BCL2-Family Dysregulation in B-Cell Malignancies: From Gene Expression Regulation to a Targeted Therapy Biomarker

BCL2-family proteins have a central role in the mitochondrial apoptosis machinery and their expression is known to be deregulated in many cancer types. Effort in the development of small molecules that selectively target anti-apoptotic members of this family i.e., Bcl-2, Bcl-xL, Mcl-1 recently opened novel therapeutic opportunities. Among these apoptosis-inducing agents, BH3-mimetics (i.e., venetoclax) led to promising preclinical and clinical activity in B cell malignancies. However, several mechanisms of intrinsic or acquired resistance have been described ex vivo therefore predictive markers of response as well as mechanism-based combinations have to be designed. In the present study, we analyzed the expression of the BCL2-family genes across 10 mature B cell malignancies through computational normalization of 21 publicly available Affimetrix datasets gathering 1,219 patient samples. To better understand the deregulation of anti- and pro-apoptotic members of the BCL2-family in hematological disorders, we first compared gene expression profiles of malignant B cells to their relative normal control (naïve B cell to plasma cells, n = 37). We further assessed BCL2-family expression according to tissue localization i.e., peripheral blood, bone marrow, and lymph node, molecular subgroups or disease status i.e., indolent to aggressive. Across all cancer types, we showed that anti-apoptotic genes are upregulated while pro-apoptotic genes are downregulated when compared to normal counterpart cells. Of interest, our analysis highlighted that, independently of the nature of malignant B cells, the pro-apoptotic BH3-only BCL2L11 and PMAIP1 are deeply repressed in tumor niches, suggesting a central role of the microenvironment in their regulation. In addition, we showed selective modulations across molecular subgroups and showed that the BCL2-family expression profile was related to tumor aggressiveness. Finally, by integrating recent data on venetoclax-monotherapy clinical activity with the expression of BCL2-family members involved in the venetoclax response, we determined that the ratio (BCL2+BCL2L11+BAX)/BCL2L1 was the strongest predictor of venetoclax response for mature B cell malignancies in vivo

Assessment by Whole Exon Sequencing of pathway dysregulations in Multiple Myeloma and their functional impacts, notably on p53 pathway

Au sein des hémopathies malignes B, les plasmocytoses malignes (myélome multiple [MM) et leucémie à plasmocyte [PCLI) occupent une place particulière par leur biologie et leurs aspects cliniques. Biologiquement, elles présentent une forte proportion d’anomalies oncogéniques· (RAS, c-MYC) et de fréquentes altérations de la voie p53 (CDKN2ADel, TP53Del/Mut) qui conduisent, cliniquement, à l’inefficacité des traitements cytostatiques conventionnels. Des lignées cellulaires de MM (HMCls) qui recouvrent en partie la diversité des patients ont été générées depuis 50 ans. Nous avons caractérisé l’exome complet de 33 lignées cellulaires humaines de MM. Les mutations faux-sens sont les plus fréquentes (92%). les HMCLs portent entre 307 et 916 mutant par HMCL, TP53 étant le gène le plus altéré (67%). Des pertes bi-alléliques des voies du cycle cellulaire (CDKN2C, RB1), de la voie NFkB (TRAF3, BIRC2) et de la voie p53 (TP53, CDKN2A) sont fréquentes. La fréquence des mutations/délétion est semblable à celle des patients ( DIS3, PRDM1, KRAS), ou majorée (TP53, CDKN2C, NRAS, PRKD2). la voie MAPK est lá plus altérée (82% des HMCls), principalement par des mutants de RAS: peu décrites, les HMCLs présentent des altérations des voies épigénétiques (73%), de l’ anémie de Fanconi (54%) et très peu d’anonalies directes de la machinerie apoptotique. Nous avons mis en relation les données dexpression, de mutation/délétion et de réponse aux traitements et démontré que l’efficacité de plusieurs traitements est indépendante des mutations. Finalement, le développement de stratégies prenant en compte ces altérations peu décrites dans le MM (Fanconi, Epigenetique) sont nécessaires.Among B CeH malignancies, plasma-cell the NFKB pathway (TRAF3, BIRC2) and the p53 malignancies (multiple myeloma [MM] and plasma cell pathway (TP53, CDKN2A). Frequency of leukemia [PCL]) harbor particular biological and mutations/deletions in HMCLs were either similar to clinical insights. Biologically, they present with both a that of patients (e.g. DIS3, PRDM1, KRAS), or highly high frequency of oncogenic abnormalities (RAS, e- increased (e.g. TP53, CDKN2C, NRAS, PRKD2). MYC) and a high frequency of p53 pathway MAPK was the most altered pathway (82% of abnormalities (CDKN2Adel, TP53 del/mut). Those two HMCLs), mainly by RAS mutants. Surprisingly, latter leading to chemo-resistance to conventional HMCLs displayed alterations in epigenetic (73%) and cytostatic drugs. Human myeloma cell lines (HMCLs) Fanconi anemia (54%) and few alterations in are widely used for their representation of primary apoptotic machinery. We further identified mutually myeloma cells as they cover patient diversity, exclusive and associated mutations/deletions in afthough not fully. We performed whole-exon genes involved in the MAPK and p53 pathways as sequencing of 33 HMCLs, which were established well as in chromatin regulator/modifier genes. over the last 50 years. Missense mutations were the Finally, by combining the gene expression profile, most frequent mutations {92%). HMCLs harbored gene mutation. gene deletion and drug response, we between 307 and 916 mutations per sample, with demonstrated that several targeted drugs overcome TP53 being the most mutated gene (67%). Recurrent or bypass some mutations bi-allelic losses were found in genes involved in cell cycle regulation (RB1. CDKN2C)

Les indications actuelles et futures des cellules T à récepteur antigénique chimérique dans les lymphomes

International audienceLes cellules T à récepteur antigénique chimérique (CAR-T) ont fait leur apparition dans le paysage thérapeutique français il y a maintenant deux ans. L’efficacité dans les lymphomes B de haut grade est maintenant acquise avec une survie de 40 à 50 % à deux ans dans les essais thérapeutiques, bénéfice qui semble se reproduire dans les études en vie réelle. Actuellement, les efforts se concentrent sur l’amélioration de l’efficacité de ces traitements, en y associant des immunomodulateurs des fonctions lymphocytaires T, ou en précisant mieux les patients devant en bénéficier. Plusieurs essais sont en cours en première ligne, ainsi que trois essais randomisés qui les confrontent à l’intensification thérapeutique en deuxième ligne dans les lymphomes diffus à grandes cellules B. Dans le lymphome à cellules du manteau, les résultats sont plus récents, mais près des deux tiers des patients ont obtenu une rémission complète dans l’essai ZUMA-2. Avec un suivi moyen de deux ans, la réponse s’est maintenue dans 50 % des cas environ. Ces résultats permettent une utilisation temporaire du KTE-X19 dans le lymphome à cellules du manteau en France. Dans les autres histologies, notamment le lymphome folliculaire, le recul nécessaire à l’appréciation du bénéfice thérapeutique va prendre du temps dans cette pathologie indolente. Le développement des CAR-T dans la leucémie lymphoïde chronique semble plus complexe, les résultats initiaux prometteurs, notamment en association avec l’ibrutinib, semblant difficile à reproduire

Bridging Refract-Lyma and CHUN Clinical Data Warehouse: from a research cohort to a regional electronic medical record system and back

International audienc

Extensive myelitis with eosinophilic meningitis after Chimeric antigen receptor T cells therapy

Abstract Immune effector cell‐associated neurotoxicity syndrome (ICANS) is a frequent adverse event after Chimeric antigen receptor T cells (CAR‐T cells). A patient treated with anti‐CD19 CAR‐T cells for a refractory mantle cell lymphoma presented at Day 8 post‐infusion with extensive myelitis. Unusual eosinophilia was disclosed in the patient's cerebrospinal fluid. After treatment with methylprednisolone and siltuximab, a decrease in clinical symptoms and magnetic resonance imaging lesions were obtained. This unprecedented presentation of eosinophilic meningitis after CAR‐T cells therapy highlights the need for a better understanding of the physiopathology of ICANS, especially to identify potentially targetable pathways

PRIMA-1Met induces myeloma cell death independent of p53 by impairing the GSH/ROS balance

International audienceThe aim of this study was to assess the efficiency of p53 reactivation and induction of massive apoptosis (PRIMA-1(Met)) in inducing myeloma cell death, using 27 human myeloma cell lines (HMCLs) and 23 primary samples. Measuring the lethal dose (LD50) of HMCLs revealed that HMCLs displayed heterogeneous sensitivity, with an LD50 ranging from 4 μM to more than 200 μM. The sensitivity of HMCLs did not correlate with myeloma genomic heterogeneity or TP53 status, and PRIMA-1(Met) did not induce or increase expression of the p53 target genes CDKN1A or TNFRSF10B/DR5. However, PRIMA-1(Met) increased expression of NOXA in a p53-independent manner, and NOXA silencing decreased PRIMA1(Met)-induced cell death. PRIMA-1(Met) depleted glutathione (GSH) content and induced reactive oxygen species production. The expression of GSH synthetase correlated with PRIMA-1(Met) LD50 values, and we showed that a GSH decrease mediated by GSH synthetase silencing or by and L-buthionine sulphoximine, an irreversible inhibitor of γ-glutamylcysteine synthetase, increased PRIMA-1(Met)-induced cell death and overcame PRIMA-1(Met) resistance. PRIMA-1(Met) (10 μM) induced cell death in 65% of primary cells independent of the presence of del17p; did not increase DR5 expression, arguing against an activation of p53 pathway; and synergized with L-buthionine sulphoximine in all samples. Finally, we showed in mouse TP53(neg) JJN3-xenograft model that PRIMA-1(Met) inhibited myeloma growth and synergized with L-buthionine sulphoximine in vivo

Characteristics and Prognosis Factors of Pneumocystis jirovecii Pneumonia According to Underlying Disease

International audienceBackground: Pnemocystis jirovecii pneumonia (PcP) remains associated with high rates of mortality, and the impact of immunocompromising underlying disease on the clinical presentation, severity, and mortality of PcP has not been adequately evaluated.Research question: Does the underlying disease and immunosuppression causing PcP impact the outcome and clinical presentation of the disease?Study design and methods: In this multicenter retrospective observational study, conducted from January 2011 to December 2021, all consecutive patients admitted with a proven or probable diagnosis of PcP according to The European Organisation for Research and Treatment of Cancer consensus definitions were included to assess the epidemiology and impact of underlying immunosuppressive diseases on overall and 90-day mortality.Results: Overall, 481 patients were included in the study; 180 (37.4%) were defined as proven PcP and 301 (62.6%) were defined as probable PcP. Patients with immune-mediated inflammatory diseases (IMIDs) or solid tumors had a statistically poorer prognosis than other patients with PcP at day 90. In multivariate analysis, among the HIV-negative population, solid tumor underlying disease (OR, 5.47; 95% CI, 2.16-14.1; P < .001), IMIDs (OR, 2.19; 95% CI, 1.05-4.60; P = .037), long-term corticosteroid exposure (OR, 2.07; 95% CI, 1.03-4.31; P = .045), cysts in sputum/BAL smears (OR, 1.92; 95% CI, 1.02-3.62; P = .043), and SOFA score at admission (OR, 1.58; 95% CI, 1.39-1.82; P < .001) were independently associated with 90-day mortality. Prior corticotherapy was the only immunosuppressant associated with 90-day mortality (OR, 1.67; 95% CI, 1.03-2.71; P = .035), especially for a prednisone daily dose ≥ 10 mg (OR, 1.80; 95% CI, 1.14-2.85; P = .010).Interpretation: Among patients who were HIV-negative, long-term corticosteroid prior to PcP diagnosis was independently associated with increased 90-day mortality, specifically in patients with IMIDs. These results highlight both the needs for PcP prophylaxis in patients with IMIDs and to early consider PcP curative treatment in severe pneumonia among patients with IMIDs

Catastrophic adult-onset Still’s disease as a distinct life-threatening clinical subset: case–control study with dimension reduction analysis

International audienceObjectives: Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder. Diagnosing AOSD can be challenging, as disease presentation and clinical course are highly heterogeneous. For unclear reasons, a few patients develop life-threatening complications. Our objective was to determine whether these cases resulted from therapeutic delay or could represent a peculiar AOSD subset. Methods: We conducted a multicentre retrospective study of 20 AOSD patients with organ failure requiring intensive care unit admission and 41 control AOSD patients without organ failure. Clinico-biological data at hospital admission were explored using supervised analyses and unsupervised dimension reduction analysis (factor analysis of mixed data, FAMD). Results: Disease duration before admission was shorter in patients with life-threatening AOSD (median, 10 vs 20 days, p = 0.007). Disease duration before AOSD therapy initiation also tended to be shorter (median, 24 vs 32 days, p = 0.068). Despite this shorter disease duration, FAMD, hierarchical clustering and univariate analyses showed that these patients exhibited distinctive characteristics at first presentation, including younger age; higher frequency of splenomegaly, liver, cardiac and/or lung involvement; less frequent arthralgia; and higher ferritin level. In multivariate analysis, 3 parameters predicted life-threatening complications: lack of arthralgia, younger age and shorter time between fever onset and hospitalisation. Conclusion: This study suggests that life-threatening complications of AOSD occur very early, in a peculiar subset, which we propose to name catastrophic adult-onset Still's disease (CAOSD). Its exact burden may be underestimated and remains to be clarified through large multicentre cohorts. Further studies are needed to identify red flags and define the optimal therapeutic strategy

Obinutuzumab Versus Rituximab in Transplant Eligible Untreated MCL Patients, a Matching Comparison between the Lyma and Lyma-101 Trials

International audienceAim: Obinutuzumab (O) and Rituximab (R) have never been compared in a prospective randomized trial in mantle cell lymphoma (MCL). The LYMA-101 trial (NCT02896582) investigated the Obinutuzumab-DHAP (O-DHAP) regimen followed by autologous stem cell transplant (O-BEAM, ASCT) plus O maintenance (OM) in transplant eligible patients &amp;amp;amp;lt;66y with untreated MCL (Le Gouill et al, Lancet Hem 2020). The LYMA trial (NCT00921414) used the same regimen with Rituximab instead of Obinutuzumab (Le Gouill et al, NEJM 2017). Herein, we report the long-term outcome of patients enrolled in the LYMA-101 trial and used a propensity score matching (PSM) approach to allow a comparison with patients treated in the LYMA trial (i.e. O versus R group matched comparison). Method: LYMA (n=299 pts, of whom 120 received R Maintenance, RM) is a phase III prospective trial with a median follow-up of 7.5 years (7.4-7.7) from inclusion (Sarkozy et al, ASCO 2023) that randomized, after ASCT, 240 pts between observation and RM. LYMA-101 (n=86) is a prospective single arm phase 2 trial with a median FU of 5.1y (5-5.25) at the time of the present analysis. We first compared minimal residual disease (MRD) at end of induction (EOI), assessed in both trial with quantitative PCR of clonal immunoglobulin gene and used PSM based on clinical characteristics at inclusion (Sex, Ann Arbor stage, MIPI score, B symptoms, blastoid variant, bulky disease) to balance patients&amp;#039; discrepancies between LYMA-101 and LYMA. To compare PFS and OS from inclusion of patients treated with R versus O based regimen, half of the non-randomized LYMA patients (29 out of 58) were randomly reattributed to the RM arm to create an intention to treat RM (RM-ITT) arm including 149 pts (29 non-randomized and 120 randomized) subsequently matched with the 86 LYMA-101 pts. Balance between populations was checked using standardized mean differences (SMD). Results: Eighty-five LYMA-101 pts received the first course of O-DHAP (1 withdrew consent before treatment), 81 (95.3%) completed the 4 cycles and 73 (85.9%) underwent ASCT followed by OM in 69 (81.2%). The estimated 5y PFS and OS since inclusion were 83.4% (95%CI: 73.5-89.8%) and 86.9% (95%CI: 77.6-92.5%) respectively. At EOI, ORR were similar in both studies (89.6% versus 91.8% in LYMA versus LYMA-101 respectively), but within responders, pts treated in LYMA-101 (O-DHAP) had a more frequent MRD negativity than pts treated in LYMA (R-DHAP) both in bone marrow (BM, 82.1% versus 65.3% MRD negativity in O vs R group, Chi2 p=0.011) and blood (95.5% versus 79.2% of MRD negativity in O vs R group, Chi2 p=0.002). These results were confirmed using the propensity score matched populations, with a more frequent MRD negativity in the O versus R group in BM (82.1% vs 63.4%, Chi-2, p=0.01) and blood (95.5% vs 72.9%, Chi-2, p&amp;amp;amp;lt;0.001). To compare PFS and OS since induction, a PSM was performed using the 149 patients treated in the R-group with an RM-ITT and the 85 patients in the O group, resulting in 2 sets of 82 patients with comparable characteristics at inclusion. From treatment initiation, patients treated with O presented a prolonged PFS (p=0.029, figure 1A) and OS (p=0.039, figure 1B) compared to those treated with R, with an estimated 5-year PFS of 82.8% versus 66.6% (HR 1.99, IC95 1.05-3.76) and OS of 86.4% versus 71.4% (HR 2.08, IC95 1.01-4.16) with O and R based regimen respectively. Finally, 37/120 (30.8%) patients in LYMA and 23/69 (33.3%) in LYMA-101 prematurely stopped R and OM respectively (with a similar mean maintenance duration of 29 and 29.4m with R and OM respectively). Reason for maintenance discontinuation were adverse events in 15 cases in R group (12.5% of the population) versus 14 cases in O group (20% of the population), progression or death in 10 (8.3%) versus 3 (4.3%) cases in the R versus O group respectively. Causes of death were comparable in O and R groups, the most common being lymphoma (42% in O and 53% in R group). Infectious deaths in the O group (N=3) were all COVID related (3/12 deaths, 25%), whereas in the R group (LYMA being conducted before the pandemic), 8 deaths were related to infection (8/97 deaths, 8%, including 1 infectious death out of 22 deaths during RM, 5%). Conclusion: O-DHAP followed by OM post ASCT provide prolonged PFS and OS in young patients with MCL. O-based therapy in MCL induce deeper response with increased MRD negativity and seems to outperform R-based therapy in term of PFS and OS, without any significant excess of toxicity

Description of neurotoxicity in a series of patients treated with CAR T-cell therapy

International audienceAbstract Chimeric antigen receptor-modified T (CAR T) cell therapy is a highly promising treatment for haematological malignancies but is frequently associated with cytokine release syndrome and neurotoxicity. Between July 2018 and July 2019, all patients treated with CD19-targeted CAR T-cell therapy for relapsing lymphoma were followed-up longitudinally to describe neurological symptoms and their evolution over time. Four different French centres participated and 84 patients (median age 59 years, 31% females) were included. Neurotoxicity, defined as the presence of at least one neurological symptom appearing after treatment infusion, was reported in 43% of the patients. The median time to onset was 7 days after infusion with a median duration of 6 days. More than half of the patients (64%) had grade 1–2 severity and 34% had grade 3–4. CRS was observed in 80% of all patients. The most frequent neurological symptoms were cognitive signs, being severe in 36%, and were equally distributed between language disorders and cognitive disorders without language impairment. Non-pyramidal motor disorders, severe in 11%, were reported in 42% of the patients. Elevation of C-reactive protein (CRP) within 4 days after treatment was significantly correlated with the occurrence of grade 3–4 neurotoxicity. Although sometimes severe, neurotoxicity was almost always reversible. The efficacy of steroids and antiepileptic drugs remains unproven in the management of neurotoxicity. Neurotoxicity associated with CAR T-cell therapies occurs in more than 40% of patients. The clinical pattern is heterogeneous but cognitive disorders (not limited to language disorders) and, to a minor degree, non-pyramidal motor disorders, appeared as a signature of severe neurotoxicity