Relapse Cases Research Articles

Multiparametric Flow Cytometry-MRD Assay: Lesson from Phase II Trail REL AML 001

Background: Core-binding factor (CBF) AML with RUNX1/RUNX1T1 (AML1/ETO) and CBFB/MYH11 fusion genes is known as a heterogenous group, accounting for about 10% to 15% of AML. In the Phase II Trial REL AML 001 (EudraCT Number 2017-002094-18; ClinicalTrials ID: NCT 03686345) adult CBF leukemia patients treated with a continuation therapy with Midostaurin were included, and the measurable residual disease (MRD) was performed by molecular MRD assessment (qPCR) and multiparametric flow cytometric-MRD (MCF-MRD) assay. The findings of MCF-MRD assay were compared to qPCR. Methods: 31 patients with AML1/ETO (n=15) and CBFB/MYH11 (n=16) were evaluated between December 2018 to July 2022 with both techniques. A total of 145 determinations (n. AML1/ETO = 56 and n. CBFB/MYH11= 89) were performed. MCF panel included 2 10-color tubes: CD15 FITC/ CD56 PE/ CD34 PerCP-cy5.5/ CD117 PE-cy7/ CD7 APC/ CD13 APC-R700/ CD19 APC H7/ HLADR V450/ CD45 V500C/ CD33 BV630, specific for RUNX1/RUNX1T1 cases and CD64 FITC/ CD2 PE/ CD34 PerCP-cy5.5/ CD117 PE-cy7/ CD200 APC/ CD13 APC-R700/ CD14 APC H7/ HLADR V450/ CD45 V500C/ CD33 BV630, specific for CBFB/MYH11 cases. A mean of 1,733,240 CD45 positive events were acquired, with a mean lower limit of detection (LLOD) of 0.001% (ranging 0.01-0.0003%). In 10 cases (6 RUNX1 and 4 CBFB/MYH11) the molecular and phenotypical features at onset were not available. MCF analyses were performed by InfinicytTM software and reference image tool was used wherever possible. Results: We found a concordance of 76% between MCF cases and RUNX1/RUNX1T1 qPCR, and a concordance of 83% between MCF cases and CBFB/MYH11 qPCR (Tables 1a and 1b). In relapsed cases we observed a dynamic and continuous increase of abnormal MCF events, that was not found in cases without clinical relapse although with positive qPCR (Table 2). The HLADR expression evaluated as the geo mean intensity at presentation and/or at relapse resulted higher in RUNX1/RUNX1T1 patients than in CBFB/MYH11 cases (29845 vs 8979, respectively, p=0.0039 Figure 1). Interestingly, we found in a single case with atypical CBFB/MYH11 fusion gene a high value of HLADR geo mean (44522). The down-regulated expression of HLADR in CBFB/MYH11 blasts may be a useful clue to distinguish AML blasts from the scarcely represented normal CD2 positive myeloid precursors, and from the strongly HLADR positive elements that are found in a regenerating bone marrow background. Conclusion: Although MCF-MRD assay showed lower sensitivity than CBF qPCR, MCF offered interesting informations about the dynamics of the abnormal clone size with time, evaluated as the increasing number of MRD clustering events, which may predict an impending relapse.

Salvage Autologous Stem Cell Transplant for the Treatment of First Relapse Multiple Myeloma: Evidence of Its Clinical Role from a Multicenter Italian Study

Background: Salvage autologous stem cell transplant (sASCT) has been indicated as possible therapeutic option at first (1 st) relapse, alternative to continuous treatment with novel agent combinations in selected Multiple Myeloma (MM) patients (pts). Particularly, MM pts who are eligible for a transplant procedure at the time of relapse and who have prolonged progression free survival (PFS) after the 1 st ASCT - i.e. at least 36 or 18 months, respectively, with or without Lenalidomide (Len) maintenance - are those who could benefit most from sASCT. There are limited data regarding the frequency of choice for sASCT in the current therapeutic scenario and the outcome of sASCT when incorporating novel Len-based triplets KRd (Carfilzomib-Lenalidomide-Dexamethasone) and DaraRd (Daratumumab-Lenalidomide-Dexamethasone) as induction regimens before sASCT. Aims: To explore the real-life use, efficacy, and outcome of sASCT preceded by novel agent-based re-induction therapy in a population of unselected Len-sensitive MM population in the 1 st relapse. Patients and methods: We planned a retrospective multicenter study, approved by local ethic committees, aimed at identifying MM Len-sensitive pts in the 1 st relapse addressed to sASCT. On a final cohort of 663 MM pts addressed in 22 Italian centers to Len-based triplets salvage therapy from 2017 to December 2022, sASCT after Len-based re-induction was the therapy of choice for 123 pts (18.6%), while the remaining 540 pts (81,4%) were addressed to continuous Len-based triplets until progression or unacceptable toxicity. The rate of pts addressed to sASCT at the time of the 1 st relapse was distributed as follows: 81 pts out of 512 pts (15.8%) received sASCT in the time window 2017-2019, 42 pts out 151 (27.8%) between 2020-2022 (p=0.001). Table 1 summarizes patients' characteristics and treatment history details. In our series 1 st ASCT was performed without Len maintenance. All pts entering the analysis received re-induction treatment before sASCT as well as continuous therapy with DaraRd or KRd according to standard schedule and doses. sASCT consisted of Melphalan 200 mg/m 2 as a conditioning regimen followed by infusion of ≥2*10 6 CD34* cells per kg body weight. The option to perform maintenance therapy following sASCT was chosen by the attending physician. The response was assessed according to IMWG criteria. Compared with pts treated with continuous Len-based triplets, those addressed to sASCT were younger (62 vs 68 years, p<0.001), with a longer time from diagnosis (3.9 vs 2.5 years, p<0.001), and they received a higher rate of prior ASCT (80.5% vs 53.8%, p<0.001). Regarding the sASCT program, KRd was the most common choice for the re-induction phase (102 pts, 82.9%), DaraRd was used in the remaining 21 pts (17.1%). The median number of cycles before sASCT was 6 (range 4-10), and maintenance after transplant was performed only in 18 pts (14.9%). sASCT was associated with an overall response rate (ORR) of 94.3% (116 pts), with 78% (96 pts) of very good partial response or better (≥VGPR), and 35.5% (43 pts) of CR. No case of transplant-related mortality was documented. After a median follow-up of 33.6 months (IQR 21.3-51.8), the median PFS of pts addressed to sASCT was 36.6 months, with 24-month PFS of 75% (95%CI 65-82%)(Figure 1). When a multivariableCox regression model was carried out including 1 st ASCT, the best response to 1 st line therapy and ≥36 months PFS after 1 st line therapy, as well as the number of re-induction KRd/DaraRd cycles as covariates, only PFS ≥36 months after 1 st-line therapy retained an independent statistically significant association with a reduced progression/death risk after sASCT (HR=0.5, 95%CI; 0.2-1.0, p=0.049). The median overall survival (OS) was not yet reached with a 2-year OS of 89% (95%CI: 81-93%). Conclusions: This study on 663 consecutive MM cases in the first relapse showed that salvage transplants retained a significant role in the current clinical management of MM, accounting for around 19% of selected salvage strategies. The incorporation of the highly active combinations KRd and DaraRd used as re-induction regimens before sASCT was associated with a significantly high rate of deep and long-lasting response, representing a possible alternative strategy to continuous therapy with Len-based triplets. The major benefit of Len-based triplets followed by sASCT was related to prolonged remission after first-line therapy.

The CNS Microenvironment Promotes Leukemia Cell Survival By Disrupting Tumour Suppression and Cell Cycle Regulation in Pediatric T-Cell Acute Lymphoblastic Leukemia

Although modern treatment has improved the overall survival of pediatric T-cell acute lymphoblastic leukemia (T-ALL) greatly, more than 20% of all children diagnosed with T-ALL relapse (Fattizzo et al., 2020). Approximately 30% of all relapse cases occur in the central nervous system (CNS) and CNS involvement is considered a major risk factor for treatment failure and increased mortality (Frishman-Levy & Izraeli, 2017). To date, CNS directed therapy is considered essential for complete cure to prevent relapse in the CNS, leading to severe neurotoxic effects and long-term adverse complications (Thastrup et al., 2022). Due to lack of knowledge regarding the mechanisms promoting leukemia survival in the CNS and absence of reliable biomarkers to predict CNS involvement, the development of new therapeutic drugs able to eradicate leukemia cells in the CNS is not progressing, therefor limiting the overall survival of pediatric T-ALL patients (Thastrup et al., 2022). To identify genetic alterations in CNS involved T-ALL we performed an RNA-sequencing analysis coupled with a gene set enrichment analysis (GSEA) studying pediatric T-ALL patient samples obtained from the TARGET initiative. We included 30 samples from patients at initial diagnosis subdivided by degree of CNS involvement, ranging from CNS1 (no CNS disease) to CNS3 (advanced CNS disease), as well as 13 samples from patients who had relapsed in the CNS. Our analysis identified distinct genetic alterations in CNS involved T-ALL and CNS relapse compared to diagnosis samples without CNS implications, with dysregulation of genes involved in tumour suppression, apoptosis and self-renewal. CNS relapsed patients were distinguished from diagnosis patients by a distinct gene expression pattern, with an upregulation of many genes, including cell cycle inhibitor CDKN2A and transcription factor HOXA3 (Figure 1A). We also found disruption of many signaling pathways, including enrichment of the p53 pathway in patients who relapsed in the CNS compared to non-CNS involved diagnosis patients. To further study the effects of CNS implications in pediatric T-ALL, we established a co-culture of pediatric T-ALL cell lines (n=4) and a glioblastoma cell line (U87-MG). Following co-culture, changes to mRNA expression was evaluated by RT-qPCR, revealing dysregulation of many genes, including an upregulation of cancer stem cell marker and cell adhesion molecule CD44 (Chen et al., 2018). Moreover, T-ALL cells grown in CNS co-culture displayed a downregulation of tumour suppressor TP53 and an upregulation of its negative regulator, proto-oncogene MDM2 when compared to cells grown in suspension (Figure 1B) (Hernandez Borrero & El-Deiry, 2021). Co-culture also induced pro-survival isoform switching of BCL2L1 (BCLX), part of the BCL family of apoptotic regulators (Daniel et al., 2013). Together, these results suggest an increased survival and loss of tumour suppression of T-ALL cells when grown in direct contact with CNS derived cells. To determine effects of the CNS microenvironment on therapy resistance, T-ALL cell lines grown in co-culture were exposed to 2µM methotrexate, a chemotherapeutic agent used during CNS directed therapy (Thastrup et al., 2022). Leukemia cells in co-culture displayed an increased survival compared to cells grown in suspension following 48 hours of methotrexate exposure, as well as dysregulation of several genes involved in cell survival, self-renewal and cell cycle regulation. Cyclins and CDKs involved in controlling cell cycle progression were differentially expressed in co-culture versus suspension, with a downregulation of CDK2 and cyclin A, crucial for S/G2 transition, as well as CDK1 and cyclin B, responsible for G2/M transition (Leal-Esteban & Fajas, 2020). These results indicate a shift towards cell cycle arrest and senescence of T-ALL cells during methotrexate exposure in CNS co-culture, potentially promoting leukemia survival and chemoresistance. Taken together, our findings indicate a differential gene expression pattern in CNS involved T-ALL, which could potentially be utilized as predicative biomarkers to properly identify patients at risk of CNS relapse. CNS co-culture revealed cell cycle alterations and loss of proliferation markers, promoting senescence and therapy resistance, which could serve as potential therapeutic targets.

Whole-Genome Sequencing Identifies Structural Variation As a Key Driver of Disease Relapse and Aggressive Clinical Behavior in Multiple Myeloma

INTRODUCTION: Many key genomic events leading to relapse in multiple myeloma (MM) occur outside of coding regions and can only be identified using whole-genome sequencing (WGS). Studies of MM progression examining single nucleotide variants (SNVs) and insertions/deletions (InDels) have identified a distinct pattern of mutations associated with resistance, however these do not fully account for drivers of progression. Studies of relapsed patients provide hints about the molecular mechanisms driving progression based on identification of homozygous loss of tumor suppressor genes, aberrant copy-number variants (CNVs), and rare examples of complex structural variants (SV). We have analyzed a set of presentation and relapsed MM samples, including paired data, derived from WGS of plasma cells and focused on SVs as key drivers of progression. METHODS: WGS was performed on 338 MM patient samples using CD138-sorted plasma cells, among which 237 samples were paired including 101 patients (30%) at presentation and at relapse, 35 of whom had more than one sample at relapse. A bioinformatics pipeline employing a consensus mechanism for determining the final set of somatic events was used based on Mutect2, Strelka2, and VarScan2 for SNVs; Mutect2, Strelka2, VarScan2, and SvABA for InDels; Battenberg and FACETS for CNVs; Manta, SvABA, DELLY2, and IgCaller for SVs. Additionally, an admixture workflow was used to estimate each individual's ancestral lineage using continentally-distinct references, comprising 23 regional populations within 5 super-populations from the 1000 Genomes Project (https://github.com/pblaney/mgp1000). Complex rearranged genomes were reconstructed using the graph-based R package JaBbA (https://github.com/mskilab-org/JaBbA). Additionally, the python package Pairtree (https://github.com/morrislab/pairtree) was used to describe the evolutionary history of acquired mutations in these patients. RESULTS: Themedian age of the cases studied was 67, and 42% were female. Racial admixture correlated with self-identification, including 74% of European ancestry with the remainder being predominantly of African ancestry. High-risk cytogenetic features were found in 10% and 13% at diagnosis and relapse, respectively. As expected, the tumor mutational burden of the relapse cases was higher than that at presentation. The patterns of SNV mutational drivers were similar at relapse in comparison to presentation with again evidence for a role of biallelic tumor suppressor gene inactivation as being a key mechanism. We also found that the number of SVs increased at relapse. Complex SVs including templated insertions, chromoplexy, and chromothripsis were detected and occurred exclusively at relapse in some cases as well as earlier in the natural history in others, suggesting they can occur as both early and late driver events. Characterizing complex SVs, further we identified them at lower levels in cases at presentation compared to relapse, consistent with these being at a higher clonal fraction and providing further evidence for their role as driver events. We did not see the emergence of additional rearrangements at relapse in either the templated insertions or chromoplexy events, suggesting that these occur at a single timepoint and remain structurally stable overtime. CONCLUSIONS: Complex SVs provide a novel mechanism driving relapse in MM which can deregulate multiple genes simultaneously providing new potential markers of aggressive disease behavior and disease evolution.

Modified lateral canthopexy with upper and lower blepharoplasties for aesthetic refinements: My personal technique

Blepharoplasty is a surgical procedure that modifies the shape and structure of the eyelids to restore a more youthful appearance. The procedure comprises the removal of extra muscle, fat, and skin. In order to get the optimum functional and aesthetic result, supporting components like canthal tendons can also be tightened. To evaluate the efficacy of canthopexy in conjunction with the upper and lower blepharoplasty technique and its complications. A total of 400 individuals who underwent these procedures between January 2020 and January 2021 had been recruited for this study. The frequency and clinical complications were analyzed. The complications were found to be 17 (4%) cases of relapse, 12 (3%) temporary hematoma formation, 11 (3%) cases of epiphora, 8 (2%) cases of unequal eyelid positioning, 5 (1%) patients developed conjunctivitis and chemosis. This method appears to be effective since it is simple, practicable, and capable of delivering positive functional and aesthetic effects with a minimum of side effects.

Removable Orthodontic Treatment for Managing Relapse Due to Eruption of Third Molars: A Case Report

Relapse is a return to the initial form of malocclusion after correction. Relapse occurred after the patient underwent a fixed orthodontic treatment, and it could be associated with the role of third molar eruption. The use of removable orthodontic appliances can maintain the retention period to prevent relapse. This report aims to report the use of removable orthodontic appliances in correcting a minor relapse case. A 23-year-old patient came to RSGM UMY complaining of misaligned upper and lower front teeth for several months after completing fixed orthodontic treatment. She felt her lower front teeth were crowded and moved more backward than the other teeth. The treatment used maxillary and mandibular expansion plates to gain space. The active plate on the maxilla was a medium labial arch and a simple spring on the mandible. A checkup of the patient was seen once a week which involved cleaning the oral cavity and the plate, measuring the space by the activated expansion screw, and checking for correction of individual teeth. The bilateral expansion plate can be used to correct mild anterior crowding due to relapse, followed by an active plate with a simple spring. The success of treatment was influenced by the patient’s cooperation and compliance with using removable orthodontic appliances.

Idarubicin Versus Daunorubicin Versus Mitoxantrone for Induction Chemotherapy in Acute Myeloid Leukemia: Patient Registration Study of Turkish Society of Hematology-Acute Myeloid Leukemia Working Group

Introduction: Standard induction chemotherapy in newly diagnosed acute myeloid leukemia (AML) includes a combination of standard-dose cytarabine and an anthracycline (idarubicin [IDA], daunorubicin [DNR], or mitoxantrone [MXR]). Anthracycline selection is still not standardized, and the impact of anthracycline selection on survival and response in patients with adverse genetic risk is of interest. The study aimed to retrospectively compare the effectiveness of induction regimens with respect to anthracycline preference. Methods: The study population was recruited from the Turkish AML Registry project database based on documentation of newly diagnosed AML and induction chemotherapy with IDA, DAU, or MXR in combination with cytarabine. Patients diagnosed before 31 August 2022 were received typical “7 + 3” induction chemotherapy containing 3 days of IDA, DAU, or MXR. Results: The study included 317 newly diagnosed AML patients (median age 51; range, 18 - 79; 55.2% male). Of the patients, IDA was administered in 266 (83.9%), DNR in 42 (13.2%), and MXR in 9 (2.8%). The three anthracycline treatment groups were similar between age, gender, type of AML by the World Health Organization (WHO), and risk classification by 2017 European LeukemiaNet (ELN) when evaluated according to the baseline disease characteristics. At the time of diagnosis, although the median white blood cell levels were 19 x 10 9/L (0.4 - 355) in the IDA, 7.8 x 10 9/L (0.7 - 357.2) in the DAU, and 5.5 x 10 9/L (0.6 - 34) in the MXR therapy group (p = 0.019); the hemoglobin and platelet levels and bone marrow blast percentage were similar between the treatment groups. FMS-like tyrosine kinase-3 internal tandem duplication ( FLT3-ITD) (p = 0.561) and Nucleophosmin 1 gene ( NPM1) (p = 0.430) mutation frequencies were also similar between treatment groups. Morphological complete remission (CR) was documented in 65% of all evaluable patients. Among the patient groups, CR was 67.7% for IDA, 50% for DNR, and 55.6% for MXR (p = 0.081). In univariate analysis (Table 1), significant predictors of overall survival (OS) were age ≥60 years (p <0.001), acute leukemias of ambiguous lineage (p <0.001), presence of disseminated intravascular coagulation (DIC) (p = 0.012), and FLT3-ITD mutation (p = 0.018); no significant interaction was noted between NPM1 mutation and OS (p = 0.059). Additionally, when idarubicin was taken as a reference, there was no meaningful relationship between anthracycline type and OS (p values for daunorubicin and mitoxantrone were 0.145 and 0.356, respectively). In multivariate analysis (Table 1), age ≥60 years (p = 0.001), acute leukemias of ambiguous lineage (p = 0.007), and the presence of DIC (p = 0.040) remained significant. After a median follow-up of 29.8 months, 32.5% relapse cases were documented and similarly distributed among IDA (33.1%), DNR (31%), and MXR (22.2%) therapy groups (p = 0.771). During the same period, allogeneic hematopoietic stem cell transplantation (AHSCT) was documented in 10.9% and 26.2% of patients treated for IDA and DNR, respectively. No patient progressed to AHSCT in the MXR arm (p <0.001). In the study, 142 (44.8%) deaths were reported, and there was a 48.5%, 26.2%, and 22.2% mortality rate between the IDA, DNR, and MXR treatment groups, respectively. There was no significant difference in OS by anthracycline type in both the study cohort and age group <60 years (Figures 1A and 1B). There was also no significant difference in OS in patients with the adverse genetic risk group and <60 years age group with adverse genetic risk, according to 2017ELN (Figures 1C and 1D). The results may have been influenced by the number of patients in the treatment groups of the retrospective study and by differences in fitness levels that needed to be measured systematically. Conclusions: We are encouraged that our findings mostly agree with previously published studies and that IDA, DNR, and MXR offer comparable survival values in the research and the younger patient groups. In the future, the ever-changing treatment environment in patient groups with targetable mutations makes choosing the optimal anthracycline for induction chemotherapy in AML much more difficult.

Integrative Single-Cell Tracking of Clonal Evolution, Leukemia Phenotypes and Donor Engraftment Following Allogeneic Stem Cell Transplant Using Mitochondrial DNA Mutations

Mitochondrial DNA (mtDNA) mutations can distinguish cells from unrelated individuals and their spectrum per patient sample can evolve following therapeutic bottlenecks. As such, these natural barcodes can potentially enable integrated single cell tracking of chimeric cellular populations and clonal evolution following unrelated allogeneic hematopoietic stem cell transplantation (HSCT). However, the feasibility of mtDNA-based donor-recipient deconvolution or identification of leukemia-specific phenotypes and the extent of co-evolution with somatic mutations remains unknown. If confirmed, post-transplant monitoring using mtDNA mutations could enable detection of early post-HSCT relapse and provide qualitative information on leukemia phenotypes, clonal evolution, or residual donor engraftment via a combined single cell assay. To investigate the extent of co-evolution of somatic nuclear mutations with mtDNA mutations, we generated 33,796 single cell DNA sequencing profiles (Tapestri) from 3 sample pairs of circulating chronic lymphocytic leukemia (CLL) collected before and after HSCT. The samples were characterized using a primer panel (n=67 nuclear and 21 mtDNA) targeting single nucleotide variants previously identified by whole-exome sequencing. We detected 8 mtDNA mutations that defined CLL subclones together with a median of 14 (8-19) somatic mutations from these cases. Clonal shifts defined by somatic mutations discernable pre- or post-HSCT tracked with analogous changes in mtDNA mutations and included clonal replacement, selection of a resistant subclone or skewing of CLL subclones. We thus provide clear evidence of co-segregation between somatic nuclear and mtDNA mutations. To assess the sensitivity of mtDNA-based donor-recipient deconvolution, we performed an in-silico titration and spiked 1-1,000 single cell mtDNA profiles (mtscATAC-seq) from one CLL case ('CLL4') into 7,579 profiles from another ('CLL5'). Overall, we recovered 98.3-100% of CLL4, identifying up to 1 in 7,579 cells (0.13%). Only 123 cells (1%) failed deconvolution, due to insufficient mtDNA coverage. In an in-vitro titration of expanded T cells (donor1) with peripheral blood mononuclear cells (donor2) at ratios of 1:3, 1:30 and 1:300, we recovered 1,449 of 5,345 (27%), 150 of 4,262 (3.5%) and 14 of 4,381 (0.3%) T cells of donor1. In sum, with current sequencing throughput, mtDNA-based donor-recipient deconvolution was assessed to have a sensitivity of ~0.1%. To determine if mtDNA-based deconvolution can track early AML relapse and identify leukemia phenotypes, we analyzed peripheral blood and bone marrow of 4 patients with disease recurrence 87-185 days post-HSCT and subsequent reinstatement of remission 105-184 days after tapering of immunosuppression (IST). We obtained 19,143 ATAC with select antigen profiling by sequencing (ASAP-seq) profiles at incipient relapse (pre-IST) and following response to IST (post-IST). Donor-recipient deconvolution detected recipient-derived cells in progenitor, erythroid and monocytic populations pre-IST but no recipient-derived cells post-IST, consistent with elimination of AML. Overall, chromatin accessibility of donor- and recipient-derived cells was very similar, reflecting that AML recapitulates hematopoietic differentiation states. Nevertheless, we observed differences in accessibility of genes such as IL1B, CD36, chemokine or homeobox protein genes in recipient- compared to donor-derived cells. Together, mtDNA-based donor-recipient deconvolution reflected clinical responses and identified leukemia-specific chromatin accessibility profiles. Finally, we tracked clonal evolution and donor-derived hematopoiesis in two non-responder cases of overt AML relapse following 3-10 cycles of decitabine and ipilimumab (NCT02890329). We defined 12 and 7 mtDNA-based AML subclones and observed contraction and expansion of subclones during treatment. Donor-derived non-T cells were exceedingly rare (12 of 10,708 [0.1%] and 34 of 5,863 [0.6%]), mainly of erythroid origin (12 and 23 cells) and disappeared during treatment. Thus, mtDNA mutations can monitor donor- and recipient-derived hematopoiesis and resolve short-term changes in AML subpopulations during therapy. As sequencing throughput improves, we envision single cell-based post-transplant monitoring as a powerful approach for guiding clinical decision making.

Phase I/II Study of Reduced Dosing of Post-Transplantation Cyclophosphamide (PTCy) after HLA-Identical Peripheral Blood Hematopoietic Stem Cell Transplantation

Introduction Post-transplant cyclophosphamide (PTCy)-based prophylaxis for acute graft versus host disease (aGvHD) has become a standard protocol in HLA haploidentical bone marrow transplantation. Preliminary evidence indicates that compared to the standard dosage (50 mg/kg on days +3 and +4 post-transplantation), a regimen of half the typical cyclophosphamide dosage is both feasible and effective. However, the optimal dosage and timing of PTCy for aGvHD prophylaxis in a HLA identical setting, using peripheral stem cells as the graft, remain unknown. This study aims to investigate the efficacy and safety of a reduced PTCy dosage regimen in patients undergoing peripheral blood stem cell transplants (PBSCT) with HLA indentical donors. Methods This prospective, single-center phase I/II study enrolled patients scheduled for PBSCT with HLA identical donors. The aGVHD prophylaxis regimen comprised PTCy on days +3 and +4, followed by cyclosporine initiation from day 5 post-transplant. In the phase I stage, an initial cohort of five patients received PTCy at a dosage of 50 mg/kg/day on days +3 and +4 (designated as dose level 1, DL1). This was followed by a 3+3 dose de-escalation design with subsequent dose levels as follows: DL2, 50 mg/kg on day +3 and 25 mg/kg on day +4; and DL3, 25 mg/kg on both day +3 and +4. The dose-limiting toxicity for this de-escalation was defined as the occurrence of grade III-IV aGVHD within the first 100 days post-transplantation. The phase II stage comprised an expansion cohort, which was based on the optimal dose identified during phase I. aGvHD classification was established using the Mount Sinai Acute GVHD International Consortium (MAGIC) criteria, while chronic GvHD (cGvHD) was assessed per the latest National Institutes of Health Consensus on cGvHD. Patients were closely followed-up at +1, +2, +3, +4, +6, +9, +12, +18, and +24 months post-transplant. Results In the first stage, a total of 11 patients (5 in DL1, 3 in DL2, and 3 in DL3) were included, and no patient developed grade III-IV aGVHD. Based on this, DL3 was selected as the PTCy dose for phase II, which comprised 18 patients. Overall, 29 patients (17 females, 12 males) with a median age of 39 years (range 17-65) were included, and the median follow-up duration was 12.7 months (range 2.2-22.1). Patient and disease characteristics are summarized in Table 1. By day +30 post-ASCT, all patients achieved complete remission (CR) and minimal residual disease (MRD) clearance. No patient developed grade III-IV aGVHD within 100 days post-transplantation. There was no significant difference in the neutrophil and platelet engraftment interval among the three groups (Figure 1A, B). Among the 21 patients who received the DL3 dose of PTCy, the estimated cumulative incidence of grade II to IV aGVHD at day +100 was recorded at 28.6%, and the incidence of aGVHD at day +100 presented no difference among the three DL groups (Figure 1C). In addition, 1 patient in DL3 developed grade IV intestinal aGVHD on day +141 and died one month later. The estimated 1-year cumulative incidence of hemorrhagic cystitis (HC) and cytomegalovirus (CMV) reactivation was 19.3% and 19%, respectively (Figure 1D). Five patients (all in DL3) experienced relapse, with a median interval of 6.7 months and an estimated 1-year cumulative incidence of 10.6%. A total of 5 fatalities occurred during our study (1 in DL1, and 4 in DL3), 1 due to relapse, 2 from COVID-19-associated pulmonary aspergillosis, 1 from severe septicemia and 1 due to grade IV aGVHD as mentioned above. The estimated 6-month cumulative incidence of NRM was 9.5%, presenting no difference among the three DL groups (Figure 1E). Among the 20 evaluable patients, the estimated 1-year cumulative incidence of chronic GVHD (cGVHD) and moderate cGVHD was 37.3% and 16% (Figure 1F), respectively, with no severe cGVHD observed. No cases of patient relapse were reported. The estimated 1-year progression-free survival (PFS) and overall survival (OS) were 61.2% and 80.4%, respectively (Figure 1G). Conclusion The findings of this study substantiate that a two-day regimen of PTCy at 25 mg/kg/day serves as an effective and safe prophylactic measure against aGVHD, comparable to the standard dosing protocol. However, to definitively establish whether the de-escalated PTCy dosage provides superior outcomes to the standard regimen, longer-term follow-up and comparative studies are warranted.

Idasanutlin and Navitoclax Induce a Synergistic p53-Dependent Apoptotic Cell Death in T-Cell Acute Lymphoblastic Leukemia

T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive hematologic malignancy with a five-year event-free survival rate that declines with age. Existing therapies for T-ALL, particularly in adults, are intensive and poorly tolerated, with high rates of of treatment-related morbidity and mortality and a high frequency of relapse. In T-ALL, activating Notch pathway mutations are common and thought to induce transformation in part through activation of c-Myc. Typically, increased expression of c-Myc induces apoptosis through the p19(ARF)-Mdm2-p53 tumor suppressor pathway. Unsurprisingly, over 70% of T-ALL cases have inactivating mutations in CDKN2A (p19Arf). However, greater than 95% of primary and 75% of relapsed T-ALL cases maintain wild type p53. We hypothesized that MDM2 inhibition would lead to T-ALL cell apoptosis by bypassing the loss of ARF. We reported in a previous ASH abstract initial studies evaluating the MDM2 inhibitor idasanutlin in the context of T-ALL. We observed that T-ALL patient-derived xenograft (PDX) lines treated in vitro showed modest induction of apoptosis. Additionally, we observed upregulation of pro-apoptotic p53 target genes including Bax and Puma1, leading us to hypothesize that inhibition of pro-survival BH3 domain proteins Bcl-2, Bcl-xL, and Bcl-W by navitoclax (ABT-263) would synergize to enhance apoptosis. In vitro treatment of a panel of PDX lines with combined therapy led to robust cell death with strong induction of pro-apoptotic p53 targets in all lines. In vivo, we assessed the response of four T-ALL xenografts to dual treatment. All showed a significant reduction of tumor burden compared to the most efficacious single therapy and evidence of synergy in all tested lines, as evaluated by a modified Bliss Independence test analyzing average daily change in tumor burden. Overall survival was significantly increased in the combination treatment group. We report here further mechanistic characterization of idasanutlin and navitoclax dual therapy in the context of T-ALL, as well as several therapeutically-oriented comparisons. While our initial studies used navitoclax due to prior work showing that T-ALL frequently expresses and is dependent on Bcl-xL ( Chonghaile et al., 2014), navitoclax can cause a dose-limiting thrombocytopenia due to on-target Bcl-xL inhibition in circulating platelets. Therefore, we treated our PDX panel with a dose matrix of idasanutlin with navitoclax or venetoclax, which lacks Bcl-xL activity. We observed that the navitoclax combination showed strong evidence of synergic activity, as measured by zero interaction potency (ZIP) score ( Yadav et al., 2015). Idasanutlin and navitoclax combination therapy had global ZIP scores suggesting an additive effect in 1 line and strongly synergic activity in the remaining 4 lines. Venetoclax showed an additive benefit in 3 lines, but was only synergistic in 1 of 5 lines tested. These results underscore the importance of Bcl-xL targeting in T-ALL and support further investigation of whether combination treatment with idasanutlin permits a more tolerable navitoclax dosing regimen. We also evaluated ruxolitinib in combination with idasanutlin, as recent work has shown overlapping responses to inhibitors of Jak/Stat or Bcl-2 ( Yuan et al. 2022). While we observed moderate activity of ruxolitinib monotherapy, combination with idasanutlin was additive against one and synergistic in none of the tested lines. To confirm the p53-dependence of idasanutlin dual therapy, we engineered p53 knockout T-ALL cell lines and observed strong induction of apoptosis and p53 target genes in wildtype cells, which was entirely abrogated in p53 LOF lines. Additionally, we performed RNA-seq on PDX cells treated with single or dual therapy to mechanistically characterize transcriptional responses to the drug combination. We observed minimal changes in navitoclax-only treated cells at the RNA level, consistent with its on-target post-transcriptional regulation of apoptotic induction. Idasanutlin and combination therapy samples clustered closely in PCA analysis, with p53 response a strongly-induced pathway, as expected. Our data suggest that the rational combination of idasanutlin and navitoclax is highly active against T-ALL, with greater synergic opportunity compared to other available idasanutlin combination treatments, through induction of a p53-dependent apoptotic cell death.

Heterogeneous Gene Fusion Transcripts Found in t(7;12)(q36;p13) Acute Myeloid Leukemia but with Similar Gene Expression Profile

Cytogenetic aberrations are often involved in acute myeloid leukemia (AML) and can serve as diagnostic markers, prognosis predictors and impact the choice of therapy. A translocation t(7;12)(q36;p13) is reported in up to 20-30% of AML patients typically diagnosed before 24 months of age (Beverloo, Panagopoulos et al. 2001, Cancer Res 61(14): 5374-5377). However, in a retrospective survey of the Nordic Organization of Pediatric Hematology and Oncology (NOPHO) registry, only 4% of reported AML diagnosed before 24 months of age had t(7;12) (Espersen, Noren-Nystrom et al. 2018, Genes Chromosomes Cancer 57(7): 359-365). The t(7;12) is difficult to identify with conventional karyotyping, why the true frequency of t(7;12) may be underestimated. Similarly, the reported prognosis for t(7;12) patients has varied ranging from good (Espersen, Noren-Nystrom et al. 2018) to dismal (von Bergh, van Drunen et al. 2006, Genes Chromosomes Cancer 45(8): 731-739). The translocation has been reported to give rise to an in-frame fusion transcript, MNX1::ETV6. However, detection of this fusion is reported only in 50% of cases in contrast to high expression of MNX1 in 100% (von Bergh, van Drunen et al. 2006). The aim of this study was to determine the frequency of the t(7;12) in pediatric AML patients in the NOPHO AML-2004/2012 protocols, their event-free and overall survival and to investigate the presence of additional genetic alterations. Patients in Sweden, Denmark, or Iceland between 2004 to 2020 diagnosed with AML before 2 years of age that had not been reported with a recurrent genetic aberration plus all patients diagnosed with t(7;12) AML were identified. Bone marrow, or peripheral blood samples from patients were retrieved from the NOPHO biobank. This cohort constituted 86% (31 out of 36) of all patients that fulfilled these criteria. In total 89 AML patients were diagnosed before 2 years of age. The t(7;12) AML cases were identified by screening for high expression of MNX1 and presence of fusion transcripts using whole transcriptome sequencing (WTS). Whole genome sequencing (WGS) was done to identify chromosomal rearrangements, and translocation breakpoints. At diagnosis, four patients were diagnosed with t(7;12). A central karyotype review of all patients reported two additional cases. No further cases were identified using WTS. Thus, the frequency of t(7;12) AML was 7% (6 out of 89) and for patients diagnosed before 12 months of age 11% (5 out of 47). In total 12 cases with t(7;12) were identified in the complete NOPHO registry but only 11 patients received treatment according to NOPHO protocol. The relapse rate was 54% (6 out of 11). All relapse cases underwent allogeneic hematopoietic stem cell (HSC) transplantation in complete remission two (CR2), and their overall survival (OS) was 83% (5 out of 6). Hence OS for all t(7;12) patients treated according to the NOPHO2004 and NOPHO2012 protocols was 91% (10 out of 11). Analysis of WTS data showed similar gene expression profile between our t(7;12) cases and t(7;12) cases retrieved from the TARGET database. Genes that were typically overexpressed in all t(7;12) AML were, MNX1, MNX1-AS1, MNX1-AS2, LIN28B, BAMBI, MAF, CRISP3, EDIL3, CTTNBP2, KRT72, and AGR2, where MNX1 seems to be uniquely expressed in this type of leukemia (Nilsson et al. 2022, Int J Cancer 151(5): 770-782). Analysis of fusion transcripts showed presence of MNX1::ETV6 in just one case. The remaining cases instead showed presence of other fusion transcripts involving ETV6, NOM1::ETV6, ETV6::NOM1, ETV6::LMBR1 and ETV6::BMAL2. WGS verified a fusion between NOM1 and ETV6 in 3 cases. The patient with ETV6::BMAL2 showed that 16 Mb of chromosome 12 was inserted into chromosome 7 placing a large part of ETV6 near MNX1. The fusion transcript ETV6::BMAL2 is the product of what remains on chromosome 12. In conclusion, frequency of t(7;12) AML in the NOPHO treatment cohort was approximately 7%, with 54% relapse rate, but most patients were salvaged by HSCT in CR2. Heterogeneous gene fusion transcripts were identified in this subgroup of AML where ETV6::NOM1 was most frequent. However, all cases showed similar gene expression signatures which underlines that the leukemia driving event is ectopic expression of MNX1 (Waraky, A., 2023, Haematologica, DOI: 10.3324/haematol.2022.282255) and should therefore be the defining classifying criteria of this type of AML.

A Study of Dyslipidemia and Its Clinical Implications in Childhood Nephrotic Syndrome.

Nephrotic syndrome in children is characterized by dyslipidemia, which is an indirect risk factor for cardiovascular diseases, progressive glomerulosclerosis, and related complications. The objective is to determine the range of lipid profile abnormalities in relation to onset, relapse, and remission, as well as to determine if there is any relationship between dyslipidemia and the frequency of relapses. One hundred and two diagnosed cases of nephrotic syndrome in the age group of less than 12 years were included, out of which 64 patients belonged to the first episode of nephrotic syndrome and 38 patients were relapse cases. Steroid-resistant nephrotic syndrome cases or patients with a history of diabetes mellitus, hypothyroidism, familial hypercholesterolemia, children with chronic kidney disease, and edema due to other causes were excluded from the study. There was a statistically significant increase in lipid parameters except for high-density lipoprotein (HDL) cholesterol at the disease onset when compared to remission in cases of the first episode as well as relapse cases of nephrotic syndrome. There was a positive correlation between relapse frequency and dyslipidemia. Dyslipidaemia was also associated with low serum albumin, with a p-value <0.001, which is statistically significant. Dyslipidemia is significantly higher in relapse cases of nephrotic syndrome and remains higher even during remission. Dyslipidemia is a directly associated risk factor for atherosclerosis and coronary heart disease (CAD), along with progressive glomerulosclerosis. Early identification and treatment of hyperlipidemia is therefore justified so that along with longevity, we can also improve the quality of life of children suffering from nephrotic syndrome.

Oncological Skull Base Reconstruction with Microvascular Tissue Transplantation in Advanced Relapsed Cases

Introduction: Tumors involving the skull base are real challenges to reconstructive surgeons. Many articles have been published about these reconstructions, especially in primary cases. In tumor relapses after previous surgeries or irradiation, the surgical options for reconstruction are extremely narrowed and is our opinion that microvascular autologous tissue transplantation is specially indicated in those patients, even though it requires a technically demanding procedure. Materials and Methods: We analyzed retrospectively all patients treated at our institution between March 2014 and December 2018 and that met all the inclusion criteria: 1) oncological surgery for a tumor involving the skull base; 2) previous surgical treatment for that tumor; 3) cranial base bone resection; 4) dural exposure or defect; 5) reconstruction done with a free flap. The patient's age, comorbidities, number of previous surgeries and/or irradiation, oncological excisional procedures, type of defect, type of reconstruction, postoperative complications and mortality were reviewed. Results: Fifteen flaps were used in the 14 patients that met all the inclusion criteria. The used flaps were: Anterolateral Thigh (ALT) perforator or chimeric ALT/Vastus Lateralis (VL) (n=6), profunda artery perforator (n=3), muscular Rectus Abdominis (n=2), Vertical Rectus Abdominis Myocutaneous (VRAM) (n=2), chimeric osteomuscular scapular tip/Latissimus Dorsi (LD) (n=1) and radial forearm (n=1). Dural defects were reconstructed with Pericranial or fascia Lata grafts in 7 patients. No total flap failures or vascular thrombotic events were noted and just one case of partial flap necrosis was registered (treated conservatively). There was one case of cerebrospinal fluid leakage, one diffuse cerebral edema and one donor site wound dehiscence, all successfully treated with conservative measures. The only complication that required a second operation was a cranioplasty prosthetic exposure that required a second free flap. One patient had a tracheostomy bleeding followed by a pneumothorax and died 8 weeks postoperatively with a nosocomial pneumonia. In the follow-up period, one patient died 19 months postoperatively with a local relapse and another with a metastatic disease (at month 15). Conclusion: Secondary or multiple relapsed cases in the skull base require reconstructions that are technically demanding and the defects are often extensive. The surgical options are extremely reduced by previous treatments and if the basic concepts of cranial base reconstruction were strictly respected, the microsurgical free flaps can offer the best chance to avoid severe complications. However, it is not without some postoperative complications and mortality can be significant in the follow-up because of the advanced stage of the oncologic disease.

Childhood Leprosy in Postelimination Era: A Clinico-Epidemiological Prospective Observational Study from India

Background: Although India has achieved national level elimination of leprosy in December 2005, it reports highest number of leprosy cases in the world. Incidence of leprosy amongst young children indicates active foci of transmission in the community, making it a robust epidemiological indicator to assess the progress of leprosy control programs. Aim and Objectives: To study prevalence, clinical spectrum, patterns of extracutaneous involvement, reactions, relapse, demographic profile, anthropometric characteristics of children with leprosy. Materials and Methods: A prospective observational study of children younger than 14 years old with clinical signs and symptoms of leprosy, including cases diagnosed from October 2018 through September 2020 at a tertiary hospital in Eastern India. Results: Childhood leprosy constituted of 10.4% of total new leprosy cases. Mean age observed was 11.14 ± 1.5 years. 30.4% were females and 69.6% were males. The mean average duration was 9.95 ± 12.3 months. 82.1% of children belong to below poverty line (BPL) status. 19.6% of children had malnourishment/stunting/thinness, and 55.4% had anemia. 84.1% presented with skin discoloration. The most common site affected was upper limb (57.1%). 29.2% had contact history. A single case of relapse (1.7%) was reported. Most common peripheral nerve involved was ulnar nerve (67.8%). 8.9% of children had type 1 lepra reaction, and 1.7% had type 2 lepra reaction. 73.21% presented with borderline tuberculoid clinical type of leprosy. 19.6% showed slit skin smear positivity. Conclusion: Pockets of high endemicity of childhood leprosy as detected in the current study point toward the unmet need of better healthcare facilities along with increased awareness, campaigns, and school surveys for early diagnosis and treatment for the prevention of complications and spread in community.

Interventions for promoting patients’ adherence to 14-day primaquine treatment in a highly malaria-endemic township in Myanmar: a qualitative study among key stakeholders

BackgroundPlasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients’ commitment to PQ treatment in a highly malaria-endemic township in Myanmar.MethodsA qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis.ResultsResponsible individuals from different levels of the Myanmar National Malaria Control Programme participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community’s malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted.ConclusionIn rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

Clinical experience of using brentuximab-vedotin as therapy in relapsed/refractory Hodgkin's lymphoma at Hospital Guillermo Grant Benavente, Concepción, Chile

Hodgkin's lymphoma is a B-cell neoplasm with a good prognosis but a poor response to chemotherapy in refractory or relapsed cases. Brentuximab-vedotin is an anti-CD30 monoclonal antibody approved for use in these cases. This study aims to describe the clinical experience of patients treated with brentuximab-vedotin through expanded access modality. A retrospective study on clinical information of patients diagnosed with refractory or relapsed Hodgkin's lymphoma treated with brentuximab-vedotin at the Regional Hospital of Concepción in the period 2015-2021. 7 patients were identified, 5/7 male, with a median age of 35 years (21-50). Five cases were mixed cellularity, and two were nodular sclerosis. Four were in stage II, 1/7 in stage III, and 3/7 in stage IV. The median number of previous treatment lines was 4 (3-5), and the relapse was post-transplantation in two cases. In 6/7 cases, brentuximab-vedotin was used as induction, and in one case, it was used as post-autologous bone marrow transplant maintenance. The administration was outpatient via a peripheral route with a median dose of 150 mg and ten cycles. In one case, dose adjustment was required due to toxicity. Three out of 6 patients achieved complete remission and underwent autologous stem cell transplantation. brentuximab-vedotin is an outpatient medication with low toxicity that can optimize the treatment of patients with relapsed-refractory Hodgkin's lymphoma.

Pulmonary Tuberculosis and Rifampicin Resistant Mycobacterium Tuberculosis in Children and Adolescents using Gene Xpert MTB/RIF Assay in Tigray, Northern Ethiopia.

Tuberculosis (TB) continues to be a global health problem. While childhood TB contributes 10% to the global TB burden, the paucibacillary nature of TB disease in children and the absence of reliable diagnostic methods have made MTB diagnosis in children to be a great challenge. This study aimed to determine the prevalence of MTB and rifampicin-resistant MTB (RR-MTB) among children using Gene Xpert MTB/RIF Assay in Tigray, Ethiopia. A retrospective database study was conducted among children in ten governmental hospitals in the Tigray region. Gene Xpert MTB/RIF results of sputum/gastric lavage samples from children with presumptive TB from January 2016 to December 2019 were extracted using a data extraction sheet. Data were collected and analyzed using Statistical Package for the Social Sciences version 21. The prevalence of bacteriologically confirmed MTB by Gene-Xpert in children with presumptive TB was 7.3% (95% CI: 6.7%-7.9%) and the proportion of those that were Gene-Xpert MTB positive who also have rifampicin resistance was 10.9% (95% CI: 8.2-13.6%). Older children aged 11-15 years [AOR = 1.76; 95% CI = 1.33-2.33, p < 0.001] and adolescents 16-17 years [AOR = 2.18; 95% CI = 1.63-2.92, p < 0.001] were more likely to be MTB positive. Relapse cases [AOR = 1.66; 95% CI = 1.09-2.51, p = 0.017] and lost/failure cases [AOR = 8.82; 95% CI = 3.94-19.76, p < 0.001] were more likely to have MTB compared to the new cases. The proportion of MTB-positive among the TB presumptive patients was 7.3%. The proportion of rifampicin-resistant TB to all positive patients was 10.9%. Female participants had more MTB than males (or younger children). The result highlights the need for due attention in children because it is very helpful in determining the future control of the disease.

Evaluation of hematological and biochemical factors of hypertension during the induction chemotherapy for childhood acute lymphoblastic leukemia

Background: Acute lymphoblastic leukemia (ALL) is a prevalent childhood cancer, accounting for approximately 25% of all pediatric cancer cases. The incidence of hypertension in ALL patients is significantly higher compared to the general pediatric population, emphasizing the need for a better understanding and management of this condition. The aim of the study was to evaluate hematological and biochemical factors of hypertension during the induction of chemotherapy for childhood ALL. Methods: This prospective observational study was conducted in the Department of Pediatric Hematology and Oncology at BSMMU from July 2017 to June 2018. The study included 93 newly diagnosed cases of ALL in children aged 1 to 17.9 years, excluding those below 1 year and above 18 years, known cases of hypertension, patients with pre-existing hypertension before chemotherapy, and old or relapse cases of ALL. Results: The study found that 17.2% of the study population experienced renal derangement during the induction remission phase, while the majority (82.8%) did not. The presence of renal derangement was not significantly associated with hypertension. However, patients who developed tumor lysis syndrome (TLS) had a higher percentage (12.5%) of hypertension compared to the non-hypertensive group (1.3%). Febrile neutropenia, convulsion, and coagulopathy were also observed in patients who developed hypertension more frequently. The median time to detect hypertension during induction chemotherapy was on day 8, with a mean duration of 13.6 days. Conclusions: In this study, hypertension is observed in 17.2% of patients during induction chemotherapy for ALL with higher frequency in the second week and associations with tumor lysis syndrome, febrile neutropenia, convulsion, and coagulopathy.

Биологические эффекты богатой тромбоцитами плазмы в лечении макулярного разрыва

Aim of the work is to describe the mechanisms of therapeutic effect of platelet-rich plasma (PRP) components on the retina in macular hole (MH) surgery. Methods. This study presents the results of 36 cases of surgical treatment of MH and the use of autologous PRP. Cellular composition of PRP of 24 patients was analyzed. Results. 2 months after the operation, all the patients had restoration of all retinal layers in the MH region and positive dynamics of visual acuity in comparison with preoperative period. After follow-up for 6 months after surgery, no cases of MH relapse were detected. Conclusion. The accumulation of data on the effective use of PRP components makes it possible to plan its wider and more effective use in the treatment of degenerative, infectious, post-traumatic and other disorders of the structures of the eye. Key words: macular hole; platelet-rich plasma.

Abstract PR09: Detection of minimal residual disease in post-surgical drain fluid can predict locoregional recurrence in HPV-negative head and neck cancer patients

Abstract Introduction: Locoregional cancer relapse remains a major cause of failure in head and neck squamous cell carcinoma (HNSCC), particularly for HPV-negative patients whose 3-year locoregional failure rate is 32.5%. There is a major unmet need for an accurate diagnostic test that predicts risk of locoregional recurrence prior to adjuvant therapy selection. We present a novel proximal assay for minimal residual disease (MRD) profiled in lymphatic exudate collected via surgical drains (“lymph”). Methods: Lymph, plasma, and peripheral blood were collected from 22 HPV-negative HNSCC patients postoperatively at 24 hours along with resected tumor. Cell-free DNA was extracted from lymph and plasma and sequenced using the TruSeq Oncology 500 panel to a depth of &amp;gt;100 million reads. One plasma sample failed due to inadequate coverage. Two patients were censored due to lack of clinical data, yielding 9 patients with disease recurrence (REC) and 11 with no evidence of disease (NED) with &amp;gt;1 year of follow-up. Somatic mutations were identified from exome sequencing (200x) in tumor with matched blood. Tumor-specific variants were force-called in lymph and plasma using a custom bioinformatic pipeline. Mutation calls were filtered by a base-specific error model to eliminate artifacts. Student’s t-test was used for group comparisons. The Kaplan-Meier (KM) estimator with log-rank test and Cox proportional-hazards model were used for survival analyses. Results: ctDNA allelic fraction was 1.5x higher in lymph than in plasma (lymph = 0.11% ± 0.16%; plasma = 0.076% ± 0.12%. p = 0.018, N = 100 mutations). Significantly more mutations were detected in REC lymph compared to NED (p = 0.009), but not in plasma REC vs. NED (p = 0.16). We classified patients as positive (&amp;gt;1) or negative (£1) for detected mutations in each analyte and performed a KM survival analysis, showing lymph could accurately predict recurrence (sensitivity = 89%, specificity = 82%; p &amp;lt; 0.005) while plasma could not (sensitivity = 67%, specificity = 40%; p = 0.59). The hazard ratio in lymph was 12.52 (95% CI 1.54-101.61). We stratified REC patients by locoregional or locoregional + distant relapse and observed significantly more mutations detected in lymph (p = 0.01) from locoregional relapse while lymph and plasma performed similarly for locoregional + distant relapse (p = 1.0). We compared lymph MRD outcomes to extranodal extension (ENE), a high-risk pathologic feature. Lymph was concordant with ENE in 12/20 patients and identified an additional 6 ENE-negative relapse cases. Conclusion: Postoperative ctDNA analysis of lymph from surgical drains represents a novel MRD approach in HPV-negative HNSCC. Lymph significantly outperforms plasma for prediction of recurrence, particularly in patients with locoregional relapse. Accurate MRD identification in patients with lower risk pathologic features suggests that postoperative lymph MRD testing has the potential to significantly augment traditional pathology and provide more personalized adjuvant treatment decision-making in patients with HPV-negative HNSCC. Citation Format: Aadel A. Chaudhuri, Zhuosheng Gu, Damion Whitfield, Noah Earland, Adam Harmon, Megan Long, Peter Harris, Zhongping Xu, Ricardo Ramirez, Sophie Gerndt, Maciej Pacula, Marra S. Francis, Wendy Winckler, Jose P. Zevallos. Detection of minimal residual disease in post-surgical drain fluid can predict locoregional recurrence in HPV-negative head and neck cancer patients [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Innovating through Basic, Clinical, and Translational Research; 2023 Jul 7-8; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2023;29(18_Suppl):Abstract nr PR09.