The prognostic Impact of microRNA-181a expression levels in patients with cytogenetically normal acute myeloid leukemia

Despite advances in the understanding of cancer biology, most patients with acute myeloid leukemia (AML) still die of their disease. Improving risk-stratification and identifying new targets are important steps towards personalized medicine and outcome improvement. MicroRNAs, short non-coding RNAs that hybridize to their target messenger RNAs (mRNAs) and repress the expression of the encoded proteins, are known to be involved in physiological processes like cellular differentiation, proliferation and cell survival but also play an essential role in cancer, including AML. In this thesis we demonstrated that higher expression of a single microRNA miR-181a was associated with clinical outcome in cytogenetically normal AML (CN AML) patients. In multivariable models, higher expression of miR-181a was associated with achievement of complete remission (CR), with longer disease-free (DFS) and overall survival (OS) even in consideration of other validated prognostic clinical and molecular variables. Measurement of pretreatment levels of this microRNA may improve risk-stratification for AML patients. A genome-wide gene-expression signature gave biological insights into miR-181a associated AML, and provides a basis for further functional studies. Furthermore, as higher miR-181a expression associated with improved treatment response, increasing miR-181a levels by delivering synthetic miR-181a or by agents increasing endogenous levels of this microRNA in AML blasts may represent a novel and personalized therapeutic approach in AML.:Bibliografische Beschreibung 1 Vorbemerkung / Preliminary Remarks 2 Referat / Abstract 3 Einführung / Introduction 4 Publication 13 Zusammenfassung / Conclusion 31 Ausgewählte Publikation / Selected Publication 38 Komplette Publikationsliste / Complete List of Publications 39 Lebenslauf / Curriculum Vitae 46 Erklärung über die eigenständige Abfassung der Arbeit 50 Danksagung / Acknowledgements 5

Novel molecular biomarkers and their clinical consequences in acute myeloid leukemia

Die Akute Myeloische Leukämie (AML) ist eine sowohl zytogenetisch als auch molekulargenetisch äußerst heterogene Erkrankung, die durch die klonale Proliferation myeloider Vorläuferzellen sowie eine Ausreifungsblockade charakterisiert ist. Trotz des in den letzten Jahren zugenommenen Wissens über die Biologie dieser Erkrankung und Weiterentwicklung von Therapiemethoden bleibt das Gesamtüberleben der Patienten mit AML überwiegend schlecht. Damit für mehr Patienten eine Heilung der AML möglich werden kann, sind ein tieferes Verständnis über die funktionellen Zusammenhänge in der Leukämogenese, eine bessere Risikostratifizierung und neue Therapieoptionen erforderlich. Diese Habilitationsschrift fasst Publikationen zusammen, die neue molekulare Biomarker und deren klinischen Einfluss in der AML untersucht haben. Der Fokus liegt auf der Erfassung molekularbiologischer Veränderungen bei Diagnose einer AML oder im Krankheitsverlauf, die die Risikostratifizierung der Patienten verbessern kann. Außerdem gestattet die Arbeit Einblicke in die mit diesen molekularen Markern verbundene Biologie der AML, sowie mögliche neue Therapieoptionen. Der erste bis dritte Abschnitt der Arbeit fokussiert sich auf Genmutationen und Genexpressionen in der AML. Es wird dargelegt, wie das Vorhandensein bestimmter Fusionstranskripte (hier CBFB-MYH11), rekurrenter Mutationen allein (hier im DNMT3A Gen) sowie als Teil genetischer Risikoklassifikationssysteme (hier die genetischen Risikogruppen des European LeukemiaNet) und die abberrante Expression AML-assoziierter Gene (hier BAALC, ERG und MN1) Beiträge zur Prognoseabschätzung der AML bieten. Darüber hinaus hat sich in den letzten Jahren die entscheidende Rolle von MicroRNAs in der Pathophysiologie der AML herausgestellt. Heute weiß man, dass für die Leukämieentstehung und die Aggressivität der Erkankung schon die Dysregulation einer einzelnen microRNA entscheidend sein kann. Im vierten Abschnitt wird auf den progostischen Einfluss der Expressionslevel zweier MicroRNAs – miR-181a und miR-29b – und deren klinische und biologische Konsequenzen eingegangen. Außerdem wird dargestellt, wie verschiedene therapeutische Interventionen zu günstigen Änderungen des Expressionsniveaus dieser beiden neuen Biomarker und so zu potentiell neuen Therapiestrategien in der AML führen können. Weiterhin wächst die Erkenntnis, dass in der AML so gennannte Leukämie-initiierende Zellen für Therapieresistenz und Rezidive verantwortlich zu sein scheinen. Der letzte Abschnitt dieser Habilitationsschrift fokussiert sich auf das CD34+/CD38- Zellkompartiment, welches einen Großteil der Leukämie-initiiernden Zellen enthält. Es wird gezeigt, dass die Bestimmung der Größe des CD34+/CD38- Zellkompartiments bei Diagnose geeignet ist, AML Patienten mit einem erhöhten Rezidivrisiko nach allogener Stammzelltransplantation zu identifizieren. Zusammenfassend zeigt die Arbeit verschiedene Ansätze, wie neue molekulare Biomarker zu einer besseren Risikostratifizierung und einem tieferen Verständnis der AML zugrunde liegenden Biologie führen können. Des Weiteren beschreibt sie Möglichkeiten der therapeutischen Intervention und weist insgesamt auf die klinischen Implikationen dieser neuen Biomarker hin

Clinical Challenges and Consequences of Measurable Residual Disease in Non-APL Acute Myeloid Leukemia

The ability to detect residual levels of leukemic blasts (measurable residual disease, MRD) has already been integrated in the daily routine for treatment of patients with chronic myeloid and acute lymphoblastic leukemia. In acute myeloid leukemia (AML), a variety of mostly retrospective studies have shown that individuals in AML remission who tested positive for MRD at specific time-points or had increasing MRD levels are at significantly higher risk of relapse and death compared to MRD-negative patients. However, these studies differ with respect to the “MRD-target”, time-point of MRD determination, material analyzed, and method applied. How this probably very valuable MRD information in individual patients may be adapted in the daily clinical routine, e.g., to separate patients who need more aggressive therapies from those who may be spared additional—potentially toxic—therapies is still a work-in-progress. With the exception of MRD assessment in acute promyelocytic leukemia (APL), the lack of randomized, prospective trials renders MRD-based decisions and clinical implications in AML a difficult task. As of today, we still do not have proof that early intervention in MRD-positive AML patients would improve outcomes, although this is very likely. In this article, we review the current knowledge on non-APL AML MRD assessment and possible clinical consequences

Analytische Moralphilosophie: Grundlagentexte

Die Moralphilosophie des 20. und 21. Jahrhunderts hat mit Konsequentialismus, Deontologie, Kontraktualismus und Tugendethik nicht nur höchst einflussreiche Theorieparadigmen produktiv weiterentwickelt, sondern auch eine Reihe wichtiger neuer Probleme aufgeworfen. Der vorliegende Band versammelt zentrale Beiträge der analytischen Moralphilosophie, u. a. von David Gauthier, Shelly Kagan, Frances Kamm, Thomas Nagel, Michael Slote, Christine Swanton und Susan Wolf, die für ein Verständnis gegenwärtiger Diskussionen in der normativen Ethik unabdingbar sind. Inhaltsverzeichnis: Vorwort Einleitung: Analytische Moralphilosophie der Gegenwart 1. Konsequentialismus Shelly Kagan: Ein Plädoyer gegen die Alltagsmoral Peter Railton: Entfremdung, Konsequentialismus und die Anforderungen der Moral 2. Deontologie Thomas Nagel: Ethik William David Ross: Was macht richtige Handlungen richtig? 3. Kontraktualismus David Gauthier: Warum Kontraktualismus? Thomas Scanlon: Die Struktur des Kontraktualismus 4. Tugendethik Christine Swanton: Eine tugendethische Theorie des richtigen Handelns Michael Slote: Akteursbasierte Tugendethik 5. Moralische Aggregation John Taurek: Zählt die Anzahl? Frances M. Kamm: Aggregation und zwei moralphilosophische Methoden 6. Das Prinzip der Doppelwirkung Jonathan Bennett: Vorhergesehene Nebenwirkungen vs. beabsichtigte Folgen Ralph Wedgwood: Zur Verteidigung der Lehre von der Doppelwirkung 7. Moralische Rechte H. L. A. Hart: Gibt es natürliche Rechte? Joseph Raz: Über die Beschaffenheit von Rechten 8. Moralischer Zufall Thomas Nagel: Moralischer Zufall Susan Wolf: Die Moral des moralischen Zufall

Risk Stratification, Measurable Residual Disease, and Outcomes of AML Patients with a Trisomy 8 Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Background: For most patients with acute myeloid leukemia (AML) harboring a trisomy 8 an allogeneic hematopoietic stem cell transplantation (HSCT) is a suitable and recommended consolidation therapy. However, comparative outcome analyses between patients with and without trisomy 8 undergoing allogeneic HSCT have not been performed so far. Methods: We retrospectively analyzed clinical features, outcomes, and measurable residual disease (MRD) of 659 AML (12%, n = 81, with a trisomy 8) patients subjected to allogeneic HSCT as a consolidation therapy. Results: The presence of a trisomy 8 associated with a trend for higher age at diagnosis, AML of secondary origin, lower white blood cell counts at diagnosis, worse ELN2017 genetic risk, wild-type NPM1, and mutated IDH1/2 and JAK2. Outcomes after allogeneic HSCT in the entire cohort did not differ between patients with a sole trisomy 8, trisomy 8 with additional cytogenetic aberrations or without a trisomy 8. A trisomy 8 did not affect outcomes within the three ELN2017 risk groups. In accordance with findings in unselected patient cohorts, persistent MRD at allogeneic HSCT in patients with a trisomy 8 identified individuals with a higher risk of relapse following allogeneic HSCT. Conclusions: Outcomes of trisomy 8 patients after allogeneic HSCT did not compare unfavorably to that of other AML patients following allogeneic HSCT. Rather than the presence or absence of a trisomy 8, additional genetic aberrations and MRD at HSCT define outcome differences and aid in informed treatment decisions

Case Report: Graft Versus Tumor Effect After Non-Myeloablative Allogeneic Stem-Cell Transplantation in a Patient With Brentuximab-Vedotin Refractory Sezary Syndrome

Sezary Syndrome (SS) is a rare leukemic variant of primary cutaneous T-cell lymphoma. Relapsed or refractory disease is generally considered incurable by conventional therapeutic approaches, although durable responses can be achieved with novel monoclonal antibodies. Allogeneic hematopoietic stem cell transplantation (alloHSCT) may have potential value by inducing graft vs-lymphoma (GvL) effects, but there is currently no consensus regarding the timing of alloHSCT or type of conditioning regimen. Here we present the case of a male patient who achieved a complete remission (CR) of primary refractory SS after non-myeloablative alloHSCT. Patient: Two years prior to HSCT, the patient had been refractory to CHOEP-based chemotherapy, interferon, extracorporeal photopheresis (ECP), and bexarotene. Directly prior to alloHSCT brentuximab-vedotin (BV) was applied resulting in a partial remission of the skin compartment and overall in a stable disease. Prior to HSCT, flow cytometry of the bone marrow and peripheral blood showed an infiltration with T-cells positive for CD5, CD4, low CD3, low CD2 and negative for CD7, CD38, HLA-DR and CD8. The trephine biopsy showed a 7% infiltration of SS cells. The CD4:CD8 ratio in peripheral blood (pb) was massively increased at 76.67, with 63.5% of white blood cells expressing a SS immune phenotype. The conditioning regimen included 30 mg/m2 fludarabine on days -5, -4 and -3 and total body irradiation with 2 Gy on day -1. Immunosuppression consisted of cyclosporine A from day-1 and mycophenolate mofetil from day 0. The patient received 6.55x106 CD34+ cells and 1.11x108 CD3+ cells/kg body weight. Bone marrow evaluation on day 28 still showed persistent SS cells by flow cytometry. After tapering immunosuppression until day 169, the CD4:CD8 ratio in pb normalized. CR was documented on day 169 after alloHSCT and is now ongoing for almost 3 years after alloHSCT. Conclusions: We confirm that an alloHSCT can be a curative option for refractory patients with SS. The achievement of a CR after tapering the immunosuppressive therapy indicates a significant role of the GvL effect. In present treatment algorithms for patients with SS, the timing of an alloHSCT and the intensity of conditioning should be further explored

Case Report: Allogeneic Stem Cell Transplantation Following Induction With CPX-351 in Patients With Acute Myeloid Leukemia Is Feasible

Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) and treatment-related acutemyeloid leukemia (tAML) after chemotherapy or radiation therapy for other neoplasms are associated with poor outcomes. CPX-351, a dual-drug liposomal encapsulation of daunorubicin and cytarabine, has been shown to improve outcomes in AML-MRC and tAML compared with standard 7+3 regimens. Here we report the cases of four consecutive patients with AML-MRC or tAML who received CPX-351 as outpatient induction therapy immediately followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT). Two patients received allo-HSCT in remission (one in complete remission and one in partial remission) and two patients received allo-HSCT in aplasia (one at 11 days and one at 52 days after the start of induction therapy with CPX-351). With a median follow-up of 188 days after allo-HSCT, all but one patient are alive and two are in remission. Further studies will help define and expand the role of CPX-351 in the treatment of AML-MRC and tAML, especially in patients expected to undergo allo-HSCT

Analysis of stem cell collections in adult patients with Ewing sarcoma

Background: Ewing sarcoma is one of the most frequent soft-tissue tumors in pediatric patients. The current treatment protocols recommend stem cell apheresis (SCA) after completion of the second course of induction therapy with vincristine, ifosfamide, doxorubicine, and etoposide (VIDE). The feasibility of SCA and graft compositions in adult patients with Ewing sarcoma have not been previously analyzed. Methods and Materials: The authors analyzed 29 stem cell collections of 19 adult patients (9 male, 10 female) at a median age of 27 (range 19–53) years mobilized after VIDE (n = 17), cyclophosphamide/topotecan (n = 1) or vincristine, dactinomycin and ifosfamide (n = 1) chemotherapy. All patients were mobilized with filgrastim 5 μg/kg twice daily from day +7 of chemotherapy. The collections were performed if CD34+ cell count in peripheral blood was >10/μL. The target yields were ≥4106 CD34+ cells/kg body weight. Results: Median CD34+ cells/μL in peripheral blood before SCA were 45.8 (range 6.7–614.4)/μL. The median cumulative yields were 10.6 (range 1.5–38.8) CD34+ cells/kg body weight and ≥2106 in all but two patients (89%). CD34, CD3, and CD56 yields in collections after the third VIDE and after later courses did not differ. Four patients underwent high-dose therapy with autologous transplantation, and all were engrafted. Discussion: Stem cell mobilization is feasible in most Ewing sarcoma patients. Additionally, the present study's data suggest that it is safe to postpone stem cell collection to a later VIDE chemotherapy cycle if medically indicate

Salvage Therapy With Polatuzumab Vedotin, Bendamustine, and Rituximab Prior to Allogeneic Hematopoietic Transplantation in Patients With Aggressive Lymphomas Relapsing After Therapy With Chimeric Antigen Receptor T-Cells—Report on Two Cases

Up to 60% of patients with aggressive B-cell lymphoma who receive chimeric antigen receptor (CAR) T-cell therapy experience treatment failure and subsequently have a poor prognosis. Allogeneic hematopoietic stem cell transplantation (alloHSCT) remains a potentially curative approach for patients in this situation. Induction of a deep response prior to alloHSCT is crucial for long-term outcomes, but the optimal bridging strategy following relapse after CAR T-cell therapy has not yet been established. Polatuzumab vedotin, an antibody drug conjugate targeting CD79b, is a novel treatment option for use in combination with rituximab and bendamustine (Pola-BR) in relapsed or refractory disease. Patients: We report two heavily pretreated patients with primary refractory diffuse large Bcell lymphoma (DLBCL) and primary mediastinal B-cell lymphoma (PMBCL) respectively who relapsed after therapy with CAR T-cells with both nodal and extranodal manifestations of the disease. After application of three courses of Pola-BR both patients achieved a complete metabolic remission. Both patients underwent alloHSCT from a human leukocyte antigen (HLA)-mismatched donor following conditioning with busulfan and fludarabine and are disease free 362 days and 195 days after alloHSCT respectively. We conclude that Pola-BR can be an effective bridging therapy before alloHSCT of patients relapsing after CAR T-cell therapy. Further studies will be necessary to define the depth and durability of remission of this salvage regimen before alloHSCT

The EnMAP Observation Planning and Data Access for Scientific Users

EnMAP (Environmental Mapping and Analysis Program; www.enmap.org) is the first German imaging spectroscopy mission, to be launched in April 2022. After its Launch, Early Orbit and Commissioning Phase (6 months), the EnMAP mission will be available to the international user community for the data access and ordering process. EnMAP will be operated by the German Aerospace Center (DLR) covering all aspects relevant to assure successful mission operations. This comprises controlling and commanding the satellite using multi-mission infrastructures as well as observation planning, data reception, hyperspectral data processing including calibration, data archiving, data access and delivery, and providing web-interfaces to the international user community. This presentation will give an overview of EnMAP observation planning and data access concepts and outlines the data ordering workflow in particular for scientific users. The user can get access to EnMAP data using two different order options: On the one hand the user can submit future order requests through the EnMAP Data Access Portal (EDAP). The EDAP links to a set of functions for registered users that will support the international user community. This portal includes amongst others the proposal portal allowing submission of proposal for all scientific users responding to a Data Announcement of Opportunity (AO) and the Observation Request Portal providing planning support of observation requests and allowing submission of future orders. On the other hand, the already recorded data can be searched, processed and delivered based on catalogue from the archive through the EOWEB® GeoPortal. Although EnMAP is based on an open data policy and every type of user is in principle entitled to download data and request acquisitions, there will be different user categories to set acquisition priorities. The scientific (Cat-1) orders has higher priority and is requested to submit a proposal, which will undergo a scientific evaluation. The associated results will be presented by an interactive map supporting the establishment of a worldwide user network and guarantee the highest transparency of the proposal process. In the Observation Portal the user is able to submit future order requests by specifying following order parameters, such as the geographic area of interest (AOI) (between 74° North and 74° South), length of the AOI as a multiple of 30 km and up to 1000 km, the specification of the maximum allowable tilt angle of the satellite across the orbit (5° to 30°), the time span in which the acquisition should be performed and the option for time series and the number of data takes per months. To ensure acceptable illumination conditions, only images with sun zenith angle lower 60° will be considered. As for data acquisition EnMAP will be able to collect 5000 km along track and 30 km across track per day. The probability that the order will be included in the mission planning depends on the requirements for the observation as well as the specified priority and quota. Whether a specific data take is scheduled at the end depends on factors such as e.g. available data storage, cloud probabilities (e.g. historical and predicted cloud coverage) and, if requested by the user, sunglint probability (this is relevant for water products only). Users should make a request at least 25 hours before the scheduled recording to ensure the uplink. All data are available no later than 24 hours after collection for further processing into data products. The EnMAP ground segment will provide a range of standardized data products with different levels of processing of Level 1B, Level 1C and Level 2A based on archived Level 0 comprising extensive quicklooks and metadata. Due to required multiple processing options, each product is generated specifically for the order and delivered using FTPS (FTP with SSL) provided by multi-mission facilities