PAK4 and NAMPT as Novel Therapeutic Targets in Diffuse Large B-Cell Lymphoma, Follicular Lymphoma, and Mantle Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL), grade 3b follicular lymphoma (FL), and mantle cell lymphoma (MCL) are aggressive non-Hodgkin’s lymphomas (NHL). Cure rates are suboptimal and novel treatment strategies are needed to improve outcomes. Here, we show that p21-activated kinase 4 (PAK4) and nicotinamide phosphoribosyl transferase (NAMPT) is critical for lymphoma subsistence. Dual targeting of PAK4-NAMPT by the Phase I small molecule KPT-9274 suppressed cell proliferation in DLBCL, FL, and MCL. Growth inhibition was concurrent with apoptosis induction alongside activation of pro-apoptotic proteins and reduced pro-survival markers. We observed NAD suppression, ATP reduction, and consequent cellular metabolic collapse in lymphoma cells due to KPT-9274 treatment. KPT-9274 in combination with standard-of-care chemotherapeutics led to superior inhibition of cell proliferation. In vivo, KPT-9274 could markedly suppress the growth of WSU-DLCL2 (DLBCL), Z-138, and JeKo-1 (MCL) sub-cutaneous xenografts, and a remarkable increase in host life span was shown, with a 50% cure of a systemic WSU-FSCCL (FL) model. Residual tumor analysis confirmed a reduction in total and phosphorylated PAK4 and activation of the pro-apoptotic cascade. This study, using various preclinical experimental models, demonstrates the therapeutic potential of targeting PAK4-NAMPT in DLBCL, FL, and MCL. The orally bioavailable, safe, and efficacious PAK4-NAMPT dual inhibitor KPT-9274 warrants further clinical investigation.

Impact of targeted treatment in non-Hodgkin’s lymphoma with primary lymph node involvement

Background: Non-Hodgkin’s lymphomas (NHL) are malignant tumors that develop from lymphoid tissue. Primary lymph node (LN) involvement is the most common localization (52-70%). The integration of Rituximab (R) in the NHL treatment represented a turning point. The aim of this study was to evaluate the therapeutic impact of the use of R in combination with conventional polychemotherapeutic (PChT) in the treatment of nodal onset NHL. Material and methods: A descriptive cohort study was performed on 80 patients diagnosed with NHL. Results: In the study participated: men – 39(48.8%), women – 41(51.2%). The mean age of the patients was 56.09 ± 13.6 years. The onset of NHL occurred in peripheral l/n in 85.0% of cases, in mediastinal LN – 7.5%, and abdominals in 7.5%. Stages I-II were identified in 21(26.2%) patients, stages III-IV in 59(73.8%) cases. Aggressive NHLs were diagnosed in 54(67.5%) patients, indolent NHLs in 26(32.5%) cases. In 61(76.3%) patients, first-line R+PChT treatment was applied – group 1(G1), and in 19(23.8%) cases conventional PChT was applied – group 2(G2). The overall response rate (ORR) in G1 was 86.8%, in G2 – 63.1%. Complete remissions (CR) were obtained in G1 in 63.9% of patients, in G2 – 47.3% of cases. Progression-free survival (PFS) in G1 had a median of 20 months, and in G2 the median was 12 months (p <0.05). Conclusions: The use of Rituximab increased the ORR rate (86.8% vs 63.1%), the frequency of CR (63.9% vs 47.3%) and PFS (20 months vs 12 months (p <0.05).

PROGNOSTIC SIGNIFICANCE OF PLATELET- NEUTROPHIL COMPLEXES IN NON-HODGKIN’S LYMPHOMA PATIENTS

Non-Hodgkin's lymphomas (NHL) are a group of lymphoproliferative diseases with a heterogeneous spectrum of clinical, morphological, and immunophenotypic characteristics. Non-Hodgkin’s lymphoma is characterized by abnormal proliferation or accumulation of B or T lymphocytes. Circulating neutrophils and platelets have a proven role in both the pathogenesis of inflammatory processes and thrombosis and in the processes of tumorigenesis.The formation of complexes between neutrophils and circulating platelets (PNC) is a fundamental mechanism that is known but poorly studied in non-Hodgkin's lymphomas. Aim: To investigate the levels of circulating neutrophil-platelet complexes in newly diagnosed patients with aggressive and indolent NHL and the relationship of those levels with prognostic risk, prognosis, overall survival, and therapeutic response. Methods: PNC levels were analyzed by flow cytometry of peripheral blood from 88 patients with histologically verified NHL before chemotherapy. The results were statistically analyzed using dispersion, variable, comparison, correlation, and regression methods. Results: The mean age of the studied patients was 60.6 years ± 11.8 years (range 28–88 years), with men and patients with aggressive lymphoma accounting for just over half the population (52.3% each). A significant difference (p = 0.005) and an inversely weak dependence was found between IPI risk and survival (r = -0.277; p = 0.009) in aggressive lymphomas. A significant difference was found between the type of lymphoma and the therapeutic response (p = 0.030). A complete response was achieved in 42 (47.7%) patients with NHL, while progression was observed in 17 (19.3%) and relapse in 2 (2.3%) There was a strong significant correlation between PNC and IPI (р=0.021), PNC and therapeutic response (р=0.044). Conclusion: PNC measurement could be a useful diagnostic and prognostic marker in many diseases.

Impaired neutralizing antibody response to COVID-19 mRNA vaccines in cancer patients

There is currently a critical need to determine the efficacy of SARS-CoV-2 vaccination for immunocompromised patients. In this study, we determined the neutralizing antibody response in 160 cancer patients diagnosed with chronic lymphocytic leukemia (CLL), lung cancer, breast cancer, and various non-Hodgkin’s lymphomas (NHL), after they received two doses of mRNA vaccines. Serum from 46 mRNA vaccinated health care workers (HCWs) served as healthy controls. We discovered that (1) cancer patients exhibited reduced neutralizing antibody titer (NT50) compared to HCWs; (2) CLL and NHL patients exhibited the lowest NT50 levels, with 50-60% of them below the detection limit; (3) mean NT50 levels in patients with CLL and NHL was ~2.6 fold lower than those with solid tumors; and (4) cancer patients who received anti-B cell therapy exhibited significantly reduced NT50 levels. Our results demonstrate an urgent need for novel immunization strategies for cancer patients against SARS-CoV-2, particularly those with hematological cancers and those on anti-B cell therapies.

Pathology Characteristics of Lymphomas in Rwanda: A Retrospective Study

Background: Lymphomas have been a global challenge for many decades and despite measures for prevention and management, the incidence continues to increase. There are two main categories, which are Non-Hodgkin’s Lymphomas and Hodgkin’s Lymphomas and most common etiologies are environmental, genetic alteration, radiation and some viruses. Objective: To describe pathology characteristics of lymphomas in Rwanda based on Hematoxylin and Eosin stained glass slides and immuno histo chemistry, and classify them according to clinical aggressiveness. Patients and Methods: We conducted a retrospective observational and descriptive study from January 2013 to December 2019. Lymphoma cases were retrieved together with relevant clinical and pathological information, and reviewed by independent pathologists. Histological diagnosis was classified according to the 2008 World Health Organization system in order to assign clinical aggressiveness of the lymphoma. Results: Three hundred and six lymphoma cases were enrolled. Males contributed to 57% of all reviewed case, and slightly over 50% were young aged ≤35 years. Approximately 191 (62%) of cases were nodal lymphomas. Approximately one fifth (18%) of lymphoma cases were HIV positive. Most 213(70%) cases were Non-Hodgkin’s Lymphomas of aggressive forms 164(77%). Among 164 cases of aggressive Non-Hodgkin’s Lymphomas, diffuse large B cell lymphoma was the leading subtype 91(55.5%), followed by solid lymphoblastic lymphoma 32(19.5%) and Burkitt lymphoma 17(10.4%). Among all Hodgkin lymphoma cases, 90(97%) were classical Hodgkin lymphomaof nodular sclerosis subtype. Hodgkin lymphoma patients were younger compared to Non-Hodgkin’s Lymphomas patients (mean age of 24.78±16.3 years versus 38.6±22. 5years, p=.000). Conclusion: Substantial proportion of Lymphomapatients in Rwanda were also HIV positive. Interestingly, Non-Hodgkin’s Lymphomas in Rwanda are predominated by the most aggressive forms, and these mostly affect a younger population. Optimal characterisation of such cases, using advanced methods, is recommended.

Treatment and in-Hospital Overall Survival in Hematological Patients with Grade 4 Neutropenia and Coronavirus Infection

Background: According to published data, the risk of coronavirus infection (COVID-19) in patients with malignancies is 5 times higher than in those without malignancies. Objective: To evaluate in-hospital overall survival in hematological patients with grade 4 neutropenia associated with coronavirus infection. Patients: This study was conducted from April 24, 2020 to June 17, 2021 in the Department of Hematology of Moscow City Clinical Hospital No. 52 (Russian Federation) and included 76 hematological patients with grade 4 neutropenia and coronavirus infection (aged 18-91 years): • 40 patients with acute leukemias (32 with AML, 8 with ALL): 22 men with a median age of 54 years (interquartile range (IQR) 43-60) and 18 women with a median age of 61 years (IQR 56-70) and • 36 patients with lymphoproliferative diseases (mostly with aggressive non-Hodgkin's lymphomas): 13 men with a median age of 57 years (IQR 40-68) and 23 women with a median age of 63 years (IQR 35-75). All patients were brought in by ambulance from other hospitals where they had received a course of combination chemotherapy interrupted due to coronavirus infection. Results: Most pts had moderate to severe lung disease (CT severity scores were 2, 3, and 4 in 29 (38.2%), 17 (22.5%), and 8 (10%) patients, respectively); 55% of patients had high C-reactive protein and procalcitonin (above 0.5 ng/mL); lactate dehydrogenase (mean 395.7 U/L) and D-dimer (mean 2533.8) levels were significantly elevated. Patients had a higher NEWS score (mean 8) and a high Charlson comorbidity index score (mean 5). Interleukin-6 and IL-1b blockers were used as pathogenetic therapy to control hypercytokinemia. Taking into account grade 4 neutropenia, the dose of interleukin blockers was reduced. In order to prevent thromboembolic complications, low molecular weight heparins were used at therapeutic doses (with anti-Xa activity monitoring). Oxygen was administered in patients with clinical signs of respiratory failure (oxygen insufflation via nasal cannulas or mask). Patients with progressive respiratory failure were transferred to intensive care unit. In order to improve humoral immune response (due to low SARS-CoV-2 IgG antibody titers), 43.4% of patients were administered replacement therapy with pathogen-reduced fresh-frozen COVID-19 convalescent plasma. This led to a pronounced IgG increase in 7 patients only. Antifungal treatment was used in 54% of cases. Empirical antibacterial treatment for community-acquired pneumonia was administered, including inhibitor-protected aminopenicillins and respiratory fluoroquinolones (as 1st line treatment), upfront antibacterial treatment for neutropenic fever (2nd line), and targeted antibacterial treatment (3rd line). • In the acute leukemia group, 25 (63%) patients died during hospital treatment and 15 (37%) subjects survived; the median overall survival was 15 days (95% CI 15-22) (Fig. 1). • In the lymphoproliferative disease group, the numbers of deaths and survivals were 22 (61%) and 14 (39%), respectively, and the median overall survival was 25 days (95% CI 11-32) (Fig. 2). The median follow-up was 24 days. Conclusions: Coronavirus infection associated with severe neutropenia (caused by tumor progression and/or combination chemotherapy) is a significant adverse factor for overall survival in patients with hematological malignancies. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

A Third Anti-Sars-Cov2 mRNA Dose Does Not Overcome the Pejorative Impact of Anti-CD20 Therapy and/or Low Immunoglobulin Level in CLL/Lymphoma Patients

Introduction: Patients with lymphoma and chronic lymphocytic leukemia (CLL) share immune-deficiencies due to the biological features of these diseases per se and to their treatments. They are at risk to develop severe and/or prolonged forms of Covid-19. The efficacy of vaccination against COVID in lymphoma/CLL patients also raises specific concerns: Antibody response to mRNA COVID-19 vaccine was shown to be negatively affected by CLL stage and its treatments, especially in case of previous administration of anti-CD20 antibodies (Herishanu et al). Therefore, the addition of a third dose of vaccine in immunosuppressed patients is currently recommended in France. Methods: To analyse the determinants of the antibody response after anti-SARS-Cov2 mRNA vaccines (Pfizer or Moderna), we conducted a retrospective monocentric study among adults with a past or current lymphoma/CLL who underwent serology 2 weeks or more after 2 or 3 previous injections. The decision of a third dose was at the discretion of each physician. Data were extracted from the patients' medical charts on their demographics, lymphoma history and detailed treatments, vaccinations and biological parameters (immunoglobulin (Ig) G dosage, lymphocytic, B-cell and T-cell counts) and serology (Elecsys ® Anti-SARS-CoV-2 S). Statistical tests were two-tailed and p-values &lt; 0.05 were considered significant. Multivariable analysis was conducted using independent variables having univariate significance below 0.1. This study was conducted in accordance with the Declaration of Helsinki, and approved by the ethics committee of our institution. Results: Ninety-one patients with non-Hodgkin's lymphomas (NHL) (n=48), CLL (32) or Hodgkin's lymphoma (11) were enrolled. With a median interval since last dose of 47 days (range 15-125), 48 patients (53%) had a negative serology (Table). Gender and age were not associated with antibody response. The proportion of seronegativity was 57% among patients with B-cell NHL, and 41% among those with CLL. Among the biological variables reflecting immune deficiency, lymphocytopenia (&lt;1.5G/L), low B-cell counts (&lt;0.2G/L) and IgG levels (&lt;6g/L) were significantly associated with a higher risk of seronegativity with odds-ratios (OR, [95% confidence interval]) of 5.1 [1.8-15.3], p&lt;7x10 -4 , 15.0 [3.0-147.9], p&lt;7x10 -5, and 15.3 [3.7-93.0], p&lt;9x10 ⁻6 respectively). Patients under watch and wait attitude and those who did not have a lymphoma/CLL treatment since at least 12 months before vaccination had a much lower risk of negative serology (OR: 0.08 [&lt;0.01 ; 0.4], p&lt; 2.10 -4). Among lymphoma/CLL therapies, chemotherapy overall or targeted therapy with BTK inhibitors or Venetoclax were not significantly associated with a lower risk of negative serology. In contrast, the administration of anti-CD20 therapy during the year before first dose of vaccine was associated with a higher risk of negative serology (OR: 4.5 [1.7; 12.1], p&lt;8.10 -4). Of note, this treatment was also significantly associated with both lymphocytopenia and low B-cell counts. There was no association between the number of vaccine doses and the risk of negative serology, 59% of the patients who received 3 doses remained seronegative.A multivariable analysis associating IgG level and treatment history showed that negative serology is significantly associated with a low level of IgG (OR: 25.74 [5.58; 201.14], p &lt; 10 -3) and anti-CD20 treatment (OR: 28.70 [4.14, 382.60], p = 3x10 -3). Conclusion: Overall, previous anti-CD20 therapy and low IgG levels are the main independent factors associated with a lack of serological response after anti-SARS-Cov2 mRNA vaccine. Administration of a third vaccine does not overcome their pejorative impact. This should contribute to the elaboration of guidelines for the management of lymphoma/CLL patients during the Covid-19 era. In particular, in all non-critical clinical situation, SARS-CoV-2 vaccination should be proposed before the onset of lymphoma/CLL therapy. Meanwhile, individuals with CLL/lymphoma should receive the Covid-19 vaccine, be informed that they are unlikely to be protected and continue social distancing and adhere to other proven mitigation strategies. Systematic vaccination of their proxies and hospital workers should also benefit directly to patients. Figure 1 Figure 1. Disclosures Rigaudeau: Takeda: Membership on an entity's Board of Directors or advisory committees.

Case report of primary CD20 negative diffuse large B-cell lymphoma

ABSTRACT Few groups of aggressive non-Hodgkin’s lymphomas (NHL) that are refractory to standard chemotherapy are rarely reported. Primary CD20 negative diffuse large B cell lymphoma (DLBCL) without human immunodeficiency virus infection is an uncommon presentation and this case report is challenging in terms of diagnosis and treatment as well.

Diagnosis and endoscopic intervention in rare MALT lymphoma of the proximal jejunum

Summary: Extranodal lymphoma from the marginal zone mucosa-associated lymphoid tissue (MALT lymphoma) is one of the primary extranodal non-Hodgkin‘s lymphomas with low degrees of malignancy but with the risk of spreading to distant locations in the body. B-lymphomas are sometimes associated with other diseases (eg. Helicobacter pylori and Campylobacter jejuni infections or inflammatory bowel disease). B-lymphomas may manifest with a variety of clinical signs, from dyspeptic syndrome with malabsorption and weight loss to ileus or massive gastrointestinal bleeding. Dia­gnosis is based on the clinical condition and the results of laboratory tests and imaging techniques, while endoscopy is the essential procedure for visualizing the tumor mass and collecting a bio­psy sample to determine the definitive histopathological dia­gnosis. MALT lymphoma treatment is managed by oncologists and includes chemotherapy and/or radiotherapy, with resection indicated in rare cases. In this case report we present an elderly female patient who was referred to our IBD centre for non-specific abdominal pain with a positive fecal occult blood test. Computed tomography (CT) examination was used before endoscopy and showed an infiltration of the splenic flexure by an unspecified mass, a subsequent colonoscopy showed intact mucosa of the colon, including the terminal ileum. In the second reading of the CT scan the location of the infiltrate was identified more specifically as the area of the proximal jejunum and jejunal mesentery. Subsequent upper endoscopy revealed a stenosing exulcerated tumor in the proximal jejunum, with the stenosis impassable even for a pediatric colonoscope. The dia­gnosis of MALT lymphoma was confirmed by a histological examination of the bio­psied tissue. A follow-up upper endoscopy was performed after the patient had completed her oncological treatment (chemotherapy in combination with radiotherapy), showing the presence of stenosis at the proximal jejunum, still impassable for the endoscope. In clinical terms, the patient experienced weight loss, which was to some extent caused by intermittent pseudo-obstruction when on a solid diet, therefore we decided to enrich her oral intake with high-calorie sip feed. The next follow-up CT scan of the abdomen showed a regression of the infiltrate, but the stenosis of the proximal jejunum, about 7 centimeters long, persisted. To respect the patient‘s wishes, no surgical resection of the stenotic section of the intestine was performed, but we proceeded with endoscopic dilatation of the stenotic section of the jejunum with a balloon. After the first two endoscopic dilatations of the stenotic area the patient experienced a temporary improvement in solid food tolerance. Because of restenosis, a third endoscopic dilatation was performed, with the development of complications that included short-term circulatory instability with abdominal pain and eventually required an urgent surgical solution. Key words: marginal zone B-cell lymphoma – stenosis – dilatation – intestinal perforation – jejunum – MALT