Overall survival (OS) and quality of life (QoL) are clinically relevant outcomes/endpoints during examination of therapies. However, with median OS approaching 20 years for patients with follicular lymphoma (FL), it is often not feasible to use OS as a primary endpoint in clinical studies. While validated tools for assessing QoL in patient with lymphoma exist, QoL data are rarely the sole basis for drug approvals in FL. Therefore, other survival endpoints, surrogates, and intermediate clinical endpoints have all been used to measure outcomes in FL trials. In this review, we discuss the strengths and limitations of these commonly used traditional endpoints in FL trials and examine the current gaps, including delayed availability of results and suboptimal sensitivity in distinguishing difference in therapeutic effects. To help address the gaps identified, well-validated surrogates, such as complete remission 30 months after starting frontline immunochemotherapy (CR30), may be used as the primary or co-primary endpoint in confirmatory randomized trials. Emerging intermediate endpoints like minimal residual disease, may be useful in early phase trials and in guiding accelerated approvals after appropriate validation. As patient preference plays a crucial role in treatment decisions in FL, it is critical to include QoL as an important secondary trial endpoint and to measure non-medical burdens, including time and financial toxicities. Endpoints that are clinically relevant, timely, and patient-centered may identify new drugs that help patients with FL live longer and better lives.

Progress in the therapy of follicular lymphoma (FL), the most common indolent lymphoma subtype, has been achieved in recent years with significant improvement in median overall survival. Most patients diagnosed with FL will now die from other causes. Multiple novel immunotherapy and other targeted therapies are now approved for relapsed and refractory disease. However, early progression and transformation to aggressive lymphoma remain key issues requiring further innovation. We expect that bispecific antibodies will likely move to earlier use and in novel combinations. Future generations of these and chimeric antigen receptor T-cell therapy will be developed in an effort to minimize toxicity and improve efficacy. New technologies, such as circulating tumor DNA assays, may enable more rational selection and guidance of therapy duration or changes in treatment, as well as possibly substituting for follow up imaging while monitoring patients. We also look forward to more extensive use of quality of life tools to select treatment in patients who have a favorable long-term outlook with multiple options. Finally, patients and clinicians now envision a day when FL is no longer referred to as "incurable". Having a definition and possibility of a "cure" and being able to optimize such a mindset in the approach of FL would represent a major advance in our future management strategy.

Thrombus structure and composition are the main determinants of the severity, course, and outcomes of thrombosis. Detailed thrombus morphology has become available due to mechanical thrombectomy, which allows extraction of fresh thrombi from patients followed by scanning electron microscopy. The major structural elements of a thrombus are platelets, erythrocytes, and fibrin, each playing a critical role in determination of biological and physical properties of thrombi, such as permeability, stiffness, lytic and mechanical stability. The minor components include neutrophils, monocytes, von Willebrand factor, cellular microvesicles, plasma proteins, cholesterol crystals, and other structures. Platelets are responsible for contraction (retraction) of thrombi, which results in compaction with very little free space, low permeability and high stiffness. Because of clot contraction, erythrocytes, which are prevalent in all types of thrombi, undergo compressive deformation to polyhedral (polyhedrocytes) and polyhedral-like cells, altogether comprising pressure-deformed cells (piezocytes). Fibrin is the structural and mechanical scaffold of thrombi that changes in time and space both quantitatively and qualitatively during their formation. Fibrin is an equilibrium polymer that can adapt to forced deformations by reorientation at the microscopic level and unfolding at the molecular level. The relative volume fractions of thrombus components, their functional and structural forms vary substantially, providing a basis for the diverse pathogenic mechanisms and clinical manifestations of thrombosis. Modulating any of the components lead to prospective therapeutic approaches. This review summarizes recent research that describes quantitative and qualitative morphologic characteristics of arterial and venous thrombi that provide a basis for new therapeutic opportunities in thrombosis.

Natural killer (NK) cells are important effector cells in antibody-based immune therapies for multiple myeloma (MM) through antibody-dependent cellular cytotoxicity. Here, we used single-cell transcriptomics, flow cytometry and functional assays to investigate the bone marrow NK cell compartment of MM patients at diagnosis and during treatment. We show reduced proportion of CD16+ cytotoxic NK cells in a subset of patients at diagnosis, which correlated with decreased cytokine production and NK cell degranulation against MM cells in the presence of the anti-CD38 antibody daratumumab. In line with these findings, a low proportion of CD16+ bone marrow NK cells at diagnosis was associated with a reduced likelihood of achieving MRD-negativity post-consolidation in patients treated with daratumumab, bortezomib, thalidomide and dexamethasone in conjunction with autologous stem cell transplantation in the CASSIOPEIA trial. In contrast, NK cell distribution did not predict MRD-negativity in patients treated in the control arm without daratumumab. These findings highlight the impact of the bone marrow NK cell compartment on therapeutic outcomes in MM patients receiving immunotherapy with CD38-targeting antibodies.

Although the bone marrow is the main site of blood cell production in adults, rare pools of hematopoietic stem and progenitor cells have been found in extramedullary organs. In mice, we have previously shown that the lung contains hematopoietic progenitor cells and is a site of platelet production. Here, in the adult human lung, we show that functional hematopoietic precursors reside in the extravascular spaces with a frequency similar to the bone marrow and are capable of proliferation and engraftment in mice. The gene signature of pulmonary and medullary CD34+ hematopoietic progenitors indicates greater baseline activation of immune-, megakaryocyte/platelet-, and erythroid-related pathways in lung progenitors. Spatial transcriptomics mapped blood progenitors in the lung to an alveolar interstitium niche with only a few cells identified in an intravascular location. In human blood samples collected for stem cell transplantation, CD34+ cells with a lung signature enriched the mobilized pool of hematopoietic stem cells. These results identify the lung as a pool for uniquely programmed blood stem and progenitor cells with the potential to support hematopoiesis in humans.

Multiple Myeloma is driven by clonal plasma cell (cPC)-intrinsic factors and changes in the tumorigenic microenvironment (TME). To investigate if residual polyclonal PCs (pPCs) are disrupted, single-cell (sc) RNAseq and sc B-cell receptor analysis were applied in a cohort of 46 samples with PC dyscrasias and 21 healthy donors (HDs). Out of n=234,789 PCs, 64,432 were genotypically identified as pPCs with frequencies decreasing over different disease stages, from 23.66% in monoclonal gammopathy of undetermined significance (MGUS) to 3.23% in MMs (p=0.00012). Both cPCs and pPCs had a comparable expression of typical lineage markers (i.e. CD38, CD138), while others were more variable (CD27, ITGB7). Only cPCs overexpressed oncogenes (e.g. CCND1/2, NSD2), but CCND3 was often expressed in pPCs. BCMA was expressed on both p- and cPCs, while GPRC5D was mostly upregulated in cPCs with implications for on-target, off-tumor activity of targeted immunotherapies. In comparison with HDs, pPCs from patients showed upregulated autophagy and disrupted interaction with TME. Importantly, interferon related pathways where significantly enriched in pPCs from patients vs HDs (p-adjusted < 0.05) showing an inflamed phenotype affecting genotypically normal PCs. Function of pPCs was consequently impacted and correlated with immunoparesis, driven by disrupted cellular interactions with TME. Leveraging our scRNAseq data, we derived a "healthy PC signature" that could be applied to bulk transcriptomics from the CoMMpass dataset and predicted significantly better PFS and OS (log rank p < 0.05 for both). Our findings show that genotypic, single-cell identification of pPCs in PC dyscrasias has relevant pathogenic and clinical implications.

The thrombopoietin (TPO):cMPL signaling axis is a critical regulator of early hematopoiesis. However, the utility of cMPL as a standalone marker for identifying long-term repopulating hematopoietic stem cells (LT-HSCs) within the adult human CD34+ cell hematopoietic stem and progenitor cell (HSPC) population has not been validated. In this study, we established high cMPL surface expression as a defining feature of human LT-HSCs. Targeting the cMPL receptor facilitated the separation of human LT-HSCs from mature progenitors, a delineation not achievable with cKIT. Leveraging this finding, we explored the therapeutic potential of cMPL as a novel target for pre-transplant conditioning regimens. We developed a cMPL-targeting immunotoxin, demonstrating its ability to preferentially deplete host cMPLhigh LT-HSCs in murine xenograft models. Evaluation in rhesus macaques confirmed these findings and highlighted a favorable safety profile with rapid systemic clearance within 24 hours of administration. Proof-of-concept experiments validated the immunotoxin as a novel conditioning agent, enabling donor HSPC engraftment without the use of chemotherapy or irradiation. These findings advance our understanding of the molecular determinants of human hematopoiesis and underscore the potential of cMPL-targeting preparative regimens to improve therapeutic transplantation outcomes.

Rovadicitinib (TQ05105) is a novel, oral dual JAK1/2 and ROCK1/2 inhibitor targeting inflammatory and fibrotic components of chronic graft-versus-host disease (cGVHD). We aimed to evaluate the safety and efficacy of rovadicitinib for glucocorticoid-refractory or -dependent cGVHD. This phase 1b/2a, multicenter, open-label study (NCT04944043) enrolled patients with moderate or severe glucocorticoid-refractory or -dependent cGVHD. The study followed a 3+3 design with two escalating doses (rovadicitinib 10 and 15 mg twice daily) and a dose expansion cohort. Primary endpoints included safety and recommended phase 2 dose (RP2D); the best overall response (BOR) was the key secondary endpoint. Forty-four patients were enrolled, with 29 in the 10 mg twice-daily cohort and 15 in the 15 mg twice-daily cohort. Rovadicitinib was well tolerated without dose-limiting toxicity at both dosages, and no rovadicitinib-related AEs led to discontinuation. The most prevalent hematological AE was anemia (38.6%), with grade ≥ 3 of 4.6%. The RP2D was 10 mg twice daily. The BOR was 86.4% (95% confidence interval [CI], 72.6-94.8), with no difference between the two dosage cohorts. Besides, BOR achieved 72.7% (8/11) in the steroid-refractory cohort and 90.9% (30/33) in the steroid-dependent cohort. All affected organs exhibited responses regardless of prior therapy. The failure-free survival rate was 85.2% (95% CI, 64.5-94.3) at 12 months. Rovadicitinib treatment reduced the corticosteroid dose in 88.6% of patients. cGVHD-related symptoms were improved in 59.1% of patients. Rovadicitinib has favorable tolerability and notable clinical response rates, ameliorating the quality of life and reducing corticosteroid dose requirements in patients with glucocorticoid-refractory or -dependent cGVHD.

Patients with TP53-mutated acute myeloid leukemia (AML) have an extremely poor prognosis, necessitating new treatments. The global, randomized, phase 3 ENHANCE-2 trial evaluated the anti-CD47 monoclonal antibody magrolimab plus azacitidine (Magro/Aza) for previously untreated TP53-mutated AML. Patients determined inappropriate for intensive therapy were randomized to receive Magro/Aza or venetoclax plus azacitidine (Ven/Aza); those appropriate for intensive therapy were randomized to receive Magro/Aza or 7+3 induction chemotherapy. Primary endpoint was overall survival (OS) in the non-intensive arm. At interim analysis, non-intensive-arm OS hazard ratio (HR) between treatment groups was 1.191 (95% CI, 0.744-1.906), meeting the study's definition for futility and resulting in study termination. At final analysis, median OS was 4.4 vs 6.6 months (HR, 1.132; 95% CI, 0.783-1.637; P = .5070) in the non-intensive arm (n = 205) and 7.3 vs 11.1 months (HR, 1.434; 95% CI, 0.635-3.239; P = .3798) in the intensive arm (n = 52) between Magro/Aza and control groups, respectively. Incidences of grade ≥3 adverse events (AEs) were similar across Magro/Aza and control groups (non-intensive, n = 194: 96.9% and 95.9%; intensive, n = 50: 92.6% and 95.7%), including grade ≥3 anemia (non-intensive: 27.1% and 23.5%; intensive: 25.9% and 21.7%). Grade ≥3 infections were observed in 50.0% and 53.1% of patients in the non-intensive arm and 44.4% and 65.2% of intensive arm patients. ENHANCE-2 did not meet its primary endpoint of OS in TP53-mutated AML but provides important data informing future studies in this challenging population. This trial was registered at www.clinicaltrials.gov as #NCT04778397.

T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive malignancy characterized by an expansion of T-cell progenitors and DNA mutations that lead to an overactive NOTCH1 signaling in over 50% of T-ALL cases. Using synthetic models of human T-ALL, we report that NOTCH1 dimeric signaling was crucial for the leukemogenesis of human hematopoietic stem/progenitor cells (HSPCs) from cord blood. We also identified a Notch-dimerization-dependent gene signature, including HES4 transcription factor, which induced proliferative advantage in human HSPCs as well as in Notch-dimerization-dependent patient-derived xenografts (PDXs) of T-ALL. Interestingly, in human T-ALL cells, HES4 enforced the expression of D133p53 isoform with the concomitant block of pro-apoptotic p53 target genes and the induction of BCL2L1 gene expression and anti-apoptotic Bcl-xL protein. Additionally, through an integrated experimental approach including genetically modified cell lines, RNA/Chip-sequencing and single cell RNA-sequencing (scRNA-Seq) profiles of primary T-ALL samples, we revealed cell subsets with Notch-dimerization-dependent gene signature, which indirectly correlated with pro-apoptotic genes as well as directly associated with cell markers of poor clinical outcome in primary T-ALL samples. Taken together, these findings highlight the crucial role of NOTCH1 dimeric signaling in human T-cell leukemogenesis and T-ALL maintenance suggesting that a possible benefit can be obtained from a therapeutic strategy targeting NOTCH1-dimer signaling or its downstream effectors.

Venetoclax combined with hypomethylating agents is approved for frontline therapy in older/unfit acute myeloid leukemia (AML) patients. However, prospective data on this low intensity therapy in treatment-naive younger AML patients are lacking. This study investigated the efficacy and safety of venetoclax plus decitabine (VEN-DEC) as induction in untreated young fit AML patients in a randomized trial. Patients aged 18-59 years eligible for intensive chemotherapy were randomized 1:1 to receive VEN-DEC or IA-12 (idarubicin and cytarabine). All patients achieving CR/CRi underwent high-dose cytarabine consolidation. The primary endpoint was the composite complete remission rate (CRc) rate after induction therapy. Of 255 screened, 188 were enrolled and randomly assigned, with 94 in each group. In the intention-to-treat population, CRc was 89% (84/94) in the VEN-DEC group versus 79% (74/94) in IA-12 (non-inferiority P = 0.0021). MRD negativity after induction was 80% (67/84) versus 76% (56/74), respectively. VEN-DEC showed superior CRc in patients aged ≥40 years (91% vs. 75%), those with adverse risk (91% vs. 42%) or epigenetic mutations (91% vs. 67%) , but lower CRc in RUNX1::RUNX1T1 fusion cases (44% vs. 88%) compared to IA-12. Patients in the VEN-DEC group experienced fewer grade ≥3 infections (32% vs. 67%) and shorter severe thrombocytopenia duration (median 13 vs. 19 days, P < 0.001). At a median follow-up of 12.1 months, overall and progression-free survival were similar between groups. In conclusion, VEN-DEC demonstrated non-inferior response rates with superior safety over IA-12 in young AML patients. The trial was registered at ClinicalTrials.gov as #NCT05177731.

Discontinuation of lenalidomide maintenance after autologous stem cell transplantation is a burning question within the multiple myeloma (MM) community, especially after the inclusion of minimal residual disease (MRD) in the disease response criteria. In this prospective study, we evaluated the conversion to MRD positivity, the treatment-free survival (TFS), and the progression-free survival (PFS) in 52 patients with MM who discontinued lenalidomide maintenance after achieving sustained bone marrow and imaging MRD negativity for 3 years. Patients who developed MRD positivity after lenalidomide discontinuation restarted lenalidomide maintenance at the same dose. The median follow-up from lenalidomide discontinuation was 3 years. Overall, 12 (23%) patients obtained MRD positivity and restarted lenalidomide maintenance. Only 4 (7.6%) patients progressed; 3 had a biochemical progression and 1 had a clinical progression. The overall median PFS was not reached, whereas the 7-year PFS from diagnosis was 90.2%. The 1-, 2-, and 3-year TFS rates were 93.9%, 91.6%, and 75.8%, respectively, whereas the 1-, 2-, and 3-year landmark PFS rates from maintenance discontinuation (study entrance) were 96.0%, 96.0%, and 92.9%, respectively. There were no statistically significant associations among age, sex, Second Revision International Staging System, type of induction therapy, and use of consolidation therapy and the effect outcomes of PFS and TFS. We conclude that maintenance discontinuation after 3 years of sustained marrow and imaging MRD negativity is associated with low rates of MRD conversion and progressive disease. Thus, in the era of modern antimyeloma treatments, a subgroup of patients may remain treatment free while in complete remission without jeopardizing disease response.

The rationale for combining ibrutinib and venetoclax (IV) in chronic lymphocytic leukemia (CLL) treatment lies in their complementary mechanisms of action. Studies investigating IV typically begin with a short initial course of ibrutinib, followed by venetoclax introduction for a limited duration, typically 12 months. SAKK34/17 (NCT03708003) is a single-arm, open-label, multicenter, phase 2 trial evaluating the effectiveness of a modified IV schedule in patients with relapsed/refractory (R/R) CLL. No prior exposure to BTK- or BCL2-inhibitors was allowed. The lead-in phase with ibrutinib was extended to six months to reduce the tumor burden and related tumor lysis syndrome (TLS) risk. Additionally, the treatment phase with IV is prolonged to a minimum of 24 months to enhance the undetectable minimal residual disease (uMRD, 10-4) rate. The primary endpoint was the rate of complete response or complete response with incomplete bone marrow recovery (CR/CRi) with uMRD in both bone marrow (BM) and peripheral blood (PB). Secondary endpoints included assessing the proportion of patients who transitioned to a low-risk category for TLS after receiving ibrutinib lead-in. Out of the 30 patients with R/R CLL who were enrolled, 40.0% achieved a status of uMRD CR/CRi according to the intention-to-treat analysis, and 53.3% showed uMRD in the BM and PB. Following the lead-in period with ibrutinib, 57.1% of patients achieved a low-risk for TLS. At cycle 31, the progression-free survival rate was 89.9%. These results contribute to the increasing body of evidence supporting the idea that a longer IV duration is beneficial for enhancing therapeutic effectiveness.