Blood Cancer Journal

Background: Multiple myeloma (MM) progression is accompanied by remodeling of the bone marrow immune microenvironment. Local interactions among malignant plasma cells, stromal cells, myeloid cells, and immune cells not only support tumor cell survival, expansion, and immune escape, but are also closely associated with disease progression, therapeutic response, and clinical prognosis. Moreover, T cell exhaustion is a common T cells dysfunction in MM and limited efficacy of T cell-targeting therapies. However, the in situ organization and clinical significance of exhausted T cells in MM patients bone marrow remain insufficiently understood. Methods: In this study, we analyzed bone marrow Xenium 5K spatial transcriptomics data from control (Ctrl), monoclonal gammopathy of undetermined significance (MGUS), smoldering myeloma (SM), and MM samples. After canonical multi-sample integration and celltype annotation, we used Gaussian mixture model (GMM)-based spatial partitioning, and multilayer perceptron (MLP) machine learning for systematic characterization the T cell microenvironment in MM bone marrow. Results: Our results showed that exhaustion-like T cells increased during MM progression and formed spatially discrete T cell-enriched regions in the bone marrow, which we defined as exhaustion-like bone marrow T cell islands (eBM-TIs). These niches were mainly characterized by enhanced T cell-plasma cell communication associated with upregulated Galectin signaling. Pseudobulk analysis further showed enhanced IFN-related signaling in eBM-TIs, accompanied by upregulation of CXCR3 ligands such as CXCL9 and CXCL10, suggesting that the IFN-CXCL9/10 axis may contribute to T cell chemotaxis, maintenance of chronic inflammation, and formation of exhaustion-like states. By transferring spatial niche labels to scRNA-seq cohorts with available clinical staging information using MLP, we further found that the proportion of eBM-TI-like T cells was associated with higher disease risk and unfavorable prognostic outcomes. Conclusions: In summary, this study identifies eBM-TIs as a spatial niche in the MM bone marrow. These niches represent an important immune unit linking chronic inflammation, T cell exhaustion, and clinical risk, and may serve as a potential biomarker of MM disease progression.

Background CD19-directed CAR-T cell therapy can induce durable remissions in chronic lymphocytic leukemia (CLL), but response rates are lower than in other B-cell malignancies, in part because CLL is characterized by T-cell dysfunction, defective immune synapse formation, and impaired target-cell co-stimulation. Lenalidomide is an immunomodulatory drug with the potential to act on both sides of the CAR-T/CLL interface by improving T-cell fitness and modifying malignant B-cell susceptibility to immune engagement. Methods We are conducting an open-label, non-randomized phase I/II clinical trial VTB-CLL002 (ClinicalTrials.gov identifier: NCT06762431) evaluating the safety and efficacy of CD19 CAR-T cell therapy combined with concomitant lenalidomide in patients with relapsed or refractory CLL and small lymphocytic lymphoma followed by lenalidomide maintenance. The primary endpoint was safety. The secondary endpoint included overall response rate (ORR), complete response (CR), progression-free survival (PFS) and overall survival (OS). Results Twelve patients were treated. The median age was 60 years and the median number of prior lines of therapy was 2. All patients were BTK inhibitor-naive, and all had measurable disease at the time of infusion. CAR-T manufacturing was successful in all patients. All treated patients achieved complete remission, with a median time to response of 1 month. CAR T-cells expansion was observed in all patients, with a median peak expansion of 137 cells/L and a median time to peak expansion of 14 days. CAR T-cells remained detectable at the last follow-up in all patients, with persistence documented up to 24 months. At dose levels 2-3, eight of nine patients had ongoing MRD-negative responses at the time of analysis. Toxicity was clinically meaningful. Cytokine release syndrome (CRS) occurred in all patients, with severe CRS observed in 2 of 12 patients. ICANS occurred in 5 of 12 patients, including severe ICANS in 4 of 12 patients. One patient developed late grade 4 ICANS temporally associated with lenalidomide reintroduction and secondary CAR-T expansion. Early and late immune effector cell-associated hematotoxicity were common. In mechanistic studies, lenalidomide enhanced CAR-T proliferation and cytotoxicity, shifted CAR-T cells toward effector-associated phenotypes, reduced selected exhaustion markers during repeated antigen challenge, and increased IL-2 and IFN-{gamma} secretion. Lenalidomide also increased CAR-T/CLL conjugate formation and upregulated CD54/ICAM-1 on CLL target cells without broad induction of CD80, CD86, or CD40, consistent with improved adhesive target-cell engagement rather than classical co-stimulation. Transcriptomic profiling supported enhanced Th1/cytotoxic and T-cell activation-associated programs with lower T reg -associated genes in lenalidomide-treated CAR-T cells. Conclusions Lenalidomide-augmented CD19 CAR-T therapy demonstrated strong early clinical activity in relapsed/refractory CLL, characterized by deep responses, durable CAR-T persistence, and substantial incidence of immune effector-associated toxicities. These findings support further evaluation of lenalidomide as a rational CAR-T partner in CLL and suggest that its activity may involve both improved CAR-T fitness and enhanced target-cell engagement. Future studies should optimize lenalidomide timing and dosing to preserve response depth while reducing delayed immune-effector toxicity.

LZTR1 negatively regulates RAS family proteins via proteasomal degradation. Germline loss-of-function variants cause Noonan syndrome, with emerging evidence implicating LZTR1 in predisposition to childhood acute lymphoblastic leukemia (ALL), though its role in hematopoiesis remains poorly defined. Screening 1,587 children with ALL identified LZTR1 variants in 44 patients (2.8%). Germline variants were detected in 32 patients (2.0%), a frequency comparable to that observed in the general population (1.75%; 1,925/110,017; p=0.50). Somatic LZTR1 alterations were identified in 22 patients (1.4%) and were predominantly bi-allelic, arising through either a germline-plus-somatic or dual somatic configuration. They persisted at relapse. Despite enrichment in favorable-risk subtypes (ETV6::RUNX1, high-hyperdiploid, ERG/DUX4), bi-allelic LZTR1-mutated cases showed delayed minimal residual disease clearance and higher late relapse risk, identifying a subgroup unsuitable for treatment de-escalation. LZTR1 expression was increased in most wild-type leukemias, consistent with a compensatory response to aberrant RAS pathway activation. Bi-allelic LZTR1 inactivation abolished RAS regulation, leading to deregulated canonical RAS expression and ectopic expression of the non-canonical RIT1 protein, whose involvement in ALL has not previously been reported. These findings establish LZTR1 as a classical tumor suppressor in ALL via a two-hit model. Monoallelic alterations show insufficient signaling perturbation and low germline penetrance, whereas bi-allelic inactivation acts as a driver event linked to a high risk of late relapse despite favorable genomics.

Chemotherapy-induced peripheral neuropathy (CIPN) is a common neurotoxicity of cancer treatment with limited diagnostic, monitoring, and treatment options. Neurofilament light chain (NfL) is an axonal cytoskeletal protein released during neuroaxonal injury and a promising biomarker of CIPN, but prospective evidence for NfL as a marker of CIPN from vincristine-containing lymphoma chemotherapy treatment remains limited. To fill this gap, we conducted a pragmatic single-center prospective observational cohort study of adults with non-Hodgkin lymphoma (NHL) receiving first-line vincristine-containing chemotherapy to evaluate NfL dynamics across multiple pre-cycle visits and assess 68 relationships with patient-reported and clinician-graded neuropathy measures. We followed 25 participants during 4-6 months of chemotherapy, and a small subset of those participants (n=6) for 24-42 months post-chemotherapy. Serial plasma NfL was measured and CIPN symptoms were assessed using patient- and clinician-reported measures. Longitudinal changes were analyzed using mixed-effects models. Plasma NfL increased relative to pre-cycle1 at all timepoints (all p<0.001), increasing more than threefold by pre-cycle4. Patient-reported CIPN scores and clinician-graded neuropathy also increased during treatment. Exploratory pooled visit-level analyses showed a modest NfL-CIPN association (Spearman {rho}=0.393, p=0.004), while timepoint-specific, lagged, and post hoc sensitivity analyses suggested potential to predict persistent CIPN symptoms from early NfL concentrations. To our knowledge, these findings provide the first prospective evidence that NfL is sensitive to vincristine exposure in adults with NHL and may complement patient-reported symptom assessment, clinician grading, and dose-modification context in future CIPN monitoring studies.

Hematologic malignancies are diagnosed through a fragmented, sequential workup of morphology, immunophenotyping, cytogenetics, and molecular testing that can take days to weeks and is unavailable at many centers. DNA methylation profiling has transformed central nervous system tumor diagnosis, yet hematologic classifiers have remained confined to narrow acute leukemia panels. Here we present Lamprey, a deep-learning methylation classifier spanning 86 hematologic malignancy entities, trained on a reference cohort of 8,544 patients and deployed directly from nanopore sequencing. A depth-aware training framework allows confident classification from the first minutes of a run. Against blinded integrated reference diagnoses across retrospective, external, and prospective cohorts, Lamprey exceeded 98% accuracy among classified cases. Lamprey reaches a confident call within minutes, and cost as little as $82 per sample. Lamprey consolidates a sequential diagnostic workup into a single, rapid, same-day molecular readout.

Impaired cellular differentiation is a defining characteristic of myeloid malignancies and remains a major therapeutic challenge. The BRG1/Brahma-associated factor (BAF) chromatin remodeling complex, through the ATPases SMARCA4 and SMARCA2, maintains the stemness of leukemic blasts and thus represents a promising target for novel differentiation-based therapies. In a phase 1 study in advanced myeloid malignancies, the first-in-class dual SMARCA4/2 inhibitor FHD-286 combined with decitabine (DAC) was tolerated and produced an objective response rate of 12.8% (6/47) compared with no responses with FHD-286 monotherapy. To understand the basis of this activity, we integrated high-dimensional flow cytometry and single-cell genomic analyses of longitudinal bone marrow samples from responders and nonresponders. While FHD-286 monotherapy was predominantly associated with myeloid differentiation, responders to FHD-286+DAC combination therapy exhibited a range of myeloid and erythroid differentiation trajectories. FHD-286 potentiated the transcriptional impact of DAC, driving tumor clones to fully differentiate out of the immunophenotypically and transcriptionally defined blast compartment. Responders had a baseline transcriptional profile similar to that of CEBPA-mutant acute myeloid leukemia and showed further downregulation of CEBPA upon treatment. These findings reinforce tumor cell differentiation as a mechanism of response to pharmacologic SMARCA4/2 inhibition and support further evaluation of FHD-286+DAC in molecularly defined patient subsets.

Molecular testing in hematology requires different assays for disease subgroup identification, risk stratification and selection of appropriate treatment regimens. Yet, molecular tests are not necessarily standardized between diagnostic laboratories, resulting in varying turnaround times and potentially divergent results. To resolve this issue and enable single-assay molecular testing, we have developed a hierarchical classification framework that combines epigenetic and genetic data from whole genome nanopore sequencing (WGNS) with machine learning to determine disease entities, epigenetic subgroups (epitypes) and genetic aberrations in hematopoietic neoplasms. We curated DNA methylation data from 5,420 samples and trained a classifier allowing entity-level diagnostics featuring 21 conditions, including healthy controls, acute and chronic myeloid and lymphoid neoplasms. This classifier was subsequently combined with entity-specific epitype classifiers predicting 44 therapeutically or prognostically relevant states, followed by integration of genetic data. Benchmarking of the combined (epi-)genetic testing strategy using WGNS confirmed high accuracy in the detection of diagnostic groups and risk stratification, and identified diagnosis-defining molecular alterations that were not reported by standard-of-care work-up.

Immune effector cell-associated neurotoxicity syndrome (ICANS) is a major complication after CAR T cell therapy, but its underlying mechanisms remain poorly understood. We performed longitudinal immune profiling of paired whole blood and serum samples from patients with relapsed or refractory diffuse large B cell lymphoma (DLBCL) treated with CD19 CAR T cells. At peak neurotoxicity, high-dimensional mass cytometry and serum proteomics identified the expansion of CD163 monocytes and immature CD10lowCD101low neutrophils correlated with elevated serum ST2 and IL-2RA concentrations. Integrative immune module analysis identified these features among the strongest predictors of ICANS severity. Independent single-cell transcriptomic profiling validated the emergence of immunoregulatory CD163 monocytes and identified CD177 as a biomarker of ICANS-associated immature neutrophils. Together, these findings reveal a coordinated myeloid inflammatory network associated with ICANS and nominate candidate biomarkers and therapeutic targets for improving the safety of CAR T cell therapy. Significance: We demonstrate that immunoregulatory CD163+ monocytes and immature, activated CD177hiCD10lowCD101low neutrophils emerge in patients with moderate to severe ICANS at peak toxicity following CD19 CAR T cell therapy. These findings identify an uncharacterized myeloid network potentially contributing towards ICANS pathogenesis.

Background. Diagnosis and risk stratification in rare hematologic malignancies such as myeloproliferative neoplasms (MPNs) - polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) - require expert review of longitudinal, heterogeneous clinical records. This process is cognitively demanding, inconsistently applied, and difficult to scale beyond tertiary centers. No automated phenotyping workflow currently exists for hematologic malignancies. Methods. A HIPAA-compliant large language model (LLM) framework for phenotyping MPN was developed to integrate (i) rule-based retrieval of bone marrow biopsy reports, clinical notes, and structured laboratory results from the electronic health record (EHR); (ii) zero-shot extraction of diagnostic and prognostic variables from unstructured text using GPT-4 Turbo; (iii) a clinician-informed source-prioritization algorithm to reconcile conflicting multi-source data; (iv) WHO/ICC-criteria-based diagnostic classification; and (v) NCCN-based risk stratification using the conventional risk model for PV, IPSET-thrombosis for ET, and DIPSS, DIPSS-plus, and MIPSS70/MIPSS70+ v2 for MF. Patients were identified via MPN-related ICD-9/10 codes; cases met 2017 WHO criteria or had a hematologist-documented diagnosis, and controls did not. The cohort was split into a prompt-development set (n = 60) and a held-out test set (n = 450; 75 cases and 75 controls per disease). Ground truth was established by independent dual-clinician chart review with consensus adjudication. LLM performance was evaluated against the ground truth: variable-level extraction using accuracy, F1 score, and Cohen's kappa; patient-level diagnostic classification using sensitivity, specificity, and Cohen's kappa; and prognostic risk stratification (among confirmed cases) using accuracy, weighted F1 score, and quadratic-weighted Cohen's kappa. Wilson 95% confidence intervals (CIs) were used for proportions and bootstrap 95% CIs with 500 resamples for F1 scores. Results. The held-out test set included 450 patients (PV: 150; ET: 150; MF: 150) with pathology reports and structured laboratory results, and 172 patients (PV: 52; ET: 55; MF: 65) with clinical notes. From pathology reports, overall variable extraction accuracy and F1 score were 99% (95% CI, 98-100) and 1.00 (0.99-1.00) for PV, 100% (99-100) and 0.99 (0.96-1.00) for ET, and 100% (99-100) and 0.99 (0.97-1.00) for MF. From clinical notes, overall accuracy and F1 score were 96% (91-100) and 0.94 (0.85-1.00) for PV, 100% (100-100) and 1.00 (1.00-1.00) for ET, and 100% (99-100) and 0.98 (0.95-1.00) for MF. Diagnostic sensitivity was 100% (95% CI, 95.1-100.0) for PV, ET, and MF; specificity was 98.7% (92.8-99.8) for PV and 100% (95.1-100.0) for both ET and MF, with Cohen's kappa of 0.99 for PV and 1.00 for ET and MF. Risk stratification accuracy was 100% with weighted F1 score of 1.00 and quadratic-weighted Cohen's kappa of 1.00 across all three diseases. A pre-specified source-ablation analysis showed that pathology reports alone were sufficient for diagnosis (sensitivity 98.7% for PV, 100% for ET, 96.0% for MF; specificity 100% across all three subtypes) but inadequate for prognostication (accuracy 69.3% for PV, 93.3% for ET, 77.3% for MF). Adding clinical notes to pathology reports recovered full prognostic accuracy of 100% across all three diseases. Conclusions. This first-in-class automated framework achieved expert-level performance for MPN diagnosis and risk stratification from real-world EHR data, establishing a foundation for scalable, standardized phenotyping in rare hematologic malignancies. Prospective, multi-site validation is warranted before clinical deployment.

Wilms tumor, i.e., nephroblastoma, is rare in adults and lacks standardized treatment, complicating clinical decision-making. Within the functional precision medicine study (DEDUCER), we profiled two spatially distinct tumor regions (T1 and T2) of an adult Wilms tumor patient using integrated histopathology, whole-exome sequencing, FFPE transcriptomics, and ex vivo drug screening of short-term cultured patient-derived cancer cells (PDCs) with 528 compounds. Genomic profiling revealed a truncal ASXL1 frameshift and shared F7, UBA1, COL21A1, and ATM variants alongside region-specific alterations: a TP53 mutation and broad copy-number (CN) gains in T1, versus ARID1A and KMT2D stop-gains in copy-neutral T2. Transcriptomics of tumor areas identified convergent activation of the G2/M checkpoint, E2F targets, and mitotic spindle programs across regions, consistent with high proliferation and partially comparable biomarker signatures to those observed in an open-source pediatric Wilms tumor dataset (n = 130). Functional assays uncovered distinct and shared drug vulnerabilities: although ATM alterations were present in both tumors, T1 PDCs showed selective sensitivity to topoisomerase I and BCL-2 inhibition in the context of an additional T1-specific TP53 alteration, while broader single-agent sensitivity and stronger drug synergies were observed in T2. Pathway-centric data integration indicated that differential gene expression and copy-number gains, rather than single mutations alone, better predicted ex vivo drug responses, revealing actionable shared dependencies despite pronounced spatial heterogeneity and establishing a translational framework for individualized management in this rare disease. HIGHLIGHTS- In the adult Wilms tumor, multi-region genomics revealed a truncal ASXL1 frameshift together with F7, UBA1, COL21A1 and ATM mutations across two tumor regions (T1 and T2), as well as region-specific alterations: TP53 mutation and widespread copy-number gains in T1, versus ARID1A and KMT2D stop-gains in copy-neutral T2, illustrating spatial heterogeneity. - Transcriptomics showed convergent activation of E2F targets, G2/M checkpoint, and mitotic spindle programs in both regions, consistent with high proliferation and aligning with Wilms tumor signatures (TARGET dataset); these pathways were associated with higher ex vivo drug sensitivity scores. - Functional drug sensitivity testing of patient -derived cancer cells ex vivo uncovered distinct and shared vulnerabilities: Although both tumors shared an ATM mutation, T1-specific TP53 alteration and death-pathway/stress-response alterations may underlie selective sensitivity to topoisomerase I inhibitors and BCL-2 inhibition. - Clinically relevant combinations, including vincristine plus dactinomycin and doxorubicin plus dactinomycin, showed ex vivo synergy. These findings are consistent with the patients more than five-year relapse-free outcome following vincristine, doxorubicin, and dactinomycin treatment combined with surgery, supporting the translational relevance of the ex vivo drug testing approach. - Pathway-centric integration (copy-number gains and differential expression) predicted drug response better than single-gene biomarkers. Overall, pathway-level dependencies provide robust, actionable targets despite genomic and phenotypic heterogeneity in adult Wilms tumor.

Background Graft versus host disease (GVHD) remains a major determinant of morbidity and mortality following allogeneic hematopoietic stem cell transplantation (allo HSCT). Existing GVHD prediction models demonstrate modest discrimination and limited generalizability, and calibration drift across external populations is rarely characterized despite its essential role in the clinical interpretability of predicted probabilities. Objectives To develop and externally validate an explainable machine learning framework for predicting acute and chronic GVHD and associated overall survival in patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and myelodysplastic syndromes (MDS) undergoing allo HSCT, and to systematically characterize calibration across heterogeneous external validation cohorts to inform deployment requirements. Study Design The model was developed on three publicly available registry-derived datasets (N = 2,509) and externally validated across six independent cohorts (N = 14,788) comprising adult and pediatric allo HSCT recipients, including a regional Middle Eastern cohort (UAE and Jordan). A standardized preprocessing pipeline harmonized heterogeneous datasets. Gradient boosting models (CatBoost) were used for binary GVHD prediction; exploratory overall survival analysis used a Cox proportional hazards model with predicted acute GVHD risk as a covariate. Discrimination (AUROC with bootstrap 95% CI), calibration (logistic recalibration intercept and slope with analytical 95% CI), and feature importance (SHapley Additive exPlanations, SHAP) were assessed in training out-of-fold and all external cohorts. Results In internal validation, AUROC was 0.63 (95% CI 0.61-0.65) for acute GVHD and 0.72 (95% CI 0.70-0.74) for chronic GVHD. External validation demonstrated AUROC ranges of 0.51-0.57 (acute) and 0.54-0.64 (chronic), with consistent performance across disease subgroups despite substantial heterogeneity in transplant practices and feature availability. In exploratory survival analysis, the acute-GVHD-informed Cox model achieved a training-cohort C-index of 0.679 (95% CI 0.658-0.697); external C-indices ranged from 0.47-0.53. Calibration analysis identified systematic external risk overestimation (negative calibration intercept in 10 of 11 evaluable external cohort-target combinations) with heterogeneous slope drift requiring cohort-specific recalibration. Key predictors included recipient age, graft source, conditioning intensity, GVHD prophylaxis, and HLA match ratio. Conclusions An explainable, externally validated GVHD prediction framework was developed using heterogeneous registry-derived datasets, with systematic characterization of calibration drift across multiple external cohorts, an analysis rarely reported in prior GVHD prediction literature. Predictive performance was modest for acute GVHD and moderate for chronic GVHD, constrained by missing immunobiological variables and incomplete HLA characterization. Per-cohort recalibration is required before clinical deployment, with prospective validation and benchmarking against established GVHD risk scores identified as priority next steps.

Background: Ewing sarcoma (EwS) is a highly aggressive bone and soft tissue cancer mainly affecting children, adolescents, and young adults. The rarity of the disease, relatively small cohort sizes of prior studies, and overall low mutational burden of EwS have limited the ability to establish robust correlations of genomic findings and clinicopathological factors. Methods: To overcome these limitations, we integrated genomic and clinical data from the seven major sequencing studies encompassing 538 EwS patients. Mutational profiles (SNV, indels and CNVs), and their correlation with clinicopathological features in the aggregated cohort were systematically analyzed to provide an integrated view of the EwS genomic landscape. Results: This study compiles the largest EwS genomic dataset reported to date. In the aggregated cohort (n=538) bone tumors were more common (65.4%) than soft-tissue tumors (34.6%), the latter being more frequent in older male patients and associated with poorer outcomes. EWSR1::FLI1 was the most prevalent fusion (87.2%). No major clinicopathological differences were identified between fusion types. The mutational landscape was dominated by STAG2 (15.6%) and TP53 (7.1%) alterations, associated with younger or with older age at diagnosis and poor survival, respectively. Strikingly, the coexistence of STAG2 and TP53 mutations, although rare (n=12), was associated with lethal outcome in all cases. CDKN2A loss (9.1%) was associated with older age, poor survival, and linked to a higher frequency of TP53-mutations in soft tissue EwS. Among frequent CNVs, gain of chr1q (25.2%) and loss of chr16q (21.9%) were per se frequently associated with fatal outcome and their co-occurrence further increased the risk of lethality. Conclusions: We delineate recurrent genomic alterations with important clinicopathological associations, including a uniformly lethal STAG2/TP53 co-mutation and CNV signatures marking aggressive disease. This comprehensive pooled analysis of EwS genomic studies provides a foundation for refined biological risk-stratification.

Myelofibrosis (MF) originates from the stepwise acquisition of somatic mutations in Hematopoietic Stem and Progenitor Cells (HSPCs). Alongside driver events triggering JAK-STAT pathway hyperactivation, several additional mutations, usually affecting the epigenetic machinery, contribute defining therapeutic response. Specifically, JAK-inhibition (JAKi) relieves MF symptoms but rarely eradicates the neoplastic clone. To elucidate clonal dynamics associated with JAKi, we conducted a longitudinal single-cell proteogenomic study on 6 responders and 6 non-responders MF patients. Mutational analysis revealed that the mutation acquisition order determines JAKi sensitivity. Indeed, driver-only clones are highly sensitive to JAKi, while co-mutated clones persist after treatment. JAKi response is mainly limited to the differentiated myeloid compartment, while mutant HSPCs are often maintained in JAKi-responders. Co-mutated clones may evade JAKi and outcompete other neoplastic cell populations, thus contributing to disease persistence.

Preclinical evaluation of chimeric antigen receptor (CAR)-T therapies for acute myeloid leukemia (AML) is limited by the lack of models that faithfully recapitulate the human bone marrow (BM) niche. Here, we implemented a humanized ossicle-based AML model that enables simultaneous engraftment of leukemic blasts and longitudinal assessment of responses to CAR-based immunotherapies. Intravenous or intra-ossicle injection of AML blasts produced robust, reproducible disease mimicking features of human AML within its microenvironment. To monitor tumor burden and immune effector cells in real-time, we developed a dual bioluminescence system using distinct luciferases in AML and CAR-T cells. This approach allowed non-invasive longitudinal tracking of CAR-T cell localization, expansion, persistence, and leukemic clearance within the ossicle. Overall, our model provides a powerful platform to study CAR-T cell behavior within a human BM niche and, for the first time, allows simultaneous longitudinal visualization of leukemic burden and CAR-T cell dynamics in a physiologically relevant ossicle-based AML model. TeaserHumanized ossicles combined with dual BLI enable tracking of AML progression and CAR-T cell dynamics in a human stromal niche.

Approximately 30% of patients with acute graft-versus-host disease (GVHD) develop steroid-refractory disease and have very poor outcomes. Ruxolitinib has become the standard of care for steroid-refractory acute GVHD, but it is unclear which patients derive benefit. The MAGIC Composite Score (MCS), an algorithm that combines clinical symptoms and biomarkers, has been validated to predict outcomes at the start of primary GVHD treatment. Here, we evaluated its performance at the initiation of second-line treatment in 278 patients. MCS stratified patients into three risk groups (MCS1-3), with the majority (88%) classified as intermediate or high risk. Increasing MCS score was associated with progressively higher 1-year non-relapse mortality (NRM) rates (16%, 41%, and 73%; p<0.001), lower 1-year survival (77%, 56%, and 24%; p<0.001), and lower complete response (CR) rates at day 28 (47%, 38%, and 20%, respectively; p<0.01). The area under the receiver operating characteristic curve (AUROC) for 1-year NRM was significantly higher with MCS compared to clinical symptoms alone (0.70 vs. 0.63; p=0.023). Among patients treated with ruxolitinib, higher MCS similarly predicted higher NRM and lower survival and CR rates. Patients classified as MCS2/3 had poor outcomes despite ruxolitinib, underscoring the need for novel therapies in this patient population. In conclusion the MCS is an accurate predictor of outcomes for patients who require second-line treatment and may be of use as an eligibility criterion for future clinical trials in this high-risk population.

Regulatory CD8+ T-cells (CD8+ Treg) are a distinct yet understudied T-cell subset capable of simultaneous immunosuppression and cytolysis. Here, we characterized induced human CD8+ Treg (CD8-iTreg) generated from peripheral blood CD8+CD25- T-cells using anti-CD3e mAb-loaded artificial antigen presenting cells, IL-2, TGF{beta}, and Rapamycin. These CD8-iTreg differentiated into a stable, highly proliferative bifunctional population with suppressive activity comparable to CD4-iTreg while retaining cytolytic capacity similar to conventional CD8 cytotoxic T lymphocytes (CTL). Multi-parameter spectral flow cytometry and single-cell RNA-seq revealed a distinct immunoregulatory signature: a predominantly Treg-like profile marked by tissue-residency marker CD103 with increased canonical Treg markers (FoxP3, HELIOS, CD25, CD39, CTLA-4, CCR4, and IL-10) and reduced pro-inflammatory cytokines. A unique cytotoxic program was marked by elevated Granzyme-K (GzmK) and Thrombospondin-4 (Tsp-4), a thrombospondin family extracellular matrix glycoprotein upregulated in activated CD8+ T-cells. Cytolysis was primarily mediated by Perforin (Prf) and multiple Granzymes packaged into Tsp-4 supramolecular attack particles (SMAPs), with GzmK contributing to both cytotoxic and suppressive functions. After anti-CD19scFv CAR (CAR19) transduction, CAR19+ CD8-iTreg showed superior in vivo anti-tumor efficacy compared with CAR19-CTLs, significantly reducing tumor burden and prolonging survival in a CD19+ Nalm-6 human leukemia xenograft model while maintaining low pro-inflammatory cytokine production. In a xenogeneic graft-versus-host disease (GVHD) model with residual human leukemia, CAR19 CD8-iTreg inhibited GVHD lethality and controlled tumor growth without increasing systemic inflammation. Together, these findings support CD8-iTreg-based CAR therapies as a strategy to retain potent anti-leukemic activity while limiting inflammatory toxicities of conventional CAR T-cells, properties particularly beneficial in treating auto- and allo-immune diseases. One sentence summaryCD8-iTreg drive parallel tumoricidal and immunoregulatory functions mediated by releasing Tsp-4+ SMAPs containing granzyme K.

Internal-tandem-duplication of the receptor tyrosine kinase FLT3 (FLT3-ITD) generates ligand-independent signaling and is highly recurrent in acute myeloid leukemias (AMLs). One way signaling pathways can quickly influence cell fates is by phosphorylating key fate-determining proteins to trigger their proteolysis. We investigated the master transcription factor (MTF) driver of granulo-monocytic lineage-fates, CEBPA, for regulation by this mechanism because we found high CEBPA mRNA but little CEBPA protein in FLT3-ITD versus FLT3-wildtype AML cells, and inhibiting FLT3-ITD signaling with tyrosine kinase inhibitors (TKI) rapidly rescued CEBPA protein. Mass spectrometry analyses of CEBPA and its interactome demonstrated prominent interactions with major ubiquitin-proteosome pathway (UPP) components UHRF1 and USP7. TKI treatments decreased CEBPA and USP7 phosphorylations at serine 21 and serine 18 respectively alongside shifts in CEBPA interactions from degradative ubiquitin-ligase UHRF1 toward protective deubiquitinase USP7. The rescued CEBPA activated granulocytic-differentiation. Supporting that the serine-phosphorylations were phospho-degrons, UPP-inhibitors (bortezomib, MG132) increased phosphorylated and total CEBPA and USP7. The MTF regulator of apoptosis p53 is a known USP7 client, therefore, we also evaluated p53 status: TKIs and UPP-inhibitors stabilized USP7 and p53, triggering apoptosis in addition to granulocytic-differentiation specifically in FLT3-ITD but not FLT3-wildtype AML cells. UPP-inhibitors produced these consequences in TKI-resistant FLT3-ITD AML cells also. These data predicted genetic loss-of-function to CEBPA or TP53 is redundant in the FLT3-ITD context, borne out by mutual exclusivity of the mutations in clinical series. In summary, FLT3-ITD signals for CEBPA and p53 proteolysis to block lineage-maturation and apoptosis, positioning UPP-inhibitors as therapeutic candidates acting downstream of TKIs. KEY POINTSO_LIThe oncoprotein kinase FLT3-ITD signals for CEBPA and p53 proteolysis and hence suppresses lineage-differentiation and apoptosis C_LIO_LIProteosome-inhibitors are candidate remedies to restore CEBPA and p53, acting downstream of presently used FLT3-ITD kinase inhibitors C_LI GRAPHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=171 SRC="FIGDIR/small/738455v1_ufig1.gif" ALT="Figure 1"> View larger version (56K): org.highwire.dtl.DTLVardef@6ae211org.highwire.dtl.DTLVardef@12003bforg.highwire.dtl.DTLVardef@d62eb9org.highwire.dtl.DTLVardef@1958693_HPS_FORMAT_FIGEXP M_FIG C_FIG

Myelodysplastic syndromes (MDS) are driven by somatic mutations in hematopoietic stem and progenitor cells (HSPCs), leading to clonal expansion and ineffective hematopoiesis. Hypomethylating agents (HMAs; azacitidine or decitabine) are the standard of care for higher-risk MDS. However, their effects on the bone marrow (BM) microenvironment, and the extent to which these changes correlate with clinical response, remain poorly understood. We performed longitudinal analyses of BM aspirates, trephine biopsies, and peripheral blood samples from MDS patients treated with azacitidine in a clinical trial (NCT03493646), integrating CyTOF, 5' single-cell RNA and TCR sequencing, plasma proteomics, and multiplex immunofluorescence microscopy to characterize changes associated with azacitidine response. Clinical responders showed expansion of GzmBCD56CD8 T cells together with increased type I and type II interferon signaling within the T-cell compartment. Responders also exhibited marked alterations in circulating platelet- and myeloid-derived factors with the potential to remodel the BM niche. Spatial analyses revealed expansion of neighborhoods enriched for CXCL12-abundant reticular cells and CD8 T cells in responders, whereas HSPC-enriched neighborhoods were largely unchanged. In contrast, several HSPC-enriched neighborhoods expanded in non-responders. These microenvironmental changes were accompanied by evidence of enhanced myelopoiesis in clinical responders. Our findings support a model in which azacitidine response extends beyond direct effects on malignant hematopoietic cells to involve coordinated remodeling of the BM microenvironment which may be reinforced by platelet- and myeloid-derived signals that establish a feed-forward circuit promoting productive hematopoiesis.

Metastatic neuroblastoma (NB), the most common pediatric extra-cranial solid tumor, has a cure rate of <50%. DNA-sequencing studies have demonstrated rare recurrent driver mutations at diagnosis, with the most common alterations detected in ALK-RAS-MAPK pathway. Activating ALK and RAS-MAPK mutations are associated with inferior outcome and are increased at relapse, and thus, represent therapeutic vulnerabilities in NB. Previously, we identified combinations of RAS/MAPK inhibitors, including SHP2 and MEK, with efficacy in resistant MAPK-altered tumor cells, including those with the most common NB-associated RAS mutation NRAS-Q61K. However, toxicities of SHP2 inhibitors and promising results using compounds that directly target RAS suggest there may be superior strategies to target RAS/MAPK pathway in NB. Here, we have assessed the efficacy of RAS/MAPK inhibitors, including tovorafenib (pan-RAF), RMC-6236/daraxonrasib (pan-active-RAS) and avutometinib (RAF/MEK) in NB in vitro and in vivo using NB models harboring differing genomic status of RAS/MAPK pathway effectors. We demonstrate selective efficacy of RMC-6236 and avutometinib via RAS-MAPK pathway inhibition in NB cells and xenografts harboring RAS, NF1 or ALK alterations. Importantly, we demonstrate that presence of the NRAS-Q61K mutation confers drug sensitivity. Using newly generated and previously established NB cell models of acquired resistance to RMC-6236 or the ALK inhibitor lorlatinib, we identified targeted combinations, including RMC-6236 plus avutometinib, that demonstrate re-sensitization in resistant NB cell and xenograft models. Finally, transcriptomic studies of RMC-6236-resistant cells detected upregulation of RAS/MAPK signatures, as well as TNF/NF{kappa}B and IL-6/JAK/STAT3 pathway enrichment, thus informing future combinations to enhance sensitivity to RAS inhibitors. STATEMENT OF SIGNIFICANCEOur work demonstrates that newly available RAS pathway inhibitors RMC-6236/daraxonrasib and avutometinib have efficacy in neuroblastoma tumors, which have frequent alterations in the RAS/MAPK pathway. These drugs with early efficacy results in adult RAS-driven tumors provide an important option for patients with relapsed neuroblastoma alone or in combination.

Background: High ambient temperature in early pregnancy has been linked to an increased risk of childhood acute lymphoblastic leukemia (ALL). To better understand biological mechanisms, the current study evaluated potential interaction between temperature and genetic characteristics. Methods: We used data from California birth records (1982-2008) and California Cancer Registry (1988-2011) to identify ALL cases (n=3,353) diagnosed <=14 years of age and non-cancer controls (n=3,530) matched 1:1 on sex, race, ethnicity, and birth year and month. Weekly ambient temperatures throughout pregnancy were assessed on a 1-km grid around the birth address, while genetic data were available from a genome-wide association study using neonatal blood spots. We evaluated the association between ambient temperature and ALL risk by quartiles of established genetic risk score for ALL. Next, we formally tested gene-temperature interactions in the association with ALL, correcting for multiple testing, for genes previously identified with epigenetic changes due to both temperature and ALL. All analyses were adjusted for potential confounders. Results: The elevated risk of ALL per 5 degrees C increase of weekly mean ambient temperature, confined to early pregnancy, was more pronounced among children with the lowest genetic susceptibility to ALL, especially among Latino children (first quartile: odds ratio [OR] = 1.50, 95% confidence interval [CI]: 1.14-1.97); fourth quartile: OR=1.03, 95% CI: 0.83-1.28). There were significant interactions (p<0.002) between ambient temperature and polymorphisms in BNC1 among non-Latino White children, and suggestive interactions (p<0.05) with TBPL2 and NRXN1 in the full population. Conclusions: Our findings suggest that there may be interactions between ambient temperature in early pregnancy and offspring genotype in the risk of childhood ALL. Impact: If replicated, these findings could help elucidate the biological mechanisms linking high ambient temperature in early pregnancy and the risk of childhood ALL.