Therapy For Acute Leukemia Research Articles

Single-cell CAR T atlas reveals type 2 function in 8-year leukaemia remission

Despite a high response rate in chimeric antigen receptor (CAR) T cell therapy for acute lymphocytic leukaemia (ALL)1–3, approximately 50% of patients relapse within the first year4–6, representing an urgent question to address in the next stage of cellular immunotherapy. Here, to investigate the molecular determinants of ultralong CAR T cell persistence, we obtained a single-cell multi-omics atlas from 695,819 pre-infusion CAR T cells at the basal level or after CAR-specific stimulation from 82 paediatric patients with ALL enrolled in the first two CAR T ALL clinical trials and 6 healthy donors. We identified that elevated type 2 functionality in CAR T infusion products is significantly associated with patients maintaining a median B cell aplasia duration of 8.4 years. Analysis of ligand–receptor interactions revealed that type 2 cells regulate a dysfunctional subset to maintain whole-population homeostasis, and the addition of IL-4 during antigen-specific activation alleviates CAR T cell dysfunction while enhancing fitness at both transcriptomic and epigenomic levels. Serial proteomic profiling of sera after treatment revealed a higher level of circulating type 2 cytokines in 5-year or 8-year relapse-free responders. In a leukaemic mouse model, type 2high CAR T cell products demonstrated superior expansion and antitumour activity, particularly after leukaemia rechallenge. Restoring antitumour efficacy in type 2low CAR T cells was attainable by enhancing their type 2 functionality, either through incorporating IL-4 into the manufacturing process or by priming manufactured CAR T products with IL-4 before infusion. Our findings provide insights into the mediators of durable CAR T therapy response and suggest potential therapeutic strategies to sustain long-term remission by boosting type 2 functionality in CAR T cells.

Intensive Oral Hygiene Interventions during Therapy of Acute Leukemia May Result in Detrimental Outcomes: A Randomized Clinical Trial

Objectives There are no standard guidelines on oro-dental care during induction therapy of acute leukemia (AL). This study aimed to assess the effect of intensive oral hygiene practice on oral mucositis, infection, and disease outcomes compared to standard clinical practice. Materials and Methods Newly diagnosed patients with AL were randomized to receive either standard oral hygiene protocol (group A, n = 92) or comprehensive oral hygiene protocol (group B, n = 91). In group A, the oral hygiene indexes were measured by the dentist at baseline and at the end of treatment. In group B, weekly monitoring of oral hygiene indexes by the dentist and interventions in the form of oral cavity inspection, probing for gum health, and use of a soft toothbrush and education on oral hygiene practices were carried out. Results The frequency of mucositis was higher in group B (60%) than in group A (40%; p = 0.09). There was no difference in the median Simplified Oral Hygiene Index (OHI-S; 0.5 vs. 0.6) and Silness and Loe plaque index (0.4 vs. 0.25) between the groups. The local (11 vs. 1%; p = 0.005) and systemic infection rate (82.2 vs. 65.2%; p = 0.009) were higher in group B than in group A. Conclusion This study failed to show the superiority of a comprehensive oral hygiene protocol compared to standard protocol in reducing oral mucositis in patients receiving induction therapy for AL. We hypothesize that frequent intervention in the oral cavity may lead to the dissemination of infection.

Current situation and prospect of diagnosis and therapy of childhood acute leukemia in China

Acute leukemia is the most common hematopoietic stem cell malignant tumor in children, which ranks in the top one of the incidence of tumor in children, it is a major disease that affects the growth and survival of children. With the continuous improvement of medical diagnosis and treatment and the extensive development of immunotherapy, the survival rate and quality of life of children with acute leukemia have been significantly improved. In recent years, three cooperative groups of childhood leukemia have been established in China, and a series of high-level research results have been published. In the future, efforts should be made to promote the process of standardization and homogenization in the diagnosis and treatment of children's acute leukemia, explore the monitoring targets of sensitive residual diseases, and find the best treatment for refractory/recurrent cases. Speeding up the clinical research of new drugs will be an urgent problem and development direction in the field of acute leukemia diagnosis and treatment in children.

Retinoic Acid and Its Derivatives in Dermatological Disorders

Retinoids are a group of compounds consisting of vitamin A and its active metabolite all-trans-retinoic acid (ATRA). Retinoids can regulate the physiological functions of various organs and tissues and play an important role in normalising immune function, cell growth and differentiation. Vitamin A Vitamin A derivatives have a role in the treatment of tumours and ATRA has a role in the differentiation therapy of acute promyelocytic leukaemia (APL). ATRA and other retinoids also have many applications in dermatological conditions (e.g. skin cancer, psoriasis). ATRA and other retinoids also have many applications in dermatological conditions (e.g. skin cancer, psoriasis, acne and ichthyosis). In addition, the physiological functions of skin cells can also be regulated by modulating retinoic acid receptors and retinoid X (or rexinoid) receptors. The results of numerous genetic modelling experiments have shown that the regulation of retinoic acid receptors (RARs) and retinoid X (or rexinoid) receptors (RXRs) may have great potential for the treatment of serious skin diseases such as skin cancer. Here, we provide a synopsis of the main advances in understanding the role of ATRA and its receptors in dermatology.

Traditional Chinese medicine for acute myelocytic leukemia therapy: exploiting epigenetic targets.

Acute myeloid leukemia (AML) is a heterogeneous hematological malignancy with historically high mortality rates. The treatment strategies for AML is still internationally based on anthracyclines and cytarabine, which remained unchanged for decades. With the rapid advance on sequencing technology, molecular targets of leukemogenesis and disease progression related to epigenetics are constantly being discovered, which are important for the prognosis and treatment of AML. Traditional Chinese medicine (TCM) is characterized by novel pharmacological mechanisms, low toxicity and limited side effects. Several biologically active ingredients of TCM are effective against AML. This review focuses on bioactive compounds in TCM targeting epigenetic mechanisms to address the complexities and heterogeneity of AML.

Anti-CD19 chimeric antigen receptor T-cell therapy for B-cell acute lymphoid leukemia.

Anti-CD19 chimeric antigen receptor T-cell therapy for B-cell acute lymphoid leukemia.

Факторы риска развития рецидивов перианальных инфекционных осложнений у пациентов с опухолевыми заболеваниями системы крови: результаты одноцентрового проспективного исследования

Aim. To study risk factors for relapses of perianal infection (PI) in patients with hematological tumors.
 Materials & Methods. This single-center prospective clinical trial (2016–2020) enrolled all oncohematological patients at the National Research Center for Hematology who developed PI at various stages of chemotherapy. To assess the impact of some factors on relapsing perianal infectious complications, the distribution of clinical characteristics in groups of patients with single or multiple PI episodes was analyzed.
 Results. The trial addressed 158 PI episodes in 132 patients; there were 64 men and 68 women, the median age was 40 years (range 18–77 years). PI relapses were identified in 22 (16.67 %) patients, with a higher incidence in acute myeloid leukemia (AML) patients (63.64 %). Recurrent PI episodes were usually registered on program therapy of acute leukemias (73.08 %), more often at consolidation stage (38.46 %) than at other stages of treatment (17.42 %) (hazard ratio [HR] 2.96; 95% confidence interval [95% CI] 1.19–7.35; p < 0.031). With the follow-up of 360 days from the first episode, the probability of PI relapses was 16.2 %, and it was higher in AML patients (24.3 %). In non-remission AML patients having the first PI episode, the probability of PI relapses considerably increased and accounted for 52.6 %. In case of cryptogenic pararectal abscesses, it was 20 %, if solely abscess drainage was performed at the first stage. However, no relapses were registered after the surgical treatment of pararectal fistulas. The risk factors for recurrent PI, as was shown by univariate analysis, were AML diagnosis (HR 2.94; 95% CI 1.14–7.62; p < 0.032) and the lack of remission of hematological tumor by the time of the first PI episode (HR 2.98; 95% CI 1.13–7.90; p < 0.034). By multivariate analysis, the significant risk factor was non-remission AML diagnosis by the time of the first PI episode (HR 6.94; 95% CI 2.93–16.66; p < 0.0001).
 Conclusion. The significant risk factor for PI relapses is non-remission AML diagnosis by the time of the first infectious episode. This category of patients shows the maximal probability of relapsing perianal infectious complications, which is 52.6 %. To prevent PI relapses in patients with cryptogenic pararectal abscesses, abscess drainage should be combined with scheduled surgery of anal fistulas.

Coronavirus Disease 2019 mRNA Vaccination Appears Safe in Pediatric Patients With Hypersensitivity to Polyethylene Glycolated Escherichia coli L-asparaginase.

Polyethylene glycol-asparaginase (PEGAsp) is an established component of acute leukemia therapy. Hypersensitivity reactions to PEGAsp occur in 10% to 15% of patients, with polyethylene glycol suggested as the antigenic culprit. As coronavirus disease 2019 (COVID-19) mRNA vaccines contain polyethylene glycol, the safety of administration of these vaccines to patients with prior PEGAsp hypersensitivity has been questioned. Between December 21, 2020 and March 3, 2022, 66 patients with acute leukemia and PEGAsp allergy received COVID-19 vaccination. No patients (0/66 0%, 95% CI: 0%-5.4%) experienced an allergic reaction to the vaccine. COVID-19 mRNA vaccination appears to be safe in pediatric and young adult patients with acute lymphoblastic leukemia with PEGAsp allergy.

Study of the Application of CAR-T Cell Therapy in Acute Lymphocytic Leukemia

Currently, the acute lymphocytic leukemia (ALL), which is a severe blood cancer that mostly found in children, can applied with the most updated CAR-T cell therapy for the cure. ALL incidence rate is around fifteen in one hundred thousand people, which is just lower than the incidence rate of Chronic Lymphocytic Leukemia. And the ALL occupied one-fifth of the leukemia cases. With the application of CAR-T cell therapy, ALL can be cured with higher long-term survival rate. But the CAR-T cell therapy brings some negative impact towards patient body like Cytokine Release Syndrome (CRS). The limitations and adverse actions of the therapy needs to be overcome or minimized to achieve the best prospect of treating patients. In this paper, the first part will briefly introduce present situations of ALL and the CAR-T cell therapy, and the following parts will explain mechanism of CAR-T cell therapy, limitations of the therapy on this disease, and future development of the therapy.

Harnessing intermolecular G-quadruplex-based spatial confinement effect for accelerated activation of CRISPR/Cas12a empowers ultra-sensitive detection of PML/RARA fusion genes

Accurate detection and classification of the three isoforms of PML/RARA genomic fragments are crucial for predicting disease progression, stratifying risk, and administering precise drug therapies in acute promyelocytic leukemia (APL). In this study, we have developed a highly specific nucleic acid detection platform capable of quantifying the long isoform of the three main PML-RARA isoforms at a constant temperature. This platform integrates the strengths of the CRISPR/Cas12a nuclease-based method and the rolling circle amplification (RCA) technique. Notably, the RCA-assisted CRISPR/Cas12a trans-cleavage system incorporates a spatial confinement effect by utilizing intermolecular G-quadruplex structures. This innovative design effectively enhances the local concentration of CRISPR/Cas12a, thereby accelerating its cleaving efficiency towards reporter nucleic acids and enabling the detection of PML/RARA fusion gene expression through spectroscopy. The robust detection of PML/RARA fusion gene from human serum samples validates the reliability and potential of this platform in the screening, diagnosis, and prognosis of APL cases. Our findings present an approach that holds significant potential for the further development of the robust CRISPR/Cas sensor system, offering a rapid and adaptable paradigm for APL diagnosis.

Association of Hypometilating Agents (HMA) + Venetoclax (VEN) in the Therapy of Acute Myeloid Leukemias Evolved from Myelodysplastic Syndromes (AML-MDS) Already Treated with Azacytidine

Background Survival of high-risk Myelodysplastic Syndromes (MDS) treated with azacytidine during the dysplastic phase and then evolved in Acute Myeloid Leukemia (AML-MDS) is very poor. While the association of hypometilating agents (HMA) and venetoclax (VEN) is widely used in de novo AML not eligible for intensive chemotherapy, very few data are available in patients (pts) with AML-MDS. Methods Data of 42 pts with AML-MDS treated frontline with HMA+VEN in 19 hematologic Centres in Italy outside clinical trials from 5/2018 to 3/2023 were retrospectively collected and analysed. Composite overall response rate [ORR; complete remission (CR) + CR with incomplete hematologic recovery (iCR) + partial remission (PR) + hematologic improvement (HI)], duration of response and overall survival (OS) were assessed. Results: Baseline characteristics at evolution in AML are reported in the Table. Median interval from initial MDS diagnosis to evolution was 16.7 months [interquartile range (IQR) 8.2-30.1]. Pts were treated for a median of 3 courses (IQR 2-6): HMA were administered at standard dosage, VEN daily doses in the 1 st cycle are reported in the Table. On the whole, 34 pts (81.0%) had at least one hematologic toxicity of grade 3-4: in particular, severe neutropenia (PMN < 0.5 x 10 9/l) was reported in 32 pts (76.1%). Eighteen pts (42.8%) had at least one infective episode during the treatment: pulmonary infections were reported in 9 pts (21.4%). Response to treatment is shown in the Table: ORR was 52.4%, with a median response duration of 17.8 months (95%CI 3.3-32.2). After a median follow-up from AML evolution of 6.1 months (IQR 2.2-11.6), 31 pts (73.8%) died and 11 (26.2%) were alive. Median OS from AML evolution of the whole cohort was 6.9 months (95%CI 4.7-9.1), Pts with any response to HMA+VEN had a significantly longer OS compared to pts with progressive/stable disease [15.6 (95%CI 11.3-19.8) versus 3.3 (95%CI 0.7-5.8) months, respectively (p<0.001)] (Figure). Conclusions: Our real-life data suggested that HMA+ VEN combination could be useful also in AML-MDS already treated with azacytidine in the dysplastic phase, with an ORR of about 50% in pts unfit for intensive approaches: however, hematologic and infective toxicities were severe and the response duration was short, with a persistently poor median OS. As a consequence, addition of other targeted therapies driven by NGS should be explored in the next future.

Application of cfDNA-NGS Test in MRD Monitoring of Acute Leukemia Patients with CAR-T Cell Therapy

Background: The minimal residual disease (MRD) plays an important role in the comprehensive management of CAR-T cell therapy. However, some reasons hinder the application of MRD monitoring in CAR-T cell therapy. Dynamic monitoring of cfDNA in solid tumors and hematological malignancies can effectively evaluate the efficacy of treatment and predict long-term prognosis. However, there is no relevant researches on whether cfDNA can replace bone marrow for MRD monitoring after CAR-T cell therapy for acute leukemia. Methods: 23 patients with acute leukemia who received CAR-T cell therapy from January 2021 to October 2022 in the First Affiliated Hospital of Suzhou University were collected retrospectively, including 14 AML patients and 9 ALL patients. The CAR-T cell targets included CD38, CD7, CLL-1 and CD19/CD22. Bone marrow and peripheral blood samples were collected before CAR-T cell therapy, +28d and every month after CAR-T cell therapy. We used QIAamp Circulating Nucleic Acid Kit to extract cfDNA, and then conducted high-throughput sequencing through Nextseq550 sequencing platform. We compared the test results of cfDNA-NGS and BM-NGS in terms of gene mutation types and variant allele frequency (VAF), and analyzed the efficacy of cfDNA-NGS, BM-NGS and FCM on the prediction of remission and replase of CAR-T cell therapy by the receiver operating characteristic curve (ROC curve). Results: In this study, a total of 123 peripheral blood samples were collected and cfDNA was extracted from all samples. The results of 121 cfDNA-NGS and BM-NGS test were consistent, with a consistency rate of 98.4% (121/123), and the consistency rate with bone marrow FCM detection was 85.4% (105/123). cfDNA-NGS test was a good indicator for predicting the efficacy and replase after CAR-T cell therapy: compared with BM-NGS and FCM, cfDNA-NGS test before CAR-T cell therapy had the highest prediction efficiency for CR (AUC=0.767, 95%CI: 0.576-0.958, P=0.039). Survival analysis showed no difference in 1-year OS and LFS between cfDNA-NGS (+), BM-NGS (+) , FCM (+) patients at +28 days after CAR-T cell therapy (OS: 27.3% vs 33.3% vs 30%, P=0.949; LFS: 27.3% vs 33.3% vs 30%, P=0.970). At +28 days after CAR T treatment, there was no difference in 1-year OS and LFS between patients with cfDNA-NGS (-), BM-NGS (-), FCM (-) (OS: 91.7% vs 76.2% vs 83.3%, P=0.671; LFS: 73.3% vs 76.2% vs 82.1%, P=0.726). Then we assessed the long-term prognosis by cfDNA-NGS combined with traditional MRD detection methods after CAR-T cell therapy: Survival analysis showed that 1-year OS and LFS of patients with cfDNA (-), BM-MRD (-) and cfDNA1 (-), BM-MRD (+) were significantly better than those with cfDNA (+), BM-MRD (-) and cfDNA1 (+), BM-MRD (+) (OS: 90.9% vs 100% vs 50% vs 22.2%, P=0.008: LFS：68.2% vs 100% vs 50% vs 22.2%, P=0.017). Conclusions: The cfDNA-NGS test was a good indicator for predicting the efficacy and replase after CAR-T cell therapy, and was not inferior to BM-NGS and FCM detection in evaluating efficacy, replase and long-term prognosis. Combination cfDNA-NGS test with traditional MRD detection methods could evaluate the long-term prognosis of CAR-T cell therapy more comprehensively.

Acute Leukemias of Ambiguous Lineage Have Durable Response to Hypomethylating Agents Plus Venetoclax in Older Patients

Background: The standard of care for frontline therapy of acute leukemias of ambiguous lineage (ALAL) remains controversial due to their rarity; however, outcomes are generally poor. Intensive chemotherapy (IC) regimens are standard, with evidence suggesting that acute lymphoblastic leukemia regimens are more effective than those used for acute myeloid leukemia (AML). Strategies for treating older or frail patients are limited. Although treatment with a hypomethylating agent plus venetoclax (HMA/Ven) is standard therapy for IC-ineligible AML patients, the role of HMA/Ven in ALAL remains poorly characterized. We performed a retrospective chart review of patients at our institution with Philadelphia-negative ALAL, comparing the outcomes of those treated with HMA/Ven and those who received IC. Method: Patients ≥ 18 years treated at Weill Cornell Medical Center with newly diagnosed, pathologically confirmed acute undifferentiated leukemia (AUL), T/myeloid, or Philadelphia chromosome-negative B- and B/T-myeloid leukemia were included. Frontline HMA/Ven was defined as Ven plus azacytydine, decitabine, or oral decitabine/cedazuridine (one patient had initial HMA monotherapy followed by HMA/Ven). Intensive chemotherapy included patients who received variations of standard ALL or AML IC regimens (hyper- or mini-hyper-CV[A]D, cytarabine plus daunorubicin or idarubicin, or cladribine plus idarubicin and cytarabine) with or without Ven. Tyrosine kinase inhibitors including midostaurin or gilteritinib were added for patients with fms-like tyrosine kinase 3 ( FLT3) mutations. Baseline and disease characteristics were collected as well as disease response, subsequent lines of therapy, whether the patient proceeded to allogeneic hematopoietic cell transplantation (HCT), rate of morphologic complete remission (CR), and overall survival (OS). Results: Of 16 patients, 7 received frontline HMA/Ven. B/myeloid was the most common disease type (n=8), followed by T/myeloid (n=4), AUL (n=3), and 1 patient with B/T/myeloid disease. The median age was 74 years (interquartile range [IQR] 62-80). Patients who received HMA/Ven were older than those who received IC, with median ages of 79 (IQR: 77-82) and 62 (IQR: 56-70; p = 0.01), respectively. Baseline white blood cell, hemoglobin, platelet counts, and lactate dehydrogenase, as well as blast percentages in both peripheral blood and bone marrow were similar between the groups. Although not validated in ALAL, markers of adverse myeloid disease as per the ELN 2022 schema were prevalent in both groups, including mutations in RUNX1, ASXL1, SRSF2, and TP53 (Figure A). One HMA/Ven patient and 3 IC patients underwent HCT. Of evaluable patients, 83% and 88% of HMA/Ven and IC patients achieved CRs, respectively. At 2 years, both groups had 50% overall survival (95% CI 22.5-100 in both). Among HMA/Ven recipients, overall survival ranged from 10-56 months, not including two patients with ongoing follow-up at 3 and 46 months (Figure B). Discussion: The treatment of ALAL remains a challenge, particularly in older patients who may be unfit for intensive treatment strategies. In our study, patients who received HMA/Ven had similarly durable disease control to younger patients who received IC in the frontline setting. Prolonged responses were seen in both AUL and MPAL. Multicenter registry and prospective analyses are needed; however, given the rarity of these diagnoses, our findings suggest that HMA/Ven should be considered as a frontline therapy for unfit patients with ALAL.

Dissecting dual specificity: Identifying key residues in L-asparaginase for enhanced acute lymphoid leukemia therapy and reduced adverse effects

L-asparaginase from Escherichia coli (EcA) has been used for the treatment of acute lymphoid leukemia (ALL) since the 1970s. Nevertheless, the enzyme has a second specificity that results in glutaminase breakdown, resulting in depletion from the patient's body, causing severe adverse effects. Despite the huge interest in the use of this enzyme, the exact process of glutamine depletion is still unknown and there is no consensus regarding L-asparagine hydrolysis. Here, we investigate the role of T12, Y25, and T89 in asparaginase and glutaminase activities. We obtained individual clones containing mutations in the T12, Y25 or T89 residues. After the recombinant production of wild-type and mutated EcA, The purified samples were subjected to structural analysis using Nano Differential Scanning Fluorimetry, which revealed that all samples contained thermostable molecules in their active structural conformation, the homotetramer conformation. The quaternary conformation was confirmed by DLS and SEC. The activity enzymatic assay combined with molecular dynamics simulation identified the contribution of T12, Y25, and T89 residues in EcA glutaminase and asparaginase activities. Our results mapped the enzymatic behavior paving the way for the designing of improved EcA enzymes, which is important in the treatment of ALL.

Single-Cell Multi-Omics Reveals Type-2 Functionality in Maintaining CAR T Cell Longevity Associated with 8-Year Leukemia Remission

Despite a high response rate in chimeric antigen receptor (CAR) T therapy for acute lymphocytic leukemia (ALL), ~50% of patients relapse within the first year, representing an urgent question to address in the next stage of cellular immunotherapy. The pioneering clinical trials conducted at Upenn/CHOP provide a unique opportunity to examine the molecular determinants of ultra-long CAR T persistence. We performed single-cell multi-omics profiling of ~700k pre-infusion CD19-targeted 4-BB CAR T cells from 82 pediatric ALL patients and 6 healthy donors. Patient demographics were collected between Sep-2012 to July-2022. To uncover the hallmarks of CAR T longevity, we correlated the single-cell atlas with the duration of B-cell aplasia (BCA), a widely used pharmacodynamic measurement of CAR T persistence, and classified all the patients into 5 groups (Table 1). Five patients in our cohort have exhibited a median BCA duration of 8.4 years (BCA-L group) and another 11 patients continue to have BCA with a median time of 5.1 years (BCA-O group). To remove potential confounding variables between trial design, 42 patients including the 5 BCA-L were analyzed as the Discovery Cohort, while the other 40 patients including the 11 BCA-O were used as Validation Cohort. Our analysis of CD19-specific stimulated CAR T cells from the Discovery Cohort revealed a prominent role of type-1 function, which was highly represented but had no discernible correlation with long-term persistence. Unexpectedly, we identified that elevated type-2 functionality was significantly associated with BCA-L patients maintaining CAR T persistence of 8.4 years, and this signature was robustly presented in the BCA-O patients in our Validation Cohort. Higher type-2 cytokine level of long-term persistent CAR T cells was independently validated using both flow cytometry and multiplexed secretomic assay. Through ligand-receptor interaction analysis, type-2 cytokines were found to regulate a cluster of Tim-3+terminal effector cells showing over activation of cytotoxicity, impaired immune function, elevated exhaustion signature and diminished proliferative potentiality, and CAR T cells from BCA-L patients showed reduced dysfunctional hallmarks. We next conducted in vitro functional studies to assess the impact of adding type-2 cytokine (IL-4) during CAR-specific activation on CAR T fitness. The addition of 10ng/mL IL-4 significantly boosted the proliferation and mitigated dysfunction of CAR T cells from 6 patients in the BCA2 group that only mediated short-term response (~3 months) and had negligible impact on their type-1 functionality. Remarkably, the functional profile of short-term BCA2 CAR T cells after IL-4 supplementation exhibited a comparable pattern to that of long-term BCA-L CAR T cells, particularly in terms of type-2 pathway, oxidative phosphorylation metabolism, PI3K/AKT signaling, mTOR signaling, and cell cycle regulation. To investigate the response of the host following CAR T infusion, we performed a comprehensive proteomic profiling of post-infusion serum proteins in a total of 41 patients. Baseline measurements (-2 to 0 days before CAR T infusion) showed a significantly higher level of type-2 cytokines in long-term patients. From the rapid expansion period (day 6-8) until 11 days post-infusion, we consistently observed significantly higher levels of circulating type-2 cytokines in 5-year or 8-year relapse-free responders. Conversely, no difference was observed in type-1 cytokines. In a leukemic NSG mouse model, both type-2 high and low CAR T cells were highly effective in reducing tumor burden in the first two weeks. However, type-2 high CAR T had significantly superior expansion, and the absolute CAR+ cell counts in peripheral blood were 10-fold higher than type-2 low CAR T at day 8 and day 12. To mimic tumor cell relapse, a second dose of tumor cells were injected into mice on day 17. Notably, type-2 high CAR T cells demonstrated a potent capability to elicit recall responses upon leukemia rechallenge, significantly prolonging the survival of tumor-bearing mice compared to type-2 low CAR T. The superior performance could be associated with their decreased exhaustion and increased memory phenotype. Our findings provide key insights into the mediators of CAR T longevity and suggest a potential therapeutic strategy to maintain long-term remission by enhancing type-2 functionality in CAR T cells.

Optimized Double-Unit Cord Blood Transplantation Mitigates Transplant-Related Mortality Resulting in High Progression-Free Survival in Adults with Hematologic Malignancies

Background : Double-unit cord blood transplantation (dCBT) with intermediate intensity conditioning (Cy50/ Flu150/ Thio10/ TBI400cGy) and cyclosporine-A (CSA)/ mycophenolate mofetil (MMF) graft-versus-host disease (GVHD) prophylaxis has been associated with high progression-free survival (PFS) in adult patients (pts) with hematologic malignancies ( Barker JN et al, Blood Advances 2020). Now, our Center has investigated multiple refinements to further mitigate transplant-related mortality (TRM). Herein, we have analyzed transplant outcomes in these adult dCBT pts to establish an optimized dCBT platform. Methods : Consecutive adult first allograft pts with high-risk hematologic malignancies who underwent first allografts with intermediate intensity dCBT between 3/2018-8/2022 were analyzed. Optimizations involved further refined unit selection placing highest priority on unit quality (i.e. optimized banking practices) & CD34+ cell dose over HLA-match, ensuring therapeutic (CSA) levels (> 250 ng/mL) by day 0, prompt treatment of pre-engraftment syndrome (PES) & letermovir prophylaxis in CMV seropositive pts from day +7. Also, we have investigated 2 strategies to mitigate acute graft-versus-host disease (aGVHD): pts early in the study period received CSA, MMF & tocilizumab (8 mg/kg on day -1) prophylaxis ( Toci Group), whereas recent pts ( Recent Group) received CSA/ MMF with prompt therapy of clinically diagnosed aGVHD. Results : Of 74 patients (Table), 49 were in the Toci Group, & 25 in the Recent Group. Most pts were transplanted for acute leukemia (n = 55, 74%) & over half (n = 39, 53%) had non-European ancestry. Distribution of diagnoses, CMV serostatus, HCT-CI & graft characteristics were similar between the groups but Recent Group pts tended to be younger (38 vs. 47 years, p = 0.071). Toci Group pts had delayed neutrophil recovery [engraftment incidence 94% (95%CI: 87-99) at a median of 25 days (range 16-40), one graft failure], but low rates of PES (n = 19, 39%). The day-100 incidence of grade II-IV & III-IV aGVHD were 69% (95%CI: 56-82) & 10% (95%CI: 2-19), respectively. One pt (false negative CMV-serostatus) who did not receive letermovir had CMV infection. One-year TRM was 16% (95%CI: 6-27) with a 1-year relapse rate of 6% (95%CI: 3-13). TRM was due to infection (n = 3), aGVHD (n = 3, 1 with concurrent COVID-19 infection), multiorgan failure (n = 2) & graft failure (n = 1). With a median follow-up of 47 months (range 28-62), the 1-year OS was 84% (95%CI: 73-94) & 1-year PFS was 78% (95%CI: 66-89). By contrast, the engraftment incidence in Recent Group pts was 100% with a faster median neutrophil recovery of 19 days (range 11-36, p = 0.002) & all engrafted platelets at a median of 36 days (range 24-92). However, most Recent group pts developed PES [n = 20 (80%), p < 0.001] although this responded promptly to short course corticosteroids. Day 100 grade II-IV aGVHD was also higher [92% (95%CI: 81-99), p = 0.009], although grade III-IV aGVHD was low [8% (95%CI: <1-19)] & similar to tocilizumab pts. Day 100 incidence of CMV was 0%. With a median follow-up of 17 months (range 6-50), the 1-year TRM in Recent Group pts is 0% with a 1-year relapse incidence of 13% (95%CI: 7-27). Consequently, the 1-year OS & PFS are high at 96% (95%: 89-99) & 87% (95%CI: 74-99), respectively (Figure). Conclusions: Optimized dCBT with intermediate intensity conditioning, graft selection that prioritizes unit quality & CD34+ dose, CSA/ MMF prophylaxis with prompt therapy of PES & aGVHD, & letermovir CMV prophylaxis mitigates TRM in young & middle-aged adults. Thus, combined with relatively low relapse rates, the PFS & OS are high. Tocilizumab has been abandoned due to its notable association with delayed neutrophil engraftment & lack of survival advantage. Letermovir is highly effective completely preventing CMV infections & may contribute to the reduced aGVHD-related mortality recently (as compared to the pre-tocilizumab era), since avoidance of CMV antiviral therapy toxicities greatly facilitates aGVHD prevention & therapy. Given the rapid availability of cryopreserved unmanipulated CB grafts & frequent limitations of URD availability for minority populations, optimized dCBT is a highly attractive curative therapy for acute leukemias & other high-risk myeloid malignancies warranting prospective multi-center investigation.

Approach to diagnostic evaluation and prevention of invasive fungal disease in patients prior to allogeneic hematopoietic stem cell transplant.

In recent years, advancements in the treatment landscape for hematological malignancies, such as acute myeloid leukemia and acute lymphoblastic leukemia, have significantly improved disease prognosis and overall survival. However, the treatment landscape is changing and the emergence of targeted oral therapies and immune-based treatments has brought forth new challenges in evaluating and preventing invasive fungal diseases (IFDs). IFD disproportionately affects immunocompromised hosts, particularly those undergoing therapy for acute leukemia and allogeneic hematopoietic stem cell transplant. This review aims to provide a comprehensive overview of the pretransplant workup, identification, and prevention of IFD in patients with hematological malignancy. The pretransplant period offers a critical window to assess each patient's risk factors and implement appropriate prophylactic measures. Risk assessment includes evaluation of disease, host, prior treatments, and environmental factors, allowing a dynamic evaluation that considers disease progression and treatment course. Diagnostic screening, involving various biomarkers and radiological modalities, plays a crucial role in early detection of IFD. Antifungal prophylaxis choice is based on available evidence as well as individual risk assessment, potential for drug-drug interactions, toxicity, and patient adherence. Therapeutic drug monitoring ensures effective antifungal stewardship and optimal treatment. Patient education and counselling are vital in minimizing environmental exposures to fungal pathogens and promoting medication adherence. A well-structured and individualized approach, encompassing risk assessment, prophylaxis, surveillance, and patient education, is essential for effectively preventing IFD in hematological malignancies, ultimately leading to improved patient outcomes and overall survival.

Infection epidemiology in relation to different therapy phases in patients with haematological malignancies receiving CAR T-cell therapy.

We described the real-life epidemiology and causes of infections on the different therapy phases in patients undergoing chimeric antigen receptor (CAR) T-cells directed towards CD19+ or BCMA+ cells. All consecutive patients receiving CAR T-cell therapy at our institution were prospectively followed-up. We performed various comparative analyses of all patients and subgroups with and without infections. Ninety-one adults mainly received CAR T-cell therapy for acute leukaemia (53%) and lymphoma (33%). We documented a total of 77 infections in 47 (52%) patients, 37 (48%) during the initial neutropenic phase and 40 (52%) during the non-neutropenic phase. Infections during the neutropenic phase were mainly due to bacterial (29, 78%): catheter infections (11 [38%] cases), endogenous source (5 [17%]), and Clostridioides difficile (5 [17%]). Patients receiving corticosteroids after CAR T-cell therapy had a higher risk of endogenous infection (100% vs. 16%; p = .006). During the non-neutropenic phase, bacterial infections remained very frequent (24, 60%), mainly with catheter source (8, 33%). Respiratory tract infections were common (17, 43%). Infections after CAR T-cell therapy were frequent. During the neutropenic phase, it is essential to prevent nosocomial infections and balance the use of antibiotics to lower endogenous bacteraemia and Clostridial infection rates.

A GPX4 non-enzymatic domain and MDM2 targeting peptide PROTAC for acute lymphoid leukemia therapy through ferroptosis induction

Ferroptosis, an emerging form of programmed cell death, has garnered substantial attention as a potential target for cancer therapy. However, despite the potential promise, no ferroptosis-related therapies have progressed to clinical trials. Identifying disease types sensitive to ferroptosis and developing specific ferroptosis-targeting drugs are critical focal points in the field of ferroptosis-based treatment.In this study, we conducted a comprehensive database analysis and presented compelling evidence indicating a high expression of GPX4 in patients with acute lymphoblastic leukemia (ALL), significantly correlating with poor prognosis. Notably, elevated GPX4 expression is closely associated with ALL relapse, a major challenge in the treatment of this disease. Building upon these findings, we devised a novel peptide-based Proteolysis Targeting Chimeras (PROTAC) drug targeting GPX4 through computer-aided design. In contrast to existing drugs that target the conjugative enzyme active site, our design focused on a peptide drug targeting the non-active site of GPX4. Furthermore, we strategically selected MDM2, an E3 ligase highly expressed in ALL, for the PROTAC drug design. This deliberate choice amplifies the drug's effect on cancer cells while minimizing its impact on normal cells, achieving desirable selectivity for cancer cells. Leveraging nanogold delivery, we successfully facilitated intracellular action of the GPX4-targeting peptide PROTAC drug, denoted as Au-PGPD (peptide GPX4 PROTAC drug). Au-PGPD effectively induced GPX4 degradation and inhibited ALL cell proliferation. Remarkably, Au-PGPD exhibited significantly less efficacy on normal cells, underscoring the selectivity and safety of our design.

Sequential CD19 and CD22 chimeric antigen receptor T-cell therapy for childhood refractory or relapsed B-cell acute lymphocytic leukaemia: a single-arm, phase 2 study

Relapses frequently occur following CD19-directed chimeric antigen receptor (CAR) T-cell treatment for relapsed or refractory B-cell acute lymphocytic leukaemia in children. We aimed to assess the activity and safety of sequential CD19-directed and CD22-directed CAR T-cell treatments. This single-centre, single-arm, phase 2 trial, done at Beijing GoBroad Boren Hospital, Beijing, China, included patients aged 1-18 years who had relapsed or refractory B-cell acute lymphocytic leukaemia with CD19 and CD22 positivity greater than 95% and an Eastern Cooperative Oncology Group performance status of 0-2. Patients were initially infused with CD19-directed CAR T cells intravenously, followed by CD22-directed CAR T-cell infusion after minimal residual disease-negative complete remission (or complete remission with incomplete haematological recovery) was reached and all adverse events (except haematological adverse events) were grade 2 or better. The target dose for each infusion was 0·5 × 106 to 5·0 × 106 cells per kg. The primary endpoint was objective response rate at 3 months after the first infusion. Secondary endpoints were duration of remission, event-free survival, disease-free survival, overall survival, safety, pharmacokinetics, and B-cell quantification. The prespecified activity analysis included patients who received the target dose and the safety analysis included all treated patients. This study is registered with ClinicalTrials.gov, NCT04340154, and enrolment has ended. Between May 28, 2020, and Aug 16, 2022, 81 participants were enrolled, of whom 31 (38%) were female and 50 (62%) were male. Median age was 8 years (IQR 6-10), all patients were Asian. All 81 patients received the first infusion and 79 (98%) patients received sequential infusions, CD19-directed CAR T cells at a median dose of 2·7 × 106 per kg (IQR 1·1 × 106 to 3·7 × 106) and CD22-directed CAR T cells at a median dose of 2·2 × 106 per kg (1·1 × 106 to 3·7 × 106), with a median interval of 39 days (37-41) between the two infusions. 62 (77%) patients received the target dose, including two patients who did not receive CD22 CAR T cells. At 3 months, 60 (97%, 95% CI 89-100) of the 62 patients who received the target dose had an objective response. Median follow-up was 17·7 months (IQR 11·4-20·9). 18-month event-free survival for patients who received the target dose was 79% (95% CI 66-91), duration of remission was 80% (68-92), and disease-free survival was 80% (68-92) with transplantation censoring; overall survival was 96% (91-100). Common adverse events of grade 3 or 4 between CD19-directed CAR T-cell infusion and 30 days after CD22-directed CAR T-cell infusion included cytopenias (64 [79%] of 81 patients), cytokine release syndrome (15 [19%]), neurotoxicity (four [5%]), and infections (five [6%]). Non-haematological adverse events of grade 3 or worse more than 30 days after CD22-directed CAR T-cell infusion occurred in six (8%) of 79 patients. No treatment-related deaths occurred. CAR T-cell expansion was observed in all patients, with a median peak at 9 days (IQR 7-14) after CD19-directed and 12 days (10-15) after CD22-directed CAR T-cell infusion. At data cutoff, 35 (45%) of 77 evaluable patients had CAR transgenes and 59 (77%) had B-cell aplasia. This sequential strategy induced deep and sustained responses with an acceptable toxicity profile, and thus potentially provides long-term benefits for children with this condition. The National Key Research & Development Program of China, the CAMS Innovation Fund for Medical Sciences (CIFMS), and the Non-Profit Central Research Institute Fund of Chinese Academy of Medical Sciences. For the Chinese translation of the abstract see Supplementary Materials section.