B-cell receptor inhibitors (BCRi) and B-cell lymphoma-2 inhibitor (BCL2i) improved outcomes of patients with chronic lymphocytic leukemia (CLL), but relapsing after two inhibitors still represent an unmet clinical need. This multicenter real-world study analyzes outcomes of a cohort treated in Italy between May 2017 and September 2023 following prior exposure to both BCRi and BCL2i. The median follow-up after venetoclax initiation was 47 months (IQR 28-56). Of 153 double-exposed patients, 104 (68%) discontinued venetoclax and 53 of them (51%) received a subsequent treatment. Venetoclax was discontinued due to progressive disease (PD) in 51/104 cases (49.0%), with nine deaths occurring rapidly after PD without the administration of any further treatment. Fifty-three patients received treatment after venetoclax: 29/53 (54.7%) received inhibitors (13 cBTKi, 11 idelalisib, 2 BCL2i, 3 non-covalent BTKi), 19/53 (35.8%) received chemoimmunotherapy (CT: 16 intensive, 3 palliative), 5/53 (9.4%) received hematopoietic stem cell transplantation (HSCT). Overall response rate was 50%; median event free survival (EFS) in the groups of inhibitors, CT and HSCT was 11, 2, and 10 months, respectively (p < 0.0001); median overall survival (OS) was 12, 5, and 10 months, respectively (p = 0.020). Disease progression during venetoclax treatment was associated with shorter subsequent EFS compared to discontinuation for other reasons, even if the finding did not reach statistical significance (median EFS 4 vs. 10 months; p = 0.11). No decrease in EFS was associated with del17p and/or TP53 mutations, the use of venetoclax monotherapy or a previous treatment with one versus multiple BCRi. Despite its limitations, this real-world study provides additional insights into double-exposed patients, who still pose a clinical challenge, demonstrating the superior efficacy of inhibitors over alternative treatment options. Enrollment in clinical trial and treatments with novel molecules, if available, may help address this unmet clinical need.

Abstract Whether clonal hematopoiesis (CH) in follicular lymphoma (FL) patients affects clinical outcome or is merely a bystander phenomenon is unclear. We leveraged the Phase III Fondazione Italiana Linfomi FOLL12 trial, which treated patients with advanced‐stage FL with R‐CHOP or R‐Bendamustine, to evaluate the role of myeloid CH at baseline and after chemoimmunotherapy (CIT). A total of 528 serial blood samples from 242 FL were analyzed by CAPP‐Seq. At baseline, CH occurred in 35.5% patients with DNMT3A (N = 41, 16.9%) and TET2 (N = 29, 12.0%) being the most frequently mutated genes. After a median follow‐up of 8.2 years, CH at baseline did not impact progression‐free survival (PFS), overall survival (OS), or risk of transformation (P = 0.660, P = 0.230, and P = 0.584, respectively), but instead associated with therapy‐related hematological toxicities driven by TET2 mutations. CH dynamics after the genotoxic pressure imposed by CIT was evaluated in 211 patients provided with sequential samples. CIT significantly expanded both prevalence and size of CH, with clones affected by DNA damage response (DDR) gene mutations exhibiting the highest fitness. Distinct selective pressures were observed between R‐CHOP and R‐Bendamustine, with the latter creating a tighter bottleneck that facilitates the emergence of fitter CH clones preferentially carrying TP53 mutations. Patients acquiring fit DDR clones (N = 37) had inferior long‐term outcomes, including independent increased risk of second malignancies (hazard ratio [HR] 2.63, P = 0.035) that developed in 28 patients, and shorter OS (HR 3.28, P = 0.008). CH emerges as a novel and potentially valuable biomarker in FL, capable of predicting long‐term toxicities that are key endpoints in indolent lymphoid malignancies characterized by long‐lasting survival.

The clinical and biological significance of clonal hematopoiesis (CH) has not been investigated in the myeloid compartment of chronic lymphocytic leukemia (CLL). By studying 488 newly diagnosed CLL through CAPP-seq using a 28-gene panel on granulocyte genomic DNA (gDNA), CH occurred in 231 (47.3%) patients. Cell sorting of cases that never developed Richter transformation (RT) confirmed that CH mutations, including CH-related TP53 mutations, were restricted to the myelomonocytic compartment and absent in CLL cells, as also documented by single-cell DNA sequencing. CH associated with shorter overall survival (OS) (hazard ratio [HR] 1.36, 95% CI 1.04-1.77, P = 0.023); specifically, TET2 mutations independently predicted inferior OS (HR 1.62, 95% CI 1.15-2.28, P = 0.01) after adjusting for age and for CLL-related prognostic biomarkers, namely IGHV and TP53 status. Regarding therapy-related toxicities, CH correlated with a higher incidence of Grade ≥ 3 neutropenia (P = 0.004) after venetoclax-based regimens. Sequential samples (n = 57) analysis showed that Bruton tyrosine kinase (BTK) and BCL2 inhibitors do not induce CH expansion, which was instead driven by chemotherapy. CH is significantly associated with a higher risk of second hematological malignancies only in chemo-exposed patients. Single-cell RNA sequencing of seven CH+ and six CH- CLL revealed that the T-cell compartment of CH+ patients exhibits a less exhausted phenotype, documented by lower expression of TOX, the master regulator of T-cell exhaustion, and a higher pro-inflammatory profile. CH also influenced RT, since CH ASXL1 mutations independently associated with higher RT risk (HR 11.19, 95% CI 4.09-30.62, P < 0.001). Overall, CH in CLL impacts survival, therapeutic toxicity, and transformation risk while also influencing the T-cell immune compartment.

The present study comprehensively dissects the molecular landscape of elderly mantle cell lymphoma (MCL) patients enrolled in the phase II V-RBAC trial of the Fondazione Italiana Linfomi. Of the 140 patients enrolled in the trial, 132 had available gDNA extracted from lymph node biopsies or bone marrow aspirates and were included in the analysis. A CAPP-Seq assay targeting 146 genes relevant to MCL pathogenesis was employed to identify gene mutations and copy number variations. ATM was the most frequently mutated gene, detected in 55 patients (41.7%), followed by TP53 and KMT2D in 31 patients (23.5%). ATM deletion was observed in 32 patients (24%), while CDKN2A loss in 29 (22%). Beyond TP53 mutations, three other molecular lesions, including CDKN2A loss, CD36 mutations and single-hit ATM abnormalities (either mutation or deletion) were independently associated with progression-free survival after adjustment for high-risk trial-defining features, namely Ki-67 >30% and blastoid variant. Notably, patients harboring single-hit ATM alterations without any additional risk factors achieved durable long-term remission, while CD36 mutations were associated with adverse survival. Both findings represent previously unrecognized aberrations that in this cohort independently and inversely associated with survival. The four variables were integrated into a 4-factor molecular prognostic model internally validated using a bootstrapping approach, which identified four distinct patient subgroups with significantly different outcomes. These findings support the importance of i) molecular profiling in MCL, ii) risk-adapted trials like V-RBAC, and iii) the integration of other biological markers with TP53 mutations for a more precise risk assessment in MCL. (NCT03567876)

Measurable residual disease (MRD) status in chronic lymphocytic leukemia (CLL) patients treated with venetoclax is a predictive factor of outcome in clinical trials. This multicenter prospective study was aimed to show the feasibility of MRD assessment in the real-life setting and to confirm the results of clinical trials. Forty-four patients were enrolled: 43% had 17p deleted and/or TP53 mutated (del17p/TP53mut), 62% had complex karyotype, and 65% of patients were previously treated with B-cell receptor inhibitor (BCRi). MRD was evaluated by 8-color flow cytometry (FC) on peripheral blood (PB) every 3 months from therapy start and samples with 10-4 CLL cells were considered as undetectable (uMRD). PB-uMRD patients were evaluated on bone marrow (BM). In 23 patients venetoclax was combined with Rituximab (VR). Median follow-up was 39.47 months (range 31.02-43.32). Median number of PB samples for each patients was 5 (IQR 4-7). Undetectable MRD on PB at any timepoint was obtained in 34/40 patients (85%): 82% in venetoclax monotherapy (Vmono) and 86.9% in VR group. Concordance of PB/BM samples was 92% at 24 months. No significant difference in uMRD rates was detected based on del17p/TP53mut and number of previous therapies. Three-year progression-free survival (PFS) for Vmono and VR was 53.5% and 55%. Median PFS in del17pl/TP53mut was 29.8 and 34 months in Vmono and VR respectively. Landmark analysis based on 9-month MRD showed a trend towards a better PFS in uMRD patients. Median PFS was 21.7 and 13.04 months in 24-month uMRD and detectable MRD patients after VR, respectively (log rank p = 0.0309). In conclusion, in these high-risk relapsed/refractory CLL patients who were MRD-monitored in the context of a real-life study the results were similar compared to published data in more selected patients.

ABSTRACT:Bruton tyrosine kinase inhibitors (BTKis) have dramatically changed the therapeutic landscape of chronic lymphocytic leukemia (CLL), with ibrutinib, first-in-class, demonstrating durable efficacy even in high-risk patients. However, off-target adverse events (AEs) have raised concerns, prompting the development of more selective second-generation BTKis, such as zanubrutinib, designed to improve tolerability while maintaining efficacy. Despite encouraging results from clinical trials, real-world data comparing zanubrutinib with ibrutinib remain limited. In this multicenter, retrospective study, we analyzed 934 patients with CLL treated outside clinical trials, including 393 receiving zanubrutinib and 541 receiving ibrutinib. We evaluated time to treatment discontinuation (TTD) and time to next treatment or death (TTNTD) in both the overall cohort and a propensity score-matched population. Patients who were treated with zanubrutinib experienced lower 12-month discontinuation rates (overall: 12.6% vs 21.4%; matched: 12.4% vs 20.2%) and higher 12-month TTNTD rates (overall: 91.9% vs 83.0%; matched: 93.2% vs 83.4%). Multivariable analyses confirmed zanubrutinib as an independent predictor of longer TTD and TTNTD, whereas high-risk features, including age, relapsed/refractory disease, Binet stage C, TP53 disruption, Eastern Cooperative Oncology Group 2 to 3, and congestive heart failure, were consistently associated with poorer outcomes. AEs leading to discontinuation, particularly atrial fibrillation, bleeding, and infections, were less frequent with zanubrutinib, reflecting its favorable safety profile. These findings provide real-world evidence that zanubrutinib offers more durable disease control and improved persistence compared with ibrutinib, reinforcing its clinical value as a preferred second-generation BTKi. Nevertheless, the relatively short follow-up for zanubrutinib warrants cautious interpretation of long-term outcomes, and underscores the need for ongoing observation to fully characterize its durability and safety.

CD20 × CD3 bispecific antibodies (BsAbs) have emerged as a meaningful therapeutic option for relapsed or refractory diffuse large B-cell lymphoma (DLBCL), redirecting endogenous T cells against malignant B cells independently of major histocompatibility complex-mediated antigen presentation, and have received regulatory approval after at least two prior lines of therapy. However, a substantial proportion of patients experience primary resistance or early relapse, underscoring the need to characterize the underlying biological mechanisms, which are the focus of this review. Several tumor-intrinsic determinants of resistance have been identified, including CD20 loss driven by MS4A1 mutations, alternative splicing, and gene deletion, as well as genomic reprogramming involving TP53, MYC, and NOTCH1 alterations. T-cell dysfunction represents another critical resistance domain, encompassing inadequate intratumoral cytotoxic CD8+ T-cell infiltration, expansion of immunosuppressive regulatory and follicular helper T cells, progressive exhaustion with upregulation of PD-1, LAG-3, TIM-3, and TIGIT, and impaired T-cell fitness from prior treatment exposure. Microenvironmental barriers, including checkpoint ligand upregulation, PD-L1-enriched extracellular vesicles, spatial exclusion of effector cells from immune-cold germinal center-like niches, hypoxia, and metabolic competition, further reinforce immune escape. Emerging strategies to overcome resistance include epigenetic priming, checkpoint inhibitor combinations, 4-1BB costimulatory approaches, and next-generation multispecific antibody designs.

Introduction. Metabolomics is emerging as a promising tool to identify novel prognostic biomarkers in oncohematology. Its prognostic impact in diffuse large B cell lymphoma (DLBCL) is largely unknown. The aim of this study was to investigate the potential clinical impact and biological correlations of baseline metabolomics in newly diagnosed DLBCL. Methods. The study relies on a real-world cohort of 96 R-CHOP treated DLBCL provided with baseline plasma samples. After metabolite extraction, samples were analyzed with a bidimensional gas chromatography/mass spectrometry. Data were processed using a Statical Compare software. Metabolites were expressed as abundance values. Molecular clusters (A53, BN2, EZB, MCD and ST2) were identified on circulating tumor DNA using the LymphGen tool. A logistic regression approach with Ridge penalization was applied to find potential correlations. The maximally selected rank statistics was used to identify the best cutoff in predicting progression free survival (PFS) for each metabolite abundance value. Results. The median age was 68.7 years. After a median follow-up of 55.6 months, 40-month PFS and overall survival (OS) were 61.4% and 72.8%, respectively. Untargeted metabolomic analysis led to the identification of 281 metabolites, 40 of them associated with DLBCL molecular clusters. Some metabolites were common across all molecular subgroups, but each cluster was also enriched in specific upregulated metabolites (Fig.1A). Based on PFS at 24 months from diagnosis, patients were divided into progressive (N=34) and non-progressive (N=62) cases. 10 metabolites were differentially up- or downregulated in progressive cases. In multivariate analysis, low abundance of L-threonine (HR 5.65, p=0.002) and isopropyl stearate (HR 3.38, p=0.028) and high abundance of 4-hydroxybenzeneacetic acid (HR 4.12, p=0.004) and ribitol (HR 2.91, p=0.004) retained an independent association with shorter PFS, whereas other metabolites lost their prognostic value (Kaplan Meier curves: fig.1B-E). L-threonine and ribitol are mainly involved in cell energy metabolism. 4-hydroxybenzeneacetic acid and ribitol are associated with changes in intestinal microbiome composition. Conclusions. Baseline plasma metabolites harbor a promising prognostic value in DLBCL and exhibit distinct distributions across molecular clusters. If validated, these findings may provide new insights into DLBCL biology and may identify novel potential therapeutic targets.

ABSTRACT:Central nervous system involvement (CNSi) of chronic lymphocytic leukemia (CLL) is a rare condition with no consensus on diagnostic criteria and limited evidence for management and outcome. Here, we report an international, multicenter, retrospective study conducted by the European Research Initiative on CLL. The study defined CNSi of CLL by the following: (1) detection of CLL cells in the cerebrospinal fluid or confirmation of CLL infiltration of the CNS based on a tissue biopsy, (2) clinical or radiographic evidence of neurologic disease, and (3) the absence of other explanations for the neurologic findings. A total of 48 patients from 26 centers in 15 countries met all 3 diagnostic criteria of CLL-CNSi. Median age at diagnosis of CNSi was 64 years. Most patients were males (73%), had Binet stage A at CLL diagnosis (61%), and had untreated CLL at the time of CNSi (63%). Motor impairment was the most common symptom (38%) followed by visual impairment (32%). Of 47 patients who received treatment for CNSi, half (51%) received targeted agents, most often a Bruton tyrosine kinase inhibitor (BTKi), and 34% received chemoimmunotherapy. Initial treatment was highly effective, leading to a reduction (83%) or complete resolution (71%) of neurologic symptoms and imaging findings in most patients. The estimated 5-year overall survival (OS) from the CNSi diagnosis was 77.1%. The 5-year time to next treatment or death was 94% for patients treated with BTKi compared with 64% for those treated with CIT. Treatment-sensitive disease, represented by attainment of CNS complete response after initial therapy, was associated with longer OS.

Analysis of circulating free DNA (cfDNA), and in particular the tumor-derived fraction known as circulating tumor DNA (ctDNA), represents a major advance in the precision medicine of lymphoma.1 Quantification of ctDNA at baseline and at the end of induction chemoimmunotherapy and its integration with PET/CT scans provide well-established prognostic biomarkers.2-5 Beyond quantification, cfDNA analysis can provide additional insights into lymphoma biology. For example, molecular characterization of diffuse large B-cell lymphoma (DLBCL) using ctDNA recapitulates the molecular subtypes identified in tissue biopsies, offering a non-invasive approach that may guide the design of molecularly driven clinical trials.6 In plasma, cfDNA fragments vary in length, display distinct sequence motifs at their fragment ends, and show tumor-specific fragmentation patterns. Collectively referred to fragmentomics, these features provide an additional layer of biological information and may improve outcome prediction in lymphoma.7,8 For example, cfDNA fragment length has prognostic relevance in DLBCL, with shorter fragments being associated with more aggressive disease.9 Fragmentomic analyses can also help discriminate the tissue origin of cfDNA, as shorter fragments are more likely to derive from lymphoma cells, whereas longer fragments typically originate from healthy tissues. This distinction may facilitate the identification of clonal hematopoiesis (CH), that in DLBCL has been associated with an increased risk of long-term treatment-related toxicities, and help determine the origin of some mutations (i.e. TP53 and TET2) that are shared between DLBCL and CH pathogenesis.10,11 Furthermore, cfDNA fragments arising from active promoters exhibit more random fragmentation patterns compared with those from inactive promoters. This property also enables inference of transcriptomic profiles from cfDNA.12 cfDNA analysis therefore represents a powerful biomarker for assessing underlying biology and predicting outcomes in lymphoma patients. The next step will be the standardization of methodologies and their implementation within dedicated clinical trials. References Talotta D et al., Front Oncol. 2023 → https://doi.org/10.3389/fonc.2023.1164517 Dondolin R et al., Leukemia. 2025 → https://doi.org/10.1038/s41375-025-02688-2 Roschewski M et al., J Clin Oncol. 2025 → https://doi.org/10.1200/jco-25-01534 Wang S et al., J Clin Oncol. 2025 → https://doi.org/10.1200/jco-25-01712 Krupka JA et al., J Clin Oncol. 2025 → https://doi.org/10.1200/jco-25-01587 Moia R et al., Blood Adv. 2025 → https://doi.org/10.1182/bloodadvances.2024014136 Cristiano S et al., Nature. 2019 → https://doi.org/10.1038/s41586-019-1272-6 Doebley AL et al., Nat Commun. 2022 → https://doi.org/10.1038/s41467-022-35076-w Meriranta L et al., Blood. 2022 → https://doi.org/10.1182/blood.2021012852 Meriranta L et al., Blood Adv. 2025 → https://doi.org/10.1182/bloodadvances.2025015791 Maher N et al., Blood. 2025 (ASH abstract) → https://doi.org/10.1182/blood-2025-3537 Esfahani MS et al., Nat Biotechnol. 2022 → https://doi.org/10.1038/s41587-022-01222-4

The management of chronic lymphocytic leukemia (CLL) in older patients requires careful balancing of therapeutic efficacy with the risks of treatment intolerance. Frailty assessment is increasingly recognized as a critical determinant of clinical outcomes, but its specific role in guiding therapy with second-generation Bruton tyrosine kinase inhibitors remains poorly defined. We conducted a prospective, multicenter investigation of 326 consecutive CLL patients aged 65 years or older who received zanubrutinib across 52 Italian centers, aiming to evaluate whether the Clinical Frailty Scale (CFS) could predict treatment discontinuation in real-world practice. The cohort was characterized by advanced age (median 78.1 years, range 65.1-94.5), with over half of the patients presenting with Binet stage C disease. Two-thirds were treated in the frontline setting, while the remainder received zanubrutinib as salvage therapy. After a median follow-up of 8 months, 48 patients (14.7%) discontinued treatment, most commonly due to toxicity or disease progression. Receiver operating characteristic curve analysis identified a CFS of 3 as the optimal threshold for predicting discontinuation, with an area under the curve of 0.65 (95% CI 0.56-0.73, p < 0.001). At 12 months, the discontinuation rate was significantly higher among patients with a CFS > 3 (29.2%) compared with those with a CFS ≤ 3 (8.8%) (p < 0.001); among conventional prognostic variables, only relapsed/refractory disease demonstrated an independent association with TTD. These findings highlight the CFS as a simple yet powerful clinical tool that provides incremental prognostic information beyond standard disease-related factors. Incorporating frailty assessment into treatment planning may enhance patient selection and optimize therapeutic strategies for elderly CLL patients in daily practice.

Richter transformation (RT) represents a rare but highly lethal evolution of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), most frequently manifesting as diffuse large B-cell lymphoma (DLBCL). Despite therapeutic advances in CLL, DLBCL-RT remains characterized by rapid progression, profound treatment refractoriness, and short survival with conventional chemoimmunotherapy, underscoring the need for a refined biological and therapeutic framework. A defining feature of RT is clonal relatedness: most cases arise through linear or branched evolution of the antecedent CLL clone and carry an inferior prognosis compared with clonally unrelated cases that resemble de novo DLBCL. Recent multi-omic data further indicate that clonally related RT commonly originates from minute, transformation-primed subclones detectable years before clinical emergence, shifting RT from a late stochastic event to an early-established evolutionary trajectory. At transformation, recurrent genetic lesions of TP53, CDKN2A/B, NOTCH1, and MYC cooperate with B-cell receptor-associated programs, epigenetic reconfiguration, and metabolic rewiring toward OXPHOS- and mTOR-driven states, collectively promoting genomic instability and aggressive growth. In parallel, RT develops within a profoundly immunosuppressive microenvironment marked by PD-1-expressing malignant B cells, PD-L1-rich myeloid niches, exhausted T cells, expanded regulatory T cells, and M2-skewed macrophages interconnected by redundant checkpoint and cytokine networks. Therapeutic strategies are rapidly evolving, including pathway inhibitors, immune checkpoint blockade, T-cell-engaging bispecific antibodies, CAR-T therapies, and antibody-drug conjugates. This review integrates current insights into RT pathogenesis, immune escape, and emerging therapies, highlighting opportunities for biomarker-driven patient stratification, rational combinations, and earlier interception of transformation-prone disease.

Introduction: Several randomized controlled trials have demonstrated superiority of BTK inhibitors (BTKis) over chemoimmunotherapy (CIT) in patients with treatment naïve (TN) CLL. In some of these trials, BTKis have also led to a statistically significant improvement in overall survival (OS). However, it is largely unknown if the adoption of BTKis in TN CLL has improved OS of patients with CLL in the real world (RW). Methods: This is a retrospective, observational study that aimed to explore differences in the OS of patients with TN CLL treated a) in different eras [CIT-era group vs BTKi-era] and b) with BTKis vs fludarabine-cyclophosphamide-rituximab (FCR) in a RW setting. In the latter comparison, we excluded patients >70 years at first-line (1L) treatment and patients with TP53 aberrations. Patients who received 1L treatment for CLL between 2010 and 2020 in 14 countries were included in the study. Patients were allocated to two different groups (CIT-era and BTKi-era groups) according to the actual use of BTKis in each country. The year when the use of BTKis surpassed 25% was defined as the cutoff year for each country. Cases treated before the cutoff year were allocated to the CIT-era group, and cases treated after the cutoff year were allocated to the BTKi-era group. OS was defined as the time from CLL-directed treatment to death (event) or last follow-up date (censoring). For the propensity score matching (PSM), we matched patients based on age at 1L initiation, biological sex, and TP53 aberrations for the group comparison and on age at 1L initiation and biological sex for the BTKis vs FCR comparison. Results: A total of 5642 patients (CIT-era group: 4321 and BTKi-era group: 1321) from 37 centers were eligible for the study. The cutoff year was 2020 for the Czech Republic and Russia, 2019 for Brazil, Croatia, Germany, Greece, 2018 for Israel and Turkey, 2017 for Italy and Spain, and 2016 for Switzerland and the United Kingdom. Cases treated in India and Serbia did not reach the 25% cut-off and were allocated to the CIT-era group. BTKis represented the most common treatment in 1L for the BTKi-era group [484 (37%), ibrutinib-based: 443 (91.5%), acalabrutinib-based: 34 (7%), and zanubrutinib-based: 7 (1.5%)], while only 67 (5.1%) cases were treated with venetoclax-based regimens, reflecting the later approval of these regimens in 1L. In the CIT-era group, FCR (1478, 34.1%) chlorambucil-based (1131, 26.2%) and bendamustine plus anti-CD20 antibody (549, 12.7%) were the most common treatments. The use of BTKis in 1L in the CIT-era group was minimal (141, 3.3%). In both groups, most patients were males [2755 (64%) in the CIT-era group and 836 (63%) in the BTKi-era group, p=0.8]. Patients in the CIT group were younger at the start of 1L treatment [67 years (IQR=59-74) vs 69 (IQR=62, 76) p=0.001 for the CIT and BTKi-era groups, respectively]. TP53 mutations and del(17p) were similarly distributed among the two groups [del(17q): 304 (11%) vs. 130 (13%), p=0.09 | TP53 mutations: 202 (15%) vs. 100 (12%), p=0.09]. Unmutated immunoglobulin heavy variable (IGHV) gene status and del(11q) were more frequent in the CIT-era group [449 (19%) vs 126 (15%), p= 0.02 | 1.209 (65%) vs 532 (59%), p= 0.003, respectively]. The follow-up time from 1L treatment was longer for the CIT group [64 months (IQR: 31-98) vs 48 (IQR: 22- 63)] for CIT and BTKi groups, respectively. OS was similar between the two groups [HR: 0.98 (95%CI: 0.88-1.10), p=0.8), median OS: CIT-era group: 7.8 years (95% CI: 7.5, 8) vs BTKi-era group: not reached (7.5, not estimable (NE)]. However, the OS difference was statistically significantly better for the BTKi-era group when we compared OS with PSM for age at 1L initiation and biological sex (HR=0.88 (95%CI: 0.79-0.99), p= 0.04) and for age at 1L initiation, biological sex, and TP53 aberrations [HR:0.73 (95%CI: 0.61-0.88), p< 0.001]. Finally, in the PMS analysis, the OS of patients treated with BTKis was not statistically significantly different compared to cases treated with FCR in 1L (HR: 0.80 (95%CI: 0.56, 1.15), p= 0.2). The median OS for patients treated with BTKis (n=211) and FCR (n=1259) was 10 years (95% CI: 10, NE) and 10.8 years (95% CI: 9.8-11.9), respectively. Conclusion: Our findings show that the availability of BTKis has improved the OS of patients with TN CLL. Patients treated with BTKis had a similar OS with cases treated with FCR in the RW setting.

Introduction Management of chronic lymphocytic leukemia (CLL) has advanced significantly over the past decade with the introduction of targeted therapies (TT). Despite that, important challenges persist in optimizing treatment, especially for patients (pts) with concurrent cardiovascular comorbidities (CVC). We examined real-world treatment patterns and outcomes among pts with CLL and CVC, aiming to better understand therapeutic approaches and effectiveness in this complex population. Methods This retrospective multicenter longitudinal study included pts diagnosed with CLL between 2010 and 2020 (index period), who had at least one CVC at diagnosis or prior to first-line treatment (1L) initiation. Demographic and clinical variables were collected from physician-reported records. Pts were followed from the index date until the last follow-up (f/u), end of study (September 2024), or death, whichever came first. Clinical outcomes were assessed following 1L initiation and were described for both the overall study population and pts who received only TT. Results A total of 1393 pts from 20 centers in 7 countries were included. Most pts were male (898/1393, 64.5%) and had received at least 1 line of CLL-directed treatment (857/1393, 61.6%). The median f/u from diagnosis and 1L initiation were 8.4 years (yrs) [IQR=8-9] and 4 yrs [IQR=1.9-6.9], respectively. The median age (mAge) at diagnosis and 1L was 69 (IQR=62-76) and 71 (IQR=64-78) yrs, respectively. Most pts were diagnosed with arterial hypertension (1112/1393, 79.8%), followed by atrial fibrillation/flutter (AF) (180, 12.9%). Ischemic heart disease [excluding myocardial infarction (MI)], stroke, cardiomyopathy, MI, heart failure, other cardiac arrythmias (excluding AF), and cardiac valve disease were present in 139 (10%), 85 (6.1%), 61 (4.4%), 59 (4.2%), 52 (3.7%), 41 (2.9 %), 31 (2.2%), respectively. At the time of 1L initiation, most pts had unmutated IGHV genes (316/547, 57.8%), while 94/641 (14.7%) had TP53 aberrations. The most common 1L treatments were chlorambucil-based (CHL) regimens [295/857 (34.4%), CHL monotherapy: 117 (13.7%) and CHL plus anti-CD20 monoclonal antibody: 178 (20.1%)] and BTK inhibitors (BTKis) [141/857 (16.5%), ibrutinib (I): 92 (10.7%), acalabrutinib (A): 45 (5.3%), zanubrutinib (Z): 4 (0.5%)]. Fludarabine-cyclophosphamide-rituximab (FCR) and bendamustine-rituximab (BR) were used in 133 (15.6%) and 53 (6.2%), respectively. Venetoclax-based (ven) regimens were used in 55 [6.4%, 50 (5.8%) received ven-obinutuzumab] pts. I plus ven was used in 7 (0.8%) pts. After 2020, the use of BTKis [86/234 (36.7%), A: 43 (18.8%), I: 39 (16.7%), Z: 4 (1.7%)] and ven regimens (48, 20.5%) increased markedly, while chemoimmunotherapy use declined [CHL regimens: 43 (18.4%), BR: 12 (5.1%) and FCR: 5 (2.1%)]. The overall survival (mOS) and time to next treatment or death (mTTNTD) from 1L initiation were 8.4 yrs (95%CI=7.7-9.4) and 3.6 yrs (95%CI=3.2-4), respectively. Of the pts who received TT only, the mOS was not reached [95%CI=5.6 yrs, not estimable (NE)], and mTTNTD was 5.6 yrs (95%CI=4.5-NE). The 3-year-TTNTD for BTKis [mAge: 73yrs], ven regimens (mAge: 69yrs), FCR (mAge: 61), and CHL regimens (mAge: 75yrs) was 71% (95%CI=62-80), 87.1% (95%CI=74-100), 67.5% (95%CI=60-76) and 44.2% (95%CI=39-51), respectively. Overall, 54/141 (38.3%) pts discontinued BTKis in 1L. The reasons were toxicity (tox) (20, 14.2%, CV tox: 9/20 and non-CV tox: 11/20), disease progression (PD) (15, 10.6%), CLL-unrelated (CLL-u) deaths (13, 9.2%) and other reasons (6, 4.2%). Of the 55 pts who received ven regimens, 6 (10.9%) discontinued treatment earlier than scheduled [non-CV tox: 3 (5.5%), other reasons: 2 (3.6%), and CLL-u death: 1 (1.8%)]. FCR (n=133) was discontinued earlier than scheduled in 15 (11.3%) pts [non-CV tox: 12 (9%), PD: 1 (0.8%), other reasons: 2 (1.5%)]. Finally, CHL regimens (n=295) were discontinued in 36 (12.2%) pts [non-CV tox: 14 (4.7%), PD: 12 (4.1%), other reasons: 9 (0.8%), CLL-u death: 1 (0.3%)]. Conclusion We highlight a shift toward the use of TT in pts with CLL and CVC and illustrate differential patterns in TTNTD and discontinuation according to regimen. Differences in pts age and treatment duration across regimens may have contributed to the varying incidence of CV tox leading to discontinuation, especially in pts receiving BTKi. The study's retrospective nature, age and f/u differences preclude any comparison of TTNTD between treatments.

ABSTRACT:This study analyzed the genetics of classic Hodgkin lymphoma (cHL) by using circulating tumor DNA (ctDNA). Two genetic subtypes were identified, differing in genetic instability mechanisms: one subtype (64% of cases) showed a higher mutation load and a higher fraction of mutations associated with activation-induced cytidine deaminase and microsatellite instability signatures, whereas the other subtype (36% of cases) exhibited chromosomal instability with more somatic copy number alterations. Whole-genome duplication was more common in cHL compared with other B-cell tumors and emerged as a prognostic biomarker for patients undergoing Adriamycin (doxorubicin)-bleomycin-vinblastine-dacarbazine-based therapy. Noncoding regulatory mutations, similar to those in diffuse large B-cell lymphoma, were highly prevalent in 86% of cHL. A recurrent somatic expression quantitative trait locus (seQTL) involving the BCL6 gene was found in 30% of cases. The seQTL of BCL6 aligned with accessible chromatin and increased H3K27 acetylation in cHL, disrupted PRDM1 binding, and co-occurred with BCL6 expression in cHL cells. Weak to strong expression of BCL6 was observed in 68% of cases, and BCL6 expression associated with gene repression similarly in cHL and germinal center B cells. After BCL6 degradation, the core set of genes directly bound and regulated by BCL6 was derepressed in cHL, and proliferation was impaired. The number and clonality of neoantigens was associated with tumor microenvironment type and response to checkpoint blockade. Finally, ctDNA analysis was suggested as a tool to distinguish ambiguous positron emission tomography/computed tomography-positive lesions after treatment.

BACKGROUND:Bendamustine and rituximab combined with intermediate-dose cytarabine (RBAC) is one of the standard initial treatments for older, fit patients with mantle cell lymphoma. We aimed to investigate whether the addition of venetoclax to RBAC would improve progression-free survival in patients with high-risk mantle cell lymphoma. METHODS:FIL_V-RBAC was a multicentre, single-arm, phase 2 study done in 35 institutions of the Fondazione Italiana Linfomi in Italy. Treatment-naive patients with a histological diagnosis of mantle cell lymphoma, aged 65 years or older and fit according to the Fondazione Italiana Linfomi modified comprehensive geriatric assessment (or younger than 65 years and ineligible for high-dose chemotherapy with Eastern Cooperative Oncology Group performance status of 2 or less), were classified after enrolment as having low-risk or high-risk disease, based on the presence of blastoid morphology, Ki67 30% or higher, TP53, or 17p deletion. Patients with a low-risk profile received RBAC intravenously (rituximab 375 mg/m2 and day 1; bendamustine 70 mg/m2 on days 1 and 2; and cytarabine 500 mg/m2 on days 1, 2, and 3) every 4 weeks for 6 cycles. Patients with a high-risk profile received four cycles of RBAC followed by fixed-duration oral venetoclax consolidation (4 months, 800 mg/day) and maintenance (20 months, 400 mg/day). The primary endpoint was 2-year progression-free survival for patients with a high-risk profile who received at least one dose of RBAC. This trial was registered with ClinicalTrials.gov, NCT03567876, and this is the final report. FINDINGS:Between Sept 10, 2018, and July 26, 2021, 155 patients were screened for inclusion, 140 of whom were enrolled and analysed for study endpoints. Median age was 72 (IQR 69-76), 107 (76%) patients were male, 33 (24%) were female, and all were White. 54 (39%) patients had a high-risk profile (28 [20%] with TP53 mutations, 19 [14%] with 17p deletions, 34 [24%] with Ki67 ≥30%, and 13 [9%] with a blastoid morphology) and 86 (61%) had a low-risk profile. After a median follow-up of 45 months (IQR 40-55), the 2-year progression-free survival in the high-risk group was 60% (95% CI 48-74) and the median progression-free survival was 37 months (95% CI 19-not reached). The most frequent grade 3 or worse adverse events during venetoclax consolidation were neutropenia (12 [28%] of 43 patients), followed by thrombocytopenia (three [7%]) and skin reactions (three [7%]). During venetoclax maintenance, the most frequent grade 3 or worse adverse events were neutropenia (seven [19%] of 37 patients), followed by thrombocytopenia (two [5%]) and anaemia (two [5%]). One (1%) of 140 patients had a treatment-related death (tumour lysis syndrome during first induction with RBAC in a patient with a high-risk profile). INTERPRETATION:To our knowledge, this is the first prospective study to stratify patients with mantle cell lymphoma to different treatments according to their risk profile. Our results suggest that the addition of fixed-duration venetoclax improves the performance of RBAC in patients with a high-risk disease profile. Our findings point to the importance of identifying patients with high-risk disease at initial diagnosis. FUNDING:Fondazione Italiana Linfomi-Ente del Terzo Settore, Leukemia and Lymphoma Society, and Ministry of Health, Italy, and AbbVie. TRANSLATION:For the Italian translation of the abstract see Supplementary Materials section.