Spatial Multi-Omics Treatment Paradigms in a Phase II Clinical Study of Early Relapsed/Refractory Diffuse Large B-Cell Lymphoma

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma. It can be aggressive but is potentially curable with current treatment modalities. The frontline standard of care for DLBCL is the chemoimmunotherapy regimen known as R-CHOP. Despite advances in frontline therapies for DLBCL, primary refractory disease and early relapses remain significant challenges. To address this, we developed a rapid, innovative clinical therapy enhancement model utilizing spatial multi-omics and historical patient cohorts.

RESULTS

Our 40-marker Imaging Mass Cytometry (IMC) panel has revealed a detailed depiction of the DLBCL ecosystem. Notably, levels of macrophages and endothelial cells were significantly elevated in the early relapsed group, correlating with a poorer prognosis. Furthermore, our analysis pinpointed the macrophage-endothelial cellular neighborhoods as critical components. These cells play a crucial role in upregulating the expression of vascular endothelial growth factor A (VEGFA), a key factor in promoting angiogenesis, disease progression, and drug resistance. With this insight, we promptly initiated an animal experiment utilizing a combination of RGMOX and the anti-VEGF drug Anlotinib, specifically targeting these tumor microenvironment (TME) configurations. The combination therapy cohort demonstrated the most potent inhibitory effect on subcutaneously transplanted tumors, emphasizing the potential of this regimen to effectively suppress tumor proliferation in vivo.

Based on the spatial multi-omics analysis and pre-clinical experimental results, we started a clinical trial of a combinatory paradigm with Anlotinib and RGEMOX (A-RGEMOX). The trial was conducted from Oct 1, 2023. 24 patients with primary refractory or early relapsed DLBCL were screened for eligibility, and 20 patients were finally enrolled. Among the enrolled patients, the median age was 56.5 years, and half were male. 13 cases were at Ann Arbor stages III-IV. 70% of all patients were classified as intermediate/high risk (IPI ≥ 2). For 19 patients receiving the A-RGEMOX regimen, the ORR for the investigator-assessed best responses was 63.1%, with a CRR of 26.3%. The median follow-up duration was 6.8 months, while the median PFS and OS were 5.8 months (95% CI 3.5-8.0) and not reached, respectively. Throughout the study, no unexpected adverse events were reported. Clinical interventions that target this cellular interaction have successfully produced notable therapeutic outcomes in relapsed/refractory (R/R) DLBCL patients, leading to a substantial rise in the CRR from 9% to 26.3%.

METHOD

We established a rapid, innovative clinical intervention model grounded in spatial multi-omics analysis and historical patient cohorts. IMC was performed on 88 pathological samples from 88 patients. Then we crafted an IMC panel comprising 40 markers specifically suited for probing the DLBCL landscape. After identifying the key cellular interactions in the TME of early relapse patients, we promptly implemented an improved clinical trial combining RGMOX with Anlotinib, specifically targeting these TME configurations. For all enrolled patients in the prospective clinical trial, A-RGEMOX regimen was planned to be administered in 21-day cycles with a total of 6 cycles. Anlotinib was given 12 mg qd orally from d1 to d14, and rituximab intravenously 375 mg/m² on d1, gemcitabine 1000 mg/m² on d1 and d8, oxaliplatin 130 mg/m² on d1. Study treatment was continued until the progression of disease, unacceptable toxicity, or patient or physician decision. The last follow-up date of this prospective study was Jun 30, 2024.

CONCLUSIONS

Our research emphasizes the significance of spatial multi-omics in guiding precision therapy for R/R DLBCL. Through an in-depth exploration of the spatial architecture of the TME, we have identified promising therapeutic strategies, such as the combination of R-GMOX with anlotinib, that surpass the limitations observed in trials like SWOG 0515. This study not only enhances our comprehension of DLBCL pathobiology but also underscores the transformative potential of spatial multi-omics in precision oncology. Moving forward, integrating these advanced analyses into clinical decision-making is likely to refine therapy stratification and ultimately improve patient outcomes in the complex landscape of relapsed/refractory DLBCL.