Abstract
Serologic responses of COVID-19 vaccine are impaired in patients with B-cell lymphoma, especially those who had recently been treated with anti-CD20 monoclonal antibodies. However, it is still unclear whether those patients develop an immune response following vaccination. We investigated the efficacy of vaccination against SARS-CoV-2 in 171 patients with B-cell non-Hodgkin lymphoma (B-NHL) who received two doses of an mRNA-based COVID-19 vaccine and we compared the efficacy of vaccination to that in 166 healthy controls. Antibody titers were measured 3 months after administration of the second vaccine dose. Patients with B-NHL showed a significantly lower seroconversion rate and a lower median antibody titer than those in healthy controls. The antibody titers showed correlations with the period from the last anti-CD20 antibody treatment to vaccination, the period from the last bendamustine treatment to vaccination and serum IgM level. The serologic response rates and median antibody titers were significantly different between diffuse large B-cell lymphoma (DLBCL) patients in whom anti-CD20 antibody treatment was completed within 9 months before vaccination and follicular lymphoma (FL) patients in whom anti-CD20 antibody treatment was completed within 15 months before vaccination. Moreover, the serologic response rates and median antibody titers were significantly different among FL patients in whom bendamustine treatment was completed within 33 months before vaccination. We demonstrated that B-NHL patients who were recently treated with anti-CD20 antibodies and bendamustine had a diminished humoral response to COVID-19 vaccination. UMIN 000,045,267.
Similar content being viewed by others
Introduction
The novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a pandemic throughout the world and more than 5 million deaths. COVID-19 has an increased risk of mortality in patients with hematological malignancies, with a mortality rate of approximately 35% in hospitalized patients, probably due to impaired humoral and cellular immunity and therapy-related immunosuppression [1,2,3,4,5,6,7,8,9,10,11]. The results of several randomized trials for BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) vaccines against SARS-CoV-2 have shown that the vaccines are safe and effective for preventing infection or attenuating disease severity [12, 13]. It was reported that seroconversion of SARS-CoV-2 immunoglobulin G (IgG) occurred in almost all healthy individuals, but the seroconversion rate was lower in patients with hematological malignancies [14,15,16,17,18,19,20,21,22]. Moreover, several studies have shown that the seroconversion rate was decreased in patients with B-cell lymphoma, especially those who had recently been treated with anti-CD20 monoclonal antibodies due to depletion of normal B cells and thus impairment of humoral response [23,24,25,26,27,28,29,30]. However, it is still unclear whether those patients develop an immune response following vaccination. In the current study, we investigated the antibody titers of SARS-CoV-2 in patients with B-cell non-Hodgkin lymphoma (B-NHL) who received two doses of an mRNA-based COVID-19 vaccine, either BNT162b2 or mRNA-1273, and compared them to those in healthy controls to identify factors affecting the response rate to the vaccine.
Methods
Patients and healthy controls
Previously treated, actively treated at the time of vaccination, and treatment-naïve B-NHL patients, including patients with diffuse large B-cell lymphoma (DLBCL) and patients with follicular lymphoma (FL), were enrolled in this prospective study (UMIN 000,045,267). Consistent with our previous report, all patients who had been vaccinated with two consecutive doses of an mRNA-based COVID-19 vaccine, either BNT162b2 or mRNA-1273, were recruited into this study between August 17 and December 31, 2021 [31]. The BNT162b2 and mRNA-1273 vaccines were administered 21 days and 28 days apart, respectively. Individuals with a known history of COVID-19 infection were excluded from both cohorts of patients and healthy controls. Demographic and clinical data including data for histological diagnosis, disease status, response to treatment, treatment regimen, complete blood count, and blood chemistry were obtained from medical records. The response criteria in patients with B-NHL were defined according to the Lugano response criteria for non-Hodgkin’s lymphoma [32]. The disease status in all patients was determined at the time of sample collection. We recruited healthcare workers at Aiiku Hospital who had no medical history of hematological disorders and who had received two doses of BNT162b2 vaccine as healthy controls. This study was conducted in compliance with ethical principles based on the Helsinki Declaration and was approved by the institutional review board of Aiiku Hospital. All participants provided written informed consent prior to enrollment in the study.
Assessment of serological response
Peripheral blood and serum samples were drawn 3 months after administration of the second vaccine dose and were evaluated for anti-spike (S) SARS-CoV-2 antibodies using the Elecsys® □ Anti-SARS-CoV-2S immunoassay performed on the cobas e411 fully automated analyzer for the SARS-CoV-2 S protein receptor-binding domain [33,34,35]. This assay has a minimum measurement value of 0.4 U/mL, with a concentration of 0.8 U/mL or more considered to be a positive result. For individuals with an antibody titer to SARS-CoV-2 S protein of less than 0.4 U/mL, the antibody titer was calculated as 0 U/mL.
Statistical analysis
The chi-squared test or Fisher’s exact test was used to compare categorical variables and the Mann–Whitney U test or an analysis of variance test was used for continuous variables. P values were adjusted using the Bonferroni method for multiple comparisons between each pair. We used the likelihood ratio of the receiver operator characteristics (ROC) curves and area under the curve to define the optimal cutoff for continuous variables. Univariate and multivariate logistic regression analyses were performed to evaluate potential predictors of vaccine response. Multivariate analysis with stepwise variable selection was used to assess which variables were genuinely independent. Spearman’s rank correlation coefficient was used to assess the relationship between two continuous variables. Statistical significance was determined as P values below 0.05, and all statistical tests were 2-sided. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R software version 2.13.0 (R Foundation for Statistical Computing, Vienna, Austria) [36].
Results
Characteristics of patients and healthy controls
A total of 171 patients with B-NHL as well as healthy controls (n = 166) were enrolled in this study. The characteristics of the patients are summarized in Tables 1 and 2. The median age of the patient cohort was 71 years (range: 31–92 years) and 87 of the patients (50.9%) were male. The healthy controls included 23 males and 143 females with a median age of 38.5 years (range: 20–72 years). A total of 140 patients and all healthy controls received BNT162b2, while 31 patients received mRNA-1273. Each patient and healthy control determined the choice of vaccine. Most patients (n = 158, 92.4%) had been previously exposed to anti-CD20 antibody, and the median period from the last exposure to the antibody to serology testing was 639.5 days (IQR: 163–1471.5 days). Moreover, 41 patients (24.0%), including 29 FL patients, had been previously exposed to bendamustine, and the median period from the last exposure to bendamustine to serology testing was 950 days (IQR: 719–1562 days). Within a median follow-up period of 401 days (IQR: 371.5–418.5 days) from administration of the second COVID-19 vaccine, 6 patients with B-NHL (including 2 patients who had a seronegative response, and a patient who was on therapy) developed COVID-19 infections, and most of them had mild clinical courses.
Serological responses for B-NHL patients
Patients with B-NHL showed a significantly lower seroconversion rate and a lower median antibody titer to SARS-CoV-2 S protein than those in healthy controls (70.0% vs 100%, P < 0.001; 166.0 U/mL, IQR: 0–943.5 vs 1301.5 U/mL, IQR: 839–1991.5, P < 0.001, respectively) (Fig. 1A). The seroconversion rate and median antibody titer in DLBCL patients were comparable to those in FL patients (69.4% vs 63.2%, P = 0.47; 124 U/mL, IQR: 0–794 vs 149 U/mL, IQR: 0–741, P = 0.943, respectively). The median ages of seropositive and seronegative patients with B-NHL were not significantly different (70 years, IQR: 62.5–75 vs 71 years, IQR: 66.5–75.5, P = 0.165). The median antibody titers did not differ statistically between male and female patients with B-NHL as well as between patients in complete remission and those in other response categories (Figs. S1A and S1B). Patients vaccinated with mRNA-1273 tended to have a higher response rate and had a significantly higher median antibody titer than those in patients vaccinated with BNT162b2 (83.9% vs 66.4%, P = 0.083; 928 U/mL, IQR: 95–2937 vs 114.5 U/mL, IQR: 0–731, P < 0.001, respectively) (Fig. 1B).
Treatment-naïve patients with B-NHL as well as those off-therapy had significantly higher response rates (100% and 74.8%, respectively) and higher median antibody titers (500 U/mL, IQR: 142–3194 and 368 U/mL, IQR: 0.9–1183.5, respectively) than those in patients on active therapy (38.7%, P < 0.001; 0 U/mL, IQR: 0–29, P < 0.001, respectively) (Fig. 1C). The serologic response rates and median antibody titers did not differ significantly between patients who received one line of therapy and patients who received two or more lines of therapy as well as between patients with B-NHL who underwent HSCT and those who did not undergo HSCT (Figs. S1C and S1D). Among the patients with DLBCL or FL, the median antibody titers in the different types and risks are shown in Fig. S2. None of them had a statistically significant impact on median antibody titers except for FLIPI2 between low and intermediate (1768 U/mL, IQR: 1254.5–4355 vs 2.64 U/mL, IQR: 0–144, P = 0.009).
Factors affecting serological responses in B-NHL patients
In univariate analysis, the variables that were significantly associated with a lack of serological response included a period of less than 11 months from the last anti-CD20 antibody treatment to vaccination (odds ratio (OR) = 74.8, 95% confidence interval (CI): 21.1–266), previous treatment with bendamustine (OR = 2.915, 95% CI: 1.404–6.061), hemoglobin level < 12.0 g/dL (OR = 3.00, 95% CI: 1.52–5.92), serum IgA level < 166 mg/dL (OR = 5.14, 95% CI: 2.41–11.0), serum IgG level < 932 mg/dL (OR = 2.89, 95% CI: 1.47–5.71), serum IgM level < 46 mg/dL (OR = 7.65, 95% CI: 3.55–16.5), absolute lymphocyte count < 1232 cells/mL (OR = 3.91, 95% CI: 1.97–7.76), absolute neutrophil count < 2585 cells/mL (OR = 2.17, 95% CI: 1.11–4.25), and platelet count < 187,000 cells/mL (OR = 2.52, 95% CI: 1.29–4.92), based on ROC analysis (Table 3). In multivariate analysis, the independent variables associated with response included a period of less than 11 months from the last anti-CD20 antibody treatment to vaccination (OR = 85.6, 95% CI: 22.3–329.0) and previous treatment with bendamustine (OR = 3.89, 95% CI: 1.14–13.2) (Table 3). Moreover, antibody titers showed correlations with the period from the last anti-CD20 antibody treatment to vaccination (R = 0.666, P < 0.001), the period from the last bendamustine treatment to vaccination (R = 0.406, P = 0.008), and serum IgM level (R = 0.504, P < 0.001) (Fig. 2).
Serological responses to anti-CD20 antibody administration in DLBCL and FL patients
Patients who had been previously exposed to anti-CD20 antibody showed a significantly lower seroconversion rate and a lower median antibody titer than those in patients who had never received anti-CD20 therapy (67.1% vs 100%, P = 0.01; 149.5 U/mL, IQR: 0–846 vs 1240 U/mL, IQR: 161–2756, P = 0.004, respectively) (Fig. 3A). Based on ROC analysis, the serologic response rates and median antibody titers were significantly different between DLBCL patients who completed anti-CD20 antibody treatment within 9 months before vaccination (n = 41) and those who completed the treatment more than 9 months before vaccination (n = 43) (39.0% vs 97.7%, P < 0.001; 0 U/mL, IQR: 0–11.5 vs 790 U/mL, IQR: 296.5–1315, P < 0.001, respectively) (Fig. 3B and C). Similarly, the serologic response rates and median antibody titers were significantly different between FL patients who received the last anti-CD20 antibody treatment within 15 months prior to vaccination (n = 20) and those who received the last treatment more than 15 months prior to vaccination (n = 30) (5.0% vs 93.3%, P < 0.001; 0 U/mL, IQR: 0–0 vs 462 U/mL, IQR: 157.5–1348, P < 0.001, respectively) (Fig. 3D and E).
Serological responses to bendamustine administration in FL patients
Furthermore, FL patients who had previously received bendamustine had a significantly lower seroconversion rate and a lower median antibody titer than those in FL patients who had never received bendamustine (41.4% vs 85.7%, P < 0.001; 0 U/mL, IQR: 0–96.5 vs 583 U/mL, IQR: 149.5–1928.5, P < 0.001, respectively) (Fig. 4A). Among the FL patients who received the last anti-CD20 antibody treatment more than 15 months prior to vaccination (n = 30), patients who had previously received bendamustine also had a significantly lower median antibody titer than those who had never received bendamustine, although the serologic response rates did not differ statistically (84.6% vs 100%, P = 0.179; 180 U/mL, IQR: 64.8–630 vs 724 U/mL, IQR: 316–2410, P = 0.022, respectively) (Fig. 4B). Based on ROC analysis, the serologic response rates and median antibody titers were significantly different between FL patients who completed bendamustine treatment within 33 months before vaccination (n = 18) and those who completed the treatment more than 33 months before vaccination (n = 11) (22.2% vs 72.7%, P = 0.017; 0 U/mL, IQR: 0–0.5 vs 339 U/mL, IQR: 3.5–956, P = 0.004, respectively) (Fig. 4C and D).
Discussion
In the current study, the serologic responses to two doses of COVID-19 vaccine in B-NHL patients were evaluated and compared with those in age-compatible vaccinated healthy controls. Effective vaccination against SARS-CoV-2 would contribute to the protection of patients against COVID-19. However, consistent with previous reports, patients with B-NHL who had previously been exposed to treatment had a poor humoral response to COVID-19 vaccination due to inherent immune deficiency and therapy-related immune suppression [23,24,25,26,27,28,29,30]. Median antibody titers had a statistically significant impact between FLIPI2 low and FLIPI2 intermediate. The percentage of treatment-naïve patients was higher in FLIPI2 low patients than FLIPI2 intermediate patients (66.7% vs 10.0%, P = 0.07). In contrast, the percentage of treatment-naïve patients was not different significantly among the types and risks shown in Fig. S2, except for between FLIPI2 low and FLIPI2 intermediate (data not shown).
In our cohort, the main predictive factors influencing antibody levels following vaccination were the period from the last anti-CD20 antibody treatment to vaccination, the period from the last bendamustine treatment to vaccination and serum IgM level. Previous studies showed that CD19-positive lymphocyte count in peripheral blood and serum IgM titer correlated significantly with the acquired antibody titer in patients treated with anti-CD20 antibodies [23, 29, 30]. IgM titer increases within the first 2 weeks in response to an antigen such as a virus, followed by degradation over a period of several weeks, and low serum IgM titer is a manifestation of B-cell depletion [37].
From the viewpoint of therapy-related factors, patients with DLBCL and FL who received anti-CD20 antibodies within 9 months and 15 months before vaccination failed to produce anti-spike antibodies against COVID-19. The recovery of peripheral blood B-cell depletion after anti-CD20 therapy starts at 6 months after treatment with a return to normal counts at 12 months [38, 39]. In our study, 6 patients of FL received anti-CD20 antibody maintenance therapy among those on therapy. The median number of anti-CD20 antibody treatment was higher in FL patients than those in DLBCL patients (15 vs 6, P < 0.001); however, the number of anti-CD20 antibody treatment did not correlate significantly with the acquired antibody titer, and did not differ significantly between seropositive and seronegative patients among those on therapy (R = − 0.309, P = 0.124; 7 vs 8, P = 0.112). A previous study showed that the median period to achieve positive serology was prolonged in patients with indolent B-NHL compared with that in patients with aggressive B-NHL, and this difference probably reflects the deeper immune suppression imposed by longer exposure to anti-CD20 antibodies and incurable status in patients with indolent B-NHL [26]. In our study, however, all of treatment-naïve patients with indolent B-NHL (n = 8) achieved seroconversion, and the median period from the last exposure to anti-CD20 antibodies did not differ significantly between patients with DLBCL and patients with FL (424 days, IQR: 147.5–1345 vs 831 days, IQR: 180.5–1753, P = 0.102).
Our results also showed a poor response to COVID-19 vaccination in the setting of bendamustine, particularly in FL patients. To the best of our knowledge, our study is the first study showing the effects of bendamustine on humoral response to COVID-19 vaccine for B-NHL patients in a prospective cohort. We speculated that bendamustine administration was the reason for the difference in the periods from the last anti-CD20 antibody treatment to vaccination between DLBCL and FL patients. Previous studies showed that CD4-positive lymphocyte count in peripheral blood correlated significantly with the acquired antibody titer in patients treated with anti-CD20 antibodies, suggesting that CD4-positive T cells established by COVID-19 vaccination are necessary for the generation of high-affinity antibodies and development of memory B-cells and may contribute to long-term memory immunity against SARS-CoV-2 [30, 40,41,42,43,44]. Since it has been reported that bendamustine reduced CD4-positive T cells, we speculated that bendamustine might impede the serologic response [45]. In fact, there have been several studies on B-NHL patients with COVID-19 severity and mortality who were previously exposed to both anti-CD20 antibody and bendamustine [46,47,48,49,50]. Our results also suggested that these immunocompromised patients have a high risk of COVID-19 infection.
Our study has several limitations. There were differences between lymphoma patients and healthy controls in age, sex, and mRNA vaccine. Although we studied the protective impact of vaccination and its ability to prevent SARS-CoV-2 infection or clinically significant COVID-19 in B-NHL patients, further investigations with a larger cohort are required. We instructed the patients who had a high risk of COVID-19 infection to take precautions such as social distancing. Therefore, we speculated that only 6 patients developed COVID-19 infections.
Conclusion
In summary, our study demonstrated that B-NHL patients who were recently treated with anti-CD20 antibodies or bendamustine had a diminished humoral response to COVID-19 vaccination and that serum IgM titer is a biomarker to predict the antibody response. We concluded that depletion of B cells or T cells was impaired humoral response to COVID-19 vaccination.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
Mehta V, Goel S, Kabarriti R, Cole D, Goldfinger M, Acuna-Villaorduna A, Pradhan K, Thota R, Reissman S, Sparano JA, Gartrell BA, Smith RV, Ohri N, Garg M, Racine AD, Kalnicki S, Perez-Soler R, Halmos B, Verma A (2020) Case fatality rate of cancer patients with COVID-19 in a New York hospital system. Cancer Discov 10(7):935–941. https://doi.org/10.1158/2159-8290.CD-20-0516
Lee LYW, Cazier JB, Starkey T, Briggs SEW, Arnold R, Bisht V, Booth S, Campton NA, Cheng VWT, Collins G, Curley HM, Earwaker P, Fittall MW, Gennatas S, Goel A, Hartley S, Hughes DJ, Kerr D, Lee AJX, Lee RJ, Lee SM, McKenzie H, Middleton CP, Murugaesu N, Newsom-Davis T, Olsson-Brown AC, Palles C, Powles T, Protheroe EA, Purshouse K, Sharma-Oates A, Sivakumar S, Smith AJ, Topping O, Turnbull CD, Varnai C, Briggs ADM, Middleton G, Kerr R, Team UKCCMP (2020) COVID-19 prevalence and mortality in patients with cancer and the effect of primary tumour subtype and patient demographics: a prospective cohort study. Lancet Oncol 21(10):1309–1316. https://doi.org/10.1016/S1470-2045(20)30442-3
Vijenthira A, Gong IY, Fox TA, Booth S, Cook G, Fattizzo B, Martin-Moro F, Razanamahery J, Riches JC, Zwicker J, Patell R, Vekemans MC, Scarfo L, Chatzikonstantinou T, Yildiz H, Lattenist R, Mantzaris I, Wood WA, Hicks LK (2020) Outcomes of patients with hematologic malignancies and COVID-19: a systematic review and meta-analysis of 3377 patients. Blood 136(25):2881–2892. https://doi.org/10.1182/blood.2020008824
Passamonti F, Cattaneo C, Arcaini L, Bruna R, Cavo M, Merli F, Angelucci E, Krampera M, Cairoli R, Della Porta MG, Fracchiolla N, Ladetto M, Gambacorti Passerini C, Salvini M, Marchetti M, Lemoli R, Molteni A, Busca A, Cuneo A, Romano A, Giuliani N, Galimberti S, Corso A, Morotti A, Falini B, Billio A, Gherlinzoni F, Visani G, Tisi MC, Tafuri A, Tosi P, Lanza F, Massaia M, Turrini M, Ferrara F, Gurrieri C, Vallisa D, Martelli M, Derenzini E, Guarini A, Conconi A, Cuccaro A, Cudillo L, Russo D, Ciambelli F, Scattolin AM, Luppi M, Selleri C, Ortu La Barbera E, Ferrandina C, Di Renzo N, Olivieri A, Bocchia M, Gentile M, Marchesi F, Musto P, Federici AB, Candoni A, Venditti A, Fava C, Pinto A, Galieni P, Rigacci L, Armiento D, Pane F, Oberti M, Zappasodi P, Visco C, Franchi M, Grossi PA, Bertu L, Corrao G, Pagano L, Corradini P, Investigators I-H-C (2020) Clinical characteristics and risk factors associated with COVID-19 severity in patients with haematological malignancies in Italy: a retrospective, multicentre, cohort study. Lancet Haematol 7(10):e737–e745. https://doi.org/10.1016/S2352-3026(20)30251-9
Wood WA, Neuberg DS, Thompson JC, Tallman MS, Sekeres MA, Sehn LH, Anderson KC, Goldberg AD, Pennell NA, Niemeyer CM, Tucker E, Hewitt K, Plovnick RM, Hicks LK (2020) Outcomes of patients with hematologic malignancies and COVID-19: a report from the ASH Research Collaborative Data Hub. Blood Adv 4(23):5966–5975. https://doi.org/10.1182/bloodadvances.2020003170
He W, Chen L, Chen L, Yuan G, Fang Y, Chen W, Wu D, Liang B, Lu X, Ma Y, Li L, Wang H, Chen Z, Li Q, Gale RP (2020) COVID-19 in persons with haematological cancers. Leukemia 34(6):1637–1645. https://doi.org/10.1038/s41375-020-0836-7
Martin-Moro F, Marquet J, Piris M, Michael BM, Saez AJ, Corona M, Jimenez C, Astibia B, Garcia I, Rodriguez E, Garcia-Hoz C, Fortun-Abete J, Herrera P, Lopez-Jimenez J (2020) Survival study of hospitalised patients with concurrent COVID-19 and haematological malignancies. Br J Haematol 190(1):e16–e20. https://doi.org/10.1111/bjh.16801
van Doesum J, Chinea A, Pagliaro M, Pasquini MC, van Meerten T, Bakker M, Ammatuna E (2020) Clinical characteristics and outcome of SARS-CoV-2-infected patients with 8haematological diseases: a retrospective case study in four hospitals in Italy Spain and the Netherlands. Leukemia 34(9):2536–2538. https://doi.org/10.1038/s41375-020-0960-4
Cattaneo C, Daffini R, Pagani C, Salvetti M, Mancini V, Borlenghi E, D’Adda M, Oberti M, Paini A, De Ciuceis C, Barbullushi K, Cancelli V, Belotti A, Re A, Motta M, Peli A, Bianchetti N, Anastasia A, Dalceggio D, Roccaro AM, Tucci A, Cairoli R, Muiesan ML, Rossi G (2020) Clinical characteristics and risk factors for mortality in hematologic patients affected by COVID-19. Cancer 126(23):5069–5076. https://doi.org/10.1002/cncr.33160
Garcia-Suarez J, de la Cruz J, Cedillo A, Llamas P, Duarte R, Jimenez-Yuste V, Hernandez-Rivas JA, Gil-Manso R, Kwon M, Sanchez-Godoy P, Martinez-Barranco P, Colas-Lahuerta B, Herrera P, Benito-Parra L, Alegre A, Velasco A, Matilla A, Alaez-Uson MC, Martos-Martinez R, Martinez-Chamorro C, Susana-Quiroz K, Del Campo JF, de la Fuente A, Herraez R, Pascual A, Gomez E, Perez-Oteyza J, Ruiz E, Alonso A, Gonzalez-Medina J, Martin-Buitrago LN, Canales M, Gonzalez-Gascon I, Vicente-Ayuso MC, Valenciano S, Roa MG, Monteliu PE, Lopez-Jimenez J, Escobar CE, Ortiz-Martin J, Diez-Martin JL, Martinez-Lopez J, Madrilena A, de Hematologia YH (2020) Impact of hematologic malignancy and type of cancer therapy on COVID-19 severity and mortality: lessons from a large population-based registry study. J Hematol Oncol 13(1):133. https://doi.org/10.1186/s13045-020-00970-7
Fox TA, Troy-Barnes E, Kirkwood AA, Chan WY, Day JW, Chavda SJ, Kumar EA, David K, Tomkins O, Sanchez E, Scully M, Khwaja A, Lambert J, Singer M, Roddie C, Morris EC, Yong KL, Thomson KJ, Ardeshna KM (2020) Clinical outcomes and risk factors for severe COVID-19 in patients with haematological disorders receiving chemo- or immunotherapy. Br J Haematol 191(2):194–206. https://doi.org/10.1111/bjh.17027
Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Perez Marc G, Moreira ED, Zerbini C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW Jr, Hammitt LL, Tureci O, Nell H, Schaefer A, Unal S, Tresnan DB, Mather S, Dormitzer PR, Sahin U, Jansen KU, Gruber WC, Group CCT (2020) Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med 383(27):2603–2615. https://doi.org/10.1056/NEJMoa2034577
Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, Diemert D, Spector SA, Rouphael N, Creech CB, McGettigan J, Khetan S, Segall N, Solis J, Brosz A, Fierro C, Schwartz H, Neuzil K, Corey L, Gilbert P, Janes H, Follmann D, Marovich M, Mascola J, Polakowski L, Ledgerwood J, Graham BS, Bennett H, Pajon R, Knightly C, Leav B, Deng W, Zhou H, Han S, Ivarsson M, Miller J, Zaks T, Group CS (2021) Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. N Engl J Med 384(5):403–416. https://doi.org/10.1056/NEJMoa2035389
Herzog Tzarfati K, Gutwein O, Apel A, Rahimi-Levene N, Sadovnik M, Harel L, Benveniste-Levkovitz P, Bar Chaim A, Koren-Michowitz M (2021) BNT162b2 COVID-19 vaccine is significantly less effective in patients with hematologic malignancies. Am J Hematol 96(10):1195–1203. https://doi.org/10.1002/ajh.26284
Greenberger LM, Saltzman LA, Senefeld JW, Johnson PW, DeGennaro LJ, Nichols GL (2021) Antibody response to SARS-CoV-2 vaccines in patients with hematologic malignancies. Cancer Cell 39(8):1031–1033. https://doi.org/10.1016/j.ccell.2021.07.012
Gagelmann N, Passamonti F, Wolschke C, Massoud R, Niederwieser C, Adjalle R, Mora B, Ayuk F, Kroger N (2021) Antibody response after vaccination against SARS-CoV-2 in adults with haematological malignancies: a systematic review and meta-analysis. Haematologica. https://doi.org/10.3324/haematol.2021.280163
Chung DJ, Shah GL, Devlin SM, Ramanathan LV, Doddi S, Pessin MS, Hoover E, Marcello LT, Young JC, Boutemine SR, Serrano E, Sharan S, Momotaj S, Margetich L, Bravo CD, Papanicolaou GA, Kamboj M, Mato AR, Roeker LE, Hultcrantz M, Mailankody S, Lesokhin AM, Vardhana SA, Knorr DA (2021) Disease- and therapy-specific impact on humoral immune responses to COVID-19 vaccination in hematologic malignancies. Blood Cancer Discov 2(6):568–576. https://doi.org/10.1158/2643-3230.BCD-21-0139
Malard F, Gaugler B, Gozlan J, Bouquet L, Fofana D, Siblany L, Eshagh D, Adotevi O, Laheurte C, Ricard L, Dulery R, Stocker N, van de Wyngaert Z, Genthon A, Banet A, Memoli M, Ikhlef S, Sestilli S, Vekhof A, Brissot E, Marjanovic Z, Chantran Y, Cuervo N, Ballot E, Morand-Joubert L, Mohty M (2021) Weak immunogenicity of SARS-CoV-2 vaccine in patients with hematologic malignancies. Blood Cancer J 11(8):142. https://doi.org/10.1038/s41408-021-00534-z
Maneikis K, Sablauskas K, Ringeleviciute U, Vaitekenaite V, Cekauskiene R, Kryzauskaite L, Naumovas D, Banys V, Peceliunas V, Beinortas T, Griskevicius L (2021) Immunogenicity of the BNT162b2 COVID-19 mRNA vaccine and early clinical outcomes in patients with haematological malignancies in Lithuania: a national prospective cohort study. Lancet Haematol 8(8):e583–e592. https://doi.org/10.1016/S2352-3026(21)00169-1
Ollila TA, Lu S, Masel R, Zayac A, Paiva K, Rogers RD, Olszewski AJ (2021) Antibody response to COVID-19 vaccination in adults with hematologic malignant disease. JAMA Oncol 7(11):1714–1716. https://doi.org/10.1001/jamaoncol.2021.4381
Teh JSK, Coussement J, Neoh ZCF, Spelman T, Lazarakis S, Slavin MA, Teh BW (2022) Immunogenicity of COVID-19 vaccines in patients with hematologic malignancies: a systematic review and meta-analysis. Blood Adv 6(7):2014–2034. https://doi.org/10.1182/bloodadvances.2021006333
Jimenez M, Roldan E, Fernandez-Naval C, Villacampa G, Martinez-Gallo M, Medina-Gil D, Peralta-Garzon S, Pujadas G, Hernandez C, Pages C, Gironella M, Fox L, Orti G, Barba P, Pumarola T, Cabirta A, Catala E, Valentin M, Marin-Niebla A, Orfao A, Gonzalez M, Campins M, Ruiz-Camps I, Valcarcel D, Bosch F, Hernandez M, Crespo M, Esperalba J, Abrisqueta P (2022) Cellular and humoral immunogenicity of the mRNA-1273 SARS-CoV-2 vaccine in patients with hematologic malignancies. Blood Adv 6(3):774–784. https://doi.org/10.1182/bloodadvances.2021006101
Tvito A, Ronson A, Ghosheh R, Kharit M, Ashkenazi J, Magen S, Broide E, Benayoun E, Rowe JM, Ofran Y, Ganzel C (2022) Anti-CD20 monoclonal antibodies inhibit seropositive response to COVID-19 vaccination in non-Hodgkin lymphoma patients within 6 months after treatment. Exp Hematol 107:20–23. https://doi.org/10.1016/j.exphem.2021.12.396
Lim SH, Campbell N, Johnson M, Joseph-Pietras D, Collins GP, O’Callaghan A, Fox CP, Ahearne M, Johnson PWM, Goldblatt D, Davies AJ (2021) Antibody responses after SARS-CoV-2 vaccination in patients with lymphoma. Lancet Haematol 8(8):e542–e544. https://doi.org/10.1016/S2352-3026(21)00199-X
Gurion R, Rozovski U, Itchaki G, Gafter-Gvili A, Leibovitch C, Raanani P, Ben-Zvi H, Szwarcwort M, Taylor-Abigadol M, Dann EJ, Horesh N, Inbar T, Tzoran I, Lavi N, Fineman R, Ringelstein-Harlev S, Horowitz NA (2022) Humoral serological response to the BNT162b2 vaccine is abrogated in lymphoma patients within the first 12 months following treatment with anti-CD2O antibodies. Haematologica 107(3):715–720. https://doi.org/10.3324/haematol.2021.279216
Perry C, Luttwak E, Balaban R, Shefer G, Morales MM, Aharon A, Tabib Y, Cohen YC, Benyamini N, Beyar-Katz O, Neaman M, Vitkon R, Keren-Khadmy N, Levin M, Herishanu Y, Avivi I (2021) Efficacy of the BNT162b2 mRNA COVID-19 vaccine in patients with B-cell non-Hodgkin lymphoma. Blood Adv 5(16):3053–3061. https://doi.org/10.1182/bloodadvances.2021005094
Ghione P, Gu JJ, Attwood K, Torka P, Goel S, Sundaram S, Mavis C, Johnson M, Thomas R, McWhite K, Darrall A, DeMarco J, Kostrewa J, Mohr A, Rivas L, Neiders M, Suresh L, Segal BH, Griffiths EA, Ramsperger V, Shen L, Hernandez-Ilizaliturri FJ (2021) Impaired humoral responses to COVID-19 vaccination in patients with lymphoma receiving B-cell-directed therapies. Blood 138(9):811–814. https://doi.org/10.1182/blood.2021012443
Jurgens EM, Ketas TJ, Zhao Z, Joseph Satlin M, Small CB, Sukhu A, Francomano E, Klasse PJ, Garcia A, Nguyenduy E, Bhavsar E, Formenti S, Furman R, Moore JP, Leonard JP, Martin P (2021) Serologic response to mRNA COVID-19 vaccination in lymphoma patients. Am J Hematol 96(11):E410–E413. https://doi.org/10.1002/ajh.26322
Marasco V, Carniti C, Guidetti A, Farina L, Magni M, Miceli R, Calabretta L, Verderio P, Ljevar S, Serpenti F, Morelli D, Apolone G, Ippolito G, Agrati C, Corradini P (2022) T-cell immune response after mRNA SARS-CoV-2 vaccines is frequently detected also in the absence of seroconversion in patients with lymphoid malignancies. Br J Haematol 196(3):548–558. https://doi.org/10.1111/bjh.17877
Okamoto A, Fujigaki H, Iriyama C, Goto N, Yamamoto H, Mihara K, Inaguma Y, Miura Y, Furukawa K, Yamamoto Y, Akatsuka Y, Kasahara S, Miyao K, Tokuda M, Sato S, Mizutani Y, Osawa M, Hattori K, Iba S, Kajiya R, Okamoto M, Saito K, Tomita A (2022) CD19-positive lymphocyte count is critical for acquisition of anti-SARS-CoV-2 IgG after vaccination in B-cell lymphoma. Blood Adv 6(11):3230–3233. https://doi.org/10.1182/bloodadvances.2021006302
Mori A, Onozawa M, Tsukamoto S, Ishio T, Yokoyama E, Izumiyama K, Saito M, Muraki H, Morioka M, Teshima T, Kondo T (2022) Humoral response to mRNA-based COVID-19 vaccine in patients with myeloid malignancies. Br J Haematol 197(6):691–696. https://doi.org/10.1111/bjh.18138
Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, Lister TA, Alliance AL, Lymphoma G, Eastern Cooperative Oncology G, European Mantle Cell Lymphoma C, Italian Lymphoma F, European Organisation for R, Treatment of Cancer/Dutch Hemato-Oncology G, Grupo Espanol de Medula O, German High-Grade Lymphoma Study G, German Hodgkin’s Study G, Japanese Lymphorra Study G, Lymphoma Study A, Group NCT, Nordic Lymphoma Study G, Southwest Oncology G, United Kingdom National Cancer Research I (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. https://doi.org/10.1200/JCO.2013.54.8800
Avivi I, Balaban R, Shragai T, Sheffer G, Morales M, Aharon A, Lowenton-Spier N, Trestman S, Perry C, Benyamini N, Mittelman M, Tabib Y, Bar Lev T, Zavaro M, Herishanu Y, Luttwak E, Cohen YC (2021) Humoral response rate and predictors of response to BNT162b2 mRNA COVID19 vaccine in patients with multiple myeloma. Br J Haematol 195(2):186–193. https://doi.org/10.1111/bjh.17608
Kageyama T, Ikeda K, Tanaka S, Taniguchi T, Igari H, Onouchi Y, Kaneda A, Matsushita K, Hanaoka H, Nakada TA, Ohtori S, Yoshino I, Matsubara H, Nakayama T, Yokote K, Nakajima H (2021) Antibody responses to BNT162b2 mRNA COVID-19 vaccine and their predictors among healthcare workers in a tertiary referral hospital in Japan. Clin Microbiol Infect 27(12):1861e1861-1861e1865. https://doi.org/10.1016/j.cmi.2021.07.042
Benda M, Mutschlechner B, Ulmer H, Grabher C, Severgnini L, Volgger A, Reimann P, Lang T, Atzl M, Huynh M, Gasser K, Petrausch U, Fraunberger P, Hartmann B, Winder T (2021) Serological SARS-CoV-2 antibody response, potential predictive markers and safety of BNT162b2 mRNA COVID-19 vaccine in haematological and oncological patients. Br J Haematol 195(4):523–531. https://doi.org/10.1111/bjh.17743
Kanda Y (2013) Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant 48(3):452–458. https://doi.org/10.1038/bmt.2012.244
Long QX, Liu BZ, Deng HJ, Wu GC, Deng K, Chen YK, Liao P, Qiu JF, Lin Y, Cai XF, Wang DQ, Hu Y, Ren JH, Tang N, Xu YY, Yu LH, Mo Z, Gong F, Zhang XL, Tian WG, Hu L, Zhang XX, Xiang JL, Du HX, Liu HW, Lang CH, Luo XH, Wu SB, Cui XP, Zhou Z, Zhu MM, Wang J, Xue CJ, Li XF, Wang L, Li ZJ, Wang K, Niu CC, Yang QJ, Tang XJ, Zhang Y, Liu XM, Li JJ, Zhang DC, Zhang F, Liu P, Yuan J, Li Q, Hu JL, Chen J, Huang AL (2020) Antibody responses to SARS-CoV-2 in patients with COVID-19. Nat Med 26(6):845–848. https://doi.org/10.1038/s41591-020-0897-1
Piro LD, White CA, Grillo-Lopez AJ, Janakiraman N, Saven A, Beck TM, Varns C, Shuey S, Czuczman M, Lynch JW, Kolitz JE, Jain V (1999) Extended rituximab (anti-CD20 monoclonal antibody) therapy for relapsed or refractory low-grade or follicular non-Hodgkin’s lymphoma. Ann Oncol 10(6):655–661. https://doi.org/10.1023/a:1008389119525
Salles G, Barrett M, Foa R, Maurer J, O’Brien S, Valente N, Wenger M, Maloney DG (2017) Rituximab in B-cell hematologic malignancies: a review of 20 years of clinical experience. Adv Ther 34(10):2232–2273. https://doi.org/10.1007/s12325-017-0612-x
Liebers N, Speer C, Benning L, Bruch PM, Kraemer I, Meissner J, Schnitzler P, Krausslich HG, Dreger P, Mueller-Tidow C, Poschke I, Dietrich S (2022) Humoral and cellular responses after COVID-19 vaccination in anti-CD20-treated lymphoma patients. Blood 139(1):142–147. https://doi.org/10.1182/blood.2021013445
Grifoni A, Weiskopf D, Ramirez SI, Mateus J, Dan JM, Moderbacher CR, Rawlings SA, Sutherland A, Premkumar L, Jadi RS, Marrama D, de Silva AM, Frazier A, Carlin AF, Greenbaum JA, Peters B, Krammer F, Smith DM, Crotty S, Sette A (2020) Targets of T cell responses to SARS-CoV-2 coronavirus in humans with COVID-19 disease and unexposed individuals. Cell 181(7):1489-1501 e1415. https://doi.org/10.1016/j.cell.2020.05.015
Lederer K, Castano D, Gomez Atria D, Oguin TH 3rd, Wang S, Manzoni TB, Muramatsu H, Hogan MJ, Amanat F, Cherubin P, Lundgreen KA, Tam YK, Fan SHY, Eisenlohr LC, Maillard I, Weissman D, Bates P, Krammer F, Sempowski GD, Pardi N, Locci M (2020) SARS-CoV-2 mRNA vaccines foster potent antigen-specific germinal center responses associated with neutralizing antibody generation. Immunity 53(6):1281-1295e1285. https://doi.org/10.1016/j.immuni.2020.11.009
Painter MM, Mathew D, Goel RR, Apostolidis SA, Pattekar A, Kuthuru O, Baxter AE, Herati RS, Oldridge DA, Gouma S, Hicks P, Dysinger S, Lundgreen KA, Kuri-Cervantes L, Adamski S, Hicks A, Korte S, Giles JR, Weirick ME, McAllister CM, Dougherty J, Long S, D’Andrea K, Hamilton JT, Betts MR, Bates P, Hensley SE, Grifoni A, Weiskopf D, Sette A, Greenplate AR, Wherry EJ (2021) Rapid induction of antigen-specific CD4(+) T cells is associated with coordinated humoral and cellular immunity to SARS-CoV-2 mRNA vaccination. Immunity 54(9):2133-2142e2133. https://doi.org/10.1016/j.immuni.2021.08.001
Ehmsen S, Asmussen A, Jeppesen SS, Nilsson AC, Osterlev S, Vestergaard H, Justesen US, Johansen IS, Frederiksen H, Ditzel HJ (2021) Antibody and T cell immune responses following mRNA COVID-19 vaccination in patients with cancer. Cancer Cell 39(8):1034–1036. https://doi.org/10.1016/j.ccell.2021.07.016
Hiddemann W, Barbui AM, Canales MA, Cannell PK, Collins GP, Durig J, Forstpointner R, Herold M, Hertzberg M, Klanova M, Radford J, Seymour JF, Tobinai K, Trotman J, Burciu A, Fingerle-Rowson G, Wolbers M, Nielsen T, Marcus RE (2018) Immunochemotherapy with obinutuzumab or rituximab for previously untreated follicular lymphoma in the GALLIUM study: influence of chemotherapy on efficacy and safety. J Clin Oncol 36(23):2395–2404. https://doi.org/10.1200/JCO.2017.76.8960
Kamegai K, Iwamoto N, Togano T, Maeda K, Takamatsu Y, Miyazato Y, Ishikane M, Mizokami M, Sugiyama M, Iida S, Miyamoto S, Suzuki T, Ohmagari N (2022) A fatal breakthrough COVID-19 case following bendamustine-rituximab therapy. Int J Infect Dis 121:85–88. https://doi.org/10.1016/j.ijid.2022.04.058
Arai T, Mukai S, Kazama R, Ogawa Y, Nishida K, Hatanaka K, Gohma I (2022) Persistent viral shedding of severe acute respiratory syndrome coronavirus 2 after treatment with bendamustine and rituximab: a case report. J Infect Chemother 28(6):810–813. https://doi.org/10.1016/j.jiac.2022.01.014
Levi G, Rocchetti C, Magri R, Uccelli S, Bottone D, Quadri F, Novali M, Santin AD, Bezzi M (2021) Hyperimmune plasma infusion in an immunocompromised COVID-19 patient previously treated for follicular lymphoma. Monaldi Arch Chest Dis 91(4). https://doi.org/10.4081/monaldi.2021.1867
Assanto GM, Di Rocco A, Malfona F, Capriata M, Del Giudice I, Petrucci L, Girardi P, D’Elia GM, Martelli M, Gentile G, Micozzi A, Pulsoni A (2022) Impact of anti-SARS-CoV-2 monoclonal antibodies in the management of patients with lymphoma and COVID19: a retrospective study. Hematol Oncol. https://doi.org/10.1002/hon.3113
Lamure S, Dulery R, Di Blasi R, Chauchet A, Laureana C, Deau-Fischer B, Drenou B, Soussain C, Rossi C, Noel N, Choquet S, Bologna S, Joly B, Kohn M, Malak S, Fouquet G, Daguindau E, Bernard S, Thieblemont C, Cartron G, Lacombe K, Besson C (2020) Determinants of outcome in COVID-19 hospitalized patients with lymphoma: a retrospective multicentric cohort study. EClinicalMedicine 27:100549. https://doi.org/10.1016/j.eclinm.2020.100549
Acknowledgements
The authors would like to thank the nursing staff and medical staff who looked after the patients.
Author information
Authors and Affiliations
Contributions
T.I. designed the study, analyzed the data, and wrote the manuscript. S.T., E.Y., K.I., M.S., M.K., A.M., and M.M. performed recruitment and treatment of patients and provided critique to the manuscript. H.M. measured SARS-CoV-2 antibodies. T.K. designed and supervised the study and approved the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Ishio, T., Tsukamoto, S., Yokoyama, E. et al. Anti-CD20 antibodies and bendamustine attenuate humoral immunity to COVID-19 vaccination in patients with B-cell non-Hodgkin lymphoma. Ann Hematol 102, 1421–1431 (2023). https://doi.org/10.1007/s00277-023-05204-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00277-023-05204-7