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

2. The WHO classification of malignant lymphomas B-cell neoplasms Precursor B-LBL/ALL Peripheral B-CLL/PLL Lymphoplasmacytoid lymphoma Follicular lymphoma Marginal zone lymphoma Hairy cell leukaemia Plasmacytoma/myeloma Mantle cell lymphoma Diffuse large cell lymphoma Burkitt’s lymphoma T-cell neoplasms Precursor T-LBL/ALL Peripheral T-CLL/PLL Large granular lymphocyte leukaemia MF/Sezary Peripheral T-cell lymphoma unspecified Angioimmunoblastic T-cell lymphoma ExtranodalT-cell lymphoma, nasal type Enteropathy-type T-cell lymphoma Subcutaneous panniculitis like Gamma-delta T-cell lymphoma Adult T-cell lymphoma Anaplastic large cell lymphoma

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

5. Treatment of Diffuse Large B-Cell Lymphoma : Trying to do a better job Molecular subtypes : what do we need to know ? Natural history and clinical aspects of DLBCL First line treatment: R-CHOP and further improvements Second line treatment :the essential role of high dose therapy and auto transplant

6. Genetic Subgroups in DLBCL Diffuse large B cell lymphoma represents a heterogeneous group of lymphoid disease

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

9. DLBCL originates from different types of large B cells GCB ABC-like DLBCL PMBL The GCB DLBCLs appear to originate from normal germinal center B cells, ABC DLBCLs may arise from post-germinal center B cells that are arrested during plasmacytic differentiation. PMBLs originate from thymic 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

12. DNA microarray analysis 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 Prognostic significance of Genetic Classification in DLBCL Pre-Rituximab Germinal-center B-cell–like Type 3 Activated B-cell–like Genes

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

14. GCB DLBCL patients respond favorably to conventional treatment, while ABC DLBCL represents the least curable subtype Thus, to further improve treatment strategies, a better understanding of the biology of these malignancies is warranted. Genetic subgroups of DLBCL Rosenwald A et al. N Engl J Med . 2002;346:1937-1947.

15. Genetic subgroups of DLBCL Basic Features There are 3 genetic profile subgroups in DLBCL : Germinal-center B-cell GCB subgroup , > 50% of cases bcl2 t(14;18) Activated B-cell–like, ABC subgroup 30% of cases overexpression of genes that are upregulated in peripheral-blood B cells activated by mitogenic stimulation . Nuclear factor-kappa B (NF-kB) activation Primary Large Mediastinal B Cell (Type 3 ) DLBCL A GEP signature that significantly overlaps with Hodgkin lymphoma cell lines suggesting that the 2 diseases share biological features . NF-kB activation

16. Some important molecules of prognostic significance in DLBCL BCL-2 Nuclear factor-kappa B (NF-kB)

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

18. BCL2 over-expression BCL2 expression may also be up-regulated by alternate mechanisms, in the ABC subgroup of DLBCL, which lacks this translocation. BCL2 over-expression provides a survival advantage for malignant B cells and is thought to play a critical role in resistance to chemotherapy. As a result of its biologic functions, BCL2 overexpression should be of prognostic importance in DLBCL. Many new drugs targeting BCL2 activity are in early clinical development Javeed Iqbal, et alJ Clin Oncol 24:961-968. 2006

19. Transcription factor = induce gene activation positive mediators of T- and B-cell development, proliferation, survival 1 NF-kB triggers expression of multiple genes responsible for aggressive behaviour of the disease and treatment resistance Anti-apoptotic gene bcl-2 Vascular endothelial growth factor (VEGF) Matrix metalloproteinases (ECM degradation) IL-6 Jost and Ruland. Blood. 2007;109:2700-2707. Ghosh. Cancer Cell. 2006;10:215-226. Nuclear factor - kB (NF-kB)

20. GEP studies have demonstrated that the activation of (NF-κB) pathway is much more frequently observed in the ABC and PMBL subtype of DLBCL compared with the GCB-subtype, but the implications of NF-κB in ABC and PMBL are radically different NF-  B signature in DLBCL Compagno et al. Nature, 2009 Positive NF-kB activity by GSEA Negative NF-kB activity by GSEA The ABC DLBCL and the primary mediastinal LBCL variant rely on constitutive NF-kB signaling to block apoptosis, but the GCB subtype does not

21. Activation of NFκB has been recognized as a key feature of ABC-DLBCL pathophysiology Notably, the antiapoptotic effects of NF-kB counteract the action of cytotoxic chemotherapy Down-regulation of NF-kB effectively induces cell death in ABC-like tumor cells. Nuclear factor-kappa B (NF-kB) Can a drug specifically targeting the NF-kB pathway e.g. Bortezomib , provide a therapeutic benefit in the clinic for patients with ABC-DLBCL ? Davis RE,et al: Constitutive nuclear factor kappaB activity is required for survival of activated B cell–like diffuse large B cell lymphoma cells. J Exp Med. 2001;194:1861-1874

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 )

24. The potential role of Bortezomib In ABC DLBCL These results suggest bortezomib enhances the activity of chemotherapy in ABC but not GCB DLBCL, and provide a rational therapeutic approach based on genetically distinct DLBCL subtypes A randomized comparison of R-CHOP with and without Bortezomib in untreated patients with ABC DLBCL is under development.

25. Natural History of DLBCL Aggressive natural history More often localized at presentation than indolent lymphomas; more often extra-nodal Lymphoma cells are frozen at stages normally characterized by Rapid Replication , But the cells are non-circulating

26. SLL/CLL 70-80% Lymphoblastic 50% Follicular lymphoma 50% Hairy cell leukemia 80%* Burkitt’s 30% Blastoid Mantle 60% T-cell 30% Large cell B 15% (late stages) Positive Marrow : Frequency DLBCL vs other NHL subtypes

27. CNS Disease in Aggressive Lymphomas Risk factors for CNS disease identified from phase III study (N = 444) in elderly, untreated patients with aggressive lymphomas [1] Most significant risk factors Special sites : Testicle epidura, sinus, orbit Clinical stage IPI score Independent risk factors for CNS disease recurrence [2] Elevated LDH > 1 extranodal disease site 1. Bj örkholm M, et al. Ann Oncol. 2007;18:1085-1089. 2. Boehme V, et al. Ann Oncol. 2007;18:149-157. Risk Factor CNS Disease P Value No Yes Testis involvement No 210 15 .002 Yes 4 4 Clinical stage II 145 4 .005 III 113 6 IV 156 19 IPI score 1 114 7 .035 2 145 15 3 86 4

28. Managing CNS Disease NCCN recommends CNS prophylaxis for patients with aggressive lymphoma who have: Paraspinal tumors Testicular involvement Bone marrow involvement with large cell lymphoma Paranasal sinus involvement 1. Boehme V, et al. Ann Oncol. 2007;18:149-157. 2. NCCN clinical practice guidelines: non-Hodgkin’s lymphomas. V.1.2009. www.nccn.org. Intrathecal chemotherapy used for CNS involvement or for patients at high risk for CNS disease Methotrexate, cytarabine commonly used Complications include neurotoxicity, chemical meningitis, infection, and/or acute headache

29. Natural History of DLBCL Unlike the indolent lymphomas, which have a long natural history, DLBCL are: fatal if untreated, with survival measured in months curable with intensive combination chemotherapy in 30  60% cases associated with overall survival at 5 years of approximately 50  60%

30. Natural History of DLBCL The vast majority of relapses occur in the first 2 years after therapy. The risk of late relapse is higher in patients with a divergent histology of both indolent and aggressive disease

31. Diagnosis of DLBCL Lymph node or tissue biopsy for evaluation of: Histology (cell type, tissue architecture, pattern of lymphoid infiltration) Phenotyping of tumor cells Genotyping of tumor cells

32. DLBCL Clinical Data Age Lymphadenopathy, hepatosplenomegaly, organs Extra-nodal Sites Blood or bone marrow data Serum markers e.g. LDH, beta2 microglobulin Radiologic findings CSF

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

36. PS 2-4 LDH Elevated Stage III-IV Age-adjusted IPI Patients  60 years (age-adjusted) Age-adjusted Risk groups : L 0 LI 1 HI 2 H 3 Shipp. Blood. 1994;83:1165.

37. Sehn et al. Blood. 2007;109:1857 Retrospective analysis of an unselected DLBCL patient (N= 365) All patients were treated with R-CHOP: 45% were high risk (IPI 3-5) >45% high risk patients relapsed within 4 yr IPI score retains its prognostic value in the Rituximab era Rituximab era : REVISED IPI

38. Treatment of Diffuse Large B-Cell Lymphoma: Trying to do a better job First line : What if Rituximab is not available? How can we improve over R-CHOP 21 Role of high dose therapy and auto transplant

39. What if Rituximab is not available? Trying to improve over the classic standard CHOP Treatment of DLBCL

40. Pre-Rituximab Era Strategies to improve results over CHOP for Aggressive Lymphomas Strategy Examples Add standard doses CHOEP (German) of new drugs Increase dose density ACVBP (GELA) CHOP 14 (German) Myeloablative therapy Early in therapy (various) and SCT Late in therapy (various)

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.

50. GELA LNH 98.5 study: Design DLBCL Age 60–80 years No prior treatment PS 0–2 Stage II–IV R A N D O M I Z A T I O N CHOP q3wk x 8 Rituximab + CHOP q3wk x 8 Coiffier B, et al. N Engl J Med 2002; 346:235. Rituximab: 375 mg/m 2 on day 1 Cyclophosphamide: 750 mg/m 2 on day 1 Doxorubicin: 50 mg/m 2 on day 1 Vincristine: 1.4 mg/m 2 (up to 2 mg/m 2 ) on day 1 Prednisolone: 40 mg/m 2 /d days 1–5 197 patients 202 patients

51. 10-year follow-up of the LNH98.5 study PFS Bertrand Coiffier et al , ASH ,2009 Outcome after progression is poor with a 5-year survival of 25% and 15% in the R-CHOP and CHOP arm, respectively. The number of secondary cancers is nearly identical 21 (R-CHOP) and 22 (CHOP) OS=43.5% vs. 28% for patients treated with R-CHOP and CHOP, respectively.

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

55. Do we need Rituximab for patients with low-risk diffuse large B-cell lymphoma MInT : DLBCL 18–60 years, IPI 0,1 Gela : DLBCL18–65 years aaIPI = 0

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

61. Study design Untreated, localised, low-risk DLBCL 18–65 years aaIPI = 0 N = 358 R A N D O M I S E 3 x ACVBP + 4 x rituximab 3 x ACVBP 2 x MTX 4 x ifosfamide-vepaside 2 x Ara-C CR, PR Consolidation 18 weeks Induction 8 weeks ACVBP: Doxorubicin: 75 mg/m 2 Day 1 Cyclophosphamide: 1,200 mg/m 2 Day 1 Vindesine: 2 mg/m 2 Days 1 and 5 Bleomycin: 10 mg Days 1 and 5 Prednisone: 60 mg/m 2 Days 1–5 MTX = methotrexate Ara-C = cytosine arabinoside 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 –

63. DLBCL: Rituximab is needed to improve survival No matter how intensive the chemo No matter how early the disease No matter how favorable the IPI

64. Give more dense chemo: R-CHOP21 verus R-CHOP14 1 - UK NCRI Lymphoma Study ALL PATIENTS 2 - Gela Study 60–80 years aaIPI  1 Give more R How to improve survival over R-CHOP21 ?

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

66. Trial design: R-CHOP14 vs. 21 Newly diagnosed CD20+ve DLBCL R-CHOP21 CHOP21  8 cycles Rituximab  8 cycles R-CHOP14 CHOP14  6 cycles Rituximab  8 cycles Lenograstim Day 4-12 n=540 n=540 Stratified by IPI (0-1, 2, 3, 4-5) Age ≤60 vs. >60 Treatment centre 1080 patients; 119 sites Recruitment March 2005 - Nov 2008 R

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

68. Failure-free survival R-CHOP14 533 438 355 224 102 25 1 Patients at Risk R-CHOP21 534 429 358 216 116 25 1 Years from randomisation R-CHOP21 R-CHOP14 Probability 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0 1 2 3 4 5 6 0.99 (0.79–1.24) HR (95% CI) p=0.94 Log-rank test 75% 75% 2-yr FFS 153 (28) 155 (29) Events, n (%) R-CHOP14 R-CHOP21

69. Overall survival Patients at Risk R-CHOP21 R-CHOP14 540 474 392 234 120 28 1 540 476 393 242 117 30 1 R-CHOP21 R-CHOP14 Probability 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Years from randomisation 0 1 2 3 4 5 6 0.95 (0.74–1.23) HR (95% CI) p=0.70 Log-rank test 83% 81% 2-yr OS 117 (22) 123 (23) Events, n (%) R-CHOP14 R-CHOP21

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 %

71. In patients receiving Rituximab, CHOP14 for 6 cycles is not superior to CHOP21 for 8 cycles No obvious sub group appears to derive a greater benefit from R-CHOP14, including age > 60, high IPI, or non-GC phenotype As expected a higher frequency of neutropenia was observed in R-CHOP21 which reflects the primary prophylaxis with G-CSF in R-CHOP14 Conclusions

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

73. Untreated DLBCL 60–80 years aaIPI  1 N = 602 R A N D O M I S E 8 x R-CHOP q21 days 8 x R-CHOP q14 days G-CSF prophylaxis at physician discretion Delarue R, et al . ICML 2011; Abstract 106. Primary endpoint: EFS Expected improvement: 10% at 3 years with R-CHOP 14 (55 to 65%) 600 patients required (over 4 years) GELA study LNH 03-6B 61-80 years, aaIPI = 1,2,3

74. Median age was 72 years G-CSF was administered in 89% of cycles in the R-CHOP-14 arm Grade 3–4 haematological toxicity was similar between treatment arms R-CHOP-14 vs R-CHOP-21: Treatment Outcome Delarue R, et al . ICML 2011; Abstract 106. R-CHOP-14 (n = 304) R-CHOP-21 (n = 296) p -value CR/CRu 72 75 0.42 3-year EFS 57 60 0.81 3-year PFS 60 62 0.89 3-year overall survival 70 73 0.89

75. R-CHOP14 versus R-CHOP21 Lessons from the UK and French Studies These 2 studies do not support the assumption that R-CHOP-14 is more effective than R-CHOP-21 in patients with DLBCL Out side clinical trials :6-8 cycles of R-CHOP21 remains standard first-line treatment for the majority of DLBCL Still the question is : How can we improve over R-CHOP-21 ?

76. Still the question is : How can we improve over R-CHOP-21 ? Try it the French way !!!

77. Randomized Study of ACVBP Plus Rituximab Versus R-CHOP Plus in Non-Previously-Treated Patients Aged from 18 to 59 Years with CD20+ Diffuse Large B-Cell Lymphoma and an Age-Adjusted IPI of 1 Final analysis of a phase III clinical trial from the GELA study group (LNH 03-2B trial) GELA study group (LNH 03-2B trial) youg population and an Age-Adjusted IPI of 1 Récher V, et al. Blood . 2010;116: Abstract 109.

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:

79. LNH03-2B trial conducted by the Groupe d’Etude des Lymphomes de l’Adulte (GELA) At a mean follow-up of 44 months, no significant difference in response rates was observed between the arms. The rate of complete remission including cases of unconfirmed CR, was 82.7% for the R-ACVBP arm compared with 80.3% for the R-CHOP group. HOWEVER !!!! Christian Recher, et al ASH,2010

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

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

82. The R-ACVBP arm was significantly more toxic Serious adverse events The R-ACVBP arm 42% The R-CHOP arm 15% Patients taking R-ACVBP were more likely to develop grade 3/4 hematologic events and grade 3 mucositis. The GELA investigators did not evaluate quality of life, but suspected patients taking the experimental treatment would have had poorer quality of life due to the worse adverse-events profile associated with the regimen. Good news but the price may be high !!! Christian Recher, et al ASH,2010

83. Is it vendesine or is it the sequential consolidation or the dose dense/intense? Despite a higher hematologic toxicity, intensified R-ACVBP significantly improved: – EFS (+14%) – PFS (+14%) – DFS (+11%) – OS (+8%) As compared to standard R-CHOP R-ACVBP should be the standard of care for younger patients with DLBCL Récher V, et al. Blood . 2010;116: Abstract 109. ACVB plus sequential consolidation seems to provide a real Advantage compared to CHOP with or without R !!

84. A more real challenge!! Young patients With unfavorable characteristics with 2-3 factors of aaIPI Go ahead and transplant early

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

86. Schema Register CHOP/CHOP-R x 5 PR or CR <PR Randomize Off Protocol therapy CHOP/CHOP-R x 1 CHOP/CHOP-R x 3 + Auto transplant Patients were permitted to have 1 cycle of CHOP(R) prior to protocol registration Transplant regimens: SWOG TBI (12 Gy/8 Fx) or BCNU (150 mg/m 2 x 3d) + VP16 (60 mg/kg) + Cyclophosphamide (100 mg/kg)

87. Results: Grade III –IV Toxicities of Randomized Patients Toxicities CHOP (R) x 1 + ASCT (%) CHOP (R) x 3 (%) Infection GI Metabolic Lung CV Neurologic Dyspnea Hyperglycemia Hypoxia Hepatic 50 26 13 11 10 7 7 6 4 3 13 5 1 2 4 2 2 0 0 0

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)

91. Conclusions Patients with high-intermediate and High Risk diffuse aggressive NHL have a superior 2 year PFS of 69% if they receive an ASCT in first PR/CR after CHOP(R) as compared to the 56% PFS seen with standard conventional therapy alone with CHOP(R). Exploratory analyses indicated that the majority of the ASCT benefit occurred in the High IPI group for which transplant had both a PFS and OS advantage.

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

93. R-(Mega)CHOP-14 with or without HDT/ASCT: Study design Untreated DLBCL, FL grade 3b or PMBCL 18–65 years aaIPI 2–3 N = 417 R A N D O M I S E R-MegaCHOP-14: rituximab 375 mg/m 2 Day 1 cyclophosphamide 1,200 mg/m 2 Day 1 doxorubicin 70 mg/m 2 Day 1 prednisone 100 mg Days 1–5 G-CSF Day 2 R E S T A G E CR, PR Vitolo U, et al . ICML 2011; Abstract 072. R-CHOP-14 x 4 R-MegaCHOP-14 x 4 R-MegaCHOP-14 x 4 R-CHOP-14 x 4 HDT/ASCT R-MegaCHOP-14 x 2 HDT/ASCT R-CHOP-14 x 4

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

95. R-(Mega)CHOP-14 with or without HDT/ASCT: Conclusions Addition of HDT/ASCT to R-CHOP-14 or R-Mega-CHOP-14 significantly reduced the risk of progression in young patients with high-risk DLBCL R-MegaCHOP-14 offered no advantage over standard R-CHOP-14 Vitolo U, et al . ICML 2011; Abstract 072. More chemo is not essentially better

96. Going more aggressive beyond R-CHOP Do we need more Rituximab ?

97. Dose-dense rituximab with CHOP-14 improves rituximab plasma levels in DLBCL patients Pfreundschuh M, et al. J Clin Oncol 2008; 26:Abstract 8508. 200 150 125 75 50 25 0 100 175 0 20 40 60 80 100 120 R-CHOP-14 (8 x rituximab) Plasma rituximab (ng/ml) Time (days) Rituximab infusion Dose-dense R-CHOP-14 (12 x rituximab) allows for a constantly high serum level of rituximab as early as the 1 st week of treatment Dose-dense R-CHOP-14 (12 x rituximab)

98. Improved outcome of elderly patients with poor-prognosis diffuse large B-cell lymphoma (DLBCL) after dose-dense rituximab: Results of the DENSE-R-CHOP-14 trial of the German High-Grade Non-Hodgkin Lymphoma Study Group (DSHNHL). 100 elderly pat. with aggressive CD20+ B-cell lymphoma received 6 cycles of biweekly CHOP-14 combined with 12x R (375 mg/m2) on days 0,1,4,8,15,22,29,43,57,71,85, and 99. Radiotherapy was planned to sites of initial bulk and/or extranodal involvement 306 pat. treated within the RICOVER-60 trial with 6xCHOP-14 and 8 applications of R served as control. Prophylaxis with levofloxacin, acyclovir and cotrimoxazol Pfreundschuh M, et al. J Clin Oncol 2008; 26:Abstract 8508.

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

101. Treatment of relapsing DLBCL Pre -Rituximab era: The PARMA Trial Post -Rituximab era :The CORAL Trial

102. The PARMA Trial 109 relapsed patients in CR or PR after 4 courses of DHAP salvage therapy (DHAP) were randomized to either continue chemotherapy (DHAPx2) or autologous SCT (BEAC). Randomized trial comparing salvage chemotherapy with ASCT in chemo-sensitive relapse NHL .

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.

105. Relapse After CHOP : Do we have a better regimen ? Is it R-ICE or R-DHAP?

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

107. CORAL Trial The overall response rates (63.5% vs 62.8%), 3-year PFS (31% vs 42%), and 3-year OS (47% vs 51%) for R-ICE and R-DHAP were not statistically different, suggesting that either regimen can be used for salvage therapy. Gisselbrecht C, Glass B, Mounier N, et al. Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. Jul 26 2010.

108. CORAL Trial : Factors affecting 3-year OS 1) age-adjusted IPI at relapse : 2 to 3 versus 0 (32% vs 62%), 2) relapse <12 months after completion of first-line therapy (39% vs 64%), 3) prior rituximab exposure in the front-line setting (40% vs 66%). Gisselbrecht C, Glass B, Mounier N, et al. Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. Jul 26 2010.

109. CORAL study: Important alarm Given that nearly all patients with DLBCL currently receive front-line rituximab, these data call into question our current strategies for salvage therapy, particularly for patients who relapse within one year of initial therapy. Gisselbrecht C, Glass B, Mounier N, et al. Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. Jul 26 2010.

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

111. CORAL Maintenance: EFS according to treatment arm Median follow-up: 44 months post-second randomisation Survival probability EFS (months) p = 0.7435 Observation n = 120 Rituximab n = 122 Gisselbrecht C.et al ASCO 2011 ABS # 8004 Same results for patients in CR/CRu or PR after induction treatment or according to type of chemotherapy (R-ICE or R-DHAP) No difference in 3 year overall survival: 66% rituximab vs 69% observation The main prognostic factor after ASCT is secondary IPI 0.0 0.2 0.4 0.6 0.8 1.0 0 12 24 36 48 60 72

112. Role of PET

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