Relapse Status Research Articles

Abstract 3668: Plasma cell-free DNA profiling for deciphering cellular origins and immune competence in cancer patients

Abstract Plasma cell-free DNA (cfDNA) originates from apoptotic cells in the blood, providing a real-time insight into the biology of various cell types. The fragment coverage pattern of cfDNA across the genome is known to reflect the distinct chromatin status of originating cells. While extensive research has focused on fragments derived from cancer, known as circulating tumor DNA (ctDNA), for inference about cancer biology, cfDNA fragments from healthy cells have received little attention. Our study explores the potential of cfDNA to decipher the relative abundance of distinct blood cell types, particularly immune system cell types. We collected a cohort of 273 bladder (BC) and colorectal cancer (CRC) patients and 45 healthy controls for plasma whole genome sequencing and assessed the fragment coverage profile at transcription start sites (TSS) of protein coding genes. A significant negative correlation was observed between TSS coverage and whole blood gene expression (Spearman’s rho = -0.65). Furthermore, TSS coverage revealed a bimodal distribution, characterized by modes corresponding to high and low gene expression levels in blood cells. This may suggest the cfDNA coverage profile as a binary expression status classifier to distinguish between expressed and unexpressed genes in blood cells. We further evaluated TSS with differential coverage between age groups of healthy individuals and relapse status of cancer patients. Notably, out of the TSS that significantly differentiated middle-aged (aged 40-65) from older individuals (aged 65+), 31 were also able to distinguish relapse from non-relapse patients. Among these TSS were CD36, SLAMF7, TABBP and PDCD1, known to be involved in immune related pathways. Finally, we evaluated coverage at cell-type specific TSS and found dendritic cells (P-value: CRC = 8e-06, BC = 5.1e-3), monocytes (CRC = 1.6e-04, BC = 2.5e-3), and NK cells (CRC = 8.5e-04, BC = 0.026) to exhibit a significant increase in coverage in the cancer cohorts compared to healthy controls. Conversely, T-cells showed a decrease in coverage (CRC = 0.041, BC = 0.062). In conclusion, cfDNA coverage profile may identify TSS with differential coverage between patient groups and characterize a shift in blood cell type composition as a response to cancer. Future work may show if fragment coverage quantifies the relative contribution of cfDNA from distinct immune cell types. We anticipate our analysis to illuminate the utility of plasma cfDNA as a biomarker for cancer patient’s immune competency, enabling improved patient stratification for treatment, leveraging their distinct immune capabilities. Citation Format: Laura Andersen, Amanda Frydendahl, Tenna Vesterman Henriksen, Christina Demuth, Mads Heilskov Rasmussen, Iver Nordentoft, Karin Birkenkamp-Demtröder, Jakob Skou Pedersen, Søren Besenbacher, Lars Dyrskjøt, Claus L. Andersen, Nicolai J. Birkbak. Plasma cell-free DNA profiling for deciphering cellular origins and immune competence in cancer patients [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 3668.

Treatment modifiers across different regimens of natalizumab treatment in MS: An Italian real-world experience

Despite its widespread use in clinical practice, the effectiveness of natalizumab extended interval dosing (EID) adopted from treatment start across different treatment intervals and individual modifiers (body mass index - BMI) is still under-investigated. Here, seven-hundred and forty-five multiple sclerosis (MS) patients, exposed to natalizumab for 3.30 ​± ​1.34 years, were retrospectively enrolled in an observational multicenter study. After stratifying patients in EID or standard interval dosing (SID), we assessed differences in time to relapse, MRI activity and Expanded Disability Status Scale (EDSS) progression. The primary analysis was conducted on patients exposed to EID interval from 5 weeks and 1 day to 7 weeks, while a secondary analysis included also EID periods up to 8 weeks. An additional analysis explored the impact of BMI. No differences in time to first relapse, time to radiological activity, time to EDSS progression or time to EDA (evidence of disease activity) were detected between SID and EID group (EID interval from 5 weeks to 1 day to 7 weeks). When including EID periods from 7 weeks and 1 day to 8 weeks, the EID group showed a trend towards higher risk of experience clinical relapses than the SID group. A higher EDA risk was also identified in EID patients with BMI above median. In conclusion, a higher risk of relapses seems to occur for EID above 7 weeks. Independently from the EID scheme adopted, higher BMI increases the risk of EDA in these patients.

Clinical implications of additional chromosomal abnormalities in adult acute myeloid leukemia with inv (16)/t(16;16)/CBFB::MYH11.

This study assesses the clinical significance of additional cytogenetic abnormalities (ACAs) and/or the deletion of 3'CBFB (3'CBFBdel) resulting in unbalanced CBFB::MYH11 fusion in acute myeloid leukemia (AML) with inv (16)/t(16;16)/CBFB::MYH11. We retrospectively evaluated the clinicopathologic features of 47 adult de novo AML with inv (16)/t(16;16)/CBFB::MYH11 fusion. There were 44 balanced and 3 unbalanced CBFB::MYH11 fusions. Given the low frequency of unbalanced cases, the latter group was combined with 19 published cases (N = 22) for statistic and meta-analysis. Both balanced and unbalanced cases were characterized by frequent ACAs (56.5% and 72.7%, respectively), with +8, +22, and del(7q) as the most frequent abnormalities. The unbalanced group tends to be younger individuals (p = .04) and is associated with a lower remission rate (p = .02), although the median overall survival (OS) was not statistically different (p = .2868). In the balanced group, "ACA" subgroup had higher mortality (p = .013) and shorter OS (p = .011), and patients with relapsed disease had a significantly shorter OS (p = .0011). Cox multivariate regression analysis confirmed that ACAs and history of disease relapse are independent risk factors, irrespective of disease relapse status. In the combined cohort, cases with ACAs had shorter OS than those with "Sole" abnormality (p = .0109). ACAs are independent high-risk factors in adult AML with inv (16)/t(16;16)/CBFB::MYH11 fusion and should be integrated for risk stratification in this disease. Larger studies are needed to assess the clinical significance of the unbalanced CBFB::MYH11 fusion resulting from the 3'CBFBdel.

Microscopic residual disease (MRD) monitoring with circulating tumor DNA (ctDNA) across gastrointestinal (GI) malignancies.

176 Background: ctDNA is a powerful tool that can detect early evidence of tumor relapse, or MRD. There are limited studies characterizing the performance of ctDNA in non-colorectal GI cancer patients (pts). We describe the clinical outcomes of GI cancer pts who underwent real-world MRD testing at our institution. Methods: We retrospectively analyzed GI cancer pts with ≥1 ctDNA test (Natera, Inc) ordered for MRD testing between June 2020-August 2022. Descriptive statistics were used to characterize rates of ctDNA positivity (ctDNA+) and relapse rates (RR). Median relapse-free survival (mRFS) and overall survival (mOS) were calculated using Kaplan-Meier method, group comparisons by log-rank test, and hazard ratios (HR) by Cox proportional hazard models. Associations between initial mean tumor molecules per milliliter (MTM/mL) (continuous variable) and clinical factors were assessed by Kruskal-Wallis or Wilcoxon Rank-sum tests. Results: ctDNA testing was successful in 222/228 pts (table). The median follow-up was 15 months (mo) (Interquartile Range 8.6-24.7). 61/222 (27.5%) of pts had ≥1 ctDNA+ test of which 59% had relapse on their next scan obtained after a median of 40 days from the first + test. Of all relapsed pts (62/222), ctDNA detected relapse before imaging in 69.4% with a median lead time of 57 days. The positive and negative predictive values of ctDNA for relapse were 82% and 92.5%, respectively. The mRFS was 10.8 mo vs. not reached (NR) (HR 18.6; p<0.0001) and mOS 43.1 mo vs. NR (HR 5.0; p=0.002) in anytime vs. never ctDNA+ pts with similar trends in the colorectal and pancreas subgroups. Of ctDNA+ pts with >1 test, 49.2% (29/59) cleared ctDNA with 79.3% of clearances on/after therapy. Between ctDNA clearers and non-clearers, RR were 72.4% vs. 93.3%, mRFS 12.4 vs. 7.6 mo (HR 0.3; p=0.6), and mOS NR vs. 43.1 mo (log-rank test p=0.01). No significant associations existed between initial MTM/mL and tumor types (p=0.6), relapse status (p=0.2), or number of relapse sites (p=0.4). Conclusions: ctDNA is a prognostic tool able to detect early relapse with high accuracy in GI cancers. The initial MTM/mL in ctDNA+ pts did not correlate with tumor histology or relapse patterns. Pts clearing ctDNA tended to have improved outcomes; however, RRs were higher than anticipated. More pts and longer follow up will help characterize the performance of ctDNA across rarer GI subtypes. [Table: see text]

Microbiota and mucosal gene expression of fecal microbiota transplantation or placebo treated patients with chronic pouchitis

ABSTRACT Altered microbiota and impaired host immune function have been linked to the pathogenesis of pouchitis. We used 16S rRNA gene sequencing and RNA sequencing data from a previous randomized clinical trial (RCT) on fecal microbiota transplantation (FMT) therapy in 26 chronic pouchitis patients with one-year follow-up. We analyzed changes in both luminal and mucosal microbiota composition, as well as in host mucosal gene expression to gain insights into the host–microbiota interactions possibly underlying clinical outcomes of the patients. Antibiotic type and pattern of use were significant drivers of the luminal microbiota at baseline. Differential gene expression analysis indicated transition from ileal to colonic gene expression in the pouch, and upregulation in inflammation- and immune system-related pathways in the pouch. At 4 weeks, the non-relapsed FMT patients had a lower microbiota dissimilarity to the donor than the non-relapsed placebo patients (p = .02). While two FMT-treated patients showed a shift toward the donor’s microbiota during the one-year follow-up, the overall FMT microbiota modulation effect was low. Patient’s luminal and mucosal microbiota profiles were unstable in both FMT and placebo groups. Expression of the chemokine receptor CXCR4 was downregulated at 52 weeks compared to the baseline in the non-relapsed patients in both FMT and placebo groups. Microbiota modulation by FMT seems to be low in this patient group. The microbiota composition or alterations did not explain the relapse status of the patients. Some evidence for remission-related host gene expression pattern was found; specifically, CXCR4 expression may have a role in sustained remission.

Prevalence of Tuberculosis Patients Treated in Ba’qhuba Primary Health Care Centers (PHCCs)

Background: Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is the leading cause of death worldwide. It can be both prevented and treated. There are two types of tuberculosis (pulmonary TB and extrapulmonary TB).
 Objective: To describe the prevalence of TB cases in PHCCs that covers health services in Ba’qhuba second health sector.
 Patients and Methods: A cross sectional study was conducted in Ba’qhuba second health sector by using Data of all patients (61 cases) registered in the tuberculosis unit from 1st of Jan 2021 to 1st of Jan 2023, regarding their prevalence and relapse status. The data has been analyzed using Microsoft Excel version 2019.
 Results: The findings revealed 57% of patients lived in urban areas, the gender ratio was 1:2 male to female, and 26% of cases were among the 45–54 age group. The Incidence of the disease during the two years was 16.1 cases per 100,000 persons while the prevalence was 18.2 cases per 100,000 person-year, TB prevalence regarding the PHHCs was (AL-Yarmouk, Al-Gatton, Bani Saad, and Hay Al-Mustafa) was (5, 4, 2.4, and 0.32 cases per 10,000 person-year, respectively). In terms of TB type, 51% were pulmonary TB (PTB). Regarding EPTB patients 67% had symptoms. According to the sites of infection of EPTB (bones and vertebrae, other, lymph node, pleural effusion, meningitis), they were 33%, 30%, 20%, 13%, and 3%, respectively. And 85% of all patients were in category I of treatment and 15% were in category II due to relapses and 44%of them were laboratory- confirmed and 66% of relapses were pulmonary TB.
 Conclusion: The prevalence of Al-Yarmouk PHCCs was the highest, almost half of the patients were suffering from Extra-pulmonary TB, while according to relapsed cases pulmonary TB cases were two time more than extra-pulmonary.

Prevalence of Tuberculosis Patients Treated in Ba’qhuba Primary Health Care Centers (PHCCs)

Background: Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is the leading cause of death worldwide. It can be both prevented and treated. There are two types of tuberculosis (pulmonary TB and extrapulmonary TB). Objective: To describe the prevalence of TB cases in PHCCs that covers health services in Ba’qhuba second health sector. Patients and Methods: A cross sectional study was conducted in Ba’qhuba second health sector by using Data of all patients (61 cases) registered in the tuberculosis unit from 1st of Jan 2021 to 1st of Jan 2023, regarding their prevalence and relapse status. The data has been analyzed using Microsoft Excel version 2019. Results: The findings revealed 57% of patients lived in urban areas, the gender ratio was 1:2 male to female, and 26% of cases were among the 45–54 age group. The Incidence of the disease during the two years was 16.1 cases per 100,000 persons while the prevalence was 18.2 cases per 100,000 person-year, TB prevalence regarding the PHHCs was (AL-Yarmouk, Al-Gatton, Bani Saad, and Hay Al-Mustafa) was (5, 4, 2.4, and 0.32 cases per 10,000 person-year, respectively). In terms of TB type, 51% were pulmonary TB (PTB). Regarding EPTB patients 67% had symptoms. According to the sites of infection of EPTB (bones and vertebrae, other, lymph node, pleural effusion, meningitis), they were 33%, 30%, 20%, 13%, and 3%, respectively. And 85% of all patients were in category I of treatment and 15% were in category II due to relapses and 44%of them were laboratory- confirmed and 66% of relapses were pulmonary TB. Conclusion: The prevalence of Al-Yarmouk PHCCs was the highest, almost half of the patients were suffering from Extra-pulmonary TB, while according to relapsed cases pulmonary TB cases were two time more than extra-pulmonary. Keywords: TB, Prevalence, Diyala, Mycobacterium

Comparing Phenotyping, Gene Expression, and Function of T Lymphocytes before Mobilization Chemotherapy Versus after Stem Cell Harvesting in Patients with B Cell Lymphoma and Multiple Myeloma

Chimeric Antigen Receptor T cell (CAR-T) therapy is an effective treatment for relapsed and refractory hematological diseases. However, a significant medical unmet need persists, particularly for patients at the relapse and refractory (R/R) status, who often experience leukopenia or lymphopenia during lymphocyte collection. This limitation poses considerable challenges to the successful implementation of CAR-T treatment, primarily due to the impaired function of T cells resulting from multiple lines of treatment and disease progression. As a consequence, the quality of the CAR-T cell product may be compromised. Before introducing CAR-T therapy, most patients with B cell lymphoma or multiple myeloma (MM) experienced mobilization chemotherapy and high-dose granulocyte colony-stimulating factor (G-CSF) administration for stem cell harvesting, followed by autologous stem cell transplantation as a salvage or consolidation treatment. Given that the procedure of lymphocyte collection for CAR T cell manufacturing is quite similar to stem cell harvesting, it becomes reasonable to explore the possibility of collecting lymphocytes immediately after the stem cell harvesting process. The advantage of this strategy is that patients are typically in a healthier condition with better T cell function compared to their status during R/R status. However, the effects of mobilization chemotherapy and high-dose G-CSF on T lymphocytes remain inadequately understood. To assess the feasibility of lymphocyte collection, it is essential to delve into the function of T lymphocytes at two critical time points: before mobilization chemotherapy compared to after stem cell harvesting. In this study, we recruited 19 patients with B cell lymphoma or MM. Paired peripheral blood samples were obtained before administering mobilization chemotherapy and after stem cell harvesting. Flow cytometry analysis using CCR7 and CD45RA markers was applied to classify T cell subsets, including T naive or T stem cell-like (TN/SCM, CCR7+/CD45RA+), T central memory (TCM, CCR7+/CD45RA-), T effector memory (TEM, CCR7-/C5RA-), and T effector (Teff, CCR7-/CD45RA+) (Figure A). The data indicated no significant difference in T cell phenotype between pre-mobilization chemotherapy and after stem cell harvesting. CD4and PD-1 expression were also analyzed and showed no significant difference between the two time points. To gain further insights, we performed RNA sequencing on 3 paired samples from patients with large B cell lymphoma (UPN#3, UPN#11, UPN#16). Through our observations, we noticed that these 3 paired samples could be clustered into 2 groups based on differential gene expression (Figure B), which corresponds to pre-mobilization chemotherapy versus post-stem cell harvesting status. Our findings strongly indicate that T cells at the pre-mobilization chemotherapy status exhibit significant differences in gene expression compared to those at the post-stem cell harvesting status. Specifically, T cells from post-stem cell harvesting show significantly higher expression of NIBANI, ALOX5AP, and GLUL compared to those from pre-mobilization. NIBANI plays a vital role in down-regulating apoptosis by interacting with the MDM2/p53/Bcl2/Bax pathway, promoting cell survival under stress-dependent conditions. GLUL is responsible for glutamine synthetase, and glutamine is an important source of biosynthetic precursors in active T cells. On the other hand, T cells from pre-mobilization show higher expression of TOX, DUSP4, and TGFBR3 compared to those from post-stem cell harvesting. TOX is a transcription factor involved in T cell exhaustion and senescence, while DUSP4 expression is associated with defective TCR signaling and accelerated T cell senescence. Our data indicate that the proportion of T naive or T stem cell-like phenotypes remains unchanged after mobilization chemotherapy and G-CSF injections during stem cell harvesting. RNA sequencing data further reveal that T cells at the post-stem cell harvesting status are associated with down-regulated apoptosis, favorable survival and activation, and reduced exhaustion and senescence compared to those at the pre-mobilization stage. This study suggests that instead of collecting lymphocytes during relapse or refractory status, collecting them right after stem cell harvesting may be a viable alternative.

Prior Knowledge Integration Improves Relapse Prediction and Identifies Relapse Associated Mechanisms in Childhood B Cell Acute Lymphoblastic Leukemia

Introduction Despite decades of research and advancement in frontline treatments of B cell acute lymphoblastic leukemia (B-ALL), relapse remains the major barrier to survive this diagnosis in children and young adults. Although the majority of children will respond to initial treatment, 50% of children who relapse will die. Hence, there is a critical unmet need to prevent relapse in these patients. Previously, using proteomic features and predictive modeling we reported that patients who will eventually suffer relapse have cells predictive of their future relapse detectable at the time of diagnosis. These cells sit at the pro-B to pre-B transition in B-cell development and have elevated expression of signaling proteins: SYK, rpS6, CREB and 4EBP1. Although, our model outperformed standard risk models such as NCI criteria and MRD relapse risk, our model lacks higher accuracy and precision. Here, we utilize novel immunological Elastic-Net (iEN) model for relapse prediction which incorporates per-feature prior knowledge into the predictive model and improves the predictive power of the model. Methods and Results We analyzed 160 diagnosis bone marrow samples of children with newly diagnosed B-ALL treated on the cooperative group protocols. These samples comprised multiple cytogenetic subtypes and were annotated for clinical outcome (MRD status, relapse status, time to relapse) and patient attributes. Cells in these samples were analyzed using single-cell mass cytometry and expression of markers defining B cell developmental stages(CD34, CD38, CD127, CD24, TdT, CD179a, CD179b, IgHi, IgHs, CD19, CD20), signaling molecules (p4EBP1, pSTAT5, pPLC-γ2, pAKT, pSYK, pRPS6, pERK1-ERK2, pCREB) and transcription factors(TFs) (IKAROS, PAX5) were detected in the basal condition as well as after short-term ex vivo stimulation. Following data acquisition and preprocessing, cells were developmentally classified to the closest healthy B-cell population using a single-cell developmental classifier. Following cell-type classification, 1) frequency of cells with each of signaling molecules and TFs in the unstimulated state and in response to each of 3 stimulations, 2) age and WBC counts for each patient were extracted. These data were split in 90% training and 10% validation cohort. Prior knowledge for signaling molecules and TFs in response to each ex vivo stimulation condition is included after evaluation by a panel of expert cancer biologists such that molecules more consistent with known relapse biology have score of 1 and less consistent molecules have <1. This prior knowledge and training phase data were utilized to construct the iEN. The performance of model was determined using ten-fold cross-validation. Once constructed the model was applied to a validation cohort. The iEN predicts relapse status with AUROC 0.85 ± 0.06 and outperforms our published model as well as standard risk models. Piecewise regression analysis of iEN revealed that pro-BI and pro-BII cells highly expressing pSYK, pCREB, pRPS6, p4EBP1 and pAKT have the highest coefficient magnitudes and are associated with relapse, consistent with our prior results. These molecules act within the network downstream of the pre-B cell receptor, suggesting relapse associated cells to have activated preBCR signaling. The transcriptomic profile of these cells revealed enrichment of PI3K-mTOR pathway genes, consistent with activated signaling profiles predicted by iEN. However, these cells were also enriched for expression of genes associated with metabolic pathways: oxidative phosphorylation, glycolysis, and fatty acid metabolism. Using a CyTOF panel focused on metabolic proteins, we confirmed co-expression of preBCR associated molecules and metabolic proteins (GLUT1, Enolase 1 and lactate dehydrogenase A) in pro-BI (TdT+/CD24-/CD179a+/CD179b+) and pro-BII (TdT+/CD24+/IgMi-/IgMs-) cells from relapse patients. Together this data suggests a relationship between active preBCR signaling with cellular metabolism and relapse. Conclusions Supervised predictive models integrating specific domain knowledge may improve prediction of relapse and identification of relapse associated mechanisms in B-ALL. Further analysis and integration of clinical data are underway and will be presented.

Determinants and Clinical Impact of Time to Plasma Exchange in Patients with Immune Thrombotic Thrombocytopenic Purpura

Background: Immune thrombotic thrombocytopenic purpura (iTTP) is a hematologic emergency characterized by severe acquired deficiency in the von Willebrand factor-cleaving metalloprotease ADAMTS13 and thrombotic microangiopathy, resulting in end organ damage and death if untreated. Plasma exchange (PLEX) is vital to the management of iTTP and has dramatically improved survival in this disorder since the 1980s. Guidelines recommend initiation of PLEX within 4-8 hours of presentation. However, despite the importance of prompt medical intervention, determinants of the total interval between symptom onset and initiation of PLEX (S2P) and time from presentation at the pheresis center to PLEX (door to PLEX, D2P) remain unclear. Further, the impact of S2P and D2P on clinical outcomes in iTTP have not been evaluated. Objective: Identify factors that predict S2P and D2P in patients with iTTP and assess the clinical impacts of S2P and D2P. Methods: We retrospectively evaluated cases in the Harvard TMA Research Collaborative (HaTRC), a curated single-center rare disease registry containing all consecutive iTTP cases seen between 2004 and 2022 at the three main Harvard teaching hospitals. We restricted our modeling analyses to patients who resided <350 km from downtown Boston. S2P was defined as time from patient-reported symptom onset until initiation of PLEX. D2P was defined as the time from the first complete blood count specimen drawn at a HaTRC hospital until the initiation of PLEX. Determinants of S2P and D2P were identified using multiple linear regression modeling of covariates derived from the HaTRC registry. The impacts of S2P and D2P on mortality and the composite of mortality and need for ICU admission were assessed using multiple logistic regression modeling. Results: A total of 155 unique patients comprising 243 separate iTTP episodes were recorded ( Figure 1). Analyses were limited to patients who resided <350 km from downtown Boston (n = 147 patients, 227 cases). The median (IQR) age was 40 (29-53) years. The cohort was 76% female, 63% of European ancestry, and 45% of episodes were relapse presentations. The median (IQR) S2P for the entire cohort was 4.3 (1.8-7.5) days, and the median D2P was 8.4 (5.0-16.0) hours. Excluding relapse presentations, crude S2P correlated with distance from Boston (Spearman r = 0.216, 95% CI: 0.029-0.389, p=0.02). After adjusting for age, sex, race, and LDH, we found that higher platelet count at presentation (β=0.039, 95% CI: 0.00047 to 0.077, p=0.047) and increased distance from Boston (β=0.030, 95% CI: 0.007 to 0.053, p=0.011) were associated with longer S2P, while patents with relapse presentations experienced a shorter S2P (β=-1.9, 95% CI: -3.7 to -0.12, p=0.037) ( Table 1). By contrast, increased D2P was significantly associated with male sex (β=7.43, 95% CI: 1.128 to 13.73, p=0.021) and higher platelet count (β=0.16, 95% CI: 0.41 to 0.27, p=0.008) but not with distance from Boston or relapse status. Longer S2P or D2P times were not associated with increased mortality, hospital LOS, or the composite of mortality and need for ICU admission; however, there was a non-significant trend towards increased LOS with relapse presentations (p=0.06) and longer D2P times (p=0.09). Conclusions: Our data suggest that iTTP patients who live farther from the hospital where they ultimately receive PLEX, those with higher platelet counts at presentation, and those presenting for the first time with iTTP experience a longer time to initiation of care. After hospital presentation, the determinants of a longer time to PLEX initiation shift to male sex and higher platelet count, both of which may be associated with lower clinical suspicion for iTTP and delayed diagnosis. These findings should be externally validated in an independent dataset.

Therapy Related Multiple Myeloma: A Distinct Entity

Background The development of therapy-related multiple myeloma (t-MM) is a poorly described entity. Multiple myeloma (MM) is the second most common hematologic malignancy. Despite significant strides in MM treatment over recent decades, identifying modifiable risk factors, optimizing screening methodologies, and identifying potential treatment strategies or targets to address t-MM remains of utmost importance, as this disease continues to pose a significant therapeutic challenge and remains incurable. This retrospective review seeks to explore the incidence and characteristics of t-MM at a medium-sized, academic center. Methods We performed a single institution retrospective chart review of patients diagnosed with multiple myeloma between 2008-2023 and evaluated for prior diagnosis of solid malignancy, excluding all skin cancers, lymphomas or myeloproliferative neoplasm (MPN). We collected data for the following: prior treatment for solid malignancy, lymphoma or MPN, lapsed time between prior therapy and development of MM, cytogenetics, prominent subtype present, renal failure and hypercalcemia if present at time of diagnosis, management of t-MM including transplant data, disease progression including relapse status, and survival data. Results In our study, we identified a subgroup of 17 individuals who had a previous history of solid malignancy, 1 patient with unknown prior solid tumor, 1 patient with history of Hodgkin's lymphoma, and 1 additional patient with history of MPN who received chemotherapy and/or radiation therapy, with 3 patients having MGUS prior to development of MM. Notably, among this population, 70% were male. All patients developed MM following the treatment for a solid malignancy, lymphoma or MPN. The average amount of time from diagnosis of solid tumor, lymphoma or MPN to development of MM was 9.53 years (1-25 years). 50% of the individuals were White Americans, while the remaining 50% were African Americans. A significant majority (85%) of the population had a single primary solid tumor. Among the primary solid tumors, 45% were prostate cancer, 15% were breast cancer, and 10% were renal cell carcinoma (Figure 1). 5 patients received chemotherapy alone without documented prior radiation exposure while 13 had prior radiation exposure for prior solid malignancy. At time of diagnosis, 45% of patients had renal failure with 10% of patients having both renal failure and hypercalcemia. Within the t-MM subtypes, we discovered that 50% had IgA type, with 70% of these individuals exhibiting the IgA Kappa subtype. 45% of the individuals who developed t-MM had the IgG type, with 78% of them with IgG Kappa subtype. 15 (75%) of the patients received transplant and only 2 patients had confirmed relapse with 2 patients unknown and 2 additional patients who passed away prior to starting maintenance therapy following transplant. 4 patients are very early in their disease process and as of yet have not undergo transplant. 55% of our patients are presumed living. The OS for patients with t-MM was 1190 days compared to the average OS of 2326 days in our institutional MM database without t-MM. Conclusion Our analysis focused on patients diagnosed with MM who had a prior history of solid primary tumors, lymphoma or MPN treated with chemotherapy and/or radiotherapy in hopes of providing valuable insights into the characteristics and outcomes of individuals who developed MM following treatment for solid tumors, lymphoma or MPN. Our findings highlighted specific risk factors associated with t-MM in this population. Being male and having a history of prostate cancer was associated with higher incidence of development of t-MM. This is likely related to the radiation therapy associated with prostate cancer, as radiation exposure has been a known risk factor for the development of MM. We observed that the predominant subtype of MM among these individuals was IgA kappa, which diverges from the prevalent subtype, IgG kappa, observed in the general population. IgA is known to typically have more cytogenetic abnormalities and overall poorer prognosis, likely contributing to the difference in OS compared to patients with t-MM and MM not associated with prior malignancy. These insights shed light on the unique characteristics and potential influences of treatment-related MM in patients with prior malignancies or MPN.

Study protocol for Ketamine as an adjunctive therapy for major depression (2): a randomised controlled trial (KARMA-Dep [2

BackgroundDepression is a common psychiatric disorder and a leading cause of disability worldwide. Conventional monoaminergic antidepressants have limited efficacy and take weeks to exert a therapeutic effect. Single infusions of subanaesthetic doses of ketamine exhibit rapid antidepressant action but effects are transient and relapse is common. One potential strategy for increasing ketamine’s antidepressant efficacy and/or prolonging its therapeutic benefit may be serial infusions. There is limited evidence on the efficacy and safety of repeated ketamine infusions against an active comparator.MethodsThis protocol describes an ongoing pragmatic, randomised, controlled, parallel-group, patient- and rater-blind, superiority trial. Eligible adult inpatients with a confirmed DSM-5 diagnosis of a major depressive episode (unipolar or bipolar) are randomly allocated in a 1:1 ratio to a course of up to eight infusions of ketamine or midazolam twice-weekly over four weeks. The primary objective is to assess the efficacy of serial adjunctive ketamine infusions versus active comparator midazolam by measuring Montgomery-Åsberg Depression Rating Scale score difference between arms from before the first infusion to 24 h after the final infusion, supplemented by a 95% confidence interval. To facilitate generalisability of results, the trial takes place under “real world” conditions with both groups continuing to receive regular inpatient care including treatment-as-usual pharmacotherapy, nursing care, and psychological and other therapies during the randomised treatment phase and regular outpatient care thereafter. Participants are monitored for relapse during a 24-week follow-up after the end of the randomised phase. Secondary objectives of the trial are to assess: response and remission rates at the end of randomised phase; relapse status during the 24-week follow-up after the end of the randomised phase; the safety and tolerability of repeated ketamine infusions regarding psychotomimetic and other psychiatric side effects, cognitive side effects, as well as withdrawal symptoms, haemodynamic stability, neurological, urological, and other physical side effects; and quality of life and cost-effectiveness.DiscussionThere is an unmet clinical need for rapidly-acting novel antidepressants. This trial will provide efficacy, safety and health economic data on serial ketamine infusions and thus help inform clinical practice on the potential role of this treatment in the management of depression.Trial registrationEudraCT 2019-003109-92. Registered 2 October 2019. ClinicalTrials.gov NCT04939649. Registered 25 June 2021.

Abstract 14968: Clonal Hematopoiesis and Cardiotoxic Risk After Hematopoietic Stem Cell Transplantation

Background: Clonal hematopoiesis (CH) occurs as part of normal hematopoietic stem cell senescence and prior chemotherapy administration. As such, CH is frequent for patients undergoing allogeneic stem cell transplants (ASCT). CH has been identified as a driver of inflammation. In animals, inflammation plays a role in atrial fibrillation (AF) development, the most common cardiotoxicity after ASCT treatment. Yet, whether the presence of post-ASCT CH associates with AF risk is unknown. Methods: We analyzed bone marrow derived mononuclear cells from 201 cancer patients treated with ASCT by deep targeted amplicon sequencing (next generation sequencing) to detect the presence of select CH (defined as DNMT3A, TET2, ASXL1, IDH1, FLT3, JAK2 at VAF of ≥ 2%), irrespective of relapse status; at median 4 months post ASCT. Observed incident AF rates were compared to Framingham heart predicted rates. Cox regression and survival analysis were used to define factors associated with incident AF and MACE, as well as the relationship between the presence of post-transplant CH mutations and MACE risk. Further, we also assessed the effect of CH on post-ASCT survival outcomes. The presence of mutations was analyzed for an association with post-ASCT incident AF and overall survival. Results: Overall, the prevalence of CH in post-ASCT patients was 42.3% (85), including 29.5% with ≥2 mutations. Over a median follow-up of 33 months, 11.5% of patients developed incident AF and 29.9% experienced MACE. In those without prior AF, the weighted average incidence was 407/10,000 person-years compared to the Framingham-predicted 63/10,000 person-years (RR 6.4, P <0.001; AER 344). In follow-up, increased CH burden associated with increased risk of incident AF (HR 3.6, P =0.04), cancer-progression (HR 2.6, P =0.006), and mortality (HR 2.09, P =0.047); Figure . There was no difference in non-AF MACE. Conclusions: The presence of CH in ASCT treated cancer patients appears to associate with increased AF risk.

THU670 Serum TSI Concentration In Patients With Graves’ Disease Undergoing Maintenance-dose Of Antithyroid Drug (ATD) And Its Relationship With Disease Relapse After ATD Withdrawal

Abstract Disclosure: P.V. Nguyen: None. K.T. Nguyen: None. Background: Graves' disease (GD) is an autoimmune disorder in which thyroid-stimulating immunoglobulin (TSI) plays a key role in its pathogenesis. TSI assays have been recently optimized in their accuracy, and the procedure has also been simplified, which can potentially replace TRAb measured by conventional TSH-binding inhibitory immunoglobulins (TBII) assays in routine clinical practice. Objectives: Our objective was to study the serum TSI concentration in patients with Graves’ disease undergoing maintenance-dose ATD. We also aimed to assess the predictive value of TSI immunoassay, as well as the clinical signs and thyroid function tests in predicting Graves’ disease relapse following ATD discontinuation. Finally, follow-up would be continued to check for relapse or long term euthyroid status. Methods: Retrospective follow-up study of 352 patients with hyperthyroidism due to GD, treated at the endocrine outpatient clinic of Medic Medical Center, Ho Chi Minh City from January 2000 to April 2021. TSI was measured several times during the course of treatment when planning to stop the medication (at the discretion of the attending physician). ATD withdrawal would be considered when the patients achieved clinical euthyroidism with normal FT4 tests for at least 3 months with minimal dose of ATD. The decision to withdraw ATD was also based on TSI concentration, as well as the goiter’s characteristics and parenchymal vascularity observed via thyroid Doppler ultrasound. Results: The median TSI concentration of patients with GD undergoing maintenance-dose ATD was 1.45 IU/L (normal range <0.10 IU/L), and their thyroid function measured at the same time tended to be euthyroid in our study. TSI cut-off level at ATD withdrawal to predict the recurrence of GD was 1.31 IU/L which corresponded with the sensitivity, specificity, positive and negative predictive values of 63.64%, 78,79%, 50% and 86.67%, respectively. Multiple logistic regression analysis showed that the following factors were associated with an increased risk of relapse after the end of medical treatment: Graves' ophthalmopathy (GO), OR 3.69 (95% CI: 1.06-12.87; p=0.04), treatment duration less than 18 months, OR 7.77 (95% CI: 1.92-31.42; p<0.01), TSI level before ATD withdrawal ≥1.31 IU/L, OR 9.92 (95% CI: 2.77-35.42; p<0.01). Conclusion: At the time of ATD withdrawal, while normal FT4 levels were observed, high TSI levels were indicative of an ongoing immune process. These findings suggest that TSI measurements, in addition to clinical and ultrasound evaluations, may aid in the prediction of GD relapse after ATD discontinuation. In addition, GO, treatment duration of less than 18 months and TSI level before ATD withdrawal ≥1.31 IU/L were associated with an increased risk of relapse of GD after ATD discontinuation. Our study contributes to the expanding literature supporting the clinical utility of TSI assay in the management of GD. Presentation: Thursday, June 15, 2023

Challenges in Administering Salvage Therapy and Outcomes of Relapsed/Refractory Diffuse Large B-Cell Lymphoma Patients: A LMIC Real-World Study.

Standard therapy for patients with Relapsed/Refractory Diffuse Large B-Cell Lymphoma (RR DLBCL) involves salvage chemotherapy followed by autologous hematopoietic stem cell transplant. However, information regarding the number of patients receiving salvage therapy and associated factors is not available from low/middle income countries (LMICs). All patients treated at our center with RR DLBCL from 2016 to 2021 were included in the study. Univariate and multivariate analyses was performed to find factors associated with the lack of receipt of salvage chemotherapy. Eighty-five patients were included in the study. Most patients had primary refractory disease (69.4%). Only 26 patients received standard salvage therapy, while the others (N = 59) received metronomic/palliative oral therapy. On univariate analysis, patients with an annual income below India's Gross National Income per capita (p = 0.014), an education level below Class XII (p = 0.025), Stage III/IV disease at relapse (p = 0.018) and CNS relapse (p = 0.027) were more likely to receive palliative therapy. Conversely, patients with a late relapse were more likely to receive salvage therapy (p = 0.001). On multivariate analysis, patients with Stage III/IV relapse (p = 0.030) and an education level less than Class XII (p = 0.012) were more likely to receive palliative therapy, while patients with a late relapse (p = 0.001) were more likely to receive salvage therapy. Patients who received salvage therapy had a longer Median OS than those who received palliative therapy (p < 0.001). Timing of relapse, stage at relapse and educational status of the patient are significant factors affecting access to effective therapy for patients with RR DLBCL in LMICs.

Significant gut microbiota related to patterns of drinking and alcohol relapse in patients with alcoholic hepatitis undergoing stool transplant or corticosteroid therapy.

Alcohol-induced gut microbiota (GM) alterations are linked to alcohol use disorder (AUD) pathogenesis. Healthy donor stool transplant (fecal microbiota transplant [FMT]) reduced alcohol desire and improved clinical outcomes in small animal and human studies. Baseline and post-therapy-related GM changes in a real-world cohort with severe alcohol-related liver disease and AUD, patterns of drinking, and relapse have not been studied. We prospectively analyzed retrospective clinical data and stored samples to examine GM alterations in a cohort of severe alcohol-associated hepatitis (SAH) patients who underwent FMT or corticosteroid treatment followed for at least 12 months. The GM changes at baseline in the context of a pattern of drinking (binge vs. every day) and baseline and post-treatment alcohol relapse status (relapser vs. non-relapser). We identified 28 patients on FMT and 25 on corticosteroids who survived 1 year post-treatment. After necessary exclusions, the final cohort for various grouped GM analysis included 16 patients in the FMT arm and 14 on corticosteroids. Pedobacter and Streptophyta species at the commencement of treatment predicted alcohol relapse in steroid-ineligible patients receiving FMT and steroid-treated patients, respectively. At 6-12 months post-FMT, non-relapsers had elevated short-chain fatty acid-producing bacterial taxa linked with lower alcohol cravings. Alcohol relapse was significantly more in those on steroid therapy and was associated with the upregulation of the nucleotide metabolism pathway related to ethanol metabolism. We demonstrate pertinent baseline and post-treatment intestinal bacterial alterations that impact patterns of AUD patterns and relapse in SAH patients in the context of the therapy offered.

Predictors of relapse in patients with oligoarticular juvenile idiopathic arthritis in remission off medication.

The aim of this study was to evaluate the predictors of relapse in patients with oligoarticular juvenile idiopathic arthritis (oJIA) who achieved clinical remission off medication. This retrospective observational study was conducted between June 2009 and July 2022 in 126 patients with oJIA who achieved remission off medication. The relationships between relapse status and demographic, clinical and laboratory findings, and treatment details were evaluated using electronic medical records. Of the 126 oJIA patients who achieved remission off medication, 85 (67.5%) were female. Relapse occurred in 31 patients (24.6%) with remission off medication after a median of 18months (IQR 7-26). No statistically significant relationship was found between gender, age at diagnosis, oJIA subtype, number of joints, ANA, ESR, CRP level, initial Juvenile Arthritis Disease Activity Score and relapse in oJIA patients who achieved remission off medication (p = 0.66, p = 0.25, p = 1, p = 0.54, p = 0.29, p = 0.59, p = 0.95 and p = 0.52, respectively). There was a statistically significant relationship between the number of intraarticular corticosteroid injections (IACIs) and relapse (p = 0.01). Patients who underwent IACI 2-3 times had more relapses than those who never underwent IACI and those who underwent IACI only once (p = 0.01, p = 0.02, respectively). A relationship was found between the length of follow-up and relapse in patients with oJIA who achieved remission off medication (p = 0.035). Conclusion: In oJIA patients who achieve remission off medication, the probability of relapse increases in patients who need ≥ 2 IACI during the period until remission. The length of follow-up period is associated with the probability of relapse. What is Known: • Approximately one-fourth of oJIA patients who are in remission off medication have relapse. • There is a need for markers that can predict the risk of relapse in oJIA patients who achieve remission on or off medication. What is New: • The possibility of relapse should be considered in patients with oJIA who need ≥ 2 IACIs until achieving remission off medication. • The relapse rate may increase as the follow-up period prolongs in patients who achieve remission off medication.

Understanding and predicting future relapse in depression from resting state functional connectivity and self-referential processing

BackgroundThe recurrent nature of Major Depressive Disorder (MDD) asks for a better understanding of mechanisms underlying relapse. Previously, self-referential processing abnormalities have been linked to vulnerability for relapse. We investigated whether abnormalities in self-referential cognitions and functioning of associated brain-networks persist upon remission and predict relapse. MethodsRemitted recurrent MDD patients (n = 48) and never-depressed controls (n = 23) underwent resting-state fMRI scanning at baseline and were additionally assessed for their implicit depressed self-associations and ruminative behaviour. A template-based dual regression approach was used to investigate between-group differences in default mode, cingulo-opercular and frontoparietal network resting-state functional connectivity (RSFC). Additional prediction of relapse status at 18-month follow-up was investigated within patients using both regression analyses and machine learning classifiers. ResultsRemitted patients showed higher rumination, but no implicit depressed self-associations or RSFC abnormalities were observed between patients and controls. Nevertheless, relapse was related to i) baseline RSFC between the ventral default mode network and the precuneus, dorsomedial frontal gyrus, and inferior occipital lobe, ii) implicit self-associations, and iii) uncontrollability of ruminative thinking, when controlled for depressive symptomatology. Moreover, preliminary machine learning classifiers demonstrated that RSFC within the investigated networks predicted relapse on an individual basis. ConclusionsRemitted MDD patients seem to be commonly characterized by abnormal rumination, but not by implicit self-associations or abnormalities in relevant brain networks. Nevertheless, relapse was predicted by self-related cognitions and default mode RSFC during remission, suggesting that variations in self-relevant processing play a role in the complex dynamics associated with the vulnerability to developing recurrent depressive episodes. Clinical trial registrationNetherlands Trial Register, August 18, 2015, trial number NL53205.042.15.

Rates and associations of relapse over 5 years of 2649 people with bipolar disorder: a retrospective UK cohort study

BackgroundEvidence regarding the rate of relapse in people with bipolar disorder (BD), particularly from the UK, is lacking. This study aimed to evaluate the rate and associations of clinician-defined relapse over 5 years in a large sample of BD patients receiving routine care from a UK mental health service.MethodWe utilised de-identified electronic health records to sample people with BD at baseline. Relapse was defined as either hospitalisation, or a referral to acute mental health crisis services, between June 2014 and June 2019. We calculated the 5-year rate of relapse and examined the sociodemographic and clinical factors that were independently associated with relapse status and the number of relapses, over the 5-year period.ResultsOf 2649 patients diagnosed with BD and receiving care from secondary mental health services, 25.5% (n = 676) experienced at least one relapse over 5 years. Of the 676 people who relapsed, 60.9% experienced one relapse, with the remainder experiencing multiple relapses. 7.2% of the baseline sample had died during the 5-year follow-up. Significant factors associated with experiencing any relapse, after adjustment for relevant covariates, were history of self-harm/suicidality (OR 2.17, CI 1.15–4.10, p = 0.02), comorbidity (OR 2.59, CI 1.35–4.97, p = 0.004) and psychotic symptoms (OR 3.66, CI 1.89–7.08, p < 0.001). Factors associated with the number of relapses over 5 years, after adjustment for covariates, were self-harm/suicidality (β = 0.69, CI 0.21–1.17, p = 0.005), history of trauma (β = 0.51, CI = 0.07–0.95, p = 0.03), psychotic symptoms (β = 1.05, CI 0.55–1.56, p < 0.001), comorbidity (β = 0.52, CI 0.07–1.03, p = 0.047) and ethnicity (β = − 0.44, CI − 0.87 to − 0.003, p = 0.048).ConclusionsAround 1 in 4 people with BD in a large sample of people with BD receiving secondary mental health services in the UK relapsed over a 5-year period. Interventions targeting the impacts of trauma, suicidality, presence of psychotic symptoms and comorbidity could help to prevent relapse in people with BD and should be considered in relapse prevention plans.

Prognostic value of combined WT1 and multiparameter flow cytometry assessment for measurable residual disease after induction in non-APL acute myeloid leukemia

The objective of this study was to investigate the expression pattern of Wilms tumor 1 (WT1) gene at diagnosis, complete remission (CR) and relapse status in non-acute promyelocytic leukemia (non-APL) acute myeloid leukemia (AML) patients, and further explore the prognostic value of measurable residual disease (MRD) assessment by WT1 gene and multiparameter flow cytometry (MFC). Our results showed that the average expression level of WT1 was 4026 ± 616.1 copies/104 ABL at diagnosis, 155.3 ± 36.03 copies/104 ABL at CR, and 1766 ± 238.8 copies/104 ABL at relapse, with statistically significant differences (p = .000). ROC analysis showed that WT1 expression levels were 118.1 copies/104 ABL and MFC-MRD was 0.155%, which had good predictive efficacy for relapse of patients during consolidation therapy. Both WT1-MRD and MFC-MRD had a significant impact on relapse-free survival (RFS) and overall survival (OS). Patients with WT1-MRD positive or MFC-MRD positive were associated with worse RFS (HR 3.840, 95% CI 1.582–9.320, p = .003), (HR 4.464, 95% CI 1.841–10.984, p = .001) and worse OS (HR 2.963, 95% CI 1.058–8.295, p = .039), (HR 3.590, 95% CI 1.254–10.280, p = .017). Besides, compared with patients who were negative for both WT1-MRD and MFC-MRD, patients who were positive both WT1-MRD and MFC-MRD were associated with worse RFS (HR 6.200, 95% CI 2.206–17.430, p = .001) and worse OS (HR 4.886, 95% CI 1.388–17.197, p = .013). This study demonstrates that combined assessment of MRD by WT1 and MFC improves relapse and prognosis prediction in non-APL AML patients, and may help guide interventions for disease relapse.