7054 Background: ALK+ Lymphomas are aggressive diseases with poor prognosis when chemoimmunotherapy (CIT) and Crizotinib fail. Lorlatinib is a 3rd-generation tyrosine kinase inhibitor (TKI), that inhibits all reported ALK kinase domain mutations responsible for resistance to Crizotinib. Methods: From 2019 to 2024, we enrolled 8 patients (pts) in a phase 2 open label monocentric study with Lorlatinib in relapse/refractory (r/r) ALK+ lymphomas previously treated with other TKI (EudraCT2016-003970-41). Overall response rate (ORR), the primary endpoint, was evaluated using 18F-FDG PET/CT scans and ALK RT-PCR on peripheral blood and bone marrow samples. Secondary endpoints were progression-free survival (PFS) and overall survival (OS) from the start of Lorlatinib to relapse and/or death. Side effects were classified according to CTCAEv4.03. Our cohort included 4 ALK+ Large B Cell Lymphoma (LBCL) with Clathrin-ALK (CLTC::ALK) rearrangement, 2 ALK+ Anaplastic Large Cell Lymphoma (ALCL) with ATIC::ALK fusion, 1 ALK+ ALCL Lymphoma with NPM::ALK translocation and 1 ALK+ histiocytosis with EML4::ALK rearrangement. Results: The median follow-up (fup) was 23 months (1,3- 62), the median age at diagnosis was 23 years (19-57); all pts were in stage IV Ann Arbor and treated with CIT and Crizotinib. 2 pts also received other TKIs (Alectinib and Ceritinib). Lorlatinib was administered daily at a dose of 100 mg. The ORR at one month (M1) was 100% (95% CI: 72-100%): 5 CR and 3 PR. 3 pts (2 ALCL [ATIC::ALK], 1 ALCL [NPM::ALK]), underwent Allogeneic Stem Cell Transplant (ASCT) while in CR and resumed Lorlatinib post-transplant. Due to hepatic GVHD and memory impairment, their Lorlatinib dosage was reduced from 100 mg to 75-50 mg/day. All of them are in CR. 2 pts (LBCL with CLTC::ALK) refused ASCT, maintained CR from M1 through their last fup at 15 and 65 months respectively, continuing with Lorlatinib at 100 mg/day. 2 ALK+ LBCL pts (CLTC::ALK) achieved PR at M1 but relapsed within 3 months and did not benefit from ASCT or salvage treatments. The pt with ALK+ histiocytosis was in PR at M1 and then obtained CR at M3 with Lorlatinib; surgical resection of a residual necrotic lung mass was performed. She has been in CR for >40 months. PFS rate at 3 months was 75%, with no additional events reported. OS was 87% at 3 and 12 months, and 72% at 24 months and stabilized thereafter. All ALK+ lymphoma pts in CR at M1 maintained a durable response, whereas those in PR died of disease progression. The type of lymphoma or of ALK translocation did not correlate with outcome. Main adverse effects (all grade I/II) included hyperlipidaemia, weight gain, muscle cramps, gastrointestinal symptoms, thrombocytopenia and memory difficulty. Conclusions: Our analysis confirms Lorlatinib's efficacy and safety as salvage therapy. Achieving a CR at M1 was found to be the most important prognostic factor for survival. Adverse events are manageable with dose adjustments. Clinical trial information: EudraCT2016-003970-41 .

Anaplastic lymphoma kinase positive (ALK+) anaplastic large cell lymphoma (ALCL) typically affects young individuals and, despite high responsiveness to cytotoxic drugs, relapses occur in over 50% of patients. Crizotinib has improved outcomes, but its management in patients desiring parenthood remains an issue. This study presents the first description of four successful pregnancies during crizotinib treatment for ALK+ALCL: a female patient achieving two pregnancies through assisted reproductive technologies (ART), temporarily discontinuing crizotinib and maintaining a complete remission (CR), and a male patient conceiving naturally while on continuous therapy. These cases demonstrate crizotinib potential to support conception without compromising disease control, even in the absence of specific guidelines on treatment discontinuation.

Lymphomatoid granulomatosis (LYG) is a rare Epstein-Barr virus (EBV)-driven lymphoproliferative disease that usually arises in the context of reduced immunological surveillance. Based on histology, two forms of the disease are recognized, namely low-grade and high-grade LYG. Clinically, LYG universally involves the lungs and, frequently, also the skin, central nervous system, liver, and kidneys. Here, we present the case of a 55-year-old woman with a difficult-to-diagnose low-grade LYG with symptomatic lung involvement, who concomitantly was newly diagnosed with human immunodeficiency virus (HIV) infection. Rapid immune recovery achieved through antiretroviral therapy led to a complete and sustained clinical and radiological remission of LYG.

The SARS-CoV2 pandemic has posed unprecedented challenges between temporary or permanent discontinuation of immunosuppressive treatment to protect patients, or disease control prioritization by not interrupting treatment. Maintenance treatment with anti-CD20 monoclonal antibodies (MoAbs) improves progression-free survival (PFS) in follicular lymphoma (FL), but also impairs anti-SARS-CoV2 immune response. This challenge has been addressed in Italy by temporary, definitive or no discontinuation of anti-CD20 treatment. We report the outcome of 539 FL patients receiving anti-CD20 MoAbs (rituximab in 431, obinutuzumab in 108), which were temporarily discontinued in 150 patients (group A), definitively discontinued in 166 (group B), or uninterrupted in 223 (group C). In the overall cohort, the 3-year progression-free survival (3y PFS) and 3-year overall survival (3y OS) rates were 80% and 88%. PFS and OS were significantly better in group A compared to group B and C (p = 0.01). Induction chemoimmunotherapy significantly influenced OS: the 3y OS was 91% vs 85% in CHOP vs bendamustine treated patients (p = 0.04), while the 3y OS was 90% vs 77% in rituximab vs obinutuzumab treated patients (p = 0.002). SARS-Cov2 infection was the main cause of death (67% of cases). Vaccination with multiple doses demonstrated to be clinically helpful, with impact on OS.

Patients with mantle cell lymphoma (MCL) who experience first relapse/refractoriness can be categorized into early or late progression-of-disease (POD) groups, with a threshold of 24 months from the initial MCL diagnosis. Bruton tyrosine kinase inhibitors (BTKi) are established standard treatment at first relapse, but their effectiveness as compared to chemoimmunotherapy (CIT) in late-POD patients remains unknown. In this international, observational cohort study, we evaluated outcomes amongst patients at first, late-POD beyond 24 months. Patients treated upfront with BTKi were excluded. The primary objective was progression-free survival from time of second-line therapy (PFS-2) of BTKi versus CIT. After accrual, all patients were prospectively followed-up. Overall, 385 late-POD patients were included from 10 countries. Their median age was 59 (range:19-70) years and 77% were males. Median follow-up from time of first relapse was 53 months (range:12-144). Overall, 114 patients had second-line BTKi, while 271 had CIT, consisting of rituximab-bendamustine (R-B, n=101), R-B and cytarabine (R-BAC, n=70), or other regimens (mostly cyclophosphamide-hydroxydaunorubicin-vincristine-prednisone-CHOP- or platinum-based, n=100). The two groups were balanced for clinicopathological features, and median time to first relapse (48 months for both). Overall, BTKi was associated with significantly prolonged median PFS-2 than CIT [not reached-NR vs 26 months, respectively, P=.0003], and overall survival [NR and 56 months, respectively, P=.03]. Multivariate analyses showed that BTKi was associated with lower risk of death than R-B and other regimens (hazard ratio-HR, 0.41 for R-B, 0.46 for others), but similar to R-BAC. These results may establish BTKi as the preferable second-line approach in BTKi-naïve MCL patients.

Introduction ALK+ Anaplastic Large Cell Lymphoma (ALCL) and ALK+ Large B Cell Lymphoma (LBCL) are aggressive T- and B-cell lymphomas with a poor prognosis when chemo-immunotherapy (CIT) and salvage treatment with Crizotinib fail. Preclinical trials have shown that Lorlatinib, a next-generation selective ALK and ROS1 TKI, inhibits all reported ALK kinase domain mutations responsible for resistance to Crizotinib. Preliminary results of Lorlatinib monotherapy have demonstrated high response rates and no additional toxicities for ALK+ lymphoma patients (pts) who failed first-line TKI treatment. It also offers a promising bridging regimen to salvage Allogeneic Stem Cell Transplantation (ASCT). Methods We present a 5-year update of the phase 2 open-label monocentric study with Lorlatinib monotherapy (EudraCT2016-003970-41). We evaluate the primary endpoint: overall response rate (ORR) using 18F-FDG PET/CT scans and ALK RT-PCR. Secondary endpoints are progression-free survival (PFS), and overall survival (OS) from the start of Lorlatinib treatment to relapse and/or death. Additionally, we assess toxicity and quality of life (QoL). From 2019 to 2024, we enrolled 7 pts with relapsed/refractory ALK+ neoplasms who had failed chemo-immunotherapy and salvage treatment with Crizotinib. Four pts had ALK+ LBCL with Clathrin-ALK (CTCL::ALK) rearrangement (#1, 2, 3, 7), and two patients (#5 and #6) had ALK+ ALCL with ATIC::ALK fusion. One pt (#4) with ALK+ histiocytosis and EML4::ALK rearrangement was also included. The median age was 23 years (range 19-57), 3 women and 4 men, and all patients were caucasian and in stage IV Ann Arbor. The median number of prior therapy lines was 3 (range 2-5); all pts had previously received Crizotinib after failing CIT, 2 pts received other TKI treatment with Alectinib and 1 pt with Ceritinib. Lorlatinib was administered daily at a dose of 100 mg. Clinical, laboratory, radiological, and molecular data were collected at screening and during scheduled follow-ups. Responses were evaluated with 18F-FDG PET/CT (and contrast-enhanced CT scans) according to the Lugano Classification, and with ALK RT-PCR on peripheral blood and bone marrow. Side effects were classified according to CTCAEv4.03. Results The median follow-up is 19,3 months (1,3- 56 months). At month 1 (M1), 4 out of 7 patients achieved complete response (CR) and reached negativity by ALK RT-PCR. The remaining 3 patients obtained a partial response (PR), resulting in an overall response rate (ORR) of 100% (95% CI: 0.6-1.0) at M1. Two pts with CR at M1 are still receiving Lorlatinib 100 mg daily without need to dose decrease and are still in CR at months 7 and 56. Two CR pts at M1 underwent ASCT, then resumed Lorlatinib after ASCT. Lorlatinib dose reduction (from 100 mg to 75 mg or 50 mg/day) was due to transplant complications (hepatic GVHD and memory dysfunction) in which a role of Lorlatinib could not be excluded. Both pts are still in CR. The 2 pts with PR relapsed within 3 months (both had ALK+ LBCL with CTCL-ALK rearrangement) and did not benefit from ASCT or salvage therapy. The patient with ALK+ histiocytosis achieved PR at M1 and then CR at M3 with Lorlatinib and surgical resection of a residual lung mass. She remains in CR also after 36 months. The median PFS and OS were not reached. The PFS at 3 month was 71%, which then, with no additional event occurring thereafter. The OS was 85% at 3 months, and 57% at 6 months, maintaining this level during subsequent follow-ups. Hypertriglyceridemia /hypercholesterolemia and muscle cramps grade I-II were the most frequent events. Two pts reported difficulty concentrating during daily activities and occasional mental confusion. Additionally, two pts reported chronic gastrointestinal disorders such as bloating or abdominal pain. Two pts experienced grade 1 thrombocytopenia. Conclusions The 5-year update confirms the efficacy and safety of Lorlatinib monotherapy as salvage therapy for ALK+ lymphoma patients who have failed first-line TKI treatment. Additionally, our work confirms that obtaining CR at M1 remains the most important prognostic factor for the durability of response. No relapse was noted after the initial 90 days of treatment.

Data on the efficacy of high-dose chemotherapy and autologous stem cell transplantation (ASCT) for classical Hodgkin lymphoma (cHL) patients who failed a PET-driven first-line therapy are limited.We retrospectively evaluated 220 adult cHL patients who underwent ASCT from 2009 to 2021 at 11 centers in Italy. Overall, 49.5% had refractory disease, 23.2% relapsed < 12 and 27.3% ≥12 months from the end of first-line chemotherapy. The 3-year progression-free survival (PFS) and overall survival (OS) were 73.8% and 89.4%. In univariable analysis for PFS events PET-2+ (HR 2.69, p = .001), anemia (HR 2.22, p = .019), refractory disease (HR 1.76, p = .045), less than CR before ASCT (HR 3.24, p < .001) and >2 lines of salvage therapy (HR 2.52; p = .004) were associated with a higher risk of failure after ASCT. In multivariable analysis, >2 lines of salvage therapy (HR 3.28, p = .004) and RT before ASCT (HR 3.00, p = 0.041) retained significance.ASCT is an effective salvage approach for cHL patients treated in the era of PET-adapted therapies.

Anaplastic large cell lymphoma (ALK+ALCL) is most frequently observed in young adults and it usually defined by the t(2; 5)(p23;q35) chromosome translocation. The advent of crizotinib has represented a turning point in relapsed-refractory disease, allowing responses in > 2/3 of cases. However, clinical unmet needs remain, such as managing therapy in patients desiring parenthood. Here we provide the first description of four cases of successful pregnancies during crizotinib treatment for ALK+ lymphomas. Patient 1, diagnosed with ALK+ALCL at 30, achieved complete response (CR) with VACOP-B. At 38, she relapsed with nodal and hepatic involvement, confirmed by positive t(2;5)/NPM1-ALK signal via RT-PCR on peripheral blood (PB). She attained a second CR with Brentuximab vedotin, followed by autologous stem cell transplant (ASCT). However, B symptoms and adenopathies reappeared at day +47 post ASCT. Crizotinib was initiated, resulting in metabolic and molecular CR after two months. After two years of treatment, at 41, the patient experienced iatrogenic menopause post-ASCT and desired motherhood through assisted reproductive technology. Prior ovarian stimulation and oocyte cryopreservation were done. In vitro fertilization (IVF) was performed, and crizotinib was stopped two weeks before embryo transfer (ET). A first-trimester scan confirmed a single gestational sac. Screening for Down syndrome (combined test and NIPT) was negative, but preeclampsia screening indicated heightened risk, leading to low-dose aspirin administration. Ultrasounds showed regular fetal growth. The pregnancy was uneventful except for a mild SARS-CoV-2 infection. Monthly NPM1-ALK RT-PCR remained negative. At 39 weeks, after spontaneous membrane rupture, labor was induced, resulting in the vaginal delivery of a healthy male newborn (3300 grams, 44th percentile on the INeS chart, Apgar scores 9 and 9 at 1 and 5 minutes). Postpartum was uncomplicated, and the patient chose not to breastfeed. Crizotinib was resumed two weeks later. The child, now 2, is healthy with normal development. After 20 months of stable molecular response, the patient, at 43, sought a second pregnancy with two cryopreserved blastocysts. Crizotinib was interrupted again. The first ET failed, but the second, attempted four weeks later, succeeded. Cardiac activity was detected in a single gestational sac at five weeks. The pregnancy, now at 16 weeks, is proceeding normally with minimal decidual detachment, and low-dose aspirin was started as in the previous pregnancy. Patient 2, a 25-year-old male with ALK+ALCL, was treated with CHOEP, achieving metabolic CR but remaining t(2;5) positive on PB. Crizotinib was started, gaining molecular response within a month without any adverse events. Despite our recommendation to use barrier contraception, he conceived a child after four years of continuous therapy and stable remission, with no crizotinib interruption. At 34, he fathered a second child. Both daughters, born at 3430 and 3500 grams, had normal, complication-free pregnancies. They are now 7 and 2 years old and in good health. Crizotinib is a specific, non-mutagenic drug, though ALK is selectively expressed in the central nervous system, and the MET gene, another target of crizotinib, can cause Non-Syndromic Autosomal Recessive Deafness if mutated. Therefore, we advised the first patient to stop crizotinib during pregnancy, whereas the second patient continued it while conceiving two daughters. Literature includes reports of women on crizotinib for ALK+ lung adenocarcinoma during pregnancy, but treatments often started either during or after pregnancy. There are no reports of men conceiving while on crizotinib. Notably, patient 1, who stopped crizotinib after 40 months, showed no lymphoma regrowth during a 10-month treatment break. A new crizotinib discontinuation is underway. Patient 2's case suggests crizotinib may not affect spermiogenesis. These cases do not pretend to provide definitive answers regarding the discontinuation of crizotinib or the safety of pregnancy during treatment; prospective studies and pharmacodynamic investigations will be required to fully address these questions. Our aim is to signal the feasibility of conceiving during crizotinib treatment considering not only the control of the underlying disease, but also the importance of quality of life and the patient's needs, including the desire for parenthood.

This is a retrospective, multicentric study, aimed to describe the real-life application of fertility preservation methods during treatment in female lymphoma patients, aged 18-40 years old, diagnosed between Oct 1st/2010 and May 31st/2018. Among 414 women included, median age was 28 years old, histologies were: HL 74%, PMBCL 13%, DLBCL 10%, others 3%. First line treatments were: ABVD in 295 (71%), R-CHOP like in 102 (25%), higher intensity regimens in 17 (4%) cases. Fertility preservation strategies were: GnRHa in 315 (78%), Oral Contraceptive in 41 (10%), oocytes and ovarian tissue cryopreservation in 55 and 42 patients, respectively. After therapy, we observed a restored regular period in 293 (70%) and premature ovarian failure (POF) in 33 (8%), Furthermore we recorded 43 pregnancies, all spontaneous with 5 years median follow-up. Median age at diagnosis and number of lines of treatment correlate with higher rate of amenorrhea, risk of POF and menopause (p < 0.001).

Background: Anaplastic lymphoma kinase (ALK) plays a role in the development of lymphoma, lung cancer and neuroblastoma. While tyrosine kinase inhibitors (TKIs) have improved treatment outcomes, relapse remains a challenge due to on-target mutations and off-target resistance mechanisms. ALK-positive (ALK+) tumors can evade the immune system, partly through tumor-associated macrophages (TAMs) that facilitate immune escape. Cancer cells use “don’t eat me” signals (DEMs), such as CD47, to resist TAMs-mediated phagocytosis. TKIs may upregulate pro-phagocytic stimuli (i.e., calreticulin, CALR), suggesting a potential therapeutic benefit in combining TKIs with an anti-CD47 monoclonal antibody (mAb). However, the impact of this combination on both TKIs-sensitive and resistant ALK+ tumors requires further investigation. Methods: A panel of TKIs-sensitive and resistant ALK+ cancer subtypes was assessed for CALR and CD47 expression over time using flow cytometry. Flow cytometry co-culture and fluorescent microscopy assays were employed to evaluate phagocytosis under various treatment conditions. Results: ALK inhibitors increased CALR expression in both TKIs-sensitive and off-target resistant ALK+ cancer cells. Prolonged TKIs exposure also led to CD47 upregulation. The combination of ALK inhibitors and anti-CD47 mAb significantly enhanced phagocytosis compared to anti-CD47 alone, as confirmed by flow cytometry and fluorescent microscopy. Conclusions: Anti-CD47 mAb can quench DEMs while exposing pro-phagocytic signals, promoting tumor cell phagocytosis. ALK inhibitors induced immunogenic cell damage by upregulating CALR in both sensitive and off-target resistant tumors. Continuous TKIs exposure in off-target resistant settings also resulted in the upregulation of CD47 over time. Combining TKIs with a CD47 blockade may offer therapeutic benefits in ALK+ cancers, especially in overcoming off-target resistance where TKIs alone are less effective.

Introduction: Both aggressive T and B cell lymphoma may harbour Anaplastic Lymphoma Kinase (ALK) translocations: ALK+ Anaplastic Large Cell lymphoma (ALCL) offer a good outcome with first line therapy with 5-year survival of 79%, but relapses occur in half of the patients (pts) and salvage therapy still represents a challenge for clinicians; ALK+ large B cell lymphoma (LBCL) are very rare cases but with dismal prognosis. In addition other hematologic neoplasms can be caused by ALK fusions. Crizotinib, an ALK/MET tyrosine kinase inhibitor (TKI), provides long-term response in up to 70% relapsed/refractory (R/R) ALK+ ALCL and can obtain a similar but less durable response rates in ALK+ LBCL. In both cases the loss of response to crizotinib is frequently a fatal event. Lorlatinib, a selective ALK and ROS1 TKI, demonstrated preclinical inhibition of all reported ALK kinase domain mutations responsible for resistance to Crizotinib. Methods: From 2019 to 2022 six relapsed/refractory ALK + neoplasm pts previously treated with at least one ALK-inhibitor were enrolled in a phase 2 open label monocentric study with lorlatinib monotherapy (EudraCT2016-003970-41): Three patients had diagnosis of ALK+ LBCL (# 1, 2, 3) and 2 (#5 and #6) had ALK+ ALCL. One patient (#4) with an ALK+ histiocytosis was also included. Median age was 22 years (range 19-57), Ratio M/F was 1, all pts were in stage IV. Median prior therapy lines was 3 (range 2-5); all pts previously received Crizotinib, two pts received also Alectinib and 1 Ceritinib as TKI treatment. Lorlatinib was administered daily at dose of 100 mg. Clinical, laboratory, radiological and molecular data were collected at screening and during scheduled follow-up. Response was evaluated with 18F-FDG PET/CT (and with contrast enhanced (ce) CT scan) according Lugano Classification, and with ALK RT-PCR on peripheral blood and bone marrow. Side effects were classified according to CTCAEv4.03. PFS and OS were determined from Lorlatinib start to relapse and/or death. The primary endpoint was the evaluation of ORR considering 18F-FDG PET/CT scan and ALK- RT-PCR. Secondary endpoints were: PFS, OS, toxicity, QoL. Results: ALK rearrangement fusion pattern was detected in 6/6 pts: 3 pts with LBCL harboured Clathrin-ALK (CTCL::ALK) rearrangement and 2 ALCL pts the ATIC::ALK fusion; the ALK+ histiocytosis patient harbored an EML4::ALK rearrangement. Median follow-up was 13.7 months (IQR 22-55). At month +1 (M1) 3/6 patients had complete response (CR) defined as complete metabolic and complete radiologic response (CMR/CR) according to PET/CT scans and ALK RT-PCR negativity. The remaining 3 pts had a partial response (PR), for an Overall Response Rate (ORR) of 100% (95%CI: 0.6-1.0). One pt is still on treatment and in CR at 45 months, receiving Lorlatinib 100 mg daily with neither toxicities nor need for Allogenic Stem Cell Transplantation (ASCT); 2 CR pts underwent ASCT after 1 month, resumed lorlatinib after ASCT and are still in CR. 2 pts with PR relapsed within month +3: one pt received salvage therapy without benefit, the other one underwent ASCT but progressed 3 months later. Both pts had ALK+ BCL with CTCL-ALK rearrangement. 1 pts in PR AT M1 (ALK+ istiocytosis) obtain CR at M3 after surgical resection of a residual lung mass and is still receiving Lorlatinib at month 36. Median PFS and OS were not reached: PFS at 6 and 12 months is 83% and 62% respectively; OS at 6 and 12 months is 83% and 55%. Safety: 2/6 pts had thrombocytopenia grade 1, whereas 3/6 pts showed grade I-II hypertriglyceridemia/hypercholesterolemia and muscle cramps. Conclusions: Lorlatinib represents a safe and effective salvage therapy for ALK+ Lymphoma patients failing first line TKI treatment. The obtainment of CR at M1 seems to represent a pivotal prognostic factor. Lorlatinib also offers a promising bridging regimen to salvage ASCT especially for ALK+ BCL patients, with high response rates and no additional toxicities, .

Background: Interim PET (PET-2), performed after two cycles of chemotherapy (CT), is widely adopted to select patients (pt) with classical Hodgkin lymphoma (cHL), who might benefit from omitting radiotherapy (RT) or reducing the number of CT cycles in early stages, as well as intensifying or de-escalating first-line therapy in advanced stages. Furthermore, PET-2 has prognostic value in the front-line and in the salvage treatment. In a retrospective multicenter Italian study on patients experiencing failure of first-line treatment, we recently observed that PET-2 seems to be an early unfavorable predictor for subsequent salvage high-dose (HD) CT and autologous stem cell transplant (ASCT). Aims of Study and Methods: To evaluate the impact of the prognostic factor PET-2, we performed a retrospective observational multicenter study on individual data of 184 pt with relapsed or refractory (R/R) cHL after first-line CT given according to a PET-adapted strategy. R/R pt were treated at 11 Italian centers with one or more lines of salvage CT followed by HD-CT and ASCT from 2009 to 2021. We compared characteristics and outcomes of 125 PET-2 negative with those of 59 PET-2 positive (PET-2+) R/R pt. Study endpoints included Progression-free survival (PFS) (defined as the time from the date of ASCT to progression or death after ASCT, whichever occurred first), Overall Survival (OS) (defined as the time from the date of ASCT to death from any cause or the last date for which information was available), and factors associated with ASCT outcome evaluated by univariate and multivariate analysis. Results Main pt characteristics at relapse or progression among 125 PET-2 negative and 59 PET-2+ pt were as follows: median age 34 vs 32 years, M/F 64/61 vs 28/31, refractory disease 38% vs 76%, early relapse (within 12 months from end of first-line CT) 27% vs 19%, late relapse 35% vs 5%, stage III or IV 43% vs 44%, B symptoms 24% vs 27%, extranodal involvement 26% vs 24% bulky disease 12% each, anemia 9% vs 22%, ECOG PS >1 11% vs 8%. First salvage treatment regimen was BeGEV in 34% vs 14%, IGEV in 34% each, Brentuximab Vedotin +/- Bendamustine in 6% vs 24%, DHAP or DHAOX in 17% vs 24% and other regimens in 10% vs 5% of pt, respectively. Before ASCT, 95 (76%) in the PET-2 negative and 32 (54%) in the PET-2+ group achieved a complete metabolic remission (mCR). After a median follow-up of 36 months, the 3-year PFS and OS were 73.8% (95% CI: 66.2-80.0%) and 89.3% (95% CI: 83.0-93.3%), respectively. Figure 1 shows PFS by PET-2 status. A total of 99 patients underwent ASCT after one line of salvage therapy. At 3 years PFS and OS in patients who underwent ASCT after one line of salvage therapy were 80.6% (95% CI: 68.9-88.3) and 92.2% (95% CI: 82.2-96.7) in the PET-2 negative group, and 56.2% (95% CI: 33.6-73.7) and 90.9% (95% CI: 68.1-97.6) in the PET-2+ group. Thirty-six patients required two and 14 more than two lines of salvage therapy in the PET-2 negative group; the same figures in the PET-2+ group were 21 and 14. There was no significant difference in PFS or OS by type of salvage therapy received in the two groups. In univariate analysis PET-2+ during frontline treatment (HR 2.68, P=0.001), anemia (HR 2.18, P=0.038), >2 lines of salvage therapy to enter a response (HR 3.68, P<0.001), achieving less than mCR prior to ASCT (HR 3.19, P<0.001) and RT performed before ASCT (HR 3.11, P=0.017) were associated with inferior PFS. Achieving less than mCR prior to ASCT (HR 2.86, P= 0.026), >2 lines of salvage therapy needed to enter a response prior to ASCT (HR 4.93, P=0.002), anemia (HR 2.96, P=0.040) and checkpoint inhibitors before ASCT (HR=5.10, P=0.032) were adverse prognostic factors for OS, whereas transplant performed after 2012 was associated with improved OS (HR 0.20, P<0.001). Cox regression multivariable analysis led to the identification of more than two lines of salvage therapy needed before ASCT (HR 3.14, P=0.008) as an independent adverse prognostic factor for PFS. PET-2+ at front-line treatment (HR 1.94, P=0.052), anemia at relapse or progression (HR 2.07, P=0.080) and RT before ASCT (HR=2.52, P=0.086) were associated with increased risk of failing ASCT, although they did not reach statistical significance Conclusions: PET-2+ during frontline CT may represent an early marker of chemo-refractoriness. Nevertheless, PET-2+ patients experiencing failure of a PET-guided treatment intensification can benefit from a prolonged OS after HDCT and ASCT.

Introduction Ibrutinib was the first FDA-approved drug for patients (pts) with relapsed or refractory (R/R) marginal zone lymphomas (MZL), based on a phase 2 trial showing an overall response rate (ORR) of 58%, a median progression-free survival (PFS) of 15.7 months (mo) and an acceptable safety profile (Noy 2021). However, accelerated approval was voluntarily withdrawn in the US in April 2023, while it was never released by EMA. Currently, very few real world data about ibrutinib or other BTK inhibitors are available, and none from European countries. Methods Since November 2020 ibrutinib was available in Italy for the treatment of R/R MZL based on 648/96 Italian national law. We designed a retrospective multicentre study with the aim to evaluate efficacy and safety of ibrutinib administered until progression or unacceptable toxicity in pts with R/R MZL of either splenic, nodal, extranodal or disseminated subtype (SMZL, NMZL, EMZL, dissMZL). The study was approved by the IRB of the 19 participating centers. All pts signed informed consent. The primary endpoints were ORR and PFS. Results We enrolled 79 pts (45 males), including 48 SMZL, 14 NMZL, 12 EMZL and 5 dissMZL. Median age was 74 years (42-88). Median number of prior therapies was 1 (1-5). Rituximab monotherapy was the only prior line in 7 pts (9%), while 72 (91%) received at least 1 prior immuno-chemotherapy regimen (BR in 74%). Sixteen pts (20%) were primary refractory, 37 (47%) were classified as POD24 and 21 (27%) were refractory to the last therapy. TP53 deletion or mutation was detected in 10/21 available samples from SMZL cases (48%). Median duration of drug exposure was 10.6 mo (95% CI 1.1-27.6). ORR was 72% (Tab 1), including 10 pts (13%) achieving a complete response (CR) and 47 (59%) a partial response (PR) (Tab 1). Median time to initial response was 3.4 mo (95% CI 0.9-10.5) and median time to best response was 6.1 mo (95% CI 1.6-16.8). NMZL or dissMZL sutype (OR 3.3, p=0.05) and pre-ibrutinib ECOG >1 (OR 8.2, p=0.008) independently predicted probability of non-response. At a median follow-up of 13.4 mo (95% CI 1.9-29.6), 29 pts progressed, including 12 responders. Median PFS was 20.5 mo (95% CI 12.3-NR, Fig 1), while median duration of response (DOR) among 57 responders was not reached (estimated 18-mo DOR 64.2%, 95% CI 43.3-79.2). None of the pts who achieved CR progressed, compared with 12/47 of those who achieved PR (18-mo DOR 100% vs 54.5%, p=0.051). At Cox regression multivariate analysis, pre-ibrutinib ECOG >1 (HR 2.09, 95% CI 1.19-3.67, p=0.01), elevated LDH (HR 2.56, 95% CI 1.13-5.79, p=0.024) and NMZL or dissMZL subtypes (HR 3.46, 95% CI 1.57-7.63, p=0.002) were associated to a worst PFS. Interestingly, pre-ibrutinib MZL-IPI,including the latter two factors plus platelet count <100 x 10 9/l, Hb <12 g/dl and absolute lymphocytes count <1 x 10 9/l ( Luminari ICML23), significantly predicted distinct PFS according to low (0, n=6, 8%, 18-mo PFS 100%), intermediate (1-2, n=50, 63%, 18-mo PFS 59%) and high risk classes (≥3, n=23, 29% 18-mo PFS 26%) (p=0.011). POD24, primary refractoriness, refractoriness to last therapy number and types of prior lines had no influence on PFS. TP53 mutation or deletion resulted significantly associated to inferior PFS in SMZL cases (p=0.015). Overall, 32 pts (40.5%) discontinued ibrutinib, 11 for adverse events (AEs) and 21 for progressive disease (PD). Hematologic AEs were reported in 13 pts, including grade (Gr) 3-4 in 8, 10% (anemia in 4, thrombocytopenia in 3 and neutropenia in 1), while extra-hematologic AEs in 39 (49%) (Gr 3-5 in 15, 19%). The most common AEs were atrial fibrillation (n=8, 10%), bleeding (n=7, 9%), rash (n=6, 8%), diarrhea in 5 (6%), and infections (n=12, 15%), which included 3 Gr 3-4 (COVID-19, pneumonia, sepsis) and 4 Gr 5 events (septic shock in 2, aspergillosis and pneumonia). Histologic transformation was detected in 8 pts (10%). A post-progression therapy was initiated in 23 pts, resulting in ongoing CR/PR in 15. Overall, 11 pts died (6 due to PD, 4 infections, 1 suicide), with a 18-mo overall survival (OS) of 81.2% (95% CI 63.9-89.4). Not achieving ORR significantly predicted worst OS (HR 6.43, 95% CI 1.87-22.09, p=0.003). Conclusions Our data confirmed that ibrutinib is associated with high ORR and durable disease control in R/R MZL in real life. Toxicity was similar to what previously reported in the registration phase 2 study in R/R MZL and in other histologies. Careful attention to infectious toxicity is advised.

Topic: 19. Aggressive Non-Hodgkin lymphoma - Clinical Background: Diffuse Large B Cell Lymphoma (DLBCL) patients (pts) carry a high risk of developing venous thromboembolism (VTE), with a 2-year cumulative incidence of 16%. The Throly and the recently published Model IX scores (Dharmavaram et al., 2020 AJH) can identify lymphoma pts at risk for thromboembolic event, but neither was developed specifically for DLBCL. Moreover the effectiveness of these two scores has never been compared in a real life DLBCL population. Aims: To evaluate the effectiveness of the Throly and Model IX scores on thrombotic risk in a real life DLBCL population, the incidence of VTE and the impact of thrombotic events on survival. Methods: Consecutive pts with a new diagnosis of DLBCL at the Lymphoma Unit of the IRCCS S.Gerardo Foundation, from January 2013 to November 2022, were enrolled. Patients with active anticoagulation therapy (therapeutic or prophylactic) were excluded. We analysed demographics, cardiovascular risk factors, thrombosis risk score (Throly and Model IX) and prognostic score for lymphoma (r-IPI). Results: A total of 208 pts were included: median age was 68 (range 27-92); 118 (57%) were male. 107 (51%) had a poor R-IPI score; 30 pts (14%) had at least a previous VTE event/ myocardial infarction/stroke. After a median follow up of 27 months (range 0,7-190), 32 VTE events (15.3%) were recorded: 9 (28%) lower extremities deep venous thrombosis (DVT), 7 pulmonary embolism (22%), 17 (53%) upper extremities or atypical DVT; 4 pts (12%) presented simultaneously with VTE in two different sites. Median time from lymphoma diagnosis to VTE was 22 days (range 0-439). According to Throly score 92 pts were low, 79 intermediate and 37 high risk, with a 2-year cumulative incidence of VTE of 8%, 20% and 24%, respectively. Having a high or intermediate (high-int) risk at diagnosis according to the Throly score was associated with a higher probability of developing VTE compared to low risk (p=0.0064). 91 pts (44%) were classified as high-int risk without developing VTE. According to Model IX score 56 pts were low and 152 high risk at diagnosis: we report a 2-year cumulative incidence of VTE of 2% and 20% respectively. High risk pts according to Model IX score had a higher probability of developing thrombosis compared to low-risk (p<0.001). 121 pts (58%) were classified as high risk without developing VTE. When comparing the Throly and Model IX score we didn’t find any significant difference (C-index=0.63vs0.63; AIC 8.3 lower for Model IX), unless the two scores were compared considering their single variables (C-index=0.66vs0.73; AIC 13 lower for Model IX). There was no difference in OS when comparing pts with and without VTE (p=0.83). Throly and Model IX high risk score was associated with shorter OS (p=0.04 and p=0.03). Summary/Conclusion: This retrospective study confirms that VTE is still a frequent complication for DLBCL pts, with a 2-year cumulative incidence of 15%. Throly and Model IX can predict VTE events in DLBCL pts with high sensitivity; pts with int-high and high risk respectively have a higher probability of developing VTE compared to those with low risk (p<0.01). Nevertheless, these scores tend to classify many patients as high risk and this impact negatively on specificity and on positive predictive value. A multivariable analysis comparison of the two risk models didn’t find any difference, unless they were compared considering their single variables; in this case Model IX seems to be the preferred model. Lastly, Throly and Model IX score can predict survival independently of VTE-mortality and IPI score.Keywords: Thrombosis, Diffuse large B cell lymphoma, Venous thrombosis, Lymphoma

In the setting of follicular lymphoma (FL), frontline therapy with rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHOP) has represented for many years the standard of care for patients with symptomatic advanced disease. More recently, the combination of bendamustine plus rituximab (R-B) has emerged as an alternative therapeutic option. We present a retrospective, multicenter, observational study aimed at comparing outcomes and toxicities observed in 145 patients diagnosed with grade 3A FL treated with a first line therapy in 15 Italian Fondazione Italiana Linfomi centers between the 1st of January 2014 and the 30th of May 2018. Seventy patients were treated with R-B and 75 with R-CHOP. In the R-B group, the median age at the time of diagnosis was 67 years compared with 59 years in the R-CHOP group. Patients in R-B group achieved a similar overall response rate (96% vs. 99%) and a better complete remission rate (87% vs. 80%, p=0.035) compared with patients in R-CHOP group. Progression free survival (PFS) was similar between individual treated with R-CHOP and R-B (48- month PFS 77.7% vs. 76.6% respectively, p=0.745). The overall survival was significantly longer with R-CHOP treatment (HR=0.16; 95% IC, 0.04-0.74; p=0.007); however, no statistical significant difference was observed after adjustment for age. With the limitations of the study design, our results suggest that both R-B and R-CHOP seem to be valid first-line treatment options in FL3A.

Mantle-cell lymphoma (MCL) is a B-cell non-Hodgkin Lymphoma (NHL) with a poor prognosis, at high risk of relapse after conventional treatment. MCL-associated tumour microenvironment (TME) is characterized by M2-like tumour-associated macrophages (TAMs), able to interact with cancer cells, providing tumour survival and resistance to immuno-chemotherapy. Likewise, monocyte-derived nurse-like cells (NLCs) present M2-like profile and provide proliferation signals to chronic lymphocytic leukaemia (CLL), a B-cell malignancy sharing with MCL some biological and phenotypic features. Antibodies against TAMs targeted CD47, a ‘don't eat me’ signal (DEMs) able to quench phagocytosis by TAMs within TME, with clinical effectiveness when combined with Rituximab in pretreated NHL. Recently, CD24 was found as valid DEMs in solid cancer. Since CD24 is expressed during B-cell differentiation, we investigated and identified consistent CD24 in MCL, CLL and primary human samples. Phagocytosis increased when M2-like macrophages were co-cultured with cancer cells, particularly in the case of paired DEMs blockade (i.e. anti-CD24 + anti-CD47) combined with Rituximab. Similarly, unstimulated CLL patients-derived NLCs provided increased phagocytosis when DEMs blockade occurred. Since high levels of CD24 were associated with worse survival in both MCL and CLL, anti-CD24-induced phagocytosis could be considered for future clinical use, particularly in association with other agents such as Rituximab.

Introduction Chronic Lymphocytic Leukemia (CLL) is an indolent B-cell lymphoproliferative disease that carries the risk of evolving into a life-threatening aggressive histology, known as Richter's syndrome. Despite the advent of new agents such as ibrutinib and venetoclax that have dramatically changed the clinical fate of CLL, young patients still experience refractory and resistant disease, with few therapeutic options available over time. Therefore, the need for new strategies is pivotal for this chronic and insidious condition. Drug resistance might be triggered by the tumor microenvironment (TME), which provides survival signals to CLL tumor cells. Their interaction is mainly established with monocyte-derived nurse-like cells (NLCs). NLCs resemble the immunosuppressive M2-like tumor-associated macrophages (TAMs) and can create a profitable connection with CLL in terms of increasing proliferation and survival (Filip, Blood Cells Mol Dis. 2013). The possibility of targeting the TME by blocking the “Don't Eat Me” signal (DEMs) CD47 has provided restoration of phagocytosis within TME and interesting clinical results in heavily pretreated cases of lymphoma (Advani, NEJM. 2019). The use of agents targeting the DEMs within TME could be a promising approach in CLL as well. CD24 is another DEMs that was first validated in a preclinical model of solid cancer (Barkal, Nature. 2019). It was subsequently found to be upregulated in Mantle-cell lymphoma (MCL) and involved in DEMs as well, since CD24 blockade provided an increase in phagocytosis of MCL cells in vitro (Aroldi, Blood. 2021). This effect was particularly evident in association with anti-CD47 monoclonal antibody (mAb) and Rituximab (Aroldi, Blood. 2022). Although MCL has different pathogenesis compared to CLL, these two entities share some features, particularly regarding the B-cell of origin and the vital interaction with non-cancerous cells within TME. In this study, we explore the possibility of targeting CD24 in human primary samples of CLL (huCLL), redirecting the activity of NLCs against CLL cells using anti-CD24 mAb alone or in combination with other agents (anti-CD47, Rituximab). Methods We analyzed a microarray dataset of patients with CLL to check for any correlation between CD24 expression and survival (GSE22762). We also checked the CD24 antigen expression of huCLL, isolated and differentiated monocytes into M2-like TAMs in vitro, as well as conducted co-culture assays using flow cytometry. These methods were previously described (Aroldi, Blood. 2021; Aroldi, Blood. 2022). Unstimulated autologous CD14+ cell population - defined as precursors of NLCs - were isolated from patients with CLL and used for co-culture analysis without any previous cytokine stimulation for differentiation. Results In a cohort of CLL patients, higher CD24 levels correlated with a lower survival rate compared to lower expression ones (Figure 1). We also checked the CD24 surface in an extended cohort of huCLL and compared it to MEC-1 and PCL-12. huCLL showed higher CD24 surface levels than MEC-1 and PCL-12 and demonstrated better phagocytosis when co-cultured with M2-like TAMs and anti-CD24 mAb (Figure 2A). We then isolated precursors of circulating NLCs from 5 huCLL patients and found higher levels of Siglec-10 (CD24 ligand) than in healthy controls. In this setting, blocking CD24 redirected the phagocytic activity of NLCs against huCLL, showing higher phagocytic rate in cases of multiple combinations (anti-CD24, anti-CD47, anti-CD20, Figure 2B). Conclusions CLL could be another blood cancer subtype sensitive to CD24/Siglec-10 DEMs blocking agents, and CD24 expression negatively impacts survival. Anti-CD24 mAb, in particular, showed the ability to redirect patient-derived NLCs' phagocytic activity to cognate huCLL cancer cells, resulting in higher clearance in cases of multiple combination. Boosting the autologous innate immune system might, therefore, provide further therapeutic options in the setting of CD24 + CLL, particularly for those patients who have failed several lines of treatment and have limited options available.

Background: Classical Hodgkin lymphoma (HL) is considered a highly curable disease and nearly 80-90% of patients (pts) may achieve complete remission (CR) with standard chemotherapy (Engert et. al. NEJM 2010).However up to 30% of HL pts experience primary refractory disease or eventually relapse after first-line treatment (Barrington et. al. Blood 2016, Press O et al. Clin Oncol 2016). High-dose chemotherapy followed by autologous hemopoietic stem cell transplantation (autoHSCT) has been showed to be an active salvage treatment in approximately 50% pts with chemosensitive relapse. Before the advent of novel immunotherapies, the median survival duration for pts failing autoHSCT was only 10 months (Vose et. al. Blood 1992). In this setting the introduction of Brentuximab Vedotin (BV) (Younes et. al. JCO 2012) and of the checkpoint inhibitors (CPI) Nivolumab (nivo) (Herrera et. al. Blood 2018) or Pembrolizumab (Chen et.al. Blood 2019) have shown to significant therapeutic active. Aims: To assess the therapeutic effects of BV and CPI in prolonging PFS and OS in patients with HL r/r post autoHSCT. Methods: This is an observational, retrospective, multicentric study from 15 centers of the Fondazione Italiana Linfomi (FIL). Adult patients who received salvage treatment with BV or CPI for post autoHSCT r/r HL from January 2015 to June 2018 were included in the analysis; the times of observation was censored in December 2020. Patients that had received pre-autoHSCT BV or CPI, were excluded from the analysis. Results: 40 pts, 25 treated with BV and 15 with nivo were included into the study. Patients' main characteristics at diagnosis are summarize in Table 1. Overall response was achieved in 23 (56%) pts treated with BV and in 9 (60%) with nivo, respectively. 14 (35%) out of 40 responsive to BV (10 pts) or nivo (4 pts) received allogeneic hemopoietic stem cell transplantation (alloHSCT) consolidation. The median follow-up time from the time of autoHSCT failure of the entire cohort was 36 months (range 2-70). At last follow-up, 32 (80%) pts were in CR, 1 (2%) in PR, while 2 (5%) and 5 (13%) were in SD and PD, respectively. 34 (85%) pts were alive and 6 (15%) have died. In the entire cohort, the median PFS and OS from the time of autoHSCT failure was 36 months and not reached, respectively; the 36-months projected PFS and OS of 50% and 86%, respectively. The median PFS and the 36-months projected OS of pts who received or not received alloHSCT were superimposable (Figure 1). Conclusion: In this retrospective analysis of pts with HL failing autoHSCT, BV or nivo resulted very active therapeutic salvage therapies. The comparison with historical results of the pre BV/CPI era suggests a major significant improvement both in PFS and OS. A significant proportion of pts received post BV or nivo alloHSCT but the effect of this treatment in prolonging PFS and OS should be further evaluated.