Kaplan-Meier Survival Estimates Research Articles

Acute Lymphoblastic Leukemia in Patients 60 Years and Older Treated with Pediatric-Inspired Protocols, 20 Years of Follow-up

Background Chemotherapy-based approaches remain an essential component of current adult acute lymphoblastic leukemia (ALL) treatment. Poor outcomes in older patients with ALL result from the disease's adverse biology and poor tolerance to chemotherapy. Pediatric-inspired protocols have been used over the past 20 years in our center for patients > 60-year-old, both Philadelphia negative (Ph-), and Philadelphia positive (Ph+). Historically, Ph+ patients have been believed to have inferior outcomes. Our goal was to estimate the outcomes of this subgroup of patients and to compare outcomes between Ph- and Ph+ patients. Methods All newly diagnosed patients with ALL aged > 60 years, and receiving induction chemotherapy with a modified pediatric-inspired regimen between January 2002 and January 2022 were included. The treatment regimen consisted of induction, central nervous system prophylaxis, seven 3-week cycles of intensification, and 24 3-week cycles of maintenance (PM DFCI-based protocols). Only Ph- patients received asparginase. All Ph+ patients received a Tyrosine Kinase Inhibitor (TKI) during all phases of treatment and continued indefinitely after maintenance. There were adjustments in the type of drugs and dosages over the years. Standard descriptive statistics were used. Ninety-five percent confidence intervals were provided for estimates of interest where possible. Fisher's exact test was used to assess the impact of categorical covariates. P < 0.05 were considered to indicate a significantly different result. Kaplan-Meier survival estimate was used to evaluate Leukemia free survival (LFS) and overall survival (OS). Results A total of 122 patients were included: Ph- B-ALL, 50% (N=61); Ph+ B-ALL, 38% (N=46); Mixed Phenotype Acute Leukemia (MPAL), 4% (N=5); and T-ALL, 8% (N=10). Out of the Ph+ patients, only one had an MPAL diagnosis, the rest of them had B-ALL diagnoses. Patient and disease characteristics by Ph status are presented in table 1. For the whole cohort, the complete remission rate after induction (CR) was 83% (N=101), and allogeneic stem cell transplantation (alloSCT) in CR1 was carried out for 10% (N=12). Ten patients (8.2%) died during induction and the cumulative incidence of relapse (CIR) at 1-year was 11.7 % (95% CI 6.7 - 18.2). CR, mortality at induction, alloSCT, and CIR rates were similar in the Ph- and Ph+ groups. With a median follow-up of 52 months (range 4-209 months) among survivors, the median OS was 54 months (95%CI: 28-82). The 1-year and 4-year OS rates were 76% (95%CI: 68-83%) and 51.2% (95%CI: 41.4-60.2%), respectively. Leukemia-free survival (LFS) at years 4 years was 41.9% (95%CI: 32.7-50.9). There were no statistical differences in median OS and LFS between Ph- and Ph+ patients. OS at 4 years for patients with Ph- ALL was 49.7% (95%CI: 37.1-61) vs 53.9% (95%CI:37.9-67.5) in Ph+ ALL patients (p=0.72) (Figure 1). At 4 years LFS was 40.8% (95%CI: 29 - 52) for Ph- patients and, 43.6% (95%CI: 28 - 57) for the Ph+ population (p=0.68). Conclusion Pediatric-inspired chemotherapy protocols with appropriate dose adjustments for age are associated with good outcomes in older ALL patients. Clinical and disease characteristics and outcomes were similar between Ph- and Ph+ ALL patients. We aim to further define the optimal therapy for this group of patients with this challenging disease. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Preclinical Validation of EZH2 and HDAC I Dual Inhibition As a Potent Therapy for Refractory Myeloid Leukemia Associated with Down Syndrome

Children with Down Syndrome who are less than 5 years old have approximately 400-fold increased risk of developing myeloid leukemia. Even though children with myeloid leukemia associated with Down syndrome (DS-ML) are more sensitive to chemotherapy than their non-DS-ML counterpart, relapse and treatment-related toxicity needs to be eliminated to achieve better outcome for DS-ML children. Epigenetic alterations including DNA methylation and histone modifications play a key role in the pathogenesis of DS-ML. Enhancer of zeste homolog 2 (EZH2) is one of the epigenetic regulators that harbors high frequency of mutations in DS-ML. EZH2 is a catalytic subunit of PRC2 complex which suppresses gene expression by di- and tri-methylation of lysine27 on histone 3 (H3K27me2/3). EZH2 recruits class I histone deacetylases (HDAC, which remove acetyl groups from histones), on target genes for further suppression of gene expression. Using patient-derived xenograft models of DS-ML, we showed previously that combination of DNA hypomethylating agent azacitidine with HDAC inhibitor panobinostat or BCL2 inhibitor venetoclax showed significant improvement in median survival. Here we aimed to show synergistic effect of EZH2 inhibitor, GSK126, and class I HDAC inhibitor, romidepsin. The viability of CMK, a DS-ML cell line, and NTPL-60 and NTPL-386, in house generated DS-ML PDX lines, was determined by exclusion of propidium iodide-stained cells by flow cytometry. IC50 values for GSK126 and romidepsin were calculated using GraphPad Prism (dose-response curve). The IC50 of GSK126 was 40.5, 18.0, and 17.2 mM, while that of romidepsin was 10.2, 9.2, and 3.0 nM respectively. To determine synergy, the viability of cells exposed to a variety of concentrations of GSK126 and romidepsin alone or in combination was measured. Synergy index was calculated using relative risk ratio (RRR) formula as described previously (Quagliano et al, 56:36, Leuk Res, 2017). All the 3 DS-ML lines showed RRR value of less than 1 indicating synergistic inhibition of cell death by GSK126 and romidepsin treatment in ex vivo culture (Figure 1A). NTPL-386, a refractory DS-ML PDX line, which showed minimal response to chemotherapy (11-day improvement in median survival, Barwe et al., 134:2683, Blood, 2019), was chosen to determine the in vivo efficacy of GSK126 and romidepsin combination. NTPL-386 engrafted mice (n=5 each) were treated with GSK126 (100 mg/Kg) and/or romidepsin (2 mg/Kg) twice weekly for three weeks. Thus, one treatment cycle consisted of six doses. A separate cohort of mice were treated with four cycles of the combination, with two weeks rest between cycles. Disease progression was monitored by percentage of human cells in peripheral blood by flow cytometry. Kaplan-Meier survival estimates were plotted based on the time when mice were euthanized because they met pre-determined experimental endpoints. Compared to untreated mice, GSK126 or romidepsin treatment showed an increase in median survival by 8 days and 11 days respectively (Figure 1B, P <0.005). The combination of these drugs showed a remarkable improvement in survival (41 days). The difference in the median survival of the mice treated with the combination was statistically significant when compared to GSK126 or romidepsin (P <0.005). Further treatment for three additional cycles showed sustained remission upto 150 days post cell injection, when the study was terminated. Prolonged treatment showed a statistically significant improvement in survival compared to one treatment cycle (P <0.05). Further studies to characterize the mechanism of synergy are in progress. In summary, our data show a synergistic effect of EZH2 and HDAC class I inhibition on DS-AML growth and pave the path for clinical evaluation of this combination. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Selinexor Prolongs Survival in Patient-Derived Xenograft Models of Down Syndrome Myeloid Leukemia

Background: Selinexor, an inhibitor of the nuclear exportin protein XPO1, has been shown to promote cell cycle arrest and induce apoptosis in acute myeloid leukemia (AML) cells. By inhibiting protein export from the nucleus to the cytoplasm, Selinexor causes nuclear accumulation of proteins including tumor suppressors and translation initiation factor eIF4E, resulting in reduced translation of anti-apoptotic proteins BCL2 and MCL1. Venetoclax, a BCL2 inhibitor, has been considered to synergize with Selinexor in preclinical studies of multiple myeloma (Nguyen et a., Blood, 138:2270, 2021), lymphoma and AML (Fischer et al., Blood Adv, 4:586, 2020). A clinical trial evaluating the combination of Selinexor and venetoclax in relapsed/refractory pediatric AML is currently underway (NCT04898894). However, children with Down syndrome, who have a 500-fold increased risk of developing acute leukemia are excluded from this trial. Methods: The viability of mouse passaged Down syndrome myeloid leukemia (DS-ML) samples following exposure to Selinexor and/or venetoclax was evaluated ex vivo by flow cytometry using annexin V and propidium iodide staining. BLISS synergy scores were calculated using SynergyFinder. For the PDX models, 2-3 million cells were injected intravenously in NSG-SGM3 mice. The percentage of human cells in mouse peripheral blood was determined at periodic intervals by flow cytometry. Mice were randomly recruited to treatment groups (n=5 each) when the percentage of human CD45+ cells were first detected in blood. Selinexor (10 mg/Kg) and venetoclax (100 mg/Kg) were administered by oral gavage for 2 weeks and 4 weeks respectively. Mice were carefully monitored and euthanized at the first instance of pre-determined experimental endpoints. Kaplan-Meier survival estimates were generated using GraphPad Prism. Results: We have generated and extensively characterized patient-derived xenograft models of DS-ML, and used for preclinical evaluation of epigenetic drug combination (azacitidine and panobinostat) (Barwe et al., Blood, 134:2683, 2019), and a combination of azacitidine and venetoclax (Barwe et al., Blood, 138:3452, 2021). Ex vivo studies showed a dose-dependent decrease in the viability of mouse passaged DS-ML cells treated with Selinexor or venetoclax. The estimated EC50 concentrations for Selinexor were 0.31 uM (NTPL-60), 0.53 uM (NTPL-386), and 1.01 uM (15384-029). Venetoclax reduced cell viability at EC50 concentrations ranging from 0.37 uM to 1.54 uM. A combination of these drugs was either additive (NTPL-60), mildly synergistic (NTPL-386) or antagonistic (15384-029) (Figure 1A). We tested the efficacy of Selinexor and venetoclax alone or in combination in vivo in three distinct DS-ML PDX models. Selinexor treatment significantly increased median survival in all three models, while venetoclax was effective in two of three models (Figure 1B, *P<0.05, **P<0.01). However, unlike prior reports in multiple myeloma and AML, addition of venetoclax to the treatment regimen did not provide any survival advantage compared to Selinexor alone. This effect was also observed in the percentage of human CD45+ in blood over time, where human CD45+ blood counts were significantly higher in the combination than Selinexor treatment alone, indicating that Selinexor monotherapy was much more efficient in reducing leukemia burden. Conclusion: We evaluated a combination of Selinexor and venetoclax in DS-ML PDX models ex vivo and in vivo. The combination did not show significant synergy in any of the models ex vivo. Selinexor showed significant improvement in median survival in each of the models and performed better than venetoclax alone. Selinexor venetoclax combination was not beneficial than Selinexor alone in DS-ML PDX models. Studies are in progress to identify the determinants of combinatorial response to Selinexor and venetoclax in DS-ML. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The CAR-Hematotox Score Identifies Patients at High Risk for Hematological Toxicity, Infections and Poor Clinical Outcomes Following Brexucabtagene Autoleucel in Relapsed/Refractory Mantle Cell Lymphoma

Background: Hematological toxicity and infectious complications drive the toxicity burden of CD19 CAR-T. We recently developed the CAR-HEMATOTOX (HT) score - a validated risk-stratification system of hematotoxicity, infections, and clinical outcomes in LBCL patients (Rejeski et al. Blood 2021/JITC 2022). The score integrates parameters associated with pre-CAR-T hematopoietic reserve (e.g. ANC, hemoglobin, platelet count) and inflammation (e.g. CRP, ferritin). Whether the HT score is of prognostic utility in relapsed/refractory mantle cell lymphoma (R/R MCL) remains unstudied. Methods: In this multicenter retrospective study, we characterized the influence of the HT score on toxicity and survival in 78 patients receiving standard-of-care brexucabtagene autoleucel (brexu-cel) across seven international sites. Patterns of hematopoietic recovery were defined as quick recovery vs. intermittent recovery vs. aplastic as previously described (Rejeski et al. Blood 2021). The duration of severe neutropenia was assessed as the total cumulative days with an ANC<500/µl between days 0-60. Early infection events (day 0-90) were defined as bacterial, viral or fungal based on microbiologic data or as a clinical syndrome of infection (e.g. pneumonia, cellulitis, cystitis) based on retrospective chart review. Severe (Grade ≥3) infections were defined as requiring intravenous anti-infectives and/or hospitalization. Kaplan-Meier estimates of progression-free (PFS) and overall survival (OS) were compared using the log-rank test. Results: The study cohort comprised a representative cohort of R/R MCL patients treated in a real-world setting: median age was 68 (range 49-89), median ECOG PS was 1, median LDH was 217 U/L (interquartile range 171-289 U/L), and patients had received a median of 3 prior treatment lines (IQR 2-4). Of note, 28% of patients had received a prior autologous stem cell transplant (ASCT) and >90% were BTKi exposed. The rate of severe (grade ≥3) CRS and ICANS was 2.6% and 27%, respectively. Tocilizumab was applied in 82% of patients, while glucocorticoids were used in 64% of all cases. Across all patients, the median duration of severe neutropenia was 8 days (IQR 5-15). The distribution of neutrophil recovery phenotypes was: 30% quick, 46% intermittent, and 24% aplastic. The cumulative 90-day incidence of any-grade and severe infections was 37% and 17%, respectively. The median CAR-HEMATOTOX score was 1 (IQR 1-3), including 42 HTlow (Score 0-1) and 36 HThigh (Score ≥2) patients. When comparing risk groups, we noted higher serum LDH levels in HThigh patients(median 261 vs. 209 U/L, p=0.07).In terms of toxicity, the incidence of severe CRS and ICANS was comparable between both groups. However, the duration of neutropenia was significantly increased in HThigh patients compared to their HTlow counterparts (15 vs. 7 days, p<0.001). Moreover, the proportion of patients displaying an aplastic phenotype of neutrophil recovery, defined by continuous severe neutropenia ≥14 days, was markedly increased in the HThigh group (53 vs. 0%, p<0.0001, Fig. 1A). This translated into a higher rate of severe infectious complications in the HThighgroup (28% vs. 7%, p=0.03), including 3 life-threatening (all bacterial), and 2 fatal infections (1 bacterial, 1 fungal).Notably, a high HT score was associated with markedly inferior PFS (median 7.5 months vs. not-reached, p=0.0006, Fig. 1B) and OS (median 15.3 months vs. not-reached, p=0.0004). Comparing the HThigh vs. HTlow groups, we observed 1-year PFS of 73% vs. 38% and 1-year OS of 88% vs. 51%. Conclusions: Taken together, these findings underline the importance of pre-CAR-T bone marrow reserve and systemic inflammation in driving immunotoxicity after CD19 CAR-T therapy. Importantly, they validate the utility of the HT score to risk-stratify patients for hematotoxicity, severe infections and poor survival outcomes prior to brexu-cel infusion. The score can be used to aid clinical decision-making concerning anti-infective prophylaxis and early or prophylactic G-CSF use. Considering that ASCT represents a mainstay of frontline MCL therapy, the HT score may also guide the use of stem cell rescue (obtained at time of remission) for the patients developing severe CAR-T-related aplasia. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The CAR-Hematotox Score As a Prognostic Model of Toxicity and Response in Patients Receiving BCMA-Directed CAR-T for Relapsed/Refractory Multiple Myeloma

Introduction: Hematological toxicity and infectious complications are both common and substantially contribute to non-relapse mortality of CAR T-cell therapy. The recently developed CAR-HEMATOTOX (HT) score represents a validated risk-stratification system of hematotoxicity, infections, and clinical outcomes for R/R LBCL (Rejeski et al. Blood 2021/JITC 2022). The score integrates parameters of pre-CAR-T hematopoietic reserve (e.g. ANC, hemoglobin, platelet count) and inflammation (e.g. CRP, ferritin). Whether the HT score is of diagnostic utility in relapsed/refractory multiple myeloma (R/R MM) remains unclear. Methods: In this multicenter retrospective study, we characterized the influence of the HT score on toxicity and clinical outcomes in 102 patients receiving BCMA CAR-T with ciltacabtagene autoleucel (n=7) or idecabtagene vicleucel (n=95) in a standard-of-care setting across five international CAR-T centers. CRS and ICANS were graded according to ASTCT criteria. Neutrophil recovery phenotypes were defined as quick recovery vs. intermittent recovery vs. aplastic as previously described (Rejeski et al. Blood 2021). Early infection events (day 0-90) were defined as bacterial, viral or fungal based on microbiologic data or as a clinical syndrome of infection (e.g. pneumonia, cellulitis, cystitis) based on retrospective chart review. Severe (grade ≥3) infections were defined as requiring intravenous anti-infective agents and/or hospitalization. Kaplan-Meier estimates of progression-free (PFS) and overall survival (OS) were compared using the log-rank test. Results: The baseline patient features were representative of R/R MM patients receiving BCMA CAR-T in a real-world setting: median age was 65 (range 39-81), median ECOG was 1 (interquartile range 0-1), median LDH was 200 U/L (IQR 173-240 U/L), and patients had received a median of 6 prior treatment lines (IQR 5-7). A total of 28% had high-risk genetic abnormalities (del17p, t(4;14), t(14;16)). Notably, the large majority of patients had received a prior autologous stem cell transplant (88.2%). On the last bone marrow (BM) assessment prior to CAR-T, greater than 5% clonal plasma cells were detected in 52% of patients. In terms of toxicity, the rate of severe (grade ≥3) CRS and ICANS was 4% and 8%, respectively. Tocilizumab was applied in 79/102 patients (77%); glucocorticoids were used in 43/102 patients (42%). The median CAR-HEMATOTOX score was 1 (IQR 1-3), including 46 HThigh and 56 HTlow patients. When comparing the risk groups, we found that HThigh patients more frequently exhibited BM plasma cell infiltration (59% vs. 34%, p=0.05). Serum LDH levels did not significantly differ by HT score (median 215 vs. 193 U/L, n.s.). The duration of severe neutropenia (ANC<500/µL) was significantly increased in HThigh patients compared to their HTlow counterparts (9 vs. 3 days, p<0.0001). The proportion of patients displaying aplastic neutrophil recovery was markedly increased in the HThigh group (Fig. 1A: 30 vs. 3%, p<0.001). The rate of severe CRS (9% vs. 0%, p=0.038) and severe ICANS (17% vs. 0%, p=0.001) was higher in HThigh patients, likely resulting in the increased use of glucocorticoids (57% vs. 30%, p=0.009). When studying infectious complications, we found that infections of any-grade were more common in the HThigh cohort (61% vs. 25%, p=0.0003). This was particularly evident for severe infections (39% vs. 3.6%, p<0.0001), including 2 fatal bacterial infections in HThigh patients. Overall, the increased toxicity burden observed in the HThigh cohort translated into a longer median duration of hospitalization (12 vs. 8 days, p<0.0001). Finally, a high HT score was associated with inferior PFS (Fig. 1B: 1-year PFS 80% vs. 27%, p<0.0001) and OS (1-yr OS 93% vs. 62%, p<0.0001). Conclusions: These findings emphasize the importance of baseline inflammatory state and hematopoietic function for the subsequent development of toxicity and early progression in patients receiving BCMA-directed CAR-T. The easy-to-use CAR-HEMATOTOX score enables early risk-stratification prior to lymphodepletion. Considering their overall low risk of severe toxicity, HTlow patients represent an attractive population to explore outpatient CAR-T application. On the other hand, patients with a high HT score likely benefit from intensified monitoring, anti-infective prophylaxis, early G-CSF, and awareness for a potential stem cell boost. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Outcomes of Subsequent Anti-Lymphoma Therapies in Patients (Pts) with Large B-Cell Lymphoma (LBCL) Treated with Axicabtagene Ciloleucel (Axi-Cel) or Standard of Care (SOC) in the Second-Line (2L) ZUMA-7 Study

Background: In the pivotal Phase 3 ZUMA-7 (NCT03391466) trial, axi-cel significantly improved outcomes vs 2L SOC (event-free survival [EFS] hazard ratio, 0.398, P<.0001; Locke, et al. NEJM. 2022). Thus, chimeric antigen receptor (CAR) T-cell therapy has been proposed as the new SOC for 2L treatment for eligible pts (Westin, Sehn. Blood. 2022) and axi-cel was recently approved in the United States for the treatment of adult pts with relapsed/refractory (R/R) LBCL ≤12 mo of first-line (1L) chemotherapy. However, pts may require additional therapy and the question of optimal management after 2L therapy remains. Here, we describe outcomes for pts who received subsequent treatment in ZUMA-7. Methods: Eligible pts were randomized 1:1 to axi-cel or SOC (2-3 cycles of chemotherapy followed by high-dose therapy with autologous stem cell transplant [HDT-ASCT] for those with partial response [PR] or complete response [CR]). Subsequent therapies and disease assessments after new lymphoma therapy, not defined in the study protocol, were per investigator discretion. Treatment with subsequent third-line (3L) therapy was classified as chemotherapy and cellular immunotherapy (for axi-cel arm, axi-cel retreatment on protocol for pts who initially responded to axi-cel). Kaplan-Meier estimates for progression-free survival (PFS) and overall survival (OS) were calculated from 3L treatment initiation. Pts who did not meet the criteria for a PFS event were censored at fourth-line treatment initiation, if any, or last known alive date. Pts who received subsequent SCT while in a response from 3L axi-cel retreatment were censored at the time of SCT. Best response to subsequent therapy was evaluated. Results: In the axi-cel arm, 84 of 180 randomized pts required 3L subsequent therapy; 60 and 8 pts received 3L chemotherapy and 3L cellular immunotherapy, respectively. For pts who received 3L chemotherapy, overall median PFS was 1.7 mo (95% CI, 1.4-2.0) and median OS was 8.1 mo (95% CI, 5.8-11.5) since 3L treatment initiation, with an objective response rate (ORR) of 25% (CR rate: 13%). For 34 pts who received 3L chemotherapy after initial response to 2L axi-cel, overall median PFS was 1.7 mo (95% CI, 1.4-2.4) and median OS was 8.1 mo (95% CI, 6.8-11.9), with an ORR of 32% (CR rate: 18%). Of 60 pts who received 3L chemotherapy, 10 pts received SCT in 3L (9 ASCT, 1 alloSCT) after chemotherapy, but it is unknown how many pts who received 3L therapy were intended for SCT. Median PFS was 11.5 mo (95% CI, 2.4-not evaluable [NE]) vs 1.6 mo (95% CI, 1.2-1.8), and median OS was 17.5 mo (95% CI, 2.4-NE) vs 7.2 mo (95% CI, 4.8-9.1) for those who did vs those who did not reach SCT, respectively. Of 8 pts in the axi-cel arm who received 3L cellular immunotherapy, median PFS was 3.5 mo (95% CI, 1.1-NE); 6 received subsequent SCT (1 ASCT, 5 alloSCT) in any line, 3 (alloSCT) of which immediately followed 3L axi-cel. Of 6 pts who received SCT, 5 remained in CR; 1 pt had a PR after axi-cel retreatment and proceeded to alloSCT with best response of CR, but relapsed 7.3 mo after SCT. All 6 pts who received SCT were alive at the data cutoff date (median follow-up since 3L treatment initiation: 24.4 mo). Of 2 pts who received 3L axi-cel but did not receive SCT, 1 had disease progression after 3L axi-cel and died 8.7 mo after retreatment, and 1 had a CR after 3L axi-cel and was disease-free and alive by data cutoff (8.4 mo after retreatment). In the SOC arm, 127 of 179 randomized pts required 3L subsequent therapy; of these, 68 pts received 3L cellular immunotherapy. For pts who received 3L cellular immunotherapy, median PFS was 6.3 mo (95% CI, 3.4-16.3) and median OS was 16.3 mo (95% CI, 8.7-NE), compared with median PFS and median OS of 1.9 mo (95% CI, 1.1-2.7) and 9.5 mo (95% CI, 6.6-15.4), respectively, for those who did not receive cellular immunotherapy. Of 68 pts who received 3L cellular immunotherapy and were evaluated for response, ORR was 57% (CR rate: 34%). Conclusions: In ZUMA-7, subsequent 3L axi-cel retreatment was feasible and outcomes for these pts appeared improved, as pts were able to achieve meaningful responses. While definitive conclusions cannot be made due to the small number of pts, 3L CAR T-cell therapy after initial response in 2L may be a viable option. Outcomes for pts who received subsequent 3L cellular therapy were numerically inferior to those who received 2L cellular therapy. These findings may help inform subsequent treatment choices after failure of 2L therapy for R/R LBCL.

PATH-22. CLINICAL FEATURES AND MOLECULAR CHARACTERIZATION OF LEPTOMENINGEAL DISEASE IN PATIENTS WITH HIGH GRADE GLIOMA

Abstract INTRODUCTION Leptomeningeal disease (LMD) is a challenging complication of high grade glioma (HGG) and critical questions remain unanswered regarding clinicopathologic risk factors, molecular associations, and optimal treatment. METHODS Patients with molecularly-profiled HGG (Caris Life Sciences; Phoenix, AZ) with LMD at two institutions were included. Medical records were reviewed for clinicopathological characteristics, treatment, and outcome. Kaplan-Meier estimates of patient survival were performed on censored data using Cox’s proportional hazard model. RESULTS 43 patients (male: 33, female: 10; median age: 56 years) were identified, comprising 41 grade 4 (glioblastoma: 38; gliosarcoma: 2; H3K27M diffuse midline glioma: 1) and 2 grade 3 tumors (astrocytoma: 1; pleomorphic xanthoastrocytoma: 1). LMD diagnosed at HGG diagnosis (n=18) versus recurrence (n=22) was associated with longer post-LMD survival [pLMD-OS: 15.3m vs. 4.8m, HR: 0.07, 95% CI: 0.02-0.29, p=0.0004] but similar overall survival [mOS: 15.3m vs. 12.3m; HR: 0.82; 95% CI: 0.36-1.85; p=0.63]. Pathology-diagnosed LMD (n=15) versus MRI-diagnosed LMD (n=26) was associated with longer post-LMD survival [pLMD-OS: 15.4m vs. 5.2m, HR: 14.9, 95% CI: 0.01-0.30, p=0.0004] but similar overall survival [mOS: 17.1m vs. 12.3m; HR: 0.66; 95% CI: 0.3-1.58; p=0.38]. Post-LMD survival was significantly prolonged for supratentorial (n=28) versus infratentorial/spinal (n=4) locations regardless of the diagnostic modality [pLMD-OS: 2.6m vs. 11.3m, HR: 14.4, 95% CI: 2.73-75.7, p=0.0017], and did not significantly differ between symptomatic (n=20) and asymptomatic (n=23) patients [pLMD-OS: 4.8m vs. 11.2m, HR: 1.75, 95% CI: 0.82-3.77, p=0.15). pTERT mutation (81%), EGFR amplification (43%), and MGMT methylation (33%) were prevalent but IDH1 mutation was rare (2.8%). Comparison with a separate glioblastoma cohort (n=1400) suggested more frequent amplification of CHIC2, MDM4, and KDR, higher mutation rates of RUNX1, APC, and RAD51C, colder tumor microenvironment (TME), and lower expression of immune checkpoint-related genes. CONCLUSIONS Clinicopathological characteristics affect post-LMD survival, and cohort comparison suggests molecular and TME differences in LMD-HGG tumors.

The impact of prior cardiac surgery on patients undergoing surgical repair for acute type A aortic dissection.

To determine the impact of reoperative versus first-time sternotomy for emergent open repair of acute Type A aortic dissection (ATAAD). This was an observational study of consecutive aortic surgeries from 2007 to 2021. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of reoperative versus first-time sternotomy upon survival after ATAAD repair. A total of 601 patients with ATAAD were identified, of which 72 (12%) underwent reoperative sternotomy. The reoperative group had a higher prevalence of baseline comorbidities, including hypertension, diabetes, peripheral vascular disease, atrial fibrillation, and coronary artery disease. Central cannulation of the aorta was achieved at a similar rate across each group (81.9% vs. 81.5%, p = .923), and cardiopulmonary bypass (CPB) time was similar across each group (204 ± 84.8 vs. 203 ± 72.4 min, p = .923). Postoperative outcomes were similar across both groups, including in-hospital mortality, stroke, pulmonary complications, renal failure, and reexploration for excessive bleeding. Five-year survival was 74.5% (70.5, 78.3) for the first-time group and was 71.6% (60.0, 81.9) for the reoperative group. After multivariable Cox regression, reoperative sternotomy was not significantly associated with an increased hazard of death compared to first-time sternotomy (hazards ratio: 0.90, 95% confidence interval: 0.56, 1.43, p = .642). These findings suggest that re-sternotomy can be safely performed with similar outcomes as first-time sternotomy. Central initiation of CPB after sternal reentry limits CPB time and may therefore represent a protective strategy that enhances outcomes for patients presenting with ATAAD and prior cardiac surgery.

Abstract 14132: Comparison of Right Anterior Mini-Thoracotomy versus Partial Upper Sternotomy in Aortic Valve Replacement

Introduction: Propensity score analysis of midterm outcomes after isolated aortic valve replacement through right anterior mini-thoracotomy and partial upper sternotomy could provide information about the most beneficial minimally invasive technique for the patient based on the preoperative risk factors. Hypothesis: Can the right anterior mini-thoracotomy be used as first line surgical access for aortic valve replacement? Methods: Between March 2015 and February 2021, 694 minimally invasive isolated aortic valve surgery were performed at our institution. Among these, 441 right anterior mini-thoracotomies and 253 partial upper sternotomies were performed. A propensity score analysis was performed in 202 matched pairs. Results: Cardiopulmonary bypass time and cross clamp time were significantly shorter in right anterior mini-thoracotomy group than in the partial upper sternotomy group ( p =0.001 and p &lt;0.001, respectively). Time to first mobilization and hospital stay were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group ( p =0.005, p =0.001, respectively). A significantly lower incidence of revision surgery was noted in the right anterior mini-thoracotomy group than in the partial upper sternotomy group ( p =0.046). No significant differences in 30-day mortality ( p =1.000) and 1-year mortality ( p =0.543) were noted. Kaplan-Meier survival estimates were 96.3 % in right anterior mini-thoracotomy group and 92.7 % in the partial upper sternotomy group after 4 years (log rank 0.169), respectively. Conclusions: Despite the technical challenges, right anterior mini-thoracotomy can be chosen as first-line strategy for the isolated aortic valve replacement. For patients unsuitable for this technique, the partial upper sternotomy remains a safe method that can be performed by a wide range of surgeons.

Abstract 14072: Heart Retransplantation Under the 2018 Adult Heart Allocation Policy

Introduction: The new adult heart allocation policy was implemented on October 18, 2018. The purpose of the present study was to characterize the impact of this policy change on waitlist and post-transplant outcomes of heart retransplantation in the United States. Methods: All adults listed for heart retransplantation from May 2015 to March 2022 were identified using the United Network for Organ Sharing database. Patients were stratified into equal time eras (pre- and post-policy) based on the heart allocation change on October 18, 2018. Competing risks regressions were used to determine differences in waitlist outcomes, including waitlist death or deterioration and retransplantation rates following listing. Kaplan-Meier survival estimates were used to assess differences in 1-year post-transplant survival between eras. Results: Overall, 672 heart transplant candidates were included in analysis, with 49% listed during post-policy. Retransplantation candidates listed during post-policy were of similar age (45 vs 47 years, P=0.11) and female gender (33% vs 34%, P =0.70) compared to pre-policy candidates. Post-policy candidates had a shorter median waitlist duration (51 days vs 80 days, P&lt;0.01), along with a lower likelihood of death or deterioration on the waitlist (subdistribution hazard ratio, SHR 0.45, 95% CI 0.27-0.74) and higher likelihood of retransplantation within 30 days of listing (SHR 2.65, 95% CI 1.86-3.80) compared to pre-policy (Figure). Among those retransplanted, pre-policy recipients experienced similar rates of 30-day post-transplant mortality (6.9% vs 6.7%, P=1.00) and 1-year post-transplant survival (82% vs 87%, P=0.24). Conclusions: Heart retransplantation candidates have experienced improved waitlist outcomes following the 2018 adult heart allocation policy without significant changes to post-transplant survival. Continued monitoring for long-term outcomes is warranted in this patient population.

Abstract 12504: Outcomes of COVID-19 Positive Donor Heart Transplantation in the United States

Introduction: Small institutional case series have documented successful heart transplant outcomes using COVID-19 positive (COVID-19+) donor allografts. However, little is known regarding the impact of donor COVID-19 status on a national scale. In this study, we characterize outcomes of the first 84 COVID-19+ donor heart transplants in the United States. Methods: Retrospective analysis of the United Network for Organ Sharing database was performed for adult heart transplants from February 2021 to March 2022. Donor COVID-19+ status was defined as a positive nucleic acid amplification, antigen or other COVID-19 test within 7 days of transplant. Fisher’s exact test and Kaplan-Meier survival estimates were used to determine differences in outcomes, including graft failure, post-operative stroke and dialysis, length of stay and 30-day survival. Results: Overall, 3,289 heart transplants were included in analysis, with 84 utilizing COVID-19+ donor hearts. COVID-19+ allografts had similar cold ischemic times (3.7 vs 3.5 hours, P=0.22) compared to others. Recipients of COVID-19+ donor organs had similar lengths of stay (15 vs 17 days, P=0.19), rates of graft failure (2.4% vs 1.0%, P=0.22), post-operative stroke (0.0% vs 3.0%, P=0.18), post-operative dialysis (15.5% vs 13.4%, P=0.52) and 30-day post-transplant survival (96.1% vs 97.0%, P=0.63) compared to recipients of non-positive donors. Among the 4 deceased recipients of COVID-19+ allografts, none have died from pulmonary or infectious causes of death. Use of COVID-19+ donors for heart transplantation increased throughout the study period (r=0.79, Figure). Conclusions: Short-term outcomes of heart transplant recipients receiving COVID-19+ donor organs are reassuring, providing preliminary evidence that heart transplantation may be safely performed using appropriately selected COVID-19+ donor allografts. Continued monitoring for long-term outcomes and potential complications are warranted.

Early and Late Patient Outcomes in Urgent-Start Peritoneal Dialysis: A Prospective Study of Unplanned Initiation of Chronic Dialysis.

Peritoneal dialysis (PD) has become a well-established complementary alternative to hemodialysis (HD) as the first-line renal replacement modality. Unlike the temporary catheter for hemodialysis that can be used immediately after implementation, the PD catheter usage period remains controversial. The aim of this study was to compare the short- and long-term outcomes in patients under peritoneal dialysis according to the delay of starting the dialysis after catheter placement. This observational prospective study was conducted over an eight-year and four-month period (from April 2014 to August 2021), including all patients treated with peritoneal dialysis for 18 months (from April 2014 to October 2015). The patients were divided into two groups according to whether the catheter was used during the first 15 days (PD-E) or 15 days after (PD-L) catheter placement. The primary outcomes were early complications (mechanical and infectious) within 90 days. Secondary outcomes included technique survival. Among the 36 patients included in the study, 14 started PD early (38.8%), while 22 started it 15 days after catheter placement (61.2%). The mean age between the two groups was not significantly different (41 ± 17 years vs 35 ± 16 years, p: not significant). There were no significant differences in the Charlson comorbidity index or the degree of autonomy. The incidence of infections was not significantly different between the two groups (13.6% in PD-L vs 21.4% in PD-E, p: not significant). The total number of mechanical complications was not significantly higher in the PD-E group compared to the PD-L group (42.8% vs 27.3%, respectively, p: not significant). Kaplan-Meier estimates of technique survival were comparable between the groups (log Rank: 1.908, p: 0.67). Our study showed no increase in the risk of complications associated with early use of the PD catheter and no difference in technique survival. PD can be used as first-line renal replacement therapy in the unplanned initiation of chronic dialysis.

Immune-related adverse events in patients with pre-existing autoimmune rheumatologic disease on immune checkpoint inhibitor therapy

IntroductionImmune checkpoint inhibitors (ICIs) enhance the immune system’s ability to target and destroy cancer cells, but this non-specific immune overactivation can result in immune-related adverse events (irAEs). Patients with underlying autoimmune diseases were excluded from the original ICI clinical trials because of the theoretical risk of irAEs. This study aimed to evaluate the risk of irAEs in patients with pre-existing rheumatologic diseases on ICIs, impact of anti-rheumatic therapy on irAEs, and malignancy outcomes.MethodsWe performed a retrospective chart review of patients with a pre-existing rheumatologic diagnosis receiving ICIs at the University of North Carolina from 2014 to 2019. Risk differences (RD) and asymptotic 95% confidence intervals (95% CIs) using a continuity correction along with odds ratios (OR) and exact 95% CIs were produced between pre-specified risk factors and flares of the underlying rheumatologic disease and/or irAEs. Kaplan–Meier survival estimates for time to unfavorable cancer response between subsets of patients were compared using the log-rank test.ResultsWe identified 45 patients receiving an ICI with an underlying rheumatologic diagnosis, including 22 with rheumatoid arthritis (RA). Overall, 13 patients (29%) had a flare of their autoimmune disease, 20 patients (44%) had a new-onset irAE, and 27 (60%) had either a flare or new-onset irAE. Patients with RA had higher risk of flares compared to those with other rheumatologic disorders (45% vs 13%, RD 32%, 95% CI 2.0–56.8); all RA flares were ≤ grade 2 and treated in the outpatient setting. Concurrent treatment of the rheumatologic disease at the start of ICI therapy was not associated with a reduced risk of flare (OR 0.86, 95% CI 0.19–3.76) or new onset irAE (OR 3.21, 95% CI 0.83–13.6) compared to those not on anti-rheumatic medications. Anti-rheumatic therapy did not impact time to unfavorable malignancy outcome (p = 0.52).ConclusionThe majority of our study cohort experienced a flare or new onset irAE with ICI treatment. Treatment with anti-rheumatic therapy did not prevent disease flares or new onset irAEs, but did not negatively impact malignancy outcomes. Research is needed to determine safe anti-rheumatic therapy options to prevent flares and irAEs that do not interfere with malignancy outcomes.

Outcomes of bovine versus porcine surgical aortic valve replacement.

There are no guidelines regarding the use of bovine pericardial or porcine valves for aortic valve replacement, and prior studies have yielded conflicting results. The current study sought to compare short- and long-term outcomes in propensity-matched cohorts of patients undergoing isolated aortic valve replacement(AVR) with bovine versus porcine valves. This was a retrospective study utilizing an institutional database of all isolated bioprosthetic surgical aortic valve replacements performed at our center from 2010 to 2020. Patients were stratified according to type of bioprosthetic valve (bovine pericardial or porcine), and 1:1 propensity-score matching was applied. Kaplan-Meier survival estimation and multivariable Cox regression for mortality were performed. Cumulative incidence functions were generated for all-cause readmissions and aortic valve reinterventions. A total of 1502 patients were identified, 1090 (72.6%) of whom received a bovine prosthesis and 412 (27.4%) of whom received a porcine prosthesis. Propensity-score matching resulted in 412 risk-adjusted pairs. There were no significant differences in clinical or echocardiographic postoperative outcomes in the matched cohorts. Kaplan-Meier survival estimates were comparable, and, on multivariable Cox regression, valve type was not significantly associated with long-term mortality (hazard ratio: 1.02, 95% confidence interval: 0.74, 1.40, p = .924). Additionally, there were no significant differences in competing-risk cumulative incidence estimates for all-cause readmissions (p = .68) or aortic valve reinterventions (p = .25) in the matched cohorts. The use of either bovine or porcine bioprosthetic aortic valves yields comparable postoperative outcomes, long-term survival, freedom from reintervention, and freedom from readmission.

Clinical Outcomes of Uterine Body Cancers Treated in a Tertiary Cancer Center.

K. MuthulingeshkumarObjectives This article reports the clinical outcomes of uterine body cancers in South Indian population. The primary outcome of our study was overall survival (OS). The secondary outcomes were disease-free survival (DFS), patterns of recurrence, toxicities of radiation treatment, and the association of patient, disease, and treatment characteristics with survival and recurrence. Materials and Methods Records of the patients diagnosed as malignancy in uterus and treated with surgery alone or with adjuvant treatment from January 2013 to December 2017 were retrieved after Institute Ethics Committee approval. Demographic, surgical, histopathology, and adjuvant treatment details were retrieved. Patients of endometrial adenocarcinoma were stratified according to the European Society of Medical Oncology/European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology consensus for analysis and overall outcomes irrespective of histology were also analyzed. Statistical Analysis For the survival analysis, Kaplan-Meier survival estimator was used. Cox regression was used to test the significance of association of factors with outcomes in terms of hazard ratio (HR). Results A total of 178 patient records were retrieved. The median follow-up of all patients was 30 months (0.5-81 months). The median age of the population was 55 years. Most common histology was endometrioid type of adenocarcinoma (89%), sarcomas comprised only 4%. The mean OS of all patients was 68 months ( n = 178), median was not reached. Five-year OS was 79 %. Five-year OS rates observed in low, intermediate, high-intermediate, and high-risk were 91, 88, 75, and 81.5%, respectively. The mean DFS was 65 months, median not reached. The 5-year DFS was 76%. The 5-year DFS rates observed were 82, 95, 80, and 81.5% for low, intermediate, high-intermediate, and high-risk, respectively. Univariate analysis using Cox regression showed increase in hazard for death in case of node positivity, HR 3.96 ( p 0.033). The HR for disease recurrence was 0.35 ( p = 0.042) in patients who had received adjuvant radiation therapy. No other factors had any significant impact on death or disease recurrence. Conclusion The survival outcomes in terms of DFS and OS were comparable with other Indian and Western data reported in the published literature.

The expression of androgen receptor in triple-negative breast cancer and the effect of a traditional Chinese medicine formula on disease-free survival

Androgen receptor (AR) is becoming an important factor in the pathogenesis of breast cancer. Traditional Chinese medicine (TCM) is widely used in treating breast cancer patients. Triple-negative breast cancer (TNBC) is a subtype of breast cancer, which has worse prognosis than other subtypes. Herein, through this retrospective study, we summarize the therapeutic implications of AR and TCM in TNBC. The clinical and pathological data of TNBC patients who had undergone surgery at The First Affiliated Hospital of Zhejiang Chinese Medical University from 2017 to 2019 were collected and examined. The t-test, chi-square test, logistic regression model, and Kaplan-Meier survival estimates were used to analyze the data. We identified 823 early breast cancer patients from January 2017 to December 2019, of whom 92 (11.2%) were pathologically confirmed to have TNBC. We excluded 5 patients according to the inclusion and exclusion criteria. In relation to the remaining 87 patients, 33 (37.9%) were AR positive. In the TNBC patients, positive AR expression was correlated with an older age (P=0.006), a higher weight (P=0.006), and lower Ki-67 expression (P=0.031). After a median follow-up time of 37 months (range, 24-60 months), 13 cases of relapse and metastasis (14.9%) were observed. We found that relapse and metastasis were correlated with being unmarried [P=0.004; hazard ratio (HR) =0.105; 95% confidence interval (95% CI): 0.023-0.487], nonporous (P=0.046; HR =0.209; 95% CI: 0.045-0.971), and negative AR expression (P=0.042; HR =1.223; 95% CI: 0.049-1.012). The AR-positive TNBC patients had better disease-free survival (DFS) than the AR-negative TNBC patients 2-5 years after surgery (P<0.05). TCM was an effective treatment for TNBC (P<0.001; HR =51.682; 95% CI: 6.660-401.025). In the AR-negative group, patients who received the TCM treatment tended to have a better DFS than those who did not receive the TCM treatment (P<0.001; HR =34.832; 95% CI: 4.448-272.756); however, no such difference was found in the AR-positive group. The TNBC patients with positive AR tended to have a low expression of Ki-67 and a better prognosis than AR negative TNBC patients. TCM is an effective treatment and has slight side effects.

Long-term Mortality, Readmission, and Resource Utilization Among Hospital Survivors of Out-of-Hospital Cardiac Arrest.

Among patients with out-of-hospital cardiac arrest (OHCA), the influence of pre- and in-hospital factors on long-term survival, readmission, and resource utilization is ill-defined, mainly related to challenges combining disparate data sources. Adult nontraumatic OHCA from the British Columbia Cardiac Arrest Registry (January 2009 to December 2016) were linked to provincial datasets comprising comorbidities, medications, cardiac procedures, mortality, and hospital admission and discharge. Among hospital-discharge survivors, the 3-year end point of mortality or mortality and all-cause readmission was examined with the use of the Kaplan-Meier method and multivariable Cox regression model for predictors. The use of publicly funded home care and community services within 1 year after discharge also was evaluated. Of the 10,674 linked, emergency medical services-treated adult OHCAs, 3230 were admitted to hospital and 1325 survived to hospital discharge. At 3 years after discharge, the estimated Kaplan-Meier survival rate was 84.1% (95% CI 81.7%-86.1%) and freedom from death or all-cause readmission was 31.8% (29.0%-34.7%). After exclusions, 26.6% (n= 315/1186) accessed residential or home care services within 1 year. Independent predictors of long-term outcomes included age and comorbidities, but also favourable arrest characteristics and in-hospital factors such as revascularization or receipt of an intracardiac defibrillator before discharge. Among OHCA hospital survivors, the long-term death or readmission risk persists and is modulated by both pre- and in-hospital factors. However, only 1 in 4 survivors required residential or home care after discharge. These results support efforts to improve care processes to increase survival to hospital discharge.

Interaction of Uric Acid and Neutrophil-to-Lymphocyte Ratio for Cardiometabolic Risk Stratification and Prognosis in Coronary Artery Disease Patients.

Oxidative stress and inflammation are key factors in cardiometabolic diseases. We set out to evaluate the relationship between serum uric acid (UA) and the neutrophil-to-lymphocyte ratio (NLR) with cardiometabolic risk factors in coronary artery disease (CAD) patients, and their additive and multiplicative interactive effects on outcomes (cardiac death/CD and hard events (HE)-death plus reinfarction). A total of 2712 patients (67 ± 11 years, 1960 males) who underwent coronary angiography was retrospectively analyzed and categorized into no-CAD patients (n =806), stable-CAD patients (n =1545), and patients with acute myocardial infarction (AMI) (n =361). UA and NLR were reciprocally correlated and associated with cardiometabolic risk factors. During a mean follow-up period of 27 ± 20 months, 99-3.6% deaths, and 213-7.8% HE were registered. The Kaplan-Meier survival estimates showed significantly worse outcomes in patients with elevated UA or NLR levels. Multivariate Cox regression analysis demonstrated that NLR independently predicted CD and HE. There was no multiplicative interaction between UA and NLR; however, the use of measures of additive interaction evidenced a positive additive interaction between UA and NLR for CD and HE. Although it is clear that correlation does not imply causation, the coexistence of NRL and UA appears to have a synergistic effect, providing further information for the risk stratification of CAD patients.

Intermediate-thickness melanoma: A population-based study of surgical quality metrics

BackgroundVariability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists. MethodsT2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates. ResultsOf 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001). ConclusionsDespite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.

An asparagine metabolism-based classification reveals the metabolic and immune heterogeneity of hepatocellular carcinoma

Introduction and objectiveshepatocellular carcinoma (HCC) is the major form of liver cancer with a poor prognosis. Amino acid metabolism has been found to alter in cancers and contributes to malignant progression. However, the asparagine metabolism status and relevant mechanism in HCC were barely understood.MethodsBy conducting consensus clustering and the least absolute shrinkage and selection operator regression of HCC samples from three cohorts, we classified the HCC patients into two subtypes based on asparagine metabolism level. The Gene Ontology, Kyoto Encyclopedia of Genes and Genomes analyses and Gene Set Enrichment Analysis of the differentially expressed genes between two subgroups were conducted. Immune cell infiltration was evaluated using CIBERSORT algorithm. The prognostic values of genes were analyzed by univariate and multivariate cox regression, ROC curve and Kaplan–Meier survival estimate analyses. Cell types of sing-cell RNA sequencing (scRNA-seq) data were clustered utilizing UMAP method.ResultsHCC patients with higher asparagine metabolism level have worse prognoses. Moreover, we found the distinct energy metabolism patterns, DNA damage response (DDR) pathway activating levels, drug sensitivities to DDR inhibitors, immune cell compositions in the tumor microenvironment and responses to immune therapy between two subgroups. Further, we identified a potential target gene, glutamic-oxaloacetic transaminase 2 (GOT2). GOT2 downregulation was associated with worse HCC prognosis and increased infiltration of T regulatory cells (Tregs). ScRNA-seq revealed the GOT2 downregulation in cancer stem cells compared with HCC cells.ConclusionsTaken together, HCC subtype which is more reliant on asparagine and glutamine metabolism has a worse prognosis, and a core gene of asparagine metabolism GOT2 is a potential prognostic marker and therapeutic target of HCC. Our study promotes the precision therapy of HCC and may improve patient outcomes.