The Clinical Significance of Diagnostic Red Cell Distribution Width in Patients with Acute Myeloid Leukemia

Introduction: Acute myeloid leukemia (AML) is a highly heterogeneous disease which renders risk stratification at diagnosis of high importance to personalize therapy. Allogeneic hematopoietic stem cell transplantation (HSCT) offers the highest chance for sustained remission in most AML patients, but usually comes at the risk of a significant treatment-related mortality. The red cell distribution width (RDW) is an universally accessible parameter that identifies individuals with a higher mortality in many diseases, including some hematological entities. However, the impact of diagnostic RDW levels in AML – especially in the context of a HSCT consolidation - has not been evaluated so far. Purpose: To evaluate the prognostic impact of RDW levels at AML diagnosis. Methods: A total of 294 newly diagnosed AML patients (median age 60.6, range 14.3-76.5 years), with available diagnostic RDW levels were retrospectively included in this analysis. All patients received a consolidation therapy with an allogeneic HSCT in curative intention between August 2007 and December 2020 at the University Medical Center Leipzig. The RDW was measured in all patients at AML diagnosis before the start of cytoreductive therapies. Results: RDW levels at diagnosis were highly variable (median 16.6%, range 12%-30.6%) and above the upper level of normal (>15%) in 73% of the analyzed AML patients. Patients with RDW levels above 15% did not have worse outcomes compared to patients with low diagnostic RDW levels. However, when the cohort was dichotomized according to a receiver operating characteristic (ROC)-based optimal cut-point (20.7%), patients with high RDW levels had a significantly higher non-relapse mortality (NRM), shorter overall survival and a trend for shorter event-free survival, while the risk of relapse or disease progression was similar in both groups. In multivariate analyses, the RDW remained an independent prognostic factor for higher NRM after adjustment for the body mass index at diagnosis. Patients with a higher RDW were more likely to harbor a secondary AML, as well as to harbor secondary AML-associated gene mutations (i.e. JAK2, ASXL1, or spliceosome mutations, especially SRSF2). Conclusion: High RDW levels at diagnosis represent an independent risk marker for a higher mortality following allogeneic HSCT. When confirmed in prospective clinical trials, the RDW might help to personalize AML consolidation therapy including conditioning regimens before allogeneic HSCT.:1. Bibliographische Beschreibung 2. Abkürzungsverzeichnis 3. Einführung / Introduction 3.1. Acute Myeloid Leukemia 3.1.1. Definition 3.1.2. Epidemiology and etiology 3.1.3. Clinical presentation 3.1.4. Diagnosis of AML 3.1.4.1. Morphology 3.1.4.2. Immunophenotyping 3.1.4.3. Cytogenetic and molecular analyses 3.1.5. AML classification according to WHO classification 3.1.6. Prognostic factors in AML 3.1.6.1. Patient-related risk factors 3.1.6.2. Genetic risk factors 3.1.6.3. Measurable residual disease 3.1.7. Treatment of AML 3.1.7.1. Induction therapy in curative intention 3.1.7.2. Consolidation therapies 3.1.7.3. Palliative treatment approaches 3.1.7.4. New substances 3.2. Allogeneic HSCT 3.2.1. Principles of allogeneic HSCT 3.2.2. Conditioning regimens 3.3. Red cell distribution width 4. Aufgabenstellung / Objectives 5. Materialien und Methoden / Materials and Methods 5.1. Patients and treatments 5.1.1. Treatment protocols 5.1.2. Allogeneic HSCT and immunosuppression 5.1.3. Assessment of GvHD 5.2. Disease characterization 5.2.1. Evaluation at AML diagnosis 5.2.1.1. Morphology 5.2.1.2. Flow cytometry 5.2.1.3. Genetic analyses 5.2.1.4. Evaluation of RDW levels 5.2.2. Evaluation at HSCT 5.2.2.1. Definition of remission status at HSCT 5.2.2.2. Evaluation of measurable residual disease at HSCT 5.3. Statistical Analyses 5.3.1. Associations 5.3.2. Clinical endpoints 5.3.3. Definition of an optimal cut-point for RDW levels 5.3.4. Multivariate analyses 6. Ergebnisse / Results 6.1. Overall outcomes of the patient cohort 6.2. RDW levels at AML diagnosis regarded as continous parameter 6.3. The role of RDW levels at diagnosis as a predictor for outcomes after allogeneic HSCT 6.4. Associations of RDW levels at diagnosis 7. Diskussion / Discussion 8. Zusammenfassung / Summary 9. Literaturverzeichnis / References 10. Erklärung über die eigenständige Abfassung der Arbeit 11. Curriculum Vitae 12. Komplette Publikationsliste (Peer-reviewed) 13. Danksagun

Production and Application of CAR T Cells: Current and Future Role of Europe

Rapid developments in the field of CAR T cells offer important new opportunities while at the same time increasing numbers of patients pose major challenges. This review is summarizing on the one hand the state of the art in CAR T cell trials with a unique perspective on the role that Europe is playing. On the other hand, an overview of reproducible processing techniques is presented, from manual or semi-automated up to fully automated manufacturing of clinical-grade CAR T cells. Besides regulatory requirements, an outlook is given in the direction of digitally controlled automated manufacturing in order to lower cost and complexity and to address CAR T cell products for a greater number of patients and a variety of malignant diseases

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

Human leukocyte antigen-E mismatch is associated with better hematopoietic stem cell transplantation outcome in acute leukemia patients

The immunomodulatory role of human leukocyte antigen (HLA)-E in hematopoietic stem cell transplantation (HSCT) has not been extensively investigated. To this end, we genotyped 509 10/10 HLA unrelated transplant pairs for HLA-E, in order to study the effect of HLA-E as a natural killer (NK)-alloreactivity mediator on HSCT outcome in an acute leukemia (AL) setting. Overall survival (OS), disease free survival (DFS), relapse incidence (RI) and non-relapse mortality (NRM) were set as endpoints. Analysis of our data revealed a significant correlation between HLA-E mismatch and improved HSCT outcome, as shown by both univariate (53% vs. 38%, P=0.002, 5-year OS) and multivariate (hazard ratio (HR)=0.63, confidence interval (CI) 95%=0.48–0.83, P=0.001) analyses. Further subgroup analysis demonstrated that the positive effect of HLA-E mismatch was significant and pronounced in advanced disease patients (n=120) (5-year OS: 50% vs. 18%, P=0.005; HR=0.40, CI 95%=0.22–0.72, P=0.002; results from univariate and multivariate analyses, respectively). The study herein is the first to report an association between HLA-E incompatibility and improved post–transplant prognosis in AL patients who have undergone matched unrelated HSCT. Combined NK and T cell HLA-E-mediated mechanisms may account for the better outcomes observed. Notwithstanding the necessity for in vitro and confirmational studies, our findings highlight the clinical relevance of HLA-E matching and strongly support prospective HLA-E screening upon donor selection for matched AL unrelated HSCTs

Compliance with medical regimen among hematological cancer patients and its association with symptoms of posttraumatic stress disorder and adjustment disorder

BackgroundHematological cancer patients must comply with extensive medical instructions to prevent cancer progression or relapse. Psychological comorbidities and patient characteristics have been shown to affect compliance. However, the impact of posttraumatic stress disorder (PTSD) and adjustment disorder (AjD) on compliance in cancer patients remains unclear. This study aims to evaluate compliance in hematological cancer patients more comprehensively and to investigate its association with PTSD and AjD symptomatology as well as sociodemographic and medical factors.MethodsHematological cancer patients were cross-sectionally assessed via validated questionnaires for PTSD (PCL-5) and AjD (ADMN-20), and three internally developed items on compliance with medical regimen, with two referring to compliance behavior and one item assessing perceived difficulties with complying. Each compliance item was analyzed descriptively. Multiple linear regression models tested the association between compliance and PTSD and AjD symptomatology, sociodemographic and medical factors.ResultsIn total, 291 patients were included (response rate 58%). Nine out of ten patients reported to either never (67%) or rarely (25%) change their medical regimen. However, 8% reported to change it once in a while or often. Compliance behavior was mostly rated as very easy (36%) or easy (45%) to implement. Nevertheless, 19% perceived it to be partly difficult or difficult to follow medical regimen. Symptoms of AjD (β = 0.31, p < 0.001) were associated with more difficulties to comply. Higher compliance behavior in turn was associated with stem cell transplantation (SCT) treatment (β = −0.21, p < 0.001) and lower education (β = −0.19, p = 0.002).ConclusionAlthough most patients indicated that they comply with medical regimen, a considerable subgroup of patients indicated subjectively perceived difficulties and thus seem to require additional support in implementing medical instructions possibly through improved medical communication and patient health literacy or shared decision-making

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

Allogeneic Hematopoietic Stem Cell Transplantation in a Rare Case of Tonsillar Mast Cell Sarcoma

Mast cell sarcoma comprises a rare aggressive mast cell neoplasia with histological, clinical, and genetic features distinct from other mast cell neoplasm. Until now, prognosis is still poor due to high rates of progression to mast cell leukemia and failure of conventional chemotherapies. Our here presented first report about successful allogeneic hematopoietic stem cell transplantation leading to remission in a case of tonsillar MCS represents a promising potential curative treatment option for this rare and often fatal disease. Key-Points: - Mast cell sarcoma (MCS) is a rare, aggressive mast cell neoplasia with a very poor prognosis and a median survival of <18 months. - Allo-HSCT represents a promising potential curative treatment option for this rare and often fatal disease

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

Advanced Flow Cytometry Assays for Immune Monitoring of CAR-T Cell Applications

Adoptive immunotherapy using chimeric antigen receptor (CAR)-T cells has achieved successful remissions in refractory B-cell leukemia and B-cell lymphomas. In order to estimate both success and severe side effects of CAR-T cell therapies, longitudinal monitoring of the patient’s immune system including CAR-T cells is desirable to accompany clinical staging. To conduct research on the fate and immunological impact of infused CAR-T cells, we established standardized 13-colour/15-parameter flow cytometry assays that are suitable to characterize immune cell subpopulations in the peripheral blood during CAR-T cell treatment. The respective staining technology is based on pre-formulated dry antibody panels in a uniform format. Additionally, further antibodies of choice can be added to address specific clinical or research questions. We designed panels for the anti-CD19 CAR-T therapy and, as a proof of concept, we assessed a healthy individual and three B-cell lymphoma patients treated with anti-CD19 CAR-T cells. We analyzed the presence of anti-CD19 CAR-T cells as well as residual CD19+ B cells, the activation status of the T-cell compartment, the expression of co-stimulatory signaling molecules and cytotoxic agents such as perforin and granzyme B. In summary, this work introduces standardized and modular flow cytometry assays for CAR-T cell clinical research, which could also be adapted in the future as quality controls during the CART cell manufacturing process