bims-tremyl 2021-10-17 papers

on Therapy resistance biology in myeloid leukemia

Issue of 2021‒10‒17
twenty-six papers selected by
Paolo Gallipoli
Barts Cancer Institute, Queen Mary University of London

Pevonedistat targets malignant cells in myeloproliferative neoplasms in vitro and in vivo via NFkB pathway inhibition.
FMS-Like Tyrosine Kinase 3 Inhibitors for the Treatment of Acute Myeloid Leukemia.
GATM-Mediated Creatine Biosynthesis Enables Maintenance of FLT3-ITD-Mutant Acute Myeloid Leukemia.
ZNF521 Enhances MLL-AF9-Dependent Hematopoietic Stem Cell Transformation in Acute Myeloid Leukemias by Altering the Gene Expression Landscape.
Mutation signatures of pediatric acute myeloid leukemia and normal blood progenitors associated with differential patient outcomes.
KAT2A complexes ATAC and SAGA play unique roles in cell maintenance and identity in hematopoiesis and leukemia.
Outcomes of older patients aged 60 to 70 years undergoing reduced intensity transplant for acute myeloblastic leukemia: results of the NCRI acute myeloid leukemia 16 trial.
Clonal Architecture and Evolutionary Dynamics in Acute Myeloid Leukemias.
Allogeneic hematopoietic cell transplantation for acute myeloid leukemia in first complete remission after 5-azacitidine and venetoclax: a multicenter retrospective study.
Genetic features and clinical outcomes of patients with isolated and comutated DDX41-mutated myeloid neoplasms.
Targeting Acute Myeloid Leukemia Using the RevCAR Platform: A Programmable, Switchable and Combinatorial Strategy.
Patient characteristics, treatment patterns, and mortality in elderly patients newly diagnosed with acute myeloid leukemia meeting ineligibility criteria for high intensity chemotherapy.
BCL-2 Inhibitor ABT-737 Effectively Targets Leukemia-Initiating Cells with Differential Regulation of Relevant Genes Leading to Extended Survival in a NRAS/BCL-2 Mouse Model of High Risk-Myelodysplastic Syndrome.
The CADM1 tumor suppressor gene is a major candidate gene in MDS with deletion of the long arm of chromosome 11.
Clonal hematopoiesis is associated with risk of severe Covid-19.
Venetoclax and azacitidine followed by allogeneic transplant results in excellent outcomes and may improve outcomes versus maintenance therapy among newly diagnosed AML patients older than 60.
Combined Drug Targeting of p53-dependent and -independent Pathways Depletes Myelofibrosis Hematopoietic Stem/Progenitor Cells.
Mutant clones in normal epithelium outcompete and eliminate emerging tumours.
Carfilzomib Enhances the Suppressive Effect of Ruxolitinib in Myelofibrosis.
Insufficiency of FZR1 disturbs HSC quiescence by inhibiting ubiquitin-dependent degradation of RUNX1 in aplastic anemia.
The wider perspective: twenty years of clinical trials in myelodysplastic syndromes.
Promyelocytic leukemia protein targets MK2 to promote cytotoxicity.
Clonal hematopoiesis driven by DNMT3A and TET2 mutations: role in monocyte and macrophage biology and atherosclerotic cardiovascular disease.
Functional Precision Medicine Provides Clinical Benefit in Advanced Aggressive Hematological Cancers and Identifies Exceptional Responders.
Blastic plasmocitoid dendritic cell neoplasm with leukemic spread: a GIMEMA survey.
KMT2A-CBL rearrangements in acute leukemias: clinical characteristics and genetic breakpoints.

Blood Adv. 2021 Oct 13. pii: bloodadvances.2020002804. [Epub ahead of print]

Pevonedistat targets malignant cells in myeloproliferative neoplasms in vitro and in vivo via NFkB pathway inhibition.

Tim Kong, Angelo Brunelli Albertoni Laranjeira, Taylor Collins, Elisa S De Togni, Abigail J Wong, Mary C Fulbright, Marianna Ruzinova, Hamza Celik, Grant Challen, Daniel A C Fisher, Stephen T Oh.

Targeted inhibitors of JAK2 (e.g. ruxolitinib) often provide symptomatic relief for myeloproliferative neoplasm (MPN) patients, but the malignant clone persists and remains susceptible to disease transformation. These observations suggest that targeting alternative dysregulated signaling pathways may provide therapeutic benefit. Previous studies identified NFϰB pathway hyperactivation in myelofibrosis (MF) and secondary acute myeloid leukemia (sAML) that was insensitive to JAK2 inhibition. Here, we provide evidence that NFϰB pathway inhibition via pevonedistat targets malignant cells in MPN patient samples as well as in MPN and patient-derived xenograft mouse models that is non-redundant with ruxolitinib. Colony forming assays revealed preferential inhibition of MF colony growth compared to normal colony formation. In mass cytometry studies, pevonedistat blunted canonical TNFα responses in MF and sAML patient CD34+ cells. Pevonedistat also inhibited hyperproduction of inflammatory cytokines more effectively than ruxolitinib. Upon pevonedistat treatment alone or in combination with ruxolitinib, MPN mouse models exhibited reduced disease burden and improved survival. These studies demonstrating efficacy of pevonedistat in MPN cells in vitro as well as in vivo provide a rationale for therapeutic inhibition of NFϰB signaling for MF treatment. Based on these findings, a Phase I clinical trial combining pevonedistat with ruxolitinib has been initiated.

DOI: https://doi.org/10.1182/bloodadvances.2020002804
Clin Lymphoma Myeloma Leuk. 2021 Sep 16. pii: S2152-2650(21)02034-6. [Epub ahead of print]

FMS-Like Tyrosine Kinase 3 Inhibitors for the Treatment of Acute Myeloid Leukemia.

Elli D Novatcheva, Yasmine Anouty, Ila Saunders, James K Mangan, Aaron M Goodman.

  Acute myeloid leukemia (AML) is the most common acute leukemia of adults, with a five-year survival that remains poor (approximately 25%). Knowledge and understanding of AML genomics have expanded tremendously over the past decade and are now included in AML prognostication and treatment decisions. FMS-like tyrosine kinase 3 (FLT3) is a Class III receptor tyrosine kinase (RTK) expressed primarily in the cell membranes of early hematopoietic progenitor cells, found in 28% of all patients with AML. FLT3 is the second most frequent mutation in adult AML following Nuclear-cytoplasmic shuttling phosphoprotein (NPM1), which is found in 50% of cases.1 FLT3 inhibitors are promising new molecular therapeutics increasingly becoming standard of care for both newly diagnosed and relapsed/refractory FLT3 positive AML. This review will focus on the clinical trials/evidence, similarities, differences, clinical toxicities, and drug interactions relevant to treating clinicians as pertains to 5 FLT3-inhibitors: midostaurin, sorafenib, gilteritinib, crenolanib, and quizartinib.

Keywords:  AML; Crenolanib; FLT3-ITD; FLT3-TKD; Gilteritinib; Midostaurin; Quizartinib; Sorafenib

DOI:  https://doi.org/10.1016/j.clml.2021.09.002
Mol Cancer Res. 2021 Oct 11. pii: molcanres.MCR-21-0314-E.2021. [Epub ahead of print]

GATM-Mediated Creatine Biosynthesis Enables Maintenance of FLT3-ITD-Mutant Acute Myeloid Leukemia.

Yuan Zhang, Kimberly J Newsom, Mei Zhang, Jeffry S Kelley, Petr Starostik.

FMS-like tyrosine kinase 3 (FLT3) is one of the most frequently mutated genes in acute myeloid leukemia (AML), with the most common mutation being internal tandem duplications (ITDs). The presence of FLT3-ITD in AML carries a particularly poor prognosis and renders therapeutic resistance. New druggable targets are thus needed in this disease. In this study, we demonstrate the effects of de novo creatine biosynthesis upregulation by FLT3-ITD on AML sustainability. Our data show that FLT3-ITD constitutively activates the STAT5 signaling pathway, which upregulates the expression of glycine amidinotransferase (GATM), the first rate-limiting enzyme of de novo creatine biosynthesis. Pharmacological FLT3-ITD inhibition reduces intracellular creatinine levels through transcriptional down-regulation of genes in the de novo creatine biosynthesis pathway. The same reduction can be achieved by cyclocreatine or genetic GATM knock down with shRNA and is reflected in significant decrease of cell proliferation and moderate increase of cell apoptosis in FLT3-ITD mutant cell lines. Those effects are at least partially mediated through the AMPK/mTOR signaling pathway. This study uncovers a previously uncharacterized role of creatine metabolic pathway in the maintenance of FLT3-ITD mutant AML and suggests that targeting this pathway may serve as a promising therapeutic strategy for FLT3-ITD positive AML. Implications: FLT3-ITD mutation in AML upregulates de novo creatine biosynthesis that we show can be suppressed to diminish the proliferation and survival of blast cells.

DOI: https://doi.org/10.1158/1541-7786.MCR-21-0314
Int J Mol Sci. 2021 Oct 06. pii: 10814. [Epub ahead of print]22(19):

ZNF521 Enhances MLL-AF9-Dependent Hematopoietic Stem Cell Transformation in Acute Myeloid Leukemias by Altering the Gene Expression Landscape.

Emanuela Chiarella, Annamaria Aloisio, Stefania Scicchitano, Katia Todoerti, Emanuela G Cosentino, Daniela Lico, Antonino Neri, Nicola Amodio, Heather Mandy Bond, Maria Mesuraca.

  Leukemias derived from the MLL-AF9 rearrangement rely on dysfunctional transcriptional networks. ZNF521, a transcription co-factor implicated in the control of hematopoiesis, has been proposed to sustain leukemic transformation in collaboration with other oncogenes. Here, we demonstrate that ZNF521 mRNA levels correlate with specific genetic aberrations: in particular, the highest expression is observed in AMLs bearing MLL rearrangements, while the lowest is detected in AMLs with FLT3-ITD, NPM1, or CEBPα double mutations. In cord blood-derived CD34+ cells, enforced expression of ZNF521 provides a significant proliferative advantage and enhances MLL-AF9 effects on the induction of proliferation and the expansion of leukemic progenitor cells. Transcriptome analysis of primary CD34+ cultures displayed subsets of genes up-regulated by MLL-AF9 or ZNF521 single transgene overexpression as well as in MLL-AF9/ZNF521 combinations, at either the early or late time points of an in vitro leukemogenesis model. The silencing of ZNF521 in the MLL-AF9 + THP-1 cell line coherently results in an impairment of growth and clonogenicity, recapitulating the effects observed in primary cells. Taken together, these results underscore a role for ZNF521 in sustaining the self-renewal of the immature AML compartment, most likely through the perturbation of the gene expression landscape, which ultimately favors the expansion of MLL-AF9-transformed leukemic clones.

Keywords:  acute myeloid leukemia (AML); chromosomal translocations; cord blood-derived hematopoietic stem cells (CB-CD34+); fusion gene MLL-AF9; gene expression; human zinc finger protein 521 (hZNF521); mixed lineage leukemia gene (MLL) AF9 (MLLT3 or LTG9)

DOI:  https://doi.org/10.3390/ijms221910814
Blood Cancer Discov. 2021 Sep;2(5): 484-499

Mutation signatures of pediatric acute myeloid leukemia and normal blood progenitors associated with differential patient outcomes.

Arianne M Brandsma, Eline J M Bertrums, Markus J van Roosmalen, Damon A Hofman, Rurika Oka, Mark Verheul, Freek Manders, Joske Ubels, Mirjam E Belderbos, Ruben van Boxtel.

  Acquisition of oncogenic mutations with age is believed to be rate limiting for carcinogenesis. However, the incidence of leukemia in children is higher than in young adults. Here we compare somatic mutations across pediatric acute myeloid leukemia (pAML) patient-matched leukemic blasts and hematopoietic stem and progenitor cells (HSPCs), as well as HSPCs from age-matched healthy donors. HSPCs in the leukemic bone marrow have limited genetic relatedness and share few somatic mutations with the cell-of-origin of the malignant blasts, suggesting polyclonal hematopoiesis in pAML patients. Compared to normal HSPCs, a subset of pAML cases harbored more somatic mutations and a distinct composition of mutational process signatures. We hypothesize these cases might have arisen from a more committed progenitor. This subset had better outcomes than pAML cases with mutation burden comparable to age-matched healthy HSPCs. Our study provides insights into the etiology and patient stratification of pAML.

Keywords:  AML; HSC; childhood leukemia; human hematopoiesis; mutational processes; somatic mutations

DOI:  https://doi.org/10.1158/2643-3230.BCD-21-0010
Blood Adv. 2021 Oct 15. pii: bloodadvances.2020002842. [Epub ahead of print]

KAT2A complexes ATAC and SAGA play unique roles in cell maintenance and identity in hematopoiesis and leukemia.

Liliana Arede, Elena Foerner, Selinde Sterre Wind, Rashmi Kulkarni, Ana Filipa Domingues, George Giotopoulos, Svenja Kleinwächter, Maximilian Mollenhauer-Starkl, Holly Davison, Aditya Chandru, Ryan Asby, Ralph Samarista, Shikha Gupta, Dorian Forte, Antonio Curti, Elisabeth Scheer, Brian James Patrick Huntly, Laszlo Tora, Cristina Pina.

Epigenetic histone modifiers are key regulators of cell fate decisions in normal and malignant hematopoiesis. Their enzymatic activities are of particular significance as putative therapeutic targets in leukemia. In contrast, less is known about the contextual role in which those enzymatic activities are exercised, and specifically, how different macromolecular complexes configure the same enzymatic activity with distinct molecular and cellular consequences. We focus on KAT2A, a lysine acetyltransferase responsible for Histone 3 Lysine 9 acetylation, which we recently identified as a dependence in Acute Myeloid Leukemia stem cells, and that participates in 2 distinct macromolecular complexes: Ada Two-A-Containing (ATAC) and Spt-Ada-Gcn5-Acetyltransferase (SAGA). Through analysis of human cord blood hematopoietic stem cells and progenitors, and of myeloid leukemia cells, we identify unique respective contributions of the ATAC complex to regulation of biosynthetic activity in undifferentiated self-renewing cells, and of the SAGA complex to stabilisation or correct progression of cell type-specific programs with putative preservation of cell identity. Cell type and stage-specific dependencies on ATAC and SAGA-regulated programs explain multi-level KAT2A requirements in leukemia and in erythroid lineage specification and development. Importantly, they set a paradigm against which lineage specification and identity can be explored across developmental stem cell systems.

DOI: https://doi.org/10.1182/bloodadvances.2020002842
Haematologica. 2021 10 14.

Outcomes of older patients aged 60 to 70 years undergoing reduced intensity transplant for acute myeloblastic leukemia: results of the NCRI acute myeloid leukemia 16 trial.

Nigel H Russell, Robert K Hills, Abin Thomas, Ian Thomas, Lars Kjeldsen, Mike Dennis, Charles Craddock, Sylvie Freeman, Richard E Clark, Alan K Burnett.

Reduced Intensity Conditioning (RIC) transplantation is increasingly offered to older patients with acute myeloblastic leukemia (AML). We have previously shown that a RIC allograft, particularly from a sibling donor is beneficial in intermediate risk patients aged 35-65 years. We here present analyses from the NCRI AML16 trial extending this experience to older patients aged 60-70 inclusive lacking favorable risk cytogenetics 932 patients were studied, with RIC transplant in first remission given to 144 (sibling n=52, MUD n=92) with median follow-up for survival from CR of 60 months. Comparisons of transplant versus not are carried out using Mantel-Byar analysis. Among the 144 allografts, 93 had intermediate risk cytogenetics, 18 adverse and 33 were unknown. In transplanted patients survival was 37% at 5 years, and while the survival for siblings (44%) was better than that for MUDs (34%) this was not significant (p=0.2). When comparing RIC versus chemotherapy survival was significantly improved (37% vs 20%, HR 0.67 (0.53-0.84) p.

DOI: https://doi.org/10.3324/haematol.2021.279010
Cancers (Basel). 2021 Sep 29. pii: 4887. [Epub ahead of print]13(19):

Clonal Architecture and Evolutionary Dynamics in Acute Myeloid Leukemias.

Matthieu Duchmann, Lucie Laplane, Raphael Itzykson.

  Acute myeloid leukemias (AML) results from the accumulation of genetic and epigenetic alterations, often in the context of an aging hematopoietic environment. The development of high-throughput sequencing-and more recently, of single-cell technologies-has shed light on the intratumoral diversity of leukemic cells. Taking AML as a model disease, we review the multiple sources of genetic, epigenetic, and functional heterogeneity of leukemic cells and discuss the definition of a leukemic clone extending its definition beyond genetics. After introducing the two dimensions contributing to clonal diversity, namely, richness (number of leukemic clones) and evenness (distribution of clone sizes), we discuss the mechanisms at the origin of clonal emergence (mutation rate, number of generations, and effective size of the leukemic population) and the causes of clonal dynamics. We discuss the possible role of neutral drift, but also of cell-intrinsic and -extrinsic influences on clonal fitness. After reviewing available data on the prognostic role of genetic and epigenetic diversity of leukemic cells on patients' outcome, we discuss how a better understanding of AML as an evolutionary process could lead to the design of novel therapeutic strategies in this disease.

Keywords:  acute myeloid leukemia; clonal heterogeneity; drug resistance; evolutionary dynamics; prognosis

DOI:  https://doi.org/10.3390/cancers13194887
Ann Hematol. 2021 Oct 09.

Allogeneic hematopoietic cell transplantation for acute myeloid leukemia in first complete remission after 5-azacitidine and venetoclax: a multicenter retrospective study.

Oren Pasvolsky, Shai Shimony, Ron Ram, Avichai Shimoni, Liat Shargian, Batia Avni, Ofir Wolach, Tzippy Shochat, Ronit Yerushalmi, Odelia Amit, Pia Raanani, Moshe Yeshurun.

  The combination of hypomethylating agents and venetoclax has revolutionized the therapeutic landscape of acute myeloid leukemia (AML), especially for patients previously deemed unfit for curative-intent treatment. Some of these patients undergo allogeneic hematopoietic cell transplant (alloHCT); yet, there are scarce data regarding transplantation outcomes. We conducted a multicenter nationwide retrospective cohort study, including patients with AML who underwent alloHCT in CR1 after frontline treatment with azacitidine plus venetoclax only (aza-ven group). We collected a historical control group of patients who achieved CR1 after first-line intensive chemotherapy only, followed by alloHCT (intensive group). Patients in the aza-ven group (n = 24) were transplanted between 2019 and 2021. Compared to the intensive group, patients in the aza-ven group were older (median age 71.7 vs. 58.4 years), had higher incidence of therapy-related AML and AML with antecedent hematologic disorder and had more often adverse cytogenetics. They had a higher percentage of allografts from matched-unrelated donors, and reduced intensity conditioning was more commonly used. The estimated 12 months non relapse mortality was 19.1% in the aza-ven group and 11.8% in the intensive group. The estimated 12 months relapse-free survival and overall survival were 58% and 63% in the aza-ven group and 54% and 70% in the intensive group, respectively. The cumulative incidence of acute GVHD at 6 months and of chronic GVHD at 12 months were 58% and 40% in the aza-ven group and 62% and 42% in the intensive group, respectively. Analysis of the aza-ven group revealed that HCT-CI score and ELN risk category were predictive of RFS in both univariate analysis as well as multivariate analysis. Our data suggests that alloHCT for AML patients achieving first CR with aza-ven appears feasible, with short-term post-transplant outcomes similar to those expected after traditional intensive chemotherapy.

Keywords:  Acute myeloid leukemia; Allogeneic hematopoietic cell transplant; Azacitidine; Venetoclax

DOI:  https://doi.org/10.1007/s00277-021-04693-8
Blood Adv. 2021 Oct 13. pii: bloodadvances.2021005738. [Epub ahead of print]

Genetic features and clinical outcomes of patients with isolated and comutated DDX41-mutated myeloid neoplasms.

Hassan B Alkhateeb, Ahmad Nanaa, David S Viswanatha, James M Foran, Talha Badar, Lisa Sproat, Rong He, Phuong Nguyen, Dragan Jevremovic, Mohamad E Salama, Patricia Theresa Greipp, Naseema Gangat, Ayalew Tefferi, Mark R Litzow, Abhishek A Mangaonkar, Mithun Vinod Shah, Mrinal M Patnaik, Aref Al-Kali.

DDX41 mutations (germline and somatic) are associated with late onset myelodysplastic syndromes/acute myeloid leukemia (MDS/AML). Myeloid neoplasms (MN) with germline predisposition was identified as a distinct category in the 2016 WHO classification revision, including MN with germline DDX41 mutation. We retrospectively analyzed the molecular findings and clinical characteristics of thirty-three DDX41-mutated (mDDX41) patients at our institution. We identified 14 distinct pathogenic DDX41 variants in 32 patients and 8 DDX41 variants of unknown significance (VUS) in 9 patients. Five (16%) patients had a second DDX41 somatic mutation p.R525H and 13 (40%) had at least one additional oncogenic co-mutation in other genes. The median age at the time of diagnosis was 66 years, with male predominance (72%) and the majority of patients had normal cytogenetics (91%). Two-year overall survival (OS) was 86% and 6 (21%) MDS/AML patients with relatively preserved hematopoietic function were observed without further intervention. In comparison to AML patients with prognostically more favorable subtypes [t(8;21), n=27 and inv(16), n=40], mDDX41 patients in our cohort showed similarly favorable OS. Our study highlights that mDDX41-MN patients often have an indolent course and mDDX41-AML has comparable OS to favorable-risk AML.

DOI: https://doi.org/10.1182/bloodadvances.2021005738
Cancers (Basel). 2021 Sep 24. pii: 4785. [Epub ahead of print]13(19):

Targeting Acute Myeloid Leukemia Using the RevCAR Platform: A Programmable, Switchable and Combinatorial Strategy.

Enrico Kittel-Boselli, Karla Elizabeth González Soto, Liliana Rodrigues Loureiro, Anja Hoffmann, Ralf Bergmann, Claudia Arndt, Stefanie Koristka, Nicola Mitwasi, Alexandra Kegler, Tabea Bartsch, Nicole Berndt, Heidi Altmann, Frederick Fasslrinner, Martin Bornhäuser, Michael Philipp Bachmann, Anja Feldmann.

  Clinical translation of novel immunotherapeutic strategies such as chimeric antigen receptor (CAR) T-cells in acute myeloid leukemia (AML) is still at an early stage. Major challenges include immune escape and disease relapse demanding for further improvements in CAR design. To overcome such hurdles, we have invented the switchable, flexible and programmable adaptor Reverse (Rev) CAR platform. This consists of T-cells engineered with RevCARs that are primarily inactive as they express an extracellular short peptide epitope incapable of recognizing surface antigens. RevCAR T-cells can be redirected to tumor antigens and controlled by bispecific antibodies cross-linking RevCAR T- and tumor cells resulting in tumor lysis. Remarkably, the RevCAR platform enables combinatorial tumor targeting following Boolean logic gates. We herein show for the first time the applicability of the RevCAR platform to target myeloid malignancies like AML. Applying in vitro and in vivo models, we have proven that AML cell lines as well as patient-derived AML blasts were efficiently killed by redirected RevCAR T-cells targeting CD33 and CD123 in a flexible manner. Furthermore, by targeting both antigens, a Boolean AND gate logic targeting could be achieved using the RevCAR platform. These accomplishments pave the way towards an improved and personalized immunotherapy for AML patients.

Keywords:  acute myeloid leukemia (AML); chimeric antigen receptor (CAR); combinatorial gated targeting; tumor immunotherapy

DOI:  https://doi.org/10.3390/cancers13194785
Leuk Lymphoma. 2021 Oct 13. 1-11

Patient characteristics, treatment patterns, and mortality in elderly patients newly diagnosed with acute myeloid leukemia meeting ineligibility criteria for high intensity chemotherapy.

Shuling Li, Yuanyuan Ji, Yi Peng, Vamsi Kota, Christopher Kim.

  To describe patient characteristics, treatment patterns, and survival among elderly patients (≥66 years) newly diagnosed with acute myeloid leukemia (AML) meeting ≥1 ineligibility criteria for high-intensity chemotherapy (HIC; i.e. age >75 years, cardiac disease/prior anthracycline therapy, or secondary AML), we analyzed 2007-2017 100% Medicare hematologic cancer data. Patients were stratified based on whether they received HIC or low-intensity chemotherapy (LIC) or best supportive care (BSC) within 60 days after AML diagnosis. Of 4,152 patients, 43.2% received chemotherapy, 33.8% BSC, and 23.1% no therapy. Among chemotherapy-treated patients, HIC was more common than LIC (58.8 vs 41.2%), despite targeting patients meeting ≥1 ineligibility criteria for HIC. Poor overall survival was observed for patients receiving chemotherapy and BSC (median overall survival [interquartile range]: HIC, 1.9 [0.8, 6.6] months; LIC, 3.8 [1.4, 9.3] months; BSC, 1.0 [0.4, 2.5] months). Results highlight the need for additional effective and tolerable treatments for this population.

Keywords:  Acute myeloid leukemia; chemotherapy; elderly; real-world evidence; survival outcomes; treatment patterns

DOI:  https://doi.org/10.1080/10428194.2021.1973669
Int J Mol Sci. 2021 Sep 30. pii: 10658. [Epub ahead of print]22(19):

BCL-2 Inhibitor ABT-737 Effectively Targets Leukemia-Initiating Cells with Differential Regulation of Relevant Genes Leading to Extended Survival in a NRAS/BCL-2 Mouse Model of High Risk-Myelodysplastic Syndrome.

Petra Gorombei, Fabien Guidez, Saravanan Ganesan, Mathieu Chiquet, Andrea Pellagatti, Laure Goursaud, Nilgun Tekin, Stephanie Beurlet, Satyananda Patel, Laura Guerenne, Carole Le Pogam, Niclas Setterblad, Pierre de la Grange, Christophe LeBoeuf, Anne Janin, Maria-Elena Noguera, Laure Sarda-Mantel, Pascale Merlet, Jacqueline Boultwood, Marina Konopleva, Michael Andreeff, Robert West, Marika Pla, Lionel Adès, Pierre Fenaux, Patricia Krief, Christine Chomienne, Nader Omidvar, Rose Ann Padua.

  During transformation, myelodysplastic syndromes (MDS) are characterized by reducing apoptosis of bone marrow (BM) precursors. Mouse models of high risk (HR)-MDS and acute myelogenous leukemia (AML) post-MDS using mutant NRAS and overexpression of human BCL-2, known to be poor prognostic indicators of the human diseases, were created. We have reported the efficacy of the BCL-2 inhibitor, ABT-737, on the AML post-MDS model; here, we report that this BCL-2 inhibitor also significantly extended survival of the HR-MDS mouse model, with reductions of BM blasts and lineage negative/Sca1+/KIT+ (LSK) cells. Secondary transplants showed increased survival in treated compared to untreated mice. Unlike the AML model, BCL-2 expression and RAS activity decreased following treatment and the RAS:BCL-2 complex remained in the plasma membrane. Exon-specific gene expression profiling (GEP) of HR-MDS mice showed 1952 differentially regulated genes upon treatment, including genes important for the regulation of stem cells, differentiation, proliferation, oxidative phosphorylation, mitochondrial function, and apoptosis; relevant in human disease. Spliceosome genes, found to be abnormal in MDS patients and downregulated in our HR-MDS model, such as Rsrc1 and Wbp4, were upregulated by the treatment, as were genes involved in epigenetic regulation, such as DNMT3A and B, upregulated upon disease progression and downregulated upon treatment.

Keywords:  ABT-737; BCL-2; HR-MDS; gene regulation

DOI:  https://doi.org/10.3390/ijms221910658
Blood Adv. 2021 Oct 12. pii: bloodadvances.2021005311. [Epub ahead of print]

The CADM1 tumor suppressor gene is a major candidate gene in MDS with deletion of the long arm of chromosome 11.

Marina Lafage-Pochitaloff, Bastien Gerby, Véronique Baccini, Laetitia Largeaud, Vincent Fregona, Nais Prade, Pierre-Yves Juvin, Laura Audrey Jamrog, Pierre Bories, Sylvie Hébrard, Stéphanie Lagarde, Veronique Mansat-De Mas, Oliver M Dovey, Kosuke Yusa, George S Vassiliou, Joop H Jansen, Tobias Tekath, David Rombaut, Geneviève Ameye, Carole Barin, Audrey Bidet, John Boudjarane, Marie-Agnès Collonge-Rame, Carine Gervais, Antoine Ittel, Christine Lefebvre, Isabelle Luquet, Lucienne Michaux, Nathalie Nadal, Hélène Antoine-Poirel, Isabelle Radford-Weiss, Benedicte Ribourtout, Steven Richebourg, Stephanie Struski, Christine Terré, Isabelle Tigaud, Dominique Penther, Virginie Eclache, Michaela Fontenay, Cyril Broccardo, Eric Delabesse.

Myelodysplastic syndromes (MDS) represent a heterogeneous group of clonal hematopoietic stem-cell disorders characterized by ineffective hematopoiesis leading to peripheral cytopenias and in a substantial proportion of cases to acute myeloid leukemia. The deletion of the long arm of chromosome 11, del(11q), is a rare but recurrent clonal event in MDS. Here, we detail the largest series of 113 cases of MDS and myelodysplastic syndromes/myeloproliferative neoplasms (MDS/MPN) harboring a del(11q) analyzed at clinical, cytological, cytogenetic and molecular levels. Female predominance, a survival prognosis similar to other MDS, a low monocyte count and dysmegakaryopoiesis were the specific clinical and cytological features of del(11q) MDS. In most cases, del(11q) was isolated, primary and interstitial encompassing the 11q22-23 region containing ATM, KMT2A and CBL genes. The common deleted region at 11q23.2 is centered on an intergenic region between CADM1 (also known as TSLC1, Tumour Suppressor in Lung Cancer 1) and NXPE2. CADM1 was expressed in all myeloid cells analyzed in contrast to NXPE2. At the functional level, the deletion of Cadm1 in murine Lineage-Sca1+Kit+ cells modifies the lymphoid to myeloid ratio in bone marrow although not altering their multi-lineage hematopoietic reconstitution potential after syngenic transplantation. Together with the frequent simultaneous deletions of KMT2A, ATM and CBL and mutations of ASXL1, SF3B1 and CBL, we show that CADM1 may be important in the physiopathology of the del(11q) MDS, extending its role as tumor-suppressor gene from solid tumors to hematopoietic malignancies.

DOI: https://doi.org/10.1182/bloodadvances.2021005311
Nat Commun. 2021 10 13. 12(1): 5975

Clonal hematopoiesis is associated with risk of severe Covid-19.

Kelly L Bolton, Youngil Koh, Michael B Foote, Hogune Im, Justin Jee, Choong Hyun Sun, Anton Safonov, Ryan Ptashkin, Joon Ho Moon, Ji Yeon Lee, Jongtak Jung, Chang Kyung Kang, Kyoung-Ho Song, Pyoeng Gyun Choe, Wan Beom Park, Hong Bin Kim, Myoung-Don Oh, Han Song, Sugyeong Kim, Minal Patel, Andriy Derkach, Erika Gedvilaite, Kaitlyn A Tkachuk, Brian J Wiley, Ireaneus C Chan, Lior Z Braunstein, Teng Gao, Elli Papaemmanuil, N Esther Babady, Melissa S Pessin, Mini Kamboj, Luis A Diaz, Marc Ladanyi, Michael J Rauh, Pradeep Natarajan, Mitchell J Machiela, Philip Awadalla, Vijai Joseph, Kenneth Offit, Larry Norton, Michael F Berger, Ross L Levine, Eu Suk Kim, Nam Joong Kim, Ahmet Zehir.

Acquired somatic mutations in hematopoietic stem and progenitor cells (clonal hematopoiesis or CH) are associated with advanced age, increased risk of cardiovascular and malignant diseases, and decreased overall survival. These adverse sequelae may be mediated by altered inflammatory profiles observed in patients with CH. A pro-inflammatory immunologic profile is also associated with worse outcomes of certain infections, including SARS-CoV-2 and its associated disease Covid-19. Whether CH predisposes to severe Covid-19 or other infections is unknown. Among 525 individuals with Covid-19 from Memorial Sloan Kettering (MSK) and the Korean Clonal Hematopoiesis (KoCH) consortia, we show that CH is associated with severe Covid-19 outcomes (OR = 1.85, 95%=1.15-2.99, p = 0.01), in particular CH characterized by non-cancer driver mutations (OR = 2.01, 95% CI = 1.15-3.50, p = 0.01). We further explore the relationship between CH and risk of other infections in 14,211 solid tumor patients at MSK. CH is significantly associated with risk of Clostridium Difficile (HR = 2.01, 95% CI: 1.22-3.30, p = 6×10-3) and Streptococcus/Enterococcus infections (HR = 1.56, 95% CI = 1.15-2.13, p = 5×10-3). These findings suggest a relationship between CH and risk of severe infections that warrants further investigation.

DOI: https://doi.org/10.1038/s41467-021-26138-6
Bone Marrow Transplant. 2021 Oct 13.

Venetoclax and azacitidine followed by allogeneic transplant results in excellent outcomes and may improve outcomes versus maintenance therapy among newly diagnosed AML patients older than 60.

Daniel A Pollyea, Amanda Winters, Christine McMahon, Marc Schwartz, Craig T Jordan, Rachel Rabinovitch, Diana Abbott, Clayton A Smith, Jonathan A Gutman.

The combination of venetoclax (ven) and azacitidine (aza) has resulted in high response rates in the upfront treatment of AML in patients age > 75 and patients unfit for intensive chemotherapy. Given the poor historical outcomes in patients age ≥ 60 treated with induction chemotherapy, ven/aza has become our institutional preference for the initial treatment of non-core binding factor (CBF) AML patients age ≥ 60. The benefit of allogeneic stem cell transplant (SCT) in patients who achieve response to ven/aza is uncertain. We report outcomes of SCT-eligible patients treated at our center. Between 1/2015 and 1/2020, 119 newly diagnosed non-CBF AML patients age ≥ 60 received ven/aza as initial therapy. 21 patients underwent SCT; 31 additional patients were potentially SCT eligible but deferred SCT. Overall survival (OS) was significantly greater among SCT patients (median survival not reached) versus potentially SCT eligible patients not undergoing SCT (median 518 days) (p = 0.01). Our data suggest that ven/aza followed by SCT in newly diagnosed AML patients older than ≥ 60 results in excellent outcomes and likely improves outcomes over maintenance therapy. Ongoing investigation will further refine the optimal timing of and selection of patients for SCT based on prognostic disease features and response assessments.

DOI: https://doi.org/10.1038/s41409-021-01476-7
Leukemia. 2021 Oct 12.

Combined Drug Targeting of p53-dependent and -independent Pathways Depletes Myelofibrosis Hematopoietic Stem/Progenitor Cells.

Min Lu, Lijuan Xia, Nada Elmansy, Cara Clementelli, Douglas Tremblay, Ronald Hoffman.

Current therapy for myelofibrosis (MF) results in a limited prolongation of patient survival. In order to improve treatment outcomes, we developed a strategy to effectively deplete MF hematopoietic stem/progenitor cells (HSPCs). In the present study, an imipridone, ONC201, was combined with RG7112, an antagonist of MDM2, a p53 negative regulator, to activate downstream events of the p53 and TNF-related apoptosis-inducing ligand (TRAIL)/death receptor (DR) pathways. As compared to treatment with the individual drugs, the combination of ONC201 and RG7112 promoted greater degrees of apoptosis of MF CD34+ cells through activation of both p53-dependent and -independent pathways. Importantly, treatment with ONC201-RG7112 not only decreased the number of JAK2V617F+ and calreticulin mutated colonies assayed from MF CD34+ cells, but allowed for the persistence or appearance of JAK2 wild type colonies. Treatment with ONC201 combined with RG7112 could be a potentially effective strategy for treating MF patients.

DOI: https://doi.org/10.1038/s41375-021-01446-4
Nature. 2021 Oct 13.

Mutant clones in normal epithelium outcompete and eliminate emerging tumours.

B Colom, A Herms, M W J Hall, S C Dentro, C King, R K Sood, M P Alcolea, G Piedrafita, D Fernandez-Antoran, S H Ong, J C Fowler, K T Mahbubani, K Saeb-Parsy, M Gerstung, B A Hall, P H Jones.

Human epithelial tissues accumulate cancer-driver mutations with age1-9, yet tumour formation remains rare. The positive selection of these mutations suggests that they alter the behaviour and fitness of proliferating cells10-12. Thus, normal adult tissues become a patchwork of mutant clones competing for space and survival, with the fittest clones expanding by eliminating their less competitive neighbours11-14. However, little is known about how such dynamic competition in normal epithelia influences early tumorigenesis. Here we show that the majority of newly formed oesophageal tumours are eliminated through competition with mutant clones in the adjacent normal epithelium. We followed the fate of nascent, microscopic, pre-malignant tumours in a mouse model of oesophageal carcinogenesis and found that most were rapidly lost with no indication of tumour cell death, decreased proliferation or an anti-tumour immune response. However, deep sequencing of ten-day-old and one-year-old tumours showed evidence of selection on the surviving neoplasms. Induction of highly competitive clones in transgenic mice increased early tumour removal, whereas pharmacological inhibition of clonal competition reduced tumour loss. These results support a model in which survival of early neoplasms depends on their competitive fitness relative to that of mutant clones in the surrounding normal tissue. Mutant clones in normal epithelium have an unexpected anti-tumorigenic role in purging early tumours through cell competition, thereby preserving tissue integrity.

DOI: https://doi.org/10.1038/s41586-021-03965-7
Cancers (Basel). 2021 Sep 28. pii: 4863. [Epub ahead of print]13(19):

Carfilzomib Enhances the Suppressive Effect of Ruxolitinib in Myelofibrosis.

Simone Claudiani, Clinton C Mason, Dragana Milojkovic, Andrea Bianchi, Cristina Pellegrini, Antinisca Di Marco, Carme R Fiol, Mark Robinson, Kanagaraju Ponnusamy, Katya Mokretar, Avirup Chowdhury, Michael Albert, Alistair G Reid, Michael W Deininger, Kikkeri Naresh, Jane F Apperley, Jamshid S Khorashad.

  As the first FDA-approved tyrosine kinase inhibitor for treatment of patients with myelofibrosis (MF), ruxolitinib improves clinical symptoms but does not lead to eradication of the disease or significant reduction of the mutated allele burden. The resistance of MF clones against the suppressive action of ruxolitinib may be due to intrinsic or extrinsic mechanisms leading to activity of additional pro-survival genes or signalling pathways that function independently of JAK2/STAT5. To identify alternative therapeutic targets, we applied a pooled-shRNA library targeting ~5000 genes to a JAK2V617F-positive cell line under a variety of conditions, including absence or presence of ruxolitinib and in the presence of a bone marrow microenvironment-like culture medium. We identified several proteasomal gene family members as essential to HEL cell survival. The importance of these genes was validated in MF cells using the proteasomal inhibitor carfilzomib, which also enhanced lethality in combination with ruxolitinib. We also showed that proteasome gene expression is reduced by ruxolitinib in MF CD34+ cells and that additional targeting of proteasomal activity by carfilzomib enhances the inhibitory action of ruxolitinib in vitro. Hence, this study suggests a potential role for proteasome inhibitors in combination with ruxolitinib for management of MF patients.

Keywords:  carfilzomib; myelofibrosis; ruxolitinib; shRNA library screen

DOI:  https://doi.org/10.3390/cancers13194863
Leukemia. 2021 Oct 11.

Insufficiency of FZR1 disturbs HSC quiescence by inhibiting ubiquitin-dependent degradation of RUNX1 in aplastic anemia.

Chengfang Zhou, Mei Kuang, Zhilong Liu, Xiaoqin Jia, Zhe Chen, Yuanyuan Liu, Zhigang Li, Weiru Wu, Le Ma, Jieping Chen, Yu Hou.

FZR1 has been implicated as a master regulator of the cell cycle and quiescence, but its roles and molecular mechanisms in the pathogenesis of severe aplastic anemia (SAA) are unclear. Here, we report that FZR1 is downregulated in SAA HSCs compared with healthy control and is associated with decreased quiescence of HSC. Haploinsufficiency of Fzr1 shows impaired quiescence and self-renewal ability of HSC in two Fzr1 heterozygous knockout mouse models. Mechanistically, FZR1 insufficiency inhibits the ubiquitination of RUNX1 protein at lysine 125, leading to the accumulation of RUNX1 protein, which disturbs the quiescence of HSCs in SAA patients. Moreover, downregulation of Runx1 reversed the loss of quiescence and impaired long-term self-renew ability in Fzr1+/- HSCs in vivo and impaired repopulation capacity in BM from SAA patients in vitro. Our findings, therefore, raise the possibility of a decisive role of the FZR1-RUNX1 pathway in the pathogenesis of SAA via deregulation of HSC quiescence.

DOI: https://doi.org/10.1038/s41375-021-01445-5
Br J Haematol. 2021 Oct 10.

The wider perspective: twenty years of clinical trials in myelodysplastic syndromes.

Carolien Duetz, David G J Cucchi, Tobias B Polak, Jeroen J W M Janssen, Gert J Ossenkoppele, Elihu H Estey, Arjan A van de Loosdrecht.

  Most patients with myelodysplastic syndromes (MDS) require therapeutic intervention. However, there are few approved treatments for MDS. To explore reasons, we searched clinicaltrials.gov and clinicaltrialsregister.eu for MDS trials from 2000 to 2020. We assessed which agents were under investigation and analysed clinical trial characteristics and continuation rates from phase I to II to III to approval. As such, we identified 384 unique agents in 426 phase I, 430 phase II and 48 phase III trials. Success rates for phase III trials and agents were low, and MDS trials took markedly longer to complete than the average clinical trial. Although success rates were higher when MDS-specific phase I trials were conducted, 52% of the agents had not been evaluated in a phase I trial for MDS. MDS trials often failed to include quality of life, an especially important outcome for older MDS patients. Our work identifies factors potentially contributing to the paucity of available agents for MDS. We suggest a framework to improve clinical research in MDS that might ultimately augment the number of available agents.

Keywords:  clinical trials; drug development; myelodysplastic syndromes

DOI:  https://doi.org/10.1111/bjh.17892
EMBO Rep. 2021 Oct 11. e52254

Promyelocytic leukemia protein targets MK2 to promote cytotoxicity.

I-Ting Chen, Hsiao-Chi Chen, Yu-Hsun Lo, Peng-Yeh Lai, Fu-Yi Hsieh, Yung-Hsuan Wu, Hsiu-Ming Shih, Ming-Zong Lai.

  Promyelocytic leukemia protein (PML) is a tumor suppressor possessing multiple modes of action, including induction of apoptosis. We unexpectedly find that PML promotes necroptosis in addition to apoptosis, with Pml-/- macrophages being more resistant to TNF-mediated necroptosis than wild-type counterparts and PML-deficient mice displaying resistance to TNF-induced systemic inflammatory response syndrome. Reduced necroptosis in PML-deficient cells is associated with attenuated receptor-interacting protein kinase 1 (RIPK1) activation, as revealed by reduced RIPK1[S166] phosphorylation, and attenuated RIPK1-RIPK3-MLKL necrosome complex formation. We show that PML deficiency leads to enhanced TNF-induced MAPK-activated kinase 2 (MK2) activation and elevated RIPK1[S321] phosphorylation, which suppresses necrosome formation. MK2 inhibitor treatment or MK2 knockout abrogates resistance to cell death induction in PML-null cells and mice. PML binds MK2 and p38 MAPK, thereby inhibiting p38-MK2 interaction and MK2 activation. Moreover, PML participates in autocrine production of TNF induced by cellular inhibitors of apoptosis 1 (cIAP1)/cIAP2 degradation, since PML-knockout attenuates autocrine TNF. Thus, by targeting MK2 activation and autocrine TNF, PML promotes necroptosis and apoptosis, representing a novel tumor-suppressive activity for PML.

Keywords:  MK2; PML; RIPK1; necroptosis; p38 MAPK

DOI:  https://doi.org/10.15252/embr.202052254
Curr Opin Hematol. 2021 Oct 13.

Clonal hematopoiesis driven by DNMT3A and TET2 mutations: role in monocyte and macrophage biology and atherosclerotic cardiovascular disease.

Isidoro Cobo, Tiffany Tanaka, Christopher K Glass, Calvin Yeang.

PURPOSE OF REVIEW: Clonal hematopoiesis of indeterminate potential (CHIP), defined by the presence of somatic mutations in hematopoietic cells, is associated with advanced age and increased mortality due to cardiovascular disease. Gene mutations in DNMT3A and TET2 are the most frequently identified variants among patients with CHIP and provide selective advantage that spurs clonal expansion and myeloid skewing. Although DNMT3A and TET2 appear to have opposing enzymatic influence on DNA methylation, mounting data has characterized convergent inflammatory pathways, providing insights to how CHIP may mediate atherosclerotic cardiovascular disease (ASCVD).RECENT FINDINGS: We review a multitude of studies that characterize aberrant inflammatory signaling as result of DNMT3A and TET2 deficiency in monocytes and macrophages, immune cells with prominent roles in atherosclerosis. Although specific DNA methylation signatures associated with these known epigenetic regulators have been identified, many studies have also characterized diverse modulatory functions of DNTM3A and TET2 that urge cell and context-specific experimental studies to further define how DNMT3A and TET2 may nonenzymatically activate inflammatory pathways with clinically meaningful consequences.
SUMMARY: CHIP, common in elderly individuals, provides an opportunity understand and potentially modify age-related chronic inflammatory ASCVD risk.

DOI: https://doi.org/10.1097/MOH.0000000000000688
Cancer Discov. 2021 Oct 11. pii: candisc.0538.2021. [Epub ahead of print]

Functional Precision Medicine Provides Clinical Benefit in Advanced Aggressive Hematological Cancers and Identifies Exceptional Responders.

Christoph Kornauth, Tea Pemovska, Gregory I Vladimer, Günther Bayer, Michael Bergmann, Sandra Eder, Ruth Eichner, Martin Erl, Harald Esterbauer, Ruth Exner, Verena Felsleitner-Hauer, Maurizio Forte, Alexander Gaiger, Klaus Geissler, Hildegard T Greinix, Wolfgang Gstöttner, Marcus Hacker, Bernd Lorenz Hartmann, Alexander W Hauswirth, Tim Heinemann, Daniel Heintel, Mir Alireza Hoda, Georg Hopfinger, Ulrich Jaeger, Lukas Kazianka, Lukas Kenner, Barbara Kiesewetter, Nikolaus Krall, Gerhard Krajnik, Stefan Kubicek, Trang Le, Simone Lubowitzki, Marius E Mayerhoefer, Elisabeth Menschel, Olaf Merkel, Katsuhiro Miura, Leonhard Müllauer, Peter Neumeister, Thomas Noesslinger, Katharina Ocko, Leopold Öhler, Michael Panny, Alexander Pichler, Edit Porpaczy, Gerald W Prager, Markus Raderer, Robin Ristl, Reinhard Ruckser, Julius Salamon, Ana-Iris Schiefer, Ann-Sofie Schmolke, Ilse Schwarzinger, Edgar Selzer, Christian Sillaber, Cathrin Skrabs, Wolfgang R Sperr, Ismet Srndic, Renate Thalhammer, Peter Valent, Emiel van der Kouwe, Katrina Vanura, Stefan Vogt, Cora Waldstein, Dominik Wolf, Christoph C Zielinski, Niklas Zojer, Ingrid Simonitsch-Klupp, Giulio Superti-Furga, Berend Snijder, Philipp B Staber.

Personalized medicine aims to match the right drug with the right patient by utilizing specific features of the individual patients' tumor. However, current strategies of personalized therapy matching only provide treatment opportunities for less than 10% of cancer patients. A promising method may be drug profiling of patient biopsies with single-cell resolution to directly quantify drug effects. We prospectively tested an image-based single-cell functional precision medicine (scFPM) approach to guide treatments in 143 patients with advanced aggressive hematologic cancers. Fifty-six patients (39%) were treated according to scFPM results. At a median follow-up of 23.9 months, 30 patients (54%) demonstrated a clinical benefit of more than 1.3-fold enhanced progression-free survival (PFS) compared to their previous therapy. Twelve patients (40% of responders) experienced exceptional responses lasting three times longer than expected for their respective disease. We conclude, that therapy matching by scFPM is clinically feasible, and effective in advanced aggressive hematologic cancers.

DOI: https://doi.org/10.1158/2159-8290.CD-21-0538
Blood Adv. 2021 Oct 13. pii: bloodadvances.2021005802. [Epub ahead of print]

Blastic plasmocitoid dendritic cell neoplasm with leukemic spread: a GIMEMA survey.

Caterina Giovanna Valentini, Alfonso Piciocchi, Fabio Facchetti, Fabio Guolo, Alessandro Pulsoni, Marco Vignetti, Livio Pagano.

DOI: https://doi.org/10.1182/bloodadvances.2021005802
Blood Adv. 2021 Oct 12. pii: bloodadvances.2021005736. [Epub ahead of print]

KMT2A-CBL rearrangements in acute leukemias: clinical characteristics and genetic breakpoints.

Alex Bataller, Francesca Guijarro, Aurélie Caye, Marion Strullu, Arthur Sterin, Oscar Molina, Patrice Chevallier, Marketa Zaliova, Jan Zuna, Pablo Mozas, Laura Magnano, Nathalie Grardel, Pascale Cornillet-Lefebvre, Jen-Fen Fu, Lee-Yung Shih, Temenuzhka Boneva, Elisabeth P Nacheva, Silvia Beà, Mónica López-Guerra, Clara Bueno, Pablo Menéndez, Jordi Esteve, Patrizia Larghero, Claus Meyer, Rolf Marschalek.

DOI: https://doi.org/10.1182/bloodadvances.2021005736