Outcomes associated with allogeneic hematopoietic stem cell transplantation for relapsed and refractory Hodgkin lymphoma in the era of novel agents

BACKGROUND

Relapsed or refractory Hodgkin lymphoma (R/R HL) is a challenging disease with limited treatment options beyond brentuximab vedotin and checkpoint inhibitors. Herein we present the time-trend analysis of R/R HL patients who received allogeneic hematopoietic cell transplantation (allo-HCT) at our center from 2001-2017.

METHODS

The patients were divided into two distinct treatment cohorts: era1 (2001-2010), and era2 (2011-2017). The primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), non-relapse mortality (NRM), and cumulative incidence of acute and chronic graft versus host disease (GVHD).

RESULTS

Among the 51 patients included in the study, 29 were in era1, and 22 were in era2. There was decreased use of myeloablative conditioning in era2 (18% vs. 31%) compared to era1 and 95% of patients in era2 previously received brentuximab Vedotin (BV). Haploidentical donors were seen exclusively in era2 (0% vs. 14%) and more patients received alternative donor transplants (7% vs. 32%) in era2. The 4-year OS (34% vs. 83%, p < 0.001) and 4-year PFS (28% vs. 62%, p = 0.001) were significantly inferior in era1 compared to era2. The incidence of 1-year NRM was lower in era2 compared to era1 (5% vs. 34%, p = 0.06). The cumulative incidence of acute GVHD at day 100 was similar in both eras (p = 0.50), but the incidence of chronic GVHD at 1 year was higher in era2 compared to era1 (55% vs. 21%, p = 0.03).

CONCLUSIONS

Despite the advent of novel therapies, allo-HCT remains an important therapeutic option for patients with R/R HL.

Outcomes of patients with diffuse large B-cell and high-grade B-cell lymphomas with synchronous CNS and systemic involvement at diagnosis treated with high-dose methotrexate and R-CHOP: a single-center retrospective study

Background:

The optimal treatment of patients with systemic diffuse large B-cell (DLBCL) or high-grade B-cell (HGBL) lymphomas with synchronous central nervous system (CNS) involvement at diagnosis is not well defined. High-dose methotrexate administered concurrently with R-CHOP (RM-CHOP) is a commonly used regimen, but data on outcomes achieved with this regimen are limited.

Objective:

To report our experience with RM-CHOP in patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis.

Design:

A single-center retrospective analysis.

Methods:

We identified consecutive patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis who were treated with RM-CHOP from January 2012 to January 2021.

Results:

Fifty patients were included with a median age of 62 years; 82% had DLBCL (n = 41) and 18% had HGBL (n = 9). Treatment with RM-CHOP was followed by consolidative autologous hematopoietic cell transplantation in 14 patients (28%). The complete response (CR) rate following RM-CHOP was 62%. With a median follow-up of 40 months, the median progression-free (PFS) and overall (OS) survivals were 16 and 58 months, and the 2-year PFS and OS were 41% and 57%, respectively. The 2-year cumulative incidence of CNS progression/relapse was 29%. Outcomes were particularly poor in HGBL, with median PFS and OS of 6 and 7 months, compared with median PFS and OS of 22 months and not reached in DLBCL, respectively. The outcomes of patients with relapsed/progressive disease were poor, with only 63% of patients receiving subsequent treatments and only 21% achieving CR to next subsequent treatment. Most patients (58%) with disease relapse/progression had CNS involvement which was associated with very poor outcomes (median OS of 2 months).

Conclusion:

CNS involvement in aggressive B-cell non-Hodgkin lymphoma at diagnosis dictates clinical outcomes and requires more effective treatment options.

T-Cell Lymphomas, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of lymphoproliferative disorders arising from mature T cells, accounting for about 10% of non-Hodgkin lymphomas. PTCL-not otherwise specified is the most common subtype, followed by angioimmunoblastic T-cell lymphoma, anaplastic large cell lymphoma, anaplastic lymphoma kinase-positive, anaplastic large cell lymphoma, anaplastic lymphoma kinase-negative, and enteropathy-associated T-cell lymphoma. This discussion section focuses on the diagnosis and treatment of PTCLs as outlined in the NCCN Guidelines for T-Cell Lymphomas.

Cytokines in the Pathogenesis of Large Granular Lymphocytic Leukemia

Large granular lymphocytic leukemia (LGLL) is a lymphoproliferative disorder of older adults characterized by the clonal expansion of cytotoxic T/natural killer cells due to constitutive pro-survival signaling. In recent years, it has become clear that cytokines and their receptors are aberrantly expressed in LGLL cells. The exact initiation process of LGLL is unknown, although several cytokine-driven mechanisms have emerged. Elevated levels of several cytokines, including interleukin-15 (IL-15) and platelet-derived growth factor (PDGF), have been described in LGLL patients. Evidence from humans and animal models has shown that cytokines may also contribute to the co-occurrence of a wide range of autoimmune diseases seen in patients with LGLL. The goal of this review is to provide a comprehensive analysis of the link between cytokines and pro-survival signaling in LGLL and to discuss the various strategies and research approaches that are being utilized to study this link. This review will also highlight the importance of cytokine-targeted therapeutics in the treatment of LGLL.

Impact of Race and Geographic Area of Residence on Outcomes After Allogeneic Stem Cell Transplant

Background

Allogeneic hematopoietic stem cell transplant (allo-HCT) is a potential curative therapy for a variety of hematologic disorders. However, it requires highly specialized care that is only available at select centers across the country. Thus, minority populations are at risk for healthcare disparities in access to and outcomes of allo-HCT. Our study aimed to assess the impact of race and location of residence on outcomes of allo-HCT.

Methods

We performed a retrospective analysis of all patients who underwent allo-HCT at the Ohio State University from 1984 to 2018. Patients were divided by race (Caucasian, African American, and other) and grouped by zip code into rural, suburban, and urban groups. Primary endpoints included progression-free survival (PFS) and overall survival (OS).

Results

Of the 1,943 patients included in the study, 94.3% self-identified as Caucasian, 4.6% African American, and 1.1% other. In total, 63.4% lived in rural areas, 22.9% suburban, and 13.8% urban. There was no significant difference in OS or PFS by race (p = 0.15, 0.21) or place of residence (p = 0.39, 0.17). In addition, no difference in nonrelapse mortality, acute and chronic graft-versus-host disease (GVHD), and GVHD-free relapse-free survival (GRFS) was seen among the race or place of residence.

Conclusion

Our study suggests that when appropriate access to HCT is given, there is no difference in outcomes based on race, ethnicity or place of primary residence. Further research is needed to further evaluate barriers for these patients to undergo transplant and help mitigate these barriers.

Cytopenias After CD19 Chimeric Antigen Receptor T-Cells (CAR-T) Therapy for Diffuse Large B-Cell Lymphomas or Transformed Follicular Lymphoma: A Single Institution Experience

INTRODUCTION

Patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL) have poor outcomes. Treatment with CD19 chimeric antigen receptor (CAR-T) cells, tisagenlecleucel and axicabtagene ciloleucel, has been associated with improved outcomes. Cytopenias were observed in clinical trials with both products; however, little is known regarding the patterns and outcomes of these cytopenias.

SUBJECTS AND METHODS

We reviewed DLBCL patients (n=32) receiving either product between January and September 2018 at our institution.

RESULTS

Median duration of leukopenia, neutropenia, lymphopenia, anemia, and thrombocytopenia was 49, 9, 117.5, 125, and 95.5 days after CAR-T infusion, respectively. Filgrastim was used in 63% of patients, and 50% of patients received red cell or platelet transfusions. With the exception of neutropenia, increase in the duration of cytopenia of any lineage was associated with improvement in progression-free survival, and in overall survival in case of anemia. There was no association between the duration of cytopenias with either cytokine release syndrome or neurotoxicity.

DISCUSSION

Our data suggest a correlation between cytopenias and survival outcomes after CD19 CAR-T therapy. If validated, cytopenia may be proven useful as a biomarker of response and survival after CAR-T therapy.

Renal trace elements in barren-ground caribou subpopulations: Temporal trends and differing effects of sex, age and season

Caribou (Rangifer tarandus) are a culturally significant food resource for communities in northern Canada and Greenland. Many barren-ground caribou subpopulations are currently in decline, some dramatically; understanding the influence of stressors, such as toxic trace metals, is important. These contaminants enter Arctic terrestrial environments via atmospheric transport from industrialized areas and from local sources, accumulating there in the environment. Understanding how trace element concentrations interact and are influenced by caribou sex, age and season of collection is essential to evaluating trends in these elements over time and differences among subpopulations. We used path analysis to model the direct and indirect relationships between these variables in the Porcupine subpopulation and in barren-ground caribou from the Canadian Arctic and Greenland. Renal cadmium (Cd), copper (Cu) and mercury (Hg) varied significantly among subpopulations. Hg was positively correlated with Cd, Cu and selenium (Se) in female Porcupine caribou whereas Cd and Cu were negatively correlated in male Porcupine caribou. Age, season and sex influenced all three element concentrations and should be considered when comparing elements among caribou subpopulations or years. Renal Cd decreased slightly from the Canadian Western Arctic to Greenland and increased slightly over time, possibly reflecting patterns of atmospheric deposition. Renal Hg did not change significantly over time, and differences among subpopulations did not follow specific geographical patterns. Renal Cu declined over time, the changes being markedly different among subpopulations, sexes and seasons. This temporal decline is likely due to changes in diet, which could be driven by various environmental factors. Declining Cu concentrations in caribou is of concern as low levels could negatively affect reproductive success and therefore caribou at a population level. Continuing to monitor element concentrations in caribou is essential to better comprehend potential threats facing the species, and to promote food security in communities harvesting this important resource.

Fluoroquinolone Prophylaxis in Autologous Stem Cell Transplantation: Worthy of a Second Look

Prophylaxis with fluoroquinolone (FQ) for patients undergoing autologous stem cell transplantation (ASCT) remains controversial. We performed a retrospective review of patients undergoing ASCT with and without bacterial prophylaxis to compare endpoints of interest. In accordance with institutional policy, patients undergoing ASCT for multiple myeloma routinely receive levofloxacin prophylaxis during their period of neutropenia, whereas patients undergoing the ASCT for lymphoma do not. We retrospectively examined patients with multiple myeloma (MM) or lymphoma undergoing ASCT between July 2015 and July 2018 for evidence of positive blood cultures. A total of 172 patients underwent ASCT for lymphoma and 343 underwent ASCT for MM. The 2 cohorts were similar in terms of baseline characteristics. Almost 20% (35 of 172) of the patients with lymphoma and 5.2% (18 of 342) of those with MM had a bloodstream infection (BSI). BSI occurred an average of 2 days earlier in patients with lymphoma compared with patients with MM (day +5 versus day +7; P = .0003). The 2 cohorts recovered absolute neutrophil count at the same time. Hospital length of stay was 2 days shorter for patients with MM (median, 20 days versus 18 days; P = .01). The majority of the organisms were gram-negative in both cohorts. Of the organisms commonly tested for FQ sensitivity, only 1 of 25 was resistant in the lymphoma cohort, compared with 7 of 9 in the MM cohort (P < .0001), with 4 being multidrug resistant. The odds of developing a BSI were 4.6 times greater in the lymphoma cohort compared with the MM cohort (95% confidence interval [CI], 2.52 to 8.40; P < .0001). In total, 23 of 172 patients with lymphoma (13.4%) and 28 of 342 patients with MM (8.2%) developed Clostridium difficile infection (odds ratio, 1.73; 95% CI, .96 to 3.11; P = .066). Two infection-related deaths occurred in the MM cohort. Our data indicate that FQ prophylaxis reduces the risk of BSI in patients undergoing ASCT but increases the incidence of resistant organisms. We recommend routine antimicrobial prophylaxis in patients undergoing ASCT to reduce the risk of BSI, along with a systematic and regular review of outcomes.

Abstract LB-102: Extranodal natural killer/T cell lymphoma (ENKTL) exhibits an unprecedented degree of global DNA hypermethylation, providing a potent targeted therapy in vivo

Extranodal natural killer/T cell lymphoma (ENKTL) is a rare aggressive form of non-Hodgkin lymphoma that is uniformly EBV-positive. Despite the implementation of combinatorial chemotherapies, almost all patients with advanced ENKTL die of their disease. The rational identification of potential novel therapeutic targets in ENKTL would be greatly aided by a more complete understanding of its molecular pathogenesis. We have identified atypical NK cell populations in untreated ENKTL patient samples. These atypical NK cells consistently showed an undifferentiated immunophenotype reminiscent of immature NK developmental stages. As cellular differentiation depends on epigenetic modifications and EBV is known to disrupt epigenetic patterns, we performed genome-wide DNA methylation profiling of ENKTL tumors (n=31 patients) using Illumina MethylationEPIC BeadChip arrays. We uncovered an unprecedented degree of epigenetic dysregulation in ENKTL, primarily involving extensive DNA hypermethylation. In the majority of ENKTL cases, greater than 50% of all CpG islands were hypermethylated, thus representing the most hypermethylated tumor type identified relative to available pan-cancer data (TCGA). In order to explore strategies to target the aberrant DNA hypermethylation in ENKTL, we exposed ENKTL cell lines YT and NK-92 to the demethylating agent 5-azacytidine (5-aza). We observed an unusually high sensitivity of ENKTL cell lines to 5-aza when compared to various other hematologic cancer cell lines, including several EBV-positive lymphoma lines. Hypomethylating agents altered DNA methylation at gene promoters and led to re-expression of epigenetically-silenced tumor suppressor genes in ENKTL cells. We also found synergistic inhibition of in vitro cell growth when combining 5-aza with the standard-of-care chemotherapeutic agents oxaliplatin and gemcitabine. Finally, through engraftment of primary ENKTL patient tumor cells, we have established a patient-derived xenograft (PDX) ENKTL mouse model. In this model, treatment with 5-aza resulted in profound cytoreduction, phenotypic and molecular differentiation of ENKTL cells, as well as significantly prolonged survival. In summary, we report massive, widespread DNA hypermethylation in ENKTL that exceeds the degree of hypermethylation found in other profiled cancers, including other EBV-positive malignancies. We hypothesize that epigenetic dysregulation plays a central role in ENKTL and rational targeting with epigenetic therapies may provide therapeutic benefit to patients. Our ongoing studies aim to identify the optimal epigenetic therapy and potential synergy with chemotherapy in preclinical models, thus providing the basis for novel treatments for ENKTL.

Citation Format: Christoph Weigel, Bethany L. Mundy-Bosse, Yue-Zhong Wu, Kathleen McConnell, Anjali Mishra, Michael A. Caligiuri, Robert A. Baiocchi, Yaso Natkunam, Pierluigi Porcu, Jonathan Brammer, Aharon G. Freud, Christopher C. Oakes. Extranodal natural killer/T cell lymphoma (ENKTL) exhibits an unprecedented degree of global DNA hypermethylation, providing a potent targeted therapy in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-102.

Emerging insights on the pathogenesis and treatment of extranodal NK/T cell lymphomas (ENKTL)

Extranodal NK/T-cell lymphoma (ENKTL) is a rare aggressive extranodal non-Hodgkin lymphoma (NHL) universally associated with Epstein-Barr virus (EBV). ENKTL most commonly occurs in non-elderly immune competent males in Asia and South America. A number of antecedent lymphoproliferative disorders (LPDs) have been described in Asian and South American patients, but the majority of Caucasian ENKTL patients have no known preceding LPD or underlying immunodeficiency. Other than EBV, no environmental or extrinsic factor has been implicated in oncogenesis. The precise mechanisms by which EBV infects NK or T cells and the virus' role in the pathogenesis of ENKTL have not been fully deciphered. However, a number of recent discoveries including disturbances in cell signaling and mutations in tumor suppressor genes have been identified, which are providing insights into the pathogenesis of ENKTL. In this review, we highlight the molecular, viral, and genetic underpinnings of ENKTL and discuss potential therapeutic implications.

Postpartum spontaneous coronary dissection presenting with ventricular fibrillation

Background

Spontaneous coronary artery dissection is a rare cause of acute coronary syndromes; and one quarter of these patients present during the post-partum period. Furthermore, ventricular fibrillation is a rare presentation of this disease entity.

Case

A 32-year-old woman presented 3 days post Cesarean-section delivery with chest pain, ischemic electrocardiogram changes, and ventricular fibrillation arrest. The patient was taken for cardiac catheterization and found to have a left anterior coronary artery dissection necessitating 6 stents to restore flow to the vessel.

Conclusion

We report the first case of survival after ventricular fibrillation arrest of a woman presenting with spontaneous coronary dissection in the post-partum period. Our case underscores the importance of recognizing ventricular fibrillation as a first presenting sign of spontaneous coronary artery dissection in the post-partum period.

Developing clinical competency in crisis event management: an integrated simulation problem-based learning activity

This study aimed to evaluate the integration of a simulation based learning activity on nursing students' clinical crisis management performance in a problem-based learning (PBL) curriculum. It was hypothesized that the clinical performance of first year nursing students who participated in a simulated learning activity during the PBL session would be superior to those who completed the conventional problem-based session. The students were allocated into either simulation with problem-based discussion (SPBD) or problem-based discussion (PBD) for scenarios on respiratory and cardiac distress. Following completion of each scenario, students from both groups were invited to sit an optional individual test involving a systematic assessment and immediate management of a simulated patient facing a crisis event. A total of thirty students participated in the first post test related to a respiratory scenario and thirty-three participated in the second post test related to a cardiac scenario. Their clinical performances were scored using a checklist. Mean test scores for students completing the SPBD were significantly higher than those who completing the PBD for both the first post test (SPBD 20.08, PBD 18.19) and second post test (SPBD 27.56, PBD 23.07). Incorporation of simulation learning activities into problem-based discussion appeared to be an effective educational strategy for teaching nursing students to assess and manage crisis events.