Bone Marrow Infiltration Research Articles

Carnival Mask Sign on Bone Scan of Craniofacial Metastasis of Neuroblastoma.

A craniofacial mass may cause the first clinical symptoms of malignancy. In pediatric patients, neuroblastoma, Langerhans cell histiocytosis (LCH), and acute lymphoblastic leukemia (ALL) are the most common diseases initially manifesting with bone lesions, and bone scintigraphy is a useful modality to evaluate them. The purpose of this pictorial essay was to show the scintigraphy findings of the craniofacial bones in three patients, with neuroblastoma, ALL, and LCH, and to provide a useful scintigraphic sign to differentiate these diseases. In the bone scintigraphy of neuroblastoma with craniofacial bone metastases, strong tracer uptake was evident, resembling a carnival mask. In contrast, in the two cases with LCH and ALL involving the craniofacial bones, the tracer uptake was lower than in neuroblastoma and with different distributions. Bone metastases of neuroblastoma usually occur in the periorbital craniofacial bones, and these metastases may be locally aggressive, destroying the bones; which show stronger uptake than other cranial bones. LCH is associated with varying degrees of disease activity, and its bone imaging findings differ based on its activity. Therefore, these lesions present low uptake in bone scintigraphy, showing as "cold spots". Therefore, LCH scintigraphy of the craniofacial bones does not resemble a carnival mask. The bone marrow infiltration by leukemic cells usually shows as diffuse bone marrow. Therefore, in bone scintigraphy of leukemia, the tracer uptake in the periorbital craniofacial bones is similar to other cranial bones, not presenting as a carnival mask. In conclusion, bone scintigraphy to evaluate malignant craniofacial lesions could provide useful differential diagnostic information.

Case Report of a 60-Year-Old Woman with Autoimmune Hemolytic Anaemia after Venetoclax

Background: Chronic Lymphocytic Leukaemia (CLL) is a common haematological malignant neoplasm that is characterized by proliferation of clonal B-cell lymphocytes and infiltration of blood, lymph nodes, spleen and bone marrow. Autoimmune Hemolytic Anaemia (AIHA) is a medical condition in which patient’s red blood cells are being destructed by immune system through antibodies leading to red blood cell lysis. Venetoclax is a novel BCL-2 selective inhibitor introduced amongst patients with CLL refractory to standard treatment lines. Common adverse events in Venetoclax treatment are: neutropenia, thrombocytopenia and diarrhea. Case Report: The following case study presents 60-year-old female patient that developed an autoimmune hemolytic anemia after introducing Venetoclax for CLL diagnosed nearly 13 years before and treated with many other treatment lines. AIHA was resolved after withdrawing Venetoclax and being treated with steroids, Rituximab and plasmapheresis. After that, Venetoclax was reintroduced with carefully monitored hemolysis markers as well as maintaining steroids and Rituximab treatment with good results. Conclusion: Although AIHA caused by Venetoclax is still not mentioned by producer’s summary of product characteristic (sPC), it is valuable for clinicians to have the knowledge that such adverse event may occur (diagnosed after eliminating other causes) and how it can be handled based on experiences of fellow clinicians.

Clinicopathological Spectrum of Multiple Myeloma: Experience of an Institute in Eastern India

Introduction: Multiple myeloma (MM) is a neoplastic plasma cell disorder characterized by clonal proliferation of malignant plasma cells in the bone marrow. Incidence of MM is increasing rapidly in Asian countries. In a developing country like India diagnosis, risk stratification and access to novel treatment is still a major hurdle Objective: To study the clinico-pathological features of newly diagnosed multiple myeloma patients. Methods: This was a cross sectional hospital based retrospective study conducted in a hospital in eastern India. During the four years of study, 74 cases of multiple myeloma were diagnosed on the basis of International Myeloma Working Group: Criteria for the classification of multiple myeloma and related disorders. The clinical and laboratory characteristics of newly diagnosed patients were studied. Results: Out of the 74 patients, 69% were men and 31% were women. Median age at diagnosis was 55 years (range: 32-81 years). The commonest symptoms observed were fatigue and bone pain. Anemia was present initially in 81% of patients, hypercalcemia in 31.4%, and a serum creatinine level of 2 mg/dL or more in 24.6% patients. The most common monoclonal gammopathy was IgG kappa (44%). Diffuse pattern of bone marrow infiltration, the most common pattern observed in 59% patients. Conclusion: MM patients had male preponderance. Median age of patients was lower compared to western countries with higher percentage of patients with age less than 40 years. Quality of life in MM patients can be improved significantly if there is access to early diagnosis, risk stratification and novel treatment.

The advantage of PET/CT in detecting bone metastases: a case report

Introduction: When detecting bone metastases bone scintigraphy has been long used as the most sensitive radiological modality, especially in lytic metastases, to assess the spread of disease in skeletal structures. Currently bone scintigraphy and CT remain the gold standard for bone metastasis detection in oncological patients in our nation. Method: We describe the case of a 45-year-old man who was diagnosed with large B-cell lymphoma and was having a whole-body PET/CT scan for staging purposes. The overall report identified the pathological lymph nodes, in more than one region of lymph node stations. These nodes had increased in size compared to the previous study of the patient. Diffuse skeletal pathological uptake of the radiotracer indicated diffuse bone marrow infiltration, while the CT images alone showed no evidence of typical lytic bone lesions. Other findings included splenomegaly and secondary splenic infiltration. Discussion: One of the primary diagnoses for which PET/CT is particularly effective is lymphoma, when it comes to identifying intra and extraosseous recurrence. This is particularly true when it comes to identifying marrow infiltration. Few centers in Kosovo and Albania have used the combined PET/CT modality in the last two years, besides the importance of including it as part of the imaging protocol in the follow-up of the patients with lymphoma, or oncologic patients in general. Keywords: Case report, PET/CT, scintigraphy, metabolically active, bone lesions, lymphoma.

Koncentracija citokina (IL-4, IL-12 i IFNg) u plazmi i njena povezanost sa apoptozom limfocita pacijenata obolelih od hronične limfocitne leukemije

Introduction: Chronic lymphocytic leukemia (CLL) is a malignant disease of hematopoietic tissue and is the most common leukemia in adults. For years, the dominant view was that in the pathogenesis of chronic lymphocytic leukemia, the basic mechanism of the origin and progression of the disease is disruption in apoptosis and prolonged survival of malignant lymphocytes. Aim: The aim of our study is to determine the association between the percentage of apoptotic lymphocytes in the peripheral blood of patients suffering from chronic lymphocytic leukemia and the concentration of antiapoptotic cytokines (IL-4, IL-12, IFNg) in the patients' blood plasma. Materials and methods: The study included 29 patients suffering from chronic lymphocytic leukemia (21 men and 8 women) who had not been on a chemotherapy regimen in the preceding 6 months. Clinical parameters (clinical stage of disease, presence of lymphadenopathy, splenomegaly), biochemical parameters (LDH), and the type and percentage of bone marrow infiltration were determined in all patients. The percentage of apoptotic lymphocytes and the concentration of cytokines (IL-4, IL-12, IFNg) in the patients' plasma were determined from the patients' peripheral blood. Results: In the studied group of patients, plasma concentration values of IL-4 = 121.42 pg/ml (62.44 - 180.40), IL-12 = 7.62 pg/ml (4.36 - 10.87), IFNg = 31.45 pg/ml (18.35 - 44.56) were detected. In the cell population, less than 1% of apoptotic cells were detected, ranging from 0.03% to a maximum of 0.84%. The results show no correlation between the concentration of cytokines and the percentage of apoptotic lymphocytes in the patients' peripheral blood, however, they show that Il-12 concentration positively correlates with the stage of the disease, as well as with the percentage of bone marrow infiltration by malignant lymphocytes (p < 0.001 or p = 0.028). Conclusion: Plasma concentrations of IL-4, IL-12, IFNg are not correlated with the percentage of apoptotic lymphocytes in the peripheral blood of patients with chronic lymphocytic leukemia. Interleukin-12 nevertheless shows a positive correlation in advanced disease.

Frequency of Hematological Malignancies Based on Bone-Marrow Aspiration and Trephine Biopsy in Patients Presenting to Tertiary Care Hospital

Background: Hematological disorders are found commonly in the general population existing on both ends of the spectrum with minute disorders like iron deficiency anemia to as severe as bone marrow infiltration Objective: To assess the frequency of hematological malignancies based on bone-marrow aspiration and trephine biopsy in patients presenting to tertiary care hospital Methodology: The current study was cross-section descriptive study carried out at the Pathology department of Bacha Khan Medical College, Mardan from April 2013 to October 2021. Bone-marrow aspiration and trephine biopsy was done for all the patients. Data regarding gender, age, clinical examination and diagnosis was recorded on a proforma designed for this research. Results were analyzed by using IBM SPSS (version 23). Results: In our study, a total of 182 patients were included. The mean age (±SD) in the current study was 41 (12.6) years. Based on the malignant hematological disorder, acute myelogenous leukemia was diagnosed in 15 (23.08%) patients, acute lymphoblastic leukemia in (23.08%) patients, chronic myeloid leukemia in 14 (21.54%) patients, acute leukemias in 3 (4.62%) patients, Myeloproliferative neoplasms in 6 (9.23%) patients, Lymphoproliferative disease in 11 (16.92%) patients while plasma cell myeloma was diagnosed in 1 (1.54%) patients. Conclusion: Our study concludes that acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL) is the most common hematological malignancies in Bacha Khan Medical College followed by chronic myeloid leukemia (CML) which is the second highest malignancies in Bacha Khan Medical College in this specific time. Keywords: hematological malignancies, bone-marrow aspiration, trephine biopsy

High-intensity chemotherapy improved the prognosis of patients with high-grade B-cell lymphoma.

High-grade B-cell lymphoma (HGBL) is highly aggressive and has a poor prognosis. The clinical data of 76 patients with High-grade B-cell lymphoma treated in our lymphoma center from July 2016 to April 2020 were analyzed retrospectively. The clinical features, treatment and prognosis of patients with two types of high-grade B-cell lymphoma were compared and analyzed. Among 76 patients with high-grade B-cell lymphoma, 44 cases (57.9%) were high-grade B-cell lymphoma, accompanied by MYC and Bcl-2 and/or Bcl-6 rearrangement (HGBLR) patients, and 32 cases (42.1%) were HGBL, NOS patients. The bone marrow infiltration, IPI (international prognostic index), Ann Arbor stage (III/IV), extranodal disease are more likely to occur in HGBLR group (P <0.05). Survival analysis of patients showed that overall survival (OS) and progression free survival (PFS) in HGBLR group were significantly shorter than those in HGBL, NOS group (median OS: 21 months vs not reached, P=0. 022; median PFS: 5 months vs 12 months, P = 0. 001). Further analysis demonstrated that, as compared with R-CHOP regimen, patients with HGBL who received high-intensity chemotherapy regimens (DA-EPOCH-R, R-CODOX-M/IVAC and R-Hyper-CVAD) had longer OS (median OS, 16 months vs not reached, P=0. 007) and PFS (median PFS, 5 months vs 11 months, P<0.001). Moreover, mu1tivariate ana1ysis showed that high-intensity chemotherapy regimens were independent risk factors for both PFS (P =0.001, HR: 0.306, 95% CI: 0.153-0.610) and OS (P =0.004, HR: 0.262, 95% CI: 0.105-0.656) in patients with HGBL. HGBLR patients have worse prognosis than patients with HGBL, NOS. High-intensity chemotherapy may improve the prognosis of patients with HGBL.

Comparing the diagnostic value of 18F-FDG PET/CT scan and bone marrow biopsy in newly diagnosed pediatric neuroblastoma and ganglioneuroblastoma.

This study aims to compare the diagnostic value of 18F-fluorodeoxyglucose (18-FDG) positron emission tomography (PET)/computed tomography (CT) (18F-FDG PET/CT) scan and bone marrow biopsy (BMB) for evaluating bone marrow infiltration (BMI) in newly diagnosed pediatric neuroblastoma (NB) and ganglioneuroblastoma (GNB). We retrospectively reviewed 51 patients with newly diagnosed NB and GNB between June 1, 2019 and May 31, 2022. Each patient had undergone 18F-FDG PET/CT and BMB within 1 week and received no treatment. Clinical data were collected and statistically analyzed, including age, sex, pathologic type, and laboratory parameters. 18F-FDG PET/CT and BMB revealed the result of bone lesions. A concordance analysis showed that, in this study population, 18F-FDG PET/CT and BMB were in moderate agreement (Cohen's Kappa = 0.444; p = 0.001), with an absolute agreement consistency of 72.5% (37 of 51). The analysis of the receiver operating characteristic (ROC) curve determined that the areas under the ROC curve (AUCs) of SUVBM and SUV/HE-SUVmax were 0.971 (95% CI: 0.911-1.000; p < 0.001) and 0.917 (95% CI: 0.715-1.000; p < 0.001) to predict bone-bone marrow involvement (BMI), respectively. 18F-FDG PET/CT detects BMI with good diagnostic accuracy and can reduce unnecessary invasive inspections in newly diagnosed pediatric NB and GNB, especially patterns C and D. The analysis of the semi-quantitative uptake of 18F-FDG, including SUVBM and SUVBM/HE-SUVmax, enables an effective differentiation between patterns A and B.

Study of Hemato-morphological Features in Neuroblastoma Infiltrating Marrow.

Objective Neuroblastoma typically affects children within the first 5 years of life and accounts for 10% of all pediatric malignancies. Neuroblastoma at onset may manifest as a localized or metastatic illness. The aim of this study was to identify hematomorphological features in neuroblastoma infiltrating marrow as well as to ascertain the prevalence of bone marrow infiltration in neuroblastoma. Materials and Methods This retrospective study included newly diagnosed 79 cases of neuroblastoma, which were referred for bone marrow examination for the staging of the disease. Medical records were retrieved to acquire hematomorphological findings of peripheral blood and bone marrow smears. Statistical Package for Social Sciences, IBM Inc., USA, version 21.0 was used to analyze the data. Results The interquartile age range of neuroblastoma cases was 24.0 to 72.0 months (median = 48 months) with a male to female ratio of 2.7:1. Also, 55.6% (44/79) of cases in the study population showed evidence of marrow infiltration. The bone marrow infiltration was significantly linked to thrombocytopenia ( p = 0.043) and nucleated red blood cells ( p = 0.003) in peripheral blood. The bone marrow smears of cases with infiltration showed a significant shift to the left in the myeloid series ( p = 0.001) and an increased number of erythroid cells ( p = 0.001). Conclusion For neuroblastoma patients, a diligent, exhaustive search for infiltrating cells in bone marrow is advised if thrombocytopenia or nucleated red blood cells are identified on a peripheral blood smear and bone marrow smears showed myeloid left shift with an increased number of erythroid cells.

Clinical Features of Diffuse Large B-Cell Lymphoma Transformed from Follicular Lymphoma

To analyze the clinical manifestations, pathological characteristics, therapeutic effect and prognosis of diffuse large B-cell lymphoma (DLBCL) transformed from follicular lymphoma (FL). A total of 45 inpatients were eligible for criteria of histologic transformation from FL to DLBCL from January 2010 to January 2021, and their clinical characteristics, diagnosis, treatment and efficacy were collected and analyzed retrospectively. Among the 45 patients, transformation occurred at diagnosis in 27 cases, during " watch and wait " phase in 7 cases and after treatment of FL in 11 cases. The median age was 56 years old (ranged from 27 to 76 years), with 23 male and 22 female. The transformations were observed in 8 cases with low-grade and 37 cases with high-grade FL. Extranodal involvement was present in 26 cases, including bone marrow infiltration in 16 cases. There were 17 cases with anemia and 32 cases met the GELF criteria of high tumor burden. B symptoms were present in 12 cases. There were 38 cases with Ki-67≥50%. The germinal center B-cell-like (GCB) subtype of DLBCL was observed in 43 cases. Efficacy was evaluated in 45 cases. The OR, CR and PR rate were 80.0%, 60.0% and 20.0%, respectively. The OR,CR rate of patients received R-CHOP was higher than those of patients received other regimens (86.11% vs 55.55%, P=0.063; 66.67% vs 33.33%, P=0.126), but there was no significant statistical difference. The early transformation (at diagnosis) group showed the highest OR rate (85.18%) and CR rate (74.07%). The median follow-up time of all patients was 26 (4-120) months, and the median PFS (2-120 months) and median OS (5-120 months) had not yet reached. The 3-year PFS and OS were 55% and 70%, respectively. In univariate analysis, factors affecting PFS includ OR rate and POD24, and factors affecting OS includ IPI score, OR rate, POD24, B symptoms and anemia (P<0.05).Multivariant analysis indicated that OR rate and POD24 were the independent prognostic factors for PFS (P<0.05) and IPI score was an independent prognostic factor for OS (P<0.05). The OR and CR rates are higher in early transformation group of patients with DLBCL transformed from FL. Patients with anemia, B symptoms, POD24, and high-risk score have poor prognosis. IPI score is the independent prognosis factor for OS.

Wnt signaling pathway inhibitors, sclerostin and DKK-1, correlate with pain and bone pathology in patients with Gaucher disease.

Patients with Gaucher disease (GD) have progressive bone involvement that clinically presents with debilitating bone pain, structural bone changes, bone marrow infiltration (BMI), Erlenmeyer (EM) flask deformity, and osteoporosis. Pain is referred by the majority of GD patients and continues to persist despite the type of therapy. The pain in GD is described as chronic deep penetrating pain; however, sometimes, patients experience severe acute pain. The source of bone pain is mainly debated as nociceptive pain secondary to bone pathology or neuropathic or inflammatory origins. Osteocytes constitute a significant source of secreted molecules that coordinate bone remodeling. Osteocyte markers, sclerostin (SOST) and Dickkopf-1 (DKK-1), inactivate the canonical Wnt signaling pathway and lead to the inhibition of bone formation. Thus, circulated sclerostin and DKK-1 are potential biomarkers of skeletal abnormalities. This study aimed to assess the circulating levels of sclerostin and DKK-1 in patients with GD and their correlation with clinical bone pathology parameters: pain, bone mineral density (BMD), and EM deformity. Thirty-nine patients with GD were classified into cohorts based on the presence and severity of bone manifestations. The serum levels of sclerostin and DKK-1 were quantified by enzyme-linked immunosorbent assays. The highest level of sclerostin was measured in GD patients with pain, BMI, and EM deformity. The multiparameter analysis demonstrated that 95% of GD patients with pain, BMI, and EM deformity had increased levels of sclerostin. The majority of patients with elevated sclerostin also have osteopenia or osteoporosis. Moreover, circulating sclerostin level increase with age, and GD patients have elevated sclerostin levels when compared with healthy control from the same age group. Pearson's linear correlation analysis showed a positive correlation between serum DKK-1 and sclerostin in healthy controls and GD patients with normal bone mineral density. However, the balance between sclerostin and DKK-1 waned in GD patients with osteopenia or osteoporosis. In conclusion, the osteocyte marker, sclerostin, when elevated, is associated with bone pain, BMI, and EM flask deformity in GD patients. The altered sclerostin/DKK-1 ratio correlates with the reduction of bone mineral density. These data confirm that the Wnt signaling pathway plays a role in GD-associated bone disease. Sclerostin and bone pain could be used as biomarkers to assess patients with a high risk of BMI and EM flask deformities.

Management of cancer pain due to bone metastasis.

Bone metastases frequently occur in patients with cancer. Skeletal-related events (SREs), including pain, impaired mobility, hypercalcemia, pathological fracture, spinal cord and nerve root compression, and bone marrow infiltration, can decrease the quality of life of the patients and increase the risk of morbidity. The mechanism of pain due to bone metastasis is complicated and involves various interactions among tumor cells, bone cells, activated inflammatory cells, and bone-innervating neurons. Cancer pain due to bone metastasis can be crippling and a chronic state that causes sarcopenia. For pain management, it is important to diagnose whether the pain is based on background pain or breakthrough pain due to bone metastasis. In addition, the management goal of cancer pain due to bone metastasis is not only to achieve pain relief but also to prevent pain progression and SREs. Pain mechanisms should be applied to achieve optimal management. This review aims to discuss the mechanisms of cancer pain due to bone metastasis and review the recommended drug therapies.

T-cell immunoglobulin mucin molecule-3, transformation growth factor β, and chemokine-12 and the prognostic status of diffuse large B-cell lymphoma.

The effects of T-cell immunoglobulin mucin molecule-3 (Tim-3), transforming growth factor β (TGF-β), and chemokine-12 (CXCL12) expression on the prognosis of patients with diffuse large B-cell lymphoma (DLBCL) have not been elucidated. To examine the correlation between Tim-3, TGF-β and CXCL12 expression and DLBCL prognosis. Lymph node tissues of 97 patients with DLBCL and 93 normal-response hyperplastic lymph node tissues treated from January 2017 to May 2019 were selected as the DLBCL and control groups, respectively. The expression of Tim-3, TGF-β, and CXCL12 was detected immunohistochemically. Patients were followed up for 3 years, and progression-free survival was recorded. Cox multifactorial analysis was performed to analyze the risk factors for poor prognosis. The positive expression rates of Tim-3, TGF-β, and CXCL12 were higher in DLBCL tissues than in non-cancerous (control) tissues (P < 0.05). One-year post-surgery, the positive expression rates of Tim-3, TGF-β, and CXCL12 were higher in patients with effective treatment than in those with ineffective treatment (P < 0.05). The 3-year progression-free survival of 97 patients with DLBCL was 67.01% (65/97). Univariate analysis revealed that clinical stage, bone marrow infiltration, International Prognostic Index (IPI) score, Tim-3 positivity, TGF-β positivity, and CXCL12 positivity were associated with poor prognosis (P < 0.05). Multivariate Cox regression analysis demonstrated that clinical stage III-IV, bone marrow infiltration, mediate-to-high-risk IPI scores, Tim-3 positivity, TGF-β positivity, and CXCL12 positivity were independent risk factors affecting prognosis (P < 0.05). DLBCL tissues exhibit high positive expression of Tim-3, TGF-β, and CXCL12, and a high expression of all three indicates a poor prognosis.

Prognostic Significance of Circulating Plasma Cells Detected By Next Generation Flow Cytometry in Light (AL) Chain Amyloidosis

In light chain (AL) amyloidosis misfolded light chains that are produced by a generally small or moderate plasma cell clone residing in the bone marrow (BM) form amyloid fibrils and cause organ dysfunction. In asymptomatic myeloma (MM) and patients with MGUS, the presence of circulating clonal plasma cells (CPCs) detected by next generation flow cytometry (NGF) is associated with higher risk of progression to symptomatic disease and in patients with symptomatic MM, higher levels of CPCs are associated with poorer prognosis. In an older study in patients with AL amyloidosis, using 6-color flow cytometry and with a limit of detection (LOD) of ~ 0.01%, CPCs were detected in 42% of patients and their presence was associated with poorer prognosis. In the current study we aimed to evaluate the prognostic and biological impact of CPCs in previously untreated patients with AL amyloidosis by using NGF with a LOD of <0.001%. The presence of CPCs was prospectively evaluated in 114 consecutive patients with AL amyloidosis who were diagnosed and treated in the Department of Clinical Therapeutics, Athens, Greece. CPCs were assessed in peripheral blood (PB) according to the Euroflow guidelines, using two independent 8-color panels, both containing CD19-PC7, CD27-BV510, CD38-FITC, CD45-PerCPCy5.5, CD56-PE, CD138-BV421, and additionally CD117-APC and CD81-APCC750 only in the surface tube or CyIgκ-APC and CyIgλ-APCC750 only in the intracytoplasmic tube. A median number of 5 million events (range 3.9x106-6.1x106) were acquired for each tube and median sensitivity level was 2.3x10-6 (range 2-3.1x10-6) The median age of the cohort was 67 years (38-87), 57% were males, 86% had cardiac, 56% renal, 34% soft tissue, 24% PNS and 19% liver involvement. Mayo stage distribution was 13%, 33% and 54% for stages 1, 2 & 3 and renal stage was 20%, 57% & 23% for stages 1, 2 & 3 respectively. Median iFLC and dFLC levels were 299.3 and 288.5 mg/L respectively and median BM infiltration was 10% (range 0-60%). By FISH, 46% had t(11;14), 40% del13q, 29% +1q21, 6% del17p, 2% t(4;14) and 4% t(14;16). Treatment was bortezomib-based in 96% and contained daratumumab in 34%. CPCs were detectable in 64% of patients and their median level in those with detectable CPCs was 0.002% (range 0.0001%-11.4%). Patients with detectable CPCs had higher LDH (p=0.003), iFLCs (p=0.029), BM infiltration (p=0.002) and NTproBNP (p=0.009). Among patients with detectable CPCs, there was also a correlation of their levels with iFLC levels (p<0.001) and BM infiltration (p<0.001). CPCs were more often detectable (81.5% vs 60%, p=0.053) and their levels were also higher (p=0.014) in those with +1q21; there was no association with any other cytogenetic abnormality. Median follow up of the cohort is 2 years. There was no difference in the OS (2-year OS 65% vs 63%) or in early mortality for patients with or without detectable CPCs (p=0.965). Due to the high sensitivity of NGF in the detection of CPCs, we also evaluated different cutoffs of CPCs for their possible prognostic impact, including cutoffs proposed in the earlier study and in patients with newly diagnosed symptomatic MM (0.01%), but we found no prognostic impact on OS in our patients with AL amyloidosis (2-year OS:55% vs 66%, p=0.374). Higher BM infiltration has been associated with worse outcome in patients with AL amyloidosis: in bivariate analysis CPCs>0.01% overcame the prognostic impact of higher BM infiltration, indicating that CPCs is a more sensitive biomarker of tumor burden in patients with AL amyloidosis. Even after adjustment for Mayo stage the presence of CPCs or of CPCs >0.01% were not prognostically significant. However, patients with CPCs>0.01% had a lower probability of hematologic CR/VGPR at 1 month (23% vs 56%, p=0.03) and at 3 months (44% vs 76%, p=0.043) from start of therapy. In conclusion, circulating clonal plasma cells can be detected in the majority of patients with AL amyloidosis with more sensitive NGF methods. Their presence is associated with higher FLC levels and BM infiltration and adverse prognostic features such as higher NTproBNP level, and a lower probability of deep hematologic response at 1 and 3 months after start of therapy. However, in the era of modern therapies, CPCs do not seem to independently affect the prognosis of patients with AL amyloidosis, which is dominated by the degree of cardiac dysfunction.

Collections of Autologous Lymphocytes for Treatment with Chimeric Antigen Receptor (CAR) T-Lymphocytes - No Association of Clonal Hematopoiesis (CH) with Manufacturing Success

Manufacturing of chimeric antigen receptor (CAR) T-lymphocytes is a complex process beginning with leukapheresis of autologous lymphocytes. Tisagenlecleucel is a CAR T product licensed for treatment of patients with relapsed/refractory (r/r) diffuse large B-cell lymphoma (DLBCL), r/r B-acute lymphatic leukemia (ALL) and r/r follicular lymphoma. Production success and thus treatment outcome depends on successful collection of autologous lymphocytes. Clonal hematopoiesis (CH) describes the outgrowth of somatically mutated hematopoietic stem cells and their progeny. The relevance of CH-related mutations in the context of CAR T-cell production is largely unknown. Here, we analyzed potential effects of CH on the manufacturing process of tisagenlecleucel. We retrospectively analyzed leukapheresis preparations of 51 patients (13 female and 38 male; median age 61 years [y], range 20y - 80y) scheduled to undergo treatment with tisagenlecleucel. Fifty patients suffered from DLBCL and one from ALL. Thirty-five collections (68.6%) resulted in successful manufacturing, 6 (11.8%) were out of specification due to indeterminate mycoplasma tests, and 10 (19.6%) showed insufficient proliferation and expansion of CAR T-cells. All collections were analyzed using a custom, targeted deep sequencing approach covering 82 regions in 24 known CH and AML-related genes. Computational correction of sequencing errors via unique molecular identifiers enabled the reliable detection of mutations ≥0.5% variant allele frequency (VAF). In 27 collections (53%), no CH related mutations were detected, while CH-associated mutations with VAF <2% were identified in 11 (22%), and CH with VAF ≥2% in 13 (25%). CH was present in 47% of products that resulted in successful productions, and in 33% and 40% of the collections with indeterminate mycoplasma test and insufficient proliferation, respectively (Tab. 1). Clone size did not differ between these groups with median VAFs of 1.5%, 1.5% and 1.9% (p<.92), respectively. In our population, the frequency of CH did not associate with age (p=.16), sex (p=.75), number of prior treatment lines (<3/≥3; p=.67), previous treatment with bendamustine (p=.27) or bone marrow infiltration (p=.16). Overall, the most commonly mutated genes were DNMT3A (12/51, 24%), PPM1D (12/51, 24%) and TET2 (9/51, 18%). CH mutation spectrum was not significantly associated with manufacturing success (Fig. 1). The prevalence of mutations in TP53 and PPM1D did not differ according to number of prior treatment lines (<3/≥3; p=1) or previous treatment with bendamustine (p=0.18). Median collected CD3+ yields were similar in apheresis products without and with CH (4.66 [range 0.92 - 19.23] x109 vs. 5.17 [range 0.97 - 31.98] x109; p=.94). Collections without and with CH also did not differ regarding CD3+CD4+ yields (2.06 [range 0.30 - 10.27] x109 vs. 2.24 [range 0.26 - 6.29] x109; p=.86) or CD3+CD8+ yields (2.62 [range 0.24 - 16.41] x109 vs. 2.76 [range 0.38 - 26.68] x109; p=.94). CH-related mutations are common in patients undergoing treatment with CAR T-cells and are not associated to factors such as age, sex, previous treatment with bendamustine, bone marrow infiltration or previous treatment lines. The spectrum of CH driver mutations in this patient cohort differs from age-associated CH, with a notably higher frequency of PPM1D mutations. However, the presence of CH did not affect the manufacturing success of tisagenlecleucel CAR T-cells. Further analyses are required to determine the impact of CH on long-term outcomes after CAR T therapy, for example with regard to secondary myeloid neoplasms. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Type 1 Cryoglobulinaemia Associated with Waldenström Macroglobulinemia, IgM MGUS or Non-Hodgkin Lymphoma

Introduction: Type 1 cryoglobulinaemia is defined by monoclonal immunoglobulins which precipitate at temperatures <37°C and redissolve on warming. IgM monoclonal protein may be associated with type I cryoglobulinaemia with underlying Waldenström macroglobulinemia (WM), non-Hodgkin lymphoma (NHL) or monoclonal gammopathy of undetermined significance (MGUS). Due to its rarity, the incidence and clinical outcomes are poorly understood, with fewer than 40 patients characterised in the largest series. Clonal characteristics have not previously been described. We analysed the incidence, clinical and clonal characteristics of the largest reported series of IgM-associated type I cryoglobulinaemia. Methods: Data for consecutive adult patients (> 18 years) with IgM-associated type I cryoglobulinaemia identified between 2013-2022 from 2 centres (University College London Hospital [UCLH], UK and AMC, Netherlands) were retrospectively analysed and followed up to June 2022. In order to calculate the incidence of type I cryoglobulinaemia, the total number of requests performed at UCLH was also determined. Results: 423 samples were screened for cryoglobulinaemia between 2013-2022 from all patients with an IgM-associated disorder at the specialist centre, UCLH. 140 (33%) were positive for all-type cryoglobulinaemia; 94 (22%) patients had type I cryoglobulinaemia. Four additional patients were recruited from Amsterdam UMC, without incidence data. In total, 98 patients (58 male, 40 female) were identified with type I cryoglobulinaemia; the majority with underlying WM (defined as >10% bone marrow infiltration) (77; 79%), and remaining IgM MGUS (16; 16%) and NHL (4 marginal zone lymphoma, 1 CLL; 5%). The median age at cryoglobulin diagnosis was 66 years (range 39-90). There was a kappa light-chain predominance in the majority (85%). MYD88L265Pwas present in 44/49 (90%) of WM and 3/8 (38%) MGUS cases. CXCR4 was mutated in 5/13 (38%) WM cases. Coexistent IgM-associated disorders were present in 25: cold agglutinin disease/syndrome (CAD/CAS, 15%), Bing-Neel syndrome (7%), anti-MAG antibodies (5%), Schnitzler syndrome (1%). Those with coexistent CAD/CAS had characteristics of a CAD clone, significantly associated with MGUS (vs WM/NHL, p<0.0001) and MYD88-wild type (p<0.0001). Patients with co-existent anti-MAG antibodies were significantly more likely to have MGUS (p=0.0245). Median M-protein at diagnosis of cryoglobulinaemia was 12g/l (range 0-63) and lowest in the MGUS cohort vs WM vs NHL (4g/l vs 16g/l vs 10g/l, p=0.0003). The majority were diagnosed with cryoglobulinaemia >3 months after diagnosis of the underlying IgM disorder (60/98; 61%), at a median of 46 months (range 4-442) and longer in those with WM compared with MGUS or NHL (51 vs 17 vs 13 months, p=0.023). Forty nine percent were symptomatic at cryoglobulinaemia diagnosis, with a trend towards a greater proportion in those with MGUS/NHL vs WM (75%/60% vs 43%, p=0.0569). The most common symptoms were cutaneous/vasomotor symptoms (28%), neuropathy (21%), hyperviscosity (10%), arthralgia (7%) and renal involvement (2%). No cases had cardiac or pulmonary involvement. At a median follow up of 2.4 years (range 0-9.4), 2-year overall survival (OS) was 89% (95% CI 80-94), 5-year OS was 73% (95% CI 56-84). Age was the only predictor of OS (Hazard ratio [HR] 1.07, 95% CI 1.01-1.12, p=0.006). Fourteen patients required chemoimmunotherapy for cryoglobulinaemia at a median of 1 month (0-7) from diagnosis for cutaneous manifestations (5/14; 36%), cryoglobulinaemic glomerulopathy (2/14; 14%) or hyperviscosity (9/14; 64%). Independent predictors of cryoglobulinaemia-indicated treatment-free survival/death included cutaneous involvement (HR 1.48, 95% CI 1.21-7.7.92, p=0.018) and hyperviscosity (HR 5.21 95% CI 4.21-27.8, p<0.0001) at cryoglobulinaemia diagnosis on multivariate analysis. Conclusions: This is the largest reported series describing the characteristics of IgM-associated type I cryoglobulinaemia. It is common amongst patients with monoclonal IgM disorders and approximately half of patients may be symptomatic. Distinct clonal populations are present in which type I cryoglobulinaemia may develop including an MYD88L265P WM clone and MYD88-wild type CAD/anti-MAG clone. Treatment may be required selectively in those with hyperviscosity, cutaneous or renal involvement, in a short time from diagnosis. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Risk of Cytokine Release Syndrome with Glofitamab Is Predicted By an Updated Model with a Potential Clinical Application

Background: Cytokine release syndrome (CRS) is a potentially life-threatening toxicity caused by immune activation. CRS can be triggered non-specifically by T-cell engaging therapies. Komanduri et al. (ASH 2021) outlined a model based on eight baseline factors (CRS-risk score; CRS-RS) which allowed accurate classification of risk for Grade ≥2 CRS upon treatment with glofitamab. Glofitamab is a CD20xCD3 T-cell-engaging bispecific monoclonal antibody with a novel 2:1 (CD20:CD3) configuration that has shown promising efficacy with a manageable safety profile in NP30179 (NCT03075696), an ongoing Phase I/II dose-finding study of glofitamab in pts with relapsed or refractory (R/R) non-Hodgkin lymphoma (NHL; Dickinson et al. ASCO 2022). While CRS is observed with glofitamab, cases typically occur with Grade 1/2 severity (per ASTCT grading; Lee et al. Biol Blood Marrow Transplant 2019) mostly in the first cycle (C). Here, we introduce a streamlined model based on five baseline factors (CRS-RS.5p) derived from the original CRS-RS, an ongoing non-interventional study (GO43921) to assess the performance of CRS-RS.5p, and the potential application of the risk score in a clinical setting. Methods: In both models, using a weighted sum of baseline clinical, laboratory and imaging parameters, pts are assigned a risk score as a continuous measure for developing CRS after the first dose of glofitamab. Using a defined cut-off, pts are classified as low or high risk of CRS. The original CRS-RS model parameters were: age >64 years at study entry, lactate dehydrogenase pre-anti-CD20 treatment >280 U/L, white blood cell count pre-anti-CD20 treatment >4.5x109 cells/L, Ann Arbor Stage III/IV at study entry, sum of the product of the perpendicular diameters at study entry ≥3000mm2, cardiac comorbidity, bone marrow infiltration, and atypical or leukemic cells in peripheral blood at study entry. The simplified CRS-RS.5p concentrates on the first five parameters utilizing the same weighting scheme as in CRS-RS. The primary objective of the GO43921 study is to determine if a five-baseline-parameter model can predict Grade ≥2 CRS events after the first dose of glofitamab. Seven studies were identified in which pts with aggressive NHL (first line and R/R, excluding mantle cell lymphoma) were treated with glofitamab step-up dosing as either monotherapy or part of combination therapy. In most studies, pts are pretreated with 1000mg obinutuzumab, with intravenous glofitamab being administered on Days (D) 1 (2.5mg) and 8 (10mg) of C1, then at the target dose (30mg) from C2D1 onwards. Several combination studies started glofitamab step-up dosing after multiple cycles of R-CHOP (glofitamab D8 [2.5mg], D15 [10mg], target dose D8 [30mg] in the following cycle). Prospective data has been collected since December 2021, and retrospective data from included studies were analyzed to increase the sample of Grade ≥2 CRS events. Here, CRS-RS.5p is compared with CRS-RS for the NP30179 dataset, and CRS-RS.5p performance in the ongoing GO43921 study is analyzed. Results: In NP30179, data acquired since the introduction of CRS-RS (n=44) showed that CRS-RS and CRS-RS.5p identified as high risk the same pts who experienced Grade ≥2 events (Figure A; four Grade 2, one Grade 3). In the whole NP30179 validation cohort, both CRS-RS and CRS-RS.5p achieved negative predictive values of 0.97 (n=148, Standard error=0.02). For GO43921, at the clinical cut-off date (June 6, 2022), the CRS-RS.5p model had predicted all 11 of the Grade ≥2 CRS events in the second-line or later setting for pts with aggressive NHL (n=123, with data collected retrospectively for 82 pts; Figure B). The association of the CRS-RS.5p score with the ASTCT CRS Grade after the first dose of glofitamab was similar across all available data sets from NP30179 and GO43921 (logistic regression; p<0.001 for NP30179, p=0.004 for GO43921). No influence of steroid premedication class on CRS-RS performance was observed. A low-risk group (CRS-RS.5p <4.0) comprised 48% of pts in NP30179 and 46% in GO43921. Conclusions: Data from the CRS-RS.5p model showed identical performance with the previous 8-parameter CRS-RS model in predicting which pts with aggressive NHL are most at risk of Grade ≥2 CRS after the first dose of glofitamab. With reduced complexity, the CRS-RS.5p has a potential application as a practical, clinical decision tool to guide hospitalization for pts at high risk of Grade ≥2 CRS. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

High Metabolic Tumor Volume Is Associated with Higher Toxicity and Decreased Efficacy of BCMA CAR-T Cell Therapy in Multiple Myeloma

Background Recently, two chimeric antigen receptor T-cell (CAR-T) constructs have been FDA approved for relapsed/refractory multiple myeloma (RRMM) after exposure to at least 4 prior lines of therapy. High tumor burden has been associated with inferior outcomes, reduced CAR-T expansion and higher rates of toxicity. Patients relapsing after multiple lines of therapy more frequently have oligosecretory and extra-medullary disease that may not be well captured by serum-based markers of disease or bone marrow infiltration, respectively. Functional imaging with FDG-PET is well established as a useful tool in patients with myeloma but its prognostic impact in highly refractory patients or those proceeding with CAR-T has not been described. Metabolic tumor volume (MTV) capturing all metabolically active disease can be useful as a more global assessment of disease burden. We sought to evaluate tumor burden as measured by MTV in a cohort of patients presenting for anti-BCMA CAR-T with RRMM. Methods We identified all patients presenting to our center treated with anti-BCMA CAR-T with available restaging imaging performed within 60 days prior to lymphodepleting chemotherapy (LD-chemo). Baseline skull to midthigh with or without leg/whole-body 18F-FDG PET/CT scans were evaluated for MTV using a custom tool implemented on MIM PACS version 7.1 (MIM Software, Cleveland, OH) as previously reported (Dean et al, Blood Adv 2020). Briefly, images were semi-automatically analyzed to identify abnormal regions with reference to average metabolic activity of normal liver defined by PET SUV. Metabolically active volume at the lesion level were converged based on PERCIST criteria (41% of SUVmax). Summation of the metabolically active volumes across the human body is reported as the Metabolically Tumor Volume (MTV), measured in ml. Patient image scans were reviewed centrally by a radiologist blinded to outcomes, who removed any false positive uptake unrelated to metabolically active disease. Patients with the following FISH cytogenetics were considered high risk (HR): t(4;14), t(14;16) and deletion 17p/monosomy 17 whereas the remainder were standard risk (SR). The high and low tumor volume groups were selected based on the median MTV value in cohort. Baseline laboratory tests (e.g. beta2 microglobulin (b2M), C-reactive protein (CRP)) and repeat bone marrow biopsy were obtained prior to LD-chemo. Soluble BCMA (sBCMA) was measured by ELISA on patients with available serum samples (R&D Systems, MN, USA #DY193). All analyses were conducted in Stata (16.1, StataCorp LLC, College Station, TX). Results The study cohort consisted of 66 patients. Median age was 65 years (range 36 - 81), 55% were male, 55% had ECOG 0-1 prior to LD-chemo and 65% received bridging therapy. 25 (38%) were categorized as HR based on FISH cytogenetics. Patients had received a median of 6 prior lines of therapy and median interval between PET and date of CART infusion was 14.5 days (range 2-54). Median MTV was 26.3ml (0.26-1073.87ml) and only 3/66 (5%) had no measurable PET-avid lesions captured by this algorithm. Patients with high MTV (>26) were more likely to have elevated baseline CRP >0.5mg/dL (p=0.007) and receive bridging therapy (60% vs 40%, p=0.02). MTV correlated with sBCMA levels on day -6 (r=0.82, p=0.003), and with baseline b2M (r=0.47, p=0.005), but MTV did not correlate well with percentage plasma cells in pre-CAR-T bone marrow biopsy (r=0.12, p=0.3). The risk of ³G2 CRS was significantly higher (44% vs 12%, p=0.02) and any grade ICANS was numerically higher (27% vs 12%, p=0.1) in those with high vs low MTV, respectively. Finally, fewer patients with high MTV achieved CR by D30 (19% vs 31%, p=0.2) and with limited follow up 12/14 (86%) of deaths had occurred in patients with high baseline MTV (p=0.003). Conclusion These preliminary data confirm the added value of MTV calculated from baseline imaging as part of standard of care in patients with heavily pre-treated relapsed myeloma presenting for anti-BCMA CAR-T therapy. MTV correlated highly with sBCMA measured at day-6 and may be more representative for risk assessment than basing burden on bone marrow plasma cell percentage, which has not demonstrated a consistent relationship in predicting adverse events to date. High MTV appears to be associated with an increased risk of CAR-T specific adverse events and inferior outcomes and warrants further investigation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Single-Cell Transcriptome Analysis Reveals Stem Cell-like Subsets in the Progression of Waldenström's Macroglobulinemia

Waldenström's macroglobulinemia (WM) is an uncommon lymphoproliferative disorder characterized by monoclonal immunoglobulin M protein production and bone marrow infiltration by lymphoplasmacytoid cells. It remains an incurable disease. IgM monoclonal gammopathy of undetermined significance (MGUS) is the premalignant condition and is associated with the risk of developing WM. MYD88L265P is a recurrent mutation found in more than 90% of WM patients, and this genetic event is detectable in at least half of IgM MGUS patients. However, the precise cellular landscape and the mechanisms of progression from IgM MGUS to WM remain unclear. Single-cell RNA sequencing (scRNA-seq) provides us a powerful approach to explore tumor heterogeneity and identify rare malignant cells. Anti-CD38 monoclonal antibodies have been introduced into the therapeutic arsenal for plasma cell diseases. Therefore, we analyzed CD38+ immune microenvironment together with B cells and plasma cells to illustrate the first cellular landscape of IgM MGUS and WM in single cell resolution. We isolated bone marrow CD19+ and CD19-CD38+ cells from WM patients(n=3), IgM MGUS patients(n=3) and healthy donors(n=3) and employed the 10x Genomics platform to perform single-cell transcriptomic sequencing. After quality control, our dataset contained a total of 73024 cells. We used UMAP to visualize the cell superclusters and identified clusters including B cells, plasma cells, CD3+CD20+ (CD19+) cells, T cells and NK cells based on the expression of canonical lineage markers and cluster-specific markers. We found that healthy donors had the highest percentage of B cells (72.7% in healthy donors, 19.0% in IgM MGUS patients, 60.5% in WM patients; p<0.001) and that IgM MGUS and WM patients had more NK and T cells than healthy controls (0.06% and 17.7%, respectively, in healthy donors; 24.1% and 20.5% in IgM MGUS patients; 8.5% and 24.0% in WM patients; p<0.001). We also noticed that CD3+CD20+(CD19+) cells were present in both IgM MGUS and WM patients. First, we investigated the cell clusters correlated with WM pathology including B cells and plasma cells. We compared the B-cell gene expression profiles after removing the early B cells. Compared with those of IgM MGUS patients, mature B cells of WM patients showed upregulation of PIM1, DUSP22, HES1, NEAT1, RGS1, RGS16, and GADD45B. Light chain restriction and higher CNV levels were found in B cells of WM patients. SCENIC analysis showed that FOS, FOSB, EGR1 and JUNB were downregulated in B cells from WM and IgM MGUS patients. REL, a proto-oncogene promoting the survival and proliferation of B lymphocytes, was upregulated in B cells of WM patients, and IRF8 and ELF1 were upregulated in B cells of IgM MGUS patients. Nevertheless, plasma cells of WM patients, IgM MGUS patients and healthy donors were colocalized in one cluster, which might indicate their similar gene expression patterns. Next, we further determined the characteristics of B-cell subpopulation with aberrant T-cell antigen expression. Trajectory analysis revealed that CD3+CD20+(CD19+) cells and pro-B cells were located at the same end of the branched structure and were then directed toward mature B cell and plasma cell fates, respectively (Figure. 1A). This inferred developmental trajectory suggested that CD3+CD20+(CD19+) cells may be tumor stem cell-like subset. Using flow cytometry, we validated that CD3 was expressed in a fraction of CD19+ cells (mean: 3.69%, range: 0.28%-15.10%) of bone marrow samples from 8 WM patients. In addition, targeted gene sequencing was performed on CD3+CD19+ and CD3-CD19+ cells from 6 WM patients. MYD88 were proved to be the most frequently mutated gene in this cell subset. And we inferred that MYD88 mutation might be the early events in tumorigenesis by VAF analysis (Figure. 1B). Additional subclonal hits, such as CXCR4 and MAP2K1 mutations, could be acquired during tumor progression. In conclusion, our study provides comprehensive insights into mechanisms of progression from IgM MGUS to WM. We identified the rare CD19+ cell subpopulation with T-cell antigen expression in WM patients. It will be interesting to explore novel therapeutic strategies targeting rare potential cancer-initiating cells in future. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Clinical Outcomes, Prognostic Factors and Therapeutic Management in Extranodal Natural-Killer/T-Cell Lymphoma, Nasal-Type (ENKTL-NT) - Results of the Multicenter T-Cell Brazil Project

Introduction: Extranodal natural-killer/T-cell lymphoma, nasal-type (ENKTL-NT) is an aggressive, angiocentric, and extensively necrotic malignancy, universally associated with Epstein-Barr virus (EBV) infection. Although highly prevalent in South America, few studies involving cohorts from this region have been published. Brazil is the largest and most populous country in South America, but Brazilian data on ENKTL-NT are extremely scare. In order to fill this gap, the current study aims to describe clinical and laboratory characteristics, assess clinical outcomes, determine predictors of survival and compare responses between different therapeutic modalities applied in a multicenter cohort of Brazilian patients with ENKTL-NT. Methods: This is a retrospective, observational and multicenter study, involving 98 patients with ENKTL-NT diagnosed and treated at 20 different Brazilian institutions between January 2000 and December 2021. Endpoints included overall response rate (ORR), overall survival (OS) and progression-free survival (PFS). Survival curves were constructed using the Kaplan-Meier method and the Log-Rank test was used to assess the relationship between variables and outcomes. Univariate analysis was performed using the semi-parametric Cox test and multivariate analysis by Cox regression method or proportional ratios model. The results were presented in hazard ratio (HR) and 95% confidence interval (95% CI) and a p-value ≤ 0.05 was considered statistically significant. Results: The median age was 50 years (IqR 40-58) and 60.2% (59/98) were male. Sixty-three percent (62/98) had B-symptoms, 26.5% (26/98) had ECOG ≥ 2, 16.3% (16/98) had extranasal disease, 34.7% had advanced-stage III/IV, and 30.2% (29/98) had high-risk PINK score [Table 1A]. Table 1B summarizes the main therapeutic modalities, responses and associated adverse event profile among the 89/98 patients undergoing up-front treatment. With a median follow-up of 49.0 months (95% CI: 35.8-62.3), the estimated 2-year OS and PFS were 51.1% (95% CI: 40.4-61.6) and 17.7% (95% CI: 4.5-30.8), respectively. Among early-stage disease (IE/IIE) patients, the estimated 2-year OS were 81.3% (95% CI: 64.8-97.7) for SCRT (sequential chemoradiotherapy) followed by CHOP-like, 53.2% (95% CI: 29.3-77.1) for CCRT (concurrent chemoradiotherapy) followed by VIPD, and 50.5% (95% CI:21.4-79.5) for SCRT followed by asparaginase-based regimens, p=0.221 [Figure 1B]. CCRT-VIPD was associated with higher early-mortality (p=0.034), and higher rates of neutropenia (p=0.075), febrile neutropenia (p=0.043) and mucositis (p<0.001) [Table 1B]. Among advanced-stage (III/IV) disease, the estimated 2-year OS were 37.0% (95% CI: 8.9-65.0) for asparaginase-based regimens and 33.0% (95% CI: 1.9-68.5) for anthracycline-based regimens, p=0.851 [Figure 1C]. Chemoradiotherapy (CRT) was associated with benefit for OS (p=0.001) and PFS (p=0.007) compared to chemotherapy alone [Figure 1D and 1E]. In multivariate analysis, anemia (HR 2.052, p=0.038), lymphopenia [HR 3.600, p=0.012], advanced- stage disease (III/IV) [HR 3.101, p=0.007], bone marrow infiltration [HR 5.406, p=0.034] and omission of RT in up-front therapy [HR 2.791, p=0.023] were independent factors associated with decreased survival. Conclusion: High-dose EF-RT proved to be the cornerstone for the treatment of early-stage ENKTL-NT, and omission of this therapeutic modality was associated with decreased OS and PFS in Brazilian patients. In our real-life study, CCRT-VIPD regimen was poorly tolerated, and surprinsingly protocols based on anti-MDR agents were not associated with increased survival either in early- or advanced-stage disease. We also found that anemia, lymphopenia, advanced-stage (III/IV) and bone marrow involvement were independent predictors associated with poor clinical outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal