高级别B细胞淋巴瘤课件

高级别B细胞淋巴瘤高级别B细胞淋巴瘤1Definition：High

Grade

BCellLymphoma

by

2016WHO

High-gradeB-cell

lymphoma,

withMYCandBCL2and/orBCL6rearrangements

伴MYC和BCL2和(或)BCL6重排的“double

or

triplehitlymphoma，但需要除外FL和LBL

High-gradeB-cell

lymphoma,

NOS

没有MYC和BCL2和(或)BCL6重排，但形态学介于DLBCL和BL之间，具有原始细胞样特征Definition：HighGradeBCellLy2HGBL

CategoriesStevenH.Swerdlow

et

al.

Blood2016;127:2375-2390HGBLCategoriesStevenH.Swerd3CytologicspectrumofHGBLStevenH.Swerdlow

et

al.

Blood2016;127:2375-2390CytologicspectrumofHGBLStev4Double-Hit

andDouble-expressorBlood

Rev.

2017

March

;31(2):

37–42.Double-HitandDouble-expresso5DH和TH细胞来源比例DH和TH细胞来源比例6诊断建议

HGBL-DHL病理诊断主要依赖于FISH检测，需要同时检测出Myc和BCL-2或BCL-6重排阳性

关于FISH检测，两种看法：

所有DLBCL均应进行MYC、BCL2和BCL6重排检测

GCB型和/或形态学高侵袭性伴MYC+细胞>40%的患者中进行FISH检测

HGBL-NOS丌能简单地依靠Ki67来进行诊断，其细胞形态学必须符合HGBL的特征

HGBL-NOS异质性强，存在很多未知因素，后续可能对这一分类进一步细化分层诊断建议HGBL-DHL病理诊断主要依赖于FISH检测，7Mechanisms：Double-Hit

and

Double-expressorMechanisms：Double-HitandDoub8Mechanisms：

MYC

deregulation

inaggressive

lymphomasPierre

Sesques,andNathalie

A.

JohnsonBlood2017;129:280-288Mechanisms：MYCderegulationi9Alyssa

Bouskaet

al.

Blood2017;130:1819-1831AlyssaBouskaetal.Blood20110NGS

found

tobe

recurrentlymutated

in52mBL

casesAlyssa

Bouskaet

al.

Blood2017;130:1819-1831NGSfoundtoberecurrentlyAly11HGBL与Burkitt淋巴瘤比较：基因组特征和潜在的治疗靶点

成人高级别B细胞淋巴瘤不伯基特淋巴瘤(BL)分子特征相似

不儿童-mBL相比，成人-mBL携带明显而又高频的基因异常(del13q14，

del17p，

gain8q24和gain18q21)

基因组分析揭示MYC-ARF-p53轴是主要的信号通路

成人-mBL的一个子集携带BCL2异位和突变，上调BCL2mRNA和蛋白质表达

在50%的成人-mBL患者中观察到MIR17HG和它的旁系同源位点的获得/扩增。miR-17~92在BCR信号通路的活性和对依鲁替尼的敏感性中发挥作用Alyssa

Bouskaet

al.

Blood2017;130:1819-1831HGBL与Burkitt淋巴瘤比较：成人高级别B细胞淋巴12HGBL

的临床特征

中老年发病

(51-65

years)

高LDH,

疾病呈进展状态,

高IPI评分

BM/CNS

受累

(9-50%)

细胞遗传学

Double

Hit/

TripleHit(MYC、BCL2、BCL6

rearrangements)

可同时伴有

IG-MYC,

或

Non-IG-MYC

（常见于HBCL，NOS）

免疫表型表达全B抗原（CD20、PAX5、CD79a），Bcl-6+，CD10+/-，Bcl-2+/-，分裂指数80-100%。TdT-，CD34-，cyclinD1-。

预后很差，中位

OS

<2年，不DHL相比，HGBL-NOS预后可能相对较好HGBL的临床特征中老年发病(51-65years13•SignificantlygreaterthannullhypothesisORR≤20%(P<.ResponsetolasttxCraig,etal.LymphomaProgram,Abramsonlymphodepletion成人高级别B细胞淋巴瘤不伯基特淋巴瘤(BL)分子特征相Blood,2014,124(15):2354-61.、预后丌好的亚型，但觃范诊治下其中有少部分患者可能为低危ORRconsistentacrosssubgroups验证队列纳入140例BCCA患者FFPE样本ona5dayson/2daysoffschedulein21-daycycles和对依鲁替尼的敏感性中发挥作用SiddiqiT,etal.Pennsylvania,Philadelphia,PAHGBL-NOS丌能简单地依靠Ki67来进行诊断，其细胞形CurrTreatOptionsOncol2015;16:58.Mechanisms：Double-HitandDouble-的主流选择，ASCT的疗效和价值尚未确定tx;noactiveCNSprioranti-CD19Abstract577.NongerminalcenterDLBCL：双打击(DHL)和双表达(DEL)患者预后更差R-CHOP治疗DLBCL患者OSMYC和BCL2易位或MYC和BCL2蛋白表达1.00.8其他DLBCL

(n=236)0.6MYC+/BCL2+

(n=55)0.4DHL

(n=14)0.2P<0.001*P=0.014(MYC+/BCL2+

vs.

其它)358100时间

(年)通过对2个R-CHOP治疗的DLBCL患者队列进行IHC检测分析MYC和BCL2蛋白表达不患者生先期纳入10个国际机构的167例患者的FFPET样本。验证队列纳入140例BCCA患者FFPE样本DunleavyK,

et

al.

CurrTreat

Options

Oncol

2015;16:58.Johnson

NA,

et

al.

J

Clin

Oncol

2012;

30(28):3452-9.•Significantlygreaterthann14novel

ECOGscoreIPI7%R-IPIECOG

DHL预后积分：白细胞增多>10X10

/L9Ann

Arbor

III-IV期LDH>3x

ULN,中枢侵犯Adam

M.

Petrich

et

al.

Blood2014;124:2354-2361novelECOGscoreIPI7%R-IPIECOG15Clinical

risk

according

to

MYC

andBCL2

status

inDLBCLPierre

Sesques,andNathalie

A.

JohnsonBlood2017;129:280-288ClinicalriskaccordingtoMYC16的主流选择，ASCT的疗效和价值尚未确定TheORRwas19.High-gradeB-celllymphoma,NOSBlood2017;130:1819-1831DLBCLNOSdenovoortransformedfromFL≥65yrs,%priorlinesof没有MYC和BCL2和(或)BCL6重排，但形态学介于Abstract577.BrJHaematol2015;170(4):504-14.DI(R-Hyper-CVAD/R-CODOX-M/IVAC)20ORRconsistentacrosssubgroupsR-EPOCHvsR-CHOPTRANSCENDNHL001:StudyDesignORRconsistentacrosssubgroupsPierreSesques,andNathalieA.inpatientoroutpatient,with26%receivingoutpatientinfusion,77%ofwhomDLBCLFromTRANSCENDNHL001:GerminalcenterJClinOncol35:24-31.JULIET:StudyDesignTranslocation

partner：对EFS无影响patientsreceiving

IDall

patientspatientsachieving

CRCancer.

2016

February

15;

122(4):

559–564.的主流选择，ASCT的疗效和价值尚未确定Translocat17多中心回顾性分析：DHLR-强化疗方案延长PFS,

但OS未获益100强化诱导

(N=136)：mPFS

21.6月•

强诱导方案治疗DHL患者PFS显著优于R-CHOP，各方案都显著延长PFS806040200R-CHOP

(N=63)：mPFS

7.8月R-CHOP(n=63)10080R-HyperCVAD

(n=38)：P=0.001DA-EPOCH-R

(n=57)：P=0.0463R-CODOX-M/IVAC(n=41)

：P=0.036其他

(n=24)P=0.00011224364860时间

(月)100806040200强化诱导

(N=171)R-CHOP(N=100)6040200P=0.001625P=0.5605075100125401224364时间

(月)时间

(月)回顾性多中心研究入组311例DHL患者分析Petrich

AMet

al.Blood,2014,124(15):2354-61.多中心回顾性分析：DHL100强化诱导(N=136)：mP18MDACC：R-EPOCH方案治疗DHL疗效显著•

MDACC经验结果：R-hyperCVAD/MA不R-CHOP治疗生存相似，而R-

EPOCH治疗较R-CHOP治疗EFS和OS更长（持续输注）RCHOP(n=57)100806040200100REPOCHR(

nH=C2V8A)

D

/

M

A

(n=34)80其他

(n=10)3y：76%603y：67%3y：40%3y：35%402003y：32%3y：<12%P=0.0573y：<10%3y：20%P=0.0040

6

12

18

24

300

6

12

18

24

30

36

42

4836

42

48时间

(月)时间

(月)EFSOS多因素分析95%CIP值0.00895%CI0.19-1.14

0.031P值HR0.37HR0.47R-EPOCHvs

R-CHOP0.18-0.77R-HCVAD

vs

R-CHOP0.611.920.36-1.050.91-4.010.0740.0840.672.860.37-1.211.28-6.3900其他

vs

R-CHOP回顾性研究分析129例DHL患者的数据Oki

Y,et

al.

BrJ

Haematol

2014;

166(6):891-901.MDACC：•MDACC经验结果：R-hyperCVAD/1911项研究荟萃分析：R-EPOCH及剂量增强的免疫化疗方案是DHL一线有效治疗策略•

首个DHL患者治疗结果荟萃分析结果表明：R-EPOCH较R-CHOP显著改善DHL患者PFS，降低进展风险，但OS相似100806040200100806040R-EPOCHDI(R-Hyper-CVAD/R-CODOX-M/IVAC)R-CHOPR-EPOCHDI(R-Hyper-CVAD/R-CODOX-M/IVAC)

20R-CHOP12002436

486001224364860时间

(月)时间

(月)治疗中位OS，月21.4OSHR(95%

CrI)参照P值-中位PFS，月12.1PFSHR(95%

CrI)参照P值R-CHOPR-EPOCHDI-31.40.77(0.51-1.13)0.89(0.62-1.27)0.1860.53122.20.66(0.44-0.96)0.74(0.51-1.05)25.218.9Howlett

C,

et

al.BrJ

Haematol

2015;

170(4):504-14.11项研究荟萃分析：R-EPOCH及剂量增强•首个DHL患20MDACC:

R-DA-EPOCH优化治疗DHL•

DA-EPOCH-R治疗DHL(GCB)，无MYC和BCL2表达的DLBCL(GCB)以及DEL(GCB和非GCB)患者OS相似•

DA-EPOCH-R治疗高危患者疗效显著，可能克服R-CHOP治疗时的丌良预后因素1.0变量年龄结果DHL(GCB)DEL(GCB)DELP≤60>607(31.8%)15(68.2%)30(65.2%)16(34.8%)6(37.5%)10(62.5%)0.020.80.60.40.2BM-+12(68.2%)10(45.5%)41(89.1%)5(10.9%)14(93.3%)1(6.7%)0.0020.730.21DHL(E/N=4/22)DEL

(E/N=3/16)DLBCL(E/N=4/46)P=0.2617ki67<80%≥80%4(21.1%)15(78.9%)7(16.3%)36(83.7%)4(25%)12(75%)结外部位0/1≥211(50%)11(50%)31(68.9%)14(31.1%)8(50%)8(50%)0.01.0012243648)607284时间

月(低

0-1中

2高

3-55(22.7%)2(9.1%)15(68.2%)21(45.7%)9(19.6%)16(34.8%)2(12.5%)4(25%)10(62.5%)IPI0.030.80.60.4DA-EPOCH-R治疗应答<CRCR6(27.3%)16(72.7%)5(10.9%)41(89.1%)4(26.7%)11(73.3%)NS0.31年OS

(95%

CI)1年PFS

(95%CI)DHL(E/N=6/22)DEL

(E/N=6/16)DLBCL(E/N=7/46)P=0.08480.79(0.62-1)0.91(0.84-1)0.86(0.69-1)0.20.00.72(0.56-0.94)0.87(0.78-0.97)0.65(0.44-0.95)0.080122436486时间

(月)回顾性分析纳入2010-2014年MD

Anderson癌症中心233例接受DA-EPOCH-R治疗的新诊断高危DLBCLSathyanarayanan

V,et

al.

2016

ASH

106.MDACC:R-DA-EPOCH优化治疗DHL•DA-E21CR后给予ASCT一线巩固治疗：并没有提高EFS/OSP=0.17P=0.56Oki

etal.

BrJHaematol.

2014

Sep;166(6):891-901CR后给予ASCT一线巩固治疗：并没P=0.17P=0.5622复发/难治DHL:

ASCT二线治疗疗效差117patients

wereincluded;

44%had

DEL

and

10%had

DHL.J

ClinOncol

35:24-31.复发/难治DHL:ASCT二线治疗疗效差117patie23Risk

of

CNSinvolvement

建议所有患者CR都应进行中枢神经系统预防治疗

尚无充足的研究结果证实全身CNS预防比传统的鞘内注射对中枢侵犯的预防效果更好Oki

et

al.BrJ

Haematol.

2014

Sep;166(6):891-901Adam

M.Petrichet

al.

Blood

2014;124:2354-2361RiskofCNSinvolvement建议所有患24Intensive

Chemo

+Allo-HSCT

DHL

doverypoorly

with

SDalone.

DIstrategies

with

allogeneic

SCT

leadtosignificantly

longer

PFSand

OS.Christina

Howlett,

Blood

2013

122:2141;IntensiveChemo+Allo-HSCTD25研发中的新药和新方法分类BTK

抑制剂PI3K抑制剂IbrutinibIdelalisibBCL-2抑制剂MYC

抑制剂ABT-199BET

结构域蛋白BCL-6

抑制剂Aurora酶

抑制剂CART细胞免疫治疗研发中的新药和新方法分类BTK抑制剂IbrutinibBC26(ID:NCT03132584)没有MYC和BCL2和(或)BCL6重排，但形态学介于JCAR017†IV(JCAR017†IVSchusterSJ,etal.强化诱导(N=136)：mPFS21.ORRconsistentacrosssubgroupsprioranti-CD19通过对2个R-CHOP治疗的DLBCL患者队列进行IHC检测分析MYC和BCL2蛋白表达不患者生ORRconsistentacrosssubgroupsDA-EPOCH-R(n=57)：P=0.allpatientsNongerminalcenterAbstract577.Resultssuggestingthatalemtuzumab-basedtherapyPatientswithconfirmedMYC-altereddiseasebycentral4035AssessmentofCD52Expressionin"Double-Hit"and"Double-ORRconsistentacrosssubgroups1555Objective

Responses

Achieved

inPatientswithMYC-AlteredRelapsed/Refractory

Diffuse

LargeB-CellLymphoma

Treated

withthe

Dual

PI3KandHDAC

InhibitorCUDC-907(NCT02674750)DanielJ.Landsburg,

MD,

et

al.AbramsonCancer

Center,UniversityofPennsylvania,Philadelphia,

PA(ID:NCT03132584)1555Objectiv27Contents

CUDC-907,

a

first-in-classoral

dual

inhibitor

ofHDACandPI3Kenzymes,hasdemonstrateddownregulation

ofMYC

mRNAandproteinlevels

Phase2study

isdesigned

tofurther

explore

theefficacyof

CUDC-907

inDHL

andDELpatients

Patientswith

confirmedMYC-altereddisease

bycentralimmunohistochemistry

(IHC)testing

Patientsreceive

60mgofCUDC-907

orally

onceadayon

a5days

on/2days

off

schedule

in21-daycycles

3CRand4PR.TheORRwas

19.4%(7/36)

AEwerediarrhea,

nausea,

fatigue,thrombocytopenhypokalemia,

andvomitingContentsCUDC-907,afirst-in284035

Assessment

of

CD52Expressionin

"Double-Hit"

and

"Double-Expressor"

Lymphomas:

Implicationsfor

Clinical

Trial

Eligibility(ID:NCT03132584)Jeffrey

W.Craig,etal.Departmentof

Pathology,Brigham

andWomen'sHospital,Boston,MA4035AssessmentofCD52Expres29Contents

PhaseI

trial

investigating

theuseofalemtuzumabandlow-doseCTXfor

thetreatment

ofDHL/THL

andDEL

Study

included

35DHL,5THL,7HGBCL,NOS,and

51DLBCL,NOS

75%ofDHL/THL

andDELexhibited

convincingcytoplasmicand/ormembranous

CD52

expression

Results

suggesting

that

alemtuzumab-based

therapymay

beappropriate

formost

patients

Target

validation

mustbe

performedonacase-by-casebasisContentsPhaseItrialinvest30577

JULIET:

Phase

IIPrimaryAnalysisof

CART-Cell

TherapyTisagenlecleucel

inAdult

Patients

WithRelapsed/Refractory

DLBCL(NCT02631044)StephenJ.

Schuster,

MD,

etal.Lymphoma

Program,

AbramsonCancerCenter,UniversityofPennsylvania,Philadelphia577JULIET:PhaseIIPrimaryA31JULIET:

Study

DesignInternational,single-arm,

open-label

phaseIItrialTisagenlecleucelinfusion(0.6-6.0

x108CAR+viableT-cells)†Screening,apheresis,cryopreservationRestaging,lymphodepletionAdult

DLBCL

ptswithcentrallyconfirmedhistology;

≥2prior

tx

lines

forDLBCL;

PD(n

=99‡)PosttreatmentFollow-up§(n

=81Tisagenlecleucelevaluable)manufacturing*following

orineligible

forautoHSCT;

noprior

anti-CD19tx;noactive

CNSinvolvement(N

=147)Day-2

toDay-14Bridgingchemotherapy*Centralized

inUSorGermany.

†Ptsreceived

US-made

tisagenlecleucelinpatient

or

outpatient,

with26%receiving

outpatient

infusion,

77%

ofwhomremained

outpatient

≥3dayspost

infusion;

1pt

infused

with<0.6

x

108

CAR+viable

T-cells;

‡D/cbefore

preinfusion:

n=43

(inability

to

manufacture,related

topt

status,

n=34);

infusion

pending

for

additional

5pts.

Ima3

mos.

Data

cutoff:

March

2017.Schuster

SJ,

et

al.

ASH2017.

Abstract

577.JULIET:StudyDesignInternatio32JULIET

PrimaryAnalysis:BaselinePtCharacteristicsPts(n

=99)Pts(n=99)Baseline

CharacteristicsBaselineCharacteristics,

%Median

age,

yrs

(range).

≥

65

yrs,%56

(22-76)23No.priorlines

ofantineoplastic

tx.

2443119ECOG

PS0/1,

%55/45.

3.

4-6Histology,%.

DLBCL.

Transformed

FL8019Response

tolasttx.

Refractory.

RelapsedDouble/triple

hits

inCMYC/BCL2/BCL6,*

%524815Cell

of

origin,

%PriorautoHSCT47.

Germinal

center

B-cell

type.

Nongerminal

center

B-celltype5242

90%of

pts

received

bridgingchemotherapy,

93%of

pts

receivedlymphodepleting

chemotherapy*CMYC/BCL2,

n=4;

CMYC/BCL6,n=3;CMYC/BCL2/BCL6,

n=8.Schuster

SJ,

et

al.

ASH2017.

Abstract

577.JULIETPrimaryAnalysis:Basel33JULIET:

Best

ORR(PrimaryEndpoint)3-MoResponse(n

=81)6-MoResponse(n

=46)Best

ORR(n

=

81)Response,

%ORR

(CR

+PR)533837.

CR.

PR4014326307

Studymetprimaryendpoint

with

ORRof53%

(95%CI:42%to64%)•

Significantly

greaterthan

null

hypothesis

ORR≤20%(P<.0001)•

No

relationship

apparent

between

tisagenlecleucel

doseand

3-moresponse•

Responses

observed

acrossentire

dose

rangeSchuster

SJ,

et

al.

ASH2017.

Abstract

577.JULIET:BestORR(PrimaryEndp34Multicenter,multicohort,open-labelphaseItrialCorrelationBetweenPatientCharacteristics90%ofptsreceivedbridging(ID:NCT03132584)DLBCLafterNongerminalcenterStudymetprimaryendpointwithORRof53%(95%CI:42%to64%)Abstract577.AlyssaBouskaetal.Targetvalidationmustbeperformedonacase-by-caseDLBCLafterR-EPOCHvsR-CHOPDL1D:5x107cellsdoubleJClinOncol2012;30(28):3452-9.TisagenlecleucelinAdultPatientsWithCMYC/BCL2/BCL6,*%Abstract577.ClinicalriskaccordingtoMYCandofCUDC-907inDHLandDELpatients(NCT02631044)Blood2016;127:2375-2390DL1S:5x107cellssingleJULIET:

ORRby

SubgroupsNull

Hypothesis

of

ORR≤

20%ORR,n/N

(%)95%

CI43/81

(53.1)

41.7-64.3All

PtsAge,

yrs<

6532/64

(50.0)

37.2-62.811/17

(64.7)

38.2-85.8≥

65SexFemaleMale18/29

(62.1)

42.3-79.325/52

(48.1)

34.0-62.4Prior

antineoplastic

therapy≤

2lines>

2lines22/41

(53.7)

37.4-69.321/40

(52.5)

36.1-68.5Cell

of

origin*19/34

(55.9)

37.9-72.819/41

(46.3)

30.7-62.6Nongerminal

centerGerminal

centerRearranged

MYC/BCL2/BCL6Double/triple

hitsOther5/12

(41.7)15.2-72.338/69

(55.1)

42.6-67.1ORR

(%)*Data

missing

for

6pts

ORR

consistent

across

subgroupsSchuster

SJ,

et

al.

ASH2017.

Abstract

577.

Reprinted

withpermission.Multicenter,multicohort,op35193CAR

T-Cell

Therapy

JCAR017

inR/RDLBCL

FromTRANSCEND

NHL

001:CorrelationBetween

Patient

CharacteristicsandClinical

Outcomes(NCT02631044)JeremyS.

Abramson,

MD,

MMSc1,Massachusetts

General

HospitalCancerCenter,Boston,MA193CART-CellTherapyJCAR01736TRANSCEND

NHL001:

Study

Design

Multicenter,

multicohort,

open-label

phase

I

trial•

DLBCLCORE(n=67):high-grade

B-celllymphoma

(double/triple

hit),DLBCLNOSdenovo

ortransformedfromFL•

DLBCLFULL(n=91):CORE+ptswith

DLBCL

transformedfromCLL/MZL,PMBCL,orFL3BEnrollment,apheresis,JCAR017Pts

withR/RmanufacturingDLBCL

Dose-FindingDLBCL

Dose-ExpansionCohortCohortJCAR017†

IVDL1S:

5x107

cellssingledose,

D1;DL1D:

5x107

cellsdoubledose,

D1,D14;DL2S:

1x108

cellssingledose,

D1DLBCL

after2

lines

of

txor

R/RMCLafter

1

lineof

tx*Pivotal

DLBCL

cohortenrollment

ongoing(JCAR017†

IVDL2S)JCAR017†

IVDL1S,

DL2S*Pts

could

receivelow-dose

CT

for

disease

control

during

JCAR017manufacturing.

†Pts

received

≥1cycleofJACR017

tx,witheach

cyclepreceded

by

lymphodepletion

(fludarabine

30mg/m2

+cyclophospmg/m2

x

3days).

Follow-up:

PK,scans

Q3Mfor

1yr;

safety,viralvector

for

15yrs.Siddiqi

T,

et

al.

ASH2017.

Abstract

193.

.TRANSCENDNHL001:StudyDesig37TRANSCEND

NHL

001ExploratoryAnalysis:

Response*COREDL1SFULLAll

DoseLevelsResponse,*

n(%)All

DoseLevelsDL2SBestoverall

response.

ORR.

CRn

=6851

(75)38

(56)n

=4941

(84)30

(61)----Pts

with≥3-mo

f/u.

3-mo

ORR.

3-mo

CRn

=

5527

(49)22

(40)n

=

4026

(65)21

(53)n=

2111

(52)7(33)n

=

1512

(80)11

(73)*Data

cutoff:

November1,

2017.

In

CORE

population,

pts

with

durable

responses

(CR/PR)

at

3moshad

generally

lower

baseline

tumor

burden,

inflammation

marand

inflammatory

cytokinesSiddiqi

T,

et

al.

ASH

2017.

Abstract

193.TRANSCENDNHL001ExploratoryC38总

结

WHO2016分类HGBL尚有很多未知因素，临床表现为一类侵袭性、预后丌好的亚型，但觃范诊治下其中有少部分患者可能为低危

应当将MYC和BCL2/BCL6遗传学和免疫组化检查整合到诊断程序之中。Bcl-2/Myc的DHL大多为GCB亚型，增殖能力强，而BCL-6/Myc的DHL大多为ABC亚型

以R-CHOP为基础的化疗方案并丌适用，以R-DA-EPOCH、R-HyperCVAD、R-CODOX-M/IVAC为代表的强化方案仍然是目前的主流选择，ASCT的疗效和价值尚未确定

DHL患者有更多几率发生CNS进展，诊断时需要检查脑脊液且建议进行鞘注预防

需要更深入研究这类疾病，探索新的治疗方法：如小分子靶向疗药物、细胞免疫治疗（CART）、异基因造血干细胞移植，总结WHO2016分类HGBL尚有很多未知因素，临床表39WHO2016分类HGBL尚有很多未知因素，临床表现为一类侵袭性DoubleHit/TripleHit(MYC、BCL2、BCL6rearrangements)JULIETPrimaryAnalysis:Baselinepriorlinesof(ID:NCT03132584)NongerminalcenterB-cellR-EPOCH方案治疗DHL疗效显著DI(R-Hyper-CVAD/R-CODOX-M/IVAC)20JACR017tx,witheachcycleprecededbylymphodepletion(fludarabine30mg/m2+cyclophospBaselineCharacteristics,%回顾性分析纳入201