Genomic patterns behind primary refractoriness and outcomes of high-grade B-cell lymphomas with MYC and BCL2 double-hit. (A) Annotated schematic representation of ctDNA dynamics in highlighted patients with primary refractory disease (end response = progressive disease [PD]) and progression (REL) during follow-up. (B) Dot and line graphs of the somatic reporter mutations according to their VAFs (y-axis) in plasma samples of primary refractory patients prior to therapy and at response evaluations. PD#1 and PD#2 are high-grade B-cell lymphomas with MYC and BCL2 alterations (HGBL-DH-BCL2). PD#3, an ABC DLBCL of MCD/C5 genomic subtype (CD79B [Y197S] and MYD88 [L265P] mutations). TP53 mutations (shown in red) are labeled, ctDNA concentrations are indicated below the plots, logarithmic scale on y-axis. (C) Dot plot comparing the relative VAFs of reporter mutations between pretreatment and end-of-therapy plasma samples in PD#2. Variant allele frequencies are normalized to a shared CREBBP founder mutation in the samples. Orange and purple colors denote enriched and lost mutations during therapy, respectively. Mutations were considered enriched if the fold-change of normalized VAFs between post- and pretherapy sequences was >2 and lost if no reads were present after therapy. Nonsynonymous genomic drivers are labeled. Variants with >1% VAF in the pretreatment sample were included. Logarithmic scale on y-axis. (D) PET-CT images showing the radiological response in PD#2. Bulky lesion decreased, whereas the perihepatic lesion increased in size and activity. (E) Comparison of ctDNA concentration and MRD test results (y-axis) between TP53 wild-type (WT) and mutated lymphomas (x-axis) at midstaging. (F) Swimmers plot of the HGBL-DH-BCL2 patients according to their pretreatment ctDNA concentration. DHIT#1 was deemed double-hit signature (DHITsig)-negative according to digital gene expression analysis with DLBCL90 assay. (G) Dot and line graphs of the somatic reporter mutations according to their VAFs (y-axis) in plasma samples of TP53 WT DHIT#1 and TP53 mutated DHIT#3. TP53 mutations (shown in red) are labeled, ctDNA concentrations or MRD negativity are indicated below the plots, logarithmic scale on y-axis. SUV, standardized uptake value.