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Several functional parameters from baseline (18)F-fluorodeoxyglucose positron emission tomography (PET)/computed tomography have been proposed as promising biomarkers of treatment efficacy in diffuse large B-cell lymphoma (DLBCL). We tested their ability to predict outcome in 2 cohorts of DLBCL patients receiving conventional immunochemotherapy (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone [R-CHOP] regimen), either every 14 (R-CHOP14) or 21 days (R-CHOP21). Baseline PET analysis was performed in 141 patients with DLBCL treated with R-CHOP14 in the prospective SAKK38/07 study (NCT00544219) of the Swiss Group for Clinical Cancer Research (testing set). Reproducibility was examined in a validation set of 113 patients treated with R-CHOP21. In the SAKK38/07 cohort, progression-free survival (PFS) at 5 years was 83% for patients with low metabolic tumor volume (MTV) and 59% for those with high MTV (hazard ratio [HR], 3.4; 95% confidence interval [CI], 1.6-7.0; P = .0005), whereas overall survival (OS) was 91% and 64%, respectively (HR, 4.4; 95% CI, 1.9-10; P = .0001). MTV was the most powerful predictor of outcome also in the validation set. Elevated metabolic heterogeneity (MH) significantly predicted poorer outcomes in the subgroups of patients with elevated MTV. A model integrating MTV and MH identified high-risk patients with shorter PFS (testing set: HR, 5.6; 95% CI, 1.8-17; P < .0001; validation set: HR, 5.6; 95% CI, 1.7-18; P = .0002) and shorter OS (testing set: HR, 9.5; 95% CI, 1.7-52; P < .0001; validation set: HR, 7.6; 95% CI, 2.0-28; P = .0003). This finding was confirmed by an unsupervised regression tree analysis indicating that prognostic models based on MTV and MH may allow early identification of refractory patients who might benefit from treatment intensification. This trial was registered at www.clinicaltrials.gov as #NCT00544219.

Introduction: DLBCL subtypes may be classified by gene expression corresponding to germinal centre (GCB) or activated peripheral blood (ABC) B-cells. Treatment outcomes with R-CHOP therapy were inferior for ABCs in retrospective series, and this study investigated whether adding bortezomib could reverse the adverse prognosis. The trial used gene expression profiling (GEP) to stratify cases, with adaptive design to analyse the outcome by subtypes at predefined timepoints. Methods: Newly diagnosed patients with DLBCL underwent staging and commenced standard R-CHOP. During cycle 1, formalin-fixed paraffin-embedded (FFPE) tissue was used to extract messenger RNA for GEP using the Illumina DASL array platform. Cases were allocated to GCB, ABC or Unclassifiable (Unc) type before starting cycle 2, using an established algorithm based upon 20 genes. Patients with successful GEP were randomised 1:1 to receive R-CHOP +/- bortezomib 1.6 mg/m2 s/c on days 1+8 in cycles 2-6. The study was powered to detect a difference in progression-free survival (PFS) of 10% with bortezomib, with a 2-sided significance, 5% and 90% power. The adaptive design allowed for closure of randomization for GCB cases if 1-year PFS was Results: Between 6/2011 and 5/2015 1132 patients were enrolled from 109 sites, with 1078 samples analysed. Of these, 157 (15%) biopsies had inadequate material for GEP, but the remaining 921 were classified as 246 (27%) ABC, 476 (52%) GCB and 199 (22%) Unc. Successful classification was possible from both surgical and needle core biopsies. Median laboratory turnaround time was 12 working days and all results were available prior to the scheduled administration of cycle 2. Characteristics of the patients of different subtypes are shown in the table. Following both interim analyses the DMEC recommended continued recruitment of patients with a GCB phenotype. Table. ABC GCB Unc Age (years): median 67 63 63 Age (years) : range 23 to 86 20 to 82 20 to 85 % performance status 0-1 88 88 90 % at least one extranodal site 53 54 62 % bone marrow involved 15 14 23 % LDH>ULN 69 76 79 % IPI score 0/1 29 27 26 % IPI score 2/3 57 55 55 % IPI score 4/5 15 19 19 % B symptoms 46 43 49 % Bulk>10cm 17 26 21 Conclusions: This study has demonstrated the feasibility of GEP at diagnosis to subsequently guide therapy in a large multicentre trial. Although patients with ABC type lymphoma were in general slightly older, they did not appear to have other adverse prognostic features at diagnosis vs GCB. All patients will have completed therapy by the time of the meeting, allowing the initial response and toxicity data to be available for presentation. Disclosures Davies: GIlead: Consultancy, Honoraria, Research Funding; Mundipharma: Honoraria, Research Funding; CTI: Honoraria; Takeda: Honoraria, Research Funding; Bayer: Research Funding; GSK: Research Funding; Janssen: Honoraria, Research Funding; Roche: Honoraria, Research Funding; Pfizer: Honoraria; Celgene: Honoraria, Research Funding. Off Label Use: The addition of bortezomib to R-CHOP chemotherapy in diffuse large B-cell lymphoma. Pocock:Janssen: Honoraria. Jack:Jannsen: Research Funding. Johnson:Takeda: Honoraria; Pfizer: Honoraria; Janssen: Research Funding.

Germinal Center (GCB) and activated (ABC) B-cell subtypes of DLBCL can be identified by Gene expression profiling (GEP). These subgroups are biologically distinct, harboring mutations in different pathways. Patients classified as ABC more often have mutations of the NF-kB pathway and an inferior response to standard R-CHOP therapy. The REMoDL-B trial utilised GEP to stratify patients for the addition of bortezomib to R-CHOP, based on the hypothesis that this agent may selectively improve the outcome of the ABC subtype. GEP was performed on RNA extracted from diagnostic formalin-fixed paraffin-embedded (FFPE) biopsies using Illumina WG-DASLTM during the 1st cycle of R-CHOP. Patients were classified as GCB, ABC or Unclassified before cycle 2 using the cross-platform DAC classifier (Care et al, PLOS ONE 2013) and randomised to continue R-CHOP+/-bortezomib. Work is underway to compare data generated on Affymetrix arrays and targeted RNA-seq (Illumina TRex), as well as validation by targeted mutational analysis of 18 genes associated with DLBCL (TNFAIP3, CARD11, CD79A, CD79B, MYD88, TRAF3, TNFRSF11A, PRDM1, TP53, FAS, B2M, CD58, EZH2, MLL2, MEF2B, EP300, CREBBP, KDM2B) using Fluidigm multiplex PCR and Illumina MiSeq on DNA also from the FFPE blocks. The trial closed to recruitment in May 2015 and 1147 samples have been analysed. One hundred and fifty three (13%) biopsies were unsuitable for GEP (for insufficient tumor tissue, inappropriate block sent). The remaining samples were classified as ABC (n=261, 23%), GCB (n=471, 44%) and Unclassified (n=214, 19%), with only 11 samples (1%) failing to yield a GEP result. GEP was successful in a range of sample types, including needle and endoscopic biopsies, bone marrow trephines and formal biopsies, with results obtained from as little as 40ng of total RNA, all from FFPE samples. Mutational data were available in 199 samples, with 73% of these having a mutation detectable in 1 or more genes (range 0-5) at a AAF (alternative allele frequency) cutoff at 10%. MYD88 was most commonly mutated (in 30% of ABC and 7% of GCB). EZH2 mutations were restricted to the GCB category (26%) and MYD88, CD79a/b and PRDM1 were more commonly associated with the ABC group. MYD88/PRDM1 were the most frequently associated events, with MYD88/CD79a/b and MYD88/NF-kB being mutually exclusive. Where MYD88 was seen in GCB cases, coexisting mutations imply an origin from transformed follicular lymphoma. B2M mutations were commonly identified across all subtypes (n=26), but specifically enriched in Type III (unclassified) cases (25%), which supports the hypothesis that mutational immune escape may be a feature of DLBCL, in common with other tumor types. Cross platform validation is highly concordant using Affymetrix arrays from a pilot series (27/27 gave the same classifier output, with correlating confidences also seen between platforms). RNA-seq analysis is ongoing, however initial analysis shows 86% concordance with the DASL output. Comprehensive cross platform comparison data will be available for presentation at the meeting. This study demonstrates the feasibility of GEP classification of DLBCL at diagnosis in a large international trial. The molecular classification can also be replicated using different technologies. Mutational analysis confirmed the association between DLBCL subtype and specific mutational hotspots. Disclosures Sharon: Johnson & Johnson: Other: Funded the laboratory work for the REMoDL-B trial (ISRCTN 51837425). Davies:Takeda: Honoraria; Seattle Genetics: Research Funding. Jack:Jannsen: Research Funding. Johnson:Johnson & Johnson: Other: Funded the laboratory work for the REMoDL-B trial (ISRCTN 51837425).

RIT in CD 20 positive lymphoma has mainly been studied by using 131Iodine (131I) or 90Yttrium (90Y) labelled antibodies. Lutetium-177 linked to the chimaeric anti CD 20 antibody Rituximab (R) with DOTA (1,4,7,10-tetraaza-cyclododecane-1,4,7,10-tetraacetic acid) as chelator emits beta rays (0.497MeV) and a gamma component (113keV 7%, 208keV 11%) suitable for imaging. Its handling is less hazardous than 131I and the beta component may give a more favourable tumour to non-tumour ratio than 90Y. The aim of the study was to determine the maximum tolerated dose (MTD) and to explore clinical response. Non labelled rituximab (250mg/m2) was given on d1 and d8. 177LU-D-R was injected on d8. Pts were hospitalized for five days for sequential imaging and, at higher doses, to fulfil radiation safety requirements. From Feb 02 to Aug 08 we treated 30 pts (m:16, f: 14, median # of preTx: 3) in 7 cohorts (level 1–7) of 2 to 7 pts. Since activity was already seen at the lowest dose (20 mCi/m2), escalation was carried out in steps of only 5 mCi/m2. No Grade III/IV non- hematologic toxicity was observed (2 pts being too early to evaluate). Gr II fatigue and Gr I nausea were reported mainly on the days following treatment (Tx). Hematologic toxicity: Anemia Gr II: 2 in 7 pts (2/7) at level 4, 1/4 at level 5. No Gr III/IV was seen, no transfusions were required. Lc: Gr III was seen at levels 3–6 each (nadir wk 8), no Gr IV was seen. Neutro: Gr III: 1/5 at level 3, 1/6 at level 4, 1/4 at level 5, 3/4 at level 6 no Gr IV was observed. No neutropenic fever was observed. Tc: One brief Gr IV was seen in 1 of 5 pts at level 3, one Gr III each at levels 4–6 (nadir: wk 7), no bleeding occurred and no Tc transfusions were required (2 pts being too early). Response was assessed by [18F]FDG-PET and CT or PET/CT pre Tx, wk 10 and when clinically indicated thereafter. Responses were seen on all dose levels. Six of 12 pts with untransformed follicular lymphoma (FL) (med age: 59 y, 36–82) remain in remission 74, 71, 71, 32, 6 and 4 months after RIT. One pt treated at the lowest dose had a regression of pleural effusions after RIT, received an allogeneic transplant and has been in remission for 70 months. Two pts with FL have died. One pt with transformed FL had a brief response, then received an autologous transplant and has been in remission for 2 yrs. The 14 pts with mantle cell lymphoma (MCL) (med age: 71 y, 46–85) usually had brief responses in parts of their tumour mass. 10 pts have died. Median time to next Tx was 4 months. One pt with localized indolent MCL responded twice to 177LU-D-R, progressed after the 3rd Tx and is alive 60 months after his 1st dose. One pt had a brief response, then received bortezomib and has been in CR for 2 years (2 pts too early). Other indolent histologies had brief responses. With a maximum observation time of 75 months, no MDS or leukemia was seen. According to national radiation safety requirements 177LU-D- R at a dose of 50mCi/m2 requires a hospital stay of 5 days. This dose seems to have a promising therapeutic index mainly in FL and will be tested in a larger patient cohort. (This study was supported by the JP Obrecht Foundation, Arlesheim, Switzerland and the Swiss Cancer League. Day 1 and 8 Rituximab for pts 1 to 25 was provided free of charge by Roche Pharma Schweiz, Reinach, Switzerland. 177LU-D-R was manufactured at the Radiological Chemistry unit, University Hospital, Basel, Switzerland. Lutetium-177 was purchased either from I.D.B. Holland BV or from Perkin Elmer, USA)