bluuebunny/crossref_metadata_2025 huggingface dataset:
Rituximab Plus Bortezomib for Refractory and Relapsed Warm Autoimmune Hemolytic Anemia：a Prospective, Single-Arm, Phase Ⅱ Trial
Authors: Lin Xijuan , Yang Chen , Zhuang Junling , Zhou Daobin , Chen Miao , Han Bing
Published: December 2023

Background Treatment of refractory and relapsed warm autoimmune hemolytic anemia （RR wAIHA） is challenging, especially for those who are in emergency with severe anemia and crossmatching incompatibility. Rituximab is now the preferred second-line treatment for RR wAIHA with unsatisfactory onset speed and sustained efficacy. Bortezomib induces apoptosis of plasma cells that produce autoantibodies and has multiple immunoregulatory functions. In this study, we report the results of rituximab plus bortezomib for the treatment of RR wAIHA in a prospective phase 2 trial.

Methods A prospective single arm trial to investigate the activity and safety of the combination of rituximab and bortezomib (RB regimen) in RR wAIHA patients were conducted. Eligible patients were aged 18 years or older, had a diagnosis of primary or secondary wAIHA or EVANS syndrome, refractory or dependent to glucocorticoids. Patients were given a single dose of 500 mg rituximab infusion on day 0 and a subcutaneous injection of 1.3 mg/m 2 bortezomib twice a week for two weeks on days 1, 4, 8, and 11. A same course was repeated after 3 months, with response assessment after 3 and 6 months. Patients with response were given rituximab 500mg every three months for 6 cycles. The primary endpoint was overall response rate (ORR) after 6 months; the co-primary endpoint was the days to hemoglobin (HGB) increase >20 g/L and transfusion independence.

Findings Between Sep 2, 2019 and Jan 15, 2023, a total of 33 patients were enrolled, with 27 females (81.8%) and a median age of 56.5[interquartile range (IQR) 42.75 - 65.75]. There were 30 (91%) relapsed patients and 3 (9%) refractory patients, and 20 (60.6%) patients with primary wAIHA and 13 (39.4%) patients with secondary wAIHA. At 6 months, the ORR was 75.8%, with 11.7% of CR. The median days to HGB increase >20 g/L and transfusion independence was 19 days [interquartile range (IQR) 13 - 61.5]. After a median follow-up of 24 months [interquartile range (IQR) 6 - 24], the ORR was 84.8% with 21.2% of CR. 28.6% patients relapsed at a median interval of 12 months [interquartile range (IQR) 5.75 - 19]. 2 patients (6.1%) experienced adverse events grade ≥ 3, both of whom experienced severe pulmonary infection. There was a significant reduction in B cell counts (P = 0.011), but no significant change in quantitative measurement of serum immunoglubulin G (IgG) (P = 0.056), IgA (P = 0.052) and IgM (P = 0.057) after 6 months treatment. Mann-Whitney analysis showed that patients with a higher amount of B cells before RB regimen treatment were more likely to achieve CR (P = 0.02).

Conclusion The combination of rituximab with bortezomib for RR wAIHA patients showed excellent efficacy with rapid responses and safety. The trial was registered at ClinicalTrials.gov as NCT04083014.
Comparison of Hematopoietic Stem Cell Transplantation and Repeated Immunosuppressive Therapy As Second-Line Treatment for Relapsed/Refractory Severe Aplastic Anemia
Authors: Zhang Lining , Li Jianping , Liang Weiru , Wei Jialin , He Yi , Jiang Erlie , Zhang Fengkui , Han Mingzhe , Feng Sizhou
Published: December 2023

The optimal treatment for patients with severe aplastic anemia (SAA) who fail or have relapse after an initial course of immunosuppressive therapy (IST) has not been established. We conducted a retrospective study to compare the effectiveness of allogeneic hematopoietic stem cell transplantation (allo-HSCT) (n = 36) with repeated IST (n = 33) as salvage therapy for relapsed/refractory SAA between 2007 and 2022. In the repeated IST group, patients were treated with antithymocyte globulin (ATG) (n = 16) or high-dose cyclophosphamide (HD-CTX) (n = 17). The overall response rate was 42.4% at 6 months, and 60.6% at 12 months. In the HSCT group, 6 were matched sibling donor (MSD), 7 were matched unrelated donor (MUD), and 23 were haploidentical donor (HID). All patients achieved neutrophil engraftment and no primary graft failure was observed. The rate of platelet engraftment was 88.9%, with a median time of 16 days. The cumulative incidences of grade II-IV, III-IV acute GVHD was 36.1% ± 0.7%, 13.9% ± 0.3% at day +100, and chronic GVHD was 36.2% ± 0.7% at 5 years. Compared with IST, HSCT recipients showed much higher hematologic recovery rate at 3-, 6- and 12-months post treatment (63.9%, 83.3% and 86.1%, respectively, P < 0.001). The estimated 5-year overall survival (OS) (79.8% ± 6.8% vs. 80.0% ± 7.3%, p = 0.957) were similar; however, the estimated 5-year failure-free survival (FFS) was significantly better in the HSCT group (79.8% ± 6.8% vs. 55.2% ± 9.2%, p = 0.049). In multivariate analysis, age ≤ 35 years at salvage HSCT was the only favorable factor for OS and FFS ( p = 0.019, 95% CI 0.019-0.706). These results suggest that HSCT and repeated IST are both effective for refractory/relapsed SAA in the salvage setting. Considering the superior FFS in the HSCT cohort, especially in younger patients (age ≤ 35 years), we recommend HSCT instead of a second IST for these patients.
Successful Incorporation of Electronic Patient Reported Outcomes Using Promis-29 into Standard of Care after Hematopoietic Stem Cell Transplant and Chimeric Antigen Receptor T Cell Therapy
Authors: Shah Gunjan L. , Lobaugh Stephanie , Sukhu Ranjit , Devlin Sean M. , Atkinson Thomas , Kemeny Elizabeth , Stetson Peter , Perales Miguel-Angel , Giralt Sergio A. , Scordo Michael
Published: December 2023

Background:

Cellular therapies including hematopoietic stem cell transplant (HCT) and CAR T are mainstays of treatment for hematologic malignancies, but can have significant and prolonged side effects. Patient reported outcome (PRO) measures are instruments which allow a patient to self-report symptoms to their care team and have been shown to be more comprehensive and reliable than provider assessment. Using our center's electronic platform, we aimed to integrate PRO collection into standard of care to improve the clinical experience after HCT and CAR T.

Methods:

Patients received the PROMIS-29 survey through the patient portal. Baseline surveys were automatically generated by a chemotherapy order, and follow-up surveys on Day 0 (infusion), weekly for the first month, monthly for the first year, and every 3 months for the second year were generated off the cell infusion order. Patients were manually censored from further surveys at time of relapse or progression of disease. Survey responses in pre-identified severe ranges prompted instructions to call the clinician's office and for the clinical team to call the patient.

Results:

From May 2019 to December 2022, 1025 patients underwent a cell therapy at MSK (323 allo HCT, 450 allo HCT, 228 commercial CAR T, 24 with both HCT and CAR T) with overall median age of 63 (range 20 -85), 44% female. HCT patients had leukemia (22%), myelodysplastic syndrome (10%), myeloproliferative neoplasm (3%), non-Hodgkin lymphoma (NHL, 18%), Hodgkin lymphoma (5%), plasma cell disorders (40%), or other diseases (1%); while CAR T cell patients had NHL (85%), multiple myeloma (12%), or leukemia (3%). Seventy-eight percent answered at least one survey over the two years, with response rates at baseline, Day 0, week 1, week 2, week 3, and week 4 of 51%, 27%, 26%, 26%, 29% and 29%, respectively (Figure 1). PROMIS-29 physical health summary scores at at baseline, Day 0, week 1, week 2, week 3, and week 4 were 49 [21 - 59], 45 [22 - 59], 43 [21 - 59], 41 [21 - 59], and 42 [21 - 59], respectively (Figure 2). Mental health summary scores were 51 [30 - 64], 49 [29 - 64], 48 [29 - 64], 47 [26 - 64], 48 [24-64] and 49 [30 - 64], respectively.

Conclusions:

We demonstrate the feasibility of incorporating patient reported outcomes into standard of care practice after HCT and CAR T cell therapy. Missing surveys were more common while inpatient, which may be due to toxicity or less use of the patient portal while admitted. Additional work is ongoing to improve the response rates at all time points. Importantly, the electronic system allowed us to capture later timepoints when patients have less frequent visits and may be followed locally. Full survey results will be presented.
Extracellular Release of Damaged Mitochondria Induced By Cytotoxic Conditioning Exacerbates Graft-Versus-Host Disease
Authors: Vijayan Vijith , Yan Hao , Lohmeyer Juliane , Prentiss Kaylin , Patil Rachana , Barbarito Giulia , Lopez Ivan , Elezaby Aly , Peterson Kolten , Baker Jeanette , Ostberg Nicolai , Bertaina Alice , Negrin Robert S. , Mochly-Rosen Daria , Weinberg Kenneth I. , Haileselassie Bereketeab
Published: December 2023

Despite therapeutic advancements, graft versus host disease (GVHD) is a major complication of hematopoietic stem cell transplantation (HSCT). Pathogen and damage associated molecular patterns released following pre-transplant conditioning have an important role in the initiation of GVHD. However, the role of extracellular mitochondria (exMito) as an endogenous danger signal has not been explored. Herein, we report that cytotoxic conditioning with radiation leads to mitochondrial fission and impaired PINK-1/PARKIN-dependent mitophagy in the intestinal mucosal layer. This was coupled with extracellular release of damaged mitochondria in the plasma of BALB/c mice following irradiation. Sublethal irradiation of the Caco-2 epithelial cell line confirmed the in vivo expulsion of mitochondria in a cell-death independent manner. exMito released upon irradiation were damaged, and had impaired ATP production. Incubation of splenocytes with damaged exMito increased the cell surface expression of immune stimulatory molecules and induced Th1 cytokine release. Furthermore, in mixed lymphocyte reactions, exMito pre-treated BALB/c stimulator cells increased the activation and proliferation of C57BL6/J responder T cells. Finally, co-transplantation of isolated damaged mitochondria in a C57BL6/J to BALB/c mouse HSCT model aggravated GVHD. The translational relevance of these findings was studied in a cohort of pediatric patients who underwent HSCT. Fractionated irradiation given with their conditioning regimen increased the abundance of circulating exMito and correlated with the incidence of GVHD. Our results suggest that modulation of exMito release could be a novel therapeutic target to prevent GVHD after HSCT.
Functional Deconvolution of the Leukemia Stem Cell Pool Uncovers Co-Existing Alternative Stem Cell Driven Hierarchies
Authors: Boutzen Helena , Murison Alexander , Shah Sayyam , Kaufmann Kerstin B , Dick John E.
Published: December 2023

Leukemia stem cells (LSC) are not functionally homogenous, rather constitute a complex reservoir of multiple subtypes with distinct genetics and functional potential, that fuels disease progression in acute myeloid leukemia (AML). Understanding the intricacies within the LSC pool is critical for informed design of LSC targeting therapies. However, such in-depth studies are hampered by several technical challenges such as the scarcity of LSC and the lack of reliable cell surface markers to isolate viable LSC or distinct types of LSC. To overcome these challenges, we turned to the patient-derived OCI-AML22 model. This model includes functionally, transcriptionally, and epigenetically characterized LSC broadly representative of LSC extracted from primary AML samples. Focusing on the pool of LSC, we deconvoluted the multi-layered heterogeneity, using a panel of in vivo limiting dilution and single cell assays combined with single cell multiome analysis. We uncovered the co-existence of alternative hierarchies driven by distinct LSC subtypes that differ in quiescence depth, differentiation potential, repopulation capacities and that can be prospectively enriched. Notably, we captured the transcriptomic footprint of these newly discovered LSC subtypes within large primary AML cohorts, and even concomitantly within the same AML patient across different LSC fractions, highlighting the broad biological relevance of our findings.
Neutrophil Elastase Catalytic Activity Regulates Granulopoiesis
Authors: Seal Sudeshna , Krutein Michelle , Anderson Donovan , Horwitz Marshall
Published: December 2023

Heterozygous, autosomal dominantly inherited mutations in the gene, ELANE, encoding the neutrophil granule serine protease, neutrophil elastase, are the cause of cyclic neutropenia and the most common cause of severe congenital neutropenia. Many mutations throughout the protein occur in patients with congenital neutropenia, but they largely spare residues essential for enzymatic catalysis. Decades ago, neutrophil elastase was proposed to function as a chalone, in which its proteolytic activity feeds back to negatively regulate neutrophil production at steady state levels. To further determine if neutrophil elastase catalytic activity contributes to hematopoietic regulation and to evaluate how its mutations cause hereditary neutropenia, we have studied an induced pluripotent stem cell (iPSC) model of hematopoiesis, in which we have employed CRISPR/Cas9 to engineer a mutation not encountered in neutropenic patients. We inactivated neutrophil elastase's catalytic serine residue through substitution with alanine, generated CD34+ cells from iPSC, and directed their differentiation toward the granulocytic lineage. Compared to similarly edited isogenic controls in which the catalytic serine of neutrophil elastase remains intact, iPSC-derived CD34+ cells lacking the catalytic serine grew at a faster rate, failed to down-regulate ELANE expression while cyclically reactivating CD34 expression during granulocytic differentiation, produced greater quantities of neutrophils, and demonstrated residual progenitor cell populations in replating assays. Some, but not all, of these findings were reproducible upon treatment with small molecule inhibitors of neutrophil elastase. These observations suggest that neutrophil elastase's catalytic activity may help regulate granulopoiesis and could explain genotypic differences distinguishing cyclic neutropenia from severe congenital neutropenia.
Assessment of the Expression of Genes Related to Epigenetic and Chromatin Modifications in Diffuse Large B-Cell Lymphoma Patients Resistant to R-CHOP
Authors: NG Wern Lynn , Calderon-Martinez Evelyn , Ng Lay She , Sangha Lillian , Garg Chandi , Kovalenko Iuliia , Zevallos-Delgado Christian
Published: December 2023

Introduction

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. The mainstay of frontline therapy remains R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) or R-CHOP-like immunochemotherapy. Patients' responses to R-CHOP therapy vary depending on the stage and/or molecular subtypes of DLBCL. Approximately 40% of advanced-stage DLBCL patients suffer from a refractory or relapsed disease[1]. The outcome for patients with early relapses after rituximab-containing first-line therapy remains poor[2]. DLBCL poses a marked degree of genetic heterogeneity. Here, we compare the expression of genes related to epigenetics and chromatin modifications in DLBCL patients resistant and non-resistant to R-CHOP therapy.

Objective

The aim of this study is to assess the differences in the expression of genes related to epigenetics and chromatin modification in DLBCL patients that could lead to chemoresistance and failure of R-CHOP treatment.

Method

The gene expression profile (GEP) was obtained from Gene Expression Omnibus (GEO) database (Accession number: GSE173263) submitted by Dlouhy et al[3]. The GEP was analyzed in DLBCL cases, including 10 early failure cases (defined as refractory to induction treatment or early relapsing (<12 months from diagnosis)) and 29 responding patients, to identify features associated to primary chemoresistance. The comparison was done using the list of genes proposed by Bakhshi, T. et. al[4] , where he selected the genes that were identified to potentially cause epigenetic and chromatin modifications in DLCBL. All the comparisons were done using a T-test.

Results

There were significant differences in the gene expression related to epigenetics and chromatin modifications between DLBCL patients in the early failure arm versus the remission arm. Patients who had early failure to R-CHOP tended to have higher expression of these genes: SMARCA4 (p=0.010), SETD1B (p=0.018), SETD2 (p=0.024), EP300 (p=0.012), MLL3 (p=0.049), INO80 (p=0.001), CHD8 (p=0.007), NCOR1 (p=0.020), ARID1B (p=0.034), and SETD5 (p=0.007). Compared to the patients who were in remission after R-CHOP therapy, these patients had significantly higher expression of HIST1H1E (p=0.007).

Conclusion

Gene expression related to epigenetics and chromatin modifications significantly impacts the prognosis of DLBCL patients treated with R-CHOP. Differences in gene expression may lead to chemoresistance, and higher expression levels are associated with a worse prognosis. This study sheds light on the importance of chromatin and epigenetic modifications in DLBCL progression, guiding the development of future therapies.
A Novel BCR-ABL1 Degrader, Ubx-362, Can Overcome Resistance By BCR-ABL1 Kinase Domain Mutations in Chronic Myeloid Leukemia
Authors: Lim Ye Seul , Jeong Na-Rae , Yoo Sun-Mi , KIM Han Wool , Lee Song Hee , Kim Dong-Wook
Published: December 2023

Background

Chronic Myeloid Leukemia (CML) is a clonal hematopoietic stem cell disorder characterized by the presence of the BCR::ABL1 fusion gene. Tyrosine kinase inhibitors (TKIs) have revolutionized CML treatment, providing remarkable responses in patients. However, resistance mutations within the BCR-ABL1 kinase domain can emerge, leading to treatment failure and disease progression.

Method

To overcome TKI resistance, we developed a novel BCR-ABL1 degrader (UBX-362), which is a proteolysis-targeting chimera (PROTAC), and investigated its therapeutic potential using several Ba/F3 cell lines expressing various BCR-ABL1 mutations. UBX-362 is designed to target BCR-ABL1 through the ubiquitin-proteasome system-mediated degradation. Proliferation assays (IC 50) were performed using the Cell Titer-Glo assay, and western blotting was conducted to measure the degradation levels of the BCR-ABL1 protein in the tested cell lines. For the in vivo xenograft mice experiments, 5 × 10 6 K562 cells were subcutaneously injected into Balb/c nude mice. UBX-362 will be orally administered at doses of 5 or 20 mg/kg, and dasatinib or ponatinib will be administered at a dose of 20 mg/kg once daily for 21 days.

Results

We identified potent and orally available PROTACs, among which UBX-362 exhibited superior degradation activity against both wild-type (WT) and mutant BCR-ABL1 proteins in various Ba/F3 BCR-ABL1 kinase domain mutant-expressing cell lines. In vitro experiments showed that UBX-362 effectively degrades WT and various mutant BCR-ABL1 proteins. The levels of WT BCR-ABL1 protein were measured by western blotting, yielding a half-maximal degradation concentration of UBX-362 at ~1.78 nM. Furthermore, the DC 50 of UBX-362 against E255K, V299L, F317L, and F359C mutant BCR-ABL1 proteins were in the single-digit nM range (6.395nM, 7.679nM, 4.635nM, and 5.688nM, respectively). While UBX-362's anti-proliferative activity (~2.562nM) was not found to be superior to dasatinib (~0.378nM), it still demonstrated a strong anti-proliferative effect in the CML cell line K562 and various BCR-ABL1 mutant-expressing Ba/F3 cell lines. Specifically, the IC 50 of UBX-362 was 2.477nM in the Ba/F3 WT cell line. An in vivo anti-cancer efficacy study is currently underway in the K562 xenograft mouse model to compare its effectiveness with dasatinib or ponatinib.

Conclusion

The findings from this pre-clinical study show the possibility of clinical development of a BCR-ABL1 degrader. And, UBX-362 can overcome resistance in CML patients with BCR-ABL1 mutations and can be a good candidate for further clinical development.
Impact of COVID-19 in Thalassemia Patients Undergoing Hematopoietic Stem Cell Transplant Recipients
Authors: Jingxuan Shao , Liu Rongrong , Lai Yongrong , Wei Xinmei , Zhang Ning , Huang Cuifeng , Liu Qifa , Zhang Zhongming , Yang Gaohui , Wei Zhenbin , Liu Lianjin
Published: December 2023

Objective: This article primarily examines the clinical attributes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in transplant recipients with thalassemia, offering significant insights into the treatment and care of this patient population.

Method: The present study retrospectively analyzed the data of all thalassemia patients who underwent Hematopoietic stem cell transplantation (HSCT) at the First Affiliated Hospital of Guangxi Medical University between December 2019 and December 2022. A total of 280 patients were included, of which 81 had confirmed coronavirus disease 2019 (COVID-19). The study collected information on patient demographics, transplantation type and timing, graft-versus-host disease (GVHD), use of immunosuppressive agents, onset time and severity of COVID-19, and prognosis. Follow-up was conducted until March 31, 2023.Univariate analysis was performed using SPSS v25.0, and GraphPad Prism was used for the cumulative incidence comparisons.

Results: The median age was 3.6(2-19) years.The main type of thalassemia was β type (93.9%). Identical sibling donors accounted for 40%, haploidentical donors accounted for 25.4%, and identical unrelated donors accounted for 34.6% (10/10). The main source of hematopoietic stem cells was bone marrow combined with peripheral blood (85%).There were no significant differences in age, gender, diagnosis, donor type, graft type, use of immunosuppressive agents, GVHD, and pneumonia of pro-COVID-19 between infected patients and non-infected patients with SARS-CoV-2. Most of the patients were mild (74 cases, 91.3%) in terms of the severity of COVID-19 infection, only 8.6% of the moderate cases, and none severe and died. 74 cases were cured without drug treatment. Of the seven patients treated with medications, four were azvudine and three were nematasvir. The median number of days (IQR) of treatment for COVID-19 was 5(5) days. The cumulative incidence in the immunosuppressive group was higher than that in the non-immunosuppressive group over the same time frame. There was no significant difference in the final infection rate of COVID-19 among patients receiving transplantation in different years(2020,2021,2022), which was 24.7 26.8 36.5 ( p=0.368), respectively.

Conclusion:

The low infection rate and no severe cases may be due to scientific protection and timely medication. There are no special risk factors for COVID-19 infection in thalassemia patients after transplantation.
A Novel Indirubin-3-Monoxime Derivative Functions As Regulator of Proteostasis Via Targeting TRIM28 in Multiple Myeloma
Authors: Fang Teng , Sun Hao , Sun Xiyue , Yu Zhen , Zhang Xiaoyu , Liu Lanting , Gong Lixin , Xie Shiyi , Hao Mu , Qiu Lugui
Published: December 2023

Introduction: Multiple myeloma (MM) remains an incurable plasma cell malignancy. Agents disturbing the proteostasis play indispensable roles in MM treatment. Our previous studies have shown that the indirubin-3-monoxime (I3MO) works as a novel proteasome inhibitor that effectively inhibits MM cell growth. In this study, we aim to investigate the improvement of I3MO combined with histone deacetylase 6 (HDAC6) inhibitors, and clarified the molecular mechanisms.

Methods: We constructed a compound 8b combined with I3MO and HADC6 inhibitor. The anti-MM effects of compound 8b were investigated in vivo and in vitro studies. Western blots, immunofluorescence, and proteasome activity assay were utilized to investigate the effects of 8b on MM cell proteasome activity, aggresome and autophagosome formation. RNA-seq and Dual-luciferase reporter gene assay were performed to identify the downstream targets of 8b treatment. We constructed MM cell lines with TRIM28 overexpression or shRNA knockdown. We further explored the function of TRIM28, one of the targets of 8b treatment, by ChIP-seq and IP-MS.

Results: The novel I3MO derivative 8b more efficiently suppressed myeloma cell growth in vitro and in vivo. Compound 8b not decreased proteasome activity but inhibited the formation of aggresomes and autophagosomes. Interesting, we found that compound 8b efficiently inhibited TRIM28 promoter activity and repressed TRIM28 transcription level further. GEO data analysis demonstrated a positive correlation between TRIM28 and the expression of proteasome subunits as well as autophagy-related genes in MM. Further, we utilized ChIP-seq to confirm that TRIM28 could bind to the promoter region of multiple proteasome subunits-encoding genes, including PSMB1. Our data indicated that TRIM28 knockdown not only decreased the proteasome activity, but inhibited the formation of autophagosomes. Knockdown TRIM28 induced a higher sensitivity to BTZ treatment in MM cells. Furthermore, IP-MS with Co-IP analysis showed that TRIM28 interacts with 14-3-3ζ. TRIM28 acts as an E3 ligase in mediating the ubiquitination and degradation of 14-3-3ζ, a well-known negative regulator of autophagy. 14-3-3ζ degradation induced by TRIM28 activates autophagy in MM cells. These data suggested that TRIM28 suppressed by compound 8b would involve in proteostasis by regulation of proteasome activity and autophagy.

Conclusions: Our study identified a novel compound 8b, I3MO combined with HDAC6i, efficiently suppressed MM cells survival. Additionally, we for the first time provided novel important insights for the roles of TRIM28 in MM pathobiology by regulation of proteasome activity and autophagy.
Venous Thromboembolism in Hematopoietic Stem Cell Transplantation
Authors: Chiu Jodi , Ananthan Brianna , Lawrence Matthew , Aly Mohamed , Srikrishnaraj Dhuvaraha , Weichel Madeleine , Deotare Uday , Xenocostas Anargyros , Lazo-Langner Alejandro
Published: December 2023

Background:

Venous thromboembolism (VTE) is an underappreciated complication seen amongst allogeneic and autologous hematopoietic stem cell transplant (HSCT) patients and a major cause of morbidity and mortality. Despite these challenges, VTE in HSCT remains understudied, with a paucity of established guidelines on thrombosis surveillance, prevention, and treatment. Balancing risk of bleeding and thrombosis is particularly challenging as HSCT patients are concurrently pancytopenic and coagulopathic. We aimed to describe the incidence, predictors, and adverse events of VTE amongst patients at 90 days post-HSCT.

Methods:

We conducted a retrospective cohort study of adult patients, age >18-years-old, who underwent HSCT for a hematological malignancy between January 1, 2011 and December 31, 2021 at a tertiary care centre in Canada. Patients were followed from transplant until Day 90 post-transplant, or death. Baseline, transplant, laboratory, and cancer characteristics were analyzed.

Results:

Four Hundred and Seventy Six (476) HSCT patients were included (age range 18 - 74), 285 (59.9%) of our patients were male, and 191 (40.1%) were female. Three Hundred and Seventeen (317) (66.6%) patients underwent autologous transplant, and 159 (33.4%) patients underwent allogeneic transplant ( Table 1). Forty Seven (47) patients (9.8%) suffered from VTE within 90 days post-HSCT; 74.5% were catheter related. 9.43% of allogeneic, versus 10.09% autologous patients were diagnosed with VTE (p=0.820). 11.9% of allogeneic, versus 4.1% of autologous patients (p=0.001) suffered from bleed unrelated to anticoagulation. There was significant association of VTE post-HSCT with history of unprovoked DVT (p = 0.026), previous treatment with steroids (p = 0.032), infectious complications (including bacteremia (p = 0.025), and skin and soft tissue infection (p < 0.001)), use of peripherally-inserted central catheters (PICCs (p <0.001), left-sided CVC placement (p = 0.007), second central venous line insertion (due to complications from the first) (p < 0.001), and blocked or malfunctioning central venous catheter (p = 0.003). There was no significant association of VTE post-HSCT with transplant graft (autologous versus allogeneic), underlying hematological malignancy, age, BMI, or sex. Mortality rate at 90 days amongst VTE patients was 14.89%, versus 3.27% in non-VTE patients (p < 0.001) ( Figure 1).

Conclusion:

The majority of VTE post-HSCT were catheter-related and were more frequently associated with use of PICCs. VTE post-HSCT was associated with higher mortality. VTE prophylaxis or active surveillance could be considered in patients with the above-mentioned risk factors balancing the risk of bleeding, particularly in allogeneic stem cell transplant patients, and those who are concurrently thrombocytopenic.
Sickle Cell Disease-Eligibility for Curative Treatment in Indian Tribal Population-Urgent Need to Stop and Think
Authors: Pendharkar Dinesh , Nirmal Garima
Published: December 2023

Introduction: Sickle cell disease (SCD) is one of the most common hemoglobinopathies, with nearly 40000 children born annually to the tribal population of India. Hematopoietic stem cell transplantation is currently the only curative option available. Patients eligible for transplantation according to the ASH and other guidelines are those with multiple episodes of veno-occlusive crisis, despite disease-modifying treatment, recurrent episodes of acute chest syndrome, osteonecrosis, patients who experienced overt stroke, or abnormal transcranial Doppler ultrasound, requiring frequent admissions to the hospital. Although HSCT is the sole curative treatment, only a fraction of eligible patients receive it in resource-limited settings. To understand the requirements for bone marrow transplantation, we analyzed the number of eligible patients using clinical data.

Methods: A cross-sectional prospective research design was used that involved clinical examination and personal interviews with patients and caregivers, with the completion of questionnaires on clinical characteristics and treatment options. Two hundred fifty individuals with S ,invited to outreach clinics, were analyzed

Results: Among the 251 surveyed children, 122 (48.6%) were male and 129(51.4%) were female. Among them, 160 (63.7%) children had recurrent episodes of VOC in the past 1 year, despite 116 (72.5%) receiving regular hydroxyurea. Among them, 98 (62%) required multiple admissions for VOC. Episodes of fever were observed in 51 % of the patients. The requirement for admission to a healthcare facility was recorded in 57 % of the patients. Nearly 13 % of the patients required more than three transfusions in the preceding year.

Conclusions: There is an urgent need to organize SCD care pathways, as the whooping number of patients (64%) falls within the criteria of eligibility for HSCT, a curative option. The transplant community, along with healthcare providers and non-governmental organizations, should decide on a strategy to offer this important modality of curable alternatives.
Cinobufagin Induces Apoptosis of DLBCL Cells By Targeting the Inhibition of G6PD Activity
Authors: He Sanxiu , Zhai Liuyue , Zhang Xiaomei , Fu Huihui , Jun Li , Liu Yao
Published: December 2023

Background:Globally, there are 150,000 new cases of diffuse large B-cell lymphoma (DLBCL) each year, accounting for approximately 30% of all non-Hodgkin lymphoma cases. Although most patients can be cured with R-CHOP immunochemotherapy, 30-40% of patients progress or relapse after treatment. Therefore, there is an urgent need to find new treatments to improve the survival rate of this group of patients. Natural small molecule drugs have unique advantages as anticancer agents due to their low toxicity and multiple targets. This project aims to explore potentially effective natural compounds as new therapeutic strategies for DLBCL.

Methods:Search for suitable natural compounds through GEO database, CMAP server and bioinformatics analysis. The effects of natural compounds on the biological function of DLBCL cells were studied by IC50 assay, apoptosis assay, cell cycle assay and subcutaneous transplanted tumor model. RNA sequencing, metabolomics detection, SEA server and 3D molecular simulation docking analysis were used to explore the drug target. The drug mechanism was verified by G6PD activity assay, EdU incorporation assay, NADPH assay and ROS assay.

Results:We used GEO and CMAP databases to identify 20 natural compounds that target DLBCL prognostic genes. Cinobufagin, a natural bufodienol isolated from toad venom, became the main object of this study because of its low IC50 value. Flow cytometry analysis showed that cinobufagin can effectively induce G2 arrest and apoptosis of DLBCL cells. In addition, cinobufagin significantly inhibited the growth of tumor tissue in a mouse model of heterotopic subcutaneous tumor transplantation. The results of transcriptome sequencing suggested that cinobufagin treatment inhibited multiple metabolism-related pathways. Metabolomic analysis showed a decrease in nucleoside metabolite content and inhibition of niacinamide synthesis. Through SEA server and 3D molecular docking simulation analysis, it was found that glucose-6-phosphate dehydrogenase (G6PD) may be a potential target of cinobufagin. G6PD activity assay showed that cinobufagin could inhibit the catalytic ability of G6PD. EdU incorporation experiments showed that cinobufagin inhibited DNA synthesis in DLBCL cells. In addition, cinobufagin also promoted the up-regulation of NADP+/NADPH ratio and the increase of ROS. The addition of ROS scavengers and nucleotides partially reversed the apoptosis-inducing ability of cinobufagin.

Conclusion:G6PD is a target of cinobufagin. By inhibiting the enzyme activity of G6PD, cinobufagin can inhibit DNA synthesis and the production of reducing NADPH, thereby inducing apoptosis of DLBCL cells. This suggests that Cinobufagin has potential application as a new drug for the treatment of DLBCL.
Orelabrutinib Monotherapy in Patients with Relapsed or Refractory Waldenström's Macroglobulinemia in a Single-Arm, Multicenter, Open-Label, Phase 2 Study: Long Term Follow-up Results
Authors: Cao Xinxin , Jin Jie , Cheng Cheng Fu , Yi Shuhua , Zhao Weili , Sun Zimin , Yang Wei , Li Dengju , CUI Guohui , Hu Jianda , Liu Ting , Song Yongping , Xu Bing , Zhu Zunmin , Xu Wei , Zhang Mingzhi , Li Sichen , Wang Weige , Zhao Renbin , Zhou Daobin
Published: December 2023

Background

Orelabrutinib is a novel, small molecule, selective irreversible Bruton tyrosine kinase inhibitor, approved in China for the treatment of patients with relapsed/refractory (R/R) chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), mantle cell lymphoma (MCL), and marginal zone lymphoma (MZL). The previous publication of this study reported that orelabrutinib is highly active in R/R Waldenström's macroglobulinemia (WM), with a well-tolerated safety profile (EClinicalMedicine. 2022;52:101682). We present here the long-term results of this study.

Methods

This is a prospective, multicenter study of orelabrutinib in patients with WM who had at least one prior line of treatment (ClinicalTrials NO. : NCT04440059). Orelabrutinib was administered orally at a daily dose of 150 mg until disease progression or unacceptable toxicity. Genotyping using MYD88 L265P and CRCR4 S338X mutation were performed with qPCR assay. The primary endpoint was major response rate (MRR) assessed by the Independent Review Committee (IRC) according to IWWM-6 (Br J Haematol. 2013; 160: 171-176).

Results

Between August 2019 and December 2020, 66 R/R WM patients were assessed for eligibility. Forty-seven eligible patients were evaluated for efficacy at a median follow-up of 31.9 months (interquartile range: 28.0，36.5). As assessed by IRC, the MRR was 80.9%, and the overall response rate was 91.5%. The PFS rates was estimated as 72.1% at 36 months and the median PFS has not been reached. There is no significant difference in PFS across various MYD88 L265P and CRCR4 S338X genotype (P=0.69; Figure 1). The 30-months PFS rate in MYD88 L265P/CXCR4 NEG, MYD88 L265P/CXCR4 S338X, and MYD88 NEG/CXCR4 NEG were 86.2%, 75% and 75%, respectively. Most adverse events were Grades 1 or 2 (63.8%). The common grade 3 or higher adverse events occurred were neutropenia (10.6%), thrombocytopenia (8.5%), and pneumonia (6.4%). Treatment related serious adverse events were reported in 8.5% patients. Adverse events leading to discontinuation occurred in 4 patients (8.5%). One treatment-related death was reported (hepatitis B reactivation).

Conclusions

Results with longer follow-up continue to show that orelabrutinib has high, deep and durable response in patients with R/R WM. Data support the safety of long-term orelabrutinib treatment in R/R WM, with no new safety signals identified.
Efficacy, Safety, and Population Pharmacokinetics of Eltrombopag in Children with Different Severities of Aplastic Anemia
Authors: Zhang Wei , Chang Li-xian , Zhao Bei-bei , Shan Dan-dan , Tang Bo-hao , Yang Fan , Zhou Yue , Hao Guo-xiang , Zheng Yi , Zhang Ya-hui , Van Den Anker John , Zhu Xiaofan , Zhang Li , Zhao Wei
Published: December 2023

OBJECTIVES: Eltrombopag (EPAG) was initially approved by the U.S. Food and Drug Administration (FDA) as first-line treatment, combined with standard immunosuppressive therapy, for patients older than two years old with severe aplastic anemia (SAA). However, the use of EPAG in children with different types of aplastic anemia (AA), especially non-severe AA (NSAA) has been limited. Therefore, we decided to investigate the efficacy, safety, and pharmacokinetics of EPAG in children with NSAA, SAA, and very severe AA (VSAA).

METHODS: A prospective, open-label, observational study was conducted at the Institute of Hematology and Blood Diseases Hospital, Tianjin, China. The efficacy including complete response (CR), partial response (PR), and no response (NR), as well as safety was assessed every three months after the start of treatment. A non-linear mixed-effects population pharmacokinetic (PPK) model was used to depict the pharmacokinetic profile of EPAG. We explored the exposure-response relationship of EPAG in patients with different types of AA. This study was registered at ClinicalTrials.gov (NCT03844360).

RESULTS: A total of 23 AA children with an average age of 7.9 (range of 3.0 - 14.0) years were enrolled in this study for efficacy, safety, and PPK analysis. Fifteen patients had a treatment response (5 had CR and 10 had PR). The response rate was 12.5% after 3 months, 50.0% after 6 months, and 100% after 12 months of treatment for patients with NSAA. For patients with SAA and VSAA, these response rates were 46.7%, 61.5%, and 87.5%. Hepatotoxicity occurred in one patient. Fifty-three blood samples were collected and analyzed to build the PPK model using allometric scaling with fixed exponents. Body weight significantly affected EPAG's apparent clearance and volume of distribution. The mean (range) of the area under the concentration-time curve from time zero to infinity (AUC ∞) was 316 (131 - 809) μg×h /mL. Twenty patients with genotypes were included in the genotype analysis. The apparent clearance of EPAG was significantly higher in allele-T carriers of adenosine triphosphate-binding cassette G2 (ABCG2) (rs2231142, G>T) ( p=0.02). In patients with clinical response, children with NSAA exhibited lower AUC ∞, higher apparent clearance, and higher weight-adjusted apparent clearance than those with SAA or VSAA, although the differences were not significant.

CONCLUSIONS: This study enriched the efficacy and safety of EPAG in children with different types of AA. Body weight and ABCG2 genotype significantly influence EPAG clearance. The results may support further individualized treatment of EPAG in children with AA.
Design of an Observational Study (PROVE) to Assess the Long-Term Effects of Prophylaxis with Simoctocog Alfa or Emicizumab on Joint and Bone Health in Hemophilia a Patients
Authors: Klamroth Robert , Sidonio Robert F , Dargaud Yesim , Jiménez-Yuste Víctor , Ljung Rolf , Young Guy , Chowdary Pratima
Published: December 2023

Background: Arthropathy caused by repeated joint bleeding is a major complication in patients with severe hemophilia A and is associated with long-term morbidity. Factor VIII (FVIII) prophylaxis has proven benefits for prevention of bleeding, including joint bleeding, in these patients. Alongside preservation of joint health, FVIII prophylaxis may preserve bone mineral density (BMD) and reduce the risk of fractures. Emicizumab is a bi-specific monoclonal antibody with no structural homology to FVIII and is approved for prophylaxis in hemophilia A patients. However, data on the long-term impact of emicizumab on joint and bone health are limited.

Aims: To assess the impact of long-term prophylaxis with simoctocog alfa (Nuwiq ®; a fourth generation recombinant FVIII) versus emicizumab on joint and bone health in people with hemophilia A.

Methods: PROVE is a multinational, prospective, two-arm, low-interventional study that will collect clinical data on joint and bone health in patients receiving prophylaxis with simoctocog alfa or emicizumab in routine clinical practice. Approximately 200 male participants (100 in each treatment arm) at least 12 years of age with severe hemophilia A (FVIII activity [FVIII:C] <1%) will be enrolled. Written, informed consent will be obtained from each patient or their legal representative.

The primary objective of the study is to evaluate the long-term effect of simoctocog alfa versus emicizumab on joint health as measured by magnetic resonance imaging (MRI). The primary endpoint will be a between-group comparison of the change in total score on the extended MRI (eMRI) scale (Table 1). Secondary and exploratory endpoints include the impact of simoctocog alfa vs emicizumab on bleeding rates, joint and bone health, physical activity, quality of life and safety (Table 1). Study treatments will be defined by the treating physician prior to inclusion of a patient into the study. Patients will not be randomized to the treatment groups but will continue with their current prophylactic regimen (simoctocog alfa or emicizumab). Patients will be provided with an electronic diary (eDiary) in which to record study related data, including treatment-related data, bleeding event details, fracture details, concomitant medications and adverse drug reactions. Each patient will be followed for up to 4 years. An interim analysis is planned after 2 years.

Conclusion: ThePROVE study aims to generate real-world data on the long-term effects of prophylaxis with simoctocog alfa or emicizumab on joint and bone health in hemophilia A.
Dnmt3a-Mutant Haematopoietic Stem and Progenitor Cells Induce Mesenchymal Stromal Cell Senescence through the Production of Alarmins S100A8/A9
Authors: Mistry Jayna J. , Young Kira A. , Colom Diaz Patricia , Fernandez Maestre Ines , Levine Ross L , Trowbridge Jennifer J.
Published: December 2023

Clonal haematopoiesis (CH) is an age-related condition occurring due to somatic genetic variation in haematopoietic stem and progenitor cells (HSPCs), most frequently observed in the gene DNA methyltransferase DNMT3A. CH can be a precursor condition for haematologic malignancy, but the mechanisms driving progression of CH to malignancy are incompletely understood. Given that malignant cells are understood to reprogram their bone marrow (BM) microenvironment to create a self-reinforcing niche, we hypothesized that HSPCs carrying a CH-associated mutation in DNMT3A have microenvironment-remodelling properties that promote their clonal advantage. Using single-cell RNA-seq, we comprehensively captured bone and BM cells of haematopoietic and non-haematopoietic lineages in Dnmt3aR878H/+ mice in which the Dnmt3a mutation is present in the haematopoietic but not the non-haematopoietic compartments. In the non-haematopoietic fractions, we identified enrichment of a cellular senescence program, including transcriptional signatures of cell cycle arrest and expression of the canonical senescence-associated gene Cdkn1a (p21), in BM mesenchymal stromal cells (MSCs). The MSC cellular senescence phenotype caused by Dnmt3a-mutant haematopoiesis was confirmed at the protein level by increased expression of senescence-associated beta galactosidase (SA-β-gal) and the anti-apoptotic proteins BCL-2 and BCL-xL. In ex vivo co-culture assays, primary wild-type MSCs cultured with Dnmt3a-mutant HSPCs versus control HSPCs had increased SA-β-gal, Cdkn1a (p21), and Cdkn2a (p16) expression. Moreover, transwell assays demonstrated that MSC senescence induced by Dnmt3a-mutant HSPCs is cell contact-independent. To undercover the mechanisms driving MSC senescence, we analyzed soluble factors produced by Dnmt3a-mutant HSPCs. Conditioned mediafrom Dnmt3a-mutant HSPCs had significantly elevated levels of S100A8/A9, IL-6 and TNFα, which we confirmed were also elevated in BM fluid of Dnmt3a-mutant mice. In our single cell RNA-seq data, S100a8 and S100a9 were the top significantly increased genes in Dnmt3a-mutant versus control HSCs, making S100A8/A9 our top candidates for functional studies. We tested the direct effect of recombinant S100A8/A9 on primary wild-type MSCs and found that this was sufficient to induce SA-β-gal. Ongoing studies using the S100A8/A9 inhibitor Tasquinimod are examining the dependency of Dnmt3a-mutant hematopoiesis on alarmin production ex vivo and in vivo. Given that S100A8/A9 are heavily involved in the pathogenesis of acute inflammation and myeloproliferative neoplasms, induction of senescence through the alarmin axis is a mechanistic link between aging, clonal hematopoiesis and haematologic malignancy.
Allogeneic Hematopoietic Stem Cell Transplantation for Classical Paroxysmal Nocturnal Hemoglobinuria
Authors: Zhao Xiaoli , Jiang Erlie , Zhang Xiaoyu , Chen Shulian , Zhang Lining , Hao Mengze , SHI Yuanyuan , Gong Ming , Wei Jialin , He Yi , Han Mingzhe
Published: December 2023

Classical paroxysmal nocturnal hemoglobinuria (cPNH) is a rare acquired clonal hematopoietic cell disease. Eculizumab is effective in PNH patients, though, it must be administered indefinitely. As the technology of allogeneic hematopoietic stem cell transplantation (allo-HSCT) improves in recent years, what is the position of HSCT in treatment of cPNH? This study discusses the efficacy and safety of allo-HSCT in cPNH. The clinical data of 5 cPNH patients who underwent allo-HSCT from 2019 to 2022 were collected. All patients were diagnosed cPNH according to guidelines from International PNH Interest Group. Indications for HSCT were transfusion-dependent and nonavailability of eculizumab. The cohort was all male, with a median age of 26 years (range, 26 to 46 years) at the time of transplantation. All patients had documented hemolysis and no thrombosis during monitoring. The median time from diagnosis to allo-HSCT was 5.5 years (range, 3.6 to 18 years). The median PNH granulocyte clone size was 96.3% (range, 90% to 99.7%), and the median lactate dehydrogenase (LDH) level was 2224IU/L (8.896-fold of the upper limit of normal). All patients were detected bone marrow hyperplasia by trephine biopsy. The stem cell source came from 4 haploidentical donors and 1 HLA-identical sibling donor. Among the 5 patients, 3 patients underwent myeloablative conditioning (MAC) and 2 patients underwent reduced-intensity conditioning (RIC) treatment. None of the patients experienced primary implantation failure. Neutrophil implantation time was 15 (13-21) days, and platelet implantation time was 24 (13-60) days. 3 patients developed grade II acute graft-versus-host disease (aGVHD). No patients developed grade Ⅲ-Ⅳ aGVHD. 2 patients developed localized chronic graft-versus-host disease (cGVHD) involving lung and skin respectively, and no patients developed extensive cGVHD. PNH clones turned negative in all patients after 2 months (range, 1 to 3 months) of transplantation. At a median follow-up of 16 (6-34) months, 1 patient died of relapse and infection. The remaining 4 patients survived, of which 2 patients had discontinued all drugs. cPNH has its own unique clinical features. Allo-HSCT could cure cPNH patients who can withdrawal from treatment of all medication. Haploidentical donor HSCT is an acceptable choice for cPNH, and RIC constitutes a valid option.