Shorter Event-free Survival Research Articles

Clinical Characteristics and Outcomes of CML in Adolescents and Young Adults

BackgroundWhile Chronic Myeloid Leukemia (CML) is a disease of older adults, there is a growing population of adolescent and young adults (AYAs) with CML. This study evaluated the clinical characteristics and outcomes of CML in AYAs. Patients and methodsData from medical records of adults with chronic phase CML diagnosed and treated at our center from 2011until 2021were retrospectively analyzed. Age between 18 and 29 years was used to define AYAs. Response to tyrosine kinase inhibitors (TKIs), progression to accelerated phase (AP) or blast crisis (BC), event-free survival (EFS) and overall survival (OS) were compared between AYAs and older adults. ResultsAmong 163 patients included, 41 (25.1%) were AYAs. AYAs were more likely to be males (P = .02), to present with symptoms (P = .004), had a higher median white blood cell count (P = .007), neutrophil count (P = .029), eosinophil count (P = 0.01), low-risk Sokal (P = .033) and Hasford (P = .005) groups. TKI-sensitivity as well as median times for achievement of complete cytogenetic and major molecular response were comparable between both groups. After a median follow-up of 76 (range: 11-235) months, there was no difference in OS (P = .528), or cumulative incidence of transformation to accelerated phase or blast crisis (P = .11). On the other hand, AYA had an inferior EFS (P = .034). ConclusionA quarter of the patients diagnosed with CML in our population were AYAs. Despite being characterized as “lower-risk,” they presented with a greater disease burden, had a shorter EFS but comparable OS. Further studies are needed to better understand the disease biology of this group.

Relative Wash-In Rate in Dynamic Contrast-Enhanced Magnetic Resonance Imaging as a New Prognostic Biomarker for Event-Free Survival in 82 Patients with Osteosarcoma: A Multicenter Study.

The decreased perfusion of osteosarcoma in dynamic contrast-enhanced (DCE) MRI, reflecting a good histological response to neoadjuvant chemotherapy, has been described. In this study, we aim to explore the potential of the relative wash-in rate as a prognostic factor for event-free survival (EFS). Skeletal high-grade osteosarcoma patients, treated in two tertiary referral centers between 2005 and 2022, were retrospectively included. The relative wash-in rate (rWIR) was determined with DCE-MRI before, after, or during the second cycle of chemotherapy (pre-resection). A previously determined cut-off was used to categorize patients, where rWIR < 2.3 was considered poor and rWIR ≥ 2.3 a good radiological response. EFS was defined as the time from resection to the first event: local recurrence, new metastases, or tumor-related death. EFS was estimated using Kaplan-Meier's methodology. Multivariate Cox proportional hazard model was used to estimate the effect of histological response and rWIR on EFS, adjusted for traditional prognostic factors. Eighty-two patients (median age: 17 years; IQR: 14-28) were included. The median follow-up duration was 11.8 years (95% CI: 11.0-12.7). During follow-up, 33 events occurred. Poor histological response was not significantly associated with EFS (HR: 1.8; 95% CI: 0.9-3.8), whereas a poor radiological response was associated with a worse EFS (HR: 2.4; 95% CI: 1.1-5.0). In a subpopulation without initial metastases, the binary assessment of rWIR approached statistical significance (HR: 2.3; 95% CI: 1.0-5.2), whereas its continuous evaluation demonstrated a significant association between higher rWIR and improved EFS (HR: 0.7; 95% CI: 0.5-0.9), underlining the effect of response to chemotherapy. The 2- and 5-year EFS for patients with a rWIR ≥ 2.3 were 85% and 75% versus 55% and 50% for patients with a rWIR < 2.3. The predicted poor chemo response with MRI (rWIR < 2.3) is associated with shorter EFS even when adjusted for known clinical covariates and shows similar results to histological response evaluation. rWIR is a potential tool for future response-based individualized healthcare in osteosarcoma patients before surgical resection.

PHF19 before and post induction treatment possess favorable potency of reflecting treatment response to protease inhibitors, event-free survival, and overall survival in multiple myeloma patients

ABSTRACT Objective Plant homeodomain finger protein 19 (PHF19) regulates hematopoietic stem cell differentiation and promotes multiple myeloma (MM) progression. This study intended to explore the potency of PHF19 at baseline and post induction treatment in estimating treatment response to protease inhibitors and survival in MM patients. Methods This retrospective study screened 69 MM patients who received protease inhibitors with bone marrow (BM) samples available at both baseline and post induction treatment. Twenty healthy BM donors were included as healthy controls (HCs). PHF19 in plasma cells from BM was quantified by reverse transcription-quantitative polymerase chain reaction. Results PHF19 at baseline and post induction treatment in MM patients were increased than in HCs. In MM patients, PHF19 was declined post induction treatment. Elevated PHF19 at baseline and post induction treatment were correlated with renal impairment, beta-2-microglobulin ≥5.5 mg/L, t (4; 14), higher international staging system (ISS) stage, and higher revised ISS (R-ISS) stage. Concerning treatment response, PHF19 at baseline and post induction treatment were negatively associated with complete response and overall response rate. Notably, abnormal PHF19 (above 95% quantile value of PHF19 in HCs) at baseline and post induction treatment were linked with shortened event-free survival (EFS) and overall survival (OS). After adjustment, abnormal PHF19 post induction treatment was independently related to shortened EFS (hazard ratio = 2.474) and OS (hazard ratio = 3.124). Conclusion PHF19 is aberrantly high and declines post induction therapy, which simultaneously reflects unfavorable treatment response to protease inhibitors as well as shorter EFS and OS in MM patients.

The role of androgen response pathway in association with tumor biology and response to neoadjuvant immune-checkpoint inhibitors (ICI) in muscle-invasive urothelial bladder carcinoma (MIBC).

662 Background: Emerging findings from ICI trials are suggestive of differential outcomes in females compared with males. Sex-specific differences in tumor biology, microbiome, and outcomes in MIBC are well-established. Conversely, limited data are available regarding the role of the androgen response pathway in explaining subtype differences between males and females and, most importantly, response to ICI. Methods: We retrospectively evaluated the biomarker findings of the transurethral resection of the bladder tumors (TURBT) and baseline clinical characteristics of patients (pts) with cT2-4N0M0 MIBC who received neoadjuvant pembrolizumab and radical cystectomy (RC) in the PURE-01 study. Transcriptome-wide expression profiling was performed on 102 TURBT samples. We focused on androgen receptor (AR) gene expression and the hallmark androgen response pathway expression quantifying 117 different genes related to the androgen response pathway as previously reported (PMID: 26771021). Pt and tumor characteristics were compared between subgroups using χ2 tests and two-sided Wilcoxon rank-sum tests. Kaplan-Meier curves and log rank tests evaluated gene expression and signature scores in association with the event-free survival (EFS), calculated from start of pembrolizumab treatment. Signature scores were analyzed as continuous values and were split by median and quartile values. Results: Pts received pembrolizumab and RC from 2017 to 2022. There were 87 (85.3%) males and 15 (14.7%) females. AR gene expression was not significantly different between males and females (p = 0.5), whereas androgen response signature was significantly higher in male (p = 0.03). The AR gene expression and androgen response signature scores were more highly expressed in luminal tumors vs rest of molecular subtypes (p = 0.005 and p &lt; 0.001). Despite AR gene expression was not associated with ypT0N0 response (p = 0.425), hallmark androgen response signature scores were significantly lower in ypT0N0 responders (p = 0.033). Higher hallmark androgen response signature scores were statistically significantly associated with shorter EFS (p = 0.028), whereas AR gene expression was not (p = 0.152). Conclusions: For the first time to our knowledge, we reported the androgen response pathway expression to be a potential biomarker of ICI benefit in MIBC. This signature was also associated with a luminal subtype, linked to inferior responsiveness to ICI. If confirmed at a larger scale these analyses will strengthen the need for sex-specific approaches and potentially new combination therapies in MIBC.

Dysregulated immune and metabolic pathways are associated with poor survival in adult acute myeloid leukemia with CEBPA bZIP in-frame mutations

Acute myeloid leukemia (AML) with CEBPA bZIP in-frame mutations (CEBPAbZIP-inf) is classified within the favorable-risk group by the 2022 European LeukemiaNet (ELN-2022). However, heterogeneous clinical outcomes are still observed in these patients. In this study, we aimed to investigate the mutation profiles and transcriptomic patterns associated with poor outcomes in patients with CEBPAbZIP-inf. One hundred and thirteen CEBPAbZIP-inf patients were identified in a cohort of 887 AML patients homogeneously treated with intensive chemotherapy. Concurrent WT1 or DNMT3A mutations significantly predicted worse survival in AML patients with CEBPAbZIP-inf. RNA-sequencing analysis revealed an enrichment of interferon (IFN) signaling and metabolic pathways in those with a shorter event-free survival (EFS). CEBPAbZIP-inf patients with a shorter EFS had higher expression of IFN-stimulated genes (IRF2, IRF5, OAS2, and IFI35). Genes in mitochondrial complexes I (NDUFA12 and NDUFB6) and V (ATP5PB and ATP5IF1) were overexpressed and were associated with poorer survival, and the results were independently validated in the TARGET AML cohort. In conclusion, concurrent WT1 or DNMT3A mutations and a dysregulated immune and metabolic state were correlated with poor survival in patients with CEBPAbZIP-inf, and upfront allogeneic transplantation may be indicated for better long-term disease control.

IGLV3-21 R110 Is a Prognostic Marker for Early Stage CLL Patients Under Ibrutinib Treatment or Watch & Wait: Results from the Double-Blind, Randomized, Placebo-Controlled GCLLSG CLL12 Trial

INTRODUCTION: IGLV3-21 R110 is a point mutation that can confer the ability for autonomous signaling to B cell receptors (BCR) using light chains encoded by the allele IGLV3-21 ∗ 01 or IGLV3-21 ∗ 04. Chronic lymphocytic leukemia (CLL) patients with IGLV3-21 R110 have a shorter time to first treatment and shorter overall survival, independent of their IGHV mutational status. However, outcomes of CLL patients using IGLV3-21 R110 have not been evaluated in clinical trials of BTK inhibitors. METHODS: The CLL12 trial was a prospective, double-blind, randomized phase 3 trial that compared ibrutinib (ibr, n=182) vs. placebo (pcb, n=181) in previously untreated Binet A CLL patients with intermediate to very high risk, while low risk patients were assigned to watch &amp; wait (w&amp;w, n=152). The primary endpoint of the study was event-free survival (EFS) (event defined as death, symptomatic progression or initiation of CLL treatment), while overall survival (OS) was a secondary endpoint. The IGLV3-21 locus was sequenced via amplicon-based targeted next generation sequencing (tNGS) in 514 of 515 samples collected at enrolment. IGLV rearrangements and point mutations were detected with ScanIndel as well as IgCaller and the results of the genetic analyses were correlated with outcome. RESULTS: IGHV was unmutated (U-IGHV) in 148 (28.3%) patients (w&amp;w n=8, pcb n=70, ibr n=70) and 10 patients belonged to stereotyped B cell receptor (BCR) subset 2 (w&amp;w n=2, pcb n=1, ibr n=7). IGLV3-21 rearrangement was found in 34 of 514 patients (6.6%) and was more frequent in the intermediate/high risk groups (pcb n=16, ibr n=13) than in the low risk group (w&amp;w n=5). Twenty of 34 patients with IGLV3-21 rearrangement had an IGLV3-21 R110 mutation (w&amp;w n=3/5, pcb n=10/16, ibr n=7/13). For 5 patients with IGLV3-21 (3 pcb, 2 ibr) the mutational status for IGLV3-21 R110 could not be determined by tNGS. In the total cohort, IGLV3-21 R110 often co-occurred with mutations in SF3B1 (odds ratio 8.54, p &amp;lt; 0.001), but not with mutations in TP53 or any of the other frequently mutated genes in CLL. Conversely, SF3B1 mutations were not enriched in subset 2 patients (p = 0.165). Also, there was no association of IGLV3-21 R110 or IGLV3-21 usage in general with IGHV mutational status. At a median follow-up of 69.3 months, there were 166 events for EFS and 32 for OS. CLL with IGLV3-21 had a shorter EFS in the pcb (HR 1.93, CI95% 1.05-3.55, p=0.033) and ibr (HR 3.71, CI95% 1.62-8.46, p=0.002) arm (Figure 1A). The estimated 5-year EFS rate was 51.0% without and 21.4% with IGLV3-21 rearrangementin the pcb group vs. 80.7% and 44.8% in the ibr group, respectively. Similarly, IGLV3-21 R110 associated with shorter EFS with ibr (HR 3.30, CI95% 1.17-9.31, p=0.024) while no impact was observed in the pcb group (HR 1.51, CI95% 0.66-3.46, p=0.332, Figure 1B). Patients with IGLV3-21 R110 mutation and ibr treatment had an estimated 5-year EFS rate similar to that of patients in the pcb group without IGLV3-21 R110 (50.0% vs. 49.8%). In low risk patients with w&amp;w, both IGLV3-21 rearrangement and IGLV3-21 R110 were adverse markers for EFS (HR 4.99, CI95% 1.52-16.41, p=0.008 and HR 17.0, CI95% 4.99-58.13, p&amp;lt;0.001, respectively). For the full trial, we observed a prognostic impact of IGLV3-21 in the M-IGHV (HR 3.87, CI95% 2.14-6.99, p&amp;lt;0.001) but not in the U-IGHV (HR 1.61, CI95% 0.74-3.54, p=0.233) group. Multivariable analysis for the treatment arms including the IGLV3-21 R110 status and other variables associated significantly with EFS in univariate analyses (treatment arm, serum β2-microglobulin, IGHV status, del(17p), del(11q), +(12), mutations in XPO1, NOTCH1, SF3B1 and NFKBIE) revealed presence of IGLV3-21 R110 (HR 2.76, CI95% 1.32-5.80, p = 0.007) as an independent prognostic factor. OS was excellent in all genetic subgroups and in all arms of the trial. The estimated 5-year OS rate was between 92.9% and 95.8% for any of the 4 subgroups defined jointly by IGHV status and presence of IGLV3-21 R110. CONCLUSIONS: IGLV3-21 R110 was identified as an independent prognostic factor for shorter EFS in early stage CLL with intermediate/high risk score and was associated with reduced ibrutinib efficacy in the CLL12 trial.

Impact of Typical and Atypical Complex Karyotype Subgroups on Outcome of AML Patients Undergoing Allogeneic Stem Cell Transplantation

Introduction Acute myeloid leukemia (AML) with a complex karyotype (CKT) confers an adverse prognosis, even within the subgroup of patients (pts) with adverse risk according to European LeukemiaNet 2022 (ELN22) risk stratification. Mrózek et al. further characterized CKT pts according to distinct mechanisms of leukemogenesis into balanced (presence of ≥1 balanced rearrangement), and unbalanced CKT (CKT ub, exclusively unbalanced cytogenetic abnormalities). Considering the high incidence of deletions (del) of 5q, 7q, and 17p in CKT, CKT ub were further divided in typical CKT ub (with latter abnormalities present), and atypical CKT ub (with exclusively other abnormalities). In the context of consolidating chemotherapy, typical CKT ub was associated with shorter event-free survival (EFS) and overall survival (OS) compared to atypical CKT ub. However, we lack data in the context of allogeneic hematopoietic stem cell transplantation (HSCT) which remains the preferred treatment in eligible pts. Here we aimed to investigate this classification in CKT AML pts consolidated by HSCT. Methods We analyzed 263 pts with AML who were classified as ELN22 adverse risk and underwent an allogeneic HSCT. 105 had a CKT, while 158 fulfilled other ELN22 adverse risk criteria. Of the pts harboring a CKT, median age at HSCT was 61 (range 20 - 76) years. Remission status at HSCT was first complete remission with or without count recovery (CR/CRi, 62%) or refractory AML (38%). Conditioning intensity according to EBMT criteria were myeloablative (19%), reduced intensity (31%) or non-myeloablative (50%). Donors were matched related (16%), haploidentical (2%) or matched (65%) or mismatch unrelated (17%).Cytogenetic analyses at diagnosis were performed using standard techniques of banding and in situ hybridization. Pretreatment genomic DNA was screened for genes recurrently mutated in myeloid malignancies using next generation sequencing. Median follow-up alive was 1.3 years. Results Pts with a CKT had a significantly shorter EFS ( P&amp;lt;.01) and OS ( P&amp;lt;.01) than other ELN22 adverse risk pts. Of all pts harboring a CKT, 17% had a balanced CKT, and 83% a CKT ub. Among CKT ub, 85% were classified as typical (67% with del(5q), 49% with del(7q), 26% with del(17p), Figure 1). Comparing typical and atypical CKT ub, pts with typical CKT ub more often had a monosomal karyotype ( P&amp;lt;.01), had more cytogenetic abnormalities (in typical CKT ub median 8 [range 3-39] vs atypical CKT ub median 6 [range 3-9], P=.04), more often TP53 mutations ( P=.02), less often RUNX1 mutations ( P=.03) and a lower LDH at diagnosis ( P=.03). They also had a higher expression of the leukemic stem cell markers CD34+/CD38- ( P=.01) and GPR56 ( P&amp;lt;.01). However, after allogeneic HSCT, EFS ( P=.50) and OS ( P=.50) did not differ between pts with typical and atypical CKT ub (Figure 2). Next, we looked for other adverse prognostic factors within CKT pts receiving HSCT, which in univariate analyses were the presence of a del(5q) (EFS P&amp;lt;.01 and OS P=.03), a del(17p) (EFS P=.10 and OS P=.02), the presence of ≥5 vs &amp;lt;5 cytogenetic aberrations (EFS P=.03 and OS P=.06), a concomitant TP53 mutation (EFS P=.01 and OS P=.01), and a higher age at HSCT (≥60 years, EFS P=.04 and OS P=.08). In contrast, neither the presence of a del(7q) nor a monosomal karyotype impacted EFS or OS within pts with a CKT. In multivariate analyses for CKT pts, the presence of ≥ 5 cytogenetic aberrations (Hazard Ratio. [HR] 1.7, 95% Confidence Interval [CI] 1.0-3.0, P=.05), higher age at HSCT (HR 1.6, 95% Ci 1.1-2.5, P=.02), and no CR/CRi at HSCT (HR 1.7, 95% CI 1.1-2.7, P=.01) were adverse factors for EFS, while the presence of a del(17p) (HR 2.0, 95% CI 1.2-3.4, P=.01), higher age at HSCT (HR 1.8, 95% CI 1.1-3.0, P=.02), and no CR/CRi at HSCT (HR 1.8, 95% CI 1.1-2.9, P=.02) were adverse factors for OS. Conclusion The presence of a CKT retains its negative prognostic impact after HSCT and differentiates within the ELN22 adverse risk group. However, in contrast to chemotherapy consolidation alone, the subgroup of pts harboring a typical CKT ub did not perform worse than pts with an atypical CKT ub, indicating a potential immune-mediated beneficial effect of HSCT. Within pts with a CKT receiving HSCT, we identified additional prognostic factors including the presence of ≥5 cytogenetic aberrations. These pts are in urgent need for novel post HSCT approaches.

Clinical Outcomes of Patients with Newly Diagnosed Diffuse Large B-Cell Lymphoma in a County Hospital System

Introduction: Advances in the treatment of diffuse large B-cell lymphoma (DLBCL) have improved survival, with Surveillance, Epidemiology, and End Results (SEER) Program data showing 5-year overall survival (OS) of 64.7% (SEER*Explorer, 2023). However, insurance status in the US is related to DLBCL survival (Han et al., Cancer 2014), and real-world data for patients who are uninsured or who may have socioeconomic barriers to care remain limited. We performed a retrospective cohort study to examine outcomes for patients with newly diagnosed DLBCL treated in a large safety-net hospital system in the third most populous county in the US. Methods: Patients aged 18 years and older diagnosed with DLBCL between January 2011 and June 2022 and treated at Harris Health System, Houston, TX, were included in the analysis. Demographic, disease, treatment, response, and follow-up data were abstracted from the electronic medical record. US Census Block Group FIPS codes derived from geocoded home address at the time of initial diagnosis were used to compute the Area Deprivation Index (ADI). Eligibility for cellular therapies including hematopoietic stem cell transplantation (HSCT) and chimeric antigen receptor T-cell therapy (CAR-T) was determined by the abstractors. Time-to-event analysis was performed using the Kaplan-Meier method, and Cox proportional hazards regression was used to examine factors associated with event-free survival (EFS) and OS. Results: Among 461 patients with newly diagnosed DLBCL (Table 1), the median age was 53 years (range, 18-93), 75% were uninsured, and 80% were in the most disadvantaged ADI national quartiles, defined as at or above the fiftieth percentile. Most patients had stage III or IV disease and an Eastern Cooperative Oncology Group Performance Status (ECOG) of 0 to 1 at the time of diagnosis. One hundred ninety-eight patients (44%) had poor-risk disease by the Revised International Prognostic Index (R-IPI). Seventy-five (16%) had a history of HIV infection. Common first-line treatments included R-CHOP ( n = 210, 46%) and R-EPOCH ( n = 183, 40%); 18 received no therapy (3.9%). The median time from diagnosis to treatment initiation (DTI) was 18 days (range, 0-246); 76% completed therapy. Of 425 evaluable patients, 288 (68%) achieved a complete response (CR) and 44 (10%) had a partial response (PR); of these, 74 (22%) relapsed. Twenty-five (58%) of 43 patients eligible for cellular therapies at relapse received them: 14 (56%) underwent autologous HSCT, 8 (32%) received CAR-T, and 3 (12%) had both. Median follow-up time for the cohort was 48.8 months (range, 0.2-147). By the time of analysis, 167 patients (36%) had developed refractory/relapsed disease, and 148 (32%) had died. At 1, 2, and 5 years, EFS was 72%, 64%, and 58%, and OS was 82%, 76%, and 69% (Figure 1). At 1, 2 and 5 years, EFS was 77%, 69%, and 64% and OS was 85%, 79%, and 75% for patients with germinal center B-cell-like (GCB) DLBCL, whereas EFS was 68%, 56%, and 50% and OS was 80%, 73%, and 62% for those with non-GCB DLBCL. In multivariable Cox regression models, predictors of OS were poor-risk disease by R-IPI (HR 6.08 compared to very-good-risk disease, 95% CI 1.02-36.09), ECOG (HR 2.10 for ECOG ≥2 compared to 0-1, 95% CI 1.12-3.95), and normalized LDH (HR 1.07 per fold increase, 95% CI 1.03-1.11). Race/ethnicity, insurance status, and DTI were not associated with significant differences in OS. However, receiving fewer than planned cycles of first-line therapy was associated with higher mortality (HR 2.00, 95% CI 1.12-3.56), as was not attaining CR by the end of first-line therapy (HR 7.90, 95% CI 3.65-17.12). Conclusion: This is one of the largest real-world studies to date examining outcomes of patients with newly diagnosed DLBCL at a safety-net hospital system. Overall, patients had shorter EFS and OS compared to historical clinical trials but had similar OS to SEER estimates. In this health system with robust financial assistance programs and access to cellular therapies for some patients, uninsured status was not associated with inferior outcomes. Addressing barriers to care may improve outcomes for uninsured patients in other settings.

Genetic markers and ibrutinib vs placebo treatment in early stage chronic lymphocytic leukemia -results from the GCLLSG CLL12 trial

Background: Watch and wait is standard of care in patients with early stage chronic lymphocytic leukemia (CLL). In the CLL12 trial, 515 stage Binet-A patients were risk stratified and randomized 1:1 to ibrutinib (ibr, n=182) or placebo (pcb, n=181) when assigned to (very) high or intermediate risk, while low risk patients were only observed (w&amp;w, n=152). Treatment with ibr was associated with longer progression-free survival (PFS) (event defined as progression or death) and event-free survival (EFS) (event defined as death, symptomatic progression or initiation of CLL treatment) but not overall survival (OS) when compared to pcb (Langerbeins et al. EHA 2023). However, it is unclear if specific subgroups defined by genetic markers may derive particular benefit from early ibr treatment. Methods: Genetic markers were analyzed in all 515 patients at study entry. Genomic aberrations were assessed by FISH, IGHV mutational status by sequencing with a threshold of 98% homology and gene mutations via targeted NGS for TP53, FBXW7, NOTCH1, SF3B1, NRAS, KRAS, BRAF, BIRC3, MYD88, NFKBIE, EGR2 and XPO1. Results: The prevalence of genomic aberrations and gene mutations is shown in the table 1. At a median follow up of 69.3 months, there were 166 events for EFS and 32 for OS respectively. EFS was shorter with del(17p) (compared to del(13q): Hazard ratio (HR) 2.89, 95%CI 1.14-7.37, p&amp;lt;0.05), del(11q) (HR 4.39, 95%CI 2.48-7.76, p&amp;lt;0.001); +(12) (HR 1.78, 95%CI 1.01-3.13, p&amp;lt;0.05) in the pcb arm, while with ibr only del(17p) (HR 5.07, 95%CI 1.70-15.17 p&amp;lt;0.01) was associated with shorter EFS. IGHV mutation status had an impact on EFS with pcb (U-IGHV vs. M-IGHV, HR 4.44, 95%CI 2.88-6.85, p&amp;lt;0.001) but not with ibr (HR 1.52, 95%CI 0.81-2.85, p=0.19). In the pcb arm, mutations in NOTCH1 (HR 2.26, 95%CI 1.35-3.76, p&amp;lt;0.01), NRAS/KRAS/BRAF, (HR 5.38, 95%CI 1.92-15.03, p&amp;lt;0.01) and NFKBIE (HR 4.12, 95%CI 1.97-8.64, p&amp;lt;0.001) but not TP53 (HR 1.24, 95%CI 0.57-2.68, p=0.59) were significantly associated with a shorter EFS. In contrast, with ibr treatment, only TP53 (HR 2.88, 95%CI 1.31-6.32, p&amp;lt;0.01) and NFKBIE (HR 2.45, 95%CI 1.03-5.87, p=0.04) were associated with shorter EFS. Notably, in the full trial population (i.e. including the w&amp;w cohort) TP53 mutations were associated with shorter EFS only when combined with U-IGHV (HR 2.37, 95%CI 1.22-4.63, p&amp;lt;0.05) but not with M-IGHV (HR 0.53, 95%CI 0.26-1.10. p=0.09). In the w&amp;w cohort high risk markers were rare and only +(12) (compared to del(13q)(HR 4.66, 95%CI 1.4-15.51, p&amp;lt;0.05) and mutations in TP53 (HR 4.88, 95%CI 1.49-16.04, p&amp;lt;0.01), SF3B1 (HR 5.01, 95%CI 1.53-16.45, p&amp;lt;0.01), BIRC3 (HR 3.43, 95%CI 1.05-11.23, p&amp;lt;0.05) and NFKBIE (HR 12.58, 95%CI 3.68-42.99, p&amp;lt;0.001) were significantly associated with shorter EFS. Significant EFS benefit from ibr as compared to pcb with HR&amp;lt;0.2 was observed in subgroups with U-IGHV (HR 0.18, 95%CI 0.1-0.3, p&amp;lt;0.001); del(11q) (HR 0.10, 95%CI 0.04-0.29, p&amp;lt;0.001) and cases with mutations in NOTCH1 (HR 0.18, 95%CI 0.06-0.55, p&amp;lt;0.01) and NFKBIE (HR 0.15, 95%CI 0.04-0.53, p&amp;lt;0.01), while no significant benefit was observed with del(17p) (HR 0.68, 95%CI 0.16-2.85, p=0.59) and mutated TP53 (HR 0.69, 95%CI 0.25-1.92, p=0.48, figure 1). Regarding OS none of the subgroups defined by genetic markers derived significant benefit from ibr as compared to pcb. In multivariable analysis for EFS including treatment arms, clinical disease characteristics and genetic markers as variables, ibr treatment was an independent favorable factor (HR 0.25, 95%CI 0.16-0.37, p&amp;lt;0.001), while U-IGHV (HR 3.38, 95%CI 2.29-4.98 p&amp;lt;0.001), del(17p) (HR 3.53, 95%CI 1.76-7.06, p&amp;lt;0.001), +(12) (HR 1.58, 95%CI 1.01-2.45 p&amp;lt;0.05) and mutated NFKBIE (HR 2.22, 95%CI 1.23-4.01, p&amp;lt;0.01) were independent adverse prognostic factors. Conclusion: In addition to the well-known prognostic factors, also mutated SF3B1, NFKBIE and BIRC3 are associated with shorter EFS in low risk early stage CLL. While some genetic subgroups derived particular EFS benefit from ibr, patients with high-risk TP53 aberration and/or del(17p) did not. In summary, the CLL12 trial fails to demonstrate survival superiority by early ibr treatment, including genetic subgroups and w&amp;w remains the standard of care for all patients with Binet stage A CLL.

One Tube 23 Color Full Spectral Flow Cytometry Panel in Detecting Minimal Residual Disease in Pediatric B-Cell Acute Lymphoblastic Leukemia

Introduction Minimal residual disease (MRD) is a normalized tool for risk stratification in the treatment of pediatric acute lymphoblastic leukemia (ALL) and has been introduced into many standardized chemotherapy regimens. Flow cytometry (FC) plays an important role in the monitoring of MRD. However, FC-MRD can't reliably detect residual leukemic cells below level of 0.01% in real clinical scenarios and some patients with negative MRD relapsed, suggesting the current used set of markers are not sensitive enough or specific enough. Published studies has shown that more markers with more reliable combination of antibodies may help improve the sensitivity and specificity of FC-MRD. Spectral multicolor flow cytometry (SMFC) has shown an advantage over traditional FC that more fluorescent markers could be applied simultaneously and more complex marker combinations could be exploited to distinguish leukemic blasts from normal B cell precursors with high specificity. Here we designed a SMFC-based panel of 26 markers with 23 fluorescent colors in one tube to monitor B-ALL MRD. Method The one-tube 23-color panels was designed according to previously published studies and our clinical experience based on standardized EuroFlow 8-color MRD panel. All the leukemia-associated immunophenotypes (LAIPs) were defined based on its deviation from hematogones. For CD10, CD19, CD22, CD34, CD58, CD73, CD86, CD123, CD200and CD304, the overexpression was considered as LAIP, while the under-expression was considered as LAIP for CD24, CD38, CD45 and CD81. Asynchronous co-expression of CD34 and CD20, CD34 and CD21 were also included. The aberrant cross-lineage expression was taken as LAIP for CD2, CD56, CD65, CD15, CD13, CD33, CD66c, NG2 and CD133. For CD44, under-expression or overexpression can both be considered as LAIP. To verify the effectiveness of the panel, 317 bone marrow samples from 317 patients with B-ALL diagnosed between 2009 to 2014 at the Shanghai Children's Medical Center (SCMC) were included. These samples were collected at day 19 to 283 (median: day 35), with 213 (67.19%) collected at around day 35, which was a regular time point to monitor MRD and to readjust the risk stratification. The results were compared with those of conventional 8-color FC-MRD. Results The limit of blank (LOB), limit of detection (LOD), and lower limit of quantitation (LLOQ) were firstly determined, the results showed reproducible sensitivity up to 0.001% (1-in-10 5) after acquisition of 4.8 million cells for 23-color panel. The 8-color and 23-color MRD panels showed high correlation of the quantitation of MRD (r 2=0.80, p&amp;lt;0.0001). Among cases of discordant between 8-color MRD negative (with cutoff &amp;lt;0.01%) and 23-color MRD negative (with cutoff &amp;lt;0.001%), relapse only occurred in patients with 23-color MRD positive and 8-color MRD negative, rather than patients with 23-color MRD negative and 8-color MRD positive, suggesting a higher sensitivity and specificity for 23-color MRD assay (See Figure). Patients with detectable MRD by either 8-color or 23-color had a significantly higher incidence of relapse (CIR, p&amp;lt;0.05) and shorter event free survival (EFS, p&amp;lt;0.05). Positive 23-color MRD seemed to be an even stronger factor impacting CIR and EFS. Compared to patients with 8-color MRD negative and 23-color MRD positive, patients with 8-color MRD positive and 23-color MRD negative had a significantly lower CIR (p&amp;lt;0.05) and a better EFS (p=0.068). Patients with positive 23-color MRD lower than 0.01% showed a trend towards poorer EFS and OS (p=0.083% and p=0.061%, respectively) compared to patients with 23-color MRD negative. Conclusion Based on these evidences, SMFC-based one-tube 23-color MRD panel for B-ALL was convenient and maneuverable with higher sensitivity and specificity compared to conventional 8-color FC-MRD panel. It would be a promising method to improve the risk stratification.

Follicular Lymphoma Microenvironment Traits Associated with Event-Free Survival.

The majority of patients with Follicular Lymphoma (FL) experience subsequent phases of remission and relapse, making the disease "virtually" incurable. To predict the outcome of FL patients at diagnosis, various clinical-based prognostic scores have been proposed; nonetheless, they continue to fail for a subset of patients. Gene expression profiling has highlighted the pivotal role of the tumor microenvironment (TME) in the FL prognosis; nevertheless, there is still a need to standardize the assessment of immune-infiltrating cells for the prognostic classification of patients with early or late progressing disease. We studied a retrospective cohort of 49 FL lymph node biopsies at the time of the initial diagnosis using pathologist-guided analysis on whole slide images, and we characterized the immune repertoire for both quantity and distribution (intrafollicular, IF and extrafollicular, EF) of cell subsets in relation to clinical outcome. We looked for the natural killer (CD56), T lymphocyte (CD8, CD4, PD1) and macrophage (CD68, CD163, MA4A4A)-associated markers. High CD163/CD8 EF ratios and high CD56/MS4A4A EF ratios, according to Kaplan-Meier estimates were linked with shorter EFS (event-free survival), with the former being the only one associated with POD24. In contrast to IF CD68+ cells, which represent a more homogeneous population, higher in non-progressing patients, EF CD68+ macrophages did not stratify according to survival. We also identify distinctive MS4A4A+CD163-macrophage populations with different prognostic weights. Enlarging the macrophage characterization and combining it with a lymphoid marker in the rituximab era, in our opinion, may enable prognostic stratification for low-/high-grade FL patients beyond POD24. These findings warrant validation across larger FL cohorts.

Real-world evidence analysis of early-stage prostate cancer using natural language processing.

e17007 Background: Real-world evidence (RWE) on the epidemiology and management of localized/locally advanced prostate cancer (LPC) is lacking. Here we used EHRead, a natural language processing framework based on SNOMED CT terminology, to extract clinical information from electronic health records (EHRs) to perform a comprehensive description of a real-world cohort of LPC patients. Here we present a follow-up of the project already communicated at ESMO 2020. Methods: This is an observational, multicenter, retrospective study based on the secondary analysis of free-text and structured clinical information found in EHRs from all observed adult patients with LPC between January 2014 and December 2018 in 12 Spanish hospitals. A total of 375 variables were extracted using EHRead to assess patient clinical characteristics, treatment patterns and journey across different prostate cancer stages. Event-free survival (EFS) was analyzed in incident LPC patients with presence of Gleason or PSA and follow-up greater than 0 days. A multivariable Cox-proportional hazards model was applied to obtain adjusted hazard ratios (aHR). Results: We observed 19788 patients with LPC during a median of 3.5 (interquartile range 1.4-7.4) years of follow-up. 52% of patients had low- (LR), 21% intermediate- (IR) and 27% high-risk (HR) disease. 3938 (18%) patients transitioned to other disease stages, leading to castration-resistant prostate cancer (mCRPC) in 4%, 7%, 16% of patients with LR, IR, and HR LPC, respectively. 7884 (42%) patients received radiotherapy (RT), 7021 (38%) prostatectomy (PT), 6061 (31%) androgen deprivation therapy (ADT), and 1034 (6%) active surveillance. Local recurrence was observed in 3% and distant metastasis in 11% (57% bone, 37% visceral). Distant metastases were observed in 7%, 12% and 21% of HR, IR and LR; 8% vs. 9% of PT vs. RT; and 16% vs 6% of ADT vs. no ADT, respectively. EFS was assessed in 7465 (38%) patients, with a 4-year EFS rate of 18%. Median EFS was 22, 13, and 8 months for LR, IR, HR; 23 vs. 12 months for PT vs. RT; and 8 vs. 21 months for ADT vs. no ADT, respectively. A multivariable cox proportional hazards model is presented in the following Table. Conclusions: During the study period, 11% of all LPC patients developed metastatic disease, with only 18% remaining event-free at 4 years. Transition to mCRPC was 4- and 2-fold higher in HR vs. IR and LR disease, respectively. Disease risk, treatment with RT and/or addition of ADT were independently associated with shorter EFS. Our findings suggest that, despite adjuvant treatment, LPC local extension and histopathological characteristics at diagnosis remain critical determinants of patient prognosis. A more detailed analysis in patients with available Gleason and PSA is underway. [Table: see text]

Prognostic impact of translocation t(11;14) and of other cytogenetic abnormalities in patients with AL amyloidosis in the era of contemporary therapies.

Translocation t(11;14) is the most common cytogenetic abnormality in patients with systemic AL amyloidosis with prognostic and therapeutic relevance, which has not been clearly defined in the most recent therapeutic era. We assessed its prognostic role in 146 newly-diagnosed patients who received novel agent-based treatment combinations. Event-free survival (EFS), a composite endpoint defined by hematological progression, start of a new treatment-line or death, and overall survival (OS) were the primary endpoints. Half of the patients had at least one FISH abnormality; 40% had t(11;14) which was inversely associated with other cytogenetic abnormalities. At 1, 3, and 6-month landmarks, hematologic response rates were numerically but not statistically higher in the non-t(11;14) group. Patients with t(11;14) were more frequently switched to second-line treatment within 12 months (p = .015). At median follow-up of 31.4 months, t(11;14) was associated with shorter EFS [17.1 (95% CI 3.2-10.6) vs. 27.2 months (95% CI 13.8-40.6), p = .021] and retained its prognostic significance in the multivariate model (HR:1.66, p = .029). The effect on OS was neutral, possibly due to the use of effective salvage therapies. Our data support the use of targeted therapies for patients with t(11;14) to avoid delays in the achievement of deep hematologic responses.

Outcomes of Patients with Acute Myeloid Leukemia Receiving a Second Allogeneic Stem Cell Transplantation

Introduction Patients with acute myeloid leukemia (AML) that relapse after an allogeneic hematopoietic stem cell transplantation (HSCT) have a dismal prognosis. However, especially with novel salvage options available, a second allogeneic HSCT (2nd HSCT) may still have curative potential in selected patients. Identifying factors that influence outcomes in AML patients undergoing a 2nd HSCT is important to improve outcomes and inform treatment decisions. Here we analyzed AML patients that received a 2nd HSCT after disease relapse. Methods We identified and analyzed 57 patients (33 male) with AML who received a 2nd allogeneic HSCT at our center between 2000 and 2022. Median age at 2nd HSCT was 55.5 years (range 25.2-74.9). The primary diagnosis before the 1st HSCT was AML (n=41), myelodysplastic neoplasm (MDS, n=10), or myeloproliferative neoplasm (MPN), or MDS/MPN (n=6). All patients relapsed with an AML after 1st HSCT. European LeukemiaNet Risk (ELN) 2022 genetic risk at AML diagnosis was evaluable for 40 patients and was in 20% favorable, in 25% intermediate, and in 55% adverse. At 2nd HSCT, 37 patients (65%) were in complete remission with or without peripheral recovery (CR/CRi) or in morphologic leukemia-free state (MLFS), while 20 (35%) had active disease. Conditioning intensity according to EBMT criteria were non-myeloablative (n=33, 58%) or reduced intensity (n=24, 42%). In all but one patient, a new donor for the 2nd HSCT was selected. Donors for 2nd HSCT were matched related (4%), matched unrelated (61%), mismatched unrelated (32%), or haploidentical (4%). Median time from 1st HSCT to 2nd HSCT was 671 days (range 83-5218). Median follow up after 2nd HSCT for patients alive was 2.0 years. Results Of all analyzed patients 22 (39%) relapsed and 23 patients (40%) died in remission (Figure 1A). Two and 4 years after 2nd HSCT, event-free survival (EFS) was 26% and 21%, respectively, and overall survival (OS) was 42% and 35% (Figure 1B), respectively. In the whole cohort, patients who received their 1st HSCT for a MDS/MPN or MPN and the 2nd HSCT after disease progression to AML had a significantly shorter EFS (P=.002) and by trend a shorter OS (P=.08), compared to patients transplanted for AML after MDS or AML relapse. Early relapse after 1st HSCT (<1 year) tended to be associated with a shorter EFS (P=.10) and a shorter OS (P=.04). Development of a chronic graft-versus-host disease (GvHD) after 2nd HSCT (implicating an associated graft-versus-leukemia effect) associated with longer EFS (P=.005) and OS (P=.05). In contrast, none of the following variables: ELN2022 genetic risk at diagnosis (EFS P=.30, OS P=.20), age at 2nd HSCT (> or ≤ 60 years, EFS P=.40, OS P=.80), remission status at 2nd HSCT (CR/CRi/MLFS vs active disease, EFS P=.90, OS P=.80), the chosen conditioning intensity (NMA vs RIC, EFS P=.80, OS P=.50), or the kind of donor (matched vs mismatched, EFS P=.30, OS P=.20), impacted OS after 2nd HSCT. In multivariate analyses, prior HSCT for MDS/MPN or MPN (Odds Ratio [OR] 5.74, P=.04) and absence of a chronic GvHD (OR 0.52, P=.01) associated with shorter EFS, while early relapse after 1st HSCT (<1 year, OR 0.28, P=.05) and absence of a chronic GvHD (HR 0.33, P=.02) associated with shorter OS after a 2nd HSCT. Conclusion For patients who experience an AML relapse of their myeloid disease after HSCT, performing a 2nd HSCT after reduced intensity or non-myeloablative conditioning may be a feasible and potentially curative treatment option, with an OS of 35% after 4 years. Irrespective of diagnostic ELN2022 genetic risk, a longer remission after 1st HSCT and presence of chronic GvHD associated with improved survival following a 2nd HSCT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Detection, Monitoring and Cell Kinetics of Circulating CAR-T Cells in B-Cell Malignancies

Introduction CAR-T cell therapy has proven to be a disruptive treatment in the hematology field. Tisagenlecleucel and Axicabtagene ciloleucel showed impressive efficacy in relapsed/refractory B-cell lymphoma; however, less than 50% of patients maintain a long-term response and predictors of outcome are still inconsistently defined. Tisa-cel and Axi-cel kinetics have been poorly investigated in real life settings so it becomes necessary to evaluate possible biomarkers that predict response or toxicity. In clinical trials, the efficacy of the treatment is determined by the in vivo expansion and persistence of CAR-T cells. Real life evaluations assessing the immunophenotypic composition of CAR-T cell infusion products and analyzing how these specific features affect CAR-T cell expansion and persistence in vivo and thus outcome, are scarce. Here, we aimed to optimize the detection of CD19 CAR-T cells in blood and to identify phenotypic features associated with post-infusion expansion and outcomes. Methods CD19 CAR-T cells were monitored by flow cytometry from peripheral blood in 48 patients with diffuse large B-cell lymphoma, transformed follicular lymphoma, primary mediastinal B cell lymphoma or B-cell acute lymphoblastic leukemia. Flow cytometry approach was performed for determining cell kinetics (n=48) at days 5, 7, 11, 14, 17 and 20 (±1) after CAR-T cells infusion. In parallel, immunophenotype characterization of CAR- T lymphocytes was conducted at the day of CAR-T expansion in blood. Results After testing different commercially available antibodies for the detection of CD19 CAR-T cells, CD19 protein conjugated with biotin and identified by streptavidin showed the highest resolution in contrast to Antigen CD19 labeled FITC (stain index of 22.19 vs 4.64, p=0.0286). The median day of peak expansion of CAR-T cells was 7 days (range of 5-14 days) after infusion, reaching a median of 119 CAR+ cells/uL (range of 2.4.-1019 CAR+ cells/uL) in blood. Analysis of immune-phenotypic profile of overall circulating T lymphocytes displayed no significant differences in the distribution of naive/memory/effector from CD4+ and/or CD8+ subpopulations between non-CAR T (normal T lymphocytes) and CAR-T cells. However, CAR-T cells showed a significantly higher expression levels of activation (CD69+), proliferation (Ki67+), cytotoxicity (CD107a+) and exhaustion (PD1+TIM3+, PD1+LAG3+) markers in comparison to T lymphocytes (p<0.05). Overall, 31.6% (6/19) patients reached complete remission while 47.4% (9/19) achieved partial response at the first month after CAR-T therapy with event free survival (EFS) of 73% at 1 year (median follow-up of 1 year). Remarkably, cases with lower expression levels of PD-1 and LAG-3 (i.e <5.2%) in CD4+CAR+ T cells at the day of peak expansion had a worse outcome (EFS at 1 year 44% vs 90% for patients with low vs high expression of the above exhaustion markers, p=0.04) (Figure 1A). Similarly, patients with a highly cytotoxicity pattern (i.e CD107a expression >6%) within CD8+CAR+ T cells had a shorter EFS (50%) as compared to those with <6% of CD8+CAR+CD107a+ (89%) (p=0.06) (Figure 1B). Finally, patients with >3.2% CD4-CD8- T cells within the nonCAR T lymphocytes showed superior outcome as compared to those patients who displayed lower levels of double-negative T cells (100% vs 50% of EFS rates, respectively) (p=0.03). Conclusions In our cohort, the median day of CD19 CAR-T cell peak expansion as assessed by flow cytometry was 7 days after infusion. Markers of exhaustion within the CAR+ population and percentage of double-negative T lymphocytes allows an early identification of prognostic groups in order to guide therapeutic actions. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Hematology Referral, Stroke Recurrence and Mortality Among Patients with First Ischemic Stroke and Polycythemia or Thrombocytosis

Introduction: Stroke is the second leading cause of death and disability worldwide. In developing countries, the burden of stroke is expected to increase due to aging populations and poor management of risk factors. Essential thrombocytosis (ET), polycythemia vera (PV) and other myeloproliferative neoplasms (MPNs) are known risk factors for ischemic stroke (IS), yet the prognostic value of abnormal values of hemoglobin and platelet on admission for IS and the frequency of IS as a first manifestation of MPN are still uncertain. Objective: To determine clinical outcomes of patients with a first IS or transient ischemic attack (TIA) with and without polycythemia or thrombocytosis. Methods: We performed a retrospective analysis of all public-setting IS and TIA patients included in the Joinville Stroke Registry (JOINVASC) between January 2018 and December 2019. Data cutoff was December 2021. Patients with previous IS or TIA (n = 359), or without a complete blood count (CBC) on hospital admission were excluded (n = 13). Polycythemia was defined as hemoglobin ≥ 16 grams per deciliter in females and ≥ 16.5 in males, thrombocytosis as platelet count ≥ 450,000 platelets per microliter. Stroke recurrence was defined as a new IS or TIA after hospital discharge and event-free survival (EFS) was defined as the period over which the patient remained free from stroke recurrence or death. Study protocol was approved at the institutional review board. Results: One thousand and eleven patients were included. Median age was 67 years (interquartile range, IQR: 59-76) and 54% were male (n =546). TIA was observed as a first event in 191 patients (19%), small vessel occlusion in 143 (14%), cardioembolism in 146 (14%) and undetermined cause in 394 (39%). Mean length of hospital stay (days ± standard deviation, SD) was 12 ± 13 and 90-day mean Rankin Score (± SD) was 2 ± 1.6. At hospital admission, polycythemia was observed in 76 patients (8%), with CBCs > 6 months before admission, at hospital discharge and on outpatient follow-up also showing polycythemia in 26 (34%), 31 (41%) and 13 patients (17%). Thrombocytosis was seen in 30 patients (3%), with CBCs > 6 months before admission, at hospital discharge and on outpatient follow-up also showing thrombocytosis in 12 (40%), 20 (67%) and 11 patients (37%). Among 104 patients with either polycythemia or thrombocytosis, hematology referral was seen in 10 patients (10%), with diagnosis of MPN in 5 (5%) and solid tumor in 3 patients (3%). First IS or TIA patients with polycythemia or thrombocytosis were younger (median age 64 versus 67 years, p= 0.04) and more frequently male (72% versus 52%, p <0.0001). No differences in the incidence of stroke subtypes, length of hospital stay or 90-day Rankin Scores were observed. Stroke recurrences were more frequent among patients with polycythemia or thrombocytosis (15% versus 9%, p = 0.04) with a trend of higher mortality (34% versus 23%, p = 0.07) and a statistically significant lower 2-year EFS probability (58% versus 74%, p = 0.02) Conclusion: Polycythemia or thrombocytosis at hospital admission with first IS or TIA was associated with shorter EFS. Hematology referrals were alarmingly low, with one in every ten stroke patients with polycythemia or thrombocytosis being referred. Improving the awareness of hematological abnormalities in this patient population is key for better diagnoses of MPN or secondary polycythemia and thrombocytosis, which may result in better patient management and prevention of stroke recurrence.

Circulating Tumor DNA After Neoadjuvant Chemotherapy in Breast Cancer Is Associated With Disease Relapse.

Detection of circulating tumor DNA (ctDNA) after neoadjuvant chemotherapy in patients with early-stage breast cancer may allow for early detection of relapse. In this study, we analyzed ctDNA using a personalized, tumor-informed multiplex polymerase chain reaction-based next-generation sequencing assay. Plasma samples (n = 157) from 44 patients were collected before neoadjuvant therapy (baseline), after neoadjuvant therapy and before surgery (presurgery), and serially postsurgery including a last follow-up sample. The primary end point was event-free survival (EFS) analyzed using Cox regression models. Thirty-eight (86%), 41 (93%), and 38 (86%) patients had baseline, presurgical, and last follow-up samples, respectively. Twenty patients had hormone receptor-positive/human epidermal growth factor receptor 2-negative, 13 had triple-negative breast cancer, and 11 had human epidermal growth factor receptor 2-positive disease. Baseline ctDNA detection was observed in 22/38 (58%) patients and was significantly associated with Ki67 > 20% (P = .036) and MYC copy-number gain (P = .0025, false discovery rate = 0.036). ctDNA detection at presurgery and at last follow-up was observed in 2/41 (5%) and 2/38 (5%) patients, respectively. Eight relapses (seven distant and one local) were noted (median follow-up 3.03 years [range, 0.39-5.85 years]). After adjusting for pathologic complete response (pCR), ctDNA detection at presurgery and at last follow-up was associated with shorter EFS (hazard ratio [HR], 53; 95% CI, 4.5 to 624; P < .01, and HR, 31; 95% CI, 2.7 to 352; P < .01, respectively). Association between baseline detection and EFS was not observed (HR, 1.4; 95% CI, 0.3 to 5.9; P = .67). The presence of ctDNA after neoadjuvant chemotherapy is associated with relapse in early-stage breast cancer, supporting interventional trials for testing the clinical utility of ctDNA monitoring in this setting.

Predictors of hematologic response and survival with stem cell transplantation in AL amyloidosis: A 25-year longitudinal study.

High-dose melphalan and stem cell transplantation (HDM/SCT) is an effective treatment for selected patients with AL amyloidosis. We report the long-term outcomes of 648 patients with AL amyloidosis treated with HDM/SCT over 25 years. Hematologic CR was achieved by 39% of patients. The median duration of hematologic CR was 12.3 years, and 45% of patients with a hematologic CR had no evidence of a recurrent plasma cell dyscrasia at 15 years after HDM/SCT. With a median follow-up interval of 8 years, the median event-free survival (EFS) and overall survival (OS) were 3.3 and 7.6 years, respectively. Patients with a hematologic CR had a median OS of 15 years, and 30% of these patients survived >20 years. On multivariable analysis, dFLC >180 mg/L and BM plasma cells >10% were independently associated with shorter EFS, whereas BNP >81 pg/mL, troponin I > 0.1ng/mL, and serum creatinine >2.0mg/dL were independently associated with shorter OS. We developed a prognostic score for EFS, which incorporated dFLC >180 mg/L and BMPC% >10% as adverse risk factors. Patients with low-risk (0 factors), intermediate-risk (1 factor), and high-risk (2 factors) disease had median EFS estimates of 5.3, 2.8, and 1.0 years, respectively (p< .001). The 100-day treatment-related mortality rate was 3% in the latest treatment period (2012-2021), and the 25-year risk of t-MDS/AML was 3%. We conclude that HDM/SCT induces durable hematologic responses and prolonged survival with improved safety in selected patients with AL amyloidosis.

(Z)-Endoxifen and Early Recurrence of Breast Cancer: An Explorative Analysis in a Prospective Brazilian Study.

Adherence to treatment and use of co-medication, but also molecular factors such as CYP2D6 genotype, affect tamoxifen metabolism, with consequences for early breast cancer prognosis. In a prospective study of 149 tamoxifen-treated early-stage breast cancer patients from Brazil followed up for 5 years, we investigated the association between the active tamoxifen metabolite (Z)-endoxifen at 3 months and event-free survival (EFS) adjusted for clinico-pathological factors. Twenty-five patients (16.8%) had recurred or died at a median follow-up of 52.3 months. When we applied a putative 15 nM threshold used in previous independent studies, (Z)-endoxifen levels below the threshold showed an association with shorter EFS in univariate analysis (p = 0.045) and after adjustment for stage (HR 2.52; 95% CI 1.13–5.65; p = 0.024). However, modeling of plasma concentrations with splines instead of dichotomization did not verify a significant association with EFS (univariate analysis: p = 0.158; adjusted for stage: p = 0.117). Hence, in our small exploratory study, the link between impaired tamoxifen metabolism and early breast cancer recurrence could not be unanimously demonstrated. This inconsistency justifies larger modeling studies backed up by mechanistic pharmacodynamic analyses to shed new light on this suspected association and the stipulation of an appropriate predictive (Z)-endoxifen threshold.

Abstract P2-01-06: Detection of circulating tumor DNA post neoadjuvant chemotherapy using a personalized assay is associated with disease relapse

Abstract Background: Approximately 30% of patients with early breast cancer present disease relapse after surgery, and technologies that enable the detection of circulating tumor DNA (ctDNA) were shown to identify them earlier than standard imaging. In the present study, we aimed to interrogate the value of the SignateraTM personalized ctDNA assay for early detection of disease relapse. Methods: The study included 52 early breast cancer patients undergoing neoadjuvant chemotherapy from an ongoing translational, single-center study at Jules Bordet Institute, Brussels, Belgium. From each patient, primary tumor tissue sections, blood sample for normal DNA, and serial plasma samples were sent to NATERA Inc for ctDNA detection using the SignateraTM assay. Plasma samples were collected before the initiation of neoadjuvant chemotherapy (baseline), after neoadjuvant chemotherapy, before surgery (pre-surgery), and at follow-up post-surgery. Whole exome sequencing (WES) was performed on the primary tumor tissue and matched normal DNA to design a patient-specific ctDNA assay. The unique set of SNV’s identified in WES were tracked in serial plasma samples. Associations between baseline ctDNA detection and standard clinicopathological characteristics and primary tumor point mutations or copy number aberrations were evaluated. Association between ctDNA detection, pathological complete response (pCR) and event-free survival (EFS) were explored. Fisher, Mann-Whitney and Kruskal-Wallis tests were used to compare variables. Log-rank tests and Cox regressions were used for survival analyses. Hazard ratios (HRs) and confidence intervals (CIs) were obtained from Cox regressions. For multivariable tests, logistic regressions were used for binary outcomes and Cox regressions for survival outcomes. P-values were obtained by comparing models with and without the variable of interest using Chi-square test in ANOVAs. Results: Forty-four out of 52 (85%) initially selected patients had the required tumor cellularity (≥ 20%) and adequate tumor DNA quantity and quality and had personalized ctDNA assays designed. In these 44 patients, 154 plasma samples were successfully processed including 38, 41, 75, 38 at baseline, pre-surgery, follow-up (any timepoint) and last follow-up timepoint, respectively. Twenty (45%) patients had hormone receptor positive/HER2-negative, 13 (30%) triple-negative and 11 (25%) HER2-positive breast cancers. Detection of ctDNA was observed in 22 of 38 (58%) patients at baseline and was significantly associated with Ki67&amp;gt;20% and MYC copy number gain in the primary tumor. ctDNA detection at pre-surgery and at last follow-up was observed in 2 of 41 (5%) and 2 of 38 (5%) patients respectively. All patients who achieved pCR were ctDNA-negative at the pre-surgical time point. With a median follow-up of 3.03 years (range 0.39 - 5.85), we observed 8 relapses (7 distant and 1 local, respectively). After adjusting for pCR, ctDNA detection was associated with shorter EFS at pre-surgery and at last follow-up time points (HR: 53, 95% CI: 4.5-624, p&amp;lt;0.01, and HR: 31, 95% CI: 2.7-352, p&amp;lt;0.01, respectively), but not at baseline (HR: 1.4, 95% CI: 0.3-5.9, p=0.67). Conclusions: The detection of ctDNA post neoadjuvant chemotherapy is associated with disease relapse in early breast cancer supporting interventional trials in this setting. Citation Format: Elisa Agostinetto, Frédéric Cailleux, Matteo Lambertini, Françoise Rothé, Hsin-Ta Wu, Mustafa Balcioglu, Himanshu Sethi, Delphine Vincent, Giulia Viglietti, Andrea Gombos, Andreas Papagiannis, Isabelle Veys, Ahmad Awada, Christos Sotiriou, Ekaterina Kalashnikova, Alexey Aleshin, Denis Larsimont, David Venet, Michail Ignatiadis. Detection of circulating tumor DNA post neoadjuvant chemotherapy using a personalized assay is associated with disease relapse [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-01-06.