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Background A JAK2 mutation is detected in almost all patients with polycythemia vera (PV) and in ⁓50% of those with essential thrombocythemia (ET). The two diseases also share characteristic clinical and bone marrow morphological traits, suggesting they exist on a disease continuum rather than representing discrete entities. The objective of the current study was to compare clinical and genetic characteristics as well as long-term outcome between formally-defined PV vs. JAK2-mutated ET vs. JAK2-wild-type (WT) ET. Methods Study patients were retrospectively recruited from Mayo Clinic, USA databases (1967-2024). Diagnostic criteria were according to the International Consensus Classification (ICC; Blood 2022;140:1200). All study patients were fully annotated for JAK2, CALR, and MPL mutations while cytogenetic and additional next-generation sequencing (NGS)-derived mutation information was available in a subset of patients. Conventional statistical methods were employed for phenotypic comparisons and survival analysis. Results Among 2,010 study patients, 1,010 had PV, 617 (63%) JAK2-mutated ET, and 383 JAK2-WT ET (CALR 26%; MPL 3%; triple-negative 9%). Phenotypic comparisons revealed older age distribution in PV compared to JAK2-mutated ET (p=0.03) and the latter compared to JAK2-WT ET (p<0.01). Females were represented more in JAK2-mutated ET (69%), compared to both PV (49%; p<0.01) and JAK2-WT ET (54%; p<0.01). The frequencies of leukocytosis, palpable splenomegaly, constitutional symptoms, diabetes, hypertension, and abnormal karyotype were all significantly higher in PV, compared to both groups of ET, while JAK2-mutated compared to JAK2-WT ET displayed higher leukocyte count and incidence of hypertension. The incidences of arterial thrombosis at/prior to diagnosis were 14%, 16%, and 10% in PV, JAK2-mutated and WT ET, respectively (P=0.03), and venous thrombosis 14%, 13%, and 6% (p<0.01). After a median follow-up of 8.6 years, 632 (32%) deaths, 329 (16%) fibrotic progressions, 79 (4%) leukemic transformations, and 236 (12%) arterial and 202 (10%) venous thrombotic events were recorded, among all 2,010 study patients. Median overall survival was 19.3 years for PV vs. 17.8 years for JAK2-mutated ET vs. 23 years for JAK2-WT ET (p<0.01); however, the significant difference in favor of JAK2-WT ET was no longer apparent when analysis was adjusted for age and sex (p=0.15) and subsequently for other risk factors (p=0.86). All-inclusive multivariable analysis identified older age (p<0.01), male sex (p<0.01), higher leukocyte count (p<0.01), and arterial thrombosis history (p<0.01), but not the distinction between PV, JAK2-mutated, and JAK2-WT ET (p=0.9), to be independently associated with shortened survival. Leukemia-free survival was similar between PV and either JAK2-mutated (p=0.5) or JAK2-WT (p=0.1) ET. On the other hand, myelofibrosis-free survival was shorter in PV, compared to both JAK2-mutated (HR 1.8, 1.4-2.4; p<0.01) and JAK2-WT (HR 1.4. 1.0-1.8; p=0.03) ET. In multivariable analysis, older age (p<0.01), higher leukocyte count (p<0.01), PV vs. JAK2-mutated ET (HR 1.8; p<0.01), and JAK2-WT vs. JAK2-mutated ET (HR 1.6; p=0.01) were associated with a higher risk of fibrotic progression, with no difference noted between PV and JAK2-WT ET (p=0.4). Arterial thrombosis-free survival was similar between PV and JAK2-mutated ET (p=0.8). In univariate analysis, JAK2-WT ET vs. PV was associated with superior arterial thrombosis-free survival (p=0.02), but significance was lost when analysis was adjusted for arterial thrombosis history (p=0.1). Venous thrombosis-free survival favored JAK2-WT ET vs. PV (HR 0.3; p<0.01) and JAK2-mutated ET (HR 0.6; p=0.02) and the latter vs. PV (HR 0.6; p<0.01); the significant differences between PV and both groups of ET were sustained when analysis was adjusted for age, sex, and venous thrombosis history. Conclusions The current study highlights significant demographic and phenotypic differences between PV and JAK2-mutated ET. However, risk factor-adjusted overall, leukemia-free, and arterial thrombosis-free survival was not inferior in PV, compared to ET, regardless of the presence or absence of a JAK2 mutation in the latter. JAK2-WT ET was distinctly associated with a lower risk of venous thrombosis while JAK2-mutated ET appeared to be less vulnerable to fibrotic progression.

Background DISC-0974 is a monoclonal antibody that targets hemojuvelin, a co-receptor to BMP-SMAD signaling that stimulates hepcidin production. In healthy volunteers, DISC-0974 has been shown to be safe and induce dose-dependent decreases in serum hepcidin and corresponding increases in serum iron and absolute reticulocyte count (JCP 2024). Serum hepcidin level is abnormally elevated in myelofibrosis (MF) and is believed to contribute to iron-restricted erythropoiesis (AJH 2013:88:312). In an ongoing phase 1/2 study in MF (NCT05320198), DISC-0974 was well tolerated and associated with marked reduction in serum hepcidin levels and improvement in anemia (Blood 2023;142/DOI 10.1182). The current investigator-initiated laboratory correlative study examined the impact of mutations and baseline cytokine levels on anemia response to DISC-0974, in non-transfusion-dependent (nTD) patients with MF. Methods The current study was conducted under an institutional review board approved minimum risk protocol that allowed retrospective collection and analysis of data from Mayo Clinic patient records (Rochester, MN, USA). Study patients were selected from the aforementioned ongoing phase 1/2 study, based on availability of information on mutations and baseline cytokine levels. Definitions of nTD and anemia response criteria were according to the revised international working group (IWG) criteria (Blood 2024; in press): i) nTD was defined as the presence of ≤2 units transfused in the 12 weeks prior to enrollment; ii) a 12-week rolling average increase of hemoglobin by ≥1.5 or 1-1.4 g/dL is required for major and minor response, respectively. Mutation and cytokine analyses were performed according to institutional standard protocols; next-generation sequencing panel included 48 genes and cytokine panel 12 inflammatory cytokines. Results A total of 21 nTD patients with MF (median age 71 years; males 62%) were considered: 15 primary and 6 secondary. Driver mutation distribution was JAK2 52%, MPL 14%, and CALR-1 33%. DIPSS risk distribution was high (10%) and intermediate-2 (90%). Baseline median (range) values were 8.0 g/dL (range 7.1-9.5) for hemoglobin, 266 (41-1221) for serum ferritin, 79 (32-130) for serum iron, 32 (13-49) for transferrin saturation, and 59 (10-913) for serum erythropoietin. Karyotype was favorable (N=18) or unfavorable (N=2). Other mutations, included ASXL1 (N=5), SF3B1 (N=4), SRSF2 (N=1), U2AF1 (N=1), and “none of the above” (N=5). Elevated cytokines at baseline included TNF (90%), IL-18 (43%), IL-2R alpha (34%), IL-6 (24%), and MCP-1 (14%). DISC-0974 dose levels were 28 mg (N=2), 50 mg (N=7), 75 mg (N=7), and 100 mg (N=5). Twelve (60%) patients were on DISC-0974 monotherapy while 9 (40%) received concomitant ruxolitinib (N=5), pacritinib (N=1), or hydroxyurea (N=3). At median follow-up of 6 months (range 2-14), one (5%) patient has discontinued DISC-0974 for lack of response. Details on drug safety are summarized in another abstract (Gangat et al. ASH 2024). Per IWG criteria, 9 (43%) patients achieved major (MR) and 3 (14%) minor responses, resulting in an overall response (OR) rate of 57%. Two additional patients have surpassed the hemoglobin threshold for major response (≥1.5 g/dL) but have not yet met IWG criteria. OR and MR rates were higher in patients receiving DISC-0974 as monotherapy (OR 75% and MR 58%) vs. combined with JAK2 inhibitor or hydroxyurea (OR 33% and MR 22%) (p=0.05 for OR and 0.09 for MR), ASXL1 wild-type (N=15; OR 67% and MR 53%) vs. mutated (N=6; OR 33% and MR 17%) (p=0.16 for OR and 0.11 for MR), no ASXL1/SRSF2/U2AF1/SF3B1 (N=5; OR 100% and MR 80%) vs. at least one mutated (N=16; OR 44% and MR 31%) (p<0.01 for OR and 0.05 for MR). OR was also higher in the presence of elevated MCP-1 (p=0.05) or elevated IL-2R alpha (p=0.05) and MR in the presence of elevated IL-2R alpha (71% vs. 29%; p=0.06). Conclusions: The current study suggests that ASXL1 mutation might attenuate but not abrogate anemia response to DISC-0974, in MF. Elevated inflammatory cytokines in MF are often associated with increased hepcidin levels (AJH 2013:88:312) and this might explain their association with a higher response rate to DISC-0974, observed in the current study. Regardless, it is important to note that these observations represent preliminary data from a subset of patients from an ongoing clinical trial.

Background Absolute basophil count (ABC) might be increased in patients with myeloproliferative neoplasms and has been associated with poor prognosis in chronic myeloid leukemia (CML) and, possibly, primary myelofibrosis (PMF, Front. Oncol 2019;9:872). In a Mayo Clinic survey of 382 patients with BCR::ABL1-negative leukocytosis and ABC ≥0.09 x 109/L, 191 (50%) were associated with myeloid neoplasms, including 104 (27%) with CML, 23 (6%) essential thrombocythemia, 21 (6%) polycythemia vera (PV), and 18 (5%) PMF (AJH 2020;95:E216). Herein, we tapped into a well-characterized cohort of patients with PV, in order to describe the prevalence of basophilia, at specific ABC thresholds, and corresponding clinical, molecular, and prognostic correlates. Methods Study patients were retrospectively recruited from Mayo Clinic (USA) databases, after approval from IRB. Diagnostic criteria were according to the International Consensus Classification (Blood 2022;140:1200). Study inclusion criteria included the availability of information on ABC and absolute eosinophil count (AEC). Mayo Clinic institutional reference range for ABC was 0.01 to 0.08 x 109/L and for AEC 0.03 to 0.48 x 109/L. “Eosinophilia” was defined as an AEC of ≥0.6 x 109/L. Basophilia was evaluated both at an ABC of ≥0.1 x 109/L and ABC of ≥0.3 x 109/L, the latter representing 3 x the upper limit of the normal reference range. Cytogenetic information obtained within one year of diagnosis was available in 270 patients. Next-generation sequencing information collected before disease transformation was available in 99 patients. Conventional statistical methods were employed for comparisons of groups and survival analysis (JMP Pro 17.0.0 software SAS Institute, Cary, NC, USA). Results Information on ABC and AEC, obtained within one year of diagnosis, was available in 478 patients (median age 66 years; males 51%). Median values at presentation were 10.6 x 109/L for leukocyte count, 453 x 109/L platelet count, and 17.3 g/dL hemoglobin level. Presenting symptoms included palpable splenomegaly 24%, pruritus 31%, arterial thrombosis 12%, and venous thrombosis 17%. Median and range values for ABC and AEC were 0.12 x 109/L (0-3.2) and 0.27 x 109/L (0-6.5), respectively. ABC was ≥0.3 x 109/L in 80 (17%) patients and ≥0.1 x 109/L in 315 (66%). AEC was ≥0.6 x 109/L in 68 (14.6%) patients. ABC≥0.3 x 109/L was associated with AEC ≥0.6 x 109/L (p<0.01), leukocytosis (p<0.01), and palpable splenomegaly (p=0.02), but not platelet count, pruritus, smoking history, diabetes, or arterial or venous thrombosis; in multivariable analysis, the association with leukocytosis, but not that with splenomegaly, was confirmed. At a median follow-up of 5.7 years (range 0.03-32.8), 132 (28%) deaths, 17 (3.6%) leukemic and 40 (8.4%) fibrotic progressions were documented. Post-diagnosis events also included arterial (7%) and venous (9%) thrombosis. In univariate analysis, neither ABC (p=0.8, 0.7, and 0.96) nor AEC (p=0.7, 0.6, and 0.8), evaluated as continuous variables, affected overall (OS), leukemia-free (LFS), or myelofibrosis-free (MFFS) survival, respectively. Similarly, eosinophilia at AEC ≥0.6 x 109/L did not appear to influence OS (p=0.99), LFS (p=0.6) or MFFS (p=0.5). On the other hand, although basophilia at ABC≥0.3 x 109/L did not affect OS (p=0.27), it was significantly associated with inferior LFS (HR 6.5, 95% CI 2.3-18.0; p<0.01) and MFFS (HR 2.3, 95% CI 1.2-4.5; p=0.01); the corresponding p values for ABC≥0.1 x 109/L were 0.7, 0.1, and 0.17. The detrimental impact of basophilia (ABC≥0.3 x 109/L) on LFS was confirmed (P<0.01) with multivariable analysis that included other clinical variables, including leukocytosis (NS), platelet count (NS), basophil percentage (NS), age (p<0.01), and palpable splenomegaly (p<0.01). Results were similar during multivariable analysis for MFFS with palpable splenomegaly (p<0.01), ABC≥0.3 x 109/L (p=0.03), and age (p=0.05) sustaining independent predictive value. The number of informative cases was too small to evaluate prognostic interaction with mutations and karyotype. Conclusions: Basophilia in PV is associated with palpable splenomegaly and leukocytosis and independently predicts leukemic and myelofibrotic transformation. Additional studies are needed to confirm these observations and examine prognostic interaction with mutations and karyotype.

Background: Age-related clonal hematopoiesis (ARCH) is a precursor state to blood cancers and is associated with epigenetic age acceleration (EpiAgeAccel) (Aging Cell, 2021). While ARCH in combination with AgeAccel has the highest risk for all cause mortality and cardiovascular disease, not much is known about context-relevant clonal hematopoiesis (CRCH) - CH occurring in the context of prior chemo/radiation, bone marrow failure and germline predisposition syndromes. CRCH has a unique mutational signature enriched in genes in DNA damage response and repair (TP53 and PPM1D). To answer this question, we assessed EpiAge in a prospective cohort of patients with both ARCH and CRCH. Methods: Patients were prospectively recruited for CH and EpiAge assessment from the Mayo Clinic CH clinic between 2022 and 2024. Demographic and clinical data including chronologic age, BMI, sex, blood counts, and medical history were recorded at the time of enrollment. CH status was determined using error corrected sequencing on peripheral blood (PB) DNA. All somatic variants with a variant allele frequency (VAF) ≥0.5% were considered as CH. For EpiAge analysis PB DNA was analyzed using the Illumina MethylationEPIC array. The resulting beta values were used to obtain epigenetic age estimates using Horvath's clock (Genome Biol., 2013), Hannum's Clock (Mol Cell., 2013), PhenoAge (Aging, 2018), DunedinPACE (eLife, 2022), and predicted telomere length (Aging, 2019). Results: 106 (62%) of 170 patients assessed were found to have CH, with the most frequent mutations being TET2 (19%), PPM1D (17%), DNMT3A (16%), ASXL1 (9%), and TP53 (6%); median VAF 9.5%. Except for a higher median chronologic age (68 vs 60 years, p<0.001) in the CH group, baseline characteristics including BMI, comorbidities, baseline blood counts, sex and tobacco use history were similar between the two groups. The CH group demonstrated significant EpiAgeAccel by all three clocks: Horvath (p=0.001), Hannum (p<0.001), and PhenoAge (p<0.001); with an increase in biological age of 4.9 years (95% CI 2-7.7) by Horvath clock, 4.8 years (95% CI 2.2-7.5) by Hannum clock, and 7 years (95% CI 2.9-10.5) by PhenoAge, after adjusting for chronologic age, sex, smoking status, and cancer history. CH was also associated with increased DunedinPACE of aging by 0.13 biological year per chronologic year (bioyear/chronoyear) (95% CI 0.06-0.2, p<0.001), and shortened telomere lengths by 0.24kb (95% CI 0.11-0.35, p<0.001) after adjusting for chronologic age and excluding patients with telomere biology disorders. CH patients were then further classified into ARCH-63 (59%) and CRCH-43 (41%). While the median chronological age (69 vs 67 years) was similar between the 2 groups, CRCH patients had lower Hgb [10.9g/dL vs. 13g/dL (p=0.0001)] , lower platelet [146x109/L vs. 192x109/L (p=0.0132)] and lower WBC [4.4x109/L vs. 5.2x109/L (p=0.0345)]. The median BMI, comorbidities, and tobacco use history were similar between the 2 groups. The 3 most common ARCH mutations were TET2 (20%), DNMT3A (19%), and ASXL1 (14%), while, PPM1D (27%), TET2 (18%), and DNMT3A (14%) were frequent in CRCH. There was no significant difference found in median EpiAge via Horvath (68 vs 67.5years p=0.2826), Hannum (65 vs 66 years p=0.9333), or PhenoAge (55 vs 56 years p=0.618) between ARCH and CRCH. However, DunedinPACE of aging was higher in CRCH (1.27 vs 1.18 bioyear/chronoyear p=0.0148) and median telomere length was shorter in CRCH (6.35 vs 6.49kb p=0.0247), in comparison to ARCH. Multivariable regression analysis was completed for both ARCH and CRCH compared to non-CH, adjusting for chronologic age, smoking status, and male sex. While both ARCH and CRCH demonstrated EpiAgeAccel via Horvath(5.8years p=0.0001, 3.4 years p=0.051), Hannum(5years p=0.001, 4.5 years p=0.007), and PhenoAge (6.7years p=0.002, 7.6 years p=0.002) clocks, CRCH more than doubled DunedinPACE (0.2 bioyear/chronoyear, p<0.001) of aging compared to ARCH (0.08 bioyear/chronoyear, p=0.026). CRCH also demonstrated double the decrease in telomere length (0.34kb, p<0.001) compared to ARCH (0.17kb, p=0.015). Conclusion: Our prospective CH cohort study validates the association between CH and EpiAgeAccel using several different methylation clocks and for the first time, highlights increased pace of aging and shorter telomere lengths in CRCH versus ARCH. Correlations with cardiovascular disease and mortality outcomes are ongoing.

Introduction Clonal hematopoiesis (CH) in solid organ transplant (SOT) recipients can lead to impaired tolerance to immunosuppressive therapy, increased risk for complications, and potentially compromise graft and patient outcomes. The impact of mutational profile in CH on risk for hematological transformation and patient/graft outcomes for kidney transplant (KT) recipients is largely unknown. Our aim was to assess the prevalence of CH and progression of CH in KT, evaluate the impact of CH on allograft function, assess patient outcomes and determine Clonal Hematopoietic Risk Score status. Methods We retrospectively reviewed the CH profile of patients 18+ years of age who received a kidney transplant at Mayo Clinic Enterprise between 01/01/1994-12-31/2022 and underwent bone marrow biopsy with aspirate pre- and/or post-transplant. Bone marrow biopsies were primarily performed post-transplant in the workup for cytopenias. Transplant database was used to collect our variables of interest including post-transplant malignancy and outcomes. CH was ascertained through next-generation sequencing (NGS) on bone marrow samples. A 47-gene panel was utilized in our study. CH was defined by presence of somatic mutation with a variant allele frequency of > 2.0%. CH in absence of cytopenias was classified as CHIP while CH in individuals with one or more cytopenias was classified as clonal cytopenias of undetermined significant (CCUS). The Clonal Hematopoiesis Risk Score (CHRS) was utilized for CHIP and CCUS risk stratification We excluded the patients who had a prior hematologic malignancy. Results 305 kidney transplant recipients met our study criteria. The median time to follow up, defined as time from transplant until first bone marrow biopsy with evidence of CH, was 46.1 months. The frequency of CH in kidney recipients was 27/305 (9.0%), of these 14/27 (52%) patients were found to have CCUS and 10/27 (37%) were found to have evidence of post-transplant myeloid malignancy. Of these cases, 5/10 (50%) developed acute myeloid leukemia while 5/10 (50%) developed myelodysplastic syndrome. Both CCUS and myeloid neoplasms were more common in female patients, accounting for 8/14 (57%) and 7/13 (54%) of each cohort, respectively. Amongst CCUS, the most frequent mutations were seen in ASXL1, DNMT3A and TET2. More than half of patients with CH, 14/27 (52%), exhibited mutations in 2 or more genes. Meanwhile, in cases of myeloid malignancy, the commonly mutated genes were ASXL1 and TP53, seen in 3/10 and 3/10 cases, respectively. The CCUS risk status was intermediate, with median score of 11.8 (range 9.5-14). One CCUS patient transformed to myelodysplastic syndrome. The time to progression from CCUS to myelodysplastic syndrome was 14.3 months and their respective CHRS status was determined to be high-risk. Infectious complications, including viral and opportunistic infections, were seen in 12/27 (44%) recipients with CH, with CMV viremia being the most common, followed by BK viremia. In this cohort, post-transplant cardiovascular events and venous thromboembolic events occurred in 2/27 (7.0%) and 7/27 (26%) patients, respectively. Allograft failure was seen in 17/27 (63%) recipients at a median of 93.4 months post-transplant. After a median of 122 months, there were 14/27 (52%) deaths at a median duration of 93.4 months post-transplant. Causes of mortality included myeloid malignancy, infection, cardiovascular complications, end-stage renal disease or were unknown. Conclusions Renal transplant recipients carry mutations in epigenetic regulators resulting in adverse outcomes. Similar to the general population, DNMT3A, TET2 and ASXL1 mutations were the most common mutations in post-transplant CCUS. Infections, cardiovascular events, and allograft failure were frequent. Prospective studies in a larger cohort are needed to evaluate the impact of CCUS in survival and myeloid malignancy transformation risk.

Background Clonal hematopoiesis (CH) is defined by somatic mutations in hematopoietic stem cells, often conferring a selection advantage based on clonal selection pressures. CH in DNA Damage Response and Repair (DDR, e.g. TP53, PPM1D) genes are frequent in individuals exposed to chemotherapy and radiation (chemo/XRT). In metastatic prostate cancer (mPC) patients, the prevalence of CH is estimated at 57% and is increased among those with prior exposure to chemo or XRT. In these patients, the use of radiotheranostics is becoming more prevalent and are now being tested in earlier lines of therapy. We have identified an increase in DDR-somatic variants post lutetium-177-PSMA, raising concern for long term hematologic safety. Here, we evaluate the spectrum of CH and CCUS (clonal cytopenias of undetermined significance) in mPC patients, prior to receiving radioisotope therapies. Methods We performed error corrected next-generation sequencing (NGS) on peripheral blood samples from 67 mPC patients enrolled in the Prostate Cancer Medically Optimized Genome Enhanced Therapy Study (PROMOTE) study (NCT #01953640). All patients enrolled also had whole exome sequencing (WES) performed on initial metastatic biopsies and on whole blood for germline genotyping. Somatic variants with a variant allele fraction (VAF) ≥0.5% were considered as CH, using standard bioinformatic variant calling algorithms. Results The median age at NGS was 74.4 years (range, 58.4-92.3). While all patients received androgen deprivation therapy (ADT) +/- androgen receptor pathway inhibitor (ARPI), 67.2% (n=45, pelvic XRT- 35, palliative XRT- 10) received prior XRT and 3% (n=2) received prior docetaxel. No patients in this cohort received prior platinum or PARP inhibitor. Of those treated with XRT or chemo, the median time from first exposure to CH sample collection was 4.1yrs (range, 0.12-29.6) and 2.3yrs (range, 0.6-4.0), respectively. Of the 67 patients, we identified a total of 111 pathogenic variants in 59 (88.1%) patients. We compared our NGS data to the germline data and tumor for each patient (All samples obtained at the same time point; Wang et al 2018). Our analysis excluded 2 ATM variants likely to be germline, and 1 TP53 variant likely to be tumor-derived. Each patient had at least one somatic variant, with a median of 2 variants (range, 1-6The median CH VAF was 1.8% (range, 0.5-50.2) with 91.0% of alterations detected at a VAF of <10%. Specific somatic variants, presence/absence of CH, number of variants, nor VAF was associated with age, prior chemo, or XRT exposures. At time of NGS, 54% of patients were anemic (hgb <13g/dL), 7% were thrombocytopenic (platelets <135 x109), 6% were leukopenic (WBC <3 x 109), and no patients were neutropenic (ANC <1 x109). Persistent cytopenias, lasting >3months, were present in 25% (n=17) of patients; however, bone marrow biopsies (BMB) were performed only in 6% (n=4). Three (75%) of these 4 patients had mPC infiltration in the BM, and 1 (25%) had mild dysplasia not meeting criteria for MDS but meeting criteria for CCUS (CHEK2 somatic variant). At last follow-up, there were no patients formally diagnosed to have myeloid neoplasm (MN). Median overall survival (OS) from prostate cancer diagnosis was 8.6yrs (range, 1.4-28.4). With a median follow up of 2.2yrs (range 0.1-10.8) after CH testing, 3.0% (n=2) were alive, with most deaths occurring due to mPC. The presence of CH did not impact overall survival (OS), however, presence of cytopenias at the time of NGS testing was associated with worse outcomes (median OS 2.5yrs vs 1.2 yrs., p=0.025). Conclusions We define the landscape of CH mutations in mPC patients predominantly treated with ADT/ARPI and XRT, demonstrating that DNMT3A, TET2, PPM1D and ASXL1 are frequently mutated (88%) and largely subclonal (91% with VAF ≤10%). While 25% of these patients had cytopenias, with cytopenias negatively impacting survival, due to inadequate BM biopsy work up, the true prevalence of CCUS and MN could not be estimated. Given the advancement of genotoxic therapies and the high prevalence of subclonal CH in mPC, future studies investigating CH as a predictive biomarker of hematological dysfunction are much needed.

Background Primary Central Nervous System Lymphoma Patients (PCNSL) is a rare and aggressive form of NHL in the central nervous system or vitreoretinal space. Despite high initial response rates of high dose methotrexate-based regimens, most patients will relapse in less than two years with poor prognosis. There are no approved treatments for Relapsed/Refractory (R/R) PCNSL, representing a clear unmet medical need. IRAK4 kinase activity is required for TLR and IL-1R signaling in a variety of myeloid and lymphoid cell types, including PCNSL. Recruitment of IRAK4 to these receptors and subsequent activation is facilitated by the MyD88 adaptor protein, which is mutated in ~70% of PCNSL. This leads to constitutive activation of the NF-κB signaling pathway, increased inflammation, and tumor growth. Emavusertib is a novel and potent oral inhibitor of IRAK4, which has demonstrated the ability to cross the blood-brain barrier in PCNSL xenografts. In preclinical studies, the combination of emavusertib with Bruton tyrosine kinase inhibitors (BTKi) showed in vitro synergy of inhibition and re-sensitization of BTKi-resistant cell lines. Emavusertib + ibrutinib has demonstrated an acceptable safety profile across a broad population of R/R NHL patients, including PCNSL. Aim We present updated safety and efficacy of emavusertib in combination with ibrutinib in patients with R/R PCNSL most recently treated with BTKi regimen. Methods The safety, clinical activity, and potential biomarkers of emavusertib in R/R PCNSL are being investigated in the ongoing open-label, Phase 1/2 TakeAim Lymphoma trial (NCT03328078). The eligible patients with R/R PCNSL received emavusertib (100-300 mg BID) in combination with ibrutinib (560 mg QD) continuously until tumor progression or unacceptable toxicity. Disease staging at screening and anti-cancer therapeutic responses were evaluated according to the IPCG Response Criteria Guideline for PCNSL. Results As of 10 July 2024, 13 R/R PCNSL patients, with prior BTK exposure, received emavusertib at 100 - 300 mg BID in combination with ibrutinib at 560mg QD. The median age was 60 years (range 44 - 79). The median number of prior lines of anti-cancer therapies was 2 (range 2 - 5). Median emavusertib/ibrutinib treatment duration was 51 days (range 17 - 503). The preliminary efficacy data in 12 evaluable patients whose most recent treatment regimen included a BTKi and were treated with the combination of emavusertib and ibrutinib showed 3 complete remission (CR), 1 unconfirmed complete Response (CRu) and 2 partial responses (PR) and an overall response rate of 50%. Treatment is on-going for 5 patients with one patient pending the first assessment. All responders demonstrated more than 80% reduction in target lesion size compared to baseline. Two of the responders with a CR demonstrated durable response, with 1 patient having a duration of response (DOR) of approximately 9 months, and the second patient having a DOR of 12 months with response ongoing. Grade ≥3 Treatment-emergent adverse events (TEAEs) were reported in 7 (53.8%) patients, while Grade ≥3 treatment-related adverse events (TRAEs) were reported in 4 (30.8%) patients. No fatal TRAE were reported and the majority of Grade ≥ 3 TEAEs and all Grade ≥ 3 TRAEs were reversible and manageable. Conclusion Emavusertib in combination with ibrutinib shows promising efficacy and was well tolerated with an acceptable safety profile in R/R PCNSL patients with prior BTKi exposure. The combination of emavusertib + ibrutinib may overcome BTKi resistance and has the potential to show improved anti-cancer activity. Enrollment in this trial is ongoing (NCT03328078).

Introduction: Heparin induced-thrombocytopenia (HIT) is a severe autoimmune reaction to heparin that increases patients' risk of developing venous thrombosis, leading to fatal conditions such as pulmonary embolism. The clinical 4T scoring system guides need for further testing, based on noting fall in platelet counts, the timing of platelet counts falling in conjunction with heparin exposure, the presence of new thromboses, and ruling out other causes of thrombocytopenia. In patients in whom 4T scoring indicates a higher protest probability for HIT, screening is then performed. The Enzyme-Linked Immunosorbent Assay (ELISA) detects antibodies against platelet factor 4 (PF4)-heparin complexes. In order to confirm the diagnosis of HIT, the serotonin release assay testing is required, which refers to measuring the serotonin levels produced during platelet activation using radio-labeling techniques. Since the start of the COVID-19 Pandemic in 2020, there has been ongoing discussion regarding whether incidence of HIT diagnosis has increased. Herein we report on a retrospective observational study of a cohort of patients seen at a community hospital in Georgia between March 2017 to December 2022 to determine the changes in frequency of HIT and SRA testing, and to assess its association with the COVID-19 pandemic. Methods: We included patients aged >18 years, hospitalized at a community hospital in Georgia during the study duration and de-identified data was collected from electronic medical records. Text-based data analysis was performed to identify those patients who received HIT testing, SRA testing, and ultimately a final diagnosis of HIT (HIT positive and SRA positive). The overall rates of 4T scoring documentation and assessment in the hospital were also assessed. Several multivariable logistic regression models were constructed to examine factors associated with HIT testing and SRA testing, and their association since the start of the the COVID-19 pandemic (March 2020). Results: A total of 244,457 patients were included in the study population. Of them, 2,375 (0.97% of total) patients were tested with the HIT-ELISA, and only 468 (0.19% of total) patients were tested with SRA. In further subgroup analysis, evaluating the temporal associations of HIT and SRA testing, it was observed that the rate of HIT-ELISA testing increased since the onset of the COVID-19 pandemic, as did the rate of SRA testing (p < 0.000). Notably, of the 2,375 patients who received the HIT-ELISA testing, only 193 (8% of HIT-tested patients) had documentation of clinical suspicion of HIT with the 4T score. Discussion: An increase in HIT and SRA testing has been observed since the start of COVID-19 pandemic, with a notable lack of 4T score data in the study population preceding this testing. This study emphasizes the importance of clinician education regarding the process of accurate HIT diagnosis, which would start with clinical 4T scoring, followed by ELISA testing for screening, and finally confirmed by SRA testing. Further research is warranted to understand the barriers that may exist in providing guideline-directed evaluation of HIT so that targeted interventions can be implemented to ensure high-quality care is delivered to patients.

Pulmonary infections are commonly observed in hematologic malignancy (HM) patients.For HM patients with low immune functionality and high susceptibility to pulmonary infections, timely identification of pathogens and administration of correct medications can greatly improve patient outcomes[1, 2].The next generation sequencing can achieve an early diagnosis of respiratory infection.To date, the systematic evaluation of the clinical use of mNGS and tNGS for pneumonia in HM patients has been insufficient. A retrospective analysis was conducted on HM patients with suspected pneumonia admitted to the Hematology Department of The Third Xiangya Hospital between April 2019 and April 2024.A total of 234 patients were identified for analysis,including 126 patients used mNGS to detect bronchoalveolar lavage fluid(BALF）and 108 patients used mNGS to detect BALF.The purpose was to compare the diagnostic efficacy of mNGS and tNGS in pulmonary infection pathogens. The overall microbial detection rate of mNGS and tNGS were 88.9% (112/126) and 93.5% (101/108), respectively. And there was no significant difference between them ( p = 0.217).Viruses,bacteria and fungi accounted for 42.2%(117/277), 33.9% (94/277) and 23.8% (66/277) among the microorganisms detected in mNGS, respectively. Meanwhile,Viruses,bacteria and fungi accounted for 61.0%(147/241), 21.2% (51/241) and 17.8% (43/241) among the microorganisms detected in mNGS.In order to compare the diagnostic and concordance between mNGS and tNGS.We used the final clinical diagnosis as the “gold standard”.The sensitivity, specificity, positive predictive value and accuracy of mNGS were 92.7%,37.5%,91.1% and 85.7%, respectively, compared with 97.9%,45.5%,94.1% and 92.6% for tNGS.Further more,we compared the clinical impact of mNGS and tNGS on antibiotic usage.The mNGS results led to adjustments in antibiotic usage for 63 out of the 126 patients(56.3%). Following these alterations, 56 patients (88.9%) reported significant improvements.In tNGS,there are 59 out of the 108 patients(58.4%%) adjustmented in antibiotic usage and 56 patients(94.9%) reported significant improvements.The total death of mNGS and tNGS were 9.8%(11/126) and 4.0%（4/108), respectively. There were no significant differences between the two groups (P ＞0.05).Compared to the microbial range detected by tNGS, mNGS detected an additional 14 pathogenic microorganisms, in which had a very low proportion of pathogenic microorganisms (3.6%,4/112), which did not have any adverse effects on the clinical outcomes of patients. Collectively,we found that tNGS is comparable with mNGS in HM patients with suspected pneumonia for pathogenic microorganism detection.What's more,the ability of tNGS in guiding treatment was consistent with those of mNGS.

Introduction: The incidence of cardiovascular events in the first 100 days post-HSCT was found to be 19%, with arrhythmia having the highest incidence of 12% (p<0.0001). The incidence of cardiovascular events is 6.7% in patients with multiple myeloma treated with HSCT (HSCT-MM) [1]. However, the literature on arrhythmia in HSCT-MM patients is limited. Given the high risk of cardiac events in HSCT patients, we aimed to determine the impact of arrhythmia in patients with HSCT-MM. Methods: We conducted a retrospective analysis using the National Inpatient Sample Database (2018-2021). Adult patients with HSCT-MM who were primarily admitted for life-threatening arrhythmias were identified using ICD-10 codes [2]. We performed propensity matching and multivariate regression, considering a p-value of ≤0.05 as significant. Results: In 14,232 HSCT-MM patients, 168 (1.2%) had arrhythmia. The prevalence of arrhythmia in HSCT-MM patients was higher than in the remaining HSCT recipients (1.2% vs 0.9%, p<0.01). In HSCT-MM, atrial fibrillation (69.6%) and atrial flutter (19%) were the common arrhythmias. Arrhythmia in HSCT-MM patients was more prevalent in those over the age of 60 years (84.5% vs 68.5%, p<0.001), males (72.6% vs 58.2%, p<0.001), and in the White race (84.8% vs 67.3%, p<0.001) compared to those without arrhythmia. Arrhythmia was less common in those with bone marrow dysfunction compared to those with normocellular marrow (anemia 1% vs 1.5%, p<0.01; thrombocytopenia 1% vs 1.2%, p>0.05; neutropenia 0.7% vs 1.3%, p<0.05; pancytopenia 0.9% vs 1.4%, p<0.01). Among the HSCT-MM patients with arrhythmia, long-term anticoagulation was less frequently given than those without arrhythmia (44.6% vs 55.4%, p<0.001). The arrhythmia cohort had less frequent acute kidney injury (19.1% vs 27.5%, p=0.01). The arrhythmia cohort required more vasopressors (2.4% vs 2.1%, p>0.05) but had lower mortality (1.2% vs 4.5%, p<0.05). Patients with arrhythmia had shorter hospital stays (Coefficient -3 days; 95% CI -3.8 to -2.3 days; p<0.001) and lesser hospital charges (Coefficient $-41,200; CI $-55,700 to $-26,600; p<0.001) compared to those without. However, the arrhythmia cohort had higher rates of acute heart failure (17.9% vs 9.1%, p<0.001) and the risk of acute heart failure was also higher in those with arrhythmia (adjusted odds ratio 2.2; 95% CI 1.3 to 3.6; p<0.01). In patients with acute heart failure and arrhythmia, atrial fibrillation was present in 76.7% and atrial flutter in 20%. In patients with acute heart failure and arrhythmia, bone marrow dysfunction was more common than normocellular bone marrow (anemia 22.2% vs 12.8%, p>0.05; thrombocytopenia 38.7% vs 13.1%, p=0.001; neutropenia 18.2% vs 14.3%, p>0.05; pancytopenia 8.7% vs 21.3%, p>0.05). In the arrhythmia cohort, long-term anticoagulation was commonly given in those with acute heart failure compared to those without (53.3% vs 46.7%, p>0.05), and acute kidney injury also occurred more frequently in those with heart failure (26.7% vs 17.4%, p>0.05). Conclusion: Acute heart failure is a serious risk associated with arrhythmia in multiple myeloma patients treated with HSCT, with atrial fibrillation emerging as the most common arrhythmia. It is essential to prevent heart failure in those with arrhythmia, especially in patients with thrombocytopenia. Preventive measures could include more frequent follow-ups and having a multidisciplinary team to manage renal failure, monitor anticoagulation, and ensure rhythm control in these patients. References: Aghel N, Lui M, Wang V, et al.: Cardiovascular events among recipients of hematopoietic stem cell transplantation-A systematic review and meta-analysis. Bone Marrow Transplant. 2023, 58:478-90. 10.1038/s41409-023-01928-22021 ICD-10-CM. Accessed: July 14, 2024. https://www.cms.gov/medicare/coding-billing/icd-10-codes/2021-icd-10-cm.