History Of Hematologic Malignancy Research Articles

Ordering and Utilization of Peripheral Blood Flow Cytometry in an Academic Medical Center

Abstract Introduction/Objective The American Society for Clinical Pathology and the American Board of Internal Medicine’s Choosing Wisely campaign have developed best practice utilization guidelines for laboratory testing. Wisconsin Diagnostic Laboratories and Medical College of Wisconsin leadership noticed an increase in inappropriate peripheral blood flow cytometry testing in the last two years. An intervention was developed to help reduce inappropriate testing requests. Methods/Case Report The laboratory implemented a clinical decision support tool in the electronic medical record system that looked at patient diagnosis, history of stem cell transplant, and recommendations from pathology to help improve utilization of peripheral blood flow cytometry testing. Based on patient history, flow cytometry testing would move forward, or an alternative order of a peripheral blood pathology smear review with reflex to flow cytometry was offered. Pathologists would reflex flow cytometry if abnormalities were present by light microscopy or predetermined reflexing criteria were met. Results (if a Case Study enter NA) 314 cases were included for analysis. The intervention reduced volumes of peripheral blood flow cytometry in patients without a history of hematologic malignancy by 49.1% (p=<0.001). Appropriate utilization increased from 47.0% in the pre-intervention period to 80.4% in the post intervention period (p=<0.001). Significant diagnosis rate increased from 42.5% to 50.0% (p=.261). This resulted in a cost savings of $12,232 for the health system during the intervention period. Conclusion Clinical decision support based utilization efforts provide strong and consistent interventions to reduce the unnecessary and inappropriate ordering of peripheral blood flow cytometry.

Predictive Performance of Cardiovascular Risk Scores in Cancer Survivors From the UK Biobank

BackgroundCardiovascular preventive strategies are guided by risk scores with unknown validity in cancer cohorts. ObjectivesThis study aimed to evaluate the predictive performance of 7 established cardiovascular risk scores in cancer survivors from the UK Biobank. MethodsThe predictive performance of QRISK3, Systematic Coronary Risk Evaluation 2 (SCORE2)/Systematic Coronary Risk Evaluation for Older Persons (SCORE-OP), Framingham Risk Score, Pooled Cohort equations to Prevent Heart Failure (PCP-HF), CHARGE-AF, QStroke, and CHA2DS2-VASc was calculated in participants with and without a history of cancer. Participants were propensity matched on age, sex, deprivation, health behaviors, family history, and metabolic conditions. Analyses were stratified into any cancer, breast, lung, prostate, brain/central nervous system, hematologic malignancies, Hodgkin lymphoma, and non-Hodgkin lymphoma. Incident cardiovascular events were tracked through health record linkage over 10 years of follow-up. The area under the receiver operating curve, balanced accuracy, and sensitivity were reported. ResultsThe analysis included 31,534 cancer survivors and 126,136 covariate-matched controls. Risk score distributions were near identical in cases and controls. Participants with any cancer had a significantly higher incidence of all cardiovascular outcomes than matched controls. Performance metrics were significantly worse for all risk scores in cancer cases than in matched controls. The most notable differences were among participants with a history of hematologic malignancies who had significantly higher outcome rates and poorer risk score performance than their matched controls. The performance of risk scores for predicting stroke in participants with brain/central nervous system cancer was very poor, with predictive accuracy more than 30% lower than noncancer controls. ConclusionsExisting cardiovascular risk scores have significantly worse predictive accuracy in cancer survivors compared with noncancer comparators, leading to an underestimation of risk in this cohort.

Improving resource utilization: Axillary lymph node core biopsy triaging for lymphoma.

To evaluate the utilization of hematopathology resources within our enterprise on axillary lymph node core biopsy (AxLNCB) specimens, particularly those obtained in the context of breast cancer screening. The utilization of hematopathology resources was determined for all AxLNCB specimens over a 30-month period from across our enterprise, and chart review was performed for select patient demographics and radiographic features. The AxLNCB cases with benign histology were reviewed for subtyping of histologic patterns. Of the total 594 AxLNCB specimens, 61.6% were benign and 38.6% malignant. Of malignant cases, only 9.3% contained any hematologic malignancy, yet 94% of all cases received tissue triage for lymphoma, and 81% were reviewed at least in part by a hematopathologist. Six clinical parameters were found to independently predict risk of hematologic malignancy: male sex (P = .041), bilateral lymphadenopathy (P = .004), diffuse cortical thickening (P = .005), lack of breast cancer (P = .001), older age (P < .001), and history of hematologic malignancy (P < .001). Our enterprise overused hematopathology resources in the evaluation of AxLNCB performed in the study period. Our process could improve from the application of a simple tool generated from this cohort to predict percent risk of the specimen containing hematologic malignancy using patient characteristics easily found via routine chart review.

Multicenter Retrospective Study of Invasive Fusariosis in Intensive Care Units, France.

Invasive fusariosis can be life-threatening, especially in immunocompromised patients who require intensive care unit (ICU) admission. We conducted a multicenter retrospective study to describe clinical and biologic characteristics, patient outcomes, and factors associated with death and response to antifungal therapy. We identified 55 patients with invasive fusariosis from 16 ICUs in France during 2002----2020. The mortality rate was high (56%). Fusariosis-related pneumonia occurred in 76% of patients, often leading to acute respiratory failure. Factors associated with death included elevated sequential organ failure assessment score at ICU admission or history of allogeneic hematopoietic stem cell transplantation or hematologic malignancies. Neither voriconazole treatment nor disseminated fusariosis were strongly associated with response to therapy. Invasive fusariosis can lead to multiorgan failure and is associated with high mortality rates in ICUs. Clinicians should closely monitor ICU patients with a history of hematologic malignancies or stem cell transplantation because of higher risk for death.

Stag2-Cohesin Loss Attenuates Flt3 ITD Myeloid Blast Expansion Yet Preserves Mutant HSC

FLT3 is mutated through an internal tandem duplication (ITD) in 20-25% of acute myeloid leukemia (AML), driving aberrant STAT5/AKT signaling and leukemogenesis. Murine modelling of ITD showed marked myeloid progenitor expansion and hematopoietic stem cell (HSC) exhaustion in various co-mutant settings. Here we present a Stag2 Δ Flt3 ITD model with stark reversal of these two aforementioned features. STAG2, a cohesin complex member, maintains the integrity of the 3D genome partitioning structure known as topologically structural domains. Loss of Stag2 impairs the access and engagement of key hematopoietic transcription factors such as PU.1 to their target genes. sAML is diagnosed when patients present leukemia with known history of hematological malignancies or chemotherapy/radiotherapy treatment. Comparing to de novo AML, sAML often arises in older patients and harbors a poor prognosis with a 5-year overall survival rate of &amp;lt;30%. Advances in genomic studies found various epigenetic mutations, such as STAG2, are often associated with sAML and AML-myelodysplastic related changes (MRC) subtype. STAG2 mutations are found in 14-20% of sAML cases and is suggested to reside within a dominant clone during the pre-leukemia phase, MDS to sAML transformation, such as with FLT3 ITD acquisition and persists during remission. To understand the mechanistic contribution of STAG2-cohesin loss with FLT3 ITD, we generated sequential mutagenesis murine models where the order of Stag2 and Flt3 ITD mutation is set as either ITD 1st Stag2 2nd ( de novo like) or Stag2 1stITD 2nd (sAML like) using tamoxifen-inducible Cre/Flpo recombinase or pIpC-inducible Mx1Cre. In the de novo like model, ITD is constitutively active then Stag2 is deleted when mice reach 6-8 weeks of age. Surprisingly, loss of Stag2 attenuates LSK to MP transition at 4 weeks post deletion, while MPP3 remains elevated, suggesting aberrant remodeling of myeloid differentiation. In the sAML like model, Stag2 is deleted via Mx1Cre and waited for 4 months to mimic the MDS phase, which is then followed by activation of ITD mutation via Flpo, which represents the MDS to sAML transformation. After activating both mutations, mice were followed for another 4 months before analyzing the hematopoietic stem and progenitor compartment. In contrast to the de novo like model, sequential Stag2 1stITD 2nd preserves the HSC population defined by either immunophenotyping or transcriptome via scRNAseq ( Figure 1). The mutant HSC is more quiescent but retains the capacity to reconstitute lethally irradiated recipients in the short term. Similar to the de novo like model, sequential Stag2 1stITD 2nd mice also exhibits a blocked myeloid differentiation. Comparing to ITD mutant, Stag2 1stITD 2nd LSK cells have decreased expression of Socs2 and Cish. While functionally determining the role of mutant HSC, we are performing RNA-seq during at early timepoints post ITD activation to determine how preceding Stag2 mutation could have altered the stem cell fate decision. Targeted therapy with inhibitors of FLT3 have had an overall survival benefit in FLT3-mutant AML, though the magnitude of effect has been modest. STAG2 mutations are more likely to be identified in poor responders to FLT3 inhibition as both reported by us with Pexidartinib treatment, as well as in the setting of Crenolanib treatment where expansion of the STAG2-mutant clone was observed during treatment. Thus, remodeling of the chromatin landscape though altered CTCF binding or cohesin function might impact leukemia identity in FLT3-mutant AML. Our data highlights an important regulatory role of Stag2-cohesin in Flt3 ITD mediated leukemogenesis, while generating a model that mimics the genetic evolution of sAML. This model will not only shed light on the sAML pathogenesis but also with creates a pre-clinical testing platform with potential therapeutic relevance.

Inherited Thrombocytopenias Predisposing to Hematologic Neoplasms. Experience of the Spanish Group for Inherited Platelet Disorders (GEAPC)

Introduction In inherited thrombocytopenic disorders (IT) associated with germline genetic variants in the transcription factors RUNX1 (RUNX1-RT) and ETV6 (ETV6-RT) or ankyrin 26 (ANKRD26-RT), bleeding is usually not clinically relevant. However, patients have a high risk (10-45%) of developing hematologic malignancies (HM). Genetic diagnosis at an early stage of life is essential for these patients and their families, as the underlying genotype determines the natural history of the disease and, consequently, its prognosis and clinical management. High-Throughput Sequencing (HTS) has greatly facilitated diagnosing and providing personalized medicine for these patients. Objective The aim of this study was to evaluate the frequency, clinical characteristics, platelet phenotype and molecular alterations of patients with IT predisposing to HM, within the series of IT patients recruited by the Spanish Group of Inherited Platelet Disorders (GEAPC). Methods Since 2008, we have enrolled 296 patients (174 families) suspected of having any type of IT. They were selected according to their clinical and biological background. Bleeding (bleeding score (BS); ISTH-BAT), complete blood count and smear, and in many patients platelet phenotyping (platelet aggregation (LTA), cytometry, microscopy, etc.) were performed. Sanger sequencing of candidate genes (until 2014) or HTS was used for genetic diagnosis of patients. Candidate genetic variants were classified in accordance with the ACMG/AMP criteria, also taking into account the adapted specifications for RUNX1. Results Genetic diagnosis was obtained in 208 patients (76.3%) (135 families), identifying 26 different types of IT. Thirty patients (17 families) had RUNX1-RT (14.4%), 16 (5 families) had ANKRD26-RT (7.7%) and 7 cases (4 families) had ETV6-RT (3.4%). In patients with RUNX1-RT, the median age at identification of cytopenia and at genetic diagnosis was 17 (0-56) and 27 (1-71) years, respectively. Mild-to-moderate thrombocytopenia (95x109 pl/L (15-142)) and mild bleeding (BS=2(0-12)) was observed in 89% of these patients. Of the 13 patients evaluated, 83.3% had a reduced LTA at 2µg/ml collagen and 80% had low levels of glycoprotein Ia (collagen receptor). We identified 15 different variants in RUNX1 (8 novel); 47% missense, 30% nonsense, 12% large deletions, 6% splicing and 6% frameshift. Sixty-five percent of the variants were classified as pathogenic (PV), 6% as likely pathogenic (LPV), and 29% of uncertain significance (VUS). In 7 cases the variant was de novo. Ten patients (33.3%) developed HM (median age 49 years) (Table 1). Of these, 53% had at least one family member with HM (AML, 53.5%; MDS, 10.7%; CML, 7.1%; AML-post-MDS, 3.6%) or solid tumor (breast cancer, 14.2% [50% BRCA2+]; prostate, 7.1%; stomach, 3.6%). In 16 cases with ANKRD26-RT, thrombocytopenia was identified at age 16 (0-60 years), while the genetic diagnosis was made at age 36 (0-79 years). In all cases the thrombocytopenia was moderate [median: 53.5x109 pl/L (8-119)], mostly asymptomatic (BS=1.5(0-12)) and not associated with platelet dysfunction (5 cases studied). We detected 3 different variants in the 5'UTR of ANKRD26 (1 LPV, 2 VUS). One patient had a de novo variant. Twenty-five percent developed neoplasia (3 HM cases; 1 breast cancer) at 42 years of age (median). Two of 5 families had a history of HM (MDS or AML) (Table 1). The ETV6-RT patients were genetically diagnosed at the age of 30 (3-59) years, while thrombocytopenia, moderate [97 x 109 cells/L (8-119)] and not associated with a bleeding diathesis (BS=0 (0-4)), was detected at the age of 12 (2-33) years. In one case, a defect in LTA, activation and platelet dense granule number was detected in platelet function studies. In this group we identified 4 different ETV6 missense variants (2 PV and 2 LPV/VUS). One patient developed B-ALL at the age of 12 years (Table 1). Conclusions Inherited thrombocytopenia that predisposes to HM is the most common form of IT in this Spanish cohort (25.5% of cases [19% of families]). We found an excessive delay (10-20 years) in the genetic diagnosis of patients with respect to the age of identification of the cytopenia. The high rate of development of HM of 28% reinforces the critical importance of early genetic diagnosis of these IT in order to apply optimal surveillance and clinical management aimed at early detection of their evolution to neoplasm.

Breakthrough invasive fungal infections on isavuconazole prophylaxis in hematologic malignancy & hematopoietic stem cell transplant patients.

Isavuconazole (ISA) is a newer antifungal used in patients with history of hematologic malignancies and hematopoietic transplant and cellular therapies (HM/TCT). Although it has a more favorable side-effect profile, breakthrough invasive fungal infections (bIFIs) while on ISA have been reported. In this single-center retrospective study evaluating HM/TCT patients who received prophylactic ISA for ≥7 days, we evaluated the incidence and potential risk factors for bIFIs. We evaluated 106 patients who received prophylactic ISA. The patients were predominantly male (60.4%) with median age of 65 (range: 21-91) years. Acute myeloid leukemia (48/106, 45.3%) was the most common HM, with majority having relapsed and/or refractory disease (43/106, 40.6%) or receiving ongoing therapy (38/106, 35.8%). Nineteen patients (17.9%) developed bIFIs-nine proven [Fusarium (3), Candida (2), Mucorales plus Aspergillus (2), Mucorales (1), Colletotrichum (1)], four probable invasive pulmonary Aspergillus, and six possible infections. Twelve patients were neutropenic for a median of 28 (8-253) days prior to bIFI diagnosis. ISA levels checked within 7 days of bIFI diagnosis (median: 3.65μg/mL) were comparable to industry-sponsored clinical trials. All-cause mortality among the bIFI cases was 47.4% (9/19).We also noted clinically significant cytomegalovirus co-infection in 5.3% (1/19). On univariate analysis, there were no significant differences in baseline comorbidities and potential risk factors between the two groups. ISA prophylaxis was associated with a significant cumulative incidence of bIFIs. Despite the appealing side-effect and drug-interaction profile of ISA, clinicians must be vigilant about the potential risk for bIFIs.

Prognostic Value of Hematological Markers in Head and Neck Cancer Patients With a History of Hematological Malignancy

Background and Objectives Head and neck cancer can occur as a second primary tumor in patients with a history of hematological malignancy, and the pathological features of those are more aggressive than de novo primary head and neck cancer. However, research related to the prognostic value of hematological markers in the head and neck cancer patients with a history of hematological malignancy is scarce, so we performed this study.Subjects and Method We reviewed a total of 89 head and neck cancer patients with hematological malignancy diagnosed at a single tertiary hospital between 1997 and 2021, and enrolled 29. The analyzed hematological parameters included pre- and post-treatment hemoglobin, hematocrit, lactate dehydrogenase, absolute neturophil count (ANC), absolute platelet count, absolute leukocyte count, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio.Results Hematological malignancy was diagnosed almost 62.14±96.10 months before head and neck cancer. The most common hematological malignancy was acute myeloid leukemia. The overall survival (OS) rate was lower in patients with second primary tumor than in those with de novo primary head and neck cancer. The cox-proportional hazard ratio analysis showed that the post-treatment absolute neutrophil count was significantly correlated with disease-free survival but not with OS.Conclusion The post-treatment hematological profile, particularly ANC, can be considered a useful prognostic marker in the head and neck cancer patients with a history of hematological malignancy.

Sex/gender differences in metabolic syndrome among cancer survivors in the US: an NHANES analysis

BackgroundThe purpose of this study was to assess the association of metabolic syndrome (MetS) and its individual components in cancer survivors (CS) by gender, in comparison to participants without a history of cancer who have at least one chronic disease (CD) and those without a chronic disease diagnosis (NCD).MethodsData from participants 40 years and older (n = 12,734) were collected from the 2011 to 2018 National Health and Nutrition Examination Survey dataset. MetS was defined based on the National Cholesterol Education Program’s Adult Treatment Panel III. Chi-square test and multivariate-adjusted logistic regression was used to assess group comparisons and associations respectively.ResultsCompared to NCD, CS and CD men had increased odds of meeting MetS, OR 2.60 (CI 1.75–3.87) and OR 2.18 (CI 1.59–2.98) respectively. For women, CS and CD participants also had higher odds of meeting MetS criteria compared to their healthy counterparts, OR 2.05 (CI 1.44–2.93) and OR 2.14 (CI 1.63–2.81) respectively. In subgroup analysis by cancer site, CS men with a history of hematologic malignancies (OR 4.88, CI 1.30–18.37) and CS women with cervical cancer (OR 4.25, CI 1.70–10.59) had highest odds of developing MetS, compared to NCD. CS men also showed a strong association with elevated waist circumference, low high density lipoprotein-c, and elevated triglycerides, even by cancer site, but there were no consistent findings among women.ConclusionThis study indicates that CS men have a strong association with MetS, especially among those with blood-related cancers.

Patterns and outcomes of palliative radiation therapy with immunotherapy in locally recurrent head and neck squamous cell carcinoma.

e18015 Background: Immune checkpoint inhibitors (ICI) have been shown to improve outcomes in patients with recurrent or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC). Radiation therapy (RT) is commonly incorporated into R/M HNSCC treatment for symptom management and disease control. RT is a potential immunostimulatory treatment modality that may enhance the antitumor activity of ICI; however, ideal sequencing of RT and ICI in the palliative treatment setting is not defined. The objective of this study was to describe the patterns and outcomes of RT and ICI in locally recurrent HNSCC. Methods: All adults (≥ 18 years) with HNSCC who received palliative ICI for R/M disease from 2015-2021 were identified from the institutional electronic medical record via ICD codes under an IRB approved protocol. Patients who received ICI for non-HNSCC, had synchronous primary tumors, or had history of hematologic malignancy or immunodeficiency were excluded. Patients without documentation of clinical outcomes after palliative RT were excluded. Retrospective data were collected and underwent descriptive analysis. Results: We identified 26 patients who received palliative ICI and RT for locally recurrent HNSCC. Twelve underwent palliative RT while on ICI. In this group, there were 0 patients with complete response (CR), five with partial response (PR), two with stable disease (SD), and four with progression of disease (PD) in the target lesion. There were 10 grade 3 events. Fourteen patients had RT separately from ICI: 6 before and 8 after receiving ICI. In this group, there was one patient with CR, six with PR, one with SD, and six with PD in the target lesion. There were 3 grade 3 events. Most common grade 3 events in both groups were: dysphagia, mucositis, and voice change. The most common modalities of RT were SBRT, IMRT, and 3D conformal; 7 patients underwent SBRT, 19 underwent IMRT/3D conformal, with similar responses in target lesions. Conclusions: These data suggest that concurrent ICI and palliative RT for locally recurrent HNSCC is effective in the target lesions, but has an increase in toxicities. Although there was a small number of patients who underwent concurrent ICI and RT, the disease control rate (DCR) in this group was 58%, which is promising. Similarly, the DCR for patients receiving ICI and RT separately was 57%. Further study on the optimal type and sequence of palliative RT in this patient population is warranted.

An Unusual Presentation of Pulmonary Mucormycosis as a “Mass-like” Consolidation in an Infant with Chronic Granulomatous: A Case Report Study

Introduction: Chronic granulomatous disease (CGD) is a primary hereditary immunodeficiency condition caused by a defect in the nicotinamide adenine dinucleotide phosphate (NADP) oxidase complex. Recurrent infections and inflammatory complications with a narrow bacterial and fungal spectrum characterize CGD. Acute inflammatory and infectious complications are vexing and fatal for them. Therefore, managing CGD with prophylactic antibiotics and antifungal agents is essential. Case Presentation: We present a 23-month-old infant with a chief complaint of recent lymphadenopathy diagnosed with CGD. Two months later, she was hospitalized with uncontrolled fever and lung involvement while receiving prophylactic treatment with trimethoprim/sulfamethoxazole. A mass-like consolidation was seen in her radiography evaluation. Based on the biopsy and bronchoalveolar lavage (BAL) pathology report, pulmonary mucormycosis was confirmed. Two weeks after starting the standard treatment regimen with amphotericin B, the patient’s symptoms improved. She was discharged in good general condition with oral voriconazole and trimethoprim/sulfamethoxazole and referred to do hematopoietic stem cell transplantation (HSCT). Conclusions: Mucormycosis in CGD is not a common infection and usually infects patients with impaired cell-mediated immunity, hematological malignancies, steroid treatment, and diabetes. Patients with CGD are vulnerable when treated with a high dose of immunosuppressant medications. In our case report, the patient was infected with mucormycosis despite not receiving immunosuppressant medications and having no history of hematologic malignancies or diabetes. Our patient also had a mass-like consolidation in her radiological result, a rare feature of pulmonary mucormycosis involvement in CGD patients.

Abstract A50: Distinguishing Mosaic Li Fraumeni Syndrome, Clonal Hematopoiesis and Incidental Myeloid Neoplasms in Patients with Solid Tumors with Pathogenic TP53 Mutations Identified by Germline Testing or Cell-Free Circulating DNA Sequencing

Abstract The incorporation of panel-based germline genetic testing for assessment of pathogenic or likely pathogenic variants associated with increased risk of breast, ovarian, prostatic and pancreatic cancer in NCCN guidelines and wide adoption of cell-free circulating DNA sequencing (liquid biopsy) for patients with advanced solid tumors has increased the identification of pathogenic TP53 variants in blood of patients with solid tumors. The variant allelic frequency (VAF) of the pathogenic variant is often used to help infer the compartment of origin (germline vs somatic) with near heterozygous (~50%) VAF favoring germline; however, when VAF is low (sub heterozygous) potential considerations include mosaic Li Fraumeni syndrome, clonal hematopoiesis, or incidental myeloid neoplasms, and determining the origin of the TP53 mutation can be a challenge with important surveillance and treatment implications. We describe a cohort of patients with solid tumors or hematologic malignancies in whom pathogenic or likely pathogenic TP53 variants of uncertain origin were identified by clinical genetic testing of peripheral blood, next generation sequencing (NGS) using an 81 gene hematologic malignancy-based panel, or cell-free DNA sequencing/liquid biopsy. In a subset of patients for whom solid tumor, adjacent normal tissue and/or bone marrow (BM) was available, immunohistochemistry for p53 protein was performed. Patients (n= 17) included 11 (61%) women and 7 (39%) men with a median age of 54 years (range 8-7) at initial cancer diagnosis, with 17 unique TP53 variants with a median VAF of 16% (range, 2-50%). The most common indication for referral for additional investigation of the TP53 origin was sub-heterozygous VAF on germline testing of blood (8/47%) or saliva (1/6%); TP53 variant identified in plasma when the concurrent solid tumor was TP53 wild-type (3/18%) followed by presence of a pathogenic TP53 variant in remission BM of patients with history of hematologic malignancies (4/24%). Additional germline testing of skin fibroblasts and/or BM examination was performed in in 9 (53%) and 8 (47%) patients, respectively. p53 IHC was performed on 3 BM biopsies and 2 solid tumor tissues. A multimodality/multidisciplinary interpretation of these results allowed appropriate classification of the TP53 variants in 12/18 patients (67%). These included Li Fraumeni syndrome (5/12; 42%); clonal hematopoiesis (5/12; 42%); donor-derived clonal hematopoiesis (1/12;8%) and therapy-related myelodysplastic syndrome (1/12; 8%) patients. Appropriate awareness and distinction of clonal hematopoiesis and potential myeloid neoplasms from mosaic germline TP53 in the setting of subheterozygous VAF identified on peripheral blood or bone marrow analyses can be challenging. Multimodality testing and a multidisciplinary approach for accurate interpretation is required. Immunohistochemical staining for p53 can be useful in making this distinction in a subset of patients. Citation Format: Sanam Loghavi, Yoheved Gerstein, Mark J Routbort, Keyur P Patel, Koichi Takahashi, Molly Daniels, Julie Moskowitz, Danielle E Hammond, Kelly Chien, L. Jeffrey Medeiros, Farhad Ravandi, Hagop M Kantarjian, Guillermo Garcia-Manero, Banu Arun, Joseph D Khoury, Courtney D DiNardo. Distinguishing Mosaic Li Fraumeni Syndrome, Clonal Hematopoiesis and Incidental Myeloid Neoplasms in Patients with Solid Tumors with Pathogenic TP53 Mutations Identified by Germline Testing or Cell-Free Circulating DNA Sequencing [abstract]. In: Proceedings of the AACR Special Conference: Acute Myeloid Leukemia and Myelodysplastic Syndrome; 2023 Jan 23-25; Austin, TX. Philadelphia (PA): AACR; Blood Cancer Discov 2023;4(3_Suppl):Abstract nr A50.

Descriptive analysis of Cycle Threshold in patients with hematologic malignancies infected with SARS-COV-2

SARS-CoV-2 has caused over 200 million documented infections, more than 4 million deaths, and unprecedented consequences worldwide. The cycle threshold (Ct), the number of amplification cycles required to obtain a product detectable through fluorescence during a quantitative RT-PCR test, is an indirect measurement of viral load. Patients with hematologic malignancies have an increased risk of death by the SARS-CoV-2. We conducted a retrospective, observational, descriptive analysis of the Ct obtained from patients with history of hematologic malignancies who tested positive for SARS-CoV-2 in our hospital, from March 3rd, 2020, to August 17th, 2021. We used the mean Ct at diagnosis. 15 adults, with previous diagnosis of lymphomas, acute leukemias and chronic lymphocytic leukemia, were included. 9 of the 15 patients (60 %) developed pneumonia, 6 of them required supplementary oxygen and 5 mechanical ventilation. 5 patients died between 7-86 days from symptom onset. Ct was lower among the group of patients who died (15.5 cycles; SD= 2.28, CI95%= 9.17-21.86) compared with those who survived (20.2 cycles; SD= 8.87, CI95%= 13.9-26.6). Ct was also lower in the pneumonia group (18.2 cycles; SD= 2.28, CI95%= 12.98-23.51) than in the no-pneumonia group (19.3 cycles; SD= 4.11; CI95%= 8.73-29.9). Ct was lowest in severe forms of CoViD-19. Further studies with larger populations of patients with hematologic malignancies could establish the validity of Ct as a quantitative laboratory determination as a course-prediction and infectivity tool.

601. Characterizing Modifiable Risk Factors for Liposomal Amphotericin B (L-AMB) Nephrotoxicity

Abstract Background Liposomal amphotericin B (L-AMB) is a broad spectrum anti-fungal utilized in the treatment of serious fungal infections. Despite its liposomal formulation aimed at reducing toxicity, it is still associated with relatively high rates of nephrotoxicity. Few studies have attempted to assess the effectiveness of mitigation strategies to lower the risk of L-AMB-associated nephrotoxicity. Methods The purpose of this study is to characterize the time course of nephrotoxicity secondary to L-AMB, evaluate modifiable risk factors for L-AMB-related nephrotoxicity, and identify potential interventions to minimize nephrotoxicity. A retrospective chart review of inpatients who received L-AMB: Oct 1, 2020 through Jan 31, 2022 at the University of Washington Medical Center (UWMC) and Seattle Cancer Care Alliance (SCCA). The primary objective was to identify the incidence and onset of L-AMB related nephrotoxicity. Eligible patients ≥18 years old with a history of hematologic malignancy, solid organ transplant, or bone marrow transplant were included. Univariable associations were evaluated with either Chi-square or T-test. Results A total of 132 patients were reviewed with 77 patient courses included. The baseline characteristics are depicted in TABLE 1. The mean dose of L-AMB was 4.9 mg/kg with an average treatment duration of 8.2 days. Nephrotoxicity occurred in 33.8 % of patients with median onset of 3 days. IV hydration occurred in 88.5 and 68% of patients pre and post, respectively. Patients had at least one concomitant nephrotoxin (87 %) with an average of 2. Comparing those patients with nephrotoxicity and those without, age and L-AMB duration, were associated with nephrotoxicity. Table 1- Baseline CharacteristicsTable 2- Nephrotoxicity Risk Factors Conclusion L-AMB nephrotoxicity occurred at a relatively high rate in this patient population despite high utilization of toxicity mitigating strategies such as IV hydration. Nephrotoxicity was associated with longer durations of therapy. Further investigation is necessary to determine alternative strategies for nephrotoxicity prevention. Disclosures All Authors: No reported disclosures.

First Description of a Frameshift PAX5 Germline Variant in Two Siblings with B-Cell Precursor Acute Lymphoblastic Leukemia

Introduction: Recent studies have highlighted that about 5% of children with Acute Lymphoblastic Leukemia (ALL) carry a germline mutation that predispose to leukemogenesis. PAX5 somatic mutations are frequently identified on sporadic B-ALL, but recently pathogenic PAX5 germline variants have been described in families with recurrence of B-ALL (Shah et al. 2013; Auer et al. 2014; Yazdanparast et al. 2015, Duployez et al. 2021). We describe the case of two siblings both affected by B-ALL with evidence of a new familial PAX5 variant. Case A was a male, 13 years old, diagnosed with B-II ALL. He was enrolled into the AIEOP-BFM ALL 2009 treatment protocol and according to minimal residual disease (MRD) levels he was stratified as medium risk. Eight years later, his sister (14yrs, named as case B) was diagnosed with B-II ALL, and stratified in the medium risk group of AIEOP-BFM ALL 2017 protocol. The two patients were otherwise healthy and borne from healthy unrelated parents; no history of hematological malignancies was reported across the pedigree. Methods: We performed a custom Next Generation Sequencing ALL predisposition panel on DNA extracted from bone marrow samples of both disease onset and remission phase (defined as negativity by PCR-MRD, 10-4 sensitivity). The libraries were performed following Nextera Flex for Enrichment and sequenced on Illumina Nextseq550 platform; the analyses were carried out by Congenica software. The variants of interest were validated and investigated in the family pedigree through PCR and Sanger sequencing. Digital-MLPA testing 55 ALL hot spot genes (including all PAX5 exons) was performed. Results: Through the NGS analysis, we showed that both patients shared a novel germline heterozygous PAX5 variant (c.548delG, p.Gly183AlafsTer84); moreover, the disease samples of both patients carried an additional somatic PAX5 variant (c.239C>G, p.Pro80Arg; variant fraction: 29% in Case A and 38% in Case B). The Digital-MLPA using the ALL panel, excluded the presence of shared copy number alterations (CNV) and, specifically, did not identified CNV alterations involving the PAX5 locus. The familiar segregation showed a paternal origin of the germline PAX5 variant (p.Gly183AlafsTer84); the mother was found to be wild-type. The PAX5 variant was also found in the DNA sample of the patients' grandmother of the paternal branch; a healthy brother of probands (24 years old) was not tested. To investigate a possible impairment of PAX5 function in the development of the B-cell lineage, we evaluated in both parents the B-cell repertoire on peripheral blood fresh mononuclear cells by FACS analysis. Interestingly, the father has a significant reduction on mature IgD+/CD27+ B-cells with a concomitant accumulation of IgD+/CD27- naïve B-cells. Conclusions: We are reporting a novel germline PAX5 p.Gly183AlafsTer84 in a family with recurrence of B-ALL. In contrast to the previous PAX5 described cases that carry an inherited missense variant resulting in a modest attenuation of PAX5 activity, our patients present a germline frameshift variant that brings to premature stop of the protein, suggesting a more destructive impact on PAX5 activity. As in the other reported cases, our patients presented an additional somatic event on PAX5 that further compromise PAX5 function, leading to the establishment of the leukemic clone. Interestingly and different from the literature, the two siblings share the same PAX5 p.Pro80Arg somatic variant, that has been characterized by Gu as a pathogenic variant impairing B lymphoid development and promoting leukemogenesis (Gu et al. 2019). The detailed molecular characterization, including Whole Transcriptome NGS analysis, is ongoing to investigate whether a PAX5-specific signature can be identified. Moreover, a single-cell NGS approach on remission samples of the two siblings could help to identify specific important pathways and altered gene suppression profiles, preceding full leukemia. Consent-dependent characterization of additional family members are ongoing to assess the penetrance of leukemia associated to this new variant and possible additional features. The identification and characterization of germline PAX5 variants is of high interest in the context of leukemia predisposition because of its clinical implications in terms of familial genetic counselling and because of its contribution in the understanding ALL pathogenesis.

Bone Mineral Densitometry Diagnostic Yield Remains High Beyond 10 Years Post Allogeneic Stem Cell Transplant

Introduction: Reduced bone mineral density is a complication following allogeneic hematopoietic stem cell transplant (HSCT) resulting from the complex interplay of pre-, peri- and post- HSCT factors. Whilst guidelines recommend baseline bone mineral density (BMD) testing within a year of HSCT, evidence on the optimal timing and interval of post HSCT BMD assessment limited, and literature suggests heterogeneity in the management of abnormal results. Published literature to date largely focuses on the incidence of osteopenia and osteoporosis, within 5 years post transplant. The extent of the problem in long term post HSCT survivors remains largely unknown. The population . Here we present long-term data on bone mineral deficiency in HSCT patients from Westmead Hospital, Sydney, Australia. Method: A retrospective analysis of patients with a history of hematological malignancy who attended the long term follow up (LTFU) HSCT clinic between January 2013 and April 2022 at Westmead Hospital in Sydney, Australia, was undertaken. Patients required at least one BMD report to be included in the analysis. Data was collected from patient medical records and descriptive analysis undertaken. Timing of first post HSCT BMD was categorised as <12 months, 13-24 months, 25-36 months, 37-48 months, 49-60 months, 61-120 months, or >120 months. Bone mineral deficiency was defined according to the World Health Organization (WHO) criteria, with osteopenia at a T-score of <-1.0 to -2.5, and osteoporosis at a T-score of <-2.5. Results: Of the 355 patients who attended the clinic, 86% (305 patients) had at least one BMD study between 6 months and 36 years post transplant, with a total of 414 studies performed. Osteoporosis or osteopenia was reported in 59% of all patients undergoing their first post HSCT BMD, irrespective of the time-point post HSCT at which the BMD was performed. The median T-score for patients diagnosed with osteopenia was -1.8 (range -2.5 to -1.1), and for those with osteoporosis was -3.0 (range -4.1 to -2.6). Patient age at time of diagnosis of bone mineral deficiency ranged from 19 to 76 years. Amongst the 57 patients who had their first BMD more than 10 years post HSCT, 55.9% had evidence of osteoporosis or osteopenia, similar to the rate detected in patients having first BMD within 12 months of transplant (61.3%, n=80). Conclusion: This the largest report of the ongoing diagnostic yield of BMD in long term follow up post HSCT. Osteoporosis or osteopenia was identified in almost 60% of patients at first BMD post transplant, even when the first bone density assessment occurred beyond 10 years post transplant. The stability in detection rates over time could indicate that a bone-loss-causing insult occurs at the time of HSCT and does not necessarily progress after transplant. However longitudinal studies are required for confirmation. Osteoporosis is found at first BMD assessment in up to 15% of patients underlining the importance of interventions to optimise post-transplant bone health. Our data is limited by selection bias towards patients who continued to attend the LTFU clinic, but the diagnosis of new cases beyond 10 years post transplant highlights the importance of ongoing monitoring of BMD in the post HSCT population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prevalence of neurotrophic keratopathy in patients with chronic ocular graft-versus-host disease

PurposeTo determine the prevalence, clinical characteristics, and risk factors associated with neurotrophic keratopathy (NK) in patients with chronic ocular graft-versus-host disease (oGVHD). DesignRetrospective cohort study. MethodsWe performed a chart review of patients diagnosed with chronic oGVHD between January 2015 and December 2018 at a single academic institution and recorded demographic data, systemic and ocular comorbidities, history of hematologic malignancy, transplant characteristics, oGVHD severity scores, and adnexal and ocular examination findings. We determined the prevalence of NK and clinical characteristics associated with NK in these patients. A multivariate logistic regression analysis was performed to determine the risk factors associated with NK in these patients. Main outcome measurePrevalence of NK in chronic oGVHD. ResultsWe identified 213 patients diagnosed with chronic oGVHD following hematopoietic stem cell or bone marrow transplantation from our electronic patient database, and the prevalence of NK was 14%. The mean age of oGVHD patients with NK was 62.6 ± 12.9 years; 48% were women, 19 had unilateral NK, and ten had bilateral NK. In the cohort, 56%, 20%, and 24% eyes of the patients had grades 1, 2, and 3 of NK, respectively. The mean time to diagnose NK after transplantation was 52.9 ± 45.4 months. oGVHD patients diagnosed with NK had a significantly higher NIH oGVHD severity score (p = 0.04) and a lower corneal sensation score (p = 0.0001) than those without NK. Our analyses showed a significantly higher CFS score (p = 0.01) and a trend toward lower Schirmer test scores (p = 0.16) and tear break-up times (p = 0.08) in oGVHD patients with NK. Additionally, we observed a significantly higher prevalence of persistent epithelial defect (p = 0.0001), corneal ulceration (p = 0.0001), and corneal perforation (p = 0.005) in oGVHD patients diagnosed with NK. A logistic regression analysis to determine factors associated with NK showed that a higher NIH oGVHD score (odds ratio [OR] = 2.03, p = 0.026) and history of cataract surgery (odds ratio [OR] = 5.03, p = 0.001) are significant risk factors for NK in oGVHD patients. ConclusionsThe prevalence of NK in chronic oGVHD patients was 14% during the study period. Our analysis shows that oGVHD patients with a higher NIH oGVHD severity score and previous history of cataract surgery are at a higher risk of developing NK and may develop severe sequelae such as persistent epithelial defect or corneal ulceration.

Abstract 741: Evaluation of etiologic heterogeneity for risk of diffuse large B-cell lymphoma (DLBCL) subtype defined by cell-of-origin

Abstract Background: DLBCL is the most common non-Hodgkin lymphoma subtype in western countries and is clinically heterogeneous. Gene expression profiling has identified two major biologically distinctive DLBCL subtypes defined by their cell-of-origin (COO): germinal center B-cell (GCB) - characterized by BCL2 rearrangement and C-REL amplification, and activated B-cell (ABC) - characterized by constitutive activation of the NF-kB pathway. We evaluated putative DLBCL risk factors for etiologic heterogeneity as defined by COO. Methods: We used a clinic-based study of newly diagnosed NHL cases and frequency matched controls, enrolled from 2002-2014, with a total of 687 DLBCL cases and 2253 controls for this analysis. Using formalin-fixed, paraffin-embedded tumor tissue, we determined COO by either digital expression profiling (NanoString; classified as GCB, ABC, undetermined) or clinically using the Hans algorithm (immunohistochemical markers; classified as GCB, non-GCB, undetermined). Integrating these two sources of COO data, there were 271 GCB, 170 non-GCB, and 246 undetermined/missing (mainly due to lack of tissue) cases. Risk factor data were collected from self-administered questionnaires and included family history of hematologic malignancy; history of atopy, allergy, asthma, eczema, or autoimmune disease; blood transfusion; vaccination history; regular low-dose aspirin use; body mass index (BMI) 2 years prior diagnosis/enrollment; smoking history; alcohol consumption (never/current/former); leisure-time physical activity; and recreational sun exposure. Polytomous logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals for COO subtypes, adjusted for age, sex and residence. Results: The median age of cases was 64 years with 55% male; the median age of controls was 64 years and 53% male. The association with BMI (30+ vs. 18.5-24.9 kg/m2) was stronger for non-GCB (OR=2.21; 1.40-3.49) than for GCB (OR=1.70; 1.21-2.40) DLBCL (P-heterogeneity 0.02), while a family history of hematologic malignancy was associated with non-GCB (OR=2.27; 1.47-3.50) but not GCB (OR=1.30; 0.86-1.96) DLBCL, although the P-heterogeneity was not significant (P=0.13). For GCB, there was an inverse association with former (vs. never) alcohol use for GCB (OR=0.57; 0.39-0.83) but not for non-GCB (OR=0.98; 0.61-1.57) DLBCL (P-heterogeneity 0.007), and an inverse association with regular use of low-dose aspirin for GCB (OR=0.64; 0.47-0.87) but not for non-GCB (OR=0.88; 0.61-1.25) DLBCL (P-heterogeneity 0.05). No other risk factors evaluated showed important heterogeneity by COO. Conclusions: These initial results suggest most DLBCL risk factors do not show etiologic heterogeneity by DLBCL COO, although associations with BMI and family history with non-GCB DLBCL and alcohol and low-dose aspirin use with GCB DLBCL warrant follow-up. Citation Format: Geffen Kleinstern, Dennis P. Robinson, Lisa M. Rimsza, Melissa C. Larson, Rebecca L. King, Grzegorz S. Nowakowski, Carrie A. Thompson, Stephen M. Ansell, Matthew J. Maurer, Andrew L. Feldman, Susan L. Slager, Anne J. Novak, Thomas M. Habermann, James R. Cerhan. Evaluation of etiologic heterogeneity for risk of diffuse large B-cell lymphoma (DLBCL) subtype defined by cell-of-origin [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 741.

Abstract 5256: Incidence of squamous cell carcinoma (SCC) in a large screening cohort of monoclonal B-cell lymphocytosis (MBL)

Abstract MBL is a common pre-malignant condition characterized by circulating clonal B-cells with an absolute B-cell count &amp;lt;5x109/L and no lymphadenopathy, organomegaly, or cytopenias. MBL is the precursor to CLL. The incidence of cutaneous SCC in CLL is significantly higher compared to controls. The incidence of SCC in MBLs has not yet been determined. Study participants from the Mayo Clinic Biobank who had no prior history of hematologic malignancy, were 40 years or older, and were Olmsted County residents completed a health questionnaire and provided blood samples between 7/2009 and 12/2020. Stored peripheral blood mononuclear cells were screened for MBL using flow cytometry. We defined three MBL immunophenotypes: CLL-like MBL (CD5+, CD20dim), atypical MBL (CD5+, CD20+), and non-CLL-like MBL (CD5-, CD20+). MBL individuals were also classified by cell count into low-count MBL (LC-MBL) and high-count MBL (HC-MBL), with HC-MBL having a percent clonal B-cell count ≥85%. Data on newly diagnosed SCC was abstracted from the medical records, and prior history of skin cancer before sample collection was ascertained from patient questionnaires. Individuals were followed from sample date to the earliest of SCC, death, loss to follow-up, progression, or 12/31/2020. Cumulative SCC incidence was adjusted for competing risk of death. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CIs) adjusted for age and sex. A total of 5,470 participants were screened for MBL and included 949 (17%) with LC-MBL, 63 (1%) with HC-MBL, and 4,458 (81%) controls (negative for MBL). Individuals with HC-MBL (median age 75 years) or LC-MBL (median age 73 years) were significantly older (P&amp;lt;0.001) than controls (median age 66 years). There were 41 (65%) males among HC-MBL, 447 (47%) among LC-MBL, and 1,551 (35%) among controls. Prior skin cancer history was highest among HC-MBLs (N=17, 27%) or LC-MBLs (N=236, 25%) compared to controls (N=767, 17%). After a median follow-up of 18 months (range 0-138), 154 of the 5,470 individuals were identified to have incident SCC following MBL screening. At least one SCC was observed in 3 individuals with HC-MBL, 33 individuals with LC-MBL, and 118 controls. The 5- and 10-year cumulative incidence of SCC in individuals with MBLs was 7% and 16%, respectively; control estimates were 4% and 8%, respectively. However, after adjusting for age and sex, we observed no evidence of an association between MBL and risk of incident SCC (HR=0.95, CI=0.65-1.40, P=0.80), nor when we stratified individuals by age or by sex (all P&amp;gt;0.05). In the largest MBL screening cohort to date, individuals with MBL do not have an increased risk of incident SCC compared to controls. In contrast to individuals with CLL, these individuals with screening MBL do not need increased dermatologic examination for skin cancer, which is important given the high prevalence of MBL (18% of the population above age 40). Citation Format: Ahmed Nadeem Ansari, Sara J. Achenbach, Sameer A. Parikh, Geffen Kleinstern, Aaron D. Norman, Kari G. Rabe, Connie E. Lesnick, Timothy G. Call, Janet E. Olson, James R. Cerhan, Neil E. Kay, Celine M. Vachon, Esteban Braggio, Curtis A. Hanson, Tait D. Shanafelt, Christian L. Baum, Susan L. Slager. Incidence of squamous cell carcinoma (SCC) in a large screening cohort of monoclonal B-cell lymphocytosis (MBL) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5256.

P53: Postoperative Leukocytosis Trends in Ventricular Assist Device Implantation and Coronary Artery Bypass Graft Surgery

Background and Objective: Leukocytosis is a marker of inflammation due to infectious or non-infectious etiologies and is seen after coronary artery bypass graft surgery (CABG) and left ventricular assist device (LVAD) placement. Differentiating reactive postoperative leukocytosis from post-operative infection can drive antimicrobial stewardship initiatives. In this study, we aimed to describe the expected temporal trend of white blood cell (WBC) counts after LVAD placement compared to CABG. Methods and Analysis: We conducted a retrospective chart review of adult patients who underwent durable LVAD implantation or on-pump CABG between 2017-2019 at a single university-affiliated tertiary care hospital in Washington, DC. We excluded patients who were undergoing LVAD exchange, percutaneous VAD placement, had kidney failure requiring renal replacement therapy or transplant, had thromboembolism <14 days before the procedure, clinical or microbiological evidence of systemic infection <7 days before the procedure, were on steroids ≥5 mg prednisone daily, had a history of hematologic malignancy or acquired immunodeficiency syndrome. We compared the WBC count trend postoperatively after LVAD placement vs. CABG until day 24 or discharge, whichever was earlier. Secondary outcomes included comparing number of patients with bacteremia or clinical evidence of infection requiring antimicrobial therapy among the two groups. Results: We reviewed the charts of 116 LVAD patients and 134 CABG patients with median age 61 years [Interquartile Range (IQR) 53.0, 67.0] and BMI 28.4 kg/m2 [IQR 25.5, 32.8]. In the LVAD group, there was a peak in median WBC count to 14.2 (x103/ μL) [IQR 11.3, 17.6] on Day 2 post-operatively and another peak on Day 10 post-operatively to 14.1 [IQR 10.6, 18.4]. In the CABG group, median WBC peak was observed at Day 2 post-operatively at 11.8 [9.1, 14.2] (Fig. 1). There were 10 (8.6%) LVAD patients with clinical or microbiological evidence of infection compared to 2 (1.5%) CABG patients (p = 0.01). After excluding patients with infections there was no change observed in the trend of the postoperative WBC counts. Conclusion: Post-operative leukocytosis is common in cardiopulmonary bypass and peak WBC are higher in LVAD patients than CABG patients. WBC counts peak in LVAD patients at day 2 and 10 postoperatively. This expected peak should be taken into consideration while evaluating patients for infections and antimicrobial therapy.