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Background: PV is a myeloproliferative neoplasm that leads to excessive production of erythrocytes and increased platelet and leukocyte counts. The current standard of care is to use therapeutic phlebotomy (TP) with or without cytoreductive therapy (CRT) to treat PV. Over time, the CRT dose often needs to be increased to treat PV progression. Preliminary results from the phase 2 REVIVE study (NCT04057040) demonstrated that rusfertide was superior to placebo in achieving hematocrit (Hct) levels <45% and reducing or eliminating the need for TP in patients who were phlebotomy-dependent prior to study entry (Kremyanskaya et al. EHA2023. [Abstract LB2710]; Kremyanskaya et al. New Engl J Med 2024;390:723-35).Final data from REVIVE will be presented. Methods: In Part 1 (Weeks 1-29), subcutaneous rusfertide (starting dose: 20 mg q1w) was initiated and titrated to control Hct to <45%. In Part 2 (Weeks 29-41; blinded randomized withdrawal phase), patients were randomized to receive rusfertide or placebo. Randomized patients were eligible to participate in the open-label extension (OLE) portion of the study (Part 3), in which all patients could receive rusfertide and investigators could make CRT dose adjustments. Results: In Part 1, 70 patients were enrolled; 59 were randomized in Part 2. Fifty-eight patients continued to Part 3. As of 9 July 2024, 50 (71.4%), 37 (52.9%), and 17 (24.3%) patients received rusfertide for ≥2, ≥2.5, or ≥3 years, respectively.Overall, median (range) patient age was 57.5 years (27-77); the majority were male (70%) and had high-risk disease (55.7%). Overall, 52.9% and 47.1% of patients were treated with TP alone or TP plus CRT, respectively. Prior to enrollment, the estimated average (mean) phlebotomy rate (EAPR) in patients who enrolled on study was 8.5/year, which was reduced to <1.0/year in Part 1. In Part 2, the EAPR was <1.0/year and 6.6/year in the rusfertide and placebo groups, respectively. For patients who continued onto Part 3 and received rusfertide, the EAPR remained at <1.0/year. In Parts 1, 2, and 3, the mean (SD) weekly average rusfertide dose was 30.7 mg (12.2), 38.5 mg (21.3), and 44.9 mg (20.3), respectively. Rusfertide consistently maintained Hct <45%, including in patients receiving therapy for ≥3 years. Platelets increased following initiation of rusfertide therapy and stabilized over time; mean leukocyte counts remained stable. Prior to enrollment, iron-related parameters were consistent with systemic iron deficiency. Throughout the study, rusfertide resulted in the normalization of mean serum ferritin levels, increased mean transferrin saturation, and increased mean serum iron levels. Overall, mean corpuscular volume increased slightly over the duration of the study. Throughout the study, there was no evidence of increased markers of inflammation (eg, C-reactive protein or interleukin 6). The most common (≥20%) treatment-emergent adverse events (TEAEs) were injection site reactions (85.7%), fatigue (38.6%), COVID-19 (32.9%), pruritus (34.3%), arthralgia (30.0%), dizziness (30.0%), nausea (24.3%), headache (24.3%), and anemia (21.4%). Grade 3 TEAEs occurred in 25.7% of patients.There were no Grade 4 or 5 TEAEs. One patient developed acute myeloid leukemia after treatment discontinuation. After more than 150 patient-years of rusfertide exposure, malignancies (most of which were skin cancers) were reported in 11 patients (all had risk factors that may have contributed to the development of these malignancies). There was no obvious correlation between increasing exposure to rusfertide and malignancies reported. Six thrombotic events (5 arterial and 1 venous) occurred in 5 patients with high-risk PV. Conclusions: In REVIVE, rusfertide added to TP with or without CRT provided long-term durable control of Hct and decreased the need for TP. Patients are eligible to roll over to the phase 2 THRIVE OLE study (NCT06033586), which will continue to assess the long-term safety and efficacy of rusfertide for a total period of up to 5.8 years. The randomized phase 3 VERIFY study (NCT05210790) is ongoing and will evaluate rusfertide vs placebo in PV patients.

Background Venetoclax + hypomethylating agent (Ven-HMA) therapy results in favorable response rates (CR/CRi 66%) and overall survival (OS; median 14.7 months) in unfit patients with newly-diagnosed acute myeloid leukemia (ND-AML; N Engl J Med 2020;383). However, there is substantial heterogeneity in individual patient outcomes based on response to treatment. The objective of the current study was to develop a genetic risk model to predict survival outcome in treatment responders and non-responders, analyzed separately, and also account for allogeneic stem cell transplant (ASCT). Methods Treatment-naïve AML patients receiving Ven-HMA, outside of a clinical trial, at the Mayo Clinic, USA (MN, AZ, FL) were retrospectively recruited. Molecular studies (48-gene panel) were performed by next-generation sequencing. Response was assessed according to the 2022 European LeukemiaNet (ELN) criteria (Blood 2022;140). Standard statistical analyses were performed using JMP Pro (Version 17.0.0). Results 400 ND-AML patients (median age 73 years, 64% male, 60% de novo) received Ven-HMA. ELN cytogenetic risk included favorable 2%, intermediate 60%, or adverse 38%. Mutations involved TP53 in 26%, TET2 19%, RUNX1 19%, SRSF2 18%, ASXL1 18%, DNMT3A 15%, K/NRAS 13%, NPM1 12%, IDH2 12%, FLT3-ITD 10%, IDH1 7% and DDX41 in 4% of informative cases. 153 (38%) patients achieved CR, 94 (24%) CR with incomplete count recovery (CRi), resulting in CR/CRi in 247 (62%) patients. CR/CRi rates were higher with NPM1 (86% vs 59%), IDH2 (77% vs 60%), and DDX41 mutations (93% vs 61%) and lower with TP53 (45% vs 67%), FLT3-ITD (41% vs 64%), RUNX1 (49% vs 65%) mutations and adverse karyotype (48% vs 71%), with all retaining significance in multivariable analysis. CR/CRi rate was highest (87%) in 75 patients with one or more favorable mutations (NPM1, IDH2, DDX41) and no unfavorable mutation (TP53, FLT3-ITD, RUNX1). CR/CRi rate was lowest in 171 patients with at least one unfavorable mutation and no favorable mutation (44%; p<0.01). After a median follow up of 10.5 months (0.5-66), 105 relapses (43% of patients in CR/CRi), 248 (62%) deaths and 65 (16%) ASCT were documented. Univariate analysis for transplant-censored OS disclosed superior survival in patients achieving CR/CRi (median 21 vs 3.6 months; HR 5.4, 95% CI 4.1-7.1). Among patients achieving CR/CRi, IDH2 mutation was associated with superior (median not reached vs 20.5 months) and male gender (median 17.6 vs 29.2 months), TP53 mutations (median 11.9 vs 24.3 months) and adverse karyotype (median 12.6 vs 29.4 months) with inferior survival; multivariable analysis resulted in HRs (95% CI) of 2.1 (1.3-3.4) for male gender, 2.1 (1.2-3.8) for adverse karyotype, and 2.5 (1.1-5.7) for absence of IDH2 mutations. Male gender did not show an association with karyotype, or TP53 mutations (p>0.1). Accordingly, an HR-weighted genetic risk model was generated with assignment of one point each to male gender, adverse karyotype, and absence of IDH2 mutation: high risk = 3 risk factors (n=38; median 9.6 months; 3-year survival 0%); intermediate risk = 2 risk factors (n=129; median 22 months; 3-year survival 38%); and low-risk = ≤1 risk factor (n=78; median not reached; 3-year survival 69%; p<0.01). In patients bridged to ASCT (n=60), post-transplant survival was inferior in the presence of ≥ 2 risk factors (n=42; median 46 months) vs. ≤1 risk factor (n=18; median not reached; p=0.1). In patients not achieving CR/CRi, risk factors for OS included male gender (median 3.4 vs 6.1 months), adverse karyotype (median 3.3 vs 4.5 months) and TP53 mutation (median 3.1 vs 4.5 months) while those with IDH2 mutations lived longer (median 8.4 vs 3.4 months). In multivariable analysis, HRs (95% CI) were 1.9 (1.3-2.9) for male gender, 2.0 (1.4-2.9) for adverse karyotype, and 2.1 (1.1-4.3) for absence of IDH2 mutations. OS was shortest for non-responders harboring 3 risk factors (n=45; median 3 months; 1-year survival 0%) and longer for those harboring two (n=80; median 6 months, 1-year OS 15%) or ≤ 1 risk factor (n=25; median 14 months; 1-year OS 56%; p<0.01). Conclusion The current study describes a molecular profile for predicting response to Ven-HMA in ND-AML and also introduces a novel approach to survival prediction that considers treatment response as the starting point. In both responders and non-responders, male gender and adverse karyotype were identified as unfavorable and IDH2 mutation favorable risk factor for OS.

Background Venetoclax + hypomethylating agent (Ven-HMA) therapy has demonstrated improved outcomes in elderly/unfit patients with newly-diagnosed acute myeloid leukemia (ND-AML) (N Engl J Med 2020;383). However, ~50% of patients who respond to Ven-HMA, eventually relapse (Am J Hematol 2024;99). In the current study we examined the prognostic contribution of gene mutations, karyotype, measurable residual disease (MRD) status and clinical risk factors for relapse in patients with ND-AML treated with Ven-HMA therapy. Methods Our study population of ND-AML was retrospectively recruited from Mayo Clinic (MN, AZ, FL), after institutional review board approval and based on documentation of complete remission with/without count recovery (CR/CRi) following Ven-HMA therapy. Relapse-free survival was determined from the time of remission to relapse or last follow-up. Survival analysis was censored for transplant. The 2022 European LeukemiaNet (ELN) criteria was used to assign cytogenetic risk and classify treatment response (Blood 2022;140). Standard statistical analyses were performed using JMP Pro (Version 17.0.0). Results 247 ND-AML patients treated with Ven-HMA (median age 73 years, 62% male, 64% de novo) who achieved CR (n=153), or CRi (n=94) were included. MRD by multiparameter flow cytometry (sensitivity 0.01%) performed at the time of CR/CRi, was negative in 117 (70%) of 166 informative cases. ELN cytogenetic risk categories at diagnosis included favorable 2%, intermediate 69%, or adverse 29%. Mutations involved TET2 21%, SRSF2 21%, TP53 19%, ASXL1 18%, DNMT3A 18%, NPM1 17%, IDH2 15%, RUNX1 15%, K/NRAS 12%, IDH1 8%, FLT3-ITD 7%, and DDX41 in 6% of informative cases. Relapse was documented in a total of 99 (40%) patients who achieved CR (39%) or CRi (41%) after a median remission duration of 6 months (1-31). Patients that relapsed within the first-year vs those that did not, were more likely to be males (75% vs 55%), MRD positive (44% vs 24%), and harbor TP53 mutations (23% vs 16%). Univariate analysis for RFS identified male gender (12 vs 29 months; p=0.02), secondary AML (10 vs 21 months; p<0.01), adverse karyotype (9 vs 22 months; p<0.01), TP53 mutations (6 vs 18 months, p<0.01) and MRD positive remission (13 months vs not reached; p<0.01) as risk factors for relapse; on the other hand, IDH2 mutations (not reached vs 15 months; p<0.01) were associated with a lower risk of relapse. Multivariable analysis confirmed male gender (HR 2.2), TP53 mutations (HR 3.0) and MRD positive remission (HR 1.7) as unfavorable predictors of relapse. Subsequently, in a three-tiered relapse prediction model, RFS was significantly inferior in the presence of three risk factors (male gender, TP53 mutations, MRD positive remission) (n=10, median 4 months), vs two (n=34, median 10 months) vs ≤ 1 risk factor (n=122, median 31 months) (p<0.01); 1-year cumulative incidence of relapse was 100%, 56%, and 26% in the presence of three, two and ≤ 1 risk factors, respectively. 50 of 99 (65%) patients received salvage therapy which included cladribine-cytarabine-Ven (n=19), intensive induction chemotherapy (n=9), FLT3 inhibitors (n=5), Ven-HMA-FLT3 inhibitor (n=1), IDH1/2 inhibitors (n=5), glasdegib-cytarabine (n=4), gemtuzumab (n=3), lenalidomide (n=1), or investigational therapies (n=3); in addition, Ven-HMA was resumed in 14 patients in whom treatment had been discontinued for a median of 5 months (2-12). Overall, 20 (31%) of patients achieved second CR/CRi and response rates were similar with intensive vs less intensive therapy (CR/CRi; 44% vs 29%; p=0.37). Median follow up after relapse was 3.4 months (1-66), during which 73 (74%) deaths, and 4 (5%) ASCT were recorded. Median transplant-censored survival was 4.2 months (1-year; 22%), and inferior in patients with adverse karyotype (median 4.6 vs 3.4 months; p=0.02), and TP53 mutations (3.6 vs 4.4; p=0.11); on the other hand, male gender (3.5 vs 6.8 months; p=0.51), MRD positive remission (4.6 vs 4.2; p=0.56), and IDH2 mutations (6.7 vs 4.2; p=0.28), did not influence post-relapse survival. Conclusions The current study identifies male gender, TP53 mutations, and MRD status as powerful predictors of relapse and proposes a relapse prediction model for ND-AML patients receiving Ven-HMA therapy. Furthermore, relapse following Ven-HMA was associated with uniformly poor outcomes, regardless of salvage treatment strategy.

DDX41 MT Germline Predisposition Syndrome (GPS) is the most common adult GPS for myeloid neoplasms (MN), including MDS and AML. Although there have been reports of non-myeloid neoplasms, particularly lymphoid malignancies, in DDX41MT-GPS, these occurrences are infrequent and poorly characterized. We carried out this study in a large cohort of DDX41MT-GPS patients to address this deficiency. Following IRB approval, we retrospectively analyzed our database of 174 patients with DDX41MT-GPS to determine the rates of non-myeloid malignancies. Our previous data revealed that certain DDX41MT genotypes classified as variants of uncertain significance (VUS) exhibit a similar phenotypic spectrum to those classified as pathogenic (Badar et al Hematologica). Consequently, we included all these variants in our analysis. The median age of the cohort was 68.6 yrs (range, 13-4-93.4); 66% (n=114) male, 93% (n=162) Caucasian, with a median follow-up of 1.4 yrs (range, 0.03-5.6) from DDX41MT-GPS detection. The cohort included 34 (19.5%) asymptomatic carriers, 17 (9.8%) with clonal hematopoiesis (CH) or clonal cytopenias (CCUS), and 123 (70.7%) with MN. Eighteen (10%) patients had a lymphoid neoplasm (78% male, 100% Caucasian), with a median age at lymphoid neoplasm diagnosis of 67.7 yrs (range, 12.2-85.9). The most common lymphoid neoplasm was chronic lymphocytic leukemia (CLL) seen in 2.3% (n=), followed by follicular lymphoma (FL) and acute lymphoblastic leukemia (ALL) present in 1.7% each (n=3; 1 T-ALL and 2 B-ALL: 1 Ph+ and1 Ph-like). Additionally, there was 1 patient each with monoclonal B cell lymphocytosis (MBL), Waldenstroms macroglobulinemia , peripheral T cell lymphoma , large granular lymphocytic leukemia, and marginal zone lymphoma. Germline genotypes were classified as pathogenic in 50% (n=9, D140Gfs*2 x2, K331del, M1I x3, M316Dfs*31, P258L, Y340N) and VUS in 50% (n=9, E426K, E69D, G313D, K184R, P206A, P70S, Q246E, R164W, c.572-3T>C. Among these 18, 9 (50%) patients had co-existing myeloid disorders (CCUS x3, MDS x5, AML x1), and 5 (27.8%) patients were later diagnosed with therapy-related myeloid neoplasms (TMN) at a median of 5.9 yrs (range,1.6-38.7) after lymphoid neoplasm diagnosis and treatment. Seven (4%) patients had plasma cell dyscrasias (PCD; 3 with monoclonal gammopathy of undetermined significance(MGUS) and 4 with multiple myeloma (MM)); 57% (n=4) were male, with a median age of 61.3 yrs (range, 41.4-83.8) at PCD diagnosis. Subtypes of MGUS included IgG Kappa (n=2) and IgG Lambda (n=1), subtypes of MM included IgG Kappa (n=2), IgA Kappa (n=1), and Kappa light chain only (n=1). DDX41MT-GPS genotypes were pathogenic in 28.6% (n=2, G67Vfs*13, G313S) and VUS in 71.4% (n=5, A555T, R164W, Q246E x2, M307T). All patients with MM (n=4) received an autologous stem cell transplant, with 3 (75%) being subsequently diagnosed with a t-MN; median 3.6yrs after PCD diagnosis (range, 3.2-12.3). Seventeen percent (n=31) had visceral malignancies; 2.8% (n=5) having >1malignancy, 61% (n=19) male, 93.5% (n=29) Caucasian and 6.5% (n=2) Hispanic. Prostate cancer was most common (n=8, 4.6%), followed by breast (n=7, 4.0%), colon (n=5, 2.9%), squamous cell carcinoma (n=4, 2.3%, 3 of the head/neck and 1 of the leg), bladder (n=4, 2.3%), testicular (n=3, 1.7%), gynecologic (n=3, 1.7%), lung (n=2, 1.2%), thyroid (n=1, 0.6%) and pancreatic neuroendocrine tumor (PNET, n=1, 0.6%), respectively. The median age at first solid tumor diagnosis was 62.4 yrs (range, 10.9-81.9). DDX41MT-GPS was pathogenic in 64.5% (n=20, D140Gfs*2 x3, E113Kfs*14, G67Vfs*13, I396T, L283Cfs*21, M1I x4, M316Dfs*31 x2, p.M1?, P258L, Q368*, Q41* x2, R159*, R311*) and VUS in 35.5% (n=11, D30Y, H203Y, I215L, I337V, M155I, p.?, S289L, T13I, V318G, A555T). Of the 31 patients with visceral malignancies , 51.6% (n=16) were diagnosed with t-MN at a median of 4.9 yrs (range, 1.1-34.3) after malignancy diagnosis. While DDX41MT-GPS are clearly associated with an increased risk of myeloid neoplasms, we demonstrate potential associations with other neoplasms, especially lymphoproliferative disorders (10%). We for the first-time report associations with PCD (4%) and visceral malignancies (17%) and also highlight a worrisome trend for t-MN in DDX41MT-GPS treated with genotoxic agents. Given limitations of a retrospective analysis, this study underscores the need for a comprehensive natural history study in patients with DDX41MT-GPS .

Background The prognostic relevance of TP53 mutations (TP53MT) in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) has been extensively studied and the information accessed for defining the new International Consensus Classification (ICC) category of “myeloid neoplasms with mutated TP53” (Blood 2022;140:1200). The latter designation requires ≥10% TP53 variant allele frequency (VAF) for AML and MDS/AML and in case of MDS, multi-hit TP53 or ≥10% VAF associated with complex karyotype (CK). We examined the prognostic relevance of TP53MT in myeloproliferative neoplasms (MPN), specified by subtype and disease stage. Methods The current study was conducted under an institutional review board approved minimum risk protocol. Additional informative cases from the University of Florence, Italy and the South Australian Myeloid Neoplasm Registry were included. Diagnostic criteria and assignment of TP53 allelic state were according to the ICC. Next-generation sequencing (NGS) and cytogenetic studies were performed according to institutional standard protocols. Conventional statistical methods were employed. Survival analyses were censored for allogeneic stem cell transplantation (ASCT) and were calculated from the time of first detection of TP53MT. Results 115 patients with MPN and documented pathogenic TP53MT were considered (median age 68.5 years). ICC-defined subtype designations, at time of TP53MT detection, were polycythemia vera (PV) or essential thrombocythemia (ET) (N=9), chronic phase myelofibrosis (MF-CP; N=63), accelerated phase MPN (MPN-AP; N=16), and blast phase MPN (MPN-BP; N=27). Driver mutation distribution was JAK2 64%, CALR 18%, MPL 8%, and triple-negative 10%. Karyotype was monosomal (MK) in 42%, CK 9%, and normal (NK) 35%. Frequent co-mutations were ASXL1 (28%), TET2 (14%), and SRSF2 (14%). TP53MT were classified as ICC-defined multihit in 67 (58%) cases; karyotype in the latter was MK (58%), CK (16%), non-MK/CK (13%), or NK (13%). TP53 VAF was ≥50% in 27 (24%) patients and <10% in 25 (22%). TP53MT included one (N=96) or ≥2 (N=19). MPN subtype- and stage-specific distributions for multihit TP53MT were 91% for MPN-BP, 88% MPN-AP, 44% MF-CP, and 0% ET/PV. In order to examine disease subtype- and stage-specific prognostic contribution of TP53MT, the study population was divided into 10 operational groups: 1) PV/ET non-multihit/non-MK/CK (N=8; VAF range 3-32%); 2) MF-CP non-multihit/non-MK/CK with TP53MT VAF <10% (N=10); 3) MF-CP non-multihit VAF ≥10% and non-MK/CK (N=11); 4) PV/ET/MF-CP non-multihit with MK/CK (N=5); 5) MF-CP multihit/non-MK/CK (N=8); 6) MF-CP multihit and MK/CK (N=20); 7) MPN-BP/AP non-multihit/non-MK/CK (N=2); 8) MPN-BP/AP non-multihit with MK/CK (N=2); 9) MPN-BP/AP multihit/non-MK/CK (N=9); and 10) MPN-BP/AP multihit with MK/CK (N=30). The corresponding median survivals were “not reached”, 55, 42, 6, 18, 10, “not reached”, 4, 4, and 6 months (p<0.01). Survival was similar between groups 1, 2, and 3 (p>0.2 for all comparisons) now referred to as “PV/ET/MF-CP non-multihit/non-MK/CK (N=39)”. Survival was similarly dismal for groups 8, 9, and 10 (p values > 0.3 for all comparisons) now referred to as “MPN-BP/AP with or without multihit TP53MT or MK/CK (N=43)”. Survival was also similar between groups 4, 5, and 6 (p values >3 for all comparisons) now referred to as “PV/ET/MF-CP with multihit TP53MT or MK/CK (N=33)”. The three consolidated groups were subsequently compared for survival that showed a significantly worse outcome for “MPN-BP/AP with or without multihit TP53MT or MK/CK” with median survival of 4 months, compared to 12 months for “PV/ET/MF-CP with multihit TP53MT or MK/CK” (HR 2.3; 95% CI; 1.3-3.9) and 55 months for “PV/ET/MF-CP non-multihit/non-MK/CK” (10.9; 95% CI 5.3-22.4); survival in the latter two groups was also significantly different, in favor of PV/ET/MF-CP non-multihit/non-MK/CK (HR 4.8; 95% CI 2.3-10.1). Conclusions: The presence of multi-hit TP53MT or MK/CK, in MF-CP, and possibly in ET/PV, warrants their inclusion in the ICC category of “myeloid neoplasms with mutated TP53”. By contrast, non-multihit TP53MT in ET/PV/MF-CP, regardless of VAF and in the absence of MK/CK, does not appear to compromise short-term survival. The observations from the current study also suggest a prognostic hierarchy with blast percentage being the most unfavorable, followed by MK/CK and multihit TP53MT.

Introduction Symptom burden in myeloproliferative neoplasms (MPN) is quantified using total symptom scores (TSS) calculated from the patient-reported scores for clinically meaningful symptoms. The impact of demographic, clinical, and laboratory features on these symptoms remains unclear and warrants further investigation. Methods Patients with polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) were identified from the retrospective chart review. TSS, scores of individual symptoms (fatigue, early satiety, abdominal discomfort, inactivity, concentration difficulties, fever, night sweats, itching, bone pain, weight loss), demographic characteristics (race, ethnicity, age, and gender), clinical features (time since diagnosis, depression status, obesity status), laboratory results and season at the time of visit when the first TSS assessment was performed were recorded. Multicollinearity and homoscedasticity were assessed using variance inflation factors and visual inspection of the data, respectively. A multivariable regression analysis was performed using a robust variance estimator. A p-value <0.05 indicated a statistically significant association with the symptom scores. Results The chart review identified 557 (PV: 201; ET: 191; MF: 165) patients. The median age of patients with PV, ET, and MF was 65 (range: 27-93), 65 (20-96), and 69 (27-96) years, respectively. Most patients were white (PV: 92%; ET: 90%; MF: 93%) and non-Hispanic or Latino (PV: 93%; ET: 96%; MF: 92%). Most patients with PV and ET were female (PV: 51%; ET: 73%), while most patients with MF were male (55%). Among the included patients 22% (PV: 21%; ET: 27%; MF: 18%) had the diagnosis of depression at the time of the clinical visit. TSS was highest in MF (mean (SD): 18.1±14.6), followed by PV (15.7±14.5) and ET (15.1±14.0) patients. Fatigue was the most reported symptom by the patients (PV: 81%; ET: 82%; MF: 84%), whereas weight loss was the least reported symptom (PV: 4.5%; ET: 6.3%; MF: 16%). With regards to the TSS multivariable regression analysis showed that age (beta coefficient: 0.2; p=0.01), depression (7.2; 0.008), and low hemoglobin (1.2; 0.003) in PV, depression (11.7; 0.001) in ET, and depression (9.5; 0.001), splenomegaly (6.9; 0.01), and WBC count (0.16; 0.048) in MF patients were significantly associated with TSS. In terms of individual symptoms in PV, depression was associated with fatigue (beta coefficient: 1.31; p-value: 0.01) and concentration difficulties (1.7; <0.001), high WBC count was associated with early satiety (0.09; 0.03), and non-white race was associated with fever (1.4; 0.007). In ET, depression was associated with fatigue (1.6; <0.001), abdominal discomfort (1.4; <0.001), inactivity (2.5; <0.001), concentration difficulties (2.4; <0.001) and night sweats (1.4; <0.001), anemia was associated with fatigue (1.2; 0.03), fewer months since diagnosis was associated with inactivity (0.01; 0.02) and young age was associated with bone pain (0.02; 0.03). In MF, depression was associated with fatigue (1.8; 0.001), concentration difficulties (1.3; 0.01), fever (1.1; 0.02), and night sweats (2.2; 0.03), low hemoglobin was associated with fatigue (0.46; <0,001) and early satiety (0.31; 0.003), high WBC count was associated with fatigue (0.03; 0.04) and early satiety (0.04; 0.02), low platelet count was associated with abdominal discomfort (0.002; 0.03), splenomegaly was associated with inactivity (2.27; 0.003) and female gender was associated with itching (0.57; 0.01). Conclusions This study demonstrates that depression in PV and ET and depression, low hemoglobin, and a high WBC count in MF contribute to multiple symptoms seen in these patients. Identifying demographic groups at risk of a higher symptom burden and addressing the comorbidities that drive symptoms, in addition to disease-directed therapy, is crucial to improving the quality of life in these patients.

Background TP53-mutant (mt) myelodysplastic syndromes (MDS) are high-risk (HR) neoplasms, with high rates of AML progression and suboptimal response to hypomethylating agents (HMA). Given the lack of effective therapies for HR-MDS, azacitidine (AZA) was combined with venetoclax (VEN) in a phase Ib MDS study demonstrating safety and early efficacy (Garcia et al. ASH abstract 2023). We retrospectively sought to explore clinical outcomes comparing VEN + HMA, to HMA alone in TP53mt HR-MDS. Methods Among 221 TP53mt MDS pts treated at the Mayo Clinic between January 2007 and April 2024, we reviewed outcomes of pts who received HMA alone (n=98) or HMA+VEN combination (n=34) as their first-line chemotherapy regimen. MDS diagnosis was based on the 5th edition of WHO classification of hematolymphoid tumors (Khoury et al. Leukemia 2022). Responses were assessed according to the International Working Group 2006, MDS response criteria (Cheson et al Blood 2006). Results Baseline characteristics and response The median age (years [yrs]) was 65 (R,37-80) and 70 (range [R], 19-87) yrs in the HMA + VEN and HMA alone groups (gps) (p= 0.42), respectively. The median bone marrow (BM) blast % (9.5 [R, 0-18] vs 5 [R, 0-16], p= 0.01) and TP53 variant allele frequency (VAF) (42 [R, 6-96] vs 37 [R, 2-94], p= 0.03) were significantly higher in HMA + VEN compared to HMA gps, respectively. However, proportion of pts with biallelic (BA)/multihitTP53mt (85% vs 79%, p= 0.61) and complex cytogenetics (CG) (85% vs 81%, p= 0.85) were not different between HMA + VEN and HMA alone gps. The distribution of pts with frequently occurring myeloid co-mutations (ASXL1, TET2, DNMT3A, RAS, BCOR and splicing factor) were not significantly (NS) different between the two gps. IPSS-M scores were assessed in 108 (83%) pts; HR/very HR-MDS as per IPSS-M were NS different between HMA + VEN and HMA gps (100% vs 91%, p= 0.12). While the overall response rate (ORR) (76% vs 49%, p= 0.01) and marrow complete remission (mCR) rates (21% vs 7%, p= 0.05) were higher with HMA+VEN compared to HMA, CR rates were similar (17% vs 12%, p= 0.47). Higher proportion of pts were bridged to allogeneic stem cell transplantation (allo-HCT) (41% vs 20%, p= 0.02), while AML progression rates (29% vs 31%, p= >0.99) were comparable between HMA + VEN and HMA gps, respectively. The non-relapse mortality (NRM) at day 60 (3% vs 3%, p=0.96) and day 90 (3% vs 4%, p=0.75) were comparable between HMA + VEN and HMA gps, respectively. RFS and OS The median follow-up from the time of initiation of HMA or HMA + VEN was 9.7 months (mo) (R, 0.3-90.6). The median RFS (8.47 vs 9.90 mo, p= 0.83) and OS (16.33 vs 14.20 mo, p= 0.66) from the time of initiation of therapy were comparable between the two gps. Similarly, among transplanted pts, there was no OS difference between HMA (21.7 mo) and HMA + VEN (18.43 mo) gps, respectively (p= 0.72). Comparable results for OS and RFS were obtained in both gps after censoring pts at the time of allo-HCT. Multivariable analysis for RFS and OS We conducted multivariable analysis (MVA) for RFS and OS using baseline variables that were significant/ trended towards significance (p<0.1), on univariate analysis (UVA) censored at the time of allo-HCT. Achieving ORR (HR; 0.30, 95% CI: 0.14-0.62, p= 0.001) retained significance for better RFS in MVA. Interestingly CR (HR; 1.74, 95% CI; 0.63-4.77, p= 0.28), BA TP53mt (HR; 1.27, 95% CI; 0.13-11.72, p= 0.83) and complex CG (HR; 1.52, 95% CI 0.16-14.03, p= 0.70) did not retain significance for RFS in MVA. In MVA for OS, achievement of ORR (HR; 0.56, 95% CI; 0.30-1.05, p=0.07) and CR (HR; 0.32, 95% CI; 0.09-1.11, p=0.071) trended towards favorable OS. BA TP53mt status (p= 0.42) and complex CG (p= 0.19) did not significantly impact OS in UVA. Conclusion We conclude that while HMA+VEN combination therapy in comparison to HMA monotherapy led to improved response rates, with higher percentage of pts being bridged to allo-HCT, this was not associated with reduced risk of AML transformation, or improved RFS/OS. We eagerly await results from the prospective randomized trial of VEN + AZA in treatment-naïve HR-MDS (VERONA).

Background: While myeloproliferative neoplasms (MPN), including essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (MF), are usually sporadic, adult-onset neoplasms, an increasing number of germline risk alleles have been described (e.g. EGLN1, ETV6, SH2B3, and ATM) in these disorders. DDX41MT Germline Predisposition Syndrome (GPS) is the most common myeloid GPS in adults and while there is extensive data on MDS/AML, little is known regarding MPN occurring in this context. We carried out this study to define the prevalence and characteristics of DDX41MT-GPS associated MPN. Methods: After IRB approval, we retrospectively assessed the Mayo Clinic cohort of 174 patients with DDX41MT-GPS, which included both pathogenic and clinically relevant germline variants of undetermined significance (VUS), based on our previous analysis (Badar et al Haematologica 2023). Standard statistical measures were applied. Results: We identified 12 (6.9%) patients with MPN (ET-5, PV-2, PMF-4, MPN-NOS-1). The median age at MPN diagnosis was 61.2 years (range, 8.-70.4); 58.3% (n=7) were male, and 83.3% (n=10) were Caucasian. A family history of hematologic malignancy was present in 16.7% (n=2, AML and T-LGL), while 50% (n=6) had a family history of visceral malignancies and 41.7% (n=5) had no family history of malignancies. Among ET patients (n=5) with DDX41MT-GPS, JAK2V617F was the MPN driver in 4 (80%) while type 1-CALR (L367fs*46) was a driver in 1 (20%). This included a 9-year-old child diagnosed with JAK2V617FMT ET. The DDX41 variant was classified as pathogenic in 40% (n=2; E113Kfs*14, D140Gfs*2) and VUS in 60% (n=3; V544L, V591I, P38L). Bone marrow (BM) aspirates in the ET patients were hypercellular in 40% (n=2), normocellular in 40% (n=2) and hypocellular in 20% (n=1), and none had increased blasts, or reticulin fibrosis (RF). In addition to JAK2V617F, somatic mutations seen included SF3B1 (K666T, VAF 16%) in 1 patient and IDH2 (R140Q, VAF 6%) and DNMT3A (R882H, VAF 7%) in 1 patient, respectively. With a median follow-up from diagnosis of 3.9yrs (range 2.9-8.9), there were no thrombotic events and no disease progressions was documented. There were 2 patients with JAK2V167FMT PV in whom the DDX41MT were clinically significant VUS (c.138+5G>T and M155I). Both patients had hypercellular BM, with no increase in blasts, no RF, normal karyotypes and no additional somatic mutations. With a median follow up of 7.5yrs (range, 2.1-12.9), 1 patient developed a deep vein thrombosis (DVT) and there were no fibrotic or leukemic transformations. There were 4 patients with PMF; 3 (75%) with JAK2V617F and 1(25%) with a type 1-CALR driver mutation (L367fs*46). DIPPS-plus scores ranged from 1 to 4 (median 2.5). The DDX41 variants were pathogenic in 50% (n=2, E256K and P78Qfs*3) and VUS in 50% (n=2, P510S and M155I). The median grade of RF at PMF diagnosis was grade 2 (range, 2-3). BM were hypercellular in 75% (n=3) and hypocellular in 25% (n=1), and 1 patient had 3% peripheral blasts (and no BM blasts). Somatic co-mutations included TET2 in 1 patient with a JAK2V617F, and CBL, EZH2 and SRSF2 in 1 patient with a CALR driver-mutation, respectively. PMF patients were treated with ruxolitinib (n=3), stem cell transplant (n=1), and pIFNα (n=1). With a median follow up of 3.9yrs (range,1.1-21.9), all patients were alive, and none had leukemia transformation. There was 1 patient with a JAK2V617F MPN-NOS with trisomy 9, where the DDX41MT-GPS was a VUS (I215L). There were no somatic co-mutations and at last follow up (3.1 years), there was no evidence for progression. Conclusions: While associations between late onset MDS/AML and DDX41MT-GPS has been well established, we systematically describe the MPN landscape seen in this context. MPN was diagnosed in 7% of our cohort, with JAK2V617F being the most common driver mutation. Most importantly, unlike in AML/MDS, where somatic DDX41 mutations are frequently associated with neoplastic transformation (30-50%; R525H being most common), none of our MPN patients had a somatic DDX41 mutation. Our work underscores the importance of germline mutation testing in patients with MPN.

Background Pacritinib (PAC) is a relatively selective JAK2 vs. JAK1 inhibitor (JAKi) and is one of four FDA-approved JAKi for use in myelofibrosis (MF). PAC is indicated for MF patients with thrombocytopenia (Platelets <50 x 109/L). In a previously published controlled study of MF patients with platelet count <100 x 109/L (PERSIST-2), including JAKi-naïve and ruxolitinib-experienced, PAC therapy at the recommended dose of 200 mg BID was associated with a ≥35% spleen volume reduction rate of 22%; response rate was lower in ruxolitinib-experienced patients for both 200 mg BID (9.3%) and 100 mg BID (1.8%) dosing (JAMA Oncol 2018;4:652); a more recent post-hoc analysis suggested an additional benefit in anemia with 25-37% of transfusion-dependent patients achieving a ≥12-week transfusion-free period (Blood Adv 2023;7:5835). Herein, we describe our experience with the drug outside of a clinical trial setting. 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 documentation of PAC therapy outside of a clinical trial setting. Spleen response was adjudicated by the 2013 International Working Group-European LeukemiaNet (IWG-ELN) response criteria (Blood 2013;122:1395). Anemia response was rated by the revised 2024 IWG-ELN criteria (manuscript submitted; transfusion-free period x 12 weeks and/or 12-week average increase in hemoglobin ≥1.5 g/dL). Conventional statistical methods were employed. Results A total of 60 MF patients (median age 70 years; males 62%; primary MF 63%) received PAC upfront (N=19; 32%) or after failing treatment with another JAKi (N=41; 68%), including ruxolitinib (N=39; 65%): JAK2 60%, CALR 27%, MPL 10%. Reasons for discontinuation of previous JAKi treatment included drug intolerance (41%), relapse after initial response (33%), and suboptimal response (26%). Median interval between diagnosis and treatment with PAC was 4 years (range 0-22). At PAC treatment initiation, DIPSS-plus risk distribution was high in 48%, intermediate-2 47%, and intermediate-1 (5%). Transfusion-dependent anemia (TDA; ≥3 units during 12 weeks prior to enrollment) was present in 40% of patients, platelet count <50 x 109/L 25%, leukocyte count >11 x 109/L 40%, spleen size >15 cm 76%, constitutional symptoms 55%, complex/monosomal karyotype 27%, and mutations in SRSF2 11% or ASXL1 33%. PAC initial dose was 100 (N=41) or 200 (N=19) mg BID. Dose was increased in 44% of patients started at 100 mg BID and decreased in 55% of those started at 200 mg BID. Among 47 patients evaluable for anemia response, only one of 23 with non-TDA (2% overall and 4.3% at 200 mg BID dosing) and none of 24 with TDA responded. In evaluable patients, spleen response rate was 13% (95% CI 5.9-24.7) overall and higher in JAKi-naïve (29%; 95% CI 11.7-54.7) vs. JAKi-experienced (6%; 95% CI 1.6-19.1; p=0.04). Spleen response rate was higher in the absence of leukocytosis (21% vs. 0%; p=0.01) or complex/monosomal karyotype (17% vs. 0%; p=0.05) but similar between 100 and 200 mg BID initial dosing (p=0.9). At a median follow-up of 14 months (range 1-27), PAC was discontinued in 80% of the patients: intolerance 58%, suboptimal response 54%, transition to allogeneic stem cell transplants (ASCT) 10%. Major side effects were more frequent with 200 vs. 100 mg BID dose and included diarrhea 43%, nausea/vomitting 17%, dyspnea 25%, peripheral edema 28%, allergic reaction 13%, grade 3/4 neutropenia 22%, and grade 4 thrombocytopenia 34%. Up to the time of this writing, 17 deaths (28%), 11 (18%) ASCT, and 3 (5%) leukemic transformations were documented. In multivariable analysis, post-PAC survival was adversely affected by TDA (HR 11.9; p<0.01), platelet count <50 x 109/L (HR 7.4; p<0.01), and SRSF2/ASXL1 mutations (HR 10.7; p<0.01), all independent of ASCT, which was independently associated with longer survival (HR 9.0; p<0.01). Conclusions: The observations from the current real-world study, regarding the moderate activity of PAC for reducing spleen size, are consistent with those of the aforementioned controlled clinical trial (PERSIST-2). However, despite recent suggestions of the drug's mechanistically unique erythropoietic activity, the anemia response rate seen in the current study was underwhelming.

Introduction Prognostication in myelofibrosis (MF) currently relies on manual assessment of clinical, pathological, and laboratory variables, which is inefficient and error-prone. The potential of large language models (LLMs) and rule-based programming to automate data extraction and prognostication in these patients remains unexplored and merits investigation. Methods Patients with MF were identified from a retrospective chart review. Data regarding clinical (age, constitutional symptoms, transfusion requirements), laboratory (hemoglobin, circulating white blood cell, platelet, and blast counts), and pathological (grade of bone marrow fibrosis, chromosomal analyses, cytogenetics) features was extracted from the latest free-text clinical notes and pathology reports using the generative pretrained transformer-4 (GPT-4) model in a zero-shot setting with the prompting parameters set to generate deterministic responses. The patients were randomly sampled into development (15%) and test (85%) sets, with the documents of patients in the development set used for iterative prompt engineering. The finalized prompts were used for data extraction in the test set. Rule-based programming was used for post-processing of the extracted data and ascertaining prognosis via Dynamic International Prognostic Scoring System (DIPSS), DIPSS-plus (DIPSS+), and Mutation-enhanced International Prognostic Scoring System-70 (MIPSS-70). Automatically extracted data and prognostic categories were compared with the manually generated human annotations. Mean accuracy, precision, and recall with 95% confidence intervals (CI) were computed. Detailed error and sensitivity analyses were conducted to assess performance. Results The study included 100 patients (development: 15; test: 85) with 100 clinical notes (development: 15; test: 85) and 90 pathology reports (development: 13; test: 77). The mean age of these patients was 70 (SD: 10.6); 55 (55%) patients were men, and 93 (93%) patients were White. In the development set, the mean accuracy, precision, and recall for data extraction from clinical notes were 94% (95% CI: 90-98%), 92% (84-99%), and 99% (97-100%). For data extraction from pathology reports, the mean accuracy, precision, and recall were 96% (93-100%), 98% (92-100%), and 83% (63-100%). For prognostication, the mean accuracy, precision, and recall were 87% (79-94%), 80% (73-87%), and 100% using DIPSS (accuracy: 80%; precision: 73%; recall: 100%), DIPSS+ (accuracy: 93%; precision: 83%; recall: 100%) and MIPSS-70 (accuracy: 87%, precision: 83%; recall: 100%). In the test set, the mean accuracy, precision, and recall for data extraction from clinical notes were 96% (95% CI: 93-98%), 91% (87-96%), and 98% (97-100%). For data extraction from pathology reports, the mean accuracy, precision, and recall were 95% (92-98%), 93% (87-99%), and 90% (80-100%). For prognostication the mean accuracy, precision, and recall were 95% (94-96%), 89% (88-90%) and 99% (96-100%) using DIPSS (accuracy: 94%; precision: 89%; recall: 100%), DIPSS+ (accuracy: 95%; precision: 88%; recall: 95%) and MIPSS-70 (accuracy: 94%, precision: 90%; recall: 100%). Error analyses identified incorrect extractions by GPT-4 were related to the circulating blasts and constitutional symptoms variables from the clinical notes. Sensitivity analyses excluding the associated variables improved overall accuracy from 94% to 97% and 96% to 97% in the development and test sets, respectively. Similarly, incorrect extractions from the pathology reports were related to the CALR gene mutation variables. Sensitivity analyses excluding the associated variables improved the overall accuracy from 96% to 98% and 95% to 97% in the development and test sets, respectively. Conclusion LLMs and rule-based programming can accurately extract data from the electronic health records and prognosticate MF patients via DIPSS, DIPSS+, and MIPSS-70. The automated approach could significantly streamline clinical and research workflows, providing an efficient and less resource-intensive alternative to manual prognostication.