Genetic Risk Stratification Research Articles

Polygenic risk score: a new approach to cardiovascular prevention?

Long-lasting epidemiological studies showed that prevention of coronary artery disease (CAD) is highly feasible with the management of several conditions called "risk factors", such as hypertension, cholesterol, smoking, etc. Nevertheless, risk stratification for primary prevention using a statistical combination of risk factors is suboptimal, as conventional risk factors are age-dependent, so that their treatment would be too late to be effective. Genetic risk stratification, built on the genetic variants linked to CAD, has the advantage of being embedded in DNA and then it is independent of age. The rapid advancement of DNA analysis techniques has made it possible to identify many variants and to produce easily a statistical combination of them to obtain a polygenic risk score (PRS). Prospective clinical trials based on risk stratification for CAD using the PRS have shown that statin therapy is associated with a higher reduction in cardiac events in the high genetic risk group compared with the low genetic risk group. A wide clinical use of the PRS, however, is presently not possible, basically due to the lack of a standard in production and validation of the PRS, but genetic risk stratification has the potential to revolutionize primary prevention.

Polygenic risk, aspirin and primary prevention of coronary artery disease.

Recent aspirin primary prevention trials failed to identify a net benefit of aspirin for preventing cardiovascular disease versus the harms of bleeding. This study aimed to investigate whether a high-risk subgroup, individuals with elevated genetic predisposition to coronary artery disease (CAD), might derive more benefit than harm with aspirin, compared to those with lower genetic risk. We performed genetic risk stratification of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized controlled trial using a CAD polygenic risk score (GPSMult). For 12,031 genotyped participants (5,974 aspirin, 6,057 placebo) overall, we stratified them by GPSMult quintiles (q1-5), then examined risk of CAD (composite of myocardial infarction and coronary heart disease death) and bleeding events using Cox models. During a median 4.6 years of follow-up with randomization to 100 mg/day aspirin versus placebo, 234 (1.9%) participants had CAD and 373 (3.1%) had bleeding events. In the overall cohort, aspirin resulted in higher bleeding risk (adjusted Hazard Ratio [aHR]=1.30 [1.06-1.61], P=0.01) but no significant CAD reduction (aHR=0.84 [0.64-1.09], P=0.19). However, among the highest quintile of polygenic risk (q5, top 20% of the GPSMult distribution), there was a 47% reduction in risk of CAD events with aspirin (aHR=0.53 [0.31-0.90], P=0.02) without increased bleeding risk (aHR=1.05 [0.60-1.82], P=0.88). Interaction between the GPSMult and aspirin was significant for CAD (q5 versus q1, P=0.02) but not bleeding (P=0.80). The balance between net benefit and harm on aspirin in the primary prevention setting shifts favourably in individuals with an elevated genetic predisposition.

Hypertrophic Cardiomyopathy as a Form of Heart Failure with Preserved Ejection Fraction: Diagnosis, Drugs, and Procedures.

Hypertrophic cardiomyopathy (HCM) is a complex and heterogeneous cardiac disorder characterized by cardiac hypertrophy disproportionate to loading stimuli (e.g. hypertension or aortic stenosis). Diagnosing HCM requires a thorough examination of clinical symptoms, with echocardiography as the key initial imaging tool. Multimodality imaging further supports diagnosis, helps assess left ventricular outflow obstruction, and aids in risk stratification for sudden cardiac death. The cornerstone of HCM management remains pharmacological therapy with β-blockers and calcium channel blockers serving as first-line agents to alleviate symptoms and reduce left ventricular outflow tract obstruction. More recently, cardiac myosin inhibitors have revolutionized the treatment paradigm for obstructive HCM. Procedural interventions such as septal reduction therapy are reserved for refractory cases. Genetic testing and risk stratification for sudden cardiac death play a critical role in treatment decisions, guiding further testing in first-degree relatives and ICD implantation in high-risk individuals. Exercise recommendations have evolved based on recent data, challenging traditional restrictions and emphasizing individualized plans.

Multiomic profiling identifies predictors of survival in African American patients with acute myeloid leukemia

Genomic profiles and prognostic biomarkers in patients with acute myeloid leukemia (AML) from ancestry-diverse populations are underexplored. We analyzed the exomes and transcriptomes of 100 patients with AML with genomically confirmed African ancestry (Black; Alliance) and compared their somatic mutation frequencies with those of 323 self-reported white patients with AML, 55% of whom had genomically confirmed European ancestry (white; BeatAML). Here we find that 73% of 162 gene mutations recurrent in Black patients, including a hitherto unreported PHIP alteration detected in 7% of patients, were found in one white patient or not detected. Black patients with myelodysplasia-related AML were younger than white patients suggesting intrinsic and/or extrinsic dysplasia-causing stressors. On multivariable analyses of Black patients, NPM1 and NRAS mutations were associated with inferior disease-free and IDH1 and IDH2 mutations with reduced overall survival. Inflammatory profiles, cell type distributions and transcriptional profiles differed between Black and white patients with NPM1 mutations. Incorporation of ancestry-specific risk markers into the 2022 European LeukemiaNet genetic risk stratification changed risk group assignment for one-third of Black patients and improved their outcome prediction.

Polygenic Risk Scores Driving Clinical Change in Glaucoma.

Glaucoma is a clinically heterogeneous disease and the world's leading cause of irreversible blindness. Therapeutic intervention can prevent blindness but relies on early diagnosis, and current clinical risk factors are limited in their ability to predict who will develop sight-threatening glaucoma. The high heritability of glaucoma makes it an ideal substrate for genetic risk prediction, with the bulk of risk being polygenic in nature. Here, we summarize the foundations of glaucoma genetic risk, the development of polygenic risk prediction instruments, and emerging opportunities for genetic risk stratification. Although challenges remain, genetic risk stratification will significantly improve glaucoma screening and management.

Genetic risk stratification and outcomes among treatment-naive patients with AML treated with venetoclax and azacitidine

AbstractThe European LeukemiaNet (ELN) acute myeloid leukemia (AML) genetic risk classification systems are based on response to intensive chemotherapy; their ability to discriminate outcomes in older patients treated with venetoclax-azacitidine may be suboptimal. This pooled analysis of the phase 3 VIALE-A trial (NCT02993523) and phase 1b study (NCT02203773) examined prognostic stratification according to the 2017 and 2022 ELN risk classifications and derived new molecular signatures differentiating venetoclax-azacitidine–treated patients based on overall survival (OS). Overall, 279 patients treated with venetoclax-azacitidine and 113 patients treated with placebo-azacitidine were analyzed. The ELN 2017 or 2022 prognostic criteria classified most patients as adverse-risk AML (60.2% and 72.8% for venetoclax-azacitidine and 65.5% and 75.2% for placebo-azacitidine, respectively). Although outcomes with venetoclax-azacitidine improved across all ELN risk groups compared with placebo-azacitidine, ELN classification systems poorly discriminated venetoclax-azacitidine outcomes. By applying a bioinformatic algorithm, new molecular signatures were derived differentiating OS outcomes with venetoclax-azacitidine. The mutational status of TP53, FLT3 internal tandem duplication (FLT3-ITD), NRAS, and KRAS categorized patients into higher-, intermediate-, and lower-benefit groups (52%, 25%, and 23% of patients, respectively), each associated with a distinct median OS (26.5 months [95% confidence interval (CI), 20.2-32.7]; 12.1 months [95% CI, 7.3-15.2]; and 5.5 months [95% CI, 2.8-7.6], respectively). ELN prognostic classifiers did not provide clinically meaningful risk stratification of OS outcomes in patients treated with venetoclax-azacitidine. TP53, FLT3-ITD, NRAS, and KRAS mutation status allows the classification of these patients into 3 risk groups with distinct differences in median OS. These trials were registered at www.clinicaltrials.gov as #NCT02993523 and #NCT02203773.

Genetic Risk Stratification of Primary Open-Angle Glaucoma in Japanese Individuals

To assess the impact of genetic risk estimation for primary open-angle glaucoma (POAG) in Japanese individuals. Cross-sectional analysis. Genetic risk scores (GRSs) were constructed based on a genome-wide association study (GWAS) of POAG in Japanese people. A total of 3625 Japanese individuals, including 1191 patients and 2434 controls (Japanese Tohoku), were used for the model selection. We also evaluated the discriminative accuracy of constructed GRSs in a dataset comprising 1034 patients and 1147 controls (the Japan Glaucoma Society Omics Group [JGS-OG] and the Genomic Research Committee of the Japanese Ophthalmological Society [GRC-JOS]) and 1900 participants from a population-based study (Hisayama Study). We evaluated 2 types of GRSs: polygenic risk scores using the pruning and thresholding procedure and a GRS using variants associated with POAG in the GWAS of the International Glaucoma Genetics Consortium (IGGC). We selected the model with the highest areas under the receiver operating characteristic curve (AUC). In the population-based study, we evaluated the correlations between GRS and ocular measurements. Proportion of patients with POAG after stratification according to the GRS. We found that a GRS using 98 variants, which showed genome-wide significance in the IGGC, showed the best discriminative accuracy (AUC, 0.65). In the Japanese Tohoku, the proportion of patients with POAG in the top 10% individuals was significantly higher than that in the lowest 10% (odds ratio [OR], 6.15; 95% confidence interval [CI], 4.35-8.71). In the JGS-OG and GRC-JOS, we confirmed similar impact of POAG GRS (AUC, 0.64; OR [top vs. bottom decile], 5.81; 95% CI, 3.79-9.01). In the population-based study, POAG prevalence was significantly higher in the top 20% individuals of the GRS compared with the bottom 20% (9.2% vs. 5.0%). However, the discriminative accuracy was low (AUC, 0.56). The POAG GRS was correlated positively with intraocular pressure (r= 0.08: P= 4.0× 10-4) and vertical cup-to-disc ratio (r= 0.11; P= 4.0× 10-6). The GRS showed moderate discriminative accuracy for POAG in the Japanese population. However, risk stratification in the general population showed relatively weak discriminative performance. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Rare and Common Genetic Variation Underlying Atrial Fibrillation Risk

Atrial fibrillation (AF) has a substantial genetic component. The importance of polygenic risk is well established, while the contribution of rare variants to disease risk warrants characterization in large cohorts. To identify rare predicted loss-of-function (pLOF) variants associated with AF and elucidate their role in risk of AF, cardiomyopathy (CM), and heart failure (HF) in combination with a polygenic risk score (PRS). This was a genetic association and nested case-control study. The impact of rare pLOF variants was evaluated on the risk of incident AF. HF and CM were assessed in cause-specific Cox regressions. End of follow-up was July 1, 2022. Data were analyzed from January to October 2023. The UK Biobank enrolled 502 480 individuals aged 40 to 69 years at inclusion in the United Kingdom between March 13, 2006, and October 1, 2010. UK residents of European ancestry were included. Individuals with prior diagnosis of AF were excluded from analyses of incident AF. Rare pLOF variants and an AF PRS. Risk of AF and incident HF or CM prior to and subsequent to AF diagnosis. A total of 403 990 individuals (218 489 [54.1%] female) with a median (IQR) age of 58 (51-63) years were included; 24 447 were diagnosed with incident AF over a median (IQR) follow-up period of 13.3 (12.4-14.0) years. Rare pLOF variants in 6 genes (TTN, RPL3L, PKP2, CTNNA3, KDM5B, and C10orf71) were associated with AF. Of these, TTN, RPL3L, PKP2, CTNNA3, and KDM5B replicated in an external cohort. Combined with high PRS, rare pLOF variants conferred an odds ratio of 7.08 (95% CI, 6.03-8.28) for AF. Carriers with high PRS also had a substantial 10-year risk of AF (16% in female individuals and 24% in male individuals older than 60 years). Rare pLOF variants were associated with increased risk of CM both prior to AF (hazard ratio [HR], 3.13; 95% CI, 2.24-4.36) and subsequent to AF (HR, 2.98; 95% CI, 1.89-4.69). Rare and common genetic variation were associated with an increased risk of AF. The findings provide insights into the genetic underpinnings of AF and may aid in future genetic risk stratification.

Recurrent stroke prediction by applying a stroke polygenic risk score in the Japanese population.

Recently, various polygenic risk score (PRS)-based methods were developed to improve stroke prediction. However, current PRSs (including cross-ancestry PRS) poorly predict recurrent stroke. Here, we aimed to determine whether the best PRS for Japanese individuals can also predict stroke recurrence in this population by extensively comparing the methods and maximizing the predictive performance for stroke onset. We used data from the BioBank Japan (BBJ) 1st cohort (n=179,938) to derive and optimize the PRSs using a 10-fold cross-validation. We integrated the optimized PRSs for multiple traits, such as vascular risk factors and stroke subtypes to generate a single PRS using the meta-scoring approach (metaGRS). We used an independent BBJ 2nd cohort (n=41,929) as a test sample to evaluate the association of the metaGRS with stroke and recurrent stroke. We analyzed recurrent stroke cases (n=174) and non-recurrent stroke controls (n=1,153) among subjects within the BBJ 2nd cohort. After adjusting for known risk factors, metaGRS was associated with stroke recurrence (adjusted OR per SD 1.18 [95% CI: 1.00-1.39, p=0.044]), although no significant correlation was observed with the published PRSs. We administered three distinct tests to consider the potential index event bias; however, the outcomes derived from these examinations did not provide any significant indication of the influence of index event bias. The high metaGRS group without a history of hypertension had a higher risk of stroke recurrence than that of the low metaGRS group (adjusted OR 2.24 [95% CI: 1.07-4.66, p=0.032]). However, this association was weak in the hypertension group (adjusted OR 1.21 [95% CI: 0.69-2.13, p=0.50]). The metaGRS developed in a Japanese cohort predicted stroke recurrence in an independent cohort of patients. In particular, it predicted an increased risk of recurrence among stroke patients without hypertension. These findings provide clues for additional genetic risk stratification and help in developing personalized strategies for stroke recurrence prevention.

Genetic risk stratification of inflammatory bowel disease-associated venous thromboembolism: An Asian perspective.

The utilisation of polygenic scoring models may enhance the clinician's ability to risk stratify an inflammatory bowel disease patient's individual risk for venous thromboembolism (VTE) and guide the appropriate usage of VTE thromboprophylaxis, yet there is a need to validate such models in ethnically diverse populations.

Novel high-dense microelectrode array based multimodal bioelectronic monitoring system for cardiac arrhythmia re-entry analysis

In recent decades, significant progress has been made in the treatment of heart diseases, particularly in the field of personalized medicine. Despite the development of genetic tests, phenotyping and risk stratification are performed based on clinical findings and invasive in vivo techniques, such as stimulation conduction mapping techniques and programmed ventricular pacing. Consequently, label-free non-invasive in vitro functional analysis systems are urgently needed for more accurate and effective in vitro risk stratification, model-based therapy planning, and clinical safety profile evaluation of drugs. To overcome these limitations, a novel multilayer high-density microelectrode array (HD-MEA), with an optimized configuration of 512 sensing and 4 pacing electrodes on a sensor area of 100 mm2, was developed for the bioelectronic detection of re-entry arrhythmia patterns. Together with a co-developed front-end, we monitored label-free and in parallel cardiac electrophysiology based on field potential monitoring and mechanical contraction using impedance spectroscopy at the same microelectrode. In proof of principle experiments, human induced pluripotent stem cell (hiPS)-derived cardiomyocytes were cultured on HD-MEAs and used to demonstrate the sensitive quantification of contraction strength modulation by cardioactive drugs such as blebbistatin (IC50 = 4.2 μM), omecamtiv and levosimendan. Strikingly, arrhythmia-typical rotor patterns (re-entry) can be induced by optimized electrical stimulation sequences and detected with high spatial resolution. Therefore, we provide a novel cardiac re-entry analysis system as a promising reference point for diagnostic approaches based on in vitro assays using patient-specific hiPS-derived cardiomyocytes.

Prevalence of variant of unknown significance (VUS) in men with prostate cancer who serve as a benchmark for enhanced screening and for personalized therapy.

342 Background: Pathogenic variants (PVs) in DNA repair genes (DRG), such as in BRCA1, BRCA2, ATM, CHEK2, etc., have implications for prostate cancer (PCa) family genetic counselling, testing and risk stratification in men. However, understanding how to counsel patients with variants of unknown significance (VUS) is an unmet clinical need. On the other hand, there is the necessity to cautiously interpret VUS findings and to bolster VUS evaluations with additional evidence for pathogenicity. In this study, we aim to investigate the prevalence of germline VUS in men with PCa and their association with outcomes after robot-assisted radical prostatectomy (RARP). Methods: This is a nested cohort case study from an ongoing PCa screening, set to identify and screen men in the Italian population with a genetic predisposition (AIRC - Fondazione AIRC per la Ricerca sul Cancro project IG 2020 ID 25027). Cases for the current analysis were selected by “Adam's rib strategy” searching for germline DRG variant in men with a diagnosis of high-risk PCa who were scheduled for RARP. After informed consent was signed, a blood sample was obtained. A previously validated multigene panel test was used to assess the presence of germline variants. PVs and VUS were classified according to the American College of Medical Genetics and Genomics and Association for Molecular Pathology consensus criteria and International Agency for Research on Cancer guidelines. The primary endpoint was to describe the prevalence of VUS and the secondary to correlate VUS with pathological outcomes after RARP. Results: A total of 118 men with diagnosis of PCa who underwent RP were enrolled. The mean age at diagnosis of PCa was 65.9 (±6.42) years; pathological grade was ISUP 1-2 in 58.0% patients and 3-5 in 42.0%. Of the 76 men evaluated, 18 (23.7%) had a VUS and 1 (1.32%) a pathogenic germline variant in BRCA1 and PALB2. Among those with VUS younger men at diagnosis were more likely to carry a VUS than older at diagnosis mean (age 64 ± 6.41 vs. 66 ± 7.20 years). Additionally, 33.3% vs 16.2 % were carrier of VUS and N+ and required adjuvant androgen deprivation therapy. No difference between ISUP at final pathology and positive margin rate were found. Conclusions: Our findings showed a high prevalence of VUS germline mutations in PCa patients undergoing RARP. These mutations seem to be associated with worse pathological outcomes. Limitations includes short follow-up and absence of non-Caucasian patients.

Genetic risk and likelihood of prostate cancer detection on first biopsy by ancestry.

Despite differences in prostate cancer risk across ancestry groups, relative performance of prostate cancer genetic risks scores (GRS) for positive biopsy prediction in different ancestry groups is unknown. This cross-sectional retrospective analysis examines the association between a polygenic hazard score (PHS290) and risk of prostate cancer diagnosis upon first biopsy in male veterans using 2-sided tests. Our analysis included 36 717 veterans (10 297 of African ancestry). Unadjusted rates of positive first prostate biopsy increased with higher genetic risk (low risk: 34%, high risk: 58%; P < .001). Among men of African ancestry, higher genetic risk was associated with increased prostate cancer detection on first biopsy (odds ratio = 2.18, 95% confidence interval = 1.93 to 2.47), but the effect was stronger among men of European descent (odds ratio = 3.89, 95% confidence interval = 3.62 to 4.18). These findings suggest that incorporating genetic risk into prediction models could better personalize biopsy decisions, although further study is needed to achieve equitable genetic risk stratification among ancestry groups.

Shaping the Future of Cardiac Wellness: Exploring Revolutionary Approaches in Disease Management and Prevention

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality worldwide. Effective prevention and management strategies are essential to reduce the burden of CVDs. This review summarizes recent advances in the prevention and management of CVDs. In terms of prevention, lifestyle modifications, such as diet, exercise, and smoking cessation, remain important strategies. Pharmacological interventions, including statins, antiplatelet agents, and antihypertensive medications, have also shown benefits. Innovative approaches, such as genetic testing and risk stratification, targeted prevention strategies, and the use of mobile health technology, are being explored. In terms of management, acute management strategies, such as reperfusion therapy for myocardial infarction, acute heart failure management, and stroke management, have improved outcomes. Chronic management strategies, including medical therapy for heart failure, arrhythmia management, and device therapy for heart failure, have also shown benefits. Innovative approaches, such as precision medicine and personalized treatment, the use of artificial intelligence in diagnosis and treatment, and advances in traditional Chinese and regenerative medicine, are being investigated. While recent advances in the prevention and management of CVDs are promising, challenges remain in implementing these strategies, including cost-effectiveness, access to care, and resistance to change in clinical practice. Continued research and innovation are essential to reduce the burden of CVDs and improve patient outcomes.

Combination of minimal residual disease on day 15 and copy number alterations results in BCR-ABL1-negative pediatric B-ALL: A powerful tool for prediction of induction failure

The current genomic abnormalities provide prognostic value in pediatric Acute Lymphoblastic Leukemia (ALL). Furthermore, Copy Number Alteration (CNA) has recently been used to improve the genetic risk stratification of patients. This study aimed to evaluate CNA profiles in BCR-ABL1-negative pediatric B-ALL patients and correlate the data with Minimal Residual Disease (MRD) results after induction therapy. We examined 82 bone marrow samples from pediatric BCR-ABL1-negative B-ALL using the MLPA method for the most common CNAs, including IKZF1, CDKN2A/B, PAX5, RB1, BTG1, ETV6, EBF1, JAK2, and PAR1 region. Subsequently, patients were followed-up by multiparameter Flow Cytometry for MRD (MFC-MRD) assessment on days 15 and 33 after induction. Data showed that 58.5 % of patients carried at least one gene deletion, whereas 41.7 % of them carried more than one gene deletion simultaneously. The most frequent gene deletions were CDKN2A/B, ETV6, and IKZF1 (30.5 %, 14.6 %, and 14.6 %, respectively), while the PAR1 region showed predominantly duplication (30.5 %). CDKN2A/B and IKZF1 were related to positive MRD results on day 15 (p = 0.003 and p = 0.007, respectively). The simultaneous presence of more than one deletion was significantly associated with high induction failure (p = 0.001). Also, according to the CNA profile criteria, the CNA with poor risk (CNA-PR) profile was statistically associated with older age and positive MRD results on day 15 (p = 0.014 and p = 0.013, respectively). According to our results, the combined use of CNAs with MRD results on day 15 can predict induction failure and be helpful in ameliorating B-ALL risk stratification and treatment approaches.

Genotype-phenotype correlations of neurofibromatosis type 1: a cross-sectional study from a large Chinese cohort.

Neurofibromatosis type 1 (NF1) is a highly heterogeneous autosomal genetic disorder characterized by a broad spectrum of clinical and molecular manifestations. The correlations between genotype and phenotype in NF1 remain elusive. This study aimed to elucidate genotype-phenotype associations in a large Chinese cohort of NF1 patients. We included NF1 patients from our center who underwent genetic testing for NF1 variants and systemic examination. Genotype-phenotype correlation analyses were performed, focusing on variation types and involved neurofibromin domains. A total of 195 patients were enrolled, comprising 105 males and 90 females, with a median age of 18years. Truncating variants, single amino acid variations, and splicing variants accounted for 139/195 (71.3%), 23/195 (11.8%), and 33/195 (16.9%), respectively. Patients with splicing variants exhibited a significantly higher prevalence of spinal plexiform neurofibromas (spinal PNF) than those with truncating variants (76.4% vs. 51.8%; p = 0.022). Variations affecting the PKC domain were associated with higher rates of cutaneous neurofibromas (CNF) (100% vs. 64.9%, p < 0.001), Lisch nodules (100% vs. 61.2%, p < 0.001), plexiform neurofibromas (PNF) (100% vs. 95.7%, p = 0.009), and psychiatric disorders (11.8% vs. 1.6%, p = 0.042). Patients with mutations in the CSRD had an elevated risk of secondary primary malignancies (11.6% vs. 2.8%, p = 0.015). GRD involvement might enhance the risk of Lisch nodules (76.9% vs. 53.7%, p = 0.044). Variations in the Sec14-PH domain were correlated with a higher rate of CNF (76.8% vs. 58.6%, p = 0.014). Additionally, we found that the p.R1748* variants carry a high risk of malignancy. Our study suggested some novel genotype-phenotype correlations within a Chinese cohort, providing innovative insights into this complex field that may contribute to genetic counseling, risk stratification, and clinical management for the NF1 population.

Survival and Prognosis Among 301 Patients with Newly-Diagnosed Acute Myeloid Leukemia Following Venetoclax Plus Hypomethylating Agent Therapy

Background: Venetoclax (Ven) in combination with hypomethylating agent (HMA) is the preferred treatment for elderly/unfit patients with newly-diagnosed acute myeloid leukemia (AML). Current prognostication for AML is based on European LeukemiaNet (ELN) genetic risk stratification which has limited applicability in patients treated with Ven-HMA ( Blood, 2022). Accordingly, our primary objective was to determine predictors of treatment response and survival outcomes in treatment-naïve AML patients receiving Ven-HMA. Methods: Our study population was recruited from Mayo Clinic (MN, FL, AZ), after institutional review board approval and based on documentation of newly-diagnosed AML treated with Ven-HMA outside of clinical trials between November 2018 and April 2023. Cytogenetic and molecular studies were performed by conventional karyotype, and next-generation sequencing, respectively. Response was assessed according to the 2022 ELN criteria Results: Patient characteristics A total of 301 newly-diagnosed AML patients (median age 73 years, 66% male, 62% de novo) received a median of 3 cycles (range 1-48) of azacitidine 75 mg/m2 days 1-7 ( n=100) or decitabine 20 mg/m2 days 1-5 ( n=201) with Ven. ELN 2022 cytogenetic risk included favorable (1%, n=4), intermediate (61%, n=184) or adverse (38%, n=113). Mutations involved TP53 in 77/301 (25%), ASXL1 in 54/279 (19%), RUNX1 in 54/296 (18%), NPM1 in 44/299 (15%), DNMT3A in 40/296 (13%), K/NRAS in 41/296 (14%), IDH1 in 20/301 (6%), IDH2 in 30/301 (10%), FLT3-ITD in 25/301 (8%) and DDX41 in 9/247 (4%) of informative cases. Predictors of response Complete remission, with (CR) or without (CRi), count recovery, was documented in 182 (60%) patients, including CR in 36% and measurable residual disease (MRD) negative by flow cytometry in 77% of 105 informative cases that achieved CR/CRi. Median time to CR/CRi was 1.4 months. In univariate analysis, CR/CRi was more likely to occur in the presence of NPM1 mutation, (86% vs. 56%; p &amp;lt; .01), IDH2 mutation, (80% vs. 58%; p = .02), DNMT3A mutation, (78% vs. 57%; p = .01), or DDX41 mutation, (100% vs. 58%; p &amp;lt;.01), and in the absence of adverse karyotype, (71% vs. 42%; p &amp;lt; .01), TP53 mutation, (67% vs. 40%; p &amp;lt;.01), FLT3-ITD mutation, (63% vs. 36%; p = .01), or RUNX1 mutation, (64% vs. 44%; p = .01); in multivariable analysis, adverse karyotype, ( p &amp;lt; .01), FLT3-ITD ( p &amp;lt; .01), RUNX1 ( p &amp;lt; .01), NPM1 ( p = .03), IDH2 ( p = .04), and DDX41, ( p = .01) mutations remained significant. Predictors of survival After a median follow-up of 8.5 months (range 0.5-56), 13.2 months for living patients, 174 (58%) deaths, 73 relapses (40% of those achieving CR/CRi), and 41 (14%; including 35 in CR/CRi) allogeneic hematopoietic stem cell tranplants (AHSCT) were documented. In univariate analysis of pre-treatment variables, thrombocytopenia &amp;lt; 100 x 10 9/l, (HR 1.5, 95% CI 1.03-2.2; p = .03), adverse karyotype, (HR 2.8, 95% CI 2.1-3.8; p &amp;lt; .01) TP53 mutation, (HR 2.5, 95% CI 1.8-3.5; p &amp;lt; .01), or absence of IDH2 mutation, (HR 3.5, 95% CI 1.7-7.6; p &amp;lt; .01) predicted inferior survival. Failure to achieve CR/CRi (HR 4.5, 95% CI 3.3-6.1; p &amp;lt; .01) was also associated with inferior survival and in multivariable analysis, failure to achieve CR/CRi, (HR 3.4, 95% CI 2.5-4.8; p&amp;lt; .01), presence of adverse karyotype, (HR 1.6, 95% CI 1.1-2.6; p = .02), TP53 mutation, (HR 1.6, 95% CI 1.002-2.4; p = .04), and absence of IDH2 mutation (HR 2.2, 95% CI 1.004-4.7; p = .04) were identified as risk factors for survival. Subsequent HR-weighted scoring resulted in three-tiered risk stratification: low (0-1 point; n= 130), intermediate (2-3 points; n= 105), and high (4-5 points; n= 66), with respective median survival (3-year rate) of 28.9 (48%), 9.6 (6%), and 3.1 (0%) months ( p &amp;lt; .01) (Figure). AHSCT had an independent favorable impact on survival (HR 0.3, 95% CI 0.1-0.6; p &amp;lt; .01), most apparent in low ( p =0.04), and intermediate ( p &amp;lt;.01), as opposed to high ( p = .06) risk. Conclusions: In the current single institutional series of Ven-HMA treated newly-diagnosed AML, response to Ven-HMA was the foremost predictor of survival. Additional risk factors for survival included adverse karyotype, presence of TP53 and absence of IDH2 mutations. These observations allowed for a three-tiered genetics-enhanced survival model with CR/CRi as a backbone, and also confirmed survival advantage from AHSCT, regardless of risk category.

ELN 2022 Favorable Genetic Risk Acute Myeloid Leukemia Treated with Venetoclax Plus Hypomethylating Agent: Predictors of Response and Survival

Background: The 2022 European LeukemiaNet (ELN) genetic-risk stratification for acute myeloid leukemia (AML), assigns favorable prognosis to t(8;21)(q22;q22.1)/ RUNX1:: RUNX1T1, inv(16)(p13.1q22) or t(16;16)(p13.1;q22)/ CBFB:: MYH1, NPM1 mutations without FLT3-ITD or adverse karyotype, and bZIP in-frame CEBPA mutations (Döhner , Blood, 2022 ). This risk stratification was derived from intensively treated patients; accordingly, prognostication in ELN favorable genetic risk AML, following venetoclax and hypomethylating agent (VEN-HMA) therapy, remains unclear and was the subject of the current study. Methods: Under an institutional review board approved minimum risk protocol, the Mayo Clinic database was searched to identify AML patients with favorable genetic risk, who received treatment with VEN-HMA in the frontline setting. All patients received at least one cycle of either azacitidine 75 mg/m 2 days 1-7 or decitabine 20 mg/m 2 days 1-5 with VEN dose adjusted based on azole antifungal prophylaxis. Genetic risk stratification and treatment response were assessed according to the 2022 ELN criteria. Survival was estimated from the time of VEN-HMA treatment start to last follow-up or death. Results: Patient characteristics A total of 46 newly-diagnosed AML patients with ELN 2022 favorable genetic risk [ NPM1 mutation, n=36 (78%), CEPBA bZIP mutation, n=7 (15%) and t(8;21)(q22;q22.1)/ inv(16)(p13.1q22), n=4 (9%)] received a median of 4 cycles (range 1-32) of VEN-HMA. Median age was 71 years, with 63% males, and 87% de novo AML. Additional mutations frequently involved TET2 in 17/43 (40%), DNMT3A in 14/45 (31%), SRSF2 in 10/43 (23%), K/NRAS in 10/45 (22%), IDH1 in 8/46 (17%), FLT3-TKD in 7/46 (15%), ASXL1 in 6/43 (14%) and IDH2 in 6/46 (13%),of informative cases.Myelodysplasia (MDS)-related gene mutations ( ASXL1, RUNX1, BCOR, EZH2, SRSF2, U2AF1, SF3B1, STAG2, and/or ZRSR2) were present in 15 of 40 (38%) of patients (93% males). Predictors of response Of the 39 (85%) patients that achieved complete remission, with (CR) ( n=24; 52%), or without count recovery (CRi) ( n=15; 33%); CR/CRi rates were not significantly higher in patients with NPM1 mutations (89%), t(8;21)(q22;q22.1)/ inv(16)(p13.1q22) (75%), or CEPBA bZIP mutations (67%) ( p=0.37). Among patients achieving CR/CRi, measurable residual disease by multiparametric flow cytometry was negative in 15 of 16 (94%) of evaluable cases after cycles 1 or 2. In addition, NPM1 qPCR was negative in 15 of 24 (63%) informative patients. Median time to response was 1.2 months with median response duration of 9.4 months. CR/CRi rates were significantly higher in females vs males (100% vs 76%, p=0.01), and in the absence vs presence of MDS-related gene mutations (96% vs 60%, p=0.004). Multivariable analysis confirmed superior response in the absence of MDS-related gene mutations ( p=0.04). Predictors of survival At a median follow-up of 10.6 months (range; 1.1-51 months), 21 patients (46%) have died, 9 relapsed (23% of those achieving CR/CRi), and 6 (13%) underwent allogeneic hematopoietic stem cell transplant. Median overall survival was 21 months with 1/2/3-year survival rates of 65%/41%/41% (Figure 1a); median relapse-free survival (RFS) was not reached; 1/2/3-year RFS rates were 81%/66%/57% (Figure 1b). Overall survival was superior in patients achieving CR/CRi (23 months vs 5.6 months; p&amp;lt;0.01), in females vs males (not reached vs 9.7 months; p&amp;lt;0.01), and in the absence of MDS-related gene mutations (not reached vs 5.6 months; p=0.01) (Figure 1c). Subsequent multivariable analysis identified female gender ( p=0.01), and absence of MDS-related mutations ( p=0.17) as independent predictors of superior survival. Similar results were obtained when analysis was restricted to NPM1 mutated patients. Conclusions: In the current retrospective study, VEN-HMA therapy in elderly/unfit AML patients with ELN 2022 favorable genetic risk, resulted in response rates that were comparable to those previously appreciated from published reports of patients receiving intensive induction therapy; however, follow-up in the current study was too short to accurately assess long-term overall and relapse-free survival impact. Our study also highlights the adverse prognosis retained by MDS-related gene mutations.

Lymphoma Cell Sorting to Enrich Low Degree Infiltration Clonal B-Cells for Diagnostic Delineation of Molecular Genetic Background By NGS

Introduction: According to WHO 2022 classificationthe vast majority of B-cell lymphoma entities continue to be defined histologically and by their immunophenotype. However, genetics help to define these entities and provide prognostic information. NGS targeted panel sequencing with short turn-around time has emerged as powerful diagnostic tool to uncover relevant genes frequently mutated in B-cell lymphoma. Yet its sensitivity limits its application to lymphoma cases with clone sizes &amp;gt;5%. In case of clinical symptoms and need for therapy small B-cell clones (&amp;lt;5%) can be diagnostically challenging if tissue for histopathology is difficult to obtain and immunophenotype is not characteristic for a specific lymphoma entitiy such as splenic B-cell lymphoma. Aim: To enrich small B-cell clones (&amp;lt;5%) by cell sorting to &amp;gt;15% to enable lymphoma NGS panel sequencing for potential genetic characterization and risk stratification. Methods: Peripheral blood or bone marrow samples (n=43) that containedsmall B-cells clones (&amp;lt;5%) as identified by flow cytometric routine diagnostics were stained for cell sorting by a combination of monoclonal antibodies against 9 B-cell antigens, including CD5, CD19 and CD45. The gating strategy excludes debris and doublets and defines B- and T-cells out of CD45-positive events. By application of cell sorting (SRT Cytoflex, Beckman Coulter) we aimed at &amp;gt;500,000 cells consisting of B- and T-cells, containing &amp;gt;15% clonal B-cells to ensure sufficient NGS sensitivity but minimize sort time. DNA was extracted from sorted samples and lymphoma NGS panel sequencing (66 genes ~ 1,500x coverage, min. 400x) was performed (NovaSeq 6000, Illumina). For technical and biological validation, native sample material was sequenced in parallel for a subset of patient samples (n=30). Results: In total43samples with &amp;lt;5% clonal B-cells were applied for cell sorting and clonal B-cells were enriched to a median of 17% (range, 3-97%) in a median of 800,000 cells (range, 127,400-3,780,000). In a pilot study to optimize the sorting procedure 8 of 13 sorted samples (62%) revealed quantitatively sufficient and good quality DNA and could be successfully analyzed by NGS. In 4 of these 8 samples (50%) mutations were identified. Optimized processing regarding cell sorting and DNA extraction was applied to further 30 samples all of which could be successfully sequenced. Overall, in 50% of all samples with NGS analysis after cell sorting (19/38) one or more mutations (total number of mutations: n=30) associated with B-cell lymphoma were detected. Mutations comprised genes frequently affected in B-cell lymphoma: MYD88 (30% of detected mutations, 9/30), CXCR4 (20%, 6/30), NOTCH1 (7%, 2/30), NOTCH2 (3%, 1/30), KMT2D (7%, 2/30), TP53 (13%, 4/30), BRAF (7%, 2/30), KLF2 (10%, 3/30) and DNMT3A (3%, 1/30). All of the cases negative for NGS after sorting (n=15) were negative also by NGS on matched native sample material without prior enrichment of clonal B-cells. Out of the 15 cases with positive NGS results after sorting NGS on native sample material revealed mutations in only 4 (27%) cases (only 1 case with detection of all mutations) while in 11 (73%) cases no mutations were detected. In the 15 cases positive after sorting median variant allele frequency (VAF) was 8.8% (range 3.4-38.3%). As anticipated, in the 4 cases with mutations detected also without sorting VAF was lower in native sample material (median 3.1%, range 1.98-4.9%) as compared to sorted sample material (median 8.9%, range 6.8-23.2%, p=0.0412). Conclusion: Cell sorting can overcome the diagnostic challenge of low degree infiltration B-cell lymphoma that require molecular genetics for further classification and risk prediction prior to therapy. Analysis of 30 samples and comparison with matched native material revealed that enrichment targeting 15% of clonal B-cells in a total of &amp;gt;500.000 cells are desirable for successful and sensitive NGS panel sequencing. In 50% of such cases mutations are detectable after sorting. Cell sorting to enrich clonal B-cells thus is a powerful tool to enable NGS panel sequencing for low percentage mature B-cell lymphoma and should be considered for routine diagnostics of B-cell lymphoma.

Disparities in Genetic Profiles, Risk Stratification and Outcomes in Adults with Acute Myeloid Leukemia Comparing Patients of Hispanic and Non-Hispanic Ethnicity in Central California

Acute myeloid Leukemia (AML) is the most common type of acute leukemia in adults. Ethnic disparities due to distinct biology and socioeconomic status have been described in AML. Prior studies indicated Hispanic AML patients had a younger age at presentation, more frequent high-risk mutations, and worse survival compared with non-Hispanics. We conducted a retrospective study to investigate the differences in AML risk stratification, mutational profiles and outcomes between Hispanic and non-Hispanic AML patients treated at Community Medical Centers (CMC) in Central California. Methods: We retrospectively analyzed patients ≥ 18 years diagnosed with AML between January 2016-December 2022 and treated at CMC in Fresno, CA. Patients with Acute promyelocytic leukemia and patients without complete cytogenetic and molecular data were excluded. The clinical data including age, sex, ethnicity, race, zip code, WBC on diagnosis, cytogenetics, molecular data and treatment regimens were reviewed. Molecular profiling was performed by next generation sequencing using established myeloid panels by NeoGenomics (NeoTYPE comprising of 63 genes) or Foundation One Heme laboratory (406 genes). Risk groups were identified based on the European Leukemia Network (ELN) 2022 criteria. RedCap data collection tool was used for data collection. A comparison of patient characteristics and rate of genetic alterations between Hispanic and Non-Hispanic patients was done using the Fisher exact test or Chi-square test. Kaplan-Meier Curve with log-rank test was used for evaluation of overall survival (OS) and progression-free survival (PFS). Results: 201 patients met the study criteria, 30 of them did not receive treatment and were included for their diagnostic data only but excluded from the survival analysis. The mean age at diagnosis was 65.6. 58.5% were males and 30% were Hispanic. Hispanic patients were younger than non-Hispanics (57.6 vs 64.6 years, p=0.01). Hispanic patients were also more likely to live in the relatively low Socioeconomic status (SES) neighborhoods (i.e., living in zip codes with the 1st or 2nd quartile of median income level) p=0. 007. More Hispanic patients needed interpreter P&amp;lt;0.001. However, Hispanics were more likely to experience favorable risk AML (8.4 % vs 0.7%, p=0.012), while non-Hispanics had higher rate of poor risk disease (63.8 Vs 55.9%, p=0.012).). There was no significant difference between Hispanics and non-Hispanics in terms of sex, de novo versus secondary AML, WBC at time of diagnosis, Extramedullary or Central nervous system (CNS) involvement, type of induction regimen or rate of consolidative or subsequent allogeneic stem cell transplant. Median OS in Hispanics was 17.3 months compared to 10.28 months for non-Hispanics, p=0.117.and median PFS for Hispanics was 9.17months compared to non-Hispanics at 6.04 months P=0.034 (Figure 1). In univariate analysis PFS and OS were better in patients with normal cytogenetics compared to those with abnormal cytogenetics (15.3 vs 3.52 months and 20.4 vs 7.69 months respectively, p &amp;lt; 0.001) and in patients with favorable compared to intermediate risk and poor risk groups (84.5 vs 11.4 vs 4.1 months for PFS and Non reached vs 18.1 vs 7.8 months for OS, p&amp;lt; 0.001). There was no significant effect of income level in terms of OS or PFS. The most common genetic mutations in our patients were NPM1, FLT3-ITD, DNMT3A, TET2 and TP53. However, there were differences in the rates between Hispanics and non-Hispanics. 5q deletion and STAG2 were more common in non-Hispanics while KMT2C was detected more in Hispanics (table 1). Conclusion: Our study identified biologic differences between Hispanic and non-Hispanic AML patients with heterogeneity in genetic mutations. While Hispanic patients had lower income, they were younger at diagnosis and more likely to have favorable risk AML. Hispanic patients had better PFS and a trend towards improvement in OS. Further studies on larger patient population are warranted to evaluate the effect of ethnicity and SES on outcomes of AML patients.