This document discusses modern treatment strategies for diffuse large B-cell lymphoma (DLBCL). It summarizes that DLBCL is molecularly distinct diseases with different biological characteristics and outcomes. Targeted therapies like ibrutinib and lenalidomide show promise for the activated B-cell (ABC) subtype of DLBCL. Monitoring circulating tumor DNA is presented as a very promising tool for early detection of treatment failure or recurrence, which can allow for pre-emptive treatment changes or early intervention.

1. Biology and Modern Treatment Strategies
Diffuse Large B-cell lymphoma(s)
Mark Roschewski, MD
Lymphoid Malignancies Branch
Center for Cancer Research
National Cancer Institute
National Institutes of Health
March 6, 2016

2. 2
Disclosures for Mark Roschewski, MD
Research support None
Employee None
Consultant None
Major stockholder None
Speakers bureau None
Scientific advisory board None
Discuss off-label use of ibrutinib and lenalidomide in diffuse large B-cell lymphoma

3. 3
Objectives
Biology of DLBCL to choose chemotherapy platform
 Goal = move beyond R-CHOP
Targeted therapy (for ABC DLBCL)
Molecular monitoring of DLBCL therapy

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Близо́к локото́к, да не уку́сишь
“So Near Yet So Far”

5. 5
Coiffier et al. Blood 2010 Sep 23;116(12):2040-5
Rituximab improves survival in (all) DLBCL
R-CHOP
CHOP
Cure rate ~60%

6. 6
Dunleavy, Roschewski, Wilson Clin Cancer Res 2014 Oct 15;20(20):5182-93

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Paradigm shifts or major disappointment?
Dunleavy, Roschewski, Wilson Clin Cancer Res 2014 Oct 15;20(20):5182-93

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DLBCL is molecularly different diseases
Roschewski, Staudt, Wilson Nat Rev Clin Oncol 2014 Jan;11(1):12-23
15-20% remain unclassifiable

9. 9
Rosenwald and Staudt. N Eng J Med 2010 362:1417-1429
Outcomes by molecular subtype with R-CHOP

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Genomic landscape of DLBCL subtypes
Pasqualucci and Dalla-Favera. Sem Hematol 2015 Apr;52(2):67-76

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GCB-DLBCL and BCL6 deregulation
Pasqualucci and Dalla-Favera Sem Hematol 2015 Apr;52(2):67-76

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Outcomes of GCB with DA-EPOCH-R
Wilson et al. Haematologica 2012 May;97(5):758-65
p=0.008 p=0.008 p=0.04

13. MYC-R
GCB ABC

14. BCL-2-R
MYC-R
High BCL-2
expression
High MYC
expression
GCB ABC
Double-hit
lymphomas

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Median f/u 14 months
DA-EPOCH-R in untreated MYC-R DLBCL
Dunleavy et al. ASH abstract #395 2014

16. 16
Dunleavy et al. N Eng J Med 2013 Apr 11;368(15):1408-16

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Dunleavy and Steidl. Sem Hematol 2015 Apr;52(2):119-25

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What is the best platform for ABC DLBCL?

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Effect of proliferation on DA-EPOCH-R in non-GCB
p=0.008 p=0.008 p=0.04
Wilson et al. Haematologica 2012 May;97(5):758-65

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Powered to detect differences within molecular subtypes
Dunleavy, Roschewski, Wilson Clin Cancer Res 2014 Oct 15;20(20):5182-93

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R-ACVBP vs. R-CHOP in non-GCB
Molina et al. J Clin Oncol 2014 Dec 10;32(35):3996-4003
Subset analysis of phase III study that compared R-ACVBP to R-CHOP
Patients with DLBCL, IPI=1 and younger than 60

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Nature of treatment resistance in ABC DLBCL?

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ABC DLBCL constitutively addicted to Nf-κB
Slide courtesy of L. Staudt

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Overlapping mechanisms of NF-ĸB in ABC-DLBCL
Davis et al. Nature 2010 Jan 7;463(7277):88-92

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Oncogenic Activation of NF-ĸB in ABC-DLBCL
Slide courtesy of L. Staudt

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Slide courtesy of L. Staudt
Inhibiting BCR signaling in ABC-DLBCL
Ibrutinib

27. Ibrutinib: A First-in-Class Inhibitor of BTK
Forms covalent bond with•
cysteine-481 in BTK
High BTK specificity•
IC• 50 = 0.5 nM
Daily oral dosing•
produces 24-hr BTK
inhibition
Blocks NF• -κB activation
in DLBCL cell lines1,2

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Ibrutinib selective for ABC DLBCL
Wilson et al. Nat Med. 2015 Aug;21(8):922-6

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R-CHOP with Ibrutinib
Younes et al. Lancet Oncol 2014 Aug;15(9):1019-26
Ibrutinib safe to add to R-CHOP at 560mg
Phase III study R-CHOP +/- ibrutinib accrued

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Immune-privileged lymphomas = ABC DLBCL
Slide courtesy of K. Dunleavy

31. Etoposide
Doxil
Temozolomide
Dexamethason
e
Rituximab
Ibrutinib
DA
T
E
D
D
I
R
Maximize CNS
Penetration of
Effective
Agents
Target BCR
Signaling

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Patient 1 pre and post ibrutinib alone
Dunleavy et al. ASH 2015 abstract #472 – ongoing study

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Clinical responses to ibrutinib alone
14 patients treated
11 evaluable
10 PR
1 SD
Dunleavy et al. ASH 2015 abstract #472 – ongoing study

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Gribben et al. J Clin Oncol 2015 Sep 1;33(25):2803-11
Lenalidomide also effective in ABC DLBCL

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R-CHOP with Lenalidomide in untreated DLBCL
R2-CHOP 2 year EFS of 59% in DLBCL
Nowakowski et al. J Clin Oncol. 2015 Jan 20;33(3):251-7

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NCI approach within DLBCL subtypes
GCB-DLBCL
 R-CHOP x 6 if stage 1 and MYC negative
 DA-EPOCH-R x 6 if > stage 1 and all patients with MYC-R
PMBL
 DA-EPOCH-R x 6 cycles (most without radiation)
ABC-DLBCL
 Consider R-ACVBP in young, IPI=1
 Consider novel agent (ibrutinib or lenalidomide) added to DA-
EPOCH-R or R-CHOP in select situations
 Results of ongoing trials will greatly inform

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Molecular monitoring of DLBCL

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Rationale for monitoring DLBCL
 Interim: early treatment failure; response-adapted strategy
 Surveillance: identify recurrence at an asymptomatic stage
 CT scans are imprecise, expensive and a potential health risk
 PET scans improve sensitivity but increase false positives

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Molecular monitoring in peripheral blood
Crowley E, et al. Nat Rev Clin Oncol. August 2013;10(8):472-84

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Applications of monitoring ctDNA
Slide courtesy of S. Peter Wu

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DNA Sequencing: Fingerprinting Cells
Immunoglobulin
receptor
Genetic immune diversity
Next-generation
sequencing
Identify and quantify
“clonotypes”
Slide courtesy of Adaptive Biotechnologies

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Immunosequencing process of ClonoSEQ™
CTGGCCCCAGTAGTCATACCAACTAGCG
TTGGCCCCAGAAATCAAGACCATCTAAA
ACGGCCCCAGAGATCGAAGTACCAGTGT
TTGGCCCCAGACGTCCATATTGTAGTAG
CTGGCCCCAGAAGTCAGACCGGCTAACA
1) Collect 10cc
peripheral
blood
2) Extract DNA 3) Amplify VDJ
with multiplex
PCR
4) Prepare for
sequencing with
common PCR
5) Sequence ~1M
100bp reads
Genomic
DNA
PCR amplicons Sequencing library Sequence dataSerum
Slide courtesy of Adaptive Biotechnologies

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Roschewski, et al. Lancet Oncol. 2015 May;16(5):541-9

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Circulating tumor DNA dynamics
Roschewski, et al. Lancet Oncol. 2015 May;16(5):541-9

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Circulating tumor DNA after 2 cycles
Roschewski, et al. Lancet Oncol. 2015 May;16(5):541-9

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Test performance as a surveillance tool
Roschewski, et al. Lancet Oncol. 2015 May;16(5):541-9

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Lead-time in surveillance prior to CT scan
Roschewski, et al. Lancet Oncol. 2015 May;16(5):541-9

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Conclusions
 Important biologic differences across DLBCL subtypes
 Molecular subtypes can help select chemotherapy platform
 Targeted therapies for ABC DLBCL promising
 Monitoring circulating tumor DNA a very promising tool

49. mark.roschewski@nih.gov
Thank you for your attention