Myeloproliferative neoplasms (MPN) are shaped by epigenetic rewiring that extends beyond canonical JAK2V617F-driven signaling. This review argues that context-dependent chromatin states, not merely genetic lesions, determine disease trajectory, fibrotic transformation, and leukemic progression. We synthesize recent evidence indicating that PRC2 deficiency is supported by the strongest MPN-specific evidence for BRD4 dependency, whereas PARP/BCL-2 vulnerabilities associated with TET2/IDH mutations and USP7 dependency associated with ASXL1 remain supported primarily by related myeloid malignancies or preclinical studies. Introducing the concept of an "epigenetic clock" of clonal evolution, we propose that MPN cells acquire progressively pathological chromatin states that can be quantified through composite methylation and accessibility scores. Importantly, temporal synthetic lethality, using short epigenetic pulses to remodel chromatin before applying targeted agents, offers a rational scheduling strategy to expose non-redundant dependencies while sparing normal hematopoiesis. We outline a translational roadmap incorporating cfDNA methylome biomarkers, ongoing BET inhibitor trials, and emerging single-cell perturbation approaches. Finally, we highlight the "dark epigenome" of repetitive elements as an unexplored therapeutic frontier. Collectively, these findings suggest that context-restricted chromatin vulnerabilities may offer therapeutic opportunities for disease-modifying intervention in progression-prone MPN clones.
Early identification of refractory disease remains a significant unmet clinical need in patients with diffuse large B-cell lymphoma (DLBCL). This scoping review was conducted to assess the current knowledge on the use of circulating tumor DNA (ctDNA), either alone or in combination with immune markers, as predictive tools for treatment outcome in previously untreated DLBCL patients. A systematic search of online databases PubMed, Embase, CINAHL, and Cochrane was performed from inception to May 2025. This focused on primary research studies investigating the use of ctDNA or immune markers to assess treatment response and predict outcomes in DLBCL. 61 publications were selected for inclusion. The key points of interest for this scoping review were: pre-analytical sample handling, laboratory methodologies-including sequencing panels and platforms; and mutations or immune markers associated with prognosis or patient outcome. Strong evidence supports the utility of ctDNA analysis at key timepoints to evaluate treatment response: diagnosis, cycle 2 day 1, cycle 3 day 1, and end of treatment. ctDNA assays with adequate sensitivity can improve interpretation of FDG18-PET/CT scans, reducing unnecessary additional testing for patients. Molecular clustering on ctDNA also improves risk stratification. Elevated cytokines such as CXCL10 and IL-10 and elevated numbers of myeloid derived suppressor cells in pre-treatment samples are associated with inferior prognosis. ctDNA analysis shows promise in improving outcomes for patients with DLBCL. Assay standardization for ctDNA analysis is currently lacking. Further investigation into the additional value of immune marker analysis is required. This includes understanding the association between immune markers and molecular subgroups identified on ctDNA analysis.
Langerhans cell histiocytosis (LCH) is a rare clonal myeloid neoplasm. Canadian data on clinical characteristics, molecular profile, and treatment outcomes is limited. This study aims to report the initial experience of a Canadian rare diseases program, reflecting "real-world" diagnostic pathways, referral patterns, and treatment heterogeneity across multiple provinces. We conducted a retrospective review of patients managed in an adult-care cohort with histologically confirmed LCH diagnosed between 2000 and 2025 across multiple Canadian centers. Patients diagnosed as children and subsequently transferred to adult care were included. Clinical features, radiologic findings, histopathology, molecular testing, treatment approaches, and outcomes were collected and analyzed. Thirty-one patients were identified, with a median age at diagnosis of 42 years (range: 2-84) and a male predominance (65%). Bone (74%), lung (29%), and skin (16%) were the most commonly involved sites. Concomitant or subsequent malignancies were present in 19% of patients. Molecular testing found BRAFV600E mutations in 44% of tested patients. The most common first-line systemic therapy was cytarabine (n = 10), followed by other drugs such as hydroxyurea, vemurafenib, and cladribine. This series represents the initial experience of a Canadian rare disease referral program and captures the clinical heterogeneity and longitudinal adult care of patients with LCH across multiple provinces. Variability in treatment approaches highlights the need for collaborative prospective natural history studies and coordinated clinical trials.
Monoclonal gammopathy of undetermined significance (MGUS) is a common asymptomatic plasma cell disorder and the major precursor state of multiple myeloma (MM). Although progression is partly shaped by intrinsic genetic and epigenetic changes within the plasma cell clone, increasing evidence indicates that the bone marrow microenvironment plays a decisive role in determining whether the clone remains clinically silent or evolves toward symptomatic disease. This review examines how the marrow niche changes across the MGUS-SMM-MM continuum. In early MGUS, the microenvironment may already be permissive, but it remains partly restrained: immune control is not fully lost, stromal activation is incomplete, vascular remodeling is limited, and the bone-remodeling compartment has not yet become overtly tumor-supportive. Progression appears to occur when these initially modest stromal, vascular, skeletal, immune, and extracellular matrix alterations become functionally connected. Once linked, these changes form reinforcing circuits that enhance plasma cell retention and survival, weaken immune containment, remodel the vascular and skeletal niche, and promote resistance to therapy. In this view, MGUS-to-MM progression is not simply a plasma cell-autonomous process, but a gradual ecological shift in which the marrow niche becomes increasingly aligned with the needs of the malignant clone. Understanding this coordinated microenvironmental remodeling may improve risk stratification and support therapeutic strategies that target both the plasma cell clone and its supportive niche.
The role of allogeneic hematopoietic cell transplantation (alloSCT) in chronic lymphocytic leukemia (CLL) has decreased in recent years due to the emergence of new effective targeted agents for the treatment of this disease. However, for a certain group of heavily pretreated or high-risk CLL patients with no other therapeutic options, allo-SCT remains important. Due to the fact that in most high-risk CLL patients it is possible to achieve durable response as a result of Bruton's tyrosine kinase inhibitors (ВТК), BCL-2 inhibitor and especially in their combined application, including in the first line of therapy, the choice of time point for alloSCT becomes relevant. In this retrospective study allo-SCT was performed in 44 patients with the period from 2006 to 2023. Progression-free survival was 79.2% at 12 months and 69.3% at 24 months. Similarly, overall survival was 81.4% at 12 months and 74% at 24 months. Graft-versus-host disease relapse-free survival was 57%. Despite small sample size, our study demonstrates that alloSCT has become a significantly safer procedure in patients with CLL.
Relapsed and refractory acute myeloid leukemia (AML) remains difficult to treat, in part because leukemic cells adapt to nucleoside analogue-induced replication stress. Here, we identify thymidine kinase 1 (TK1) as a functional contributor to chemotherapy resistance in AML. Integrated analyses of TCGA, Beat AML, and murine chemoresistant AML transcriptomes revealed that high TK1 expression was associated with adverse outcome, cytarabine resistance, and enrichment of nucleotide salvage programs. In Mll-Af9/Setd2-mutant AML cells, TK1 upregulation coincided with reduced de novo nucleotide synthesis, sustained BrdU incorporation, attenuated replication stress signaling, and resistance to daunorubicin plus cytarabine. Genetic suppression of Tk1 impaired DNA synthesis, increased replication-associated DNA damage, and restored chemosensitivity. Mechanistically, TK1 accumulation was linked to impaired APC/C-CDH1 activity, and manipulation of Cdh1 altered TK1 abundance, replication stress tolerance, and drug response. Combined topoisomerase I and WEE1 inhibition increased CDH1 expression, reduced TK1 abundance, enforced replication stress, and induced leukemic cell death. In relapsed/refractory AML patient-derived xenograft models, this combination reduced leukemic burden and prolonged survival, particularly in TK1-high AML. These findings define a CDH1-TK1-associated program that promotes salvage-dependent replication stress tolerance and nominate TK1 as a candidate biomarker for replication stress-targeted therapy.
Patients with high-risk acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) continue to face a substantial risk of relapse after allogeneic hematopoietic stem cell transplantation (allo-HSCT), which remains a leading cause of treatment failure. In our previous study, maintenance therapy with a combination of venetoclax and decitabine has shown potential in reducing relapse rates; however, its efficacy and safety, particularly in relation to drug concentration levels, are not yet fully elucidated. This study aimed to evaluate the influence of venetoclax blood concentrations on the efficacy and toxicity of venetoclax plus decitabine as maintenance therapy in high-risk AML/MDS patients after allo-HSCT. We retrospectively analyzed clinical data from 58 high-risk AML/MDS patients who received this maintenance regimen at our center between April 2018 and June 2023, with a focus on the association between venetoclax blood levels, treatment response, and adverse effects. The results demonstrated that the venetoclax-decitabine maintenance regimen was effective and generally well-tolerated, improving remission rates without significantly increasing intolerable toxicities or the risk of graft-versus-host disease (GVHD). Notably, substantial interindividual variability in venetoclax blood concentrations was observed. Patients with concentrations maintained within the range of 2605-4060 ng/mL achieved superior outcomes and higher safety profiles. In conclusion, this study provides key evidence for establishing a target concentration window for venetoclax, highlighting the importance of therapeutic drug monitoring in guiding post-transplant maintenance therapy for high-risk AML/MDS patients.
In recent years, chronic lymphocytic leukemia (CLL) has undergone a radical change in the therapeutic landscape, allowing for the complete omission of chemotherapy in favor of targeted drugs. This reflects the improved understanding of the pathogenesis and biology of the disease, including both the genetic landscape of the leukemic clones and the crucial role of the numerous connections with the tumor microenvironment (TME). Regarding the latter, both in the bone marrow and in the lymph nodes, tissue architecture and function are reshaped by the lymphoid infiltrate to co-opt surrounding bystander cells, thereby supporting leukemic cell proliferation and survival. In this review, we explore the peculiarities of the CLL TME and how they translate into remarkable changes in the lymph nodal structure and in the inter-cellular interactions. We will elaborate on the potential that new multi-omics technologies might have in understanding the complex interplay occurring between CLL cells and TME.
BCL6 is a master transcriptional regulator of germinal center (GC) B cells. BCL6 is frequently translocated at the major translocation cluster (MTC) within intron 1 of the BCL6 locus, a hotspot commonly rearranged in diffuse large B cell lymphomas (DLBCLs). BCL6 amplifications are associated with therapeutic resistance and poor survival outcomes in hematological and solid cancers. However the mechanisms suppressing genome instability at the BCL6-MTC preventing BCL6 rearragements remain unclear. Here, transcriptome analysis and genome-wide mapping of histone H3 lysine 4 trimethylation (H3K4me3) in hydroxyurea (HU)-treated Raji cells (a Burkitt's lymphoma model) revealed the induced expression of MBD1, encoding the DNA CpG methylation-binding protein. Functional studies using shRNA silencing and ectopic overexpression demonstrated that MBD1 suppresses BCL6 transcription whose promoter harbors conserved CpG methylation sites, suggesting a DNA methylation-dependent regulation of BCL6 trasncription by MBD1. Conversely, BCL6 repressed MBD1 expression by binding to its promoter. MBD1-depleted Raji cells exhibited increased genomic instability at the BCL6-MTC upon HU treatment, heightened sensitivity to DNA replication inhibitors (HU, gemcitabine, and etoposide), and reduced tumorigenicity in xenograft mouse models. We propose that MBD1 prevents genomic instability at the BCL6-MTC to suppress DLBCL formation. Moreover, MBD1 promotes genomic stability and cell viability during DNA replication stress. MBD1 thus represents a potential therapeutic target for cancers exhibiting resistance to chemotherapies targeting DNA replication.
Diffuse large B-cell lymphoma (DLBCL) is the most prevalent form of non-Hodgkin lymphoma, exhibiting significant molecular and clinical heterogeneity. Advances in classification integrating phenotypic, genetic, and transcriptomic features have improved diagnosis and prognosis. However, a comprehensive and integrated molecular characterization of DLBCL cell lines is still lacking, which limits their optimal use as reliable experimental models. We employed fluorescence in situ hybridization, immunohistochemistry, and targeted DNA and RNA sequencing to identify genetic subtypes and determine the cell of origin, providing a comprehensive characterization of 29 DLBCL cell lines through the integration of phenotypic, genomic, and transcriptomic data. Principal component analysis, gene set enrichment analysis (GSEA), differential expression profiling, and regulon analysis enabled us to dissect molecular heterogeneity. We achieved high concordance in genetic subtype assignment using multiple classification algorithms (2-S, LymphGen, and DLBclass). The DHIT/DZ signature and transcriptional profiling further revealed additional molecular complexity. Some DLBCL-NOS cases exhibited high-grade features, suggesting that gene expression signatures may capture biological aggressiveness better than cytogenetic methods. GSEA confirmed the relevance of signaling pathways across DLBCL subtypes, and regulatory network analysis identified specific transcription-factor activities that support these pathways. MCD cell lines showed increased NF-κB and STAT signaling, while EZB/MYC+ cell lines demonstrated increased proliferation and cell cycle regulation, along with decreased NF-κB/STAT activity. Our study offers a detailed molecular overview of DLBCL cell lines, underscoring their relevance for mechanistic and therapeutic research. The data highlights how integrating genetic and transcriptomic analyses can refine disease classification and guide personalized therapy strategies.
Minimal residual disease (MRD) is the standard for deep response assessment in multiple myeloma but requires bone marrow sampling. Whether early serum free light chain (sFLC) response provides independent prognostic information in real-world, predominantly non-transplant patients remains unclear. We retrospectively analyzed 701 patients with newly diagnosed multiple myeloma treated at a single Chinese center (2015-2021). sFLC ratio normalization (IMWG range 0.26-1.65) during the first four induction cycles was assessed using a 4-month landmark to mitigate immortal time bias. Multivariable Cox models adjusted for R-ISS and age, with prespecified sensitivity analyses and direct comparison with established markers and MRD. Among 701 patients (median age 64 years; ASCT 12.6%), 433 (61.8%) were classified as FLC-normalized during C1-C4. FLC non-normalization was associated with inferior PFS (HR 2.10, 95% CI 1.60-2.76) and OS (HR 1.96, 95% CI 1.32-2.90) after adjustment for R-ISS stage and age. The association persisted in baseline-abnormal patients and after MRD adjustment. Adding sFLC status produced a modest improvement in model discrimination, supporting a complementary rather than stand-alone prognostic role. sFLC normalization was documented earlier than MRD negativity, a pattern that persisted in a paired-visit-restricted sensitivity analysis, although timing comparisons remain subject to retrospective assessment schedules. Early sFLC response was associated with outcomes in newly diagnosed multiple myeloma and provided complementary, incremental prognostic information beyond established risk factors and MRD. These findings support further prospective evaluation of sFLC normalization as a pragmatic blood-based marker for early risk stratification.
Mature T-cell lymphomas (TCL) are aggressive malignancies with limited effective therapies. Duvelisib (DUV), a dual inhibitor of PI3K-δ and PI3K-γ, has shown promising activity in TCL. Azacitidine (AZA), a hypomethylating agent, has demonstrated efficacy in TCL and may enhance the activity of PI3K inhibitors through epigenetic modulation and immune regulation. We conducted a phase I, open-label, 3 + 3 dose-escalation study of oral duvelisib in combination with oral azacitidine (BMS-986345) in patients with relapsed or refractory TCL. The primary objective was to identify the maximum tolerated dose (MTD) of the combination. Fourteen patients (N = 14) were enrolled with a median age of 63.5 years. The median number of prior therapies was two. Grade ≥ 3 toxicities, expressed for the full treated population (N = 14), included neutropenia (29%), anemia (21%), AST elevation (21%), ALT elevation (14%), thrombocytopenia (14%), and leukocytosis (14%). Most adverse events were grade 1-2 and manageable. The ORR was 46% (N = 6), with 31% (N = 4) complete responses (CR) and 15% (N = 2) partial responses (PR). All four evaluable patients with a T-follicular-helper (TFH) phenotype achieved CR, a hypothesis-generating observation given the small denominator. Median PFS was 2.2 months (95% CI 1.8-NE) and median OS 10.2 months (95% CI 6.3-NE); however, median duration of response was not reached, and three responders were censored at the time of allogeneic transplant. On-treatment suppression of AKT phosphorylation was enhanced during combined therapy. Duvelisib plus oral azacitidine had a manageable safety profile and encouraging activity, particularly in the TFH subtype, where responses were deep and enabled a bridge to allogeneic transplant. Randomized evaluation focused on the TFH subtype is warranted. TRIAL REGISTRATION: NCT05065866.
The molecular subtype characterized by co-occurring MYD88 and CD79B alterations (MCD) represents a biologically distinct subset of diffuse large B-cell lymphoma (DLBCL) with chronic active B-cell receptor signaling and a high risk of central nervous system (CNS) involvement. The clinical impact of Bruton tyrosine kinase inhibitors (BTKi) in this subtype remains unclear. We retrospectively analyzed 155 patients with newly diagnosed DLBCL harboring genetic features consistent with the MCD subtype. At a median follow-up of 34.1 months, the estimated 3-year progression-free survival (PFS) rate was 76.1%. BTKi exposure (n = 56) was associated with significantly improved PFS compared with no BTKi exposure (3-year PFS: 93.8% vs. 66.6%, p < 0.001) and remained independently associated with improved PFS after adjustment for IPI risk (HR 0.16, p < 0.001). Overall survival did not differ significantly between groups. Notably, all 15 CNS relapse events occurred in patients who did not receive BTKi, whereas no CNS relapse was observed in the BTKi-treated group. BTKi exposure was independently associated with a markedly reduced risk of CNS relapse (HR 0.06, p = 0.002) after adjustment for CNS-IPI risk and CNS prophylaxis. These findings suggest that BTK inhibition may improve outcomes and mitigate CNS relapse in MCD DLBCL.
Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive peripheral T-cell lymphoma with poor outcomes, and the role of autologous stem cell transplantation (ASCT) as consolidation after frontline therapy remains controversial. We conducted a retrospective cohort study using the National Cancer Database, including adults diagnosed with AITL between 2004 and 2020 who received frontline systemic therapy. Patients were categorized as chemotherapy alone (Chemo) or chemotherapy followed by ASCT (Chemo + ASCT). To mitigate immortal time bias, prespecified landmark analyses were performed, with a 6-month landmark analysis as the primary approach and a 9-month landmark analysis as a sensitivity analysis. Multivariable Cox regression and propensity score weighting using inverse probability of treatment weighting for the average treatment effect were used to address measured confounding. Among 3996 patients receiving systemic therapy, 686 (17.2%) underwent ASCT. In the 6-month landmark analysis, ASCT was associated with improved overall survival (HR, 0.53; 95% CI, 0.45-0.62; p < 0.001). Findings were consistent in the 9-month landmark analysis (HR, 0.58; 95% CI, 0.49-0.69; p < 0.001) and IPTW-adjusted model (HR, 0.51; 95% CI, 0.44-0.60; p < 0.001). In this large real-world cohort, ASCT consolidation was consistently associated with improved survival in patients with AITL. Although treatment-response data were unavailable and residual confounding cannot be excluded, these findings provide supportive real-world evidence and warrant prospective studies with treatment-timing and response data to better define patient selection.
Luspatercept has emerged as a therapeutic option for patients with lower-risk myelodysplastic neoplasms (MDS). Nonetheless, the performance of luspatercept outside of controlled clinical trials remains unclear. We aimed to synthesize real-world evidence (RWE) on the effectiveness and safety of luspatercept. This study was conducted following PRISMA guidelines. We searched for studies up to June 2025 evaluating luspatercept in adult MDS patients. Data on hematologic improvement-erythroid (HI-E), transfusion independence (TI at 8, 12, and 16 weeks), adverse events, and overall survival (OS) were extracted. Bayesian random-effects meta-analyses were performed using priors derived from pooled clinical trials. Seventeen studies were included: five clinical trials (440 patients) and twelve real-world cohorts (1821 patients). The pooled estimate for HI-E was 46.6% (95% CrI: 32.5%-63.9%). For TI, pooled rates at 8, 12, and 16 weeks were 44.7% (95% CrI: 28.6%-61.5%), 38.6% (95% CrI: 21.1%-60.0%), and 30.9% (95% CrI: 10.7%-53.9%), respectively. The subgroups with highest TI and HI-E were patients with positive SF3B1 status (58.5%, at 8 weeks) and Asian patients (54.8%), respectively. Male sex was associated with lower HI-E, 8, and 12 weeks TI rates. Hypertension and falls were more frequently reported in RWE. We estimated OS rates of 88.9% at 1 year and 74.4% at 2 years following treatment initiation. Real-world HI-E were modestly attenuated, likely reflecting selection, adherence, and monitoring differences. The response seems dependent on disease, geographical, and demographical moderators. Such aspects should be taken into account in the design of future studies and in clinical decisions.
The Phase 3 EPCORE FL-1 trial demonstrated that adding epcoritamab to lenalidomide plus rituximab (R2) significantly improved response rates and prolonged progression-free survival in patients with relapsed or refractory (r/r) follicular lymphoma (FL). However, the cost-effectiveness of this combination has not been evaluated. The objective of this study was to assess the cost-effectiveness of epcoritamab plus R2 compared with R2 alone for patients with r/r FL from a US payer perspective. A three-state Markov model was constructed with a 30-year time horizon to compare costs and health outcomes of epcoritamab plus R2 versus R2. The primary outcome was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life-year (QALY) gained. Parameter uncertainty was evaluated through one-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analyses. In the base-case analysis, epcoritamab plus R2 yielded an additional 3.94 QALYs at an incremental cost of $267,721.01 resulting in an ICER of $67,974.64 per QALY gained compared with R2 alone. In the one-way sensitivity analysis, the ICER ranged from $53,819.80 to $82,129.49 per QALY across all parameters tested. In the probabilistic sensitivity analysis, epcoritamab plus R2 had a 100% probability of being cost-effective at a willingness-to-pay (WTP) threshold of $150,000 per QALY. From a US payer perspective, epcoritamab plus R2 is estimated to be a cost-effective treatment option compared with R2 for patients with relapsed or refractory follicular lymphoma at a willingness-to-pay threshold of $150,000 per QALY.
The specific prognostic impact of FLT3-ITD variant allele frequency (VAF) in acute myeloid leukemia (AML) remains unclear. In this multi-center study of 190 AML patients harboring FLT3-ITD mutations, a VAF cut-off of 40% was applied. Patients with high VAF (≥ 40%) exhibited significantly higher white blood cell counts, lactate dehydrogenase levels, and bone marrow blast percentages, alongside markedly shorter median overall survival (OS). Although high VAF was independently associated with inferior outcomes in the overall multivariate Cox regression analysis, its effect was profoundly amplified in the presence of co-mutations in NPM1 or DNMT3A. This suggests that high VAF may function not as an absolute, independent determinant, but primarily as a potent "risk amplifier." Notably, allogeneic hematopoietic stem cell transplantation (allo-HSCT) effectively mitigated this survival disadvantage. Furthermore, we characterized a non-linear relationship between VAF and mortality risk, with a sharp increase observed once the VAF burden exceeded 34%. In conclusion, a quantitative VAF ≥ 40% should be considered a context-dependent prognostic marker for risk stratification. Allo-HSCT represents a critical intervention capable of overcoming the exceedingly poor prognosis associated with high VAF.
Post-transplant relapse remains a major challenge in T-ALL, with limited effective salvage options. We report on eight T-ALL patients who received low-dose chidamide (5 mg once weekly) as maintenance therapy after allogeneic HSCT. With a median follow-up of 22.7 months, the estimated 2-year OS and EFS are both 87.5%. Seven patients (87.5%) remain in continuous complete remission with sustained MRD negativity. Grade 3-4 neutropenia occurred in 57.1% of evaluable patients but was clinically manageable. This case series demonstrates that a low-dose chidamide maintenance regimen is feasible, well tolerated, and promising in this setting.
