HemaSphere最新文献

The mainstay of acute myeloid leukemia (AML) treatment still relies on traditional chemotherapy, with a survival rate of approximately 30% for patients under 65 years of age and as low as 5% for those beyond. This unfavorable prognosis primarily stems from frequent relapses, resistance to chemotherapy, and limited approved targeted therapies for specific AML subtypes. Around 70% of all AML cases show overexpression of the transcription factor HOXA9, which is associated with a poor prognosis, increased chemoresistance, and higher relapse rates. However, direct targeting of HOXA9 in a clinical setting has not been achieved yet. The dysregulation caused by the leukemic HOXA9 transcription factor primarily results from its binding activity to DNA, leading to differentiation blockade. Our previous investigations have identified two HOXA9/DNA binding competitors, namely DB1055 and DB818. We assessed their antileukemic effects in comparison to HOXA9 knockdown or cytarabine treatment. Using human AML cell models, DB1055 and DB818 induced in vitro cell growth reduction, death, differentiation, and common transcriptomic deregulation but did not impact human CD34+ bone marrow cells. Furthermore, DB1055 and DB818 exhibited potent antileukemic activities in a human THP-1 AML in vivo model, leading to the differentiation of monocytes into macrophages. In vitro assays also demonstrated the efficacy of DB1055 and DB818 against AML blasts from patients, with DB1055 successfully reducing leukemia burden in patient-derived xenografts in NSG immunodeficient mice. Our findings indicate that inhibiting HOXA9/DNA interaction using DNA ligands may offer a novel differentiation therapy for the future treatment of AML patients dependent on HOXA9.

The 2/20/20 International Myeloma Working Group (IMWG) score is the most employed risk score in clinical practice to evaluate the risk of progression from smoldering multiple myeloma (SMM) to symptomatic multiple myeloma. However, it faces a serious limitation: The risk score is applied at diagnosis and cannot be reapplied. Since a dynamic accurate patient risk assessment for progression is necessary, we aimed to investigate whether the detection of an evolving pattern in serum M-protein (SMP) improves the identification of high-risk patients. Eighty-three patients diagnosed with SMM between 2011 and 2020 were included. Patients were initially classified applying the 2/20/20 IMWG score at baseline and later reclassified depending on the presence of an SMP evolving pattern into six groups. We regrouped the patients into three final risk groups: low-risk, intermediate-risk, and high-risk. The risk of progression at two years for the high-risk group was 88% and all patients had progressed at 4 years. The performance measurements were superior for the new 2/20/20-Evolving score independently for the detection of high-risk patients. We show that the sequential measurement of the SMP is a noninvasive and widely available test that improves the 2/20/20 IMWG risk score.

We report the analysis of 379 cases of B-cell precursor acute lymphoblastic leukemia (BCP-ALL) using whole-transcriptome sequencing data (Table S1 and Supporting Information S1: Methods). In 48 adult, 36 pediatric, and 37 infant cases of BCP-ALL carrying t(4;11)(q21;q23)/KMT2A::AFF1 rearrangements (KMT2A-r), we observed strongly favored usage of proximal IGHV genes in V(D)J recombination and more abundant de novo DJ_H recombination than in other BCP-ALL subtypes. This finding has implications for the detection of measurable residual disease (MRD) in clinical practice as MRD-guided treatment choices have proved to provide valuable guidance in a disease that is still associated with poor prognosis in all age categories.

BCP-ALL carrying KMT2A-r is an aggressive leukemia with poor prognosis characterized by the sudden occurrence of very high white blood cell counts, a slight preference for female patients, rapid progression, and significantly shorter survival than KMT2A-r-negative patients.^{1, 2} Treatment options that significantly prolong the survival of affected patients are limited to allogeneic stem cell transplantation.² The incidence of KMT2A-r BCP-ALL is estimated between 4% and 10% in adults and 3% and 4% in childhood.³

KMT2A is a histone methyl transferase of the trithorax group involved in the establishment of epigenetic memory. It catalyzes H3K4 methylation of a large number of physiological targets including HOX genes, supporting activation of their expression.^{4, 5} In leukemogenic fusions, the N-terminal portion of KMT2A is fused in frame to more than 100 fusion partners.⁶ In the fusion product, the catalytic SET domain of KMT2A is lost. The most frequently observed fusion partners favor the interaction of the fusion product with another histone methyl transferase (DOT1L) that catalyzes H3K79 methylation. As a consequence, proper regulation of target genes activated in this aberrant fashion appears to be disturbed in cells carrying KMT2A-r.^{4, 5, 7, 8}

Proximally biased V(D)J recombination was first described in pre-B-cell lines⁹ and later shown to depend on Pax5 function.¹⁰ It is now understood that the generation of a randomized immunoglobulin repertoire depends on chromatin modifications at the IGH locus controlled by PAX5 and its target, WAPL.^{11, 12} In addition to classical V(D)J recombination,¹³ B-cell receptors (BCRs) are known to be modified by direct V_H to V_HDJ_H recombination (V_H replacement)^{14, 15} and this process is known to occur also in BCP-ALL cells.^16-18 Whether the relative contribution of V(D)J recombination and V_H replacem

Aggressive B-cell lymphomas (ABCL) represent a heterogeneous group of biologically different diseases with variable clinical outcomes.^{1, 2} Around one-third of patients are not cured with frontline treatment, and outcomes for this relapse/refractory (R/R) group are extremely poor with conventional treatments.^3-5 However, during the last years, several promising new therapies (NTs) have been progressively incorporated into the treatment arsenal, such as new monoclonal antibodies (MAs), cellular therapy with T cells with chimeric antigen receptor (CAR-T cells), or, in a lesser extent, bispecific antibodies (BiMAs). Polatuzumab vedotin–bendamustine–rituximab⁶ was approved in Europe since 2019 and funded in Spain since September 2019. Tafasitamab–lenalidomide⁷ was approved for European Medicines Agency (EMA) in August 2021 and funded in Spain in 2023. CAR-T cell was approved for EMA in 2018,^8-10 and funded in Spain in 2019. BiMAs are still only available in clinical trials.^{11, 12}

Our study aims to assess to what extent these new treatments have been incorporated into the clinical practice and how this has impacted patient survival.

This is a multicentre retrospective study based on the GELTAMO RELINF platform, which has been active since January 2014 and includes only essential variables such as histological subtype, age, gender, and current situation. From 60 centers actively registering on the platform invited to participate, 17 centers accepted. All of these centers are university hospitals, and five are CAR-T cell therapy providers. Participating centers completed a short questionnaire on disease relapse and the use of NTs in their registered patients. Conventional treatments only include chemotherapy ± anti-CD20 antibodies ± autologous transplant. Investigators in each center were required to report relapses with histological confirmation of large B-cell lymphoma (LBCL). For refractory patients, histological confirmation was not mandatory. The histologies included were diffuse LBCL (DLBCL) and high-grade B-cell lymphoma (HGBCL) not otherwise specified (NOS) and double hit. Early relapse was defined as within 12 months of completion of induction therapy, and late relapse was defined as more than 12 months.

The present analysis was based on a January 2023 data cut-off. Overall survival (OS) and progression-free survival (PFS) were determined from diagnosis. OS was also calculated since the date of the first relapse (OS2). All reported p values were two-sided, and statistical significance was set at p < 0.05. Analyses were performed using SPSS version 29 (SPSS).

From 3270 patients with ABCL registered, 2853 patients were included in the present analysis; exclusion reasons are described in Supporting Information S1: Table 1.

Supporting Information S1: Table 2

In the era of precision medicine, hematology stands at the forefront of medical disciplines. Indeed, our enduring commitment to employing molecular techniques for disease characterization, coupled with their application in individual patient management at diagnosis and during treatment monitoring, places hematology in a pivotal position. We continue to seamlessly integrate an ever-expanding array of diagnostic techniques, developed and crafted by a variety of medical and scientific specialists. These experts have collaborated in a multidisciplinary fashion to define and communicate the most appropriate diagnosis and treatment for patients with hematological cancers and nonmalignant disorders. However, this increasingly demands progressively specialized training tracks and skill sets.

The archetypical hematologist, who historically personally saw the patient, biopsied the bone marrow or even spleen, stained the cells, and then made a morphological/cytological diagnosis before starting and accompanying treatment, has become a relic of the past. At a minimum, achieving precision diagnosis of tumors of hematopoietic and lymphoid tissues requires hematologists (diagnostic and therapeutic), pathologists, geneticists, biomedical scientists/technicians/engineers, and radiologists/nuclear medicine specialists.

In any community, rules and regulations are imperative for peaceful, constructive coexistence. These regulations must be clear, concise, and up-to-date and then be communicated to and understood by all actors involved in their execution. This is a formidable challenge in a globalized world with exponentially evolving technological and informatic/data capabilities. Classifications must be provided by experts, who should be free of conflict of interest and capable of providing guidelines for the treatment of all patients across a gradient of increasingly disparate access to health.

The World Health Organization (WHO) tumor classification system, available at https://www.iarc.who.int, has long served as the accepted standard reference. This classification has undergone multiple updates over the years, reflecting our evolving knowledge of tumor biology and advancements in diagnostic and therapeutic approaches. At a more specialized level, national and international medical specialist societies have become important actors, initially in organizing scientific meetings and supporting research, and subsequently expanding into education, training, mentorship, advocacy, and support for postgraduate practice, including guideline production/endorsement. Indeed, in the latest survey of European Hematology Association (EHA) members, with replies from 4966 individuals in six continents, on the EHA services they appreciate, guidelines came second on the list, just after high-quality education. Collaboration between WHO/IARC (International Agency for Research on Cancers) and specialist societies, therefore, remains crucial.

In 2008, the co

The introduction of tyrosine kinase inhibitors (TKI) has significantly changed the outcome of children and adults with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL).¹ Several phase 2 trials have shown improved outcomes with the incorporation of ponatinib to first-line therapy, either in combination with chemotherapy or with blinatumomab,^2-4 and a matching adjusted indirect comparison of ponatinib versus imatinib as frontline treatment for Ph+ ALL showed a significant survival advantage for ponatinib over imatinib containing regimens.⁵ A phase 3 trial comparing imatinib versus ponatinib in combination with attenuated chemotherapy has shown a significantly higher measurable residual disease (MRD)-negative rate at the end of induction in adults with newly diagnosed Ph+ ALL treated with ponatinib.⁶ The phase 2 PONALFIL trial from the Spanish PETHEMA (Programa Español de Tratamientos en Hematología) group combined ponatinib with standard induction and consolidation chemotherapy followed by allogeneic hematopoietic stem cell transplantation (alloHSCT) in 30 adult patients (18–60 years, median age 49 years) with newly diagnosed Ph+ ALL.⁷ End-induction and postconsolidation complete molecular response (CMR) rates were 47% and 71%, respectively. With a median follow-up of 2.1 years, the 2-year event-free survival (EFS, considering molecular relapse as an event) and overall survival (OS) rates were 70% and 96%, respectively. Only pre-emptive administration of TKI (30 mg/d for the first year and 15 mg/d during the second year) was prescribed by the trial, and 18 out of the 26 transplanted patients did not receive any TKI after the transplant. We hereby report the follow-up of the study, with a median of 4 years.

Figure 1 shows the updated flowchart of the study. All patients (n = 30) achieved complete cytologic response (CCR), although two abandoned the trial due to retina artery thrombosis and severe gastrointestinal infection requiring partial intestinal resection (one patient each). Both patients received dasatinib and remain alive and in CMR. End-induction CMR was attained in 14/30 patients (47%), 5/30 (17%) achieved MMR, and the remaining 11 patients did not achieve molecular response. Two patients discontinued the trial after consolidation. The first showed molecular relapse and due to specific circumstances had to be treated with vincristine, steroids, and dasatinib; this patient is currently alive and in CMR under maintenance with ponatinib. The second patient was removed from the trial by physician criteria because of the lack of molecular response, being treated with blinatumomab and alloHSCT, and is currently under maintenance with dasatinib. AlloHSCT was performed in 26 patients, two of whom died due to the procedure (severe graft versus host disease—GVHD, and severe cytomegalovirus inf

The discovery that the gain of function JAK2^V617F mutation is present in myeloproliferative neoplasms (MPNs) has led to numerous clinical trials assessing the efficacy of JAK inhibitors. Most notably, ruxolitinib, a combined JAK1/2 selective inhibitor, has gained approval in patients with myeolofibrosis (MF), and additional JAK2 inhibitors including fedratinib, pacritinib, and momelotinib also under evaluation for patients with MF. However, while these inhibitors demonstrate some clinical benefit, they do not adequately reduce the mutant clone fraction.^{1, 2} Consequently, a critical question for the field has been whether the lack of a durable response is attributed to either (i) the inability of current JAK inhibitors to completely block the pathway or (ii) the possibility that mutant clones are not entirely dependent on this activated pathway.

To address these two possibilities, a new study from the laboratory of Ross Levine, published in Cancer Discovery,³ developed an innovative mouse model of Jak2^V617F alone or in combination with Tet2 loss. The novel aspect of this mouse model lies in the ability to control the expression and genetic deletion of Jak2^V617F allele from mutant clones upon development of MPN. To do so, it utilizes two orthogonal site-specific recombinases which exert precise control over the temporal expression and deletion of the Jak2^V617F allele.

The mouse model uses the well-established Cre recombinase that recognises short nucleotide target sequences called Lox sites, in conjunction with the relatively new Dre recombinase which recognizes short nucleotide sequences called Rox sites. Importantly, the strategic arrangement and orientation of these sequences can lead to either flipping or deletion of the intervening DNA sequence. In this context, Dre recombinase is employed to initiate the expression of the Jak2^V617F allele. Subsequently, a modified CreER recombinase, translocated to the nucleus upon tamoxifen treatment, can delete the Jak2^V617F allele (Figure 1A). This intricate mouse model provided a powerful tool for comparing the durability of response between JAK inhibitors and the genetic loss of Jak2^V617F in the context of MPNs.

To understand the role of Jak2^V617F in the initiation and maintenance in MPNs in vivo, lineage-negative hematopoietic stem and progenitor cells were harvested from donor Ubc:CreER-Jak2^Rox/Lox mice. These cells were then electroporated with Dre recombinase-encoding messenger RNA to induce Jak2^V617F expression and then transplanted into lethally irradiated recipient mice, that all went on to develop MPNs, confirming that Jak2^V617F is both sufficient and necessary for MPN development.

Minimal residual disease (MRD) has emerged as a promising biomarker in diffuse large B-cell lymphoma (DLBCL). Both pretreatment levels and dynamic changes in circulating tumor DNA (ctDNA) have been associated with clinical outcomes, and in many studies, ctDNA outperforms traditional response assessment tools.^1-3 Newer panel-based approaches (CAPP-Seq, PhasED-Seq) appear to have improved sensitivity compared to immunoglobulin-based high-throughput sequencing (IgHTS).^{4, 5} There is growing interest in using ctDNA to guide response-adapted treatment approaches in DLBCL and ctDNA techniques that maximize sensitivity while retaining excellent specificity are needed to optimally guide such strategies.

To improve sensitivity, whole-genome sequencing (WGS) has been used to identify patient-specific tumor fingerprints which can be assayed within plasma cell-free DNA (cfDNA). This approach increases the likelihood of detecting tumor mutations but is challenging due to the massive excess of normal cfDNA in plasma. To address this, we developed minor-allele-enriched sequencing through recognition oligonucleotides (MAESTRO) which uses short allele-specific probes to enrich thousands of prespecified mutations and enable their detection using Duplex Sequencing with up to 100-fold fewer sequencing reads.⁶ We subsequently described a new implementation of this test called MAESTRO-Pool, wherein personalized MRD tests from all patients in cohort studies are pooled into a single test.⁷ This enables both the detection of MRD in each patient's plasma cfDNA and the assessment of the specificity of each bespoke MRD test using unmatched samples from other patients. We have further described an improved “dynamic MRD caller” that accounts for varied numbers of mutations and cfDNA molecules assayed and reports a probability score for MRD detection.⁷ This safeguards against false detection and enables the identification of borderline-negative samples for follow-up testing.

Here, we applied MAESTRO-Pool and our dynamic MRD caller in a pilot study, analyzing ctDNA in plasma samples from nine patients with relapsed/refractory DLBCL undergoing autologous stem cell transplantation (ASCT) and comparing our results with those obtained using conventional IgHTS MRD testing.

The study was performed using formalin-fixed paraffin-embedded (FFPE) tissue biopsies and serial post-ASCT peripheral blood samples from patients enrolled in a phase II trial testing pembrolizumab maintenance therapy following ASCT (NCT02362997).⁸ All patients signed informed consent. Plasma samples were previously analyzed using the IgHTS ClonoSEQ® assay (Adaptive Biotechnologies), and ctDNA was found to be a significant predictor of progression-free survival (PFS).⁹ Among 31 enrolled patients, nine had leftover genomic DNA (gDN

Circulating tumor plasma cells (CTPCs) provide a noninvasive alternative for measuring tumor burden in newly diagnosed multiple myeloma (NDMM). Moreover, measurable residual disease (MRD) assessment in peripheral blood (PBMRD) can provide an ideal alternative to bone marrow MRD, which is limited by its painful nature and technical challenges. However, the clinical significance of PBMRD in NDMM still remains uncertain. Additionally, data on CTPC in NDMM patients not treated with transplant are scarce. We prospectively studied CTPC and PBMRD in 141 NDMM patients using highly sensitive multicolor flow cytometry (HS-MFC). PBMRD was monitored at the end of three cycles (PBMRD1) and six cycles (PBMRD2) of chemotherapy in patients with detectable baseline CTPC. Patients received bortezomib-based triplet therapy and were not planned for an upfront transplant. Among baseline risk factors, CTPC ≥ 0.01% was independently associated with poor progression-free survival (PFS) (hazard ratio [HR] = 2.77; p = 0.0047) and overall survival (OS) (HR = 2.9; p = 0.023) on multivariate analysis. In patients with detectable baseline CTPC, undetectable PBMRD at both subsequent time points was associated with longer PFS (HR = 0.46; p = 0.0037), whereas detectable PBMRD at any time point was associated with short OS (HR = 3.25; p = 0.004). Undetectable combined PBMRD (PBMRD1 and PBMRD2) outperformed the serum-immunofixation-based response. On multivariate analysis, detectable PBMRD at any time point was independently associated with poor PFS (HR = 2.0; p = 0.025) and OS (HR = 3.97; p = 0.013). Thus, our findings showed that CTPC and PBMRD assessment using HS-MFC provides a robust, noninvasive biomarker for NDMM patients not planned for an upfront transplant. Sequential PBMRD monitoring has great potential to improve the impact of the existing risk stratification and response assessment models.

The role of hypoxia and the transcriptional regulation by hypoxia-inducible factors (HIF) is intensively studied in many tissues and pathologies and gained the most attention in cancer including acute myeloid leukemia (AML).¹ Here, Velasco-Hernandez et al. addressed the important issue of the heterogeneity of hypoxia gene signature activation not only between major AML genetic subgroups but also between different populations of patient cells at diagnosis and relapse using single-cell transcriptomes. Their data support the potential of targeting hypoxia-induced gene regulation in leukemic stem cells (LSC) in AML.²

Oxygen homeostasis is transcriptionally regulated by a family of hypoxia-inducible factors (HIF) that act as transcriptional activators and repressors. Heterodimeric HIFs are formed by a constitutively expressed HIF1β subunit (encoded by ARNT) and a HIF1/2/3α (encoded by HIF1A, EPAS1, HIF3A, respectively). While constantly degraded by the proteasome under normoxia, mediated by the oxygen sensor PHD proteins, in hypoxia, HIF-1/2/3α binds to its cofactor and controls the transcription of target genes in a cell-context-specific manner.³

In their study, Velasco-Hernandez et al. first interrogated hypoxia-regulated gene expression signatures in patient-derived data sets. They found that the driver genetic lesions determined whether the disease was “HIF^high,” including cases with core-binding factor alterations, or “HIF^low,” including cases with KMT2A rearrangements (KMT2A-r). They also addressed the HIF expression signature in various leukemic cell populations of 11 patient samples by single-cell RNA-sequencing (scRNA) and defined fractions enriched in LSCs (LSC³⁴) or not (non-LSC^34/38), based on the highest expression of a previously established LSC-6 expression score and LSC surface markers. Comparison with six different hypoxic gene expression signatures revealed that LSC³⁴ cells had the lowest hypoxia score and lowest HIF1A levels in all patients. Importantly, in all genetic AML subgroups, the hypoxia score was higher in LSC³⁴ compared to healthy CD34⁺ hematopoietic stem and progenitor cells (HSPCs). Comparing the scRNA signatures from diagnosis and relapse revealed significant inter-patient transcriptional changes with an overall inverse evolution between hypoxia and the increased LSC-6 score.

To explore the therapeutic potential of the elevated expression of hypoxia-related genes including HIF1A in LSC³⁴, Velasco and colleagues tested the effects of small-molecule HIF inhibitors on primary cells from six AML patients. Hypoxic long-term culture-initiating cell assays revealed that BAY87-2243, a molecule reported to inhibit mitochondrial complex I activity impairing hypoxia-induced HIF-1α and HIF-2α upregulation and HIF target genes expression, fu