Chen, Dong

ABSTRACT We examined the prognostic value of routine NGS data in newly diagnosed acute myeloid leukemia (AML) treated with intensive (7 + 3 backbone) induction, specified by AML subtype. A contemporary (2015–2025) series of 545 Mayo Clinic patients (median age 56 years, females 44%) was considered. Median follow‐up was 49 months with 341 (63%) allogeneic hematopoietic stem cell transplantations (AHSCT) recorded. AML subtypes included core‐binding factor (CBF; N = 72; 13%), primary non‐CBF ( N = 403; 74%), post‐myelodysplastic syndromes (MDS) or post‐myelodysplastic/myeloproliferative neoplasms (post‐MDS‐MDS/MPN; N = 28; 5%), post‐MPN ( N = 15; 3%), and therapy‐related (t‐AML; N = 27; 5%). Corresponding complete remission rates, with/without count recovery (CR/CRi), were 89%, 76%, 64%, 27%, and 78% ( p < 0.01) and 5‐year transplant‐censored survival rates 68%, 57%, 21%, 0%, and 55% ( p < 0.01). In multivariable analyses, the prognostic value of specific mutations was mostly limited to primary non‐CBF AML where adverse karyotype (OR 1.9; p = 0.04) predicted inferior and FLT3 ‐ITD (OR 0.4; p < 0.01) or NPM1 MUT / FLT3 WT (OR 0.1; p < 0.01) superior CR/CRi while KRAS MUT (HR 8.8; p < 0.01), TP53 MUT (HR 5.4; p < 0.01), and TET2 MUT (HR 2.3; p = 0.01) predicted inferior and NPM1 MUT / FLT3 WT (HR 0.3; p = 0.01) superior survival. Prognostication in intensively‐treated AML should start with subtype specification and recognition of the limited value of NGS in non‐primary AML. Post‐MPN AML is particularly associated with dismal outcomes and should be prognostically distinguished from post‐MDS‐MDS/MPN AML. In primary non‐CBF AML, in addition to previously established risk factors, the favorable impact of FLT3 ‐ITD on achieving CR/CRi and the unfavorable impact of KRAS MUT and TET2 MUT on transplant‐censored survival were noted and require confirmation from additional studies.

Abstract Background Interpretation of multi-analyte laboratory profiles, such as lupus anticoagulant (LAC) testing, requires integration of numerous test results and clinical information. However, this process is time-consuming, requires domain knowledge, and has limited scalability. Given that rule-based systems are rigid and difficult to maintain and large language models pose risks of “hallucinations,” we developed and evaluated a novel retrieval-based approach to automate LAC profile interpretation to improve efficiency while maintaining fidelity and reliability for clinical use. Methods Our method processes laboratory values through ensemble random forest (RF) models to retrieve the most similar expert interpretation from a curated database of 347 previously interpreted LAC profiles. The system's performance was assessed through technical accuracy metrics, a work flow efficiency timing study, and expert review of interpretation accuracy for held-out cases. Results Technical validation demonstrated high accuracy in retrieving correct interpretative elements (median: 93% accuracy, interquartile range [IQR]: 67% to 100%). Retrieval accuracy was highly correlated with the prevalence of a given element (ρ = 0.8307). In a timing study of 93 consecutive LAC profiles, ensemble-assisted interpretation achieved a median time of 22 s per report (IQR: 16 s to 31 s), representing a 78.6% total reduction compared to manual interpretation (median: 118 s, IQR: 96 s to 172 s; t = 18.61, P &lt; 0.001). Furthermore, 92.5% of AI-assisted interpretations were completed within 60 s, exceeding the target of 85%. Expert review confirmed 100% concordance for LAC presence/absence. Conclusions The proposed approach significantly improves efficiency of complex laboratory interpretation for LAC profiles, while maintaining consistency and high fidelity. Future studies will explore the method’s inherent extensibility to the interpretation of other multi-analyte laboratory profiles.

Introduction: Calibrated automated thrombogram assay parameters have been shown to assess hypercoagulation state and, therefore, may independently predict posttrauma, symptomatic venous thromboembolism (VTE). Yet, calibrated automated thrombogram lacks high throughput and standardization, limiting diagnostic potential. This study analyzed thrombin generation (TG) profiles in trauma patients using a high-throughput assay, processing up to 10 samples at once, providing batch testing capabilities. We hypothesized that trauma patients who developed VTE would show distinct TG profiles compared with those who did not. Methods: Trauma patients presenting to a Level I Trauma Center had samples collected within 12 hours postinjury prospectively. Follow-up was conducted to 90 days, time to symptomatic VTE diagnosis or death, confirmed via autopsy or imaging. TG profiles were measured from the ST Genesia assay. Data were presented as median (interquartile ranges) or n (%), with the Wilcoxon rank-sum or chi-squared test. Associations between TG parameters and clinical risk factors were assessed using Spearman correlation analysis or the Wilcoxon rank-sum test. Results: Two hundred and fifty-four trauma patients were analyzed [48.5 years (31.0, 62.0), 72.0% male]: 64 patients with VTE (25.2%) to 190 with non-VTE. VTE pts had a median time to VTE of 8 days, with 29 developing deep venous thrombosis, 24 with pulmonary embolism, and 11 with deep venous thrombosis/pulmonary embolism. No significant differences were found in age, sex, or body mass index; significantly more VTE patients underwent surgery and blood transfusions within 24 hours. TG profiles demonstrated accelerated TG in patients who developed VTE compared with non-VTE, with significant differences in peak height ( P = 0.001), time to peak ( P = 0.021), endogenous thrombin potential ( P < 0.001), and velocity index ( P = 0.001). Conclusion: TG profiles using ST Genesia can differentiate trauma patients at high risk of developing VTE. The platform suits clinical labs needing high throughput by providing batch testing capabilities. Study type: Prospective study with less than large effect and no negative criteria. Level of evidence: II.

Objective: The identification of reliable biomarkers in trauma patients (pts) remains a clinical challenge. Nucleosomes, which are DNA wrapped around histone protein cores, have been used as reliable markers for quantification in sepsis, acute respiratory distress syndrome, and lymphoma. We hypothesized that: 1) levels of circulating nucleosomes quantified after traumatic injury, specifically histone H3.1 and its citrullinated R8 posttranslation modification (H3R8 Cit), would be increased after trauma and 2) that levels of circulating nucleosomes would be further, increased in pts who went on to develop venous thromboembolism (VTE), as these nucleosomes may be clot-enhancing mediators. Methods: Trauma pts presenting to a Level I trauma center were evaluated for inclusion in a prospective case-cohort study, and citrated blood samples were collected within 12 hours of injury. Pts were followed for up to 90 days and VTE occurrence was confirmed via autopsy or imaging. Pts who developed incident, symptomatic VTE, and those who did not develop VTE were selected at a 1:3 ratio. The effect of trauma was assessed by comparison with healthy volunteer samples. Circulating nucleosomes were quantified using Nu.Q H3.1 and Nu.Q H3R8 Cit assays. Data are presented as median [interquartile range] or n (%), with Wilcoxon Rank-Sum or chi-squared test performed between trauma pts who developed symptomatic VTE versus those who did not, with a P value < 0.05 as statistically significant. Results: A total of 639 trauma pts were analyzed [51 years (33, 65), 71.0% male, 94.1% blunt, injury severity scores 17 (9, 27)]. Both H3.1 [359.7 (58.4, 1769.3) vs. 21.5 (15.3, 26.6) ng/mL, P < 0.001] and H3R8 Cit levels [209.4 (45.4, 665.5) vs. 22.3 (16.2, 28.9) ng/mL, P < 0.001] were greater in trauma pts than in 10 healthy volunteers. The 160 pts with VTE were then compared with 479 without VTE. VTE pts had a median time to VTE of 8.5 days, with 91 developing symptomatic deep venous thrombosis, 48 with pulmonary embolism, and 21 with both deep venous thrombosis and pulmonary embolism. No significant differences were found in age, sex, or mechanism between pts with or without VTE. However, VTE pts had higher injury severity scores [24 (14, 34), 14 (9, 24), P < 0.001] and body mass index [29.1 (24.3, 34.2), 27.6 (24.2, 32.0) kg/m 2 , P = 0.037]. A greater percentage of VTE pts underwent surgery requiring general anesthesia (53.1%, 34.0%, P < 0.001) and received blood transfusions within 24 hours of injury (51.9%, 24.0%, P < 0.001). H3.1 levels were significantly greater in trauma pts who developed VTE compared with those who did not [828.4 (112.0, 3186.5), vs. 276.7 (50.3, 1237.0) ng/mL, P < 0.001], as were H3R8 Cit levels [350.4 (77.4, 729.5), vs. 189.2 (40.8, 632.6) ng/mL, P = 0.005]. No differences in levels of H3.1 and H3R8 Cit were found between early (diagnosed day 0–7 after injury) and late (diagnosed > day 7) VTE. Conclusions: Levels of the H3.1 and H3R8 Cit nucleosomes are elevated early after traumatic injury, especially in those who developed VTE. These findings underscore the importance of understanding the pathophysiology of nucleosomes in inducing VTE and their role as biomarkers

Abstract Background: The International Consensus Classification (ICC) for systemic mastocytosis (SM) recognizes mast cell leukemia (MCL) and SM with associated myeloid neoplasm (SM-AMN) as distinct categories of advanced SM (SM-Adv; Arber et al. Blood 2022;140:1200). Contemporary risk models in SM, including the Mayo Alliance Prognostic System (MAPS), do not account for the prognostic heterogeneity among ICC-defined SM-Adv subcategories. Methods: Mayo Clinic databases were utilized to access patient information. Diagnoses of SM and its morphological subcategories were confirmed through clinical evaluations and review of BM pathology. Diagnostic criteria were retrospectively fitted to be consistent with those of the ICC (Arber et al. Blood 2022;140:1200); diagnosis of MCL required the presence of immature cytomorphology of mast cells and only myeloid neoplasms were listed under the category of SM-AMN.Next-generation sequencing and cytogenetic studies was performed in a subset of the study patients according to previously described methodologies. Statistical analyses were conducted on clinical and laboratory data collected at the time of initial diagnosis while survival analysis was censored at the time of allogeneic stem cell transplant (ASCT). Results: A total of 910 Mayo Clinic patients with SM (median age 56 years, range 12-89; males 50%) were accessed in order to conduct a series of multivariable analyses (MVA) in search of independent risk factors for transplant-censored overall survival (OS). All patients were evaluable for assignment to specific ICC categories of SM: indolent (ISM; N=553), aggressive (ASM; N=114), SM-AMN (N=235), and MCL (N=8); the AMN components in SM-AMN included acute myeloid leukemia (N=18), chronic myelomonocytic leukemia (N=70), myelodysplastic syndromes (N=32), MDS/myeloproliferative overlap (N=81), myelofibrosis (N=7), polycythemia vera or essential thrombocythemia (PV/ET; N=19), and others (N=8). In addition, subsets of patients were evaluable for hemoglobin level (N= 865), white blood cell count (WBC; N=858), platelet count (N= 859), serum alkaline phosphatase (ALP; N=761), serum tryptase level (N=706), karyotype (N=574), and mutations (N=240). Median follow-up for living patients was 70 months (range, 0-520); during this time 346 (38%) deaths, 16 leukemic transformations, and 20 ASCTs were documented. ROC analysis-determined optimal cutoff levels for predicting OS included age at ≥60 years, platelet count &lt;150 x 109/L, tryptase level ≥100 ng/mL, WBC ≥10 x 109/L, hemoglobin below sex-adjusted lower limit of normal (anemia), and ALP &gt;210 U/L in women or &gt;170 U/L in men (increased). All except WBC ≥10 x 109/L retained significance during MVA that included ICC-specified SM categories: MCL (HR 74.8, 26.0-215.3; p&lt;0.01); SM-AMN (HR 3.9, 2.5-6.0; p&lt;0.01); ASM (HR 2.2, 1.4-3.5; p&lt;0.01); age ≥60 years (HR 3.3, 2.2-4.7; p&lt;0.01); platelets &lt;150 x 109/L (HR 2.8, 2.0-3.9; p&lt;0.01); tryptase ≥100 ng/mL (HR 2.1, 1.5-2.9; p&lt;0.01); anemia (HR 1.7, 1.1-2.4; p&lt;0.01); and increased ALP (HR1.5, 1.1-2.0; p=0.01). A subsequent HR-weighted risk model effectively delineated 5 risk levels ranging in median survivals from 11 months to 372 months (Figure 1). Figure 2 outlines complementary subtype-specific risk models; to that end, risk factors for ISM included age ≥60 years (HR 4.5, 2.5-7.9), tryptase ≥100 ng/mL (HR 3.5, 2.1-6.0); platelets &lt;150 x 109/L (HR 3.4, 1.5-7.9), and anemia (HR 2.4, 1.2-4.8); for ASM age ≥60 years (HR 2.3, 1.3-4.3), platelets &lt;150 x 109/L (HR 2.4, 1.4-4.0), and anemia (HR 2.0, 1.2-3.4); and for SM-AMN age ≥60 years (HR 2.9, 1.6-5.2), platelets &lt;150 x 109/L (HR 2.5, 1.6-3.9), and tryptase ≥100 ng/mL (HR 2.5, 1.6-3.9) [Figure 2]. In SM-AMN, additional prognostic relevance from subcategorization into PV/ET vs. all other types of AMN was appreciated (Figure 3; HR 4.0, 1.6-3.9) and incorporated into the risk model for SM-AMN (Figure 2). Abnormal karyotype (AK) and high risk mutations(HRM; ASXL1, SRSF2, RUNX1, NRAS)clustered withSM-AMN with AK and ASXL1MUT displaying independent prognostic relevance that was most apparent in SM-AMN. Conclusions : MAPS-R relies on the prognostic eminence of ICC-defined morphologic subcategories and allows for additional SM subtype-specific risk stratification. SM associated with ET or PV is a prognostically unique subcategory of SM-AMN and should be recognized as such in future classification schemes. SM-AMN must be thoroughly ruled out in the presence of AK or HRM.

Abstract Background: The primary goal of induction therapy in acute myeloid leukemia (AML) is to induce complete remission with (CR) or without (CRi) hematologic recovery. In order to accomplish this, re-induction might be necessary based on D14-residual AML. The current study examines the impact of re-induction on relapse, transplant-censored survival, and post-transplant survival in a consecutive series of AML patients who have achieved CR/CRi following intensive chemotherapy. The study also examined the impact of variations in consolidation chemotherapy including the use of anthracycline-based chemotherapy (AC) in the first consolidation cycle and the use of high (HiDAC) vs. intermediate (IDAC) dose cytarabine. Methods: The current study was conducted under IRB-approved minimum risk protocols that allowed retrospective collection and analysis of patient data. Formal criteria were used for AML diagnosis, genetic risk stratification, and adjudication of response (Blood 2022;140:1345). Patients who received less intensive induction regimens or failed to achieve CR/CRi were excluded. Relapse-free (RFS) and overall survival (OS) analysis was calculated from the date of documented CR/CRi. Patients who underwent allogeneic stem cell transplant (ASCT) were censored at the time of transplant. Conventional statistical methods were utilized (JMP Pro 17.1.0, SAS Institute, Cary, NC, USA). Results: A total of 279 AML patients diagnosed between 2004 and 2020 were included: median age 58 years, males 60%, de novo 75%, post-chronic myeloid neoplasm (post-CMN) 16%, and therapy-related 9%. Induction regimens included idarubicin (Ida) + cytarabine (Cyt) in 183 (66%) patients, daunorubicin (Da) 60 mg/m² + Cyt in 76 (27%), and Da 90 mg/m2 + Cyt in 19 (7%). Re-induction was utilized to achieve CR/CRi in 72 (27%) at a median of 18 days from start of first induction regimen. The indication for re-induction was based on residual bone marrow blast (median 30%; range 4-90) on day14 (N=53) or day 21-28 (N=15), persistent extramedullary disease (N=2) or the presence of circulating blast (N=2). At a median transplant censored follow-up of 26 months (mos), 93 (33%) deaths, 117 (42%) relapses, and 134 (48%) ASCTs were documented; ASCTs were performed in CR1 (50%) or CR2 (50%). Median RFS was 18 mos, with respective 1-, 2-, 3- year RFS of 63%, 42% and 35%. In multivariable analysis (MVA), age ≥65 years (HR 1.5, p=0.04), European LeukemiaNet (ELN) adverse karyotype (vs. intermediate HR 1.7, p=0.02; vs. favorable HR 2.8, p&lt;0.01), and the need for re-induction to achieve CR/CRi (HR 1.7, p=0.01) were independently predictive of relapse. RFS was not impacted by NPM1 mutation ( HR 0.5, p=0.09) or FLT3-ITD (HR 1.3, p=0.3). The median OS was 80 mos, with 5-year OS of 53%. In MVA, age ≥65 years (HR 2, p=0.01), ELN adverse karyotype (vs. intermediate HR 3.3, p&lt;0.01; vs. favorable HR 4.7, p&lt;0.01), FLT3-ITD (HR 1.9, p=0.04), and the need for re-induction (HR 1.9, p=0.03) independently predicted inferior OS. RFS was similar among patients who received AC (N=84; Idarubicin 9 mg/m2 or Da 60 mg/m2 days 1 to 2/3 + 100 mg/m2 Cyt days 1 to 5/7; median 18 mos) as their first consolidation cycle vs. those who received HiDAC (N=99; 3 g/m2 q12 hours on days 1,3 and 5; median 16 mos) or IDAC (N=58; IDAC; 1-2 g/m2 q12 hours on days 1, 3 and 5; median 24 mos; p=0.9); the corresponding median OS were 125, 85, and 40 mos (p=0.4). In patients aged ≥65 years, but not younger patients, both RFS (p&lt;0.01; median 23 (N=36) vs. 8 (N=24) mos) and OS (median 40 vs. 12 mos, p&lt;0.01) were significantly longer with IDAC vs. AC as their first consolidation cycle. In the AC consolidation cohort, patients who received 2-3 additional HiDAC/IDAC cycles displayed longer OS (p&lt;0.01) and RFS (p=0.047), compared to those who received less. In both the HiDAC and IDAC cohorts, RFS and OS were not significantly different between those who received 3-4 versus 1-2 consolidation cycles. The need for re-induction did not affect post-transplant survival (p=0.5), which was superior in patients receiving Ida + Cyt induction (vs. Da 60mg/m2 + Cyt, HR 0.6, p=0.04) and in those transplanted in CR1 (HR 0.5, p&lt;0.01). Conclusions: The current study signals the need for re-induction to achieve CR1 as a negative predictor of outcome in AML patients achieving CR/CRi following intensive induction chemotherapy. The particular information is potentially actionable in terms of the choice of consolidation strategy.

Abstract Background: TP53-mutated myeloid neoplasms (MNs) represent one of the most lethal subgroups of blood cancers. The World Health Organization (WHO-5) recognize TP53-mutated (TP53mut) myelodysplastic syndrome (MDS) and International Consensus Classification (ICC) recognize TP53mut MDS and acute myeloid leukaemia (AML) as distinct disease entities, acknowledging their dismal prognosis and the urgent need for novel therapeutic strategies. However, key discrepancies exist between the classifications, creating uncertainty in diagnosis, influencing therapeutic decisions, and complicating clinical trial enrolment for patients with uniformly poor survival. Importantly, neither classifications included TP53-mutated myelofibrosis (MF), other myeloproliferative neoplasms (MPN), and MDS/MPN overlap syndromes, despite growing evidence that these cases carry similar adverse outcomes. To address these critical gaps, we conducted a comprehensive analysis across the full spectrum of TP53-mutated MN. Methods: We included TP53mut cases with variant allele frequency (VAF ≥2%) of AML, MDS, MDS/MPN overlap, myelofibrosis and other MPN managed at the Mayo clinic (Rochester, USA) and Local Health Network in South Australia (Australia). Cases were classified according to the revised 4th edition WHO classification (WHO-4R). Biallelic TP53 loss was defined as: (i) ≥2 mutations with VAF ≥2%; (ii) single TP53mut with VAF ≥2% plus 17p loss on karyotype, FISH, or SNP array; or (iii) single TP53mut with VAF ≥50% with or without 17p loss. Monoallelic loss was defined as a single TP53mut with VAF &lt;50% without 17p loss or copy neutral loss of heterozygosity. The primary endpoint was overall survival (OS) from diagnosis, censored at allogeneic transplantation. Conditional inference tree analysis was performed to define the effect of individual predictors on OS. Results: We identified 853 TP53mutMN cases including WHO-4R-defined AML (BM/PB blasts ≥20%, n=314; 36.8%), MDS with excess blasts-2 (EB-2; BM 10–19% or PB 5–19%, n=129; 15.1%), MDS-EB-1 (BM 5–9% or PB 2–4%, n=100; 11.7%), and MDS with low blasts (LB; BM &lt;5% and PB &lt;1%, n=228; 26.7%). MF included chronic phase (MF-CP, n=48; 5.6%), accelerated phase (MF-AP, n=7; 0.8%), and blast phase (MF-BP, n=17; 2.0%). Additional cases comprised other MPN-chronic phase (n=3, 0.4%) and MDS/MPN overlap syndromes (n=7, 0.8%). Of 848 evaluable TP53mut MN, 616 (72.6%) harbored biallelic TP53 loss and 232 (27.4%) had monoallelic loss, with 42.4% (n=98) of monoallelic cases harboring a complex karyotype (CK). Biallelic loss was highly prevalent in AML (83.1%), MDS (70.4%), and MDS/MPN overlap (71.4%), but was less frequent in cases with MPN (33.3%) and MF-chronic phase (25.0%). Across the spectrum, the frequency of biallelic loss increased stepwise with disease progression, rising from MDS-LB (62.8%) to MDS-EB1 (76.0%), MDS-EB2 (79.5%), AML (83.1%), and MF-AP/BP (79.2%) (P&lt;0.0001). In multivariable analysis, WHO-4R category, TP53mut VAF, biallelic loss and CK were independent predictors of poor survival in TP53mut MN. Conditional inference tree analysis stratified the cohort into seven prognostic groups with distinct median OS: (1) AML, MF-BP/AP, and MDS/MPN overlap regardless of mono/biallelic and CK status (n=335, 39.7%; median OS 4.0 months); (2) MDS-EB1/EB2 with biallelic loss or monoallelic plus CK (n=212, 25.1%; 7.2 months); (3) MDS-LB, MF-CP and MPN with CK (n=156, 18.5%, OS 10.2 months); (4) biallelic MDS-LB (n=28, 3.3%; OS 15.6 months), (5) monoallelic MDS-EB1/EB2 without CK (n=20, 2.4%; OS 26.2 months), (6) monoallelic MDS-LB without CK (n=57, 6.7%; OS 33.4 months), and (7) MF-CP and other MPN without CK (n=36, 4.3%; OS 37.0 months). This analysis defines a clear stepwise risk gradient, identifying subsets with extremely poor prognosis versus a relatively indolent disease. Conclusions: This is the first study to evaluate the prognostic impact of TP53mut MN across the entire MN spectrum, providing a framework for future refinement of TP53-driven disease classification. Key findings include: (i) MF-AP/BP and MDS/MPN overlap exhibit survival outcomes as dismal as AML, irrespective of the TP53 allele status; and (ii) complex karyotype is a surrogate for “biallelic equivalent”, refining risk interpretation in monoallelic cases. Overall, our study defines seven prognostic subgroups spanning all TP53mut MN, offering a foundation for risk-adapted clinical trial design and future classification updates.