Scottsdale, Arizona Rochester, Minnesota Jacksonville, Florida Diffuse Large Cell Lymphoma Cell of Origin – Ready for Prime Time? Thomas Witzig, MD Hematology Malignancy Program Mayo Clinic Cancer Center

Disclosure  Research funding from Celgene, Novartis, Millenium for clinical trials  Research funding from Millenium for preclinical work  Advisory boards for Spectrum, Celgene, and Bayer (no personal compensation) 2

Time for Action? Origins Research in DLBCL Lancet Oncol Jun;15(7):674-5

Cell of Origin Techniques  Gene expression profiling  Microarrays on RNA expression  Frozen tissue  Thousands of genes  Year 2000 onward  Immunohistochemistry  2004; Many algorithms; Hans still most widely used  Lymph2Cx Blood Feb 20;123(8):1214-7

15 Years Ago Nature Feb 3;403(6769): “And like most overnight successes, it was about twenty years in the making” S. Walton originator of WalMart

Nature Feb 3;403(6769):

Prognostic in the Pre-RCHOP Era

Hans Method – 10 Years Ago Hans et al Blood. 2004;103(1):

OS by TMA Hans et al Blood. 2004;103(1):

Meyer PN et al J Clin Oncol 2011;29(2): cases of DLBCL; 192 had GEP

Meyer P N et al. JCO 2011;29: by American Society of Clinical Oncology

Event-free survival of patients with diffuse large B-cell lymphoma according to immunophenotype by each algorithm. Meyer P N et al. JCO 2011;29: by American Society of Clinical Oncology Tally Hans

Overall survival of patients with diffuse large B-cell lymphoma according to immunophenotype by each algorithm. Meyer P N et al. JCO 2011;29: ©2011 by American Society of Clinical Oncology Tally Hans

Blood Feb 20;123(8):1214-7

Lymph2Cx

Blood Feb 20;123(8): Lymph2Cx  Matched FFPE and frozen  Traditional GEP; IHC; and Lymph2Cx  Training cohort – 51 cases  20 GCB; 19 ABC; 12 unclassified  Validation cohort – 68 cases  28 GCB; 30 ABC; 10 unclassified  10 micron scrolls; Qiagen AllPrep FFPET kit  Extract RNA from FFPE tissue slice  Digital GEP on 200 ng RNA using Nanostring technology  Sample split and run independently in 2 labs

Blood Feb 20;123(8): Lymph2Cx  Tested 93 genes found by Lenz et al to differentiate GCB from ABC (Lenz NEJM 2008)  20 were all that were needed  15 of the 93 and 5 “housekeeping genes”  NanoString technology on 20 genes was used in these two datasets

Blood Feb 20;123(8): Lymph2Cx Gold Standard GEP PFS OS

Prognosis or Helping Choose Therapy? Which drug to add????? Cell of Origin

65 Years of Lymphoma Rx ‘02 Rituximab RIT RCHOP 2-CDA CHOP ABVD Nitrogen Mustard Vincristine Doxorubicin 1993 CHOP Wins! VP Autologous SCT Cis-platinum 03 Bort 1953 Methotrexate 1983 ‘07 Lenalidomide Everolimus Vorinostat ‘05 Bendamustine ‘09 Pralatrex Romadep Era of Targeted Therapy Era of Chemotherapy 2011 Brentux Ibrutinib Lenalidomide 2013 Idelalisib 2014

CP R-CHOP is 15% Better than CHOP Probability HR=0.64 p=0.003 HR=0.64 p=0.003 R-CHOP CHOP Probability Years from Induction Randomization HR=0.72 p=0.05 HR=0.72 p=0.05 R-CHOP CHOP Failure-Free Survival Overall Survival Coiffier et al N Engl J Med. 2002; Habermann et al J Clin Oncol 2006

R(X)CHOP Era – what is X?  Epratuzumab - ERCHOP  Lenalidomide – R2CHOP  Bortezomib – Bor-RCHOP  Everolimus – ER-CHOP; maintenance E in CRADN2301 (enrolled)  Everolimus – EverRCHOP – N1085  Ibrutinib – IR-CHOP 22 Ann Oncol Epub 2014/03/15

Lenalidomide-RCHOP (R2CHOP)  Untreated DLBCL eligible for RCHOP  Standard RCHOP-21 x 6 cycles  Lenalidomide d1-10 q 21  Three dose levels tested:  15 mg  20 mg  25 mg  All patients received prophylactic pegfilgrastim d2  All patients received aspirin 81 mg daily 23 Nowakowski G et al Leukemia. 2011;25(12):

MC078E – Phase II Results  Phase I/II trial of R2CHOP for untreated DLBCL  Any age  RCHOP + lenalidomide 25 mg days 1-10 q21 x 6 cycles  ASA daily  Pegfilgrastim day 2  No maintenance  Cell of origin by Hans algorithm Nowakowski G et al J Clin Oncol Epub 2014/08/20

MC078E  64 patients enrolled; 60 evaluable  87 controls at same time with RCHOP  ORR 98% (59/60)  CR 80% (48/60)  Event-free survival at 24 months - 59%  Overall survival at 24 months - 78%  No difference in GCB vs non-GCB in R2CHOP arm Nowakowski G et al J Clin Oncol Epub 2014/08/20

MC078E  RCHOP control  EFS/OS at two years for GCB: 46% and 78%  EFS/OS at two years for non-GCB: 28% and 64%  R2CHOP  EFS/OS at two years for GCB: 60% and 83%  EFS/OS at two years for non-GCB: 59% and 75% Nowakowski G et al J Clin Oncol Epub 2014/08/20

R2CHOP RCHOP

Nowakowski G et al J Clin Oncol Epub 2014/08/20 R2CHOP RCHOPR2CHOP RCHOP R2CHOP

Italian R2CHOP  DLBCL and FL 3b  R2CHOP in 13 centers in Italy  GCB vs non-GCB by IHC (Hans)  Standard RCHOP x 6  Lenalidomide 15 mg days 1-14 q 21  49 patients  92% (45/49) ORR with 86% functional CR 29 Lancet Oncol. 2014;15(7):730-7.

Outcome of R2CHOP (Italian) 30 Vitolo et al Lancet Oncol. 2014;15(7):730-7.

GCB vs. non-GCB 31 Lancet Oncol. 2014;15(7):730-7.

©2011 MFMER | slide-32

©2011 MFMER | slide-33 ECOG 1412 Randomized phase II of RCHOP vs. R2CHOP First patient in September 19, 2013 GCB and ABC Endpoint is response in ABC as defined by GEP Nanostring on paraffin-embedded tissue 110 patients accrued as of October 2014

DLBCL-002  FDA registrational, International Phase III  RCHOP x 6 vs. R2CHOP x 6  Lenalidomide 15 mg days 1-14 vs. placebo  Untreated DLBCL Stage II-IV  Ages years  Requires excisional biopsy  ABC by Nanostring GEP on FFPE tissue  Promised 5 day turnaround; steroids allowed  600 patients  Opening Dec

Furman RR et al Cancer. 2010;116(23):

L. Staudt

Bortezomib R-CHOP  20 patients – 16 DLBCL/4 MCL  Median age 66 years (range, 29-84)  Standard RCHOP-21  Bortezomib - Days 1 and 4 of each cycle  0.7 mg/m2 - 4 patients  1.0 mg/m2 - 9 patients  1.3 mg/m2 - 7 patients  No DLT with any dose; grade 3 neuropathy in 1  95% CR 37 Furman RR et al Cancer. 2010;116(23):

Bortezomib R-CHOP  At a median follow-up of 56 months  Overall survival at 4 years was 75%  Progression-free survival was 58%  Randomized phase II of RCHOP vs. RBCHOP in progress in US 38 Furman RR et al Cancer. 2010;116(23):

Phase III Trials  RCHOP vs. Bor-RCHOP in UK 39 Start May 2011 and predicted to end in 2015

Ibrutinib with RCHOP 40 Younes A et al Lancet Oncol Aug;15(9):

IR-CHOP  Phase 1/2  DLBCL, MCL, FL  June 2012 – May 2013  No ASA, warfarin, heparin allowed  RCHOP x 6 + ibrutinib daily  No maintenance  No prophylactic G-CSF (allowed but not mandated) 41 Younes A et al Lancet Oncol. 2014;15(9):

IR-CHOP  33 patients  No MTD for ibrutinib; thus 560 mg/d continuously with standard RCHOP-21  18% febrile neutropenia  18 pts with DLBCL in the phase 2 42 Younes A et al Lancet Oncol. 2014;15(9):

IR-CHOP  100% ORR in the DLBCL (18/18)  15 CR and 3 PR  4/4 nonGCB – CR  5/7 GCB – CR  PK not affected for either ibrutinib or vincristine  A randomized phase III is ongoing –placebo controlled (NCT ) for non-GCB type 43 Younes A et al Lancet Oncol. 2014;15(9):

Summary about COO in DLBCL  Increases understanding of the biology  Helps predict prognosis but not particularly well  May guide therapy  New treatments with lenalidomide and ibrutinib are focusing on ABC-type  New techniques of GEP will enhance the clinical utility and “bring it to your hospital”  Prediction – you will use COO to “choose X” 44