Phase I Study of Oral Azacitidine Plus Salvage Chemotherapy in Relapsed/Refractory Diffuse Large B-Cell Lymphoma

Phase I Study of Oral Azacitidine Plus Salvage Chemotherapy in Relapsed/Refractory Diffuse Large B-Cell Lymphoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Phase I Study of Oral Azacitidine Plus Salvage Chemotherapy in Relapsed/Refractory Diffuse Large B-Cell Lymphoma Brian Hess, Nina D Wagner-Johnston, Lindsey Hendrickson, James A Davis, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8563481/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Salvage chemotherapy and autologous stem cell transplantation (ASCT) offer the opportunity to cure eligible patients with relapsed diffuse large B-cell lymphoma (DLBCL). Epigenetic alterations such as aberrant DNA methylation patterns have been linked to chemotherapy resistance in DLBCL. Oral Azacitadine (AZA) is an oral hypomethylating inhibitor that inhibits DNA methyltransferase and has provided evidence of chemotherapy sensitization in DLBCL. In this phase I trial the safety and efficacy of two dose levels of AZA were investigated in combination with standard cytotoxic chemotherapy rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) in relapsed DLBCL patients who were candidates for ASCT. lymphoma dlbcl epigenetics Figures Figure 1 Figure 2 Figure 3 Introduction Approximately 40% of patients with diffuse large B-cell lymphoma (DLBCL) experience relapsed or refractory (R/R) disease. For those not meeting an indication for second-line CAR T-cell therapy, salvage chemotherapy followed by autologous stem cell transplant (ASCT) remains the standard of care for transplant eligible patients, though success is contingent upon tumor response to salvage chemotherapy [ 1 – 4 ]. Aberrant DNA methylation has emerged as a key driver of chemotherapy resistance and immune evasion in DLBCL, characterized by the silencing of tumor suppressor genes and the depletion of the lymphoma microenvironment (LME), characterized by a lack of immune infiltration [ 5 – 9 ]. DLBCL cases with a depleted LME, common in relapsed DLBCL, are also characterized by increased DNA hypermethylation. [ 10 ] Preclinical data suggest that hypomethylating agents like oral azacitidine (AZA) can reverse these epigenetic alterations, sensitizing resistant clones to cytotoxic therapy [ 10 – 12 ]. Based on this rationale, we conducted a phase I trial to evaluate the safety, efficacy, and correlative outcomes of combining AZA with standard R-ICE (rituximab, ifosfamide, carboplatin, etoposide) salvage therapy in transplant-eligible R/R DLBCL. Methods This was an open-label phase I study conducted at the Hollings Cancer Center at the Medical University of South Carolina and Sidney Kimmel Cancer Center at Johns Hopkins University Center (NCT02343536). This study was approved by the respective institutional review boards at each institution. Written informed consent was obtained from each patient, and research conducted in accordance with the Declaration of Helsinki. Eligible participants were adults (≥ 18 years) with relapsed/refractory (R/R) DLBCL, grade 3B follicular lymphoma, or transformed indolent lymphoma who were candidates for ASCT. All patients received ≥ 1 prior anti-CD20 multi-agent regimen and had measurable disease by Lugano 2014 criteria. [ 13 ] The protocol was amended post-activation to exclude patients > 70 years with ECOG PS > 1 due to toxicity concerns. Patients received rituximab (375 mg/m² day 1), ifosfamide (5,000 mg/m² day 2), carboplatin (AUC 5 day 2), and etoposide (100 mg/m² days 1–3) (R-ICE). Azacitidine (AZA) was administered (days − 6 to 0 prior to cycle 1; days 8–21 of cycles 1–2) (Fig. 1 ). Each cycle was 21-days. Dose escalation followed a standard 3 + 3 design at 200 mg (DL1), 300 mg (DL2), and 150 mg (DL-1). Dose-limiting toxicity (DLT) was defined by CTCAE v5.0 as a Grade ≥ 3 adverse event leading to a > 7-day cycle delay or Grade ≥ 2 vomiting/diarrhea persisting > 48 hours despite best supportive care. The primary objective was to determine the recommended phase 2 dose (RP2D). Secondary endpoints included overall response rate (ORR) and complete remission (CR) rate per 2014 International Working Group (IWG) criteria, stem cell mobilization feasibility, and proportion of patients proceeding to ASCT. Safety was monitored weekly via hematology assessments; response was assessed by PET-CT after treatment completion. Lymph node biopsy and/or bone marrow for RNA extraction was obtained from samples at diagnosis, at relapse prior to initiating study treatment, and relapse after initiation of study treatment when available. The SureSelect XT HS2 RNA System Library Prep Kit (Agilent) was used for cDNA preparation. Sequencing was performed using an Illumina NovaSeq 6000 10B 0.5 Flowcell at the WCM Genomics Resources Core Facility. Transcripts were quantified against Gencode hg38 genome using Salmon 1.10.0 REF1. [ 14 ] Transcript abundances were summarized with tximport 1.32.0 in R version 4.5.0. DESeq2 1.44.0 REF2 was used for differential expression analysis. [ 15 ] LME and MFP determination were done in python 3 following methods previously published. [ 12 , 16 ] Results Enrollment was completed with 9ine patients (median age 58, range 45–71; 56% male). The cohort represented a high-risk population, with 89% relapsing < 1 year after frontline therapy (Table 1 ). Table 1 Baseline Characteristics Characteristic N = 9 (%) Gender Female Male 4 (44) 5 (56) Histology DLBCL, NOS DLBCL, GCB subtype DLBCL, non-GCB subtype THRLBCL HGBCL Transformed from Indolent Lymphoma 1 (11) 1 (11) 2 (22) 2 (22) 1 (11) 2 (22) Age Median (range) 58 (45–71) Relapse After Frontline Chemotherapy < 12 months ≥ 12 months 8 (89) 1 (11) DLBCL, diffuse large B-cell lymphoma; NOS, not otherwise specified; GCB, germinal center B-cell subtype; THRLBCL, T-cell/histiocyte-rich large B-cell lymphoma; HGBCL, high-grade B-cell lymphoma Six patients were treated at DL1 (200 mg) and three at DL2 (300 mg). At DL2, one patient experienced a Grade 5 DLT (neutropenic sepsis). While subsequent DL2 patients did not strictly meet DLT criteria, frequent cycle delays (80%) and missed AZA doses (35%) due to persistent cytopenias led to a safety closure of DL2. In contrast, DL1 was well-tolerated with no DLTs, no cycle delays, and minimal missed AZA doses (4%) (Table 2 ). Based on these safety and feasibility data, DL1 (200 mg) was established as the RP2D. Table 2 Dose Delays, Missed Doses, and Adverse Events by Dose Level Dose Level (N) DL1–200 mg (6) DL2- 300 mg (3) Combined (9) Missed Doses of AZA due to Cytopenias (%) Pre-phase Cycle 1 Cycle 2 Missed/Planned Total 0 (0) 0 (0) 7 (8) 7/210 (4) 4 (19) 19 (45) 9 (32) 32/91 (35) 4 (6) 19 (15) 16 (14) 39/301 (13) Cycle 2 or 3 R-ICE chemotherapy delay (%) 0/12 (0) 4/5 (80) 4/17 (24) Completion of 3 cycles of R-ICE (%) 6 (100) 2 (67) 8 (89) Grade ≥ 3 Adverse Events Related to AZA Hematologic 5 5 15 8 20 13 Neutropenic Fever/Cycles (%) 0/18 (0) 2/7 (28) 2/25 (8) Dose Limiting Toxicity (%) 0 (0) 1 (33) 1 (11) The most frequent adverse events (AEs) across all grades included nausea (78%), thrombocytopenia (78%), and anemia/neutropenia (56%) (Fig. 2 ). Grade ≥ 3 hematologic toxicity was significantly more prevalent at DL2 compared to DL1, specifically neutropenia (100% vs. 17%) and neutropenic fever (67% vs. 0%). Among eight evaluable patients, the overall response rate (ORR) was 50%, with all responders achieving complete remission (CR). Four patients (50%) successfully proceeded to ASCT. All transplant-eligible patients achieved adequate peripheral blood stem cell (PBSC) collection (median 4.08 x 10⁶ CD34 cells/kg). At a median follow-up of 15 months, the median progression-free survival (PFS) was 6 months (95% CI: 2.5–NR) and median overall survival (OS) was 35.5 months (95% CI: 9.5–NR). RNA-sequencing of pre-treatment biopsies (n = 5) revealed that patients with durable CRs exhibited lower tumor proliferation signatures and higher immune infiltration (NK cells, T cells, and T-cell attractant cytokines) compared to non-responders or those who relapsed (Fig. 3 ). This pattern is consistent with the notion that DLBCL patients with immune-infiltrated LMEs exhibit a higher response to therapies, including epigenetic agents and immunochemotherapy. [ 16 ] Serial sequencing in one relapsing patient demonstrated progressive T-cell/NK-cell depletion and a marked increase in cancer-associated fibroblasts (CAF). Progression was further characterized by upregulation of FGFR1 and downregulation of IFNG , suggesting an evolving immune-depleted microenvironment as a mechanism of resistance. [ 17 ] Discussion While therapeutic advances have improved outcomes for DLBCL, patients with relapsed/refractory (R/R) disease not meeting an indication for second-line CAR T-cell therapy still face suboptimal prognoses. [ 18 – 19 ] We report the first phase I results investigating the addition of azacitidine (AZA) to R-ICE chemotherapy as an epigenetic sensitizing salvage strategy for transplant-eligible patients. Our findings establish 200 mg (DL1) as the recommended phase 2 dose (RP2D). At this level, the regimen was well-tolerated with expected hematologic adverse events, no neutropenic fevers, and no dose-limiting toxicities. In contrast, 300 mg (DL2) resulted in excessive toxicity and R-ICE cycle delays, precluding its further use. Notably, our correlative studies identified an immune-infiltrated lymphoma microenvironment (LME) signature as predictive for durable complete remission (CR) with this epigenetic-chemotherapy combination. Notably, we observed a 50% CR rate despite 89% of our cohort experiencing early relapse (< 1 year post-frontline therapy), a group historically associated with poor chemotherapy sensitivity and inferior post-ASCT outcomes. [ 21 – 22 ] While CAR T-cell therapy has rightfully become the standard for early-relapsing DLBCL, its current regulatory approval does not extend to transplant eligible patients relapsing > 12 months after frontline treatment. This may represent an ideal population for future to further test this combination. Additionally, this study provides a further rationale for pharmacological reversal of epigenetic resistance to chemotherapy in relapsed lymphoma. Declarations Conflict of interest: B.H. participated in advisory board with Incyte, Kite/Gilead, ADC Therapeutics, Genmab and has Speaker's bureau with BMS. N.WJ. has Research funding from Astra Zeneca, Genetech, Merck. J.D. has consultancy with Jannsen Biotech, BMS, GSK and speaker’s bureau with Janssen Biotech This study involved human participants and all procedures involved in this study were in accordance with the ethical standards of the Institutional Review Board of MUSC and Johns Hopkins University. Informed consent was obtained from all participants. The study followed the principles of the Declaration of Helsinki. Data supporting the findings of this study are available within the paper and its supplementary information. All other data is available upon request. Authors contributions: B.H. was responsible for conceptualization, methology, investigation, funding acquisition, writing original draft as well as writing (review and editing). N.W-J. was responsible for investigation and writing (review and editing). L.H. was responsible for investigation J.D. was responsible for investigation and writing (review and editing). E.H. was responsible for methodology, formal analysis, and writing (review and editing). A.G. was responsible for investigation and writing (review and editing). K.A. was responsible for data curation and writing (review and editing). M.R. was responsible for investigation, visualization, figure preparation, and writing (review and editing). S.S and R.K. were responsible for data curation and project administration L.C. was responsible for methodology, investigation, formal analysis, and writing (review and editing). Funding information: Funding was provided by Hollings Cancer Center Medical University of South Carolina, Lymphoma Research Foundation, and Bristol-Myers Squibb References Philip T, Guglielmi C, Hagenbeek A, Somers R, Van der Lelie H, Bron D, Sonneveld P, Gisselbrecht C, Cahn JY, Harousseau JL et al (1995) Autologous bone marrow transplantation as compared with salvage chemotherapy in relapses of chemotherapy-sensitive non-Hodgkin's lymphoma. N Engl J Med. ;333(23):1540-5. 10.1056/NEJM199512073332305 . PMID: 7477169 Gisselbrecht C, Glass B, Mounier N, Singh Gill D, Linch DC, Trneny M, Bosly A, Ketterer N, Shpilberg O, Hagberg H, Ma D, Brière J, Moskowitz CH, Schmitz N (2010) Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. ;28(27):4184-90. doi: 10.1200/JCO.2010.28.1618. Epub 2010 Jul 26. Erratum in: J Clin Oncol. 2012;30(15):1896. PMID: 20660832; PMCID: PMC3664033 Hamadani M, Hari PN, Zhang Y, Carreras J, Akpek G, Aljurf MD, Ayala E, Bachanova V, Chen AI, Chen YB, Costa LJ, Fenske TS, Freytes CO, Ganguly S, Hertzberg MS, Holmberg LA, Inwards DJ, Kamble RT, Kanfer EJ, Lazarus HM, Marks DI, Nishihori T, Olsson R, Reddy NM, Rizzieri DA, Savani BN, Solh M, Vose JM, Wirk B, Maloney DG, Smith SM, Montoto S, Saber W, Alpdogan O, Cashen A, Dandoy C, Finke R, Gale R, Gibson J, Hsu JW, Janakiraman N, Laughlin MJ, Lill M, Cairo MS, Munker R, Rowlings PA, Schouten HC, Shea TC, Stiff PJ, Waller EK (2014) Early failure of frontline rituximab-containing chemo-immunotherapy in diffuse large B cell lymphoma does not predict futility of autologous hematopoietic cell transplantation. Biol Blood Marrow Transpl 20(11):1729–1736. 10.1016/j.bbmt.2014.06.036 Epub 2014 Jul 5. PMID: 25008330; PMCID: PMC4194275 Martín A, Conde E, Arnan M, Canales MA, Deben G, Sancho JM, Andreu R, Salar A, García-Sanchez P, Vázquez L, Nistal S, Requena MJ, Donato EM, González JA, León A, Ruiz C, Grande C, González-Barca E, Caballero MD, /TAMO Cooperative Group) (2008) R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 93(12):1829–1836. 10.3324/haematol.13440 Epub 2008 Oct 22. PMID: 18945747 Grupo Español de Linfomas/Trasplante Autólogo de Médula Osea (GEL Clozel T, Yang S, Elstrom RL, Tam W, Martin P, Kormaksson M, Banerjee S, Vasanthakumar A, Culjkovic B, Scott DW, Wyman S, Leser M, Shaknovich R, Chadburn A, Tabbo F, Godley LA, Gascoyne RD, Borden KL, Inghirami G, Leonard JP, Melnick A, Cerchietti L (2013) Mechanism-based epigenetic chemosensitization therapy of diffuse large B-cell lymphoma. Cancer Discov 3(9):1002–1019. 10.1158/2159-8290.CD-13-0117 Epub 2013 Aug 16. PMID: 23955273; PMCID: PMC3770813 Amara K, Ziadi S, Hachana M, Soltani N, Korbi S, Trimeche M (2010) DNA methyltransferase DNMT3b protein overexpression as a prognostic factor in patients with diffuse large B-cell lymphomas. Cancer Sci 101(7):1722–1730. 10.1111/j.1349-7006.2010.01569.x Epub 2010 Mar 19. PMID: 20398054; PMCID: PMC11159814 Lenz G, Wright G, Dave SS, Xiao W, Powell J, Zhao H, Xu W, Tan B, Goldschmidt N, Iqbal J, Vose J, Bast M, Fu K, Weisenburger DD, Greiner TC, Armitage JO, Kyle A, May L, Gascoyne RD, Connors JM, Troen G, Holte H, Kvaloy S, Dierickx D, Verhoef G, Delabie J, Smeland EB, Jares P, Martinez A, Lopez-Guillermo A, Montserrat E, Campo E, Braziel RM, Miller TP, Rimsza LM, Cook JR, Pohlman B, Sweetenham J, Tubbs RR, Fisher RI, Hartmann E, Rosenwald A, Ott G, Muller-Hermelink HK, Wrench D, Lister TA, Jaffe ES, Wilson WH, Chan WC, Staudt LM (2008) Stromal gene signatures in large-B-cell lymphomas. N Engl J Med 359(22):2313–2323. 10.1056/NEJMoa0802885 PMID: 19038878; PMCID: PMC9103713 Lymphoma/Leukemia Molecular Profiling Project Kihslinger JE, Godley LA (2007) The use of hypomethylating agents in the treatment of hematologic malignancies. Leuk Lymphoma. ;48(9):1676-95. 10.1080/10428190701493910 . PMID: 17786703 Pan H, Jiang Y, Boi M, Tabbò F, Redmond D, Nie K, Ladetto M, Chiappella A, Cerchietti L, Shaknovich R, Melnick AM, Inghirami GG, Tam W, Elemento O (2015) Epigenomic evolution in diffuse large B-cell lymphomas. Nat Commun 6:6921. 10.1038/ncomms7921 PMID: 25891015; PMCID: PMC4411286 Kotlov N, Bagaev A, Revuelta MV, Phillip JM, Cacciapuoti MT, Antysheva Z, Svekolkin V, Tikhonova E, Miheecheva N, Kuzkina N, Nos G, Tabbo F, Frenkel F, Ghione P, Tsiper M, Almog N, Fowler N, Melnick AM, Leonard JP, Inghirami G, Cerchietti L (2021) Clinical and Biological Subtypes of B-cell Lymphoma Revealed by Microenvironmental Signatures. Cancer Discov 11(6):1468–1489. 10.1158/2159-8290.CD-20-0839 Epub 2021 Feb 4. PMID: 33541860; PMCID: PMC8178179 Cerchietti L (2024) Genetic mechanisms underlying tumor microenvironment composition and function in diffuse large B-cell lymphoma. Blood 143(12):1101–1111. 10.1182/blood.2023021002 PMID: 38211334; PMCID: PMC10972714 Martin P, Bartlett NL, Chavez JC, Reagan JL, Smith SM, LaCasce AS, Jones J, Drew J, Wu C, Mulvey E, Revuelta MV, Cerchietti L, Leonard JP (2022) Phase 1 study of oral azacitidine (ORAL AZACITADINE) plus R-CHOP in previously untreated intermediate- to high-risk DLBCL. Blood 139(8):1147–1159. 10.1182/blood.2021011679 PMID: 34428285; PMCID: PMC9211445 Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, Lister TA, Alliance, Australasian Leukaemia and Lymphoma Group; Eastern Cooperative Oncology Group, Study Group; Japanese Lymphorra Study Group; Lymphoma Study Association; NCIC Clinical Trials Group (2014) Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 32(27):3059–3068. 10.1200/JCO.2013.54.8800 PMID: 25113753; PMCID: PMC4979083 European Mantle Cell Lymphoma Consortium; Italian Lymphoma Foundation; European Organisation for Research; Treatment of Cancer/Dutch Hemato-Oncology Group; Grupo Español de Médula Ósea; German High-Grade Lymphoma Study Group; German Hodgkin'sNordic Lymphoma Study Group; Southwest Oncology Group; United Kingdom National Cancer Research Institute Patro R, Duggal G, Love MI, Irizarry RA, Kingsford C (2017) Salmon provides fast and bias-aware quantification of transcript expression. Nat Methods 14(4):417–419. 10.1038/nmeth.4197 Epub 2017 Mar 6. PMID: 28263959; PMCID: PMC5600148 Love MI, Huber W, Anders S (2014) Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2. Genome Biol 15(12):550. 10.1186/s13059-014-0550-8 PMID: 25516281; PMCID: PMC4302049 Bagaev A, Kotlov N, Nomie K, Svekolkin V, Gafurov A, Isaeva O, Osokin N, Kozlov I, Frenkel F, Gancharova O, Almog N, Tsiper M, Ataullakhanov R, Fowler N (2021) Conserved pan-cancer microenvironment subtypes predict response to immunotherapy. Cancer Cell 39(6):845–865e7 Epub 2021 May 20. PMID: 34019806 Di Siervi N, Revuelta MV, Cacciapuoti MT, Zamponi N, Marullo R, Melnick A, Inghirami G, Cerchietti L (2022) FGFR1 Is a Novel Therapeutic Target in Relapsed/Refractory Diffuse Large B Cell Lymphoma (RR-DLBCL). Blood 140(suppl 1):1322 Sehn LH, Salles G, Diffuse Large B-C, Lymphoma (2021) N Engl J Med 384(9):842–858. 10.1056/NEJMra2027612 PMID: 33657296; PMCID: PMC8377611 Crump M, Neelapu SS, Farooq U, Van Den Neste E, Kuruvilla J, Westin J, Link BK, Hay A, Cerhan JR, Zhu L, Boussetta S, Feng L, Maurer MJ, Navale L, Wiezorek J, Go WY, Gisselbrecht C (2017) Outcomes in refractory diffuse large B-cell lymphoma: results from the international SCHOLAR-1 study. Blood. ;130(16):1800–1808. doi: 10.1182/blood-2017-03-769620. Epub 2017 Aug 3. Erratum in: Blood. 2018;131(5):587–588. 10.1182/blood-2017-11-817775 . PMID: 28774879; PMCID: PMC5649550 Bishop MR, Dickinson M, Purtill D, Barba P, Santoro A, Hamad N, Kato K, Sureda A, Greil R, Thieblemont C, Morschhauser F, Janz M, Flinn I, Rabitsch W, Kwong YL, Kersten MJ, Minnema MC, Holte H, Chan EHL, Martinez-Lopez J, Müller AMS, Maziarz RT, McGuirk JP, Bachy E, Le Gouill S, Dreyling M, Harigae H, Bond D, Andreadis C, McSweeney P, Kharfan-Dabaja M, Newsome S, Degtyarev E, Awasthi R, Del Corral C, Andreola G, Masood A, Schuster SJ, Jäger U, Borchmann P, Westin JR (2022) Second-Line Tisagenlecleucel or Standard Care in Aggressive B-Cell Lymphoma. N Engl J Med 386(7):629–639. 10.1056/NEJMoa2116596 Epub 2021 Dec 14. PMID: 34904798 Locke FL, Miklos DB, Jacobson CA, Perales MA, Kersten MJ, Oluwole OO, Ghobadi A, Rapoport AP, McGuirk J, Pagel JM, Muñoz J, Farooq U, van Meerten T, Reagan PM, Sureda A, Flinn IW, Vandenberghe P, Song KW, Dickinson M, Minnema MC, Riedell PA, Leslie LA, Chaganti S, Yang Y, Filosto S, Shah J, Schupp M, To C, Cheng P, Gordon LI, Westin JR (2022) All ZUMA-7 Investigators and Contributing Kite Members. Axicabtagene Ciloleucel as Second-Line Therapy for Large B-Cell Lymphoma. N Engl J Med 386(7):640–654. 10.1056/NEJMoa2116133 Epub 2021 Dec 11. PMID: 34891224 Kamdar M, Solomon SR, Arnason J, Johnston PB, Glass B, Bachanova V, Ibrahimi S, Mielke S, Mutsaers P, Hernandez-Ilizaliturri F, Izutsu K, Morschhauser F, Lunning M, Maloney DG, Crotta A, Montheard S, Previtali A, Stepan L, Ogasawara K, Mack T, Abramson JS (2022) TRANSFORM Investigators. Lisocabtagene maraleucel versus standard of care with salvage chemotherapy followed by autologous stem cell transplantation as second-line treatment in patients with relapsed or refractory large B-cell lymphoma (TRANSFORM): results from an interim analysis of an open-label, randomised, phase 3 trial. Lancet. ;399(10343):2294–2308. doi: 10.1016/S0140-6736(22)00662-6. Erratum in: Lancet. 2022;400(10347):160. 10.1016/S0140-6736(22)01207-7 . PMID: 35717989 Additional Declarations Competing interest reported. B.H. participated in advisory board with Incyte, Kite/Gilead, ADC Therapeutics, Genmab and has Speaker's bureau with BMS. N.WJ. has Research funding from Astra Zeneca, Genetech, Merck. J.D. has consultancy with Jannsen Biotech, BMS, GSK and speaker’s bureau with Janssen Biotech Supplementary Files Appendixs.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 30 Apr, 2026 Reviews received at journal 29 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviews received at journal 04 Apr, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 26 Jan, 2026 Submission checks completed at journal 26 Jan, 2026 First submitted to journal 09 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8563481","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":583723287,"identity":"e2e98929-25ff-422e-a1c0-57666a161e36","order_by":0,"name":"Brian 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Carolina","correspondingAuthor":false,"prefix":"","firstName":"Shanta","middleName":"","lastName":"Salzer","suffix":""},{"id":583723305,"identity":"c31afe6c-8bed-4f6f-a24c-3dadcc828cd7","order_by":9,"name":"Robin Klingenberg","email":"","orcid":"","institution":"Medical University of South Carolina","correspondingAuthor":false,"prefix":"","firstName":"Robin","middleName":"","lastName":"Klingenberg","suffix":""},{"id":583723306,"identity":"7a178704-dd48-4fcf-8cc9-76e627c1d440","order_by":10,"name":"Leandro Cerchietti","email":"","orcid":"","institution":"NewYork–Presbyterian Hospital","correspondingAuthor":false,"prefix":"","firstName":"Leandro","middleName":"","lastName":"Cerchietti","suffix":""}],"badges":[],"createdAt":"2026-01-09 18:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8563481/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8563481/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101880859,"identity":"8a019aa4-8e12-40bb-8541-22b4855dbc04","added_by":"auto","created_at":"2026-02-04 15:07:11","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":273987,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDosing Schedule\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8563481/v1/a5e7805d8a3db561db210b96.jpeg"},{"id":101787893,"identity":"5a7968de-4e4a-44d4-8bc2-d22cb5166af5","added_by":"auto","created_at":"2026-02-03 15:51:42","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":492972,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTop 20 Adverse Events Ranked by Frequency (All Doses)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8563481/v1/eaa0019f9392fac093114c36.jpeg"},{"id":101787891,"identity":"0400d1b8-d154-4bac-a5c0-acba4f3b504b","added_by":"auto","created_at":"2026-02-03 15:51:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":132971,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLymphoma microenvironment (LME), MAPK and TNF pathway activity, and transcriptional analysis of select patients. \u003c/strong\u003eTME composition was performed utilizing cell signature deconvolution (see text) on available samples and in serial samples in patient DL2(2). LME of patients not obtaining durable CR were found to have depletion of T-cells, NK cells, and T cell attractant cytokines. Successive samples for patient DL2(2) show progressive T cell and NK cell depletion, increase in fibrosis at relapse, and variant expression of several individual genes.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8563481/v1/ae41e09bd3713997902cee41.png"},{"id":102962063,"identity":"b1c4b6fc-a3a3-445c-a243-aaeab8431857","added_by":"auto","created_at":"2026-02-19 03:59:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1577647,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8563481/v1/20cffb3e-6f96-451b-a6f1-f6c4aeed4c19.pdf"},{"id":101787890,"identity":"43d9a8e4-b71f-4c76-97a3-a270149e405f","added_by":"auto","created_at":"2026-02-03 15:51:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18470,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixs.docx","url":"https://assets-eu.researchsquare.com/files/rs-8563481/v1/a75e4dbeb33df4f3e1650ed1.docx"}],"financialInterests":"Competing interest reported. B.H. participated in advisory board with Incyte, Kite/Gilead, ADC Therapeutics, Genmab and has Speaker's bureau with BMS. \nN.WJ. has Research funding from Astra Zeneca, Genetech, Merck. \nJ.D. has consultancy with Jannsen Biotech, BMS, GSK and speaker’s bureau with Janssen Biotech","formattedTitle":"Phase I Study of Oral Azacitidine Plus Salvage Chemotherapy in Relapsed/Refractory Diffuse Large B-Cell Lymphoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eApproximately 40% of patients with diffuse large B-cell lymphoma (DLBCL) experience relapsed or refractory (R/R) disease. For those not meeting an indication for second-line CAR T-cell therapy, salvage chemotherapy followed by autologous stem cell transplant (ASCT) remains the standard of care for transplant eligible patients, though success is contingent upon tumor response to salvage chemotherapy [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Aberrant DNA methylation has emerged as a key driver of chemotherapy resistance and immune evasion in DLBCL, characterized by the silencing of tumor suppressor genes and the depletion of the lymphoma microenvironment (LME), characterized by a lack of immune infiltration [\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. DLBCL cases with a depleted LME, common in relapsed DLBCL, are also characterized by increased DNA hypermethylation. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Preclinical data suggest that hypomethylating agents like oral azacitidine (AZA) can reverse these epigenetic alterations, sensitizing resistant clones to cytotoxic therapy [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Based on this rationale, we conducted a phase I trial to evaluate the safety, efficacy, and correlative outcomes of combining AZA with standard R-ICE (rituximab, ifosfamide, carboplatin, etoposide) salvage therapy in transplant-eligible R/R DLBCL.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was an open-label phase I study conducted at the Hollings Cancer Center at the Medical University of South Carolina and Sidney Kimmel Cancer Center at Johns Hopkins University Center (NCT02343536). This study was approved by the respective institutional review boards at each institution. Written informed consent was obtained from each patient, and research conducted in accordance with the Declaration of Helsinki. Eligible participants were adults (\u0026ge;\u0026thinsp;18 years) with relapsed/refractory (R/R) DLBCL, grade 3B follicular lymphoma, or transformed indolent lymphoma who were candidates for ASCT. All patients received\u0026thinsp;\u0026ge;\u0026thinsp;1 prior anti-CD20 multi-agent regimen and had measurable disease by Lugano 2014 criteria. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The protocol was amended post-activation to exclude patients\u0026thinsp;\u0026gt;\u0026thinsp;70 years with ECOG PS\u0026thinsp;\u0026gt;\u0026thinsp;1 due to toxicity concerns.\u003c/p\u003e \u003cp\u003ePatients received rituximab (375 mg/m\u0026sup2; day 1), ifosfamide (5,000 mg/m\u0026sup2; day 2), carboplatin (AUC 5 day 2), and etoposide (100 mg/m\u0026sup2; days 1\u0026ndash;3) (R-ICE). Azacitidine (AZA) was administered (days \u0026minus;\u0026thinsp;6 to 0 prior to cycle 1; days 8\u0026ndash;21 of cycles 1\u0026ndash;2) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Each cycle was 21-days. Dose escalation followed a standard 3\u0026thinsp;+\u0026thinsp;3 design at 200 mg (DL1), 300 mg (DL2), and 150 mg (DL-1). Dose-limiting toxicity (DLT) was defined by CTCAE v5.0 as a Grade\u0026thinsp;\u0026ge;\u0026thinsp;3 adverse event leading to a\u0026thinsp;\u0026gt;\u0026thinsp;7-day cycle delay or Grade\u0026thinsp;\u0026ge;\u0026thinsp;2 vomiting/diarrhea persisting\u0026thinsp;\u0026gt;\u0026thinsp;48 hours despite best supportive care.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe primary objective was to determine the recommended phase 2 dose (RP2D). Secondary endpoints included overall response rate (ORR) and complete remission (CR) rate per 2014 International Working Group (IWG) criteria, stem cell mobilization feasibility, and proportion of patients proceeding to ASCT. Safety was monitored weekly via hematology assessments; response was assessed by PET-CT after treatment completion.\u003c/p\u003e \u003cp\u003eLymph node biopsy and/or bone marrow for RNA extraction was obtained from samples at diagnosis, at relapse prior to initiating study treatment, and relapse after initiation of study treatment when available. The SureSelect XT HS2 RNA System Library Prep Kit (Agilent) was used for cDNA preparation. Sequencing was performed using an Illumina NovaSeq 6000 10B 0.5 Flowcell at the WCM Genomics Resources Core Facility. Transcripts were quantified against Gencode hg38 genome using Salmon 1.10.0 REF1. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Transcript abundances were summarized with tximport 1.32.0 in R version 4.5.0. DESeq2 1.44.0 REF2 was used for differential expression analysis. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] LME and MFP determination were done in python 3 following methods previously published. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEnrollment was completed with 9ine patients (median age 58, range 45\u0026ndash;71; 56% male). The cohort represented a high-risk population, with 89% relapsing\u0026thinsp;\u0026lt;\u0026thinsp;1 year after frontline therapy (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eBaseline Characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;9 (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4 (44)\u003c/p\u003e\n\u003cp\u003e5 (56)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eHistology\u003c/p\u003e\n\u003cp\u003eDLBCL, NOS\u003c/p\u003e\n\u003cp\u003eDLBCL, GCB subtype\u003c/p\u003e\n\u003cp\u003eDLBCL, non-GCB subtype\u003c/p\u003e\n\u003cp\u003eTHRLBCL\u003c/p\u003e\n\u003cp\u003eHGBCL\u003c/p\u003e\n\u003cp\u003eTransformed from Indolent Lymphoma\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1 (11)\u003c/p\u003e\n\u003cp\u003e1 (11)\u003c/p\u003e\n\u003cp\u003e2 (22)\u003c/p\u003e\n\u003cp\u003e2 (22)\u003c/p\u003e\n\u003cp\u003e1 (11)\u003c/p\u003e\n\u003cp\u003e2 (22)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedian (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e58 (45\u0026ndash;71)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRelapse After Frontline Chemotherapy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt; 12 months\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026ge;\u003c/span\u003e 12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e8 (89)\u003c/p\u003e\n\u003cp\u003e1 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003eDLBCL, diffuse large B-cell lymphoma; NOS, not otherwise specified; GCB, germinal center B-cell subtype; THRLBCL, T-cell/histiocyte-rich large B-cell lymphoma; HGBCL, high-grade B-cell lymphoma\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSix patients were treated at DL1 (200 mg) and three at DL2 (300 mg). At DL2, one patient experienced a Grade 5 DLT (neutropenic sepsis). While subsequent DL2 patients did not strictly meet DLT criteria, frequent cycle delays (80%) and missed AZA doses (35%) due to persistent cytopenias led to a safety closure of DL2. In contrast, DL1 was well-tolerated with no DLTs, no cycle delays, and minimal missed AZA doses (4%) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Based on these safety and feasibility data, DL1 (200 mg) was established as the RP2D.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDose Delays, Missed Doses, and Adverse Events by Dose Level\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDose Level (N)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDL1\u0026ndash;200 mg (6)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDL2- 300 mg (3)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCombined (9)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMissed Doses of AZA due to Cytopenias (%)\u003c/p\u003e\n\u003cp\u003ePre-phase\u003c/p\u003e\n\u003cp\u003eCycle 1\u003c/p\u003e\n\u003cp\u003eCycle 2\u003c/p\u003e\n\u003cp\u003eMissed/Planned Total\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003cp\u003e7 (8)\u003c/p\u003e\n\u003cp\u003e7/210 (4)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4 (19)\u003c/p\u003e\n\u003cp\u003e19 (45)\u003c/p\u003e\n\u003cp\u003e9 (32)\u003c/p\u003e\n\u003cp\u003e32/91 (35)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4 (6)\u003c/p\u003e\n\u003cp\u003e19 (15)\u003c/p\u003e\n\u003cp\u003e16 (14)\u003c/p\u003e\n\u003cp\u003e39/301 (13)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCycle 2 or 3 R-ICE chemotherapy delay (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0/12 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4/5 (80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4/17 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCompletion of 3 cycles of R-ICE (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (89)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGrade\u003c/strong\u003e\u0026thinsp;\u003cspan class=\"BoldUnderline\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;\u003cstrong\u003e3 Adverse Events\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRelated to AZA\u003c/p\u003e\n\u003cp\u003eHematologic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNeutropenic Fever/Cycles (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0/18 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2/7 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2/25 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDose Limiting Toxicity (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe most frequent adverse events (AEs) across all grades included nausea (78%), thrombocytopenia (78%), and anemia/neutropenia (56%) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Grade\u0026thinsp;\u0026ge;\u0026thinsp;3 hematologic toxicity was significantly more prevalent at DL2 compared to DL1, specifically neutropenia (100% vs. 17%) and neutropenic fever (67% vs. 0%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong eight evaluable patients, the overall response rate (ORR) was 50%, with all responders achieving complete remission (CR). Four patients (50%) successfully proceeded to ASCT. All transplant-eligible patients achieved adequate peripheral blood stem cell (PBSC) collection (median 4.08 x 10⁶ CD34 cells/kg). At a median follow-up of 15 months, the median progression-free survival (PFS) was 6 months (95% CI: 2.5\u0026ndash;NR) and median overall survival (OS) was 35.5 months (95% CI: 9.5\u0026ndash;NR).\u003c/p\u003e\n\u003cp\u003eRNA-sequencing of pre-treatment biopsies (n\u0026thinsp;=\u0026thinsp;5) revealed that patients with durable CRs exhibited lower tumor proliferation signatures and higher immune infiltration (NK cells, T cells, and T-cell attractant cytokines) compared to non-responders or those who relapsed (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). This pattern is consistent with the notion that DLBCL patients with immune-infiltrated LMEs exhibit a higher response to therapies, including epigenetic agents and immunochemotherapy. [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] Serial sequencing in one relapsing patient demonstrated progressive T-cell/NK-cell depletion and a marked increase in cancer-associated fibroblasts (CAF). Progression was further characterized by upregulation of \u003cem\u003eFGFR1\u003c/em\u003e and downregulation of \u003cem\u003eIFNG\u003c/em\u003e, suggesting an evolving immune-depleted microenvironment as a mechanism of resistance. [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile therapeutic advances have improved outcomes for DLBCL, patients with relapsed/refractory (R/R) disease not meeting an indication for second-line CAR T-cell therapy still face suboptimal prognoses. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] We report the first phase I results investigating the addition of azacitidine (AZA) to R-ICE chemotherapy as an epigenetic sensitizing salvage strategy for transplant-eligible patients.\u003c/p\u003e \u003cp\u003eOur findings establish 200 mg (DL1) as the recommended phase 2 dose (RP2D). At this level, the regimen was well-tolerated with expected hematologic adverse events, no neutropenic fevers, and no dose-limiting toxicities. In contrast, 300 mg (DL2) resulted in excessive toxicity and R-ICE cycle delays, precluding its further use. Notably, our correlative studies identified an immune-infiltrated lymphoma microenvironment (LME) signature as predictive for durable complete remission (CR) with this epigenetic-chemotherapy combination.\u003c/p\u003e \u003cp\u003eNotably, we observed a 50% CR rate despite 89% of our cohort experiencing early relapse (\u0026lt;\u0026thinsp;1 year post-frontline therapy), a group historically associated with poor chemotherapy sensitivity and inferior post-ASCT outcomes. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] While CAR T-cell therapy has rightfully become the standard for early-relapsing DLBCL, its current regulatory approval does not extend to transplant eligible patients relapsing\u0026thinsp;\u0026gt;\u0026thinsp;12 months after frontline treatment. This may represent an ideal population for future to further test this combination. Additionally, this study provides a further rationale for pharmacological reversal of epigenetic resistance to chemotherapy in relapsed lymphoma.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of interest:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eB.H. participated in advisory board with Incyte, Kite/Gilead, ADC Therapeutics, Genmab and has Speaker's bureau with BMS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN.WJ. has Research funding from Astra Zeneca, Genetech, Merck.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJ.D. has consultancy with Jannsen Biotech, BMS, GSK and speaker’s bureau with Janssen Biotech\u003c/p\u003e\n\u003cp\u003eThis study involved human participants and all procedures involved in this study were in accordance with the ethical standards of the Institutional Review Board of MUSC and Johns Hopkins University. Informed consent was obtained from all participants. The study followed the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eData supporting the findings of this study are available within the paper and its supplementary information. All other data is available upon request.\u003c/p\u003e\n\u003cp\u003eAuthors contributions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eB.H. was responsible for conceptualization, methology, investigation, funding acquisition, writing original draft as well as writing (review and editing).\u003c/p\u003e\n\u003cp\u003eN.W-J. was responsible for investigation and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eL.H. was responsible for investigation\u003c/p\u003e\n\u003cp\u003eJ.D. was responsible for investigation and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eE.H. was responsible for methodology, formal analysis, and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eA.G. was responsible for investigation and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eK.A. was responsible for data curation and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eM.R. was responsible for investigation, visualization, figure preparation, and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eS.S and R.K. were responsible for data curation and project administration\u003c/p\u003e\n\u003cp\u003eL.C. was responsible for methodology, investigation, formal analysis, and writing (review and editing).\u003c/p\u003e\n\u003cp\u003eFunding information: Funding was provided by Hollings Cancer Center Medical University of South Carolina, Lymphoma Research Foundation, and Bristol-Myers Squibb\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePhilip T, Guglielmi C, Hagenbeek A, Somers R, Van der Lelie H, Bron D, Sonneveld P, Gisselbrecht C, Cahn JY, Harousseau JL et al (1995) Autologous bone marrow transplantation as compared with salvage chemotherapy in relapses of chemotherapy-sensitive non-Hodgkin's lymphoma. N Engl J Med. ;333(23):1540-5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJM199512073332305\u003c/span\u003e\u003cspan address=\"10.1056/NEJM199512073332305\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 7477169\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGisselbrecht C, Glass B, Mounier N, Singh Gill D, Linch DC, Trneny M, Bosly A, Ketterer N, Shpilberg O, Hagberg H, Ma D, Bri\u0026egrave;re J, Moskowitz CH, Schmitz N (2010) Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. ;28(27):4184-90. doi: 10.1200/JCO.2010.28.1618. Epub 2010 Jul 26. Erratum in: J Clin Oncol. 2012;30(15):1896. PMID: 20660832; PMCID: PMC3664033\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamadani M, Hari PN, Zhang Y, Carreras J, Akpek G, Aljurf MD, Ayala E, Bachanova V, Chen AI, Chen YB, Costa LJ, Fenske TS, Freytes CO, Ganguly S, Hertzberg MS, Holmberg LA, Inwards DJ, Kamble RT, Kanfer EJ, Lazarus HM, Marks DI, Nishihori T, Olsson R, Reddy NM, Rizzieri DA, Savani BN, Solh M, Vose JM, Wirk B, Maloney DG, Smith SM, Montoto S, Saber W, Alpdogan O, Cashen A, Dandoy C, Finke R, Gale R, Gibson J, Hsu JW, Janakiraman N, Laughlin MJ, Lill M, Cairo MS, Munker R, Rowlings PA, Schouten HC, Shea TC, Stiff PJ, Waller EK (2014) Early failure of frontline rituximab-containing chemo-immunotherapy in diffuse large B cell lymphoma does not predict futility of autologous hematopoietic cell transplantation. Biol Blood Marrow Transpl 20(11):1729\u0026ndash;1736. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bbmt.2014.06.036\u003c/span\u003e\u003cspan address=\"10.1016/j.bbmt.2014.06.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2014 Jul 5. PMID: 25008330; PMCID: PMC4194275\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;n A, Conde E, Arnan M, Canales MA, Deben G, Sancho JM, Andreu R, Salar A, Garc\u0026iacute;a-Sanchez P, V\u0026aacute;zquez L, Nistal S, Requena MJ, Donato EM, Gonz\u0026aacute;lez JA, Le\u0026oacute;n A, Ruiz C, Grande C, Gonz\u0026aacute;lez-Barca E, Caballero MD, /TAMO Cooperative Group) (2008) R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 93(12):1829\u0026ndash;1836. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3324/haematol.13440\u003c/span\u003e\u003cspan address=\"10.3324/haematol.13440\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2008 Oct 22. PMID: 18945747 Grupo Espa\u0026ntilde;ol de Linfomas/Trasplante Aut\u0026oacute;logo de M\u0026eacute;dula Osea (GEL\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClozel T, Yang S, Elstrom RL, Tam W, Martin P, Kormaksson M, Banerjee S, Vasanthakumar A, Culjkovic B, Scott DW, Wyman S, Leser M, Shaknovich R, Chadburn A, Tabbo F, Godley LA, Gascoyne RD, Borden KL, Inghirami G, Leonard JP, Melnick A, Cerchietti L (2013) Mechanism-based epigenetic chemosensitization therapy of diffuse large B-cell lymphoma. Cancer Discov 3(9):1002\u0026ndash;1019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1158/2159-8290.CD-13-0117\u003c/span\u003e\u003cspan address=\"10.1158/2159-8290.CD-13-0117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2013 Aug 16. PMID: 23955273; PMCID: PMC3770813\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmara K, Ziadi S, Hachana M, Soltani N, Korbi S, Trimeche M (2010) DNA methyltransferase DNMT3b protein overexpression as a prognostic factor in patients with diffuse large B-cell lymphomas. Cancer Sci 101(7):1722\u0026ndash;1730. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1349-7006.2010.01569.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1349-7006.2010.01569.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2010 Mar 19. PMID: 20398054; PMCID: PMC11159814\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLenz G, Wright G, Dave SS, Xiao W, Powell J, Zhao H, Xu W, Tan B, Goldschmidt N, Iqbal J, Vose J, Bast M, Fu K, Weisenburger DD, Greiner TC, Armitage JO, Kyle A, May L, Gascoyne RD, Connors JM, Troen G, Holte H, Kvaloy S, Dierickx D, Verhoef G, Delabie J, Smeland EB, Jares P, Martinez A, Lopez-Guillermo A, Montserrat E, Campo E, Braziel RM, Miller TP, Rimsza LM, Cook JR, Pohlman B, Sweetenham J, Tubbs RR, Fisher RI, Hartmann E, Rosenwald A, Ott G, Muller-Hermelink HK, Wrench D, Lister TA, Jaffe ES, Wilson WH, Chan WC, Staudt LM (2008) Stromal gene signatures in large-B-cell lymphomas. N Engl J Med 359(22):2313\u0026ndash;2323. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa0802885\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa0802885\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 19038878; PMCID: PMC9103713 Lymphoma/Leukemia Molecular Profiling Project\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKihslinger JE, Godley LA (2007) The use of hypomethylating agents in the treatment of hematologic malignancies. Leuk Lymphoma. ;48(9):1676-95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10428190701493910\u003c/span\u003e\u003cspan address=\"10.1080/10428190701493910\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 17786703\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePan H, Jiang Y, Boi M, Tabb\u0026ograve; F, Redmond D, Nie K, Ladetto M, Chiappella A, Cerchietti L, Shaknovich R, Melnick AM, Inghirami GG, Tam W, Elemento O (2015) Epigenomic evolution in diffuse large B-cell lymphomas. Nat Commun 6:6921. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/ncomms7921\u003c/span\u003e\u003cspan address=\"10.1038/ncomms7921\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 25891015; PMCID: PMC4411286\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotlov N, Bagaev A, Revuelta MV, Phillip JM, Cacciapuoti MT, Antysheva Z, Svekolkin V, Tikhonova E, Miheecheva N, Kuzkina N, Nos G, Tabbo F, Frenkel F, Ghione P, Tsiper M, Almog N, Fowler N, Melnick AM, Leonard JP, Inghirami G, Cerchietti L (2021) Clinical and Biological Subtypes of B-cell Lymphoma Revealed by Microenvironmental Signatures. Cancer Discov 11(6):1468\u0026ndash;1489. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1158/2159-8290.CD-20-0839\u003c/span\u003e\u003cspan address=\"10.1158/2159-8290.CD-20-0839\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2021 Feb 4. PMID: 33541860; PMCID: PMC8178179\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerchietti L (2024) Genetic mechanisms underlying tumor microenvironment composition and function in diffuse large B-cell lymphoma. Blood 143(12):1101\u0026ndash;1111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1182/blood.2023021002\u003c/span\u003e\u003cspan address=\"10.1182/blood.2023021002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 38211334; PMCID: PMC10972714\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin P, Bartlett NL, Chavez JC, Reagan JL, Smith SM, LaCasce AS, Jones J, Drew J, Wu C, Mulvey E, Revuelta MV, Cerchietti L, Leonard JP (2022) Phase 1 study of oral azacitidine (ORAL AZACITADINE) plus R-CHOP in previously untreated intermediate- to high-risk DLBCL. Blood 139(8):1147\u0026ndash;1159. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1182/blood.2021011679\u003c/span\u003e\u003cspan address=\"10.1182/blood.2021011679\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 34428285; PMCID: PMC9211445\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, Lister TA, Alliance, Australasian Leukaemia and Lymphoma Group; Eastern Cooperative Oncology Group, Study Group; Japanese Lymphorra Study Group; Lymphoma Study Association; NCIC Clinical Trials Group (2014) Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 32(27):3059\u0026ndash;3068. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.2013.54.8800\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2013.54.8800\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 25113753; PMCID: PMC4979083 European Mantle Cell Lymphoma Consortium; Italian Lymphoma Foundation; European Organisation for Research; Treatment of Cancer/Dutch Hemato-Oncology Group; Grupo Espa\u0026ntilde;ol de M\u0026eacute;dula \u0026Oacute;sea; German High-Grade Lymphoma Study Group; German Hodgkin'sNordic Lymphoma Study Group; Southwest Oncology Group; United Kingdom National Cancer Research Institute\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatro R, Duggal G, Love MI, Irizarry RA, Kingsford C (2017) Salmon provides fast and bias-aware quantification of transcript expression. Nat Methods 14(4):417\u0026ndash;419. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nmeth.4197\u003c/span\u003e\u003cspan address=\"10.1038/nmeth.4197\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2017 Mar 6. PMID: 28263959; PMCID: PMC5600148\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLove MI, Huber W, Anders S (2014) Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2. Genome Biol 15(12):550. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13059-014-0550-8\u003c/span\u003e\u003cspan address=\"10.1186/s13059-014-0550-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 25516281; PMCID: PMC4302049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagaev A, Kotlov N, Nomie K, Svekolkin V, Gafurov A, Isaeva O, Osokin N, Kozlov I, Frenkel F, Gancharova O, Almog N, Tsiper M, Ataullakhanov R, Fowler N (2021) Conserved pan-cancer microenvironment subtypes predict response to immunotherapy. Cancer Cell 39(6):845\u0026ndash;865e7 Epub 2021 May 20. PMID: 34019806\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Siervi N, Revuelta MV, Cacciapuoti MT, Zamponi N, Marullo R, Melnick A, Inghirami G, Cerchietti L (2022) FGFR1 Is a Novel Therapeutic Target in Relapsed/Refractory Diffuse Large B Cell Lymphoma (RR-DLBCL). Blood 140(suppl 1):1322\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSehn LH, Salles G, Diffuse Large B-C, Lymphoma (2021) N Engl J Med 384(9):842\u0026ndash;858. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMra2027612\u003c/span\u003e\u003cspan address=\"10.1056/NEJMra2027612\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 33657296; PMCID: PMC8377611\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrump M, Neelapu SS, Farooq U, Van Den Neste E, Kuruvilla J, Westin J, Link BK, Hay A, Cerhan JR, Zhu L, Boussetta S, Feng L, Maurer MJ, Navale L, Wiezorek J, Go WY, Gisselbrecht C (2017) Outcomes in refractory diffuse large B-cell lymphoma: results from the international SCHOLAR-1 study. Blood. ;130(16):1800\u0026ndash;1808. doi: 10.1182/blood-2017-03-769620. Epub 2017 Aug 3. Erratum in: Blood. 2018;131(5):587\u0026ndash;588. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1182/blood-2017-11-817775\u003c/span\u003e\u003cspan address=\"10.1182/blood-2017-11-817775\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 28774879; PMCID: PMC5649550\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBishop MR, Dickinson M, Purtill D, Barba P, Santoro A, Hamad N, Kato K, Sureda A, Greil R, Thieblemont C, Morschhauser F, Janz M, Flinn I, Rabitsch W, Kwong YL, Kersten MJ, Minnema MC, Holte H, Chan EHL, Martinez-Lopez J, M\u0026uuml;ller AMS, Maziarz RT, McGuirk JP, Bachy E, Le Gouill S, Dreyling M, Harigae H, Bond D, Andreadis C, McSweeney P, Kharfan-Dabaja M, Newsome S, Degtyarev E, Awasthi R, Del Corral C, Andreola G, Masood A, Schuster SJ, J\u0026auml;ger U, Borchmann P, Westin JR (2022) Second-Line Tisagenlecleucel or Standard Care in Aggressive B-Cell Lymphoma. N Engl J Med 386(7):629\u0026ndash;639. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa2116596\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa2116596\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2021 Dec 14. PMID: 34904798\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLocke FL, Miklos DB, Jacobson CA, Perales MA, Kersten MJ, Oluwole OO, Ghobadi A, Rapoport AP, McGuirk J, Pagel JM, Mu\u0026ntilde;oz J, Farooq U, van Meerten T, Reagan PM, Sureda A, Flinn IW, Vandenberghe P, Song KW, Dickinson M, Minnema MC, Riedell PA, Leslie LA, Chaganti S, Yang Y, Filosto S, Shah J, Schupp M, To C, Cheng P, Gordon LI, Westin JR (2022) All ZUMA-7 Investigators and Contributing Kite Members. Axicabtagene Ciloleucel as Second-Line Therapy for Large B-Cell Lymphoma. N Engl J Med 386(7):640\u0026ndash;654. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa2116133\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa2116133\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2021 Dec 11. PMID: 34891224\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamdar M, Solomon SR, Arnason J, Johnston PB, Glass B, Bachanova V, Ibrahimi S, Mielke S, Mutsaers P, Hernandez-Ilizaliturri F, Izutsu K, Morschhauser F, Lunning M, Maloney DG, Crotta A, Montheard S, Previtali A, Stepan L, Ogasawara K, Mack T, Abramson JS (2022) TRANSFORM Investigators. Lisocabtagene maraleucel versus standard of care with salvage chemotherapy followed by autologous stem cell transplantation as second-line treatment in patients with relapsed or refractory large B-cell lymphoma (TRANSFORM): results from an interim analysis of an open-label, randomised, phase 3 trial. Lancet. ;399(10343):2294\u0026ndash;2308. doi: 10.1016/S0140-6736(22)00662-6. Erratum in: Lancet. 2022;400(10347):160. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(22)01207-7\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(22)01207-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35717989\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"annals-of-hematology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aohe","sideBox":"Learn more about [Annals of Hematology](http://link.springer.com/journal/277)","snPcode":"277","submissionUrl":"https://submission.nature.com/new-submission/277/3","title":"Annals of Hematology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"lymphoma, dlbcl, epigenetics","lastPublishedDoi":"10.21203/rs.3.rs-8563481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8563481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSalvage chemotherapy and autologous stem cell transplantation (ASCT) offer the opportunity to cure eligible patients with relapsed diffuse large B-cell lymphoma (DLBCL). Epigenetic alterations such as aberrant DNA methylation patterns have been linked to chemotherapy resistance in DLBCL. Oral Azacitadine (AZA) is an oral hypomethylating inhibitor that inhibits DNA methyltransferase and has provided evidence of chemotherapy sensitization in DLBCL. In this phase I trial the safety and efficacy of two dose levels of AZA were investigated in combination with standard cytotoxic chemotherapy rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) in relapsed DLBCL patients who were candidates for ASCT.\u003c/p\u003e","manuscriptTitle":"Phase I Study of Oral Azacitidine Plus Salvage Chemotherapy in Relapsed/Refractory Diffuse Large B-Cell Lymphoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 15:51:25","doi":"10.21203/rs.3.rs-8563481/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-30T13:32:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T15:26:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7224163405744392735232647239178532865","date":"2026-04-08T05:05:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T19:34:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330894309703809925254373230853709416187","date":"2026-03-04T00:05:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176216140908546477606431835259082949747","date":"2026-01-30T19:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T20:30:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-26T09:42:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-26T09:39:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Annals of Hematology","date":"2026-01-09T17:50:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"annals-of-hematology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aohe","sideBox":"Learn more about [Annals of Hematology](http://link.springer.com/journal/277)","snPcode":"277","submissionUrl":"https://submission.nature.com/new-submission/277/3","title":"Annals of Hematology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a8eb3e92-a3c5-464f-81da-9b2782668b84","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-30T13:32:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T15:26:12+00:00","index":46,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T13:40:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 15:51:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8563481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8563481","identity":"rs-8563481","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}