Current Hematologic Malignancy Reports最新文献

Purpose of review: Richter transformation (RT), the progression of chronic lymphocytic leukemia (CLL) to aggressive lymphomas, poses a significant therapeutic challenge with historically poor outcomes. Chemoimmunotherapy (CIT) regimens have demonstrated limited efficacy with short durations of response. This review aims to evaluate the evolving treatment landscape for RT, with a focus on recent advances in targeted therapies, immunotherapies, and cellular therapies that are redefining the current and future standards of care.

Recent findings: The treatment paradigm for RT is rapidly shifting away from cytotoxic chemotherapy. The combination of the B-cell lymphoma 2 inhibitor venetoclax with CIT has emerged as a new first-line benchmark with promising response rates and overall survival. Covalent Bruton tyrosine kinase (BTK) inhibitors had modest activity as monotherapy but showed improved responses when given with an immune checkpoint inhibitor. Pirtobrutinib has demonstrated responses even in heavily pretreated patients. Furthermore, advancement in immunotherapy has expanded treatment options for this patient population with bispecific T-cell engagers achieving high response rates and chimeric antigen receptor T-cell therapy providing deep, durable responses and favorable median overall survival in the relapsed/refractory (R/R) setting. The therapeutic landscape for RT has broadened with the introduction of targeted agents and immunotherapy. Venetoclax-based regimens represent a new standard for chemotherapy-eligible patients, allowing for a more effective bridge to potentially curative consolidation with transplantation. For R/R disease, novel BTK inhibitors, bispecific antibodies, and cellular therapies are demonstrating substantial efficacy. Ongoing trials investigating combinations of these agents are poised to further transform RT management.

Purpose of review: B-cell acute lymphoblastic leukemia (B-ALL) is a highly aggressive hematologic malignancy, with particularly poor outcomes in relapsed or refractory cases. Relapses remain a major challenge, often resulting in short remission durations and limited survival. This review summarizes emerging therapeutic strategies for B-ALL, focusing on novel immunotherapies and targeted approaches beyond the relapsed/refractory setting.

Recent findings: Transformative therapies such as chimeric antigen receptor (CAR) T-cell therapy, antibody-drug conjugates (ADCs), and bispecific antibodies have shown promising efficacy. Beyond the R/R setting, both blinatumomab and inotuzumab ozogamicin demonstrated high rates of eradication of measurable residual disease (MRD) up to 97% and 80%, respectively. Furthermore, the addition of blinatumomab following chemotherapy in the frontline setting in patients with patients with Philadelphia chromosome (Ph)-negative B-ALL who achieved negative MRD was showing to improve outcomes with a 3-year overall survival rate of 85% compared to 68% with chemotherapy alone. Tisagenlecleucel, brexucabtagene autoleucel, and obecabtagene autoleucel, are chimeric antigen receptor (CAR) T-cell therapies that improved survival compared to chemotherapy alone in patients with relapsed/refractory ALL. In newly diagnosed Ph-positive ALL, chemotherapy-free regimens combining blinatumomab with TKIs resulted in high rates of MRD negativity and improved survival. The combination of blinatumomab and ponatinib led to a 98% MRD negativity rates by next-generation sequencing and a 3-year overall survival of 91% without reliance on allogeneic stem cell transplantation. Novel immunotherapies and targeted agents offer new avenues to improve outcomes in B-ALL. Expanding the use of blinatumomab, inotuzumab ozogamicin, and CAR T-cell therapy across treatment phases, together with strategic sequencing, may help overcome relapsed/refractory disease. These approaches provide renewed hope for achieving durable remissions and extending survival in patients with B-ALL.

Purpose of review: Plasmacytoid dendritic cell-expansion in acute myeloid leukemia (pDC-AML) is an uncommon AML subset that differs from conventional AML and from blastic plasmacytoid dendritic cell neoplasm (BPDCN). This review synthesizes the clinicopathologic, immunophenotypic, cytogenetic, and molecular features of pDC-AML, highlights its outcomes, and discusses emerging therapeutic approaches, while underscoring the need for further studies to refine classification and guide therapy.

Recent findings: Published cohorts show that pDC-AML occurs mainly in older male adults, with CD123 and HLA-DR forming a consistent immunophenotypic backbone across both myeloblasts and pDCs. pDC-restricted markers (CD303, CD304, CD4, TCL1) are confined to the pDC compartment, whereas myeloblasts are enriched for CD34, CD117, and TdT. Cytogenetic findings are heterogeneous but often adverse, with recurrent - 7/del7q and trisomy 13. RUNX1 mutations and secondary-type co-mutations (ASXL1, DNMT3A, TET2, splicing factors) are frequent, while activating mutations such as FLT3 or NRAS are variably present. Outcomes are generally inferior compared with other AML subsets, though allogeneic transplantation can achieve durable remissions in a subset. Reports on venetoclax-based therapy show mixed outcomes, while CD123-directed therapies are being explored. pDC-AML is emerging as a potentially higher-risk AML phenotype, with clinicopathologic and biologic features distinct from BPDCN. Early recognition, dual-compartment minimal residual disease assessment, timely transplant consideration, and referral for clinical trials are central to management. Standardized immunophenotypic criteria, integrated genomic profiling, and prospective evaluation of CD123-targeted and rational combination therapies are priorities to improve classification, risk stratification, and patient outcomes.

Purpose of review: Given the high risk of relapse for Philadelphia-negative (Ph-negative) B-cell acute lymphoblastic leukemia (ALL), allogeneic hematopoietic cell transplantation (allo-HCT) is often recommended following first complete remission (CR1) in high-risk patients. However, in the era of measurable residual disease (MRD) testing, allo-HCT may not be indicated for patients with standard-risk disease. Here we review the use of allo-HCT and other consolidative approaches for standard- and high-risk Ph-negative ALL, based on MRD following induction therapy.

Recent findings: Allo-HCT is strongly indicated for patients with high-risk Ph-negative ALL, especially those who are MRD positive at end of induction. Ongoing trials using cellular and immune therapies such as blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor (CAR) T-cell therapies have shown promising results in deepening response and decreasing relapse. Further, these agents have demonstrated overall manageable safety profiles. The role for allo-HCT following CR1 in patients with standard risk Ph-negative ALL is evolving with advances in therapeutic approaches. MRD is emerging as a critical prognostic factor regardless of treatment strategy, thus questioning the necessity of transplant in MRD-negative patients. With the advances in safety and accessibility of allo-HCT as well as novel therapeutics, overall outcomes in ALL continue to improve.

Purpose of review: Advances in modern molecular and genomic testing have spurred tremendous progress in our understanding of MDS pathogenesis. Here we review common diagnostic methods, the evolving multi-omics landscape of MDS, molecular subtypes, and targeted therapies.

Recent findings: MDS is a heterogeneous disease defined by a wide array of chromosomal abnormalities and > 40 common somatic mutations affecting RNA splicing complex, chromatin modification, DNA methylation, lineage specific transcription, DNA damage, RAS/MAPK signaling, and cohesin complex pathways. This has shaped current WHO/ICC classification criteria with the inclusion of 3 genetically defined subgroups: del(5q), SF3B1, and TP53-mutated. IDH1/2-mutated MDS is a new, emerging subgroup, for which multiple clinical trials are underway. Several recent targeted drug approvals including luspatercept and imetelstat have greatly expanded the treatment arsenal for lower-risk MDS. Standard of care therapy options for high-risk MDS, in particular TP53-mutated, remain limited beyond HMAs and transplant and are an active area of investigation.

Purpose of review: This review will summarize recent research into the diverse biological consequences of splicing factor mutations, and possible therapeutic vulnerabilities uncovered by such mutations, with a dedicated focus on chronic myelomonocytic leukemia.

Recent findings: Splicing factor mutations dysregulate alternative splicing transcriptome-wide. The global nature of such dysregulation has pleiotropic effects on cellular function. Splicing factor mutations can alter NF-κβ and IFN-γ signaling, alter malignant hematopoietic cell differentiation, degrade the function of epigenetic complexes, and predispose cells to DNA replicative stress. Therapeutic strategies to target the altered biology of clones harboring splicing mutations have had varying degrees of success. Because splicing factor mutations are highly prevalent in chronic myelomonocytic leukemia and many other hematologic malignancies, an understanding of their downstream effects and therapeutic vulnerabilities is of key interest in the field. This review highlights recent developments and opportunities for targeted therapies.

Purpose of review: Management of chronic myeloid leukemia (CML) with tyrosine kinase inhibitors has improved patient survival. However, patient quality of life (QOL) continues to be impacted by disease symptoms and treatment-related adverse events. Patient-reported outcome measures (PROMs) provide evidence of the patient experience. A scoping literature review was conducted to identify and summarize the evidence on PROMs used for patients with CML.

Recent findings: Embase and MEDLINE databases were searched for publications from 2001 to 2023 that reported PROMs. Ongoing and completed trials listed on ClinicalTrials.gov were also reviewed. Results were summarized according to the PROMs used and the information collected in these PROMs. After screening 6337 records, 208 unique studies were identified with published PRO evidence reporting data from 92 unique PROMs. The most commonly reported PROMs (in ≥5% of publications) were used in 115 studies, of which 45 were exclusively in the frontline setting. The most commonly used PROMs in studies in the frontline setting were variations of European Organisation for Research and Treatment of Cancer QLQ, Functional Assessment of Chronic Illness Therapy Measurement System/Functional Assessment of Cancer Therapy, and 36-Item Short Form Survey. This scoping literature review highlighted that a variety of PROMs are used in CML studies, including studies in the frontline setting. Different QOL aspects are measured by commonly used PROMs, and the choice of PROM is dependent on the study setting and objectives. A more comprehensive understanding of QOL gained by using appropriate PROMs will help optimize patient-centered treatment selection in CML.

Purpose of review: Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic malignancy characterized by monocytosis and dysplasia. While mutations in genes like TET2 and SRSF2 have helped us understand its molecular foundations, the role of inflammation in driving disease behavior is becoming increasingly evident. This review explores the role of inflammation in the biology and clinical progression of CMML, with a focus on its impact on disease initiation, progression, and potential therapeutic strategies.

Recent findings: Recent studies have shown that inflammatory cytokines, especially IL-6, TNF-α, and IL-8, are not just bystanders but active participants in promoting clonal hematopoiesis, immune dysregulation, and bone marrow dysfunction in CMML. Patients with systemic inflammation or autoimmune conditions are at a higher risk of developing CMML, suggesting a potential causal relationship. On the therapeutic front, drugs targeting cytokine pathways, such as ruxolitinib (a JAK inhibitor) and lenzilumab (an anti-GM-CSF antibody), have shown early promise in modifying disease activity and improving symptoms. Inflammation plays a central role in CMML, from disease onset to transformation into acute leukemia. Understanding and targeting these inflammatory circuits may not only help slow disease progression but also improve quality of life for patients. As our knowledge grows, incorporating inflammation into both our diagnostic frameworks and treatment approaches will likely become standard in the care of CMML.

Purpose of review: Polycythemia vera (PV) is a Philadelphia chromosome-negative myeloproliferative neoplasm (MPN) caused by a somatic gain-of-function mutation of the Janus kinase2 (JAK2) gene in hematopoietic stem and peripheral blood cells, leading to erythrocytosis which is often accompanied by leukocytosis and thrombocytosis. Historically, PV management has mainly focused on maintaining hematocrit (HCT) levels below 45% to reduce major thrombotic risk, improving symptoms and monitoring disease progression. Phlebotomy alone or in combination with cytoreductive therapy, where indicated, form the current standard of care. This review explores the potential correlation between the depletion of neoplastic clones in patients with PV with the achievement of durable complete molecular remission (CMR), and long-term treatment effects on thrombotic events and survival, as well as implications for re-defining treatment goals.  RECENT FINDINGS: Past management practices do not ideally optimize outcomes for patients with PV. Specifically, these approaches do not adequately address the underlying risk of disease progression driven by the neoplastic cells carrying mutated JAK2 and additional mutations. Patients with PV who are treated with interferon-based therapies can achieve complete hematologic response, together with a significant reduction of JAK2V617F Variant Allele Frequency (VAF). Continued reduction of the JAK2VAF may lead to CMR and is correlated with in vivo drug exposures and durable improvement of thrombotic risk, as well as increased probability of event-free survival (EFS). The results indicate that reduction in JAK2V617F VAF, and by extension depletion of neoplastic cells, is essential for favorable long term clinical outcomes in patients with PV. Emerging data suggest a direct correlation between deep reduction in JAK2V617F VAF as a measure of suppressing neoplastic cells and improved probability of EFS and delayed disease progression. These observations suggest a treatment paradigm shift from solely managing symptoms and preventing thrombotic events, toward achieving durable clonal depletion with potential for remission and preventing transformation to myelofibrosis or acute myeloid leukemia. Integration of molecular biomarkers into risk-adapted treatment algorithms may enable personalized approaches to achieve deep molecular responses and durable disease modification in PV. Clonal molecular response, therefore, deserves attention as a biomarker of response that should be evaluated in clinical trials, as well as for treatment monitoring.