Vojjala, Nikhil

Abstract Background: Luspatercept, an erythroid maturation agent, has shown efficacy in improving anemia in both β-thalassemia and lower-risk myelodysplastic syndromes (MDS). In the BELIEVE trial, which led to its approval in transfusion-dependent β-thalassemia, thromboembolic events were notably higher in patients with risk factors such as splenectomy. More recently, the COMMANDS trial demonstrated superior transfusion independence with luspatercept over erythropoiesis-stimulating agents (ESAs) in ESA-naive, lower-risk MDS patients. However, limited data exist regarding comparative thrombotic risk in real-world MDS populations. We conducted a multicenter, real-world study to evaluate thrombotic event rates associated with luspatercept versus ESAs in MDS patients without prior venous thromboembolism (VTE). Methods: We queried the TriNetX Research Network, a federated real-time electronic health record (EHR) database covering over 100 million patients across major healthcare organizations. Adults (≥18 years) with a diagnosis of MDS (ICD-10-CM code D46) and no prior history of deep vein thrombosis (DVT) or pulmonary embolism (PE) were included. Patients were stratified based on treatment with luspatercept or ESAs (epoetin alfa or darbepoetin alfa). Propensity score matching (PSM) using a 1:1 nearest-neighbor algorithm without replacement was performed to balance demographics and clinical covariates. Primary outcomes included the incidence of DVT, PE, and composite VTE events within 12 months of therapy initiation. Results: A total of 6,448 patients with MDS and no prior VTE were identified: 5,698 received ESAs and 750 received luspatercept. The overall mean age was 72.5 ± 13.5 years, with 48.1% male. After PSM, 741 patients were included in each treatment arm. The matched cohort had a mean age of 76.7 ± 10.7 years, and 41.3% were female. In the ESA group, 58/741 (7.8%) developed DVT compared to 27/741 (3.6%) in the luspatercept group (Hazard Ratio [HR] 1.4; 95% CI, 0.9–2.3). PE occurred in 27 ESA-treated patients (3.6%) versus 13 luspatercept-treated patients (1.8%) (HR 1.3; 95% CI, 0.6–2.7; p=0.941). The overall composite VTE rate was 10.0% (74/741) in the ESA group and 4.9% (36/741) in the luspatercept group (HR 1.3; 95% CI, 0.9–2.0; p=0.732). Conclusion: In this large, multicenter real-world analysis, we observed a numerically lower incidence of thrombotic events with luspatercept compared to erythropoietin-based agents in patients with MDS, though differences did not reach statistical significance. These findings support the thrombotic safety profile of luspatercept observed in clinical trials and warrant further prospective validation.

Abstract Introduction: CAR T-cell therapy is an important treatment option for patients with relapsed or refractory (R/R) DLBCL. Three CAR T-cell products have received approval: axicabtagene ciloleucel (Yescarta), lisocabtagene maraleucel (Breyanzi), and tisagenlecleucel (Kymriah). Although direct head-to-head studies comparing the three therapies do not exist, clinical trials have revealed notable differences in response rates and remission rates among them. All three products induce CRS and ICANS; however, variations in the incidence and severity of these adverse effects have been observed. We utilized data from the National Inpatient Sample (NIS) to gain further insights into the incidence of various adverse events associated with different CAR-T products in DLBCL. Method: In this retrospective study, the 2022 NIS database was used to identify hospitalizations with DLBCL and those who received Yescarta, Breyanzi, or Kymriah using appropriate ICD-10-CM diagnostic and ICD-10-PCS procedure codes. Data on CRS, ICANS, infections, and adverse cardiac events were extracted using relevant ICD-10-CM codes. These outcomes were compared across different CAR-T products using Pearson's chi-square analysis. Multivariate logistic regression was also performed, adjusting for demographics, hospital-specific characteristics, and comorbidities. Results: We identified 1440 patients with DLBCL. Among these, 1100 patients (64.6% male; 70.7% Caucasian, 8.8% African American, 20.5% other ethnicities) received Yescarta, 90 patients (66.7% male; 82.4% Caucasian, 0% African American, 17.7% other ethnicities) received Kymriah and 250 patients (64% male; 82.6% Caucasian, 10.9% African American, 6.5% other ethnicities) received Breyanzi. The incidence of CRS was 52% for Breyanzi, 44.4% for Kymriah and 68.6% for Yescarta, and the difference was statistically significant by chi-square analysis (p = 0.03). This difference remained statistically significant for Kymriah after multivariate analysis [Adjusted Odds ratio (OR) = 0.3, CI 0.1 to 0.9, p=0.032], but not for Breyanzi (Adjusted OR = 0.3, CI 0.1 to 0.9, p=0.032) in comparison to Yescarta. The incidence of ICANS was 16% for Breyanzi, 22.2% for Kymriah, and 33.2% for Yescarta, with a statistically significant difference observed by chi-square analysis (p = 0.05). This difference remained statistically significant for Breyanzi after multivariate analysis [Adjusted OR = 0.3, CI 0.1 to 0.6, p=0.002], but not for Kymriah (Adjusted OR = 0.6, CI 0.1 to 2.9, p=0.551) in comparison to Yescarta. Among cardiovascular events, there was no significant difference in the incidence of acute myocardial infarction (Yescarta vs Kymriah vs Breyanzi, 0.5% vs 0% vs 0.2%, p = 0.487), stroke (0.5% vs 5.6% vs 2%, p = 0.07), cardiogenic shock (0.5% vs 0% vs 0%, p = 0.880), and arrhythmias (20.9% vs 27.8% vs 32%, p = 0.258) among these CAR T-cell therapies. Furthermore, there were no significant differences in the incidence of infectious complications, including pneumonia (5.9% vs 5.6% vs 2%, p = 0.510), sepsis (5% vs 5.6% vs 6%, p = 0.962), or septic shock (2.3% vs 0% vs 0%, p = 0.535) among these CAR T-cell therapies. There was no difference in all-cause in-hospital mortality across these therapies (2.3% vs 5.6% vs 2%, p = 0.692). Conclusion: Kymriah showed lower CRS rates and Breyanzi showed lower ICANS rates in comparison to Yescarta in our study. All CAR T-cell therapies have the potential to cause infections and cardiac events, which require monitoring, early identification and prompt treatment. When selecting among various CAR T-cell products, several factors must be considered, including the patient's lymphoma type, prior treatment history, manufacturing turnaround time, cost, availability, and potential short-term and long-term side effects. The limitations of our study include its retrospective nature, reliance on ICD-10 codes to identify patients with adverse events, and the absence of longitudinal data on long-term adverse events. Nevertheless, this study provides essential insights for hematologists regarding the incidence of specific adverse events associated with different CAR T-cell products within the real-world population.

Background: Cerebral venous sinus thrombosis (CVT) is a rare cause of stroke, constituting 0.5–3% of all strokes with an extremely varied spectrum of presentation, predisposing factors, neuroimaging findings, and eventual outcomes. A high index of suspicion is needed because timely diagnosis can significantly alter the natural course of the disease, reduce acute complications, and improve long-term outcomes. Due to its myriad causative factors, protean presentation, and association with several systemic diseases, CVT is encountered not only by neurologists but also by emergency care practitioners, internists, hematologists, obstetricians, and pediatricians. Discussion: Anticoagulation remains the mainstay of treatment for CVT. Heparin and warfarin previously had been the anticoagulation of choice. Recently there has been an increased interest in utilizing direct-acting oral anticoagulants in the treatment of CVT given comparable safety and efficacy with ease of utilization. However recent clinical guidelines given by multiple societies including the American Stroke guidelines and European guidelines do not include these agents so far in their treatment recommendations. Ongoing multicentric clinical trials are currently reviewing the role of these agents in both short-term as well as long-term. Our review of the literature supports the safety and reinforces the efficacy of DOAC in the treatment of CVT. Additionally, patient satisfaction has been shown to be better with the use of DOAC. In conclusion, DOAC continues to have a valid role in the management of CVT.

Bleeding diathesis is an uncommon side effect of ibrutinib use and is seen in less than 5% of the population. We describe a case of an elderly woman with ibrutinib-induced spontaneous major extradural haematoma presenting as acute compressive myelopathy. She is a known case of splenic marginal zone lymphoma with multiple extramedullary relapses and presented to the emergency department with acute-onset low backache, followed by urinary retention. MRI revealed extradural haemorrhage. After possible evaluation, she was diagnosed with ibrutinib-induced extradural haematoma.

Key Clinical MessageStone heart syndrome has a complex interaction with digoxin toxicity, where, theoretically, the administration of intravenous calcium can worsen a patient's condition. Research on this subject is conflicting, so it is imperative to approach it cautiously.

Blood transfusion is a common therapeutic intervention in hospitalized patients. There are numerous indications for transfusion, including anemia and coagulopathy with deficiency of single or multiple coagulation components such as platelets or coagulation factors. Nevertheless, the practice of transfusion in critically ill patients has been controversial mainly due to a lack of evidence and the need to consider the appropriate clinical context for transfusion. Further, transfusion carries many risk factors that must be balanced with benefits. Therefore, transfusion practice in ICU patients has constantly evolved, and we endeavor to present a contemporary review of transfusion practices in this population guided by clinical trials and expert guidelines.

e23537 Background: Follicular Dendritic Cell Sarcoma (FDCS) is a rare, indolent, low-grade sarcoma known for local recurrences managed primarily by surgery. The role for adjuvant therapy has not been established for either radiation or chemotherapy. We aimed to comprehensively analyze clinical and epidemiological profiles and responses to treatment in these patients. Methods: This is a retrospective study using the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Result (SEER) database. Cases of FDCS between 2001 to 2022 were identified utilizing the International Classification of Diseases for Oncology edition 3 (ICD-O-3) code 9758/3. Only adults > 18 years of age and diagnosed by positive histology or cytology were included. Descriptive statistics were used to describe demographic and tumor characteristics. Logistic regression was used to identify the factors influencing survival. Kaplan-Meier method was used to plot survival based on different treatment regimens and stages. Results: A total of 168 patients with FDCS were identified, with more than 50% of the patients ≥ 50 years of age. The mean age at diagnosis was 52.6 years, 56% were female, and 74.4% were white. Most of the patients had localized disease (63.7%), 17.9% had distant disease, and the remaining had unknown stages. About 90% of the patients underwent surgery, with 41% receiving local tumor excision. In Univariate analysis, older age, and distant disease were found to have poor outcomes. Surgery, irrespective of stage, was found to improve overall Survival (Table 1). While chemotherapy and distant disease had poor outcomes in univariate analysis, they were not statistically significant in multivariate analysis. The majority of the patients who received chemotherapy alone without surgical intervention had distant disease, explaining the poor outcome seen in univariate analysis. Among 107 patients with localized disease, 41 patients (41.1%) underwent only surgery and 43 patients (40.1%) received adjuvant therapy (either chemotherapy or radiation vs both) along with surgery. 5-year overall survival was significantly lower in patients who received adjuvant therapy. (88.4% vs 68.4%, p = 0.001). Conclusions: In conclusion, FDCS has a fair overall 5-year survival with surgery alone. Patients with localized disease, who received adjuvant therapies had poor survival outcomes as compared to the surgery-only group owing to disease burden. Large prospective studies are required to properly evaluate the benefit of adding chemotherapy or radiotherapy in resectable disease.