Aggressive Lymphoid Malignancy Research Articles

Preclinical testing of CT1113, a novel USP28 inhibitor, for the treatment of T-cell acute lymphoblastic leukaemia.

T-cell acute lymphoblastic leukaemia (T-ALL) is a highly aggressive and heterogeneous lymphoid malignancy with poor prognosis in adult patients. Aberrant activation of the NOTCH1 signalling pathway is involved in the pathogenesis of over 60% of T-ALL cases. Ubiquitin-specific protease 28 (USP28) is a deubiquitinase known to regulate the stability of NOTCH1. Here, we report that genetic depletion of USP28 or using CT1113, a potent small molecule targeting USP28, can strongly destabilize NOTCH1 and inhibit the growth of T-ALL cells. Moreover, we show that USP28 also regulates the stability of sterol regulatory element binding protein 1 (SREBP1), which has been reported to mediate increased lipogenesis in tumour cells. As the most critical transcription factor involved in regulating lipogenesis, SREBP1 plays an important role in the metabolism of T-ALL. Therefore, USP28 may be a potential therapeutic target, and CT1113 may be a promising novel drug for T-ALL with or without mutant NOTCH1.

Prognostic Understanding in Newly Diagnosed Older Adults with Diffuse Large B Cell Lymphoma (DLBCL) or DLBCL/High Grade B-Cell Lymphoma with MYC and BCL2 rearrangements

Background: Diffuse large B cell lymphoma (DLBCL) is an aggressive lymphoid malignancy that often affects older adults. Therapy is potentially curative, with up to two-thirds of patients cured with chemoimmunotherapy but carries substantial risk of toxicity. Treatment of older adults must balance the potential for cure with the risk of therapy toxicity and intensive healthcare utilization. Therefore, prognostic understanding is a crucial component of informed decision-making for this patient population. Yet, data regarding prognostic understanding in older adults with DLBCL are lacking. Methods: We conducted a prospective study of older adults with aggressive non-Hodgkin lymphomas at two tertiary care hospitals between 9/2020 and 01/2023. Eligible patients were age >= 65 years at time of treatment initiation receiving a combination chemoimmunotherapy. Patients could enroll up until cycle 1 day 8 of therapy. Patients completed questionnaires at baseline that assessed demographics as well as information preferences and prognostic understanding (Prognosis and Treatment Perception Questionnaire) and underwent a comprehensive geriatric assessment. We used descriptive statistics to examine patient beliefs regarding likelihood of cure, the importance of knowing about prognosis, and preferences for information about treatment at baseline. We focused on the subset of patients (N=92) with DLBCL or DLBCL/high grade B-cell lymphoma with MYC and BCL2 translocations (double hit lymphoma) in order to have a relatively homogenous population for prognosis and likelihood of cure. Results: The parent study enrolled 106/163 (65.0%) patients, with 92 patients having DLBCL or double hit lymphoma. 88/92 enrolled patients with DLBCL (95.7%) submitted the prognostic understanding questionnaire. Among DLBCL/double hit lymphoma patients (N=92), the median age was 74 years (range: 66-99), and most were male gender (63%), White race (96.7%), and married/with a life partner (73.9%). 48/91 (52.7%) had an age-adjusted International Prognostic Index of 2 or 3, 30/92 (32.6%) had a Charlson comorbidity index of 2+ (not counting the patients' lymphoma), 14/92 (15.2%) had an Eastern Cooperative Group performance status of 2-4, and 50% (46/92) were frail based on comprehensive geriatric assessment. When asked about their likelihood of cure, 37.5% (33/88) selected >90% chance, 37.5% (33/88) selected 75-90% chance, 20.5% (18/88) selected 50-74% chance, 3.4% (3/88) selected 25-49% chance, and 1.1% (1/88) selected 10-24% chance of cure. Most (88.6%;78/88) patients believed that the primary goal of their current treatment was to cure their cancer, and most (93%; 80/86) believed that was their oncologist's primary goal. When asked if they would prefer a course of treatment focused on extending life as much as possible even if it meant more pain and discomfort versus a plan of care focused on relieving pain and discomfort as much as possible, even if it meant not living as long, 30.0% (26/88) chose extending life as much as possible, 40.9% (36/88) chose relieving pain as much as possible, and 30.0% (26/88) did not know. 94.0% (78/83) reported that they had a conversation about prognosis with their oncologist. The majority (91%; 78/86) felt it was extremely important or very important to know about their prognosis over time, and felt (81.4%; 70/86) they had just the right amount of information about their prognosis. Patients stated that knowing about their prognosis was extremely helpful in making decisions about treatment (75.3%; 61/81), preparing for the future (68.3%; 56/82), maintaining hope (79.3%; 65/82), and coping with the disease (72.5%; 58/80). 74.4% (61/82) said that overall knowing about prognosis was extremely helpful. Conclusion: In this cohort of older adults receiving treatment for DLBCL or double hit lymphoma, the vast majority felt it was important to know prognostic information over time and found that this information was helpful for decision making. Our finding that the majority estimated their likelihood of cure to exceed 75% despite most having aa-IPI scores indicating average cure rates < 60 suggests that older adults with newly diagnosed DLBCL hold overly optimistic views of their prognosis.

Role of the S1P Signaling Pathway in the Pathogenesis of Angioimmunoblastic T-Cell Lymphoma

Peripheral T cell lymphomas (PTCLs) are a group of aggressive lymphoid malignancies originating from mature T cells. Angioimmunoblastic T-cell lymphomas (AITL) represent 20% to 30% of all PTCL diagnoses and are associated with autoimmune features, poor response to chemotherapy, and dismal prognosis. Molecular profiling of AITL has identified T-follicular helper (TFH) cells as the cell of origin of AITL, while mutational analysis has identified frequent alterations in epigenetic regulators ( TET2, DNMT3A, and IDH2) and elements of the TCR pathway as drivers of AITL transformation. Our group identified the highly recurrent RHOA G17V mutation as a defining hallmark of AITL and other T-cell lymphomas of TFH-cell origin (Palomero et al., 2014). Using a novel conditional knockin mouse model, we demonstrated that expression of Rhoa G17V in CD4+ T-cells induces TFH cell specification and promotes AITL lymphomagenesis in the context of loss of Tet2 (Cortes et al., 2018). Recently, we have identified that Rhoa G17V regulates the expression of the sphingosine-1-phosphate (S1P) receptor 1 (S1PR1) one of the five members of the receptor family of S1P, which plays an essential role in immune response and lymphocyte trafficking. During thymic T-cell development, expression of Rhoa G17V in CD4+ cells inhibited S1PR1 downregulation after the double positive stage leading to altered positive selection, reduced CD4+ single positive cell numbers and premature thymic egress of autorreactive T-cells which results in the development of systemic inflammation and autoimmunity. In our Tet2 −/− RHOA G17V AITL tumor model, constitutive activation of S1P receptors supported activation of the STAT3 and NFkB pathway and enhanced migration of malignant cells to peripheral organs. Mechanistically, expression of Rhoa G17V in mature CD4+ T-cells impaired re-phosphorylation of the Ezrin-Radoxin-Moesin (ERM) complex independently of ROCK signaling and led to the activation and increased migration of CD4+ T-cells. Importantly, blockade of S1PR1 signaling by fingolimod induced anti-tumor activity in Tet2 −/− RHOA G17V lymphoma-bearing mice in vivo with significant reductions in tumor burden associated with increased apoptosis and decreased STAT3 phosphorylation. Furthermore, analysis of a panel of primary tumors from AITL patients using a multiplexed staining panel and PhenoImager platform revealed significantly higher S1PR1 expression in AITL tumor cells than normal TFH cells from benign reactive lymph nodes. Our findings highlight the role of S1P signaling pathway in the pathogenesis of RHOA G17V-driven AITLs and the potential therapeutic benefit of targeting this pathway.

Molecular Classification of Relapsed DLBCL Reveals Novel Biologic Subgroups

Background Diffuse large B cell lymphoma (DLBCL) is the most common aggressive lymphoid malignancy in adults. Though standard immunochemotherapy regimens can result in clinical remission and cure in a majority of patients, approximately 30% of patients are primary treatment resistant or eventually relapse (rrDLBCL), and their prognosis is very poor. Recent molecular classification by large scale genomic and transcriptomic profiling of newly diagnosed DLBCL tumors has resulted in a deeper understanding of disease drivers, however, the molecular heterogeneity of rrDLBCL is yet to be fully explored. Therefore, in this study, we used an unsupervised approach to better define transcriptional and genetic programs in rrDLBCL samples hypothesizing that molecular stratification within this high-risk group may lead to a better understanding of this disease, which remains an unmet need, and a more personalized therapeutic approach. Methods Data used in this study included RNA (n=143) and whole exome (n=126) sequencing data from available FFPE tumor samples at the time of a relapse (any line of treatment, r1-r10 relapse timepoints included in analysis, one per patient), consented to the Molecular Epidemiology Resource (n=61), banked in the Mayo Lymphoma Biobank (n=50), or consented to the CC-122-ST-001 clinical trial (n=32, NCT01421524). Unsupervised clustering was performed on protein coding gene expression values using the non-negative matrix factorization (NMF) approach. NMF was carried out by performing 200 runs on cluster sizes from 2 to 6. Cell of origin (COO) was determined using the method described by Reddy et al. The tumor microenvironment was analyzed using CIBERSORTx and Lymphoma Microenvironment Classification (LME). Genetic classification was done using LymphGen. Results In order to identify unique transcriptional programs in rrDLBCL, we implemented NMF and consensus clustering to define an ideal quantity of stable patient clusters. We identified 4 rrDLBCL patient clusters (rrC1-rrC4) as the most stable solution, based on consensus clustering selection criteria of iterative NMF runs. While relapse timepoint was not associated with individual clusters, we did observe significant differences in tumor characteristics between the clusters. COO classification found that rrC1 and rrC4 were enriched for GCB-DLBCL while rrC3 was enriched for ABC-DLBCL classification (P < .001). To explore the biologic programs in each cluster, we used pathFindR, which leverages protein-protein interaction networks to identify disease related pathways, rrC1 and rrC4 were defined by pathways involved in cell cycle and mismatch repair; oxidative phosphorylation in rrC2; and MAPK and NF-kB in rrC3. Next, LME classification was done to define patterns in the tumor microenvironment and we found a significant difference between groups (P < .001), with rrC2 and rrC4 tumors enriched for a depleted TME, while rrC1 and rrC3 had a more immune rich or inflammatory TME. This was supported by CIBERSORTx analysis identifying significant differences (P > .001) in abundance of CD8 T cells, memory CD4 T cells, and M1 macrophages between clusters, with rrC4 having the lowest abundance. We then explored genetic patterns in each cluster. Gene level mutation enrichment analysis showed BCL7A mutation exclusively in C4 (6/6, P = .03). The clusters were not associated with LymphGen classification. Lastly, our recently published high risk signature classification that is associated with early clinical failure and is characterized by metabolic dysregulation, a depleted TME, T53 alterations, and poor outcome, was significantly different between the groups (P = .03) with enrichment for high-risk cases in rrC4. In summary, we show for the first time that rrDLBCL patients can be classified into four gene expression clusters that are associated with distinct pathway, TME, and genetic programs. These clusters should now be tested to learn if they can help select patients for newer therapies for rrDLBCL such as CAR-T and bispecific antibodies.

Targeting Bcl-xL is a potential therapeutic strategy for extranodal NK/T cell lymphoma

Extranodal natural killer/T cell lymphoma, nasal type (ENKTL) is an aggressive lymphoid malignancy with a poor prognosis and lacks standard treatment. Targeted therapies are urgently needed. Here we systematically investigated the druggable mechanisms through chemogenomic screening and identified that Bcl-xL-specific BH3 mimetics effectively induced ENKTL cell apoptosis. Notably, the specific accumulation of Bcl-xL, but not other Bcl-2 family members, was verified in ENKTL cell lines and patient tissues. Furthermore, Bcl-xL high expression was shown to be closely associated with worse patient survival. The critical role of Bcl-xL in ENKTL cell survival was demonstrated utilizing selective inhibitors, genetic silencing, and a specific degrader. Additionally, the IL2-JAK1/3-STAT5 signaling was implicated in Bcl-xL dysregulation. Invivo, Bcl-xL inhibition reduced tumor burden, increased apoptosis, and prolonged survival in ENKTL cell line xenograft and patient-derived xenograft models. Our study indicates Bcl-xL as a promising therapeutic target for ENKTL, warranting monitoring in ongoing clinical trials by targeting Bcl-xL.

ADAR1-mediated RNA editing promotes B cell lymphomagenesis

Diffuse large B cell lymphoma (DLBCL) is one of the most common types of aggressive lymphoid malignancies. Here, we explore the contribution of RNA editing to DLBCL pathogenesis. We observed that DNA mutations and RNA editing events are often mutually exclusive, suggesting that tumors can modulate pathway outcomes by altering sequences at either the genomic or the transcriptomic level. RNA editing targets transcripts within known disease-driving pathways such as apoptosis, p53 and NF-κB signaling, as well as the RIG-I-like pathway. In this context, we show that ADAR1-mediated editing within MAVS transcript positively correlates with MAVS protein expression levels, associating with increased interferon/NF-κB signaling and Tcell exhaustion. Finally, using targeted RNA base editing tools to restore editing within MAVS 3'UTR in ADAR1-deficient cells, we demonstrate that editing is likely to be causal to an increase in downstream signaling in the absence of activation by canonical nucleic acid receptorsensing.

Allogeneic hematopoietic stem cell transplantation for NK/T-cell lymphoma: an international collaborative analysis

Natural killer/T-cell lymphomas (NKTCL) represent rare and aggressive lymphoid malignancies. Patients (pts) with relapsed/refractory disease after Asparaginase (ASPA)-based chemotherapy have a dismal prognosis. To better define the role of allogeneic hematopoietic stem cell transplantation (allo-HSCT), we conducted a retrospective analysis of data shared with the European Society for Blood and Marrow Transplantation (EBMT) and cooperating Asian centers. We identified 135 pts who received allo-HSCT between 2010 and 2020. Median age was 43.4 years at allo-HSCT, 68.1% were male. Ninety-seven pts (71.9 %) were European, 38 pts (28.1%) Asian. High Prognostic Index for NKTCL (PINK) scores were reported for 44.4%; 76.3% had >1 treatment, 20.7% previous auto-HSCT, and 74.1% ASPA-containing regimens prior to allo-HSCT. Most (79.3%) pts were transplanted in CR/PR. With a median follow-up of 4.8 years, 3-year progression-free(PFS) and overall survival were 48.6% (95%-CI:39.5–57%) and 55.6% (95%-CI:46.5–63.8%). Non-relapse mortality at 1 year was 14.8% (95%-CI:9.3–21.5%) and 1-year relapse incidence 29.6% (95%-CI:21.9–37.6%). In multivariate analyses, shorter time interval (0–12 months) between diagnosis and allo-HSCT [HR = 2.12 (95%-CI:1.03–4.34); P = 0.04] and transplantation not in CR/PR [HR = 2.20 (95%-CI:0.98–4.95); P = 0.056] reduced PFS. Programmed cell death protein 1(PD-1/PD-L1) treatment before HSCT neither increased GVHD nor impacted survival. We demonstrate that allo-HSCT can achieve long-term survival in approximately half of pts allografted for NKTCL.

Galbanic Acid Improves Accumulation and Toxicity of Arsenic Trioxide in MT-2 Cells.

Galbanic acid (GBA) is a sesquiterpene coumarin with valuable pharmacological effects. Adult T-cell lymphoma (ATL) is an aggressive lymphoid malignancy with a low survival rate. Although arsenic trioxide (ATO) is a standard therapeutic agent for ATL treatment, the efficacy of chemotherapy is limited due to the chemoresistance of cells. The present study was carried out to investigate whether GBA in combination with ATO would improve cytotoxicity against ATL cells. GBA was isolated from the roots of Ferula szowitsiana by column chromatography on silica gel. MT-2 cells were treated with 20 μM GBA + 4 μM ATO, and viability was evaluated by alamarBlue assay. The cell cycle was analyzed by PI staining, while the activity of P-glycoprotein (P-gp) was evaluated by mitoxantrone efflux assay. To understand the molecular mechanisms of GBA effects, the expression of NF-κB (RelA), P53, CDK4, c-MYC, c-FLIPL, and c-FLIPS was evaluated using real-time PCR. Combinatorial use of GBA + ATO significantly reduced the viability of MT-2 cells and induced cell cycle arrest in the sub-G1 phase. GBA improved mitoxantrone accumulation in cells, indicating that this agent has inhibitory effects on the functionality of the P-gp efflux pump. Moreover, real-time PCR analysis revealed that GBA + ATO negatively regulated the expression of P53, CDK4, c-FLIPL, and c-FLIPS. Due to the interesting effects of GBA on the accumulation and toxicity of ATO, combinatorial use of these agents could be considered a new therapeutic approach for ATL treatment.

Pretreatment C-reactive protein-to-albumin ratio predicts clinical outcomes in patients with peripheral T-cell lymphoma.

Peripheral T-cell lymphoma (PTCL) is an aggressive and heterogenous T-cell lymphoid malignancy. The prognostic value of C-reactive protein-to-albumin ratio (CAR) has never been assessed in PTCL. This study retrospectively reviewed the medical records of 76 patients diagnosed with various subtypes of PTCL. A CAR cutoff value of 0.794 was determined, and clinical outcomes, including response rate, overall survival (OS), and progression-free survival (PFS), were compared between the high (> 0.794) and low (≤ 0.794) CAR groups. After induction therapy, complete response was achieved in 8 (32.0%) and 39 patients (76.5%) in the high and low CAR groups, respectively. During the median follow-up of 57.5months, the high CAR group had significantly worse 5-year PFS and 5-year OS rates. Even with adjustment for the International Prognostic Index (≥ 3), Prognostic Index for PTCL-unspecified (≥ 3), and T cell score (≥ 2), high CAR remained a significant prognostic factor for PFS (hazard ratio [HR]: 4.01, 95% confidence interval [CI] 2.04-7.86, p < 0.001) and OS (HR: 2.97, 95% CI: 1.33-6.64, p = 0.008). CAR may play a complementary role in predicting prognosis in patients with PTCL, considering its simplicity, objectivity, and easy accessibility.

Allogeneic Blood or Marrow Transplantation (alloBMT) Using Haploidentical Grandchildren Donors and Post-Transplant Cyclophosphamide (PTCy) -Based Gvhd Prophylaxis

Background: High dose PT-Cy allows the safe and effective use of haploidentical relatives as an allograft source. This platform increased the pool of related donors to include haploidentical siblings, parents, and children; more recently, second-and third-degree relatives have also been shown to be safe allograft donors. There is no consensus on the ideal donor; our standard practice is to prioritize young relatives such as siblings, children, or rarely parents- is safe and feasible. AlloBMT using nonmyeloablative (NMA) conditioning is safe and feasible in select patients aged 70 and above, a large group with hematologic malignancies. An increasing number of older patients have been treated with allogeneic blood or marrow transplantation (alloBMT) using related haploidentical donors. Older patients are more likely to have older siblings and children, and recent reports associated older donor age with worse outcomes. Therefore, we report the safety and utility of grandchildren (GC) as haploidentical donors and compare outcomes to patients with children donors. Methods: We reviewed records of patients at Johns Hopkins Hospital who received T-cell replete related allogeneic haploidentical donor blood or marrow grafts. We identified eight hundred and seven consecutive adults (≥18 years) between May 1, 2016, to October 1, 2021. Patients with aggressive myeloid and lymphoid malignancies were included. Only the first transplant was included for patients who received more than one transplant. All patients received NMA conditioning consisting of fludarabine, cyclophosphamide, and total body irradiation at 200 or 400 cGy. GVHD prophylaxis consisted of PT-Cy on days 3 and 4, followed by mycophenolate mofetil and either tacrolimus or sirolimus starting on day 5. Statistical analysis was performed using t-test, Wilcoxon rank sum test, or Chi-square test. Overall survival (OS), progression-free survival (PFS), relapse and non-relapse mortality (NRM) were estimated using Kaplan-Meier methods. Additionally, propensity score matching analysis (PSMA) for patient's age, BMT year, and graft source was performed. Results: Analysis was done on four hundred and sixty patients who received grafts from children donors and twenty-nine grandchildren donors. The median follow-up for patients was 28.8 (range 0.2 - 70.8) and 30 (range 0.8-50.4) months in children and GC, respectively. The most common diagnosis in both groups was acute leukemia compromising about a third of the patients, followed by myelodysplastic syndrome/ myeloproliferative disorders and Non-Hodgkin's (Table 1). Median age of patients in the GC group was 11 years older, 73 years (range 57-78) compared to 62 years (range 36 - 78) in the children group. The median age of children donors was 30 years (range 12-52), and 21 years (range 14-34) in the GC group. Patients in the GC group had higher comorbidities compared to patients in the children group, with a median hematopoietic cell transplantation comorbidity index (HCT-CI) of 2 (range 1-5) and 1 (range 0-7) respectively, (P=0.001). There was almost twice as many patients with HCT-CI of ≥3 in the GC compared to the children group, 38% and 21% respectively. The use of marrow vs PBSC as the graft source was not significantly different between the two groups (table 1). The two-year cumulative incidence of NRM was statistically significant higher for the GC group at 27% compared to 12% in the children group (P= 0.02). Since NRM is more likely in older patients, and older patients were more likely to be in GC group, we performed a PSMA. When matched for age, BMT-year and HCT-CI, PSMA did not show significant differences in NRM (HR 1.49, 95% 0.7-3.4, P=0.35). Similarly, OS, relapse and PFS did not show differences before or after PSMA. The two-year OS was 58% and 64% for children and GC, respectively (HR 0.82, 95% CI 0.36-1.88, P=0.63). Two-year relapse cumulative incidence was 24% and 7% for children and grandchildren, respectively (HR 0.45, 95% CI 0.15-1.34, P=0.15). Two-year PFS was comparable 52% and 56% for children and GC groups, respectively (HR 0.93, 95% CI 0.5-1.73, P=0.82) (fig. 1). Conclusions: Despite older age and comorbidities, the outcomes of alloBMT from grandchildren were at least as good as those from children, with 2-year OS of 64% and 58%, respectively. Choosing grandchildren as donors was associated with promising outcomes and should be examined further. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A tRNA-Derived Small RNAs Expression Signature As a Predictive and Prognostic Biomarker in Diffuse Large B Cell Lymphoma

Background: Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma, which features highly aggressive and heterogeneous lymphoid malignancy, and remains to identify novel predictive molecular markers an overdue challenge in the disease's clinical management. Patients and methods: Small non-coding RNA sequencing was performed in serum of 10 DLBCL patients and 5 healthy controls, 6 feature tsRNAs were selected by employing random forest and principal component analysis, a 6-tsRNA-based classifier was established using cox proportional hazards modeling with leave-one-out (LOO) cross-validation strategy, RT-qPCR was used to measure tsRNA expression in 100 DLBCL patients and 35 healthy controls. Results: we found that tsRNA were sensitive biomarkers in both lymphoma early detection, drug response, and prognosis. Specifically, high-risk patients stratified by using the classifier had significantly lower overall survival (Hazard ratio: 6.657, 95%CI 2.827-15.68, P=0.0006) compared with low-risk patients. Meanwhile, the 6-tsRNA-based classifier was significantly correlated with the patient's histology subtype, stage, and aaIPI scores. Dynamic classifier analysis demonstrated that patients who achieved 1.06 drops after one cycle (early molecular response [EMR]) showed better treatment response and superior prognosis. In addition, the 6-tsRNA-based signatures precisely discriminate between healthy control and lymphoma with AUC 0.882 (95%CI 0.826-0.939). Conclusion: our risk classifier comprising the 6-tsRNA expression may make contributions to individual prognosis prediction and treatment decision-making. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Allogeneic Hematopoietic Stem Cell Transplantation Achieves Long-Term Survival in Extranodal Natural Killer/T-Cell Lymphoma: A Retrospective Analysis of the EBMT Lymphoma Working Party

Introduction Extranodal NK/T-cell lymphomas (ENKTL) represent aggressive lymphoid malignancies predominantly occurring in Asia and South America being rare in the Western world. Stage I/II patients are treated with asparaginase-containing (ASP) chemotherapy and local radiotherapy. For advanced stages III/IV and patients (pts) with relapsed/refractory disease current guidelines recommend ASP-based chemotherapy followed by allogeneic hematopoietic stem cell transplantation (HSCT). These recommendations, however, are mostly based on small series of patients (<20 pts) partly reported decades ago. The largest series reported by CIBMTR comprised 82 pts, most of them still having been treated with anthracycline-containing regimens before HSCT (Kanate AS Br J Haematol 2018,182, 909). Methods We conducted a retrospective analysis of EBMT registry data and data from registries of cooperating Asian centers in China and South Korea. The following inclusion criteria were applied: pts with confirmed ENKTL, age ≥18 years, first HSCT between 2013 and 2020, previous autologous stem cell transplantation allowed. Outcome data were calculated from the day of HSCT until the respective event. Results In total, 137 pts were identified with a median age of 43.4 years (95% CI: 18.3 - 67.7 years) at the time of HSCT; 68.6% were male. Median follow-up was 4.8 years (95% CI: 3.7 - 5.9 years). Recipients were predominantly European (99 pts), 38 pts were of Asian ethnicity. High PINK scores at diagnosis were reported for 67.8%; 32.2% had low/intermediate PINK scores. Two or more treatment lines had been applied in 79.5% of cases prior to HSCT. Importantly, 73.5% of our pts had received ASP-containing regimens prior to HSCT. Autologous transplantation prior to HSCT had been performed in 21.9% of cases. Remission status at the time of HSCT was complete remission (CR) in 53.7%, partial remission (PR) in 26.5%, and chemorefractory/progressive disease in 12.5%. Reduced-intensity conditioning (RIC) and myeloablative conditioning (MAC) were used in 46.7% and 53.3% of cases, respectively. The 1-year and 3-year progression-free survival (PFS) rate for all pts on the study was 55.5% (95% CI: 46.6 - 63.6%) and 48.6% (95% CI: 39.7 - 57%), respectively. The corresponding overall survival (OS) rates were 66.6% (95% CI: 58 - 73.9%) and 55.6% (95% CI: 46.5 - 63.7%), respectively. The cumulative incidence of non-relapse mortality (NRM) at 1 year and 3 years was 15.3% (95% CI: 9.7 - 22.1%) and 17.8% (95% CI: 11.8 - 24.9%) with a relapse incidence (RI) of 29.1% (95% CI: 21.6 - 37.1%) and 33.5% (95% CI: 25.4 - 41.8%) at 1 year and 3 years, respectively. Of note, no relapse was noted beyond 3 years after HSCT. In univariate analyses, ethnicity (European vs. Asian) did not significantly influence PFS (p=0.57), OS (p=0.57), NRM (p=0.79) or RI (p=0.65). Among patients receiving RIC vs. MAC regimens, the relapse incidence (p=0.29) and NRM (p=0.20) were not significantly different. For haploidentical (n=27 pts) vs. HLA-matched related and unrelated donors, no significant differences in terms of PFS (39% (95% CI: 20.2 - 57.4%) vs. 51% (95% CI: 40.9 - 60.2%)), OS (52.6% (95% CI: 31.5 - 70%) vs. 56.1% (95% CI: 46 - 65.1%)), NRM (20.3 (95% CI: 7.1 - 38.3%) vs. 17.3% (95% CI: 10.7 - 25.2%)) and RI (40.7% (95% CI: 21 - 59.6%) vs. 31.7% (95% CI: 22.9 - 40.8%)) at 3 years were observed. For the group of ASP-pretreated patients, 3 year PFS, OS, RI and NRM were 42.4% (95% CI: 32.1 - 52.2%), 52.2% (95% CI: 41.5 - 61.8%), 39.6% (29.5 - 49.5%) and 18.1% (95% CI: 11 - 26.6%), respectively. PD-1 treatment prior to HSCT was applied in 13 patients; these pts did not show significant differences in PFS or OS as compared to all other pts. We also did not observe an increased risk for NRM or acute/chronic GvHD in these pts. Conclusions In a large cohort of Asian and European pts, we demonstrate that HSCT is an effective treatment approach for advanced ENKTL with almost half of the pts achieving long-term survival. These results obtained with the majority of pts having been treated with state-of-the-art ASP-containing therapy prior to transplant compare favorably to previous analyses and show that HSCT is the preferred option for younger pts with ENKTL. PD-1 antibodies given prior to HSCT may help to bring more pts to HSCT without negatively influencing treatment outcomes or GvHD.

Progenitor Sub-Populations in Treatment Resistant T-ALL

T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive lymphoid malignancy for which optimal therapeutic approaches for relapsed/refractory disease and biomarkers for upfront risk stratification are currently unknown. Comprehensive, large-cohort bulk-level profiling of T-ALL is currently underway with the promise to reveal novel drivers and associate genetics with treatment response. To synergize with these studies, we designed a single-cell (sc) genomics study powered to comprehensively characterize intra-tumoral arrest states in T-ALL. Using integrated scRNA and scATAC-seq analysis on 40 T-ALL cases alongside a novel, single cell atlas of pediatric T-cell development, we identified and characterized a bone-marrow progenitor-like (BMP-like) tumor sub-population associated with resistance to conventional therapy across distinct immunophenotypic subtypes of T-ALL. We first compared 10 treatment-refractory ETP-ALL patients (End of Induction MRD > 20%) to 10 treatment sensitive ETP-ALL patients (EOI MRD negative), where we identified a strong and consistent enrichment of ETP-ALL blasts that were transcriptomically and epigenetically analogous to multipotent BMP. BMP-like blasts had higher surface protein expression of myeloid and stem cell markers, such as CD33, CD123, HLA-DR, and CD34, and lowered expression of T-lineage surface protein markers, such as sCD3, CD4, CD2, and CD10. The top differentially expressed (DE) genes for BMP-like blasts included stem cell markers (C1QTNF4, CD44, LGALS1, HOPX), myeloid-lineage (S100A4, SPINK2), and B-lineage markers (IGLL1, IGKC, IGHM). The top DE transcription factors (TFs) in BMP-like blasts included TFs associated with self-renewal (MEF2C, HOXA3/4/5/6/9/10/11, MEIS1, HHEX, SPI1) and recovery from genotoxic stress (BCL11A). Several of the genes involved in self renewal (MEF2C, HOXA9, FLI1), or T-cell developmental block (SPI1) also had increased motif accessibility. We integrated these signatures with large-cohort bulk-genomic results of 1300+ T-ALL patients treated in the Children's Oncology Group (COG) AALL0434 clinical trial. The molecular signature of BMP-like blasts predicted poor outcome across multiple subtypes of T-ALL (ETP & Non-ETP) and were validated in two independent COG trials (AALL0434, full cohort sequenced; AALL1231, partially sequenced cohort) with corresponding bulk-RNAseq data (Panel A, ETP-ALL patient stratification). We also utilized single-cell derived transcriptional signatures in conjunction with bulk-sample-derived mutation calls to identify fusion drivers (eg, MLLT10, KMT2A, NUP98, NUP214) and gene mutations (eg, NOTCH1 WT, IL7R WT, ETV6 mut, and SAT1B mut) that are associated with the BMP-like state and poor outcome. Computational analysis and in vitro experiments indicated that BMP-like tumors would be highly resistant to conventional ALL-directed cytotoxics. To address the pressing need for targeted therapy in chemo-refractory T-ALL, we performed multi-database drug screening against the BMP-like signature derived from our single cell data, nominating a number of surface markers (CD44, ITGA4, LGALS1) and intracellular targets (BCL-2, MCL-1, BTK, NFKB) for experimental follow-up in patient derived xenografts (PDX) which we generated and characterized in our single cell study. Notably, experimental studies of PDX expanded blasts indicated consistent and selective vulnerability of BMP-like blasts to apoptosis-inducing agents (Panel B). Other agents with potent activity in this population included TEC-kinase inhibitors and proteasome inhibitors. Follow-up in-vivo studies in PDX are underway with the promise to bridge these therapies to the clinic. Our work comprehensively defines the developmental arrest states of T-ALL in reference to human early T-cell development. By doing so, we reveal a previously unappreciated sub-population level overlap between patients with distinct subtypes of T-ALL and identify one common BMP-like sub-population that associates with poor response to current therapy. As T-ALL thus far is solely defined by bulk-sample immuno-phenotype, we propose the prospective identification of BMP-like sub-populations and use of non-conventional cytotoxic agents for upfront-risk-stratification and targeted therapy to be realized in high-risk T-ALL. JX & CC, as well as DTT & KT, contributed equally to the work. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Crosstalk between hypoxia and inflammation in non-Hodgkin lymphoma

Tumor hypoxia is a well-known biological circumstance that has an impact on cancer growth and metastasis. This phenomenon is associated with poor patient outcomes, particularly in patients with non-Hodgkin lymphoma. As the tumor mass grows, aggressive lymphoid malignancies necessitate a constant increase in perfusion, activating the hypoxia-inducible factor (HIF)-1α. HIF-1α is an important regulator widely discussed in various studies and pathological states that influence the expression of several genes through transcriptional regulation, including metabolism/respiration, cell cycle, apoptosis, proliferation, angiogenesis, and others that may favor tumor growth. Tumor hypoxia also induces the expression of other important regulators, such as microRNA-210 (miR-210) and Nuclear Factor Kappa B (NF-κB), which propagate the tumorigenesis process. This article reviewed the molecular mechanisms of how HIF-1α correlates with NF-κB and other factors in non-Hodgkin lymphoma patients.

Management of Peripheral T-cell Lymphomas and the Role of Transplant.

Here, we review the management of peripheral T-cell lymphoma, particularly focusing on the role of autologous and allogeneic stem cell transplant. Peripheral T-cell lymphomas are a rare subset of non-Hodgkin's lymphomas that are treated with curative intent. While therapy has been based on other aggressive lymphoid malignancies, outcomes are generally poorer than B-cell lymphomas with 5-year overall and progression-free survival of 30-40% and 20-30%, respectively. In effort to improve outcomes, transplant has been used in both the frontline and salvage settings. Although not studied in randomized studies, consolidation with autologous stem cell transplant in first remission has been associated with an approximate 5-year overall survival of 50-60% and 5-year progression-free survival of 40-45%. Unfortunately, most patients relapse, and, in this setting, allogeneic transplant remains the only curative option for those who are transplant-eligible. Multiple series have now shown that 3-year overall survival with allogeneic transplant is approximately 60%. However, outcomes with transplant are associated with disease control at the time of transplant. In contrast to B-cell malignancies, treatment decisions for peripheral T-cell lymphomas are supported mostly by phase II studies, retrospective series, and expert opinion. For patients with peripheral T-cell lymphoma able to achieve sufficient disease control, autologous stem cell transplantation in first remission and allogeneic stem cell transplantation in relapsed disease offer modest benefit over chemotherapy alone.

USP9X Increased Tumor Angiogenesis in Mantle Cell Lymphoma by Upregulation of CCND1-Mediated SOX11.

Mantle cell lymphoma (MCL) is an aggressive lymphoid malignancy with a poor prognosis. Ubiquitin-specific peptidase 9, X-linked (USP9X), has been associated with multiple physiological pathways and regulates various cellular activities. In this study, we explored the role of USP9X in MCL in vitro and in vivo. USP9X was verified to be increased in peripheral blood mononuclear cells (PBMCs) of MCL patients and MCL cells. Moreover, CCND1 and SOX11 were also upregulated in PBMCs of MCL patients. The positive correlation between USP9X and CCND1, USP9X and SOX11, and CCND1 and SOX11 were identified.Further, USP9X overexpression and knockdown were performed in MCL cells. We proved that USP9X overexpression promoted proliferation and cell cycle and suppressed cell apoptosis in MCL cells. Upregulation of angiogenesis and cell migration were induced by USP9X overexpression in MCL cells. However, the USP9X knockdown showed opposite effects. In addition, USP9X was discovered to decrease Cyclin D1 (CCND1)-mediated SOX11 expression in MCL cells. We demonstrated that SOX11 overexpression reversed USP9X knockdown-mediated angiogenesis in MCL cells. Besides, tumor formation was inhibited by USP9X knockdown in mice in vivo. In conclusion, these results revealed that USP9X promoted tumor angiogenesis in MCL via increasing CCND1-mediated SOX11.

Elevated serum IL-13 level is associated with increased Treg cells in tumor microenvironment and disease progression of diffuse large B-cell lymphoma.

Diffuse large B cell lymphoma (DLBCL) is the most common aggressive lymphoid malignancy, with an immunosuppressive microenvironment affecting clinical outcome. Interleukin (IL)-13 overexpression is observed in multiple solid tumors and contributes to tumor progression. This study aims to investigate pretreatment serum IL-13 levels and their relationship with the prognosis of DLBCL patients. One hundred and sixty-six patients with newly diagnosed DLBCL from June 2015 to July 2017 were included. Patients with elevated pretreatment serum IL-13 levels (IL-13≥1.63pg/ml) were classified into the high IL-13 group and they had significantly lower complete remission rate (60% vs. 74%, p=0.0059), higher progression rate (43% vs. 23%, p=0.0051), and poor progression-free survival (2-year PFS, 63% vs. 78%, p=0.0078) and overall survival (2-year OS, 75% vs. 92%, p=0.0027), when compared to those in the low IL-13 group (IL-13<1.63pg/ml). Meanwhile, increased Treg cell ratio in peripheral blood (p=0.0147) and elevated serum IL-2 levels (p=0.0272) were observed in the high IL-13 group. Moreover, RNA sequencing data showed that patients in the high IL-13 group had significantly elevated expression of chemokines and chemokine receptors (CCR4, CCL19, CCL21, CXCL2) related to Treg activation and recruitment. Consistent with the chemokine profile, tumor immunophenotyping analysis revealed that higher Treg cells recruitment in the high IL-13 group than the low IL-13 group (p=0.0116). In vitro, when lymphoma cells co-cultured with peripheral blood monocytes of healthy controls, metformin down-regulated both IL-13 level and Treg cell ratio, in consistent with the decreased serum IL-13 levels of patients after 6months of metformin maintenance therapy in the high IL-13 group. Taken together, pretreatment serum IL-13 level is related to the immunosuppressive microenvironment and poor clinical outcome of DLBCL patients and could be targeted by metformin, thus providing a new therapeutic strategy in treating DLBCL with high serum IL-13 levels.

Diagnostic and prognostic implications of tumor expression of the GATA-3 gene in nodal peripheral T-cell lymphoma (nPTCL): Retrospective data from a Latin American cohort

BackgroundNodal peripheral T-cell lymphomas (nPTCL) encompass a heterogeneous group of mature and aggressive lymphoid malignancies, including peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS), angioimmunoblastic T-cell lymphoma (AITL) and anaplastic large cell lymphoma (ALCL) ALK-positive and ALK-negative. Their differential diagnosis and prognosis are an issue in clinical practice. Accurate biomarkers to define the different subtypes of nPTCL and to stratify their prognosis are essential to improve their treatment approach. The aim of this study was to test the prognostic impact of GATA-3 gene expression, and its capability to discriminate the different subtypes of nPTCL. Patients and methodsWe retrospectively assessed GATA-3 gene expression by quantitative real time PCR (qRT-PCR) from neoplastic biopsies in Formalin-Fixed Paraffin-Embedded samples (FFPE) of 80 patients with nPTCL that were admitted in a single cancer treatment center from 2000 to 2017. ResultsMedian age was 49 years-old (IqR 34–59), 43/80 (53.7%) were male. Median follow-up was 1.72 years, 36.3% were classified as PTCL, NOS, 31.2% as ALK-negative ALCL, 21.2% as ALK-positive ALCL and 11.3% as AITL. The majority of cases had advanced stage cancer (III/IV). Two-year estimated overall survival (OS) and progression-free survival (PFS) were 52.2% and 39.5%, respectively. The median GATA-3 gene expression level was 0.49 (range 0 – 7.07) in all cohort, with 0.11 for ALK-positive ALCL, 0.46 for ALK-negative ALCL, 0.86 for PTCL, NOS and 0.67 for AITL. The difference of GATA-3 gene expression among distinct variants of nPTCL was statistically significant (p < 0.001). GATA-3 gene expression levels ≥ 0.71 discriminate PTCL, NOS from ALK-negative ALCL and AITL with sensitivity of 62.0% and specificity of 80.3%. GATA-3 gene expression level ≥ median was associated with poor 2-year OS for PTCL, NOS (46.7% versus 21.4%, p = 0.04) and ALK-negative ALCL (85.7% versus 54.5%, p = 0.04). In multivariate analysis, GATA-3 expression ≥ median was an independent factor associated with poor OS in nPTCL (HR: 2.34, 95% CI: 1.12–4.39, p = 0.041). ConclusionGATA-3 gene overexpression may be an important biomarker associated with poor prognosis in PTCL, NOS and ALK-negative ALCL. Moreover, it may also discriminate different subtypes of nPTCL. Further studies with larger series of patients should confirm our findings.

The First Real-World Evidence Prospective Registry of Patients with Blastic Plasmacytoid Dendritic Cell Neoplasm Treated with Tagraxofusp, a CD123-Targeted Therapy, in Europe

The First Real-World Evidence Prospective Registry of Patients with Blastic Plasmacytoid Dendritic Cell Neoplasm Treated with Tagraxofusp, a CD123-Targeted Therapy, in Europe

Role of the Bone Marrow Niche in Supporting the Pathogenesis of Lymphoid Malignancies.

While the bone marrow (BM) microenvironment is the primary location for nurturing the multipotent hematopoietic stem cells and developing the blood cells of either myeloid or lymphoid origin under normal physiological conditions, it could provide a supportive milieu for the proliferation of blood cancer cells. In fact, the multiple and complex direct cell-to-cell or indirect soluble factors-mediated interactions taking place among the BM cells of different origins are shown to play a significant role in tumorigenesis of hematological cancers. In the current review, we focus on lymphoid malignancies and highlight the novel insights surrounding the role of both cellular as well as non-cellular BM compartments in modulating hematopoiesis and promoting growth and proliferation of cancer cells across a variety of aggressive and indolent lymphoid malignancies, including diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, and Waldenstrom Macroglobulinemia. We also discuss the mechanisms of potential intervention and discuss their therapeutic impact in clinical settings.