Preliminary safety of Bcl-2 inhibitor BGB-11417 in relapsed/refractory multiple myeloma Harbouring t(11,14): Phase 1b/2 study

Background: B-cell lymphoma-2 (Bcl-2) proteins play an important role in multiple myeloma (MM) cell survival and represent an attractive therapeutic target. In prior trials, a subgroup analysis of patients with t(11;14)-positive relapsed/refractory (R/R) MM showed the combination of a Bcl-2 inhibitor, a proteasome inhibitor, and dexamethasone improved progression-free survival with no increased mortality. BGB-11417, a Bcl-2 inhibitor, is more potent and selective than venetoclax. BGB-11417- 105 (NCT04973605) is a phase 1b/2 study assessing the safety and efficacy of BGB-11417 monotherapy, in combination with dexamethasone, or with dexamethasone+carfilzomib in patients with t(11;14)-positive R/R MM. Preliminary safety results for the combination of BGB-11417 + dexamethasone are presented. Method(s): Eligible patients had t(11;14)-positive R/R MM and had been exposed to a proteasome inhibitor, immunomodulatory agent, and anti-CD38 therapy. Patients received 80-, 160-, 320-, or 640-mg BGB-11417 daily with 40-mg dexamethasone weekly until death, intolerability, or disease progression. Dose escalation was guided by a mTPI-2 design and overall review by a safety monitoring committee. Pharmacokinetics (PK) were also assessed. Result(s): As of 1 July 2022, 10 patients were enrolled in the 80-, 160-, and 320-mg (3 patients each) and 640-mg (1 patient) dose-escalation cohorts of BGB-11417 + dexamethasone. The median age was 69 years (range, 52-81) and median prior lines of therapy was 3 (range, 1-5). The median treatment duration was 3.2 months (range, 0.5-6.5). No patients experienced dose-limiting toxicity at any dose level. Three patients died whilst on study: 1 due to COVID-19 complications 157 days after treatment discontinuation (day 208), 1 due to progressive disease 50 days after treatment discontinuation (day 89), and 1 due to COVID-19 whilst on study treatment (day 78). No deaths were associated with study treatment. Two patients experienced Grade >= 3 treatment-emergent adverse events (TEAEs). One patient in the 160-mg cohort experienced Grade 3 increase in liver enzymes and lymphopenia. One patient in the 320-mg cohort experienced Grade 3 lymphopenia. The most common TEAEs were insomnia (50%), fatigue (30%), arthralgia (20%), back pain (20%), lymphopenia (20%), and nausea (20%). BGB-11417 exposure increased dose-dependently from 80 mg to 320 mg with high interpatient PK variability. BGB-11417 exposures after single and multiple doses appeared similar, indicating limited accumulation. Conclusion(s): BGB-11417 plus dexamethasone was generally well-tolerated in patients with R/R MM harbouring t(11;14) at doses <=640 mg. Efficacy data are forthcoming. Recruitment is ongoing in the US, Australia, and New Zealand;the BGB-11417, dexamethasone, and carfilzomib combination arm will open in the future.

Leukemic phase follicular lymphoma in a young adult.

BACKGROUND: Leukemic presentation of follicular lymphoma (FL) is uncommon, with most cases reported in older adults. DESIGN: This report describes an unusual case of a young adult diagnosed with leukemic phase of FL. We reviewed the existing literature on this rare presentation of the disease and its potential impact on patient outcomes. RESULTS: Leukemic phase of FL in young adults can be mistaken for other high-grade hematologic malignancies. Morphology assessment and ancillary testing, such as flow cytometry and FISH analysis, can assist in achieving an accurate diagnosis of the leukemic phase of FL. Notably, our young patient responded well to therapy, which is different from what is typically observed in older patients who have a poorer prognosis. Further cases are needed to investigate the prognostic impact of the leukemic phase of FL in younger patients.

B-cell lymphoma-2 family proteins-activated proteases as potential therapeutic targets for influenza A virus and severe acute respiratory syndrome coronavirus-2: Killing two birds with one stone?

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to a global health emergency. There are many similarities between SARS-CoV-2 and influenza A virus (IAV); both are single-stranded RNA viruses infecting airway epithelial cells and have similar modes of replication and transmission. Like IAVs, SARS-CoV-2 infections poses serious challenges due to the lack of effective therapeutic interventions, frequent appearances of new strains of the virus, and development of drug resistance. New approaches to control these infectious agents may stem from cellular factors or pathways that directly or indirectly interact with viral proteins to enhance or inhibit virus replication. One of the emerging concepts is that host cellular factors and pathways are required for maintaining viral genome integrity, which is essential for viral replication. Although IAVs have been studied for several years and many cellular proteins involved in their replication and pathogenesis have been identified, very little is known about how SARS-CoV-2 hijacks host cellular proteins to promote their replication. IAV induces apoptotic cell death, mediated by the B-cell lymphoma-2 (Bcl-2) family proteins in infected epithelia, and the pro-apoptotic members of this family promotes viral replication by activating host cell proteases. This review compares the life cycle and mode of replication of IAV and SARS-CoV-2 and examines the potential roles of host cellular proteins, belonging to the Bcl-2 family, in SARS-CoV-2 replication to provide future research directions.

Real-world evidence on venetoclax in chronic lymphocytic leukemia: The Italian experience.

Chronic lymphocytic leukemia (CLL) is the most common form of adult leukemia in the western world. In Italy, venetoclax was approved for use in patients with CLL as monotherapy in 2017 and in combinations in 2019. As a result of this delayed approval, there are relatively few real-world studies from Italian clinical practice and much of the data are in heavily pretreated patients. We have collected the available studies in Italian routine practice. Three studies confirm the effectiveness and tolerability of this agent in patients with relapsed/refractory CLL and high-risk disease characteristics, many of whom had received prior B-cell receptor signaling treatment. Addition of rituximab to venetoclax produced more complete responses in patients with relapsed/refractory CLL, while higher disease burden and progression while receiving a prior Bruton's tyrosine kinase inhibitor were both associated with poorer outcomes in patients treated with venetoclax. Venetoclax was well-tolerated with low discontinuation rates. No studies of venetoclax plus obinutuzumab for the first-line treatment of patients with CLL were available due to the short time since approval in Italy. Several cohorts addressed the impact of COVID-19 on patient management and outcomes, suggesting that treated patients and those in clinical observation had similar rates of COVID-19-related hospital admission, intensive care unit admission, and mortality. Overall, the responses and tolerance to venetoclax observed in the Italian real-world setting confirm the tolerability and effectiveness of venetoclax regimens in high-risk patients.

Pathobiome Transformation and Features of Enteral Insufficiency in Patients with Peritonitis during the Covid-19 Pandemic

We studied the features of acute enteral failure in patients with peritonitis in the setting of COVID-19 by studying the properties of the enteral pathobiome, biochemical, functional, pro-inflammatory and anti-apoptotic markers in diffuse peritonitis. A retrospective randomized cohort controlled study was conducted;it included 84 patients divided into two groups. Stratified randomization was used. The species composition and properties of the enteral luminal pathobiome were studied. 699 inoculations were made, resulting in 3024 isolates. The enteral morphofunctional coefficient, the level of alkaline phosphatase and its intestinal isoform were dynamically studied. In immunohistochemical studies, we studied the expression of CD-3 and Bcl-2. Patients with COVID-19 in addition to a decrease in the level of saprophytic microflora, showed a significant increase in Klebsiella spp., Candida, Clostridium spp. and Citrobacter (p <= 0.05). The rate of antibiotic resistance in the comparison group was 8.3%, in the main group - 36.9%. MRSA pathogens were noted in 86.4% of cases, VRSA strains were found in 20.6% of cases. Patients with COVID-19 had a deficiency of intestinal alkaline phosphatase, which persisted even on the day 5 of treatment. Macro- and microscopic studies showed pronounced inflammatory and apoptotic changes in the intestinal wall of patients in the main group. A specific enteral pathobiome that is multiresistant to antibiotics, pronounced inflammatory and apoptotic changes in the intestinal wall, and a predisposition to perforation of the small intestine are characteristics of enteral failure in diffuse peritonitis in the setting of COVID-19.

The Possible Role of Allicin in Ameliorating Azithromycin Induced Cardiotoxicity in Adult Male Albino Rat: A Histological and Immunohistochemical Study

Introduction: Azithromycin (AZ) is a broad-spectrum macrolide that is incorporated in the treatment of various infectious diseases, and recently enlisted in the protocol of Covid-19 management. Allicin is a classical garlic extraction with cardioprotective, antioxidant, anti-inflammatory, and anti-apoptotic properties. Aim of the Work: To evaluate the cardiotoxic effect of AZ and evaluate the possible protective effect of Allicin against AZ cardiotoxicity using various histological and immunohistochemical techniques. Materials and Methods: Forty adult male albino rats were randomly divided into four main groups: group-I acted as a control group, group-II was given Allicin (20 mg/kg/day) orally for consecutive 14 days, group-III was given AZ (30 mg/kg/ day) orally for consecutive 14 days and group-IV was given both AZ and Allicin in the same doses for consecutive 14 days. The cardiac specimens were processed for different histological and immunohistochemical techniques. Morphometrical and statistical studies were also done. Results: Azithromycin induced several myocardial changes in the form of focal areas of destruction of cardiac muscle fibers, darkly stained pyknotic nuclei and cytoplasmic vacuoles. Wavy muscle fibers, widening of the intercellular spaces, mononuclear cellular infiltration, fatty infiltration and hemorrhage were obvious. Dilated and congested blood vessels were also noticed. A significant increase in the mean area percentage of both Masson and α-SMA immunoreactivity was detected while a significant decrease in the mean area percentage of Bcl-2 was demonstrated. In contrast, most of the histological changes disappeared by Allicin co-treatment except in few localized areas. Conclusion: Azithromycin induced several destructive changes in cardiac muscle fibers. Allicin had a potent ameliorative role in prevention of cardiotoxicity induced by AZ. © 2022. All rights served.

Combinacao Bem Sucedida De Azacitidina E Venetoclax: Mudando Paradigmas No Tratamento De Leucemia Mieloide Aguda E Sindrome Mielodisplasica

Objetivos: O Venetoclax tem como alvo a proteina BCL-2. Aprovado para LLC, mostrou eficacia tambem LMA em combinacao com agentes hipometilantes como a Azacitidina. No ultimo ano, tivemos experiencias bem-sucedidas com a utilizacao desta associacao. Selecionamos 4 casos representativos de LMA e SMD para relatar nossa experiencia com este protocolo e desfechos obtidos. Material e Metodos: As informacoes foram obtidas por meio de revisao do prontuario. Resultados: Caso 1 - E.Q.O., 42 anos, sexo feminino, diagnosticada em janeiro de 2019 com LMA, evoluiu com 3 recidivas, quando foi optado pela associacao de Azacitidina e Venetoclax. Realizou ciclos com boa evolucao. Caso 2 - F.G.S., 72 anos, sexo feminino, historico de Linfoma Folicular EIIA em 2003. Em janeiro de 2021 recebeu diagnostico de LMA. Houve associacao de Azacitidina e Venetoclax como tratamento. Foram realizados 2 ciclos sem intercorrencias. Entretanto, antes do terceiro ciclo, a paciente relatou sindrome gripal, com diagnostico de COVID-19 e evoluiu a obito. Caso 3 - J.W.L.L., 37 anos, sexo masculino, em agosto de 2020 foi diagnosticado com SMD. Evolui com remissao e melhora significativa das citopenias de base. Foi submetido a TCTH nao aparentado com sucesso em julho de 2021, com enxertia no D+16 e internacao sem intercorrencias. Caso 4 - Paciente de 72 anos, sexo masculino, com diagnostico de SMD com excesso de blastos. Iniciou protocolo com Azacitidina associado a Venetoclax, persistia com elevada necessidade transfusional. Houve reducao das dosagens no segundo ciclo. O paciente evoluiu com melhor tolerabilidade, mantendo padrao transfusional. Manteve dose de Azacitidina e ajustada novamente dose de Venetoclax. Apos o quarto e quinto ciclos, paciente retornou com melhora significativa de indices hematimetricos O mielograma estava normal, bem como a imunofenotipagem e o cariotipo. Discussao: Apresentamos aqui 4 casos distintos de indicacao bem-sucedida da associacao entre Azacitidina e Venetoclax. A dose padrao utilizada foi de 75 mg/m2/dia de Azacitidina, do D1 ao D7 e 100 mg/dia de Venetoclax, com escalonamento progressivo ate atingir 400 mg/dia, do D1 ao D28. O caso 1 descreve paciente com doenca refrataria. Na literatura, esse perfil de pacientes tem beneficio importante com essa combinacao. Em nossa pratica clinica, o ajuste de dose ou duracao do Venetoclax e/ou espacamento entre os ciclos tem se mostrado uma alternativa viavel para minimizar os impactos da neutropenia. O caso 2 refere-se a paciente idosa, com mutacao do NPM1, sem status performance para quimioterapia intensiva, em primeira linha de tratamento. O impacto favoravel da mutacao NPM1 tende a reduzir em pacientes idosos (>65 anos). Nos casos 3 e 4 relatamos pacientes com SMD. Os bons resultados de Azacitidina e Venetoclax em LMA levaram os pesquisadores a avaliar a combinacao em pacientes com SMD de alto risco. Conclusao: A escolha do tratamento depende em grande parte da idade do paciente, status performance, remissao, caracteristicas geneticas e moleculares.A quimioterapia de baixa intensidade, em especial a associacao de Azacitidina com Venetoclax e uma opcao viavel, mesmo em pacientes com recidiva multipla/doenca refrataria ou naqueles com baixo status performance. Tambem aparenta ser promissora nos casos de SMD de alto risco. Os efeitos adversos mais frequentes dizem respeito as infeccoes decorrentes da neutropenia prolongada, mas nos 4 casos relatados, os pacientes evoluiram com estabilidade. Copyright © 2022

Eficacia Do Tratamento Baseado Em Venetoclax Em Paciente Jovem Com Leucemia Mieloide Aguda Recidivada Candidato a Transplante De Medula Ossea Alogenico

Introducao: A Leucemia Mieloide Aguda (LMA) e uma doenca agressiva, e em geral, de prognostico reservado. O tratamento com intuito curativo e realizado com altas doses de quimioterapia, seguido ou nao por transplante de medula ossea (TMO) alogenico. Porem, a recidiva ainda representa um desafio a ser superado, levando a busca de novas opcoes terapeuticas, como o inibidor de bcl-2, Venetoclax. Objetivo: Relatar o caso de um paciente jovem com LMA recidivada com resposta ao tratamento baseado em Venetoclax, seguido por TMO alogenico. Metodo: Levantamento de dados do prontuario e revisao da literatura. Relato do caso: VSV, sexo masculino, 21 anos, diagnosticado com LMA em 18/02/2020, mielograma com 60,4% blastos, com fenotipo CD45+ intermediario;CD34+;CD13+;CD33 parcial;CD64 parcial;HLA-DR parcial;MPO parcial e cariotipo 46, XY [20]. Sem possibilidade de avaliacao molecular da doenca. O paciente recebeu tratamento de inducao padrao (D3A7) atingindo remissao completa apos um ciclo e seguindo com consolidacao com 3 ciclos de ARA-C 3g/m2 ate maio de 2020 (optou-se por nao realizar o 4ciclo devido a pandemia por COVID19). Apresentava doenca residual minima (DRM) negativa em reavaliacao medular de agosto de 2020, mantendo-se ate junho de 2021, quando apresentou recidiva com 33,8% de blastos em imunofenotipagem de reavaliacao. Internado em julho de 2021 para QT de resgate com FLAG, evoluiu com choque septico e insuficiencia respiratoria, sendo necessario suporte em unidade de terapia intensiva. Apos recuperacao clinica, obteve novamente DRM negativa, sendo encaminhado para TMO alogenico aparentado (irma "full match"). Entretanto, enquanto aguardava o transplante, apresentou nova recidiva (IF com 5,4% de blastos), sendo optado por tratamento com Venetoclax + Azacitidina, com reducao de DRM para 1,5%. Recebeu o segundo ciclo de Venetoclax combinado com citarabina, devido a indisponibilidade da Azacitidina, seguido por DRM negativa. O paciente foi submetido ao TMO alogenico em 31/03/22, com avaliacao medular no D+60 com quimerismo de 100%, mantendo DRM negativa no D+120. Discussao: O uso do inibidor de BCL-2 (Venetoclax), em combinacao com agentes hipometilantes ou doses baixas de citarabina, foi aprovado para pacientes recem-diagnosticados com LMA inelegiveis para quimioterapia intensiva, revolucionando o tratamento da doenca. Publicacoes recentes vem demonstrando novos beneficios dessa associacao, tanto previamente ao TMO (em primeira linha ou com doenca recidivada), como na terapia de resgate para recidiva pos-TMO. Tambem tendo sido evidenciado sucesso terapeutico em faixas etarias menores (incluindo criancas). Esses novos estudos motivaram o uso de terapia baseada em venetoclax nesse paciente jovem, com doenca recidivada, conseguindo atingir e manter DRM negativa. Conclusao: O caso relatado demonstra eficacia do Venetoclax (em combinacao com hipometilante ou citarabina) em promover remissao profunda da doenca, tornando o paciente habil para o transplante e aumentando a probabilidade de sobrevida a longo prazo. Copyright © 2022

Uso De Acalabrutinib Em Paciente Transplantado Renal Com Linfoma Do Manto R/R

Introducao: Linfoma de celulas do manto (MCL) e uma doenca rara, mais frequente em homens, com idade media ao diagnostico de 68 anos. A terapia para MCL nao e curativa e praticamente todos os pacientes terao doenca refrataria ou recorrente. Quimioimunoterapia e a principal modalidade de tratamento de 1 linha, combinada a consolidacao com transplante autologo de medula ossea nos pacientes elegiveis. Mais recentemente, com a incorporacao de novas drogas na pratica clinica, ha mais opcoes de tratamento a partir da 2 linha, como os inibidores de tirosina quinase de Bruton (iBTK) e inibidor de bcl-2. Objetivos: Relatar um caso de paciente com MCL R/R, com historico de transplante renal e uso de imunossupressores, tratado com acalabrutinib com necessidade de ajuste de dose. Relato de caso: RCM, masculino, 70 anos, coronariopata, transplantado renal de doador cadaver em janeiro de 2018 devido a doenca renal cronica dialitica por sindrome hemolitico-uremica atipica em 2014, em uso de tacrolimus, micofenolato de mofetila e prednisona. Poucos meses apos o transplante apresentou linfocitose (14.900) e esplenomegalia, sem sintomas B. Biopsia de medula ossea mostrou infiltracao por MCL, positivo para CD20, BCL-2 e ciclina-D1. Na ocasiao, o paciente encontrava-se assintomatico e a doenca foi caracterizada como MCL leucemizado e indolente, foi optado por acompanhamento ambulatorial. Apos dois anos, apresenta linfocitose progressiva, aumento da esplenomegalia e trombocitopenia. Realizou tratamento com 6 ciclos de R-CHOP (ate 29/10/2020), atingindo resposta parcial. Apresentava 2,73% de linfocitos B monoclonais ao final do tratamento. Devido ao uso concomitante de imunossupressores para profilaxia de rejeicao do enxerto renal, durante a pandemia de COVID-19, optou-se por nao realizar manutencao com rituximabe. Apresentou recaida precoce, novamente com linfocitose progressiva e esplenomegalia 6 meses apos o termino do tratamento de 1 linha. Em junho de 2021 iniciou tratamento de 2 linha com iBTK de 2geracao - acalabrutinibe 200 mg/dia. Atingiu resposta hematologica com rapida normalizacao da linfocitose e resolucao da esplenomegalia, porem evoluiu com diarreia cronica, perda de peso e desnutricao, com prejuizo a qualidade de vida. Diante dos possiveis diagnosticos diferenciais - infeccao oportunista em paciente severamente imunossuprimido, infiltracao colonica por linfoma ou toxicidade medicamentosa, foi submetido a colonoscopia, com resultado normal, tornando toxicidade medicamentosa a principal hipotese. A dose do acalabrutinibe foi reduzida para 100 mg/dia em 20/04/22. Desde entao houve melhora da diarreia, o paciente voltou a ganhar peso e mantem resposta hematologica completa. Discussao e conclusao: Nao ha descricao de interacao entre acalabrutinib e inibidores de calcineurina, sirolimus e micofenolatomofetil. A posologia recomendada de acalabrutinibe e 100 mg de 12/12h, de forma universal. Pacientes transplantados em uso de imunossupressores nao foram incluidos nos estudos clinicos que levaram a aprovacao da droga para uso na pratica clinica. Esse caso ilustra que em cenarios especificos pode ser necessario realizar ajuste de dose para reduzir o risco de efeitos colaterais, sem prejuizo na eficacia do tratamento. Copyright © 2022

Repurposing BCL-2 and Jak 1/2 inhibitors: Cure and treatment of HIV-1 and other viral infections.

B cell lymphoma 2 (BCL-2) family proteins are involved in the mitochondrial apoptotic pathway and are key modulators of cellular lifespan, which is dysregulated during human immunodeficiency virus type 1 (HIV-1) and other viral infections, thereby increasing the lifespan of cells harboring virus, including the latent HIV-1 reservoir. Long-lived cells harboring integrated HIV-1 DNA is a major barrier to eradication. Strategies reducing the lifespan of reservoir cells could significantly impact the field of cure research, while also providing insight into immunomodulatory strategies that can crosstalk to other viral infections. Venetoclax is a first-in-class orally bioavailable BCL-2 homology 3 (BH3) mimetic that recently received Food and Drug Administration (FDA) approval for treatment in myeloid and lymphocytic leukemia. Venetoclax has been recently investigated in HIV-1 and demonstrated anti-HIV-1 effects including a reduction in reservoir size. Another immunomodulatory strategy towards reduction in the lifespan of the reservoir is Jak 1/2 inhibition. The Jak STAT pathway has been implicated in BCL-2 and interleukin 10 (IL-10) expression, leading to a downstream effect of cellular senescence. Ruxolitinib and baricitinib are FDA-approved, orally bioavailable Jak 1/2 inhibitors that have been shown to indirectly decay the HIV-1 latent reservoir, and down-regulate markers of HIV-1 persistence, immune dysregulation and reservoir lifespan in vitro and ex vivo. Ruxolitinib recently demonstrated a significant decrease in BCL-2 expression in a human study of virally suppressed people living with HIV (PWH), and baricitinib recently received emergency use approval for the indication of coronavirus disease 2019 (COVID-19), underscoring their safety and efficacy in the viral infection setting. BCL-2 and Jak 1/2 inhibitors could be repurposed as immunomodulators for not only HIV-1 and COVID-19, but other viruses that upregulate BCL-2 anti-apoptotic proteins. This review examines potential routes for BCL-2 and Jak 1/2 inhibitors as immunomodulators for treatment and cure of HIV-1 and other viral infections.

NSP4 and ORF9b of SARS-CoV-2 Induce Pro-Inflammatory Mitochondrial DNA Release in Inner Membrane-Derived Vesicles.

Circulating cell-free mitochondrial DNA (cf-mtDNA) has been found in the plasma of severely ill COVID-19 patients and is now known as a strong predictor of mortality. However, the underlying mechanism of mtDNA release is unexplored. Here, we show a novel mechanism of SARS-CoV-2-mediated pro-inflammatory/pro-apoptotic mtDNA release and a rational therapeutic stem cell-based approach to mitigate these effects. We systematically screened the effects of 29 SARS-CoV-2 proteins on mitochondrial damage and cell death and found that NSP4 and ORF9b caused extensive mitochondrial structural changes, outer membrane macropore formation, and the release of inner membrane vesicles loaded with mtDNA. The macropore-forming ability of NSP4 was mediated through its interaction with BCL2 antagonist/killer (BAK), whereas ORF9b was found to inhibit the anti-apoptotic member of the BCL2 family protein myeloid cell leukemia-1 (MCL1) and induce inner membrane vesicle formation containing mtDNA. Knockdown of BAK and/or overexpression of MCL1 significantly reversed SARS-CoV-2-mediated mitochondrial damage. Therapeutically, we engineered human mesenchymal stem cells (MSCs) with a simultaneous knockdown of BAK and overexpression of MCL1 (MSCshBAK+MCL1) and named these cells IMAT-MSCs (intercellular mitochondrial transfer-assisted therapeutic MSCs). Upon co-culture with SARS-CoV-2-infected or NSP4/ORF9b-transduced airway epithelial cells, IMAT-MSCs displayed functional intercellular mitochondrial transfer (IMT) via tunneling nanotubes (TNTs). The mitochondrial donation by IMAT-MSCs attenuated the pro-inflammatory and pro-apoptotic mtDNA release from co-cultured epithelial cells. Our findings thus provide a new mechanistic basis for SARS-CoV-2-induced cell death and a novel therapeutic approach to engineering MSCs for the treatment of COVID-19.

INHIBITION OF PROTEIN KINASE CK2 AND BCL-2: A NOVEL THERAPEUTIC STRATEGY TO ANTAGONIZE MANTLE CELL LYMPHOMA CELL GROWTH

Background: Mantle cell lymphoma (MCL) is a B-cell tumor which often relapses. BCR inhibitors (Ibrutinib, Acalabrutinib) and antiapoptotic BCL2-family members blockers BH3-mimetics (Venetoclax, ABT-199) are effective drugs to fight MCL. However, the disease remains incurable, due to therapy resistance, even to the promising Venetoclax and Ibrutinib combination. Therefore, there is a profound need to explore novel useful therapeutic targets. CK2 is a S/T kinase overexpressed in several solid and blood tumors. We demonstrated that CK2, operating through a 'non-oncogene addiction' mechanism promotes tumor cell survival, and counteracts apoptosis, by activating pro-survival signaling cascades, such as NF-κ B, STAT3 and AKT. CK2 could regulate also BCL2 family members. The CK2 chemical inhibitor CX-4945 (Silmitasertib, Sil) is already under scrutiny in clinical trials in relapsed multiple myeloma, solid tumors and COVID-19. Aims: In this work, we tested the effect of CK2 chemical inhibition or knock down on Venetoclax (Ven)-induced cytotoxicity in MCL pre-clinical models to effectively reduce MCL cell growth and clonal expansion. Methods: CK2 expression and BCR/BCL2 related signaling components were analyzed in MCL cells and control cells by Western blotting. CK2 and BCL2 inhibition was obtained with Sil and Ven, respectively and with CK2 gene silencing through the generation of anti-CK2 shRNA IPTG-inducible MCL cell clones. Survival, apoptosis, mitochondrial membrane depolarization and proliferation were investigated by FACS analysis of AnnexinV/PI and JC-10 staining. The synergic action of Ven and Sil was analyzed by the Chou-Talalay combination index (CI) method. CK2 knock down in vivo was obtained in xenograft NOD-SCID mouse models Results: CK2 inactivation (with Sil or CK2 silencing) determined a reduction in the activating phosphorylation of S529 p65/RelA and S473 and S129 AKT, important survival cascades for MCL. Sil or CK2 silencing caused BCL2 and related MCL1 protein reduction, causing cell death. Importantly, we confirmed these results also in an in vivo xenograft mouse model of CK2 knockdown in MCL. Sil +Ven combination increased MCL cell apoptosis, as judged by the augmented frequency of Annexin V positive cells and expression of cleaved PARP protein, and JC-10 mitochondrial membrane depolarization, with respect to the single treatments. Captivatingly, Sil or CK2 gene silencing led to a substantial reduction of the Ven-induced increase of MCL-1, potentially counteracting a deleterious Ven-induced drawback. Analysis of cell cycle distribution confirmed an increased frequency of apoptotic cells in the sub G1 phase in CK2-silenced cells and a modulation of the other phases of the cell cycle. Remarkably, the calculated CI less than 1 suggested a strong synergic cell-killing effect between Sil and Ven, on all the cell lines tested, including those less sensitive or resistant to Ven Summary/Conclusion: We demonstrated that the simultaneous inhibition/knock down of CK2 and BCL2 synergistically cooperates in inducing apoptosis and cell cycle arrest of MCL malignant B-lymphocytes and has the potential of reducing MCL clonal growth, also counterbalancing mechanism of resistance that may arise with Ven. Therefore, CK2 is a rational therapeutic target for the treatment of MCL to be tested in combination with Ibrutinib or Ven.

B-CELL MALIGNANCIES TREATED WITH TARGETED DRUGS AND SARS-COV-2 INFECTION. A EUROPEAN HEMATOLOGY ASSOCIATION SURVEY (EPICOVIDEHA)

Background: Patients with lymphoproliferatie diseases (LPD) appear particularly ulnerable to SARS-CoV-2 infection, partly because of the effects of the anti-neoplastic regimens (chemotherapy, signaling pathway inhibitors, and monoclonal antibodies) on the immune system. The real impact of COVID-19 on the life expectancy of patients with different subtypes of lymphoma and targeted treatment is still unknown. Aims: The aim of this study is to describe and analyse the outcome of COVID-19 patients with underlying LPD treated with targeted drugs such as monoclonal antibodies (obinutuzumab, ofatumumab, brentuximab, niolumab or pembrolizumab), BTK inhibitors (ibrutinib, acalabrutinib), PI3K inhibitors (idelalisib), BCL2 inhibitors (enetoclax) and IMIDs, (lenalidomide). Methods: The surey was supported by EPICOVIDEHA registry. Adult patients with baseline CLL or non-Hodgkin Lymphoma (NHL) treated with targeted drugs and laboratory-confirmed COVID-19 diagnosed between January 2020 and January 2022 were selected. Results: The study included 368 patients (CLL n=205, 55.7%;NHL n=163, 44.3%) treated with targeted drugs (Table 1). Median follow-up was 70.5 days (range 19-159). Most used targeted drugs were ITKs (51.1%), anti-CD20 other than rituximab (16%), BCL2 inhibitors (7.3%) and lenalidomide (7.9%). Of note, only 16.0% of the patients were accinated with 2 or more doses of accine at the onset of COVID-19. Pulmonary symptoms were present at diagnosis in 244 patients (66.2%). Seere COVID-19 was obsered in 47.8 % patients while 21.7% were admitted to to intensie care unit (ICU), being 55 (26.8%) CLL patients and 25 (15.3%) NHL patients. More comorbidities were reported in patients with seere-critical COVID-19 compared to those with mild- asymptomatic infection (p=0.002). This difference was releant in patients with chronic heart diseases (p=0.005). Oerall, 134 patients (36.4%) died. Primary cause of death was COVID-19 in 92 patients (68.7%), LPD in 14 patients (10.4%), and a combination of both in 28 patients (20.9%).Mortality was 24.2% (89/368) at day 30 and 34.5%(127/368) at day 200. After a Cox multiariable regression age >75 years (p<0.001, HR 1.030), actie malignancy (p=0.011, HR 1.574) and admission to ICU (p<0.00, HR 4.624) were obsered as risk factors. Surial in patients admitted to ICU was 33.7% (LLC 38.1%, NHL 24%). Mortality rate decreased depending on accination status, being 34.2% in not accinated patients, 15.9-18% with one or two doses, decreasing to 9.7% in patients with booster dose (p<0.001). There was no difference in OS in NLH s CLL patients (p=0.344), nor in ITKs s no ITKs treated patients (p=0.987). Additionally, mortality rate dropped from the first semester 2020 (41.3%) to last semester 2021 (25%). Summary/Conclusion: - Our results confirm that patients with B--mallignancies treatted with targeted drugs hae a high risk off seere infection (47.8%) and mortality (36.4%) from COVID-19. - Pressence of comorbidities,, especially heart disease,, is a risk factor for seere COVIID--19 infection in ourr series. - Age >75 years,, actie mallignancy att COVIID--19 onset and ICU admission were mortality risk factors. - COVIID--19 acination was a protectie factor for mortality,, een iin this popullation wiitth humorall immunity impairment. - The learning cure in the management of the infection throughout the pandemiic and the deelopmentt off COVIID--19 treatments showed benefit in this partticullarlly ullnerablle popullation? (Table Presented).

PEDIATRIC-TYPE FOLLICULAR LYMPHOMA - A NEW PARADIGM IN DIAGNOSIS?

Background: Recognized as an entity in the 2016 WHO Classification of Tumors of Hematopoietic and Lymphoid Tissues, Pediatric-Type Follicular Lymphoma (PTFL) is a rare nodular follicular lymphoma that affects primarily children and young adults. The clinical presentation is characterized by the sudden appearance of an isolated lymphadenopathy, with a predilection for the head and neck region, without systemic symptoms. The incidence is higher in men. It has an excellent prognosis with the excision of the affected ganglion. By definition, diagnosis is histological, immunocytochemical and molecular. There are no known risk factors or any described association with immunodeficiency or viral infections. Aims: We report two clinical cases. Methods: Case 1 - a previously healthy 18-year-old boy with an isolated, non-painful, cervical lymphadenopathy of approximately 20 mm, which was incidentally found. Case 2 - a 13-year-old boy without relevant personal history, who, after the second dose of vaccination against COVID-19, developed multiple adenomegalies that spontaneously regressed. However, one month later, a right submandibular adenomegaly appeared. It was analysed by ultrasound and was described as suspicious. In both cases, a fine-needle lymph node biopsy was performed for cytological diagnosis and material was sent for immunophenotyping by flow cytometry and molecular cytogenetics by FISH. Results: Immunophenotyping suggested a large-cell B-lymphoma with a phenotype compatible with Burkitt's Lymphoma (BL). In the cytology of both cases, the population observed was more consistent with diffuse large B cell lymphoma (DLBCL) or possibly high-grade follicular lymphoma (FL). In the FISH study, no rearrangements in the MYC, BCL2, BCL6 or IRF4 genes were detected in the samples of the two cases. The lymphadenopathies were excised with a probable diagnosis of PTFL or DLBCL. Histological examination confirmed the PTFL diagnosis. Summary/Conclusion: We did not find in the literature any reference to clear causal relationship between vaccination against COVID-19 and the onset of lymphoproliferative diseases. The cytological/immunophenotypic/molecular approach of this entity in both cases seems to define a characteristic pattern, which may eventually allow, in a first approach, to suspect this diagnosis. More extensive studies will be needed to establish the role of these methodologies in the diagnosis of this pathology.

Impact of cancer diagnosis, stage, and systemic therapies on immunogenicity after COVID-19 vaccination in patients with cancer: A systematic review and metaanalysis

Background: Patients (pts) with cancer are at increased risk of severe COVID-19. Both underlying malignancy and anti-cancer treatments influence the immune system, potentially impacting the level of vaccine protection achieved. Methods: A systematic literature search of PubMed, Embase, CENTRAL and conference proceedings (ASCO annual meetings and ESMO congress) up to 28/09/21, was conducted to identify studies reporting anti-SARS-CoV-2 spike protein immunoglobulin G seroconversion rates (SR) at any time point after complete COVID-19 immunization (mRNA- or adenoviral-based vaccines) in cancer pts. Complete immunization was defined as 1 dose of JNJ-78436735 vaccine or 2 doses of BNT162b2, mRNA-1273 or ChAdOx1 nCoV-19 vaccines. Subgroup analyses were performed to examine the impact of cancer diagnosis, disease stage, and anticancer therapies on the SR. Overall effects were pooled using random-effects models and reported as pooled SR with 95% confidence intervals (CI). Results: Of 1,548 identified records, 64 studies were included in this analysis reporting data from 10,511 subjects. The Table shows the SR in the overall population and specific subgroups. In pts with solid malignancies (SM), disease stage and primary site did not significantly impact the SR. In pts with hematologic malignancies (HM), SR were significantly lower in pts with chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL) compared to acute lymphoblastic leukemia (ALL), Hodgkin lymphoma (HL), and multiple myeloma (MM). Concerning the impact of cancer therapies on SR, pts with SM undergoing chemotherapy had numerically lower SR (N = 1,234, SR 87%, CI 81-92) compared to those treated with immune checkpoint inhibitors (N = 574, SR 94%, CI 88-97) or endocrine therapy (N = 326, SR 94%, CI 86-97) with or without another targeted therapy. Pts with HM treated with anti-CD20 therapy (within the last 12 months: N = 360, SR 7%, CI 2-20;or more than 12m: N = 175, SR 59%, CI 35-80), immune-modulating agents (BTK or BCL2 inhibitors) (N = 462, SR 47%, CI 32-64%) or other immunotherapies (anti-CD19/CART or anti-CD38) (N = 293, SR 37%, CI 23-53) had lower SR compared to pts treated with autologous (N = 353, SR 77%, CI 67- 85) or allogenic stem cell transplantation (N = 509, SR 77%, CI 68-84). Conclusions: SR varies between cancer types and anticancer therapies with some cancer pts having low protection against COVID- 19 even after complete vaccination.

Annual Conference of National Cancer Institute - Cairo University “Bridging Gaps in Oncology”

The proceedings contain 12 papers. The topics discussed include: prognostic implication of MYC/BCL2 expressions in patients with diffuse large B-cell NHL;clinical outcomes of pediatric-inspired chemotherapy protocol in adolescent and young adults (AYAs) acute lymphoblastic leukemia patients;effect of nutritional status on survival of Egyptian patients with gastrointestinal malignancies;characterization of COVID-19 disease in cancer patients, single institute experience, low income setting;malignant obstructive jaundice;review of 232 patients;determining resectability in pancreatic tumors;review of 70 cases;Inhibition of dynamins restricts the survival of vasopressin stimulated and PI3K/Akt/mTOR inhibited breast cancer cells;and complete mesocolic excision and central vascular ligation in colon cancer surgery, feasibility and outcome.

LINFOMA PRIMÁRIO DE SISTEMA NERVOSO CENTRAL EM PACIENTE PEDIÁTRICO HIV POSITIVO: RELATO DE CASO

Relato: Paciente de 6 anos, HIV+, iniciou quadro com crise de ausência em jan/2021. Recebeu tratamento para encefalite com melhora clínica temporária. Evoluiu com cefaleia frontal de forma progressiva, desenvolvendo ataxia, afasia, vômitos em jato e novo episódio convulsivo após 1 mês da alta. RNM de crânio evidenciou lesão expansiva em hemisfério cerebral direito com compressão do 4° ventrículo e pequenas imagens nodulares difusas com edema cerebral. Realizou cirurgia para derivação ventricular externa e biópsia das lesões. Descartadas causas infecciosas, foi diagnosticado em mar/2021 com linfoma de células B de alto grau através de exame histopatológico. Estadiamento não evidenciou doença em outros sítios. Iniciou tratamento em mar/2021 com o protocolo NHL BFM 2012 associado a rituximabe. Após o bloco AAZ1 apresentou mucosite grau IV. Após BBZ1, evoluiu com mucosite grau III precoce, íleo paralítico, tiflite e infecção leve pelo SARS-CoV-2. RNM após 2 blocos de tratamento apresentando expressiva redução das lesões previamente identificadas. Após CCZ1 apresentou íleo paralítico e pneumonia, evoluindo com quadro de insuficiência respiratória grave e óbito. Discussão: Linfoma primário do SNC (LPSNC) é um tipo raro e agressivo de LNH, mais comum em pacientes imunodeficientes, que corresponde a 0,5–2% dos tumores primários de SNC e 0,7–0,8% de todos os linfomas. A incidência desse tipo de neoplasia na população pediátrica é desconhecida devido a raridade de casos reportados. Seu subtipo mais frequente é o linfoma difuso de grandes células B. O paciente em questão foi diagnosticado com Linfoma de células B de alto grau estádio IV, duplo expressor (myc e bcl2) através do histopatológico e imuno-histoquímica com Ki67 >95%, padrão menos comum em crianças. A co-expressão das proteínas MYC e BCL2 está associada a um pior prognóstico. Pacientes duplo-expressores têm idade média de 71 anos, apresentam pior performance-status, doença mais avançada e maior índice de proliferação Ki-67. O cenário ideal seria o rastreio de MYC, BCL2 e BCL6 em todos os pacientes com linfoma de alto grau no diagnóstico e, se positivo, a complementação por FISH para avaliação de double-hit, que já confere novas abordagens prognósticas e terapêuticas em adultos. Os principais fatores prognósticos do LPSNC são idade e performance status. O tratamento de primeira linha em crianças é baseado em quimioterapia (QT) com HD-MTX. O papel da radioterapia (RT) nesses pacientes é questionável. O estudo com maior número de casos pediátricos (29) mostrou sobrevida de 82% em 3 anos, apresentando melhores taxas que dos adultos (20–40% em 5 anos) e a maioria dos casos não fez RT. A adição do anticorpo monoclonal anti-CD20, Rituximabe, ao tratamento, foi baseada em estudos recentes realizados com crianças e adolescentes com LNH de células B maduras de alto grau. Houve remissão em 95% dos pacientes que usaram a terapia combinada (rituximabe e QT) com uma maior taxa de sobrevida livre de eventos em 3 anos quando comparado àqueles que receberam somente QT (95,1% vs. 87,3%). Devido a agressividade da doença, a intensificação do tratamento se faz necessária. O uso combinado do rituximabe com a poliquimioterapia, gera maior risco de toxicidade, principalmente mielotoxicidade. O paciente em questão teve boa resposta parcial ao tratamento, porém apresentou intercorrências graves durante os 3 períodos de aplasia pós QT, o que levou ao seu óbito.

SARS-COV-2 INDUCED REMISSION OF DIFFUSE LARGE B-CELL LYMPHOMA: A CASE REPORT

Introduction: Diffuse Large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma, which accounts for approximately 30% of all non-Hodgkin lymphoma cases. Spontaneous remission of DLBCL is exceedingly rare, with only a handful of case reports that describe the phenomenon present in the literature. Specialists are investigating similar cases to find out whether the SARS-CoV-2 infection triggered an antitumor immune response, as has been described with other infections in the context of high-grade non-Hodgkin lymphoma. We report one case of an elderly woman with EBV positive DLBCL diagnosed with PCR-positive SARS-CoV-2 pneumonia in the course of the disease and their outcomes. Case report: A 81 years-old woman, was referred to the consult ambulatory of intern medicine with progressive cervical, axillary and inguinal lymphadenopathy with local pain, fever and weight loss. The biopsy of an axillary lymph node demonstrated diffuse atypical lymphoid infiltrate. Immunohistochemistry stains showed positive CD20, CD30, Bcl-2 and MUM-1. It was negative for CD3, CD10, Bcl-6, c-Myc and CMV. The Ki-67 proliferation index was 80%. Epstein-Barr virus (EBV) stain were positive. These findings were consistent with DLBCL, EBV positive, clinical Stage IIIB and R-IPI 4 (poor prognosis and high risk). Since PET-CT was unavailable, thorax and abdomen computed tomographies were performed and revealed enlarged lymph node on pulmonary hilum, pathological lymph node enlargement in the axillary and supraclavicular chains bilaterally and peri aortocaval adenomegaly, extending along the bilateral femoral iliac vessels (larger lymph nodes of 2.5cm). She was treated with 4 cycles of R-CVP (rituximab with cyclophosphamide, vincristine and prednisone). When an interim PET-CT was performed, disease progression was revealed (Lugano score 5). Therefore, considering patient age and clinical status, treatment scheme was changed to R-mini-CHOP (rituximab with reduced doses of cyclophosphamide, doxorubicin, vincristine and prednisone), achieving partial response after 4 cycles (Lugano score 4). A month after this evaluation, she was admitted to the Emergency Department with diarrhea, fever and was diagnosed with PCR-positive SARS-CoV-2 pneumonia. After 6-days hospitalization with no significant ventilatory impairment, she was discharged. No corticosteroid or immunochemotherapy was administered. Two months later, she had no palpable lymphadenopathy and a PET/CT scan revealed widespread resolution of the lymphadenopathy and reduced metabolic uptake throughout (Lugano score 1). After a 7-months follow-up, the patient still has no clinical relapse. Discussion: The putative mechanisms of action include cross-reactivity of pathogen-specic T cells with tumour antigens and natural killer cell activation by inammatory cytokines produced in response to infection. It is important to consider that the more cases of SARS-CoV-2 infection in patients with non-Hodgkin lymphoma, the more likely it is to analyze lymphoma remissions and demonstrate the exact mechanism of pathogen-specific T cells with tumor antigens. Conclusion: Because spontaneous remission of DLBCL associated with SARS-CoV-2 infection is a new event, careful investigation of these cases is important, because the information gained may lead to new therapeutic targets or treatment strategies for future patients.

LINFOMA GÁSTRICO DOUBLE HIT: RELATO DE CASO

Introdução: O linfoma não-Hodgkin (LNH) é a neoplasia hematológica mais comum, mais frequente em homens e em países subdesenvolvidos. De acordo com estudo do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), o LNH corresponde à 80% dos linfomas, destes 50% linfoma difuso de grandes células B (LDGCB), com idade média de 59,6 anos, 33% de acometimento extranodal, 62% de doença avançada, IPI (Índice Internacional de Prognóstico) intermediário alto de 24% e alto de 19% para portadores de LDGCB. Objetivos: Relatar caso de paciente diagnosticada com LNHDGCB double hit gástrico durante investigação ambulatorial de síndrome dispéptica e sua abordagem. Materiais e métodos: Levantamento de prontuário, descrição e discussão de relato de caso clínico, por meio de uma revisão integrativa utilizando bases de dados PUBMED, MEDLINE, BVS e SCIELO. Relato de caso: Feminina, 47 anos, sem comorbidades, com queixa de epigastralgia pós-prandial há 9 meses e perda ponderal de 15 kg no período, sem outros sinais e sintomas. Há 2 meses, em investigação com gastroenterologista foi realizada EDA com biópsia de lesão gástrica associada a painel imuno-histoquímico (BCL6, CD20, CD30, MYC e Ki-67 positivos) compatíveis com LNHDGCB gástrico com alto índice proliferativo, além de tomografia de abdome total com contraste, evidenciando infiltração em lobo hepático esquerdo e hilo esplênico (estádio IV), sendo encaminhada ao serviço de hematologia há aproximadamente 15 dias. Atualmente, paciente segue em programação de quimioterapia com R-da-EPOCH após término de isolamento contactante Covid. Discussão: O linfoma double-hit (LDH) é uma neoplasia de alto grau e agressiva, que integra o subgrupo de LDGCB e se traduz na translocação do gene MYC combinada à translocação gênica adicional de BCL2, BCL3, BCL6 ou CCND1. Nesses casos, há maior tendência de infiltração de medula óssea e sistema nervoso central, além de prognóstico reservado associado ao alto índice de proliferação celular, elevação de DHL sérica, acometimento acima de 70 anos, apresentação clínica em estádio avançado e má resposta terapêutica. O diagnóstico é realizado por meio de biópsia excisional do local suspeito, estudo imuno-histoquímico, e, preferencialmente, acrescido da pesquisa FISH (hibridação in situ por Fluorescência) para MYC, BCL2 e BCL6. O estadiamento obedece a classificação Lugano, baseada no antigo sistema Ann Arbor: envolvimento de região linfonodal única (I);duas ou mais regiões linfonodais do mesmo lado do diafragma (II);regiões linfonodais em ambos lados do diafragma (III);sítio extranodal fora do sistema linfático (IV). O tratamento quimioterápico envolve ciclos de R-da-EPOCH (rituximabe, dose ajustada de etoposídeo, prednisona, doxorrubicina, ciclofosfamida e vincristina) a cada 21 dias. A Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH) considera R-da-EPOCH o tratamento padrão-ouro, porém, durante a pandemia Covid, diante da indisponibilidade de leitos e/ou bombas de infusão portáteis para tratamento ambulatorial, orienta levar em consideração a terapia com R-CHOP, seguido de estratégias de consolidação, que incluem TCTH, a fim de não atrasar o tratamento. Conclusão: O LNHDGCB double hit pode acometer jovens, em sítio extranodal e exige abordagem diferenciada por sua agressividade e alto grau associados a prognóstico reservado. Apesar disso, com as novas terapêuticas e estadiamento clínico precoce é uma neoplasia potencialmente tratável e curável, cujo tratamento pode se beneficiar do uso de técnicas citogenéticas para pesquisa de translocações gênicas.