Significant strides have been made in the treatment of follicular lymphoma, leading to improvements in long-term patient outcomes. However, the disease's heterogeneity presents challenges in selecting the optimal therapy at each stage of treatment. The expanding array of therapeutic options introduces new complexities, including making the right initial choice, sequencing treatments effectively, and redefining treatment goals. As the landscape evolves, there is a growing need to shift toward precision-based treatment decisions, potentially guided by underlying disease biology. Here, we explore recent advancements in both upfront and relapsed/refractory treatment strategies, addressing considerations in therapy selection, and the current progress toward precision approaches with its potential to enhance decision-making.

Despite the clinical and molecular heterogeneity of follicular lymphoma (FL), there remains a lack of biomarker-directed therapeutic approaches in routine clinical practice, with the notable exception of the EZH2 inhibitor tazemetostat in EZH2-mutant FL. Here we examined whether gene mutation status predicts response to clinical mTOR inhibitors (mTORi) in FL, by performing targeted mutational profiling of biopsies from 21 relapsed/refractory FL patients treated with mTORi everolimus or temsirolimus within clinical trials. We observed an enrichment of mutations within the catalytic histone acetyltransferase (HAT) domain of CREBBP in mTORi-responders, and describe distinct transcriptional characteristics and co-occurring mutations of FL harbouring these mutations; reinforcing the growing appreciation of CREBBPHAT mutation as a key biological determinant and its promise as a therapeutic biomarker in FL.

Despite the effectiveness of immuno-chemotherapy, 40% of patients with diffuse large B-cell lymphoma (DLBCL) experience relapse or refractory disease. Longitudinal studies have previously focused on the mutational landscape of relapse but fell short of providing a consistent relapse-specific genetic signature. In our study, we have focused attention on the changes in GEP accompanying DLBCL relapse using archival paired diagnostic/relapse specimens from 38 de novo patients with DLBCL. COO remained stable from diagnosis to relapse in 80% of patients, with only a single patient showing COO switching from activated B-cell-like (ABC) to germinal center B-cell-like (GCB). Analysis of the transcriptomic changes that occur following relapse suggest ABC and GCB relapses are mediated via different mechanisms. We developed a 30-gene discriminator for ABC-DLBCLs derived from relapse-associated genes that defined clinically distinct high-and low-risk subgroups in ABC- DLBCLs at diagnosis in datasets comprising both population-based and clinical trial cohorts. This signature also identified a population of <60-year-old patients with superior PFS and OS treated with ibrutinib-R-CHOP as part of the PHOENIX trial. Altogether this new signature adds to the existing toolkit of putative genetic predictors now available in DLBCL that can be readily assessed as part of prospective clinical trials.

Introduction: Transformation of follicular lymphoma (FL) from an indolent to aggressive high-grade diffuse large B-cell lymphoma (tFL) is associated with poor outcomes compared to that of patients that do not transform, and is a leading cause of FL-related mortality. We and others have previously reported the evolution of the genetic landscape from FL to aggressive tFL from bulk DNA-sequencing. However, a detailed understanding of the biological determinants of this high-risk phenotype to identify both lymphoma-intrinsic and -extrinsic vulnerabilities are lacking, but are needed to inform rational therapeutic approaches. Methods: To characterize the co-evolution of both the lymphoma and its tumor microenvironment (TME), we enriched specific populations by flow sorting lymph node cell suspensions to provide a higher cellular resolution of 3 distinct populations: malignant B-cells, T-cells and other CD45+ immune cells. Our cohort comprised 3 FL patients with no transformation (ntFL) and 4 patients with transformation (paired pre-transformed (pFL) and later tFL samples). Within these populations we simultaneously interrogated: single cell transcriptomic, B-cell receptor (BCR) and T-cell receptor (TCR) analyses (10X Genomics) on approximately 5000 cells/population and parallel bulk DNA and RNA-sequencing. We compared our observations to single cell transcriptomic data from reactive lymph nodes (RLNs), pediatric tonsils and additional validation cohorts of tFLs and de novo DLBCLs. Results: We profiled >110,000 cells from our discovery cohort (malignant B-cells >50,000 and TME cells >60,000 cells). Combined analyses of somatic copy number alterations (CNAs) derived by InferCNV and BCR clonotypes indicated that these genetic alterations were not the dominant drivers of transcriptional heterogeneity, in either indolent FL or aggressive tFL. Instead, by using non-negative matrix factorization (NMF) to probe the common lymphoma-specific metaprograms (MPs), we found malignant B-cells were composed of a broader spectrum of cellular states beyond the classical germinal center (GC) cell-of-origin, ranging from naïve-, GC- to memory-like states. Strikingly, specific lymphoma MPs mapped with a high degree of semblance to signatures identified within RLN and tonsils, suggesting that part of the normal B-cell transcriptional architecture is preserved in both FL and tFL. We identified fluctuations in the B-cell states and programs across ntFLs and paired pFL-tFLs, for example an increase in interferon-memory and plasma-like states and a decrease in MHC class I expression in tFL malignant B-cells indicating that the balance of these states contribute to shaping the different clinical phenotypes. Integrated analyses of the TME revealed substantial heterogeneity in the tumor-infiltrating T-cell (CD4, CD8), natural killer (NK) and myeloid subpopulations. We observed higher tumor-infiltrating CD4+ cells in patients without transformation (ntFL) compared to higher proportions of CD8+ sub-populations accompanying transformation (paired pFL-tFL). Many T-follicular helper (Tfh) populations including activated (CD69, TNFRSF4, TNFRSF18) were mostly enriched in ntFL and pFL but significantly reduced in tFL. In contrast, there was a progressive shift towards dysfunctional CD8+ populations in those with transformation. Using a computed 12-gene exhaustion score to quantify this activity in CD8+ populations, we demonstrated a gradient from effector to exhausted clusters, with the most marked enrichment in the tFL state (ntFL vs tFL; p <2.2x10-16), and a degree of exhaustion already pre-existing in the pFL. We identified significantly expanded TCR clonotypes at transformation, many of which were not detected prior to transformation. Notably, many of these unique clonotypes resided within the CD8+ exhausted populations. Similarly, there was a divergence in NK cell states between non-transformed (cytotoxic NK) and transformed FL patients (inflamed and exhausted). Overall, the immune axis differs in non-transformed patients and becomes progressively dysfunctional from pFL to tFL. Conclusions: In summary, we present detailed single cell multi-omic analyses providing novel insights into the co-evolutionary B-cell and TME dynamics of FL towards transformation, with distinct composition and states in non-transformed, pre- and transformed FL patients.

Follicular lymphoma (FL) represents a heterogeneous disease both clinically and biologically. The pathognomonic t(14;18) translocation can no longer be thought of as the primary genetic driver, with increasing recognition of the biological relevance of recurrent genetic alterations in epigenetic regulators that now feature as a pivotal hallmark of this lymphoma subtype. Furthermore, sequencing studies have provided a near complete catalogue of additional genetic aberrations. Longitudinal and spatial genetic studies add an additional layer to the biological heterogeneity, providing preliminary molecular insights into high-risk phenotypes such as early progressors and transformation, and also supporting evidence for the existence of persisting re-populating cells that act as lymphoma reservoirs and harbingers for FL recurrence. Simultaneously, understanding of the tumour microenvironmental cues promoting lymphomagenesis and disease progression continue to broaden. More recently, studies are beginning to unravel the convergence and co-operation between the genetics, epigenetics and microenvironment. There is a pressing need to marry biology with therapeutics, especially with the burgeoning treatment landscape in FL, to aid in optimising patient selection and guiding the 'right drug to the right patient'.

Loss-of-function mutations in KMT2D are a striking feature of the germinal centre (GC) lymphomas, resulting in decreased H3K4 methylation and altered gene expression. We hypothesised that inhibition of the KDM5 family, which demethylates H3K4me3/me2, would re-establish H3K4 methylation and restore the expression of genes repressed upon loss of KMT2D . KDM5-inhibition increased H3K4me3 levels and caused an anti-proliferative response in vitro , which was markedly greater in both endogenous and CRISPR-edited KMT2D mutant DLBCL cell lines, whilst tumour growth was inhibited in KMT2D mutant xenografts in vivo . KDM5-inhibition reactivated both KMT2D-dependent and -independent genes, resulting in diminished B-cell receptor signalling and altered expression of BCL2 family members, including BCL2 itself, allowing it to synergise with agents targeting these pathways. KDM5-inhibition may offer an effective therapeutic strategy for ameliorating KMT2D loss-of-function mutations in GC-lymphomas. Statement of significance We detail a novel way of reverting the effects of loss-of-function mutations in the histone methyltransferase KMT2D by inhibiting the KDM5 demethylase family, increasing levels of H3K4me3 and restoring expression of KMT2D regulated genes.

Haematology patients receiving chemo- or immunotherapy are considered to be at greater risk of COVID-19-related morbidity and mortality. We aimed to identify risk factors for COVID-19 severity and assess outcomes in patients where COVID-19 complicated the treatment of their haematological disorder. A retrospective cohort study was conducted in 55 patients with haematological disorders and COVID-19, including 52 with malignancy, two with bone marrow failure and one immune-mediated thrombotic thrombocytopenic purpura (TTP). COVID-19 diagnosis coincided with a new diagnosis of a haematological malignancy in four patients. Among patients, 82% were on systemic anti-cancer therapy (SACT) at the time of COVID-19 diagnosis. Of hospitalised patients, 37% (19/51) died while all four outpatients recovered. Risk factors for severe disease or mortality were similar to those in other published cohorts. Raised C-reactive protein at diagnosis predicted an aggressive clinical course. The majority of patients recovered from COVID-19, despite receiving recent SACT. This suggests that SACT, where urgent, should be administered despite intercurrent COVID-19 infection, which should be managed according to standard pathways. Delay or modification of therapy should be considered on an individual basis. Long-term follow-up studies in larger patient cohorts are required to assess the efficacy of treatment strategies employed during the pandemic.

Histologic transformation of follicular lymphoma remains the leading cause of follicular lymphoma-related mortality in the rituximab era. Both the diverse timing of transformation and heterogeneity in associated genomic events suggest that histologic transformation may itself comprise distinct disease entities. Successive indolent and transformation episodes occur by divergent clonal evolution from an inferred common progenitor cell, representing a potential therapeutic target. Existing biological knowledge largely pre-dates anti-CD20 therapy, and further prospective validation is essential. Inclusion of transformation cases in clinical trials incorporating biomarker discovery, and an integrated understanding of the genetic and microenvironmental factors underpinning transformation, may unearth renewed clinical opportunities.

Introduction: Although diffuse large B cell lymphoma (DLBCL) can be cured using immuno-chemotherapy, 40% of patients experience relapse or refractory disease. Large-scale profiling studies have mainly focused on DLBCL at diagnosis with a limited number of longitudinal studies and no compelling biomarkers linked to relapse identified. To address this, we utilized a multifaceted approach integrating transcriptomic and intratumoral T-cell repertoire analyses in paired diagnostic/relapse tumors to enable identification of signaling pathways and microenvironmental changes underlying disease relapse. Methods: We retrospectively collected archival paired diagnostic/relapse tumor biopsies from 38 de novo DLBCL patients (stage I-IV, 38-89 years old) treated with rituximab-based immuno-chemotherapy. We performed gene expression profiling (GEP) and T-cell repertoire analysis using the Ion AmpliSeq Transcriptome Kit and TCR-β sequencing (immunoSEQ), respectively. Cell-of-origin (COO) classification was performed by the Lymph2Cx assay on NanoString to distinguish activated B-cell-like (ABC) and germinal center B-cell-like (GCB) subtypes. Results: COO remained stable from diagnosis to relapse in >90% of pairs. In examples where we observed a switch in COO between diagnosis/relapse, targeted-seq analysis revealed some shared mutations suggesting that relapse tumors originated from a common ancestral clone. Our global GEP of 17 ABC-ABC and 11 GCB-GCB pairs identified 163 and 136 genes that were differentially expressed in ABC and GCB relapse tumors relative to their matched diagnostic biopsies respectively, with minimal overlap. Gene set enrichment analysis showed that ABC and GCB relapses are potentially mediated via different mechanisms, with tumor growth and proliferation signatures enriched in ABC relapse, compared with adaptive immunity-related signatures accompanying GCB progression. In parallel, we assessed the dynamics of the T-cell repertoire in paired biopsies observing a reduction in T-cell fraction upon relapse that was most pronounced in ABC pairs and was positively correlated with changes in CD8+ T cells. Furthermore, we noted a decrease in T-cell clonal diversity that was independent of COO at relapse with evidence for significant T-cell specific clonal expansion. Conclusions: The nature of the biological mechanisms responsible for DLBCL relapse has remained fairly elusive that may be inherent to the diagnostic tumor or acquired/enriched at disease relapse. Gene expression profiling of a series of DLBCL tumor pairs, resolved changes in gene expression that support distinct mechanisms of lymphoma relapse, based on a patient's COO, that parallel changes in the overall T-cell composition of the tumor microenvironment. Keywords: diffuse large B-cell lymphoma (DLBCL); gene expression profile (GEP); T-cells. Disclosures: Korfi, K: Consultant Advisory Role: Roche. Rule, S: Consultant Advisory Role: Celgene, Sunesis, Astrazeneca, Napp, Pharmacyclics, TG Therapeutics, Kite, Gilead, Roche, Janssen; Honoraria: Celgene, Sunesis, Astrazeneca, Pharmacyclics, TG Therapeutics, Gilead, Roche, Janssen; Research Funding: Roche, Janssen; Other Remuneration: Roche, Janssen. Davies, A: Consultant Advisory Role: Roche, Kite, Celgene, Acerta Pharma, MorphoSys, BioInvent; Honoraria: Roche, Celgene, Kite, Janssen; Research Funding: Roche, Acerta Pharma, Celgene, Gilead, Karyopharm, GSK; Other Remuneration: Roche, Celgene. Gribben, J: Honoraria: Janssen, Acerta, Celgene; Research Funding: Janssen, Acerta, Celgene. Johnson, P: Consultant Advisory Role: Janssen; Honoraria: Bristol-Myers Squibb, Takeda, Novartis, Celgene, Janssen, Epizyme, Boeringher Ingelheim, Kite, Genmab, Incyte; Research Funding: Janssen, Epizyme. Fitzgibbon, J: Consultant Advisory Role: Epizyme; Honoraria: Gilead; Research Funding: Epizyme.

Background:With an expanding array of novel treatment options in follicular lymphoma (FL), we largely lack effective biomarkers to predict response in this molecularly heterogeneous disease. Activating mutations focused on components of the nutrient‐sensing arm of the mTORC1 pathway (RRAGC, ATP6V1B2, ATP6AP1), are particularly enriched in FL, occurring in ∼30% of cases. Meanwhile, clinical mTOR inhibitors (mTORi) have shown some promise, with response rates of 50–60% in relapsed/refractory FL.Aims:We therefore sought to determine whether gene mutation status ‐ particularly in genes regulating the mTOR pathway – may represent biomarkers of mTORi‐response in FL.Methods:We retrospectively analyzed pre‐treatment tumor samples from relapsed/refractory FL patients treated on two phase II clinical trials with single agent mTOR inhibitors, everolimus (NCT00436618) or temsirolimus (NCT00290472), with well characterized clinical outcomes. In total, 21 patients had available biopsies, consisting of 15 everolimus‐ and 6 temsirolimus‐treated cases.Tumor DNA extracted from formalin fixed paraffin embedded (FFPE) tissue was subjected to targeted sequencing using a 22 gene panel comprising genes recurrently mutated in FL, and PI3K/AKT/mTOR pathway genes mutated in germinal center lymphomas. Libraries were prepared using capture‐based target enrichment (Nonacus), and sequenced on the NextSeq550 (Illumina) with a mean coverage depth of x700. A stringent bioinformatic pipeline was adopted with variants called with VarScan2, and a 10% variant allele frequency (VAF) threshold was employed to filter out sequencing artefacts due to the FFPE material. 100% (15/15) of a selection of variants were validated by Sanger sequencing. Staining for pS6 was undertaken on tissue slides to examine downstream mTOR activation by immunohistochemistry.Results:Overall response rate (CR and PR) was 48% (10/21). Mutational analysis showed no significant association between clinical response and mTORC1‐pathway mutations (mut) taken individually or collectively; although, absolute numbers of mutations in these genes were low, including RRAGC (responder: 0/10 mut vs non‐responder: 1/11 mut), ATP6AP1 (responder: 1/10 vs non‐responder: 1/11), and ATP6V1B2 (responder: 1/10 vs non‐responder 3/11). Notably, no difference in pS6 staining was seen between responders and non‐responders.However, we found mutations in the epigenetic regulator CREBBP to be enriched in the responder group (100% (10/10) responders vs 54.5% (6/11) non‐responders, p = 0.04). This effect was more pronounced when considering only mutations within the catalytic histone acetyltransferase (HAT) domain of CREBBP, with HAT mutations seen in 100% (10/10) responders, and 27.3% (3/11) non‐responders (p = 0.001).Summary/Conclusion:Mutations in the mTOR pathway did not predict for response to mTOR inhibition in our study. The enrichment of CREBBP mutations in responders, and particularly those affecting the catalytic HAT domain, points to CREBBP as a potential biomarker of response which warrants validation in trials of drugs modulating the PI3K/AKT/mTOR axis. More broadly our data may lend support to a distinct clinical and biological behavior of CREBBP HAT domain‐mutant disease that also warrants further evaluation. Taken together, our findings highlight the potential opportunities afforded by undertaking correlative studies, and underlines the need to incorporate prospective biomarker discovery into clinical trials in order to help focus future therapeutic strategies more rationally.

Next Generation Sequencing (NGS) has dramatically improved the flexibility and outcomes of cancer research and clinical trials, providing highly sensitive and accurate high-throughput platforms for large-scale genomic testing. In contrast to whole-genome (WGS) or whole-exome sequencing (WES), targeted genomic sequencing (TS) focuses on a panel of genes or targets known to have strong associations with pathogenesis of disease and/or clinical relevance, offering greater sequencing depth with reduced costs and data burden. This allows targeted sequencing to identify low frequency variants in targeted regions with high confidence, thus suitable for profiling low-quality and fragmented clinical DNA samples. As a result, TS has been widely used in clinical research and trials for patient stratification and the development of targeted therapeutics. However, its transition to routine clinical use has been slow. Many technical and analytical obstacles still remain and need to be discussed and addressed before large-scale and cross-centre implementation. Gold-standard and state-of-the-art procedures and pipelines are urgently needed to accelerate this transition. In this review we first present how TS is conducted in cancer research, including various target enrichment platforms, the construction of target panels, and selected research and clinical studies utilising TS to profile clinical samples. We then present a generalised analytical workflow for TS data discussing important parameters and filters in detail, aiming to provide the best practices of TS usage and analyses.

Take home messages The genetic landscape of follicular lymphoma (FL) is skewed toward frequent mutations in epigenetic regulators. Divergent clonal evolution from a therapy-evading common progenitor cell is proposed as the predominant mechanism underpinning relapse and transformation. Genomic studies are revealing new disease biomarkers and therapeutic targets, with the promise of achieving a precision medicine approach for subsets of FL patients.

Background: Although diffuse large B cell lymphoma (DLBCL) can be cured using immuno-chemotherapy, 40% of patients experience relapse or refractory disease. Large-scale profiling studies have mainly focused on DLBCL at diagnosis, resolving different outcome groups based on gene expression (e.g. cell-of-origin (COO) or molecular high grade), MYC/BCL2 translocations (double-hit lymphoma) or gene mutations and copy number aberrations (Schmitz et al, NEJM 2018; Chapuy et al, NatureMedicine 2018). In comparison, longitudinal studies have been hindered by the limited availability of sequential biopsy samples. To date, the relapse-specific gene mutations identified are limited and inconsistent across studies. In our study, we have focussed attention on the changes in gene expression profile (GEP) accompanying DLBCL relapse. Methods: We retrospectively collected archival paired diagnostic/relapse formalin fixed paraffin embedded tumor biopsies from 38 de novo DLBCL patients collected from multiple UK sites treated with rituximab-based immuno-chemotherapy, where partial or complete remission was reported following treatment. COO classification was performed by the Lymph2Cx assay on NanoString to distinguish activated B-cell-like (ABC) and germinal center B-cell-like (GCB) subtypes. The Ion AmpliSeq™ Transcriptome Human Gene Expression Kit was used to measure the expression levels of > 20,000 genes on the paired samples. Results: COO remained stable from diagnosis to relapse in 17 ABC-ABC pairs, 11 GCB-GCB pairs and 4 unclassified (UNC)-UNC pairs. Frank COO switching was observed in 6 cases (1 ABC-GCB, 2 ABC-UNC, 2 GCB-UNC, 1 UNC-ABC). Pairs with stable COO were taken forward for further analysis. Gene expression analysis using the limma R package identified 163 and 136 genes as differentially expressed (DE) (p <= 0.01 and absolute log2FC > 1) between the diagnostic and relapse biopsies in ABC and GCB tumors respectively, with only a one gene overlap. Gene Set Enrichment Analysis further suggested that ABC and GCB relapses are mediated via different mechanisms, with tumor growth and proliferation signatures enriched in ABC relapses, whilst adaptive immunity-related signatures accompanied GCB relapses. Next, we aimed to utilise our relapse-specific genes to identify outcome predictors at diagnosis using publicly available GEP datasets. In order to increase our discovery power and accuracy, a larger set of DE genes from the paired differential analysis (796 genes in ABC pairs and 387 from GCB pairs) were selected (p <= 0.05) and subsequently used in a training cohort (GEP from Reddy et al, Cell 2017). The Prediction Analysis for Microarrays R (PAMR) algorithm identified a 30-gene signature within DE genes from ABC pairs (Fig1.A), capable of separating the 249 ABC cases into 136 low and 113 high-risk cases with significantly inferior overall survival (Hazard Ratio (HR)=1.89, log-rank p=0.0017, measure of goodness-of-fit C-index=0.71; Fig1.B). No equivalent signature was found in the GCB cases using this approach. The prognostic significance of this 30-gene discriminator was successfully validated using a linear predictor in two independent GEP datasets: 1) a population-based cohort (Lenz et al, NEJM 2008) with 93 R-CHOP-treated ABC cases identifying 47 low and 46 high-risk cases (HR=1.92, p=0.046, C-index=0.77; Fig1.C) and 2) a clinical trial dataset (REMoDL-B, Davies et al, Lancet Oncol 2019) with 255 ABC cases identifying 110 low and 145 high-risk ABC cases (HR=1.95, p=0.0051, C-index=0.70; Fig1.D). Conclusions: Here we describe a 30-gene discriminator in ABC-DLBCL, derived from genes differentially expressed between diagnosis and relapse, that allowed the definition of clinically distinct high and low risk subgroups in ABC-DLBCLs at diagnosis. The clinical translation of such a tool may be useful to guide therapy for this unfavourable subgroup of ABC-DLBCLs. Validation of this signature is currently underway in additional datasets and further study is required to understand the contribution of these genes in DLBCL pathology. Disclosures Korfi: Roche: Consultancy. Burton:Celgene: Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees. Rule:TG Therapeutics: Consultancy, Honoraria; Napp: Consultancy; Kite: Consultancy; Pharmacyclics: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Sunesis: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria, Research Funding; Astra-Zeneca: Consultancy, Honoraria; Celgene: Consultancy, Honoraria. Crosbie:Janssen: Honoraria. Scott:Celgene: Consultancy; Janssen: Consultancy, Research Funding; NanoString: Patents & Royalties: Named inventor on a patent licensed to NanoSting [Institution], Research Funding; Roche/Genentech: Research Funding. Rimsza:NanoSting: Patents & Royalties: Named inventor on a patent licensed to NanoSting [Institution]. Davies:Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Research Funding; Bayer: Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Honoraria, Research Funding; Karyopharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Research Funding; Acerta Pharma: Honoraria, Research Funding; ADCT Therapeutics: Honoraria, Research Funding; BioInvent: Research Funding; Kite Pharma: Membership on an entity's Board of Directors or advisory committees; MorphoSys AG: Honoraria, Membership on an entity's Board of Directors or advisory committees. Gribben:Abbvie: Consultancy, Honoraria, Research Funding; Acerta/Astra Zeneca: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding. Okosun:Gilead Sciences: Honoraria, Research Funding. Johnson:Epizyme: Honoraria, Research Funding; Novartis: Honoraria; Kite: Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria; Boehringer Ingelheim: Honoraria; Takeda: Honoraria; Genmab: Honoraria; Celgene: Honoraria; Incyte: Honoraria. Fitzgibbon:Epizyme: Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Speakers Bureau.

Purpose of review The treatment of the germinal center lymphomas, diffuse large B cell (DLBCL) and follicular lymphoma, has changed little beyond the introduction of immunochemotherapies. However, there exists a substantial group of patients within both diseases for which improvements in care will involve appropriate tailoring of treatment. Recent findings DLBCL consists of two major subtypes with striking differences in their clinical outcomes paralleling their underlying genetic heterogeneity. Recent studies have seen advances in the stratification of germinal center lymphomas, through comprehensive profiling of 1001 DLBCLs alongside refinements in the identification of high-risk follicular lymphoma patients using m7-FLIPI and 23G models. A new wave of novel therapeutic agents is now undergoing clinical trials for germinal center lymphomas, with BCR and EZH2 inhibitors demonstrating preferential benefit in subgroups of patients. The emergence of cell-free DNA has raised the possibility of dynamic disease monitoring to potentially mitigate the complexity of spatial and temporal heterogeneity, whilst predicting tumor evolution in real time. Summary Altogether knowledge of the genomic landscape of germinal center lymphomas is offering welcome opportunities in patient risk stratification and therapeutics. The challenge ahead is to establish how best to combine upfront or dynamic prognostication with precision therapies, while retaining practicality in clinical trials and the real-world setting.

Background. The pathogenesis and natural history of HIV-associated immune complex kidney disease (HIVICK) is not well understood. Key questions remain unanswered, including the role of HIV infection and replication in disease development and the efficacy of antiretroviral therapy (ART) in the prevention and treatment of disease.Methods. In this multicentre study, we describe the renal pathology of HIVICK and compare the clinical characteristics of patients with HIVICK with those with IgA nephropathy and HIV-associated nephropathy (HIVAN). Poisson regression models were used to identify risk factors for each of these pathologies.Results. Between 1998 and 2012, 65 patients were diagnosed with HIVICK, 27 with IgA nephropathy and 70 with HIVAN. Black ethnicity and HIV RNA were associated with HIVICK, receipt of ART with IgA nephropathy and black ethnicity and CD4 cell count with HIVAN. HIVICK was associated with lower rates of progression to end-stage kidney disease compared with HIVAN and IgA nephropathy (P < 0.0001). Patients with HIVICK who initiated ART and achieved suppression of HIV RNA experienced improvements in estimated glomerular filtration rate and proteinuria.Conclusions. These findings suggest a pathogenic role for HIV replication in the development of HIVICK and that ART may improve kidney function in patients who have detectable HIV RNA at the time of HIVICK diagnosis. Our data also suggest that IgA nephropathy should be viewed as a separate entity and not included in the HIVICK spectrum.

OBJECTIVES:To describe the spectrum of renal tubular disease (RTD) in HIV-positive patients and its association with exposure to antiretroviral therapy (ART). DESIGN:Review of 265 consecutive renal biopsies from HIV-positive patients attending eight clinics in the United Kingdom between 2000 and 2012. METHODS:We described the clinical characteristics of patients with RTD and compared current/recent exposure (at the time of, or up to 3 months prior to the date of biopsy) to potentially nephrotoxic ART [tenofovir (TDF), atazanavir (ATV), indinavir (IDV) and lopinavir/ritonavir (LPV/r)]. We also analysed the incidence of RTD in the UK CHIC cohort. Kruskall-Wallis, analysis of variance and Fisher's exact tests were used to evaluate between-group differences. RESULTS:Of the 60 RTD cases, 54 (90%) were included in the analyses. RTD comprised of three distinct patterns: acute tubular injury (ATI, n = 22), tubulo-interstitial nephritis (TIN, n = 20) and interstitial fibrosis and tubular atrophy (IFTA, n = 12). Compared with TIN and IFTA, ATI cases were less likely to be of black ethnicity (10 vs. 42-55%; P = 0.006), more likely to be on ART (100 vs. 55-68%; P = 0.001), with HIV-RNA below 200 copies/ml (100 vs. 54-58%; P < 0.001), and more likely to have current/recent exposure to TDF (P < 0.001). We did not find evidence for an association between exposure to TDF, ATV/r or LPV/r and either TIN or IFTA. CONCLUSION:RTD was present in approximately 20% of renal biopsies and comprised three distinct injury patterns with considerable clinical overlap. ATI was associated with TDF exposure, although the overall incidence of biopsy-defined ATI was low.

BACKGROUND:Insertion of percutaneous hemodialysis catheters is an invasive procedure with a small but definite risk of morbidity and mortality. OBJECTIVES:Assessing potential benefits of using real-time 2-dimensional Doppler ultrasound imaging guidance for the insertion of hemodialysis catheters compared with insertion based solely on anatomic landmarks. STUDY DESIGN:Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES:MEDLINE (1966 to July 2010), EMBASE (1980 to July 2010), Cochrane Renal Group Specialised Register, and Cochrane Central Register of Controlled Trials (CENTRAL). SETTING & POPULATION:Patients requiring hemodialysis catheter insertion. SELECTION CRITERIA FOR STUDIES:We included all randomized controlled trials regardless of publication status or language. INTERVENTIONS:Real-time 2-dimensional Doppler ultrasound image guidance. OUTCOMES:Catheter placement failures, catheters failed to be placed in the first attempt, attempts per catheter inserted, time taken for successful venous puncture, and complications (carotid artery puncture, pneumo- or hemothorax, neck hematoma, and brachial plexus injury). Treatment effects were summarized with the RR measure for dichotomous outcomes and mean difference for continuous outcomes. RESULTS:7 trials with 830 catheters were identified. Ultrasound guidance significantly decreased the risk of the following outcomes: catheter placement failure (7 studies, 830 catheters; RR, 0.12; 95% CI, 0.04-0.37), failure to place catheter on first attempt (5 studies, 595 catheters; RR, 0.40; 95% CI, 0.29-0.56), arterial punctures (6 trials, 785 catheters; RR, 0.22; 95% CI, 0.06-0.81), and hematoma formation (4 trials, 323 catheters; RR, 0.27; 95% CI, 0.08-0.88). It also significantly decreased the time to cannulate the vein (1 trial, 73 catheters; mean difference, -1.40; 95% CI, -2.17 to -0.63), and number of attempts per catheter insertion (1 trial, 110 catheters; mean difference, -0.35; 95% CI, -0.54 to -0.16). LIMITATIONS:Only 7 studies were identified, of which 3 were reported in only a conference abstract form. Some outcomes were reported in only 1 study. CONCLUSIONS:Use of real-time Doppler ultrasound guidance has benefits with respect to several important clinical outcomes, and its routine use in the insertion of hemodialysis catheters is strongly recommended.

BACKGROUNDA significant proportion of patients starting dialysis do so with a temporary or tunnelled haemodialysis catheter. Insertion of these catheters can be achieved either by using the anatomical landmarks for the veins into which they are inserted or using ultrasound guidance. It has been suggested that the use of ultrasound guidance reduces the immediate complications of haemodialysis catheter insertions such as pneumothorax or arterial puncture.OBJECTIVESThe aim of the review was to compare the use of real-time 2-dimensional (2-D) Doppler ultrasound venous imaging in the insertion of percutaneous central venous catheters for dialysis versus the traditional "blind" landmark method.SEARCH METHODSWe searched the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL). Reference lists of identified studies and relevant narrative reviews were also screened. Search date: January 2011.SELECTION CRITERIAAll randomised controlled trials (RCTs) and quasi-RCTs evaluating ultrasound guidance in the percutaneous insertion of central venous catheters for dialysis (both cuffed and uncuffed) against the traditional blind landmark method.DATA COLLECTION AND ANALYSISTwo authors assessed risk of bias and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI).MAIN RESULTSWe identified seven studies enrolling 767 patients and with 830 catheter insertions. Three of seven studies described the method of random sequence generation, none described allocation concealment, and blinding of participants and personnel was not possible. Real-time ultrasound guidance was found to significantly reduce the risk of catheter placement failure on the first attempt (5 studies, 595 catheters): RR 0.40, 95% CI 0.30 to 0.52), significantly reduce the risk of arterial puncture (6 studies, 535 catheters: RR 0.13, 95% CI 0.04 to 0.37) and haematomas (4 studies, 323 catheters: RR 0.22, 95% CI 0.06 to 0.81) when compared to the landmark method. The time taken for successful cannulation was significantly lower with the use of real-time ultrasound guidance (1 study, 73 catheters: MD -1.40 min, 95% CI -2.17 to -0.63) and there were less attempts/catheter insertion (1 study, 110 catheters: -0.35, 95% CI -0.54 to -0.16).AUTHORS' CONCLUSIONSUse of real-time 2-D Doppler ultrasound guidance has significant benefits with respect to the number if catheters successfully inserted on the first attempt, reduction in the risk of arterial puncture and haematomas and the time taken for successful vein puncture.