Pharmacologic blockade of JAK1/JAK2 reduces GvHD and preserves the graft-versus-leukemia effect.

We have recently reported that interferon gamma receptor deficient (IFNγR-/-) allogeneic donor T cells result in significantly less graft-versus-host disease (GvHD) than wild-type (WT) T cells, while maintaining an anti-leukemia or graft-versus-leukemia (GvL) effect after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We demonstrated that IFNγR signaling regulates alloreactive T cell trafficking to GvHD target organs through expression of the chemokine receptor CXCR3 in alloreactive T cells. Since IFNγR signaling is mediated via JAK1/JAK2, we tested the effect of JAK1/JAK2 inhibition on GvHD. While we demonstrated that pharmacologic blockade of JAK1/JAK2 in WT T cells using the JAK1/JAK2 inhibitor, INCB018424 (Ruxolitinib), resulted in a similar effect to IFNγR-/- T cells both in vitro (reduction of CXCR3 expression in T cells) and in vivo (mitigation of GvHD after allo-HSCT), it remains to be determined if in vivo administration of INCB018424 will result in preservation of GvL while reducing GvHD. Here, we report that INCB018424 reduces GvHD and preserves the beneficial GvL effect in two different murine MHC-mismatched allo-HSCT models and using two different murine leukemia models (lymphoid leukemia and myeloid leukemia). In addition, prolonged administration of INCB018424 further improves survival after allo-HSCT and is superior to other JAK1/JAK2 inhibitors, such as TG101348 or AZD1480. These data suggest that pharmacologic inhibition of JAK1/JAK2 might be a promising therapeutic approach to achieve the beneficial anti-leukemia effect and overcome HLA-barriers in allo-HSCT. It might also be exploited in other diseases besides GvHD, such as organ transplant rejection, chronic inflammatory diseases and autoimmune diseases

Impact of cluster of differentiation 20 expression and rituximab therapy in classical Hodgkin lymphoma: Real world experience

The prognostic impact of CD20 expression and rituximab therapy in classical Hodgkin lymphoma (cHL) is unclear. Among 310 patients, CD20 was expressed in 66 (22%) cases. The 3-year PFS was 75.1% for CD20+and 70% for CD20− (p = 0.36). The 3-year PFS was 84.7% for the rituximab group and 67.8% for the no rituximab group (p = 0.23). Only constitutional symptoms and positive interim PET/CT were significantly associated with worse outcome, HR 3.2 (1.14–9.01; p = 0.028) and 4.3 (2.27–8.1; p < 0.0001), respectively. Neither CD20 expression nor rituximab use significantly impacted outcome

Selective targeting of histone modification fails to prevent graft versus host disease after hematopoietic cell transplantation

<div><p>Allogeneic hematopoietic cell transplantation is often complicated by graft versus host disease (GvHD), primarily mediated through allo-reactive donor T cells in the donor stem cell graft. Enhancer of Zeste Homolog 2 (EZH2), a histone-lysine N-methyltransferase and a component of the Polycomb Repressive Complex 2, has been shown to play a role in GvHD pathology. Although not yet clear, one proposed mechanism is through selective tri-methylation of lysine 27 in histone 3 (H3K27me3) that marks the promoter region of multiple pro-apoptotic genes, leading to repression of these genes in allo-reactive T cells. We found that selective pharmacologic inhibition of H3K27me3 with EPZ6438 or GSK126 did not prevent murine GvHD. This suggests the GvHD mitigating properties of DZNep are independent from H3K27me3 inhibition. Furthermore, while pharmacologic inhibition of EZH2 by DZNep has been shown to be effective in abrogating mouse GvHD, we found that DZNep was not effective in preventing GvHD in a human T cell xenograft mouse model. Although EZH2 is an attractive target to harness donor allo-reactive T cells in the post-transplant setting to modulate GvHD and the anti-leukemia effect, our results suggest that more selective and effective ways to inhibit EZH2 in human T cells are required.</p></div

<i>In</i><i> </i><i>vivo</i> administration of INCB018424 maintains a beneficial GvL effect and improves survival after allo-HSCT.

<p>Allo-HSCT was performed as described in the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109799#s2" target="_blank">Materials and Method</a>. CBRluc-expressing A20 B cell lymphoma cells were injected either i.v. (1×10⁴ cells) or s.c. (1×10⁵ cells in 100 ul PBS). <i>In vivo</i> BLI imaging technique was used to measure tumor burden once every week starting day 1 to day 43 after allo-HSCT. INCB018424 was injected for three weeks (days 3–23) twice a day (100 µg/injection, i.p.). (<b>A</b>) Systemic leukemia (left panel) and solid tumor (right panel) models. Photon flux was measured with a region of interest drawn over the entire body of each mouse. (<b>B</b>) Actual images of 1 representative mouse from each group are shown. Data represents the pool of three independent experiments. Systemic A20 lymphoid leukemia model is shown in upper panels and solid tumor A20 lymphoid leukemia model shown in bottom panel. (<b>C</b>) Survival of mice shown in Kaplan-Meier plots of both a systemic (left panel) and a solid tumor model (right panel).</p

Prolonged administration of INCB018424 further improves survival after allo-HSCT.

<p>(<b>A</b>) Administration of INCB018424 for one month (days +1–+31) twice a day (100 µg/injection, s.c.) significantly improves survival after allo-HSCT (<i>p</i> = 0.0003). (<b>B–C</b>) Prolonged administration of INCB018424 improves survival while preserving GvL (<b>B</b>). 1×10⁵ A20 cells (i.v) were transplanted along with allogeneic TCD BM and pan T cells at day 0. Clinical GvHD scores according to Cooke et al <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109799#pone.0109799-Cooke1" target="_blank">[10]</a> (<b>C</b>). (<b>D–E</b>) B6 mice were lethally irradiated (1,200 cGy) at day -1 and injected (i.p.) with 50 µg of anti-NK1.1 mAb (PK136). BM cells (5×10⁶) and whole splenocytes (20×10⁶) harvested from Balb/c were transplanted into lethally irradiated B6 at day 0, followed by INCB018424 for 31 days (days +1–+31). Clinical GvHD scores according to Cooke et al <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109799#pone.0109799-Cooke1" target="_blank">[10]</a> (<b>D</b>) and weight change (<b>E</b>). (<b>F–G</b>) B6 mice were lethally irradiated (1,200 cGy) at day -1 and injected (i.p.) with 50 µg of anti-NK1.1 mAb (PK136). TCD BM (5×10⁶) and pan T cells (5×10⁶) isolated from Balb/c were transplanted into the lethally irradiated B6 at day 0. Banked primary APL cells (5×10⁵) were injected (i.v.) along with TCD BM and pan T cells at day 0. INCB018424 was administered s.c. twice a day for 31 days (days +1–+31). (<b>F</b>) Percentage of APL cells in the PB was measured by flow cytometry after staining PB cells starting at day +16 once every week until day +41. Anti-H-2Kb and anti-CD45.2 antibodies were used to identify the APL cells. H-2^b+ CD45.1+ B6 recipients and H-2^d+ CD45.2+ Balb/c donors were used to discriminate APL from all other cells. (<b>G</b>) Shown is a Kaplan-Meier survival curve. (<b>H</b>) INCB018424 is superior to other JAK inhibitors, such as TG101348 and AZD1480, in blocking IFNγR signaling. As an indicator of IFNγR signaling, we assessed STAT1 phosphorylation by intracellular pSTAT1 staining and FACS. MFI: geometric mean fluorescence intensity. (<b>I</b>) Lethally irradiated (900 cGy) Balb/c mice were transplanted with TCD BM (5×10⁶) obtained from B6 WT mice and pan T cells (5×10⁵) isolated from B6 WT or IFNγR−/− mice at day 0. INCB018424 was administered s.c. twice a day for 31 days (days +1–+31). INCB018424 treatment for 31 days results in free of GvHD in 90% of recipients and 100% survival when mice are transplanted with IFNγR−/− T cells.</p

Guide lines for management of adult histiocytic disease

BACKGROUND: Histiocytic disease is a diverse disease, characterized by multisystem involvement, diagnosis and management can be challenging. Guidelines are important tool to provide evidence-based management; however, guidelines for management of adult histiocytic disease are scarce. METHODOLOGY: A multidisciplinary team from Saudi Arabia developed guidelines to manage the adult histiocytic disease with an intention to provide standard of care for diagnosis and management of the most frequently encountered subtypes of adult histiocytic disease in the region. RESULTS: Detailed guidelines to different categories of histiocytic disease were finalized after review of many international guidelines and extensive literature review. CONCLUSION: Local guidelines for adults histiocytic disease was developed and can be shared with different hematology centers

Pro106Leu MPL mutation is associated with thrombocytosis and a low risk of thrombosis, splenomegaly and marrow fibrosis

The P106L mutation in the human myeloproliferative leukemia virus oncogene (MPL) was shown to be associated with hereditary thrombocythemia in Arabs. The clinical and bone marrow (BM) features of P106L mutation are unknown. Genetic databases at two tertiary hospitals in Saudi Arabia were searched to identify patients with the MPL P106L mutation. Clinical data were collected retrospectively and the BM aspirates and biopsies were independently reviewed by two hematopathologists. In total, 115 patients were included. Median age was 33 years of which 31 patients were pediatric and 65 were female. The mutation was homozygous in 87 patients. Thrombocytosis was documented in 107 patients, with a median platelet count of 667 × 109/L. The homozygous genotype was associated with a higher platelet count. Thirty-three patients had an evaluable BM and clustering of megakaryocytes was observed in 30/33 patients. At the time of last follow-up, 114 patients were alive. The median follow-up was 7.8 years from the time of thrombocytosis. No patients developed disease progression to myelofibrosis. The P106L mutation was associated with marked thrombocytosis at a younger age and with a low risk of thrombosis, splenomegaly, and marrow fibrosis. The BM demonstrated normal or hypocellular marrow with megakaryocyte clusters

Chemotherapy effect on fertility in male patients with Hodgkin and Non-Hodgkin Lymphoma

Introduction: The chemotherapeutic agents are effective in destroying cancerous cells for patient with hematological malignancies, but can damage the germinal cells. Hence, the infertility is the therapy-induced complication, which can be transient or permanent, depending on type of treatment protocol used and other factors. The aim of the study was to assess the fertility status among patients treated for Hodgkin lymphoma (HL) and Non-Hodgkin lymphoma (NHL). Methods: A chart review was done for patients followed up in hematology clinic. All male patients treated for hematological malignancies during the period from 2004-2014 were assessed. The infertility status was assessed using WHO infertility criteria. The fertility status was defined based on semen analysis or having a child post chemotherapy. The data was captured for type of protocol, number of cycles, fertility status, having a child pre and post chemotherapy, and sperm bank utilization. Results were summarized as frequency and percentages. Data was analyzed using SAS. Results: 400 medical charts were reviewed. 208/400 were included based on age inclusion criteria (18-60 years). 59/208 included based on available fertility data, of which 31 were diagnosed with HL, 21 NHL, 4 acute lymphocytic leukemia, and 3 acute myeloid leukemia. Only HL and NHL were considered for further analysis. 9/31 (29%) with HL and 1/21 (4.7%) with NHL had infertility prior to starting chemotherapy based on semen analysis with no follow-up fertility assessment done post-treatment. The final sample consisted of 42 patients who had data available on their fertility status post-treatment (22 HL and 20 NHL) (Figure 1). The mean age was 38 ± 8 years. 25(68%) had advanced disease. Among HL, 8/22 (36.36%) were fertile (7 conceived a child and 1 with normal semen analysis) (Figure 2). This includes 6 out of 9 (66.7%) patients who received ABVD protocol alone, 0 out of 6 who received ABVD + BEACOPP protocol, and 2 (28.6%) out of 7 who received salvage chemotherapy. Among the NHL, 11/20 (55%) were fertile (8 conceived a child and 3 with normal semen analysis) (Figure 2). This includes 7 out of 11 (63.6%) who received CHOP +/-Rituximab protocol, 3 out of 5 (60%) who received CHOP + other chemotherapy (MTX/CVP), 1 out of 3 (33.3%) who received only other chemotherapies (Hyper CVAD/MTX) (Figure 2). 9 out of 22( 41%) HL and 6 out of 20 NHL patients had sperm banking done, and only two utilized their sperms with one successful conception in a patient with NHL (Figure 3). Conclusion: Although the sample size is very small, we found a trend that may suggest HL to affect fertility and that ABVD protocol may not be as safe as it thought to be on fertility. The advanced stage of the disease being the majority may have influenced this finding. We found the documentation of fertility status among patients receiving chemotherapy to be scarce. Hence, it is important to educate physicians and dedicate a protocol for assessment of fertility pre- and post-treatment with encouragement to utilize sperm banking. Disclosures No relevant conflicts of interest to declare

Comparison of a modified pediatric protocol versus a hyper-CVAD protocol in adolescents and young adults with Philadelphia-negative acute lymphoblastic leukemia: a multicenter retrospective analysis

Background The outcomes of Pediatric acute lymphoblastic leukemia (ALL) have improved dramatically whereas outcomes for ALL amongst adolescents and young adults (AYA) have lagged behind. The introduction of pediatric-like regimens to manage adult ALL has shown promising outcomes across several analyses. Materials and Methods In this analysis, we aimed to retrospectively compare the differences in outcomes among patients aged 14-40 years with Philadelphia-negative ALL treated with a Hyper-CVAD protocol versus a modified pediatric protocol. Results A total of 103 patients were identified with 58 (56.3%) in the modified ABFM group and 45 (43.7%) in the hyper-CVAD group. The median duration of follow-up for the cohort was 39 months (range 1-93). There were significantly lower rates of MRD persistence after consolidation (10.3% vs. 26.7%, P=0.031) and transplantation (15.5% vs. 46.6%, P<0.001) in the modified ABFM group. 5-year OS rates (83.9% vs. 65.3%, P=0.036) and DFS rates (67.4% vs. 44%, P=0.014) were higher in the modified ABFM groups. The incidence of grade 3 and 4 hepatotoxicity (24.1% vs. 13.3%, P<0.001) and osteonecrosis (20.6% vs. 2.2%, P=0.005) were higher in the modified ABFM group. Conclusion Our analysis demonstrates that the use of a pediatric modified ABFM protocol demonstrated superior outcomes compared to the hyper-CVAD regimen in the treatment of Philadelphia-negative ALL amongst AYA patients. However, the modified ABFM protocol was associated with an increased risk of certain toxicities including high grade liver toxicity and osteonecrosis. Data Availability Statement The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population