Management Of Hematologic Malignancies Research Articles

Current challenges and therapeutic advances of CAR-T cell therapy for solid tumors.

The application of chimeric antigen receptor (CAR) T cells in the management of hematological malignancies has emerged as a noteworthy therapeutic breakthrough. Nevertheless, the utilization and effectiveness of CAR-T cell therapy in solid tumors are still limited primarily because of the absence of tumor-specific target antigen, the existence of immunosuppressive tumor microenvironment, restricted T cell invasion and proliferation, and the occurrence of severe toxicity. This review explored the history of CAR-T and its latest advancements in the management of solid tumors. According to recent studies, optimizing the design of CAR-T cells, implementing logic-gated CAR-T cells and refining the delivery methods of therapeutic agents can all enhance the efficacy of CAR-T cell therapy. Furthermore, combination therapy shows promise as a way to improve the effectiveness of CAR-T cell therapy. At present, numerous clinical trials involving CAR-T cells for solid tumors are actively in progress. In conclusion, CAR-T cell therapy has both potential and challenges when it comes to treating solid tumors. As CAR-T cell therapy continues to evolve, further innovations will be devised to surmount the challenges associated with this treatment modality, ultimately leading to enhanced therapeutic response for patients suffered solid tumors.

Abstract 35: In situ CAR T cell engineering using lipid nanoparticles for B cell lymphoma therapy

Abstract Chimeric antigen receptor (CAR)-T cell therapy represents a breakthrough in immunotherapy, offering promising outcomes in the management of hematological malignancies. Current CAR-T cell in vitro manufacturing routes involve T cell isolation, purification, activation, gene transduction and cell expansion. The process duration and the costs present significant barriers. Therefore, there is a need for innovative strategies to address these concerns. Herein, we developed lipid nanoparticles (LNPs) to deliver CAR-mRNA efficiently and safely to T cells in vivo, thereby enabling in situ CAR-T cell engineering. By optimizing their composition and introducing anti-CD5 as the targeting ligand, we were able to enhance mRNA delivery and T cell transfection efficiency while maintaining T cell function. Furthermore, to augment T cell responsiveness to exogenous genetic elements, we investigated the pretreatment of T cells with interleukin (IL-7), thereby modulating T cell homeostasis by enhancing survival and proliferation, and rendering the cells more receptive to exogenous genetic modifications. We tracked firefly luciferase (FLuc) in naïve Balb/c mice using in vivo and ex vivo bioluminescence imaging after intravenous injection of anti-CD5 FLuc-mRNA LNPs. We observed positive mRNA expression in lymphoid organs, particularly in the spleen. Additionally, we harvested the lymphoid organs, and performed immunophenotyping analysis using flow cytometry after the administration of anti-CD5 LNPs encapsulating mRNA encoded CD19-CAR with a flag tag. We showed enhanced LNP binding in 65.2% of T cells and CAR expression in 11.64% of T cells as compared with non-treated controls, anti-CD5 FLuc-mRNA LNPs, or IgG CAR-mRNA LNPs. In a CD19+ A20 tumor-bearing mouse model, treatment with CAR-LNPs resulted in a significant increase in chemoattractants (CCL2, CCL4, CCL5, CCL7 and CXCL10) and pro-inflammatory cytokines (TNF-α, IFN-γ, IL6, IL8 and IL15) in blood, and infiltration of T cells and other immune cells in tumors, compared to the non-treated control group over 48 hours post treatment. In vivo engineering allows simultaneous CAR T cell engineering and delivery, reducing the time between manufacturing and treatment, minimizing contamination risks, eliminating complex ex vivo processes, and reducing the need for high-dose preconditioning chemotherapy. In conclusion, the adoption of in situ CAR-T cell production holds promise for improving this therapeutic approach. The authors acknowledge the funding support from NIHR01CA253316 and Leukemia and Lymphoma Society (LLS, Grant ID: 8022-20) Citation Format: Nisi Zhang, Elise Robinson, Angelie Rivera-Rodriguez, James Wang, Yutong Guo, Bo Wu, Spencer K. Tumbale, Marina Raie, Mohammed Inayathullah, Debra K. Czerwinski, Ronald Levy, Katherine W. Ferrara. In situ CAR T cell engineering using lipid nanoparticles for B cell lymphoma therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 35.

Hypofractionated Radiotherapy for Hematologic Malignancies during the COVID-19 Pandemic and Beyond.

Radiotherapy is integral in the management of hematological malignancies (HM). Standard radiotherapy dose fractionation regimens range between 20 and 50 Gy in 10-25 fractions over 2-5 weeks. This study presents the outcomes of patients with HM treated with hypofractionation radiotherapy (HFRT) during the COVID-19 pandemic. Patients (n = 36) were treated with HFRT between January 2020 and September 2022. The outcomes measured were the overall response rate (ORR), freedom from local progression (FFLP), and overall survival (OS). The median follow-up was 13.2 months. Thirty-three patients (92%) had non-Hodgkin (NHL) or Hodgkin lymphoma (HL). Eighteen patients (50%) had aggressive and nine (25%) had indolent NHL. Nineteen patients (53%) presented with stage I/II and fifteen (42%) with stage III/IV disease. Twenty-five (69.4%) and eleven (30%) received consolidative and definitive RT, respectively. Twenty patients (56%) received treatment to the neck and/or thorax and nine (25%) to the abdomen or pelvis. The total dose ranged from 18 to 42.5 Gy in 6-17 fractions/2.67-5 Gy per fraction. The median dose in 2 Gy fractions for an alpha/beta (α/β) ratio of 10 amounted to 39 Gy (SD ± 13.86) and 43.6 Gy (SD ± 12) for an α/β of 3. The most commonly used fractionation scheme was 39 Gy in 13 fractions. ORR was 94.4% for the entire cohort, and 100, 94.4, and 83.3% for indolent NHL, aggressive NHL, and HL patients. The two-year FFLP was 76% (95% CI: 34-93%) for the entire cohort and 100, 87 (95% CI: 56.4-96.5%), and 42% (95% CI: 1.1-84.3%) for the indolent NHL, aggressive NHL, and HL patients. Two-year OS for the entire cohort was 80% (95% CI: 59.9-90.5%) and 100, 66.1 (95% CI: 36.4-84.4%), and 100% for the indolent NHL, aggressive NHL, and HL patients. Only one patient presented with grade two pulmonary toxicity. HFRT in HM provides excellent local control to be validated in a larger prospective study.

Promising and Minimally Invasive Biomarkers: Targeting Melanoma.

The therapeutic landscape of malignant melanoma has been radically reformed in recent years, with novel treatments emerging in both the field of cancer immunotherapy and signalling pathway inhibition. Large-scale tumour genomic characterization has accurately classified malignant melanoma into four different genomic subtypes so far. Despite this, only somatic mutations in BRAF oncogene, as assessed in tumour biopsies, has so far become a validated predictive biomarker of treatment with small molecule inhibitors. The biology of tumour evolution and heterogeneity has uncovered the current limitations associated with decoding genomic drivers based only on a single-site tumour biopsy. There is an urgent need to develop minimally invasive biomarkers that accurately reflect the real-time evolution of melanoma and that allow for streamlined collection, analysis, and interpretation. These will enable us to face challenges with tumour tissue attainment and process and will fulfil the vision of utilizing "liquid biopsy" to guide clinical decisions, in a manner akin to how it is used in the management of haematological malignancies. In this review, we will summarize the most recent published evidence on the role of minimally invasive biomarkers in melanoma, commenting on their future potential to lead to practice-changing discoveries.

Revolutionizing Hematologic Cancer Treatment: The Promise of Bispecific T-Cell Engagers

The advent of bispecific T-cell engager (TCE) therapies has marked a turning point in the management of hematologic malignancies. Several clinical trials of these agents have led to approvals from the FDA, resulting in their subsequent incorporation into standard patient care. Although ongoing efforts are being made to optimize bispecific TCE therapies, a focus on their equitable distribution is needed. At the NCCN 2023 Annual Congress: Hematologic Malignancies, panelists presented clinical trial data, 2 case studies, and updates from NCCN Guidelines to develop an evidence-based approach for the use of these immunotherapies in various clinical contexts.

Challenges associated with living with haematological malignancies in sub-Saharan Africa

The incidence of haematological malignancies is growing in sub–Saharan Africa. It currently account for about 10% of all cancers diagnosed in region. The management of these malignancies in the region is not as optimized as in most developed economies. There are several challenges associated with the effective management of these malignancies in the region; population-based cancer registries in the region is underdeveloped, suboptimal research on these malignancies, challenges with early diagnosis and appropriate treatment, suboptimal professional human and infrastructural endowment. Patients with these malignancies face several challenges, lack of optimum and safe blood transfusion support, huge cost of chemotherapeutic remedies including radiotherapy and iron chelation agents and lack of laboratory investigation for monitoring response to treatment. Success and management of haematological malignancies in Sub-Saharan Africa, need the collaboration of the entire cancer community, medical experts, teamwork, and advocacy.

Clinical Pharmacology Profile of AMG119, the First Chimeric Antigen ReceptorT (CAR-T) Cell Therapy Targeting Delta-Like Ligand3 (DLL3), in Patients with Relapsed/Refractory Small Cell Lung Cancer (SCLC).

With the promise of a potentially single-dose curative regimen, CAR-T cell therapies have brought a paradigm shift in the treatment and management of hematological malignancies with 6 approved products in the USA. However, there are no approved CAR-T cell therapies for solid tumors. Herein, we report the clinical pharmacology profile of AMG119, the first CAR-T cell therapy targeting delta-like ligand3 (DLL3), in patients with relapsed/refractory (R/R) small cell lung cancer (SCLC). AMG119 demonstrated robust cellular expansion with long-lasting cell persistence and a favorable exposure-response relationship. AMG119 has been demonstrated to be clinically safe and well tolerated at the doses tested, with no dose-limiting toxicities (DLTs) reported. This is the first publication of the clinical pharmacology profile of a CAR-T cell therapy in SCLC, with encouraging cellular kinetics data supporting the potential for CAR-T cell therapy in solid tumor space.

Pharmacological and therapeutic potentials of cordycepin in hematological malignancies

Hematological malignancies(HMs) are highly heterogeneous diseases with globally rising incidence. Despite major improvements in the management of HMs, conventional therapies have limited efficacy, and relapses with high mortality rates are still frequent. Cordycepin, a nucleoside analog extracted from Cordyceps species, represents a wide range of therapeutic effects, including anti-inflammatory, anti-tumor, and anti-metastatic activities. Cordycepin induces apoptosis in different subtypes of HMs by triggering adenosine receptors, death receptors, and several vital signaling pathways such as MAPK, ERK, PI3K, AKT, and GSK-3β/β-catenin. This review article summarizes the impact of utilizing cordycepin on HMs, and highlights its potential as a promising avenue for future cancer research based on evidence from in vitro and in vivo studies, as well as clinical trials.

Best Practices and Considerations for Clinical Pharmacology and Pharmacometric Aspects for Optimal Development of CAR-T and TCR-T Cell Therapies: An Industry Perspective.

With the promise of a potentially "single dose curative" paradigm, CAR-T cell therapies have brought a paradigm shift in the treatment and management of hematological malignancies. Both CAR-T and TCR-T cell therapies have also made great progress toward the successful treatment of solid tumor indications. The field is rapidly evolving with recent advancements including the clinical development of "off-the-shelf" allogeneic CAR-T therapies that can overcome the long and difficult "vein-to-vein" wait time seen with autologous CAR-T therapies. There are unique clinical pharmacology, pharmacometric, bioanalytical, and immunogenicity considerations and challenges in the development of these CAR-T and TCR-T cell therapies. Hence, to help accelerate the development of these life-saving therapies for the patients with cancer, experts in this field came together under the umbrella of International Consortium for Innovation and Quality in Pharmaceutical Development (IQ) to form a joint working group between the Clinical Pharmacology Leadership Group (CPLG) and the Translational and ADME Sciences Leadership Group (TALG). In this white paper, we present the IQ consortium perspective on the best practices and considerations for clinical pharmacology and pharmacometric aspects toward the optimal development of CAR-T and TCR-T cell therapies.

Imaging Recommendations for Diagnosis, Staging, and Management of Hematological Malignancies

AbstractThe NIC defines hematological cancers as those that begin in blood forming tissues such as bone marrow or cells of the immune system and these broadly include three groups: leukemias, lymphomas, and myelomas. The role of imaging is also fundamentally different between the three main groups of hematological malignancies. While imaging is the main tool for staging as well as treatment response assessment in lymphoma, it represents one of several key criteria for the diagnosis and follow-up of myeloma; whereas in leukemia, imaging has a role to play in the detection and management of treatment-related complications which is a crucial part of post-transplant treatment.

Management of adult patients with haematological malignancies in critical care.

There are a diverse range of haematological malignancies with varying clinical presentations and prognoses. Patients with haematological malignancy may require admission to critical care at the time of diagnosis or due to treatment related effects and complications. Although the prognosis for such patients requiring critical care has improved, there remain uncertainties in optimal clinical management. Identification of patients who will benefit from critical care admission is challenging and selective involvement of palliative care may help to reduce unnecessary and non-beneficial treatments. While patients with haematological malignancy can present a challenge to critical care physicians, good outcomes can be achieved. In this narrative review, we provide a brief overview of relevant haematological malignancies for the critical care physician and a summary of recent treatment advances. Subsequently, we focus on critical care management for the patient with haematological malignancy including sepsis; acute respiratory failure; prevention and treatment of tumour lysis syndrome; thrombocytopaenia; and venous thromboembolism. We also discuss immunotherapeutic-specific related complications and their management, including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome associated with chimeric antigen receptor T-cell therapy. While the management of haematological malignancies is highly specialised and increasingly centralised, acutely unwell patients often present to their local hospital with complications requiring critical care expertise. The aim of this review is to provide a contemporary overview of disease and management principles for non-specialist critical care teams.

Impact of the COVID-19 pandemic on treatment approaches of multiple myeloma

Cancer has been recognized as one of the major comorbidities associated with severe outcomes in the novel coronavirus disease 19 (COVID-19) patients. Compared to those with solid tumors and those without cancer, patients with hematologic malignancies appear to have more severe clinical outcomes and higher rate of mortality from COVID-19. This was particularly demonstrated during the early pandemic period. The COVID-19 pandemic has posed additional challenges in the management of hematologic malignancies, including establishing prompt diagnoses, providing optimal treatment while minimizing the risk and sequela of COVID-19 infection. Given these challenges, clinical practice guidelines and recommendations on management of hematologic malignancies during the COVID-19 pandemic were developed and proposed based on expert panels and individual expert opinions. Multiple myeloma is the second most common hematologic malignancy. The management of patients with multiple myeloma during the COVID-19 pandemic is extremely challenging as patients with multiple myeloma are particularly vulnerable to infections due to underlying humoral and cellular immune dysfunction, cytotoxic chemotherapy, immunotherapy, cellular therapy and steroid regimens, advanced age, and the presence of other comorbidities. In this paper, we attempt to provide a general review of clinical practice management patterns during and after the COVID-19 pandemic in patients with multiple myeloma and demonstrate how changes evolved as more knowledge was gained over time. Specifically, we review the impact of the pandemic on treatment approaches, supportive care, and vaccinations for patients with newly diagnosed multiple myeloma, relapsed/refractory multiple myeloma, patients with stable disease, and those with precursor states like monoclonal gammopathy and smoldering multiple myeloma. During early pandemic several changes were noted in myeloma care including minor delay in time to treatment initiation and tendency to defer autologous stem cell transplant. However, after 2022, with the advent of effective vaccines and treatment strategies the severity of COVID-19 infection decreased and care of myeloma returned to usual management, incorporating transplant, CART and multiple novel immune therapy approaches. Finally, we highlight the importance of meticulous vaccination schedule for patients with myeloma for all common viral, bacterial pathogens and vaccination against COVID-19.

“A.B.C.” of Immunotherapy in Hematological Malignancies…Promise and Perils

AbstractThe treatment landscape of hematological malignancies has been evolving at an extremely fast pace. Hematological malignancies are diverse and distinct from solid tumors. These constitute challenges, which are also unique opportunities for immunotherapy. The five categories of immunotherapies that have found success in the management of hematological malignancies are allogeneic hematopoietic stem cell transplant, monoclonal antibodies and innovative designs, immune checkpoint inhibitors, chimeric antigen receptor (CAR) T cells, and B cell targeting small immunomodulatory molecules. Allogeneic stem cell transplant rightly called our bluntest weapon is the oldest form of successful immunotherapy. Alternate donor transplants and improvement in supportive care have improved the scope of this immunotherapy option. Among monoclonal antibodies, rituximab forms the prototype on which over a dozen other antibodies have been developed. The bispecific T-cell engager (BiTE) blinatumomab engages cytotoxic CD3 T cells with CD19 acute lymphoblastic leukemia (ALL) cells, which is an effective treatment method for relapsed refractory ALL. Immune checkpoint inhibitors have established their role in hematological malignancies with high PD-L1 expression, including relapsed refractory Hodgkin's lymphoma and primary mediastinal B cell lymphoma (BCL). Small immunomodulatory drugs targeting the B cell receptor downstream signaling through BTK inhibitors, SYK inhibitors, PI3K inhibitors (idelalisib), and BCL-2 inhibitors (venetoclax), and immunomodulatory imide drugs (lenalidomide) have also emerged as exciting therapeutic avenues in immunotherapy. CAR T cells are one of the most exciting and promising forms of adoptive immunotherapy. CAR T cells are rightly called living drugs or serial killers to keep patients alive. CAR T cells are genetically engineered, autologous T cells that combine the cytotoxicity of T cells with the antigen-binding specificity of CARs. CARs are antigen-specific but major histocompatibility complex/human leukocyte antigen-independent. There are five approved CAR T cell products for the management of relapsed refractory leukemias, lymphoma, and multiple myeloma. The past and present of immunotherapy have been really exciting and the future looks incredibly promising. The challenges include widening the availability and affordability beyond specialized centers, identification of potentially predictive biomarkers of response, and experience in the management of complications of these novel agents. The combinational approach of multiple immunotherapies might be the way forward to complement the treatment strategies to harness the immune system and to improve survival with good quality of life.

Multi-Omics Reveal Plasma Molecular Signatures of B-ALL Patients during CAR-T Cell Therapy

Background: The Chimeric antigen receptor (CAR) T cell therapy for hematological malignancies has revolutionized anticancer therapy. However, CAR-T cells can cause immunity-related adverse events, such as cytokine release syndrome and neurotoxicity; the efficacy of CAR-T cell therapy also varies substantially with different patients. Poor understanding of plasma proteomic and metabolomic features during chimeric antigen receptor (CAR) T cell therapy may affect the exploitation of therapeutic potential in the management of hematological malignancies. Methods: We longitudinally performed proteomic and metabolomic profiling of plasma from 20 patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) on CAR-T cell therapy. Blood samples were collected from B-ALL patients at different time points, including before fludarabine/cyclophosphamide lymphodepletion (Pre-FC), Day 0 (D0), Day 7 (D7), Day 14 (D14), Day 28 (D28), and Peak-IL-6 during CAR-T cell therapy. The plasma samples from 22 age- and gender-matched healthy controls (HC) were used as controls. Results: Compared with HC, 239, 217, 282, 260 and 261 proteins were markedly different in terms of expression level in these five groups (Pre-FC, D0, D7, D14, D28 versus HC), respectively (Figure 1). The pathways of differentially expressed proteins (DEPs) were highly enriched in processes implicated in actin binding, cadherin binding, regulation of ion transport, platelet aggregation and regulation of actin cytoskeleton, with actin binding obtaining the most significant change (Figure 1). 104, 139, 175, 223 and 87 metabolites were significantly different in these five groups, respectively (Figure 1). Interestingly, the alterations of plasma metabolites became more extensive on the 14th day after CAR-T cell infusion, indicating that the change of metabolites may lag behind that of proteins. Furthermore, CAR-T cell therapy reshaped plasma proteome and metabolome with discrete kinetics, as represented by upregulated acute-phase response and triglycerides metabolism and downregulated actin cytoskeleton organization, retrograde endocannabinoid signaling and glycosylphosphatidylinositol (GPI)-anchor biosynthesis during the therapy. We also identified sets of covarying molecules that were involved in acute inflammatory response, epithelial mesenchymal transition, glutathione metabolism and tryptophan metabolism in concert with the dynamics of circulating IL-6 in patients with cytokines storm. Subgroup analysis further revealed numerous prognostic biomarkers, such as proteins related to allograft rejection, which were down-regulated in patients who achieved stable complete remission. Conclusions: This study provided a dynamic landscape of plasma proteome and metabolome in B-ALL patients during CAR-T cell therapy and offered novel insights into CAR-T cell therapy-related toxicities and prognostic heterogeneity. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Discovery, Optimization, and Evaluation of Potent and Selective PI3Kδ-γ Dual Inhibitors for the Treatment of B-cell Malignancies.

Nowadays, PI3Kδ-γ dual inhibitors have been approved for the treatment of B-cell malignancies. Dual inhibition of PI3Kδ and PI3Kγ represents a unique therapeutic opportunity and may confer greater benefits than either isoform inhibition alone in the management of hematological malignancies. However, currently available dual inhibitors of PI3Kδ-γ compromise in at least one of several essential properties in terms of potency, selectivity, and pharmacokinetic (PK) profiles. Hence, the main challenge of our optimization campaign was to identify an oral available PI3Kδ-γ dual inhibitor with an optimum balance of potency, selectivity, and PK profiles. The medicinal chemistry efforts culminated in the discovery of compound 58, which exhibited strong potency and high selectivity along with excellent in vivo profiles as demonstrated through PK studies in rats and through pharmacodynamic studies in an SUDHL-6 xenograft model. All the results suggest that compound 58 may be a promising candidate for the treatment of B-cell malignancies.

P1442: DYNAMIC LANDSCAPE OF PLASMA PROTEOME AND METABOLOME IN B-ALL PATIENTS DURING CAR-T CELL THERAPY

Background: Poor understanding of plasma proteomic and metabolomic features during chimeric antigen receptor (CAR) T cell therapy may affect the exploitation of therapeutic potential in the management of hematological malignancies. Aims: This word was designed to illustrate the dynamic landscape of plasma proteome and metabolome in B-ALL patients during CAR-T cell therapy and detailed the kinetics of proteins and metabolites during cytokines storm. Methods: In this study, we performed proteomic and metabolomic profiling of plasma from 20 patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) on CAR-T cell therapy and 22 healthy controls. Results: We identified molecular changes in the plasma of B-ALL patients compared to healthy controls. Many of the changes involved actin cytoskeleton organization, acute-phase responses, autophagy, branched-chain amino acid, and lipid metabolism (Figure A). Furthermore, CAR-T cell therapy reshaped plasma proteome and metabolome with discrete kinetics, as represented by upregulated acute-phase response and triglycerides metabolism and downregulated actin cytoskeleton organization, axon extension, retrograde endocannabinoid signaling, autophagy, and glycosylphosphatidylinositol (GPI)-anchor biosynthesis during the therapy (Figure B). Moreover, we identified sets of covarying molecules involved in the acute inflammatory response, epithelial-mesenchymal transition, glutathione metabolism, and tryptophan metabolism and change in concert with the dynamics of circulating IL-6 in patients with cytokines storm (Figure C). Subgroup analysis further revealed numerous prognostic biomarkers, such as proteins related to allograft rejection, which were down-regulated in patients who achieved stable complete remission. Image:Summary/Conclusion: This study provided a dynamic landscape of plasma proteome and metabolome in B-ALL patients during CAR-T cell therapy and offered novel insights into the pathogenesis of B-ALL and CAR-T cell therapy-related toxicities.

Epigenetic Therapies and Biomarkers in Breast Cancer.

Simple SummaryEpigenetic therapies are promising agents for overcoming clinical resistance to conventional treatments in breast cancer. In the assessed trials, the use of epigenetic therapies for the management of breast cancer has not translated from the pre-clinical to clinical setting. However, novel epigenetic treatments remain promising, especially in the era of personalized medicine and improved genomic evaluation. The aim of our review was to assess the published evidence for the clinical utility of epigenetic therapies and their biomarkers in breast cancer and the potential value of epigenetic biomarkers to direct clinical management.Epigenetic therapies remain a promising, but still not widely used, approach in the management of patients with cancer. To date, the efficacy and use of epigenetic therapies has been demonstrated primarily in the management of haematological malignancies, with limited supportive data in solid malignancies. The most studied epigenetic therapies in breast cancer are those that target DNA methylation and histone modification; however, none have been approved for routine clinical use. The majority of pre-clinical and clinical studies have focused on triple negative breast cancer (TNBC) and hormone-receptor positive breast cancer. Even though the use of epigenetic therapies alone in the treatment of breast cancer has not shown significant clinical benefit, these therapies show most promise in use in combinations with other treatments. With improving technologies available to study the epigenetic landscape in cancer, novel epigenetic alterations are increasingly being identified as potential biomarkers of response to conventional and epigenetic therapies. In this review, we describe epigenetic targets and potential epigenetic biomarkers in breast cancer, with a focus on clinical trials of epigenetic therapies. We describe alterations to the epigenetic landscape in breast cancer and in treatment resistance, highlighting mechanisms and potential targets for epigenetic therapies. We provide an updated review on epigenetic therapies in the pre-clinical and clinical setting in breast cancer, with a focus on potential real-world applications. Finally, we report on the potential value of epigenetic biomarkers in diagnosis, prognosis and prediction of response to therapy, to guide and inform the clinical management of breast cancer patients.

11. Optical genome mapping for chromosomal structural variants analysis in hematological malignancies

Knowledge of copy number (CNVs) and structural variants (SVs) is important for the diagnosis and management of hematological malignancies (HM). In myelodysplastic syndromes (MDS), the number and type of SVs/CNVs are essential for prognostic risk-stratification using R-IPSS. Optical genome mapping (OGM) is a novel, single-platform, cytogenomic technique for genome-wide characterization of all types of CNVs/SVs at a high resolution. In this study, we evaluated the performance of OGM in a series of previously well-characterized 49 hematological malignancies (46 MDS, 1 AML and 2 T-ALL) compared to standard-of-care cytogenetic tests.

Chimeric Antigen Receptor T-Cell Therapy (Car T-Cells) in Solid Tumors, Resistance and Success

CARs are chimeric synthetic antigen receptors that can be introduced into an immune cell to retarget its cytotoxicity toward a specific tumor antigen. CAR T-cells immunotherapy demonstrated significant success in the management of hematologic malignancies. Nevertheless, limited studies are present regarding its efficacy in solid and refractory tumors. It is well known that the major concerns regarding this technique include the risk of relapse and the resistance of tumor cells, in addition to high expenses and limited affordability. Several factors play a crucial role in improving the efficacy of immunotherapy, including tumor mutation burden (TMB), microsatellite instability (MSI), loss of heterozygosity (LOH), the APOBEC Protein Family, tumor microenvironment (TMI), and epigenetics. In this minireview, we address the current and future applications of CAR T-Cells against solid tumors and their measure for factors of resistance and success.

Clinical evidence for a biological effect of epigenetically active decitabine in relapsed or progressive rhabdoid tumors.

Refined therapy has helped to improve survival rates in rhabdoid tumors (RT). Prognosis for patients with chemoresistant, recurrent, or progressive RT remains dismal. Although decitabine, an epigenetically active agent, has mainly been evaluated in the management of hematologic malignancies in adults, safety in children has also been demonstrated repeatedly. A retrospective series of patients who received decitabine upon relapse or progression following therapy according to the EU-RHAB regimen is presented. Due to the retrospective nature of analyses, response was defined as measurable regression of at least one lesion on imaging. 850k methylation profiling was done whenever tumor tissue was available. A total of 22 patients with RT of any anatomical localization were included. Most patients (19/22) presented with metastases. All received low-dose decitabine with or preceding conventional chemotherapy. Patients received a median of two (1-6) courses of decitabine; 27.3% (6/22) demonstrated a radiological response. Molecular analyses revealed increased methylation levels in tumors from responders. No excessive toxicity was observed. Clinical benefits for responders included eligibility for early phase trials or local therapy. Responders showed prolonged time to progression and overall survival. Due to small sample size, statistical correction for survivorship bias demonstrated no significant effect on survival for responders. Patients with RT demonstrate promising signs of antitumor activity after multiagent relapse therapy including decitabine. Analyses of methylation data suggest a specific effect on an epigenetic level. We propose to consider decitabine and other epigenetic drugs as candidates for further clinical investigations in RT.