Journal of Hematology & Oncology

In developed countries, the rate of childhood B-cell acute lymphoblastic leukemia (B-ALL), the most common pediatric cancer with a peak incidence at 2-5 years of age, has been rising for several decades. Epidemiological studies suggest that reduced exposure to common infections in early life increases the risk of B-ALL. However, no specific infection capable of protecting against such cancer has been identified. One of the most prevalent infectious agents in humans is Epstein-Barr virus (EBV), a B-cell tropic tumor virus that infects ~95% of the global population by adult age. Paradoxically, recent studies reveal that EBV, through its signaling protein LMP1, elicits potent cytotoxic CD4+ and CD8+ T cell responses against a wide range of tumor-associated antigens (TAAs), which can recognize and attack EBV-unrelated cancer cells via shared TAAs. In developed countries, primary EBV infection is often delayed from early childhood into adolescence or young adulthood. Taken together, we hypothesized that EBV (LMP1)-induced TAA-specific T cells may help protect against some childhood B-ALL by targeting shared TAAs. If so, lack of EBV infection in early life may contribute to the rise of childhood B-ALL seen in developed countries. In this work, EBV serology assessment in pediatric B-ALL patients revealed strong exclusion of the commonest high hyperdiploid (HHD) subtype of B-ALL in children having recent primary EBV infection. Our mouse model studies demonstrated that LMP1-induced T cell immunity can eradicate some B-ALL-like leukemias via shared TAAs during the effector phase. These findings support the notion that EBV-induced anti-tumor immunity may help protect against some childhood B-ALL.

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.

Cancer immunotherapy targeting B-cell specific CD19 antigen meant a major breakthrough in the treatment of B-cell malignancies. Yet, vast proportion of treated patients experience relapse and failure of the therapy. Although multiple mechanisms of CD19-immunotherapy failure have been described, CD19-negative relapses represent the major hurdle in achieving higher and durable response rates. Our established in vitro co-culture models revealed that suboptimal CAR-T cell performance, inefficient to mediate target cell killing, results in robust downregulation of CD19 target antigen. Using genome-wide CRISPR screening, we addressed the mechanisms responsible for such CD19 downregulation and identified Cullin-1 and CD81 playing instrumental role in negative and positive regulation of CD19 expression, respectively. Inhibiting Cullin-1 activity with pevonedistat prevents the loss of CD19 under immunotherapeutic pressure, results in higher CD19 surface levels and consequently enhances the efficacy of target cell killing by CD19-CAR-T cells, CD19-CAR-NK cells and CD19-targeting antibody treatment. Mechanistically, we show that pevonedistat blocks the degradation of CD19 upon its internalization and allows its recycling back to the plasma membrane. CD81 chaperone protein is critically involved in this process as the absence of CD81 abrogates the effect of pevonedistat. In summary, we identify Cullin-1 as a novel and druggable regulator of CD19 protein stability. Cullin-1 inhibition augments CD19 surface expression, thereby improving the efficiency of CD19-targeting immunotherapies, thus arguing for potential incorporation of pevonedistat into novel combination therapies. Key PointsO_LICullin-1 inhibition stabilizes CD19 surface expression, preventing its loss under immunotherapeutic pressure C_LIO_LIPevonedistat treatment enhances the efficacy of CD19-CAR-T cells, CAR-NK cells and CD19-targeting antibodies C_LI

The success of Chimeric Antigen Receptor (CAR) T cell therapy is heavily dependent on the quality of the final cellular product. Current expansion protocols often rely on reagents that require removal from cell culture media, posing logistical challenges in manufacturing, and can also lead to terminal differentiation. Here, we evaluate the use of a soluble, bead-free T cell activator, T cell expansion protein (T-CEP), as a streamlined alternative for generating potent CAR-T cells. Human T cells were activated with T-CEP or known T cell activators (Dynabeads and TransAct) and transduced with either CD19 or interleukin-13 (IL-13) mutein (tetravariant-13; TV-13)-based CAR lentiviral vectors. Our results demonstrate that T-CEP supports robust CAR-T cell expansion and achieves transduction efficiencies comparable to commercial reagents for both types of CAR-T cells. Notably, T-CEP significantly favored the expansion of CD8+ T cells, yielding an enhanced CD27+ phenotype and a lower CD4:CD8 ratio compared to TransAct. Cytotoxicity assays confirmed that T-CEP-expanded CAR-T cells possess cytolytic function equivalent to commercial reagents for both CARs, while exhibiting lower levels of inflammatory cytokine secretion. In summary, T-CEP represents a competitive alternative to existing expansion agents, as it does not require its removal during CAR-T manufacturing and generates a CD8+ dominant, less-differentiated phenotype without compromising efficacy.

T cell-based immunotherapies have become central to the treatment of multiple myeloma (MM), yet their efficacy depends on the functionality of endogenous T cells. How cumulative treatment exposure, particularly high-dose melphalan, together with disease-intrinsic high-risk features shapes T-cell composition and immune competence remains incompletely understood. Here, we analyzed T cell composition and function in bone marrow (BM) and peripheral blood (PB) samples from MM patients across different stages of their treatment journey using flow cytometry (BM, n=162; PB, n=1,733), single-cell RNA sequencing (n=19), and cytotoxicity assays (n=20). We reveal reduced overall T cell frequencies and CD4+/CD8+ T cell ratio, associated with lines of therapy and driven in part by depletion of naive CD4+ T cells in gene-expression defined high risk (HR) disease. Among therapeutic agents, melphalan exerted the strongest effects on T cell populations and induced pronounced redox stress in both T cells and myeloma cell lines. This oxidative stress signature was enriched in HR patients and was reversible with N-acetyl-L-cysteine treatment. Together, these findings identify immune dysregulation as a defining feature of HR MM that extends beyond tumor-intrinsic genomic alterations and is further shaped by treatment-induced remodeling of the BM microenvironment. Given the association between higher CD4+ T cell numbers and improved CAR-T cell outcomes, our data highlight the translational importance of treatment sequencing, particularly in HR MM. One Sentence SummaryMelphalan-induced redox stress depletes CD4+ naive T cells, particularly in patients with high-risk multiple myeloma.

The extent to which rare and common genetic variants jointly contribute to the risk of acute myeloid leukemia (AML) still remains relatively unexplored in large-scale biobank whole-genome sequencing cohorts. Here, we leverage the latest sequencing and phenotypic data from the All of Us Research Program to identify variants, genes, and gene-sets associated with AML. We performed set-based association tests for rare protein-coding variants (Ncases=265 and Ncontrols=169,706) and single-variant association tests for common variants (Ncases=265 and Ncontrols=169,705) utilizing the large European-like ancestry sample. For the rare-variant set-based tests conducted using SAIGE-GENE+, four genes were statistically significant: DNMT3A, TET2, SRSF2, and IDH2 (Bonferroni-corrected Cauchy p-value < 0.05). We also constructed multiple rare-variant burden risk scores using different gene-sets to identify those with a substantial rare-variant burden for AML. Gene-sets derived from Genomic Data Commons whole-genome sequencing data, comprising two distinct groups-genes observed to harbor somatic mutations in AML and genes observed to harbor somatic mutations across all cancer types-showed a statistically significant rare-variant burden (Bonferroni-corrected p-value < 0.05). Ultimately, these findings demonstrate that leveraging whole-genome sequencing in large-scale biobanks enables the identification of rare protein-coding variants, genes, and gene sets associated with AML.

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.

Hyperleukocytosis (white blood cell [WBC] count >100 000/uL) at diagnosis is an important prognostic risk factor in pediatric acute lymphoblastic leukemia (ALL), though its significance with contemporary therapy is unclear. We analyzed 1 826 pediatric ALL patients from a multi-institution cohort to determine whether hyperleukocytosis independently predicts outcomes using multivariable Cox proportional hazard modeling. Hyperleukocytosis occurred in 211 patients (12%), with 121 having B-ALL, and showed no prognostic significance in T-ALL patients. In B-ALL, 5-year event-free survival (EFS) was 65% versus 89% for non-hyperleukocytosis patients, and overall survival (OS) was 78% versus 93%. After adjustment for age, cytogenetic risk, central nervous system disease status, and treatment site, hyperleukocytosis remained an independent predictor of end-of-induction minimal residual disease (MRD) positivity (odds ratio 2.53 [95% confidence interval [CI]: 1.71-3.94; p<0.001]), inferior EFS (hazard ratio [HR] 2.44; 95% CI: 1.77-3.38; p<0.001) and inferior OS (HR 2.00; 95% CI: 1.29-3.12; p=0.002). A continuous dose-response relationship was observed between WBC count and these outcomes. Survival associations persisted across all cytogenetic risk categories and MRD strata. Despite risk-adapted therapy with treatment intensification for high-risk features, hyperleukocytosis identifies an aggressive B-ALL phenotype with persistently inferior outcomes, suggesting these patients may benefit from novel therapeutic approaches.

Chimeric antigen receptor (CAR)-T cell therapy has improved outcomes for patients with multiple myeloma (MM), but its broader use is restricted by manufacturing complexities and treatment-related toxicities. AZD0120 is a dual-targeting B-cell maturation antigen (BCMA)/CD19 CAR-T cell therapy manufactured via the rapid FasTCAR process. We developed a dual-targeting "loop" CAR that incorporates a novel humanized anti-BCMA single-chain variable fragment (scFv), clone SG, and an FMC63-derived anti-CD19 scFv. This AZD0120 CAR preserved functional binding to both antigens and conferred robust in vitro and in vivo cytotoxicity while maintaining single-antigen reactivity. Conventional manufacture of CAR-T cells with the AZD0120 CAR (AZD0120C) yielded cells with minimal tonic signaling, limited responsiveness to soluble BCMA, and preservation of naive/stem cell memory-enriched phenotypes, yet robust cytokine production upon BCMA+ target engagement. AZD0120C demonstrated cytotoxicity comparable to benchmark BCMA CAR-Ts across MM lines in vitro and showed strong in vivo expansion and tumor control in xenograft models. FasTCAR manufacturing - designed to shorten vein-to-vein timelines and enrich less-differentiated phenotypes - further enhanced in vivo performance: AZD0120 consistently achieved superior tumor control and greater CAR-T expansion vs AZD0120C across disseminated MM.1S, NALM-6, and JeKo-1 models, with superior efficacy observed at lower cell doses. Collectively, these data support clinical evaluation of AZD0120 as a differentiated BCMA/CD19 CAR-T cell therapy with the potential to improve disease control and patient access in MM. Key PointsO_LIAZD0120 is a dual-targeting CAR-T that displays a favorable anti-myeloma functional profile and co-targets a source of potential relapse C_LIO_LIThe FasTCAR process yields TN/SCM-rich CAR-T populations, promotes in vivo expansion and achieves potent tumor control in xenograft models C_LI

CD19-4-1BBL is a bispecific antibody fusion protein that targets CD19 and costimulates 4-1BB on T cells and other immune cells. Its antitumor activity has been reported in B-cell non-Hodgkin lymphoma with emphasis on its T-cell mediated cytotoxic activity. Its effect on other 4-1BB expressing immune cells is unexplored. Here, we investigated the molecular mechanisms and the antileukemic effect of CD19-4-1BBL in chronic lymphocytic leukemia (CLL), a B-cell malignancy profoundly marked by the immunosuppressive activity of myeloid-derived suppressor cells, tumor-associated macrophages and CD4+ regulatory T cells. We demonstrated that CD19-4-1BBL simultaneously mitigates the immunosuppressive phenotype and transcriptome machinery of these cells and promotes antitumor CD8+ T-cell immunity. Finally, in a preclinical, patient-derived xenograft model of CLL, we observed a favourable survival impact, especially in mice transplanted with immune cells from patients with high-risk/progressive leukemia. Our findings provide evidence that the CD19-4-1BBL treatment is a multifaceted, immune-based strategy that should be clinically explored in patients with chronic lymphocytic leukemia. KEY POINTSO_LICD19-4-1BBL sharpens the myeloid cell transcriptome and stimulates diverse memory CD8+ T cell clonotypic responses. C_LIO_LICD19-4-1BBL costimulation can be therapeutically exploited in high-risk chronic lymphocytic leukemia. C_LI

BackgroundChimeric Antigen Receptor (CAR) T cell therapy targeting B-cell maturation antigen (BCMA) has demonstrated impressive clinical efficacy in relapsed/refractory multiple myeloma (MM). Nonetheless, disease relapse limits durable response for most patients. Trogocytosis of target antigen by effector cells has emerged as a potential contributor to reduced surface antigen density, CAR T cell dysfunction, and fratricide. Although {gamma}-secretase inhibitors (GSI) significantly increase cell surface BCMA density and decrease soluble BCMA (sBCMA), their effects on BCMA trogocytosis and the resulting impact on CAR T-cell function remain incompletely understood. MethodsWe investigated the effects of GSI on BCMA-directed CAR T cell function and trogocytosis using in vitro co-culture systems with MM cell lines across a spectrum of BCMA expression. We validated findings using confocal microscopy and cytotoxicity assays. Trogocytosis and fratricide were assessed in time-resolved functional studies. Phenotypic and functional differences between trogocytosis-positive (CAR T Trogo+) and trogocytosis-negative (CAR T) cells were evaluated using multiparametric flow cytometry, proteomic profiling, single-cell RNA sequencing (scRNA-seq), T-cell receptor (TCR) sequencing, and in vitro rechallenge assays. We also interrogated clinical samples from two Phase I trials (NCT03338972 and NCT03502577) which employed the identical CAR T cell construct with or without GSI respectively, to evaluate the relationship between trogocytosis, CAR T cell persistence, and treatment outcome. ResultsGSI driven increases in BCMA density on MM cell lines enhanced CAR T cell cytotoxicity but concomitantly increased trogocytosis, particularly in high-antigen-density cell lines-(H929+GSI vs H929; 30 min (P<0.0001), 1 h (P<0.0001), 2 h (P<0.0001), 6 h (P<0.0001), and 24 h (P<0.0001) and in CD4 CAR T cells (K562mCherry+GSI, CD4 vs CD8 CAR T cells;10 min (P=0.01), 2 h (P=0.01), and 6 h (P=0.004). Following BCMA acquisition, CAR T cells (CAR T Trogo) exhibited reduced proliferative capacity, diminished cytotoxic function (CAR T Trogo+ vs CAR T; (P=0.01), and an increase in markers of exhaustion/activation (CD4+ CAR T Trogo+ vs CD4 CAR T and CD8+ CAR T Trogo+ vs CAR T; PD-1+LAG-3+, PD-1+TIM-3+, and TOX+TIM-3 co-expression, (P=0.007, P<0.0001, P=0.006 and P=0.004, P=0.03, P=0.006). In fratricide assays, CAR T Trogo cells were susceptible to killing by naive CAR T cells. Single cell RNA-seq supports the phenotypic findings revealing transcriptional features of heightened activation and accelerated exhaustion in CAR T Trogo+ cells. Clinical phase I trial data confirm BCMA trogocytosis in patient samples. ConclusionsOur findings highlight the paradoxical effects of increased BCMA density on BCMA CAR T cell therapy: enhancement of initial tumor targeting and promotion of trogocytosis-associated dysfunction. Trogocytosis may contribute to antigen modulation, CAR T cell exhaustion, and fratricide, potentially muting the therapeutic benefits of enhanced antigen density. To optimize GSI and mitigate trogocytosis-associated resistance mechanism, future clinical trial designs should incorporate early time-point sampling, a sample size providing sufficient statistical power to determine an impact on CAR T cell persistence and treatment response, and mechanistic assessments.

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.

Certain aspects of lipid metabolism are known to regulate hematopoietic stem cell (HSC) function, including fatty acid oxidation and lipid uptake, but there is a limited understanding of the contribution of de novo fatty acid synthesis to HSC homeostasis. Here, we show that endogenous fatty acid synthesis is essential for HSC function. Conditional deletion of Acaca, the gene that encodes the rate-limiting enzyme for de novo fatty acid synthesis, acetyl-CoA carboxylase 1 (ACC1), in hematopoietic cells profoundly reduces HSC function, marked by a reduced ability to reconstitute irradiated mice after competitive transplantation. ACC1 deficiency reduced quiescence, increased uptake of extracellular lipids, and increased reactive oxygen species in HSCs. The loss of HSC function is partly caused by increased fatty acid oxidation as deletion of CPT1a, which is required for long-chain fatty acid oxidation, partially rescued HSC function. A balance between fatty acid synthesis and fatty acid oxidation is thus critical for the maintenance of HSC function.

Chronic myelomonocytic leukemia (CMML) is an aggressive hematologic malignancy characterized by excess inflammatory signaling and clonal myeloproliferation. The relative contribution of neutrophils (PMNs) to the inflammatory milieu in CMML is poorly understood. In this study we sought to understand whether neutrophil extracellular trap (NET) formation, a key mediator of neutrophilic inflammation, is dysregulated in CMML and can be therapeutically targeted with a novel peptide inhibitor of NETosis called neonatal NET-inhibitory factor (nNIF). Here, we demonstrate that baseline NET formation is aberrantly increased in primary CMML PMNs transcriptionally primed for NETosis, and that soluble factors produced during CMML NET formation promote clonogenicity in CMML CD34+ hematopoietic cells matched to the same patient. Further, we show that nNIF and clinical agents under investigation in CMML effectively inhibit NETosis, warranting further study of NET inhibitory agents in this rare disease with limited treatment options.

Haematopoietic stem cells (HSC), while usually quiescent, can rapidly divide following specific stimuli (mobilization). These HSC can seed additional niches, allowing for the swift generation of essential blood cells. However, studies in mice and humans have clearly demonstrated that cycling bone marrow (BM) HSC (cells in the G1/S/G2/M phases) engraft and reconstitute the haematopoietic system poorly compared with HSC in the G0 phase1. This raises the question why mobilized HSC, immediately following 3 or more cell divisions2, efficiently reconstitute the haematopoietic system. We studied this phenomenon in human HSC using scRNAseq analysis. We found that mobilized HSC rapidly start transcribing genes associated with quiescence, specific for the G0 phase of the cell cycle. We hypothesize that this rapid switch from actively dividing to quiescent cells combined with our extensive RNA expression data will allow us to better define pathways involved in this process.

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.

AML is an aggressive blood cancer associated with poor clinical outcomes. Chemotherapy remains the standard of treatment, but unfortunately relapse is very common, highlighting the need for alternative therapies. T cell dysfunction and exhaustion are prominent in AML and may represent a barrier to effective immunotherapy yet remains poorly studied in AML. DNA methylation is a major driver of T cell exhaustion and inhibition of de novo methylation can block exhaustion and restore T cell function in chronic viral infections and other cancers but is understudied in AML. Here, we investigated the impact of azacytidine (Aza), an FDA-approved hypomethylating agent, on T cell exhaustion in AML. Using a spontaneous AML mouse model and samples from patients with AML, we found that Aza treatment modulates T cell function. In vivo Aza-treatment of AML-bearing mice decreased tumor burden and reshaped CD8+ T cell states, with increases in frequencies of memory subsets and decreases in regulatory T cells (Tregs). Functionally, Aza treatment overcame the impaired proliferation displayed by both CD4 and CD8+ T cells in our model. DNA methylation sequencing of T cells after Aza treatment revealed hypomethylation and increased expression of stem-like precursor gene TCF7 and E2F2, a regulator of cell cycle progression and proliferation. Similar changes in phenotypes were observed in cultures of AML patient samples treated with Aza. Collectively, we show that Aza remodels epigenetic and functional states in AML and has the potential to reverse T cell exhaustion, with enhanced memory and proliferation capacity. Our work generates a mechanistic framework that provides rationale of combining hypomethylating agents with T cell-based immunotherapies in this lethal disease. Data Sharing StatementRRBS data is available in GEO under the accession number GSE328721. For original data please contact Dr. Evan F. Lind. Key PointsAzacytidine mediated epigenetic modulation can alleviate T cell exhaustion in AML Translational RelevanceImmune therapy has shown limited efficacy in AML, despite increasing evidence of T cell dysfunction in this malignancy. Azacytidine (Aza) is an FDA approved drug for AML, but patients develop therapy resistance and relapse. Studies have mainly focused on Azas tumor intrinsic effects. In this study, we investigated the impact of Aza on immune function, especially T cell exhaustion in AML, since exhaustion is a major mechanism of disease resistance. We demonstrated that Aza can modulate T cell phenotype and restore T cell proliferation. Mechanistically, Aza induces epigenetic reprogramming in T cells and increases the expression of a stem-like precursor marker, TCF7. By shifting the focus on T cell biology, our study provides a rationale for combining Aza with other immunotherapies that can enhance durable immune responses in this malignancy.

DNA methylation-based classification offers a rapid diagnostic complement to conventional molecular workflows in acute leukemia. Existing classifiers are trained on array-derived reference cohorts whose construction favors specimens with adequate tumor content, leaving clinically relevant low-purity specimens underrepresented and classifier robustness in this regime uncharacterized. On held-out low-purity specimens, existing classifiers were concordant with expert pathology in only 7 of 10 (MARLIN) and 5 of 10 (ALMA) cases, motivating a classifier built to maintain accuracy at low tumor purity. We developed MOSAIC (Methylation-Oriented Site Analysis and Information Classifier), a neural network classifier built to maintain accuracy across the full range of tumor purities encountered in clinical practice. MOSAIC is a neural network trained on publicly available array-based methylation data augmented with native methylation calls from Oxford Nanopore sequencing. MOSAIC was evaluated on low-purity specimens held out entirely from training. On these held-out low-blast leukemia specimens, all below 25% blasts and including a case at 1.4%, MOSAIC was concordant with expert pathology in every case, recovering the correct subtype where diluted disease signal would otherwise be mistaken for normal or unrelated tissue. Gradient-based saliency analysis showed that the network relies on a partially distinct set of discriminative CpG probes when classifying low-blast specimens. MOSAIC demonstrates that augmenting training with clinically representative clinical specimens yields methylation-based leukemia classification that maintains effectiveness under the variable tumor purity of real clinical cohorts.

1Adoptive cell therapy using tumor antigen-targeting T cell receptors (TCRs) offers a compelling approach to treat both hematological cancers and solid tumors due to broad antigen accessibility and the ability to target cancer-specific neoantigens. However, unlike clinically validated second generation CAR-T cells bearing built-in co-stimulatory signaling modules (i.e. 41BB or CD28), TCR-T cells receive little to no co-stimulation within most tumor microenvironments leading to attenuated cellular responses. Additionally, CD4+ TCR-T cells engineered to express HLA-Class I restricted TCRs possess minimal T-helper cell activity and thus do not effectively mobilize CD8+ TCR-T cells or host anti-tumor immune responses. To address these limitations, we used CRISPR-Cas9 to engineer TCR-T cells with targeted integration of chimeric CD8 constructs containing intracellular co-stimulatory domains. We found that expression of wild-type CD8{beta}, but not CD8, could promote CD4+ T cell activities in HLA-Class I restricted TCR-T cells. However, this was insufficient to drive durable anti-tumor responses in challenging tumor mouse models when using a high-affinity WT1-directed TCR. To address this, several CD8 co-stimulatory fusion constructs containing CD28 or 41BB intracellular domains were designed and screened, identifying two CD8-41BB based chimeras that substantially increased TCR-T cell activity relative to wild-type CD8{beta}. WT1-TCR-T cells co-expressing the CD8-41BB fusions demonstrated not only enhanced CD4+ activity including strong and polarized Th1-type cytokine secretion, but also enhanced the proliferation, cytokine release, and cytotoxicity of CD8+ CTLs. Remarkably, when combined with TGFBR2 gene disruption, WT1-TCR-T cells co-expressing CD8-41BB receptors were able to completely regress established cell line-derived ovarian tumors, showed robust in vivo expansion and persistence, and provided long-term protection from tumor rechallenge. Importantly, the specificity profile of the WT1-TCR including its HLA-A*02:01 restriction and WT1 peptide recognition motif was preserved upon expression of CD8-41BB. To simplify cell engineering processes for clinical applications, we configured a homology directed repair (HDR) cassette to allow for efficient CRISPR-Cas9-based insertion of both the TCR and CD8-41BB transgenes in the TRAC locus in a single step with >80% efficiency. Lastly, the enhanced activity conferred by CD8-41BB expression was validated with a second clinically relevant TCR targeting PRAME, suggesting this platform can be a universal approach for enhancing the therapeutic potential of TCR-based cell therapies.

The PIK3CA gene encodes p110α, the catalytic subunit of phosphoinositide 3-kinase (PI3K), and is among the most frequently mutated oncogenes in multiple cancers, including breast and colorectal cancer (CRC) 1 . Two FDA-approved PI3Kα-specific inhibitors, Alpelisib and Inavolisib, are currently used in combination with fulvestrant to treat hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–), PIK3CA-mutated breast cancer. However, extending PI3Kα-targeted therapy to PIK3CA-mutant CRC requires new and effective combination strategies. Most oncogenic PIK3CA/p110α mutations cluster in two hotspot regions: the helical domain and the kinase domain. Approximately half of all p110α mutations arise in the helical domain, with E545K being the most common recurrent alteration 1 . Our previous work demonstrated that helical-domain mutant p110α aberrantly interacts with insulin receptor substrate 1 (IRS1) while losing its interaction with the regulatory subunit p85β 2 . The disengaged p85β subsequently translocates to the nucleus and stabilizes EZH1/2 3 . We further showed that combining Alpelisib with the EZH1/2 inhibitor Tazemetostat induces regression of xenograft tumors harboring a helical-domain PIK3CA mutation 3 . Here, we report that the combination of Alpelisib and Tazemetostat additively upregulates interleukin-15 (IL15) expression in helical-domain mutant CRC, leading to activation of natural killer (NK) cells, which in turn contributes to robust CRC tumor suppression.