9 +M7 +M11 +M12 +M3 +M7 +M12 R A N D O M I S E D D0 D28

110. Do we need Maintenance with rituximab after autologous stem cell transplantation ?

113. Value of interim PET in DLBCL

114. .. .. .. PET-scan in DLBCL: a new tool for response assessment Value of interim PET in DLBCL Poor responder 2 cycles 2 cycles 4 cycles 4 cycles C Haioun Blood 2005; 106: 1376–81 Good responder

115. Kostakoglu et al, Cancer 107: 2678, 2006 Haioun et al, Blood 106: 1376, 2005 Mikhaeel et al, Ann Oncol 16: 1514, 2005 Spaepen et al, Ann Oncol 13: 1356, 2002 Early clinical trials of interim PET in lymphoma PET after 4th cycle PET after 3rd cycle PET after 2nd cycle PPV 50 % NPV 74 % Accuracy 68.5% PET after 1st cycle Interim-PET +

116. Cashen A et al, ASH 2009 FDG-PET/TC after cycle 2 FDG-PET/TC end of therapy These results demonstrate that in DLCBL patients treated with R-CHOP who are assessed prospectively , interim FDG-PET/CT does not predict PFS Early evaluation of 18-FDG-PET in DLBCL NPV 85% PPV 25%

117. 18-months PFS Interim PET 18-months PFS Final PET Median follow-up 18 months PFS ACCORDING TO PET RESULTS (all R-CHOP treated DBLCL; n=82) Pregno et al, ASH 2009 PET positive 61% PET negative 84% PET positive 74% PET negative 84% p.198 p. 015

118. Juweid et al. J Clin Oncol 2005 53 pts with aggressive NHL Final evaluation with CT and FDG-PET after CHOP PFS – IWC / IWC + PET Response Assessment of Aggressive NHL by Integrated International Workshop Criteria and FDG-PET

119. Revised Response Criteria for Malignant Lymphoma Cheson et al. J Clin Oncol 2007

120. Ancillary trial 18-FDG-PET in IIL-DLCL04 Staging CT scan and 18-FDG-PET R-CHOP14/R-MegaCHOP14 X 2 R-CHOP14/R-MegaCHOP14 X 2 R-MADx 2 Final restaging CT scan and 18-FDG-PET Early response evaluation 18-FDG-PET Interim response evaluation by CT scan R-CHOP14/RMegaCHOP14 18-FDG-PET pre ASCT BEAM-ASCT RESPONSE EVALUATION NO CHANGE OF TREATMENT BASED ON EARLY 18-FDG-PET RESULTS

121. Treatment of limited-stage DLBCL can be effectively tailored using a PET-based approach LH Sehn et al. 11-ICML (Lugano 2011) - Ann Oncol 2011, 22 Suppl 4:iv91 (abs 028) N=134 Majority of limited stage patients will be PET negative after 3 cycles of R-CHOP and have excellent outcome with systemic therapy alone PET positive patients who complete treatment with IFRT have a high rate of distant relapse, and alternative approaches may be necessary OS N=134