Caring for pediatric hematology-oncology patients from families identifying as Jehovah's Witnesses presents opportunities to align clinical and ethical care considerations, particularly regarding blood transfusion refusal. Although transfusion avoidance is often presumed, patient and family preferences are heterogeneous and influenced by individual conscience, cultural context, and interpretation religious guidance. This article explores practical approaches to transfusion‑averse care through three illustrative cases. The first involves an adolescent with relapsed Hodgkin lymphoma considering autologous hematopoietic cell transplantation, highlighting tensions between emerging autonomy, deeply held beliefs, and standard‑of‑care oncology practices. The second examines an infant with severe aplastic anemia, illustrating intrafamilial disagreement, the role of surrogacy and delegation of consent, and circumstances justifying legal intervention to protect a child's best interests. The third case involves chronic transfusions and underscores the longitudinal nature of decision-making. We review the doctrinal framework underlying the cases, emphasize the importance of assessing the depth and personal ownership of beliefs, and outline evidence‑based strategies to reduce transfusion exposure, including anemia mitigation, bleeding prophylaxis, and blood conservation techniques. The article also addresses ethical thresholds, use of preemptive court orders, and communication practices that preserve trust and minimize moral distress. Thoughtful, proactive, and individualized care (grounded in ethical humility, data‑driven assessment, and interdisciplinary collaboration) can honor religious beliefs while maintaining safe, patient‑centered outcomes.
Diffuse Large B-cell lymphoma is an aggressive lymphoma in which management is constrained by incomplete molecular characterization and the absence of sensitive markers of treatment response. Cell-free DNA offers a noninvasive approach for tumor genotyping and minimal residual disease monitoring. Nevertheless, technical challenges persist, including low cfDNA abundance and the discrimination of low allele fraction variants from background noise. Tumor-informed assays tracking multiple genetic markers substantially improve sensitivity of disease monitoring. Standardization and prospective validation will facilitate routine clinical implementation.
Epstein-Barr virus (EBV) infects many people and causes T-cell and natural killer (NK)-cell disorders, such as chronic active EBV disease and extranodal NK/T-cell lymphoma, which are aggressive and lack a common genetic driver. This suggests that virus-associated, non-genetic mechanisms contribute to disease. We studied primary T cells, NK cells, Epstein-Barr virus-positive cell lines derived from these disorders, virus-negative controls, and clinical chronic active EBV disease samples. Using genome-wide and single-cell multiome approaches, we examined three-dimensional chromatin organization, histone modifications, viral-host chromatin proximity, regulatory element activity, and transcription. EBV-positive lines shared a chromatin compartment pattern distinct from primary and virus-negative cancer cells. Regions that changed from inactive to active chromatin states showed increased activating histone marks and higher expression of nearby genes. EBV-interacting regions were enriched in inactive chromatin and inactive-to-active shifting regions, and contained activated promoters and enhancers associated with increased expression of neighboring genes in both T-cell and NK-cell backgrounds. Locus-level analyses identified CACNA2D1 and RGS1 as representative target genes with chromatin activation, and knockdown of each gene impaired cell growth in EBV-positive lines. Single-cell multiome profiling of clinical chronic active EBV disease samples identified EBV read-positive T-cell or NK-cell populations consistent with independently defined infected lineages and validated epigenomic and transcriptional rewiring at EBV-interacting regions. These findings support a model in which EBV contributes to oncogenic transcriptional programs in these diseases by coupling three-dimensional chromatin reorganization and regulatory element activation to physical interactions with the host genome.
We discovered that vitamin C import through the vitamin C transporter SLC23A2 in stress-specific erythroid progenitors represents a key regulatory nexus in the recovery of the erythron. In response to erythroid stress, such as blood loss, Epo induces the expression of Slc23a2 in stress erythroid progenitor cells, increasing intracellular vitamin C levels and promoting their differentiation into erythroblasts. Vitamin C-induced erythroid differentiation is blocked by Slc23a2 deletion or in EpoR mutant mice unable to induce Slc23a2. Both mice show attenuated erythron recovery in stress. These defects are rescued by exogenous expression of either SLC23A2 or the related vitamin C transporter SLC23A1, but not by a transport-defective SLC23A2 mutant. Mechanistically, intracellular vitamin C promotes erythroid progenitor differentiation independently of its antioxidant activity. Instead, it regulates 2-oxoglutarate-dependent dioxygenases, TET2, KDM6A and ALKBH8, facilitating the upregulation of the master erythroid transcription factor GATA1. These findings identify vitamin C uptake as an Epo-licensed, rate-limiting determinant of stress erythropoiesis.
CAR T-cells targeting CD19 have revolutionized the treatment of relapsed/refractory B-cell malignancies. However, approximately 50% of patients relapse. Patient-derived data indicates that CD19+ relapse is linked to poor CAR T-cell proliferation and/or persistence. We aimed to improve CD19-CAR T-cell survival by manipulating Notch1, a receptor that is activated following T-cell receptor ligation and is essential for upregulating pro-inflammatory and survival genes in T-cells. However, its role in the context of CAR T-cells remains poorly understood. We found that both lentiviral overexpression of Notch1's intracellular domain (N1ICD) and Notch1 genetic knockout resulted in defective CAR-T cell activation and proliferation. This suggests that CAR T-cells require a precise, balanced level of Notch1 signaling for strong effector function. The PEST domain, located at the most distal C-terminus of the Notch1 intracellular domain, regulates the receptor's half-life through ubiquitylation. To augment the levels of active Notch1 and prolong the receptor's signaling, we genetically deleted this domain in the endogenous N1ICD of CAR T-cells. Notch1 PEST-deleted CAR T-cells showed enhanced proliferation post-activation, leading to increased cytotoxicity against CD19+ tumors in vitro. Transcriptionally, Notch1 PEST deletion resulted in upregulation of interferon response pathways and proliferative genes during CAR activation, consistent with Notch1 activation. In B-ALL xenograft in vivo models, treatment with Notch1 PEST-deleted CAR T-cells resulted in greater tumor reduction and increased CAR-T expansion compared to control CAR T-cells. Our findings demonstrate a critical role of Notch1 in CAR-T effector function and provide a novel strategy to augment endogenous Notch1 activity by leveraging native gene regulation.
The ability of activated neutrophils to release decondensed chromatin as neutrophil extracellular traps (NETs) in response to stimuli is conserved throughout evolution. While NETs support host defense by forming physical barriers against microbes, their toxicity can cause tissue damage. Large NET networks, generated through the activation of the NLRP3 inflammasome, the citrullinating enzyme PAD4, and neutrophil-derived enzymes, are central to the pathogenesis of numerous diseases. Chronic disorders often originate in a localized site, for example the joints in rheumatoid arthritis, or following a major inflammatory event, before progressing to distant organs, such as the heart. In this perspective, we hypothesize that circulating primed neutrophils represent the "seeds" of chronic disease, that adhere to activated vessels, the "soil" of susceptible organs. We explore the mechanisms underlying NET formation and discuss animal and human evidence supporting our hypothesis.
Outcomes for pediatric patients with refractory or relapsed T-cell acute lymphoblastic leukemia (T-ALL) are poor, underscoring the need for improved therapeutic strategies. CD38, a type II transmembrane glycoprotein, is a promising target in T-ALL, with clinical trials evaluating CD38-targeting immunotherapies in frontline and relapsed settings. However, the biological role of CD38 in T-ALL has not been systematically defined. We interrogated CD38 biology through multimodal profiling of pediatric T-ALL samples. Bulk RNA sequencing of 1,335 primary tumors revealed that CD38 expression varies across genomic and immunophenotypic subtypes in T-ALL. Flow cytometry of 150 primary samples and CITE-sequencing of 40 cases demonstrated broad surface expression of CD38. A transcription factor CRISPR-screen identified RUNX1, RUNX3, and TP53 as candidate positive regulators of CD38. Metabolomic profiling of cell lines further revealed disruption of the polyamine pathway following CD38 perturbation. Supporting this finding, co-targeting CD38 with difluoromethylornithine (DFMO), a polyamine metabolism disruptor, improved survival in preclinical models. Across transcriptomic datasets, including primary tumors, cell lines, and patient-derived xenograft models, IL32 expression consistently decreased following CD38 loss or negativity, supporting an association between CD38 and inflammatory signaling pathways. Additionally, CD38 and LCK expression were positively correlated across majority of genomic subtypes, implicating SRC kinase signaling. Consistent with this, daratumumab in cell lines increased LCK phosphorylation, and combination therapy with dasatinib improved survival compared to monotherapy. Collectively, these findings define previously unrecognized interactions between CD38 and targetable pathways and genes in T-ALL and identify rational combinatorial strategies to enhance CD38-directed therapies and reduce relapse risk.
Regulation of oncogenic transcriptional programs in multiple myeloma requires the interplay of histone modifications, their writers and readers with lineage-affiliated transcription factors. The transcription factors IKZF1/3, IRF4 and MYC form an aberrant, myeloma-specific regulatory loop that drives myelomagenesis and resistance to immunomodulatory drugs (IMiDs) such as lenalidomide. Chromatin-based mechanisms that regulate these processes remain incompletely understood. Here we investigate the role of CXXC1, a core component of the H3K4 methyltransferase complex COMPASS, in the activity of the IKZF1/3-IRF4-MYC regulatory loop. We find that clinically, high CXXC1 expression is associated with high-risk proliferative, adverse prognosis disease. Consistent with this, CXXC1 is a myeloma dependency and it regulates cellular fitness programs including cell cycle, MYC targets and DNA damage response. High CXXC1 expression in primary myeloma cells is associated with higher chromatin accessibility, while acute depletion of degron-tagged CXXC1 further validates its role in regulating myeloma cell fitness programs and high-risk transcriptional signatures. CXXC1 interacts with and extensively co-binds to chromatin with IRF4 and IKZF3. Notably, in both lenalidomide-sensitive and -resistant myeloma cells, CXXC1 depletion results in loss of IRF4 and IKZF3 chromatin binding and in parallel it 'breaks' the IRF4 transcriptional self-regulatory loop. Thus, CXXC1 and COMPASS emerge as novel therapeutic targets in IMiD-sensitive and -resistant myeloma by regulating the activity of IRF4 and essential myeloma cell fitness programs.
Follicular lymphoma (FL) has traditionally been considered an incurable malignancy characterized by repeated relapses. However, emerging long-term data are increasingly challenging this paradigm. With rituximab, median overall survival approaches 20 years, and only 35-40% of patients require more than one treatment line. Drawing on frameworks established in chronic viral infections and other hematologic malignancies, including chronic myeloid leukemia and multiple myeloma, this review examines the evolving concepts of cure and functional cure. We propose a framework supporting the probability of functional cure based on several observations: durable remission following treatment discontinuation; absence of clinically meaningful progression, sustained deep remission defined by sensitive biomarkers including minimal residual disease and PET/CT; and normalization of survival relative to the general population and patient-reported quality of life. We further discuss how early clinical milestones, such as event-free survival at 24 months (EFS24) and complete remission at 30 months (CR30), may also assist in identifying patients with particularly favorable long-term disease trajectories. Together, these findings support reconsideration of long-standing assumptions regarding the natural history of FL and provide a conceptual framework for defining functional cure in FL, with implications for therapeutic goals, survivor follow-up strategies, biomarker development, and personalized therapeutic.
Genetic alterations activating NF‑κB have been described in mature B‑cell malignancies. These alterations include loss of the negative regulator TRAF3, allowing NIK (NF‑κB-inducing kinase) to drive non-canonical NF‑κB (ncNF‑κB) signaling. In this study, we characterized two recurrent synonymous variants of MAP3K14, the gene encoding NIK, across mature B‑cell malignancies including chronic lymphocytic leukemia, lymphoplasmacytic lymphoma/Waldenström's macroglobulinemia, multiple myeloma and mantle cell lymphoma. These variants were shown to introduce splice donor sites that result in removal of the critical TRAF3 binding motif. Cell line models prime edited to contain the synonymous variants demonstrated NF‑κB activation and transcriptional reprogramming with enhanced cell proliferation and survival, as well as increased secretion of several cytokines/chemokines including IP10/CXCL10. We also characterized distinctive cell surface proteomic changes with NF‑κB activation, identifying candidate markers (e.g.,CD132/IL‑2Rγ) for assessing NF‑κB activation at a single cell level using flow cytometry. This study expands the spectrum of genetic lesions that result in activation of NF‑κB in mature B‑cell malignancies and highlights our incomplete understanding of NF‑κB drivers in mature B‑cell malignancies.
Engineered T-cells have transformed hematooncology, but CAR transgene-bearing T-cell malignancies have emerged as a rare and serious genomic safety signal after CAR-T therapy. Available data support a multistep model in which pre-existing clonal fitness, CAR-T manufacture, vector integration, construct biology and post-infusion selection may contribute to different degrees. We review reported cases of CAR-transgenic T-cell lymphoproliferative neoplasms (CTTLN) and propose practical diagnostic criteria with a proportionate approach to genomic surveillance.
Beyond mere gas exchange, erythrocytes significantly influence vascular health and inflammation. For example, in sickle cell disease (SCD), microvascular occlusion due to abnormal red blood cells (RBCs) and hemolysis are known to cause endothelial dysfunction. However, this model fails to explain the chronic vasculopathy found throughout the entire circulation or the cardiovascular complications associated with iron deficiency anemia (IDA), suggesting additional mechanisms at play. Here we propose a paradigm shift: that the biophysical alterations of erythrocytes-such as reduced cell deformability and altered size-are, in and of themselves, sufficient to induce widespread endothelial dysfunction via mechanisms that are entirely independent of cell adhesion, hemolysis, or vascular obstruction. Through the fluid dynamic phenomenon of cell margination, aberrant RBCs invade the protective cell-free layer, leading to physical interactions with the endothelium that ultimately directly induce vascular pathology. These brief collision-like events and resulting high-magnitude transient fluctuations in local wall shear stress serve as potent mechanobiological stimuli. Physically, these pathologic RBCs are like hailstones, compared to the much softer and deformable snowflake-like healthy RBCs. The endothelium, acting as the "roof" that is constantly and chronically pummeled and pelted by the "hailstorm" of these pathologic RBCs, physiologically responds to these purely physical interactions via mechanotransduction that, in turn, induce proinflammatory signals. This Perspective synthesizes recent experimental and computational evidence across multiple disease states associated with RBC abnormalities, including SCD, IDA, and COVID-19, to reconsider the erythrocyte's biophysical properties not merely as disease biomarkers, but as primary and targetable mechanobiological drivers of vascular inflammation.
Warm autoimmune hemolytic anemia (wAIHA) is a rare, life-threatening disease characterized by autoantibody-mediated destruction of red blood cells with no approved treatments. Nipocalimab, an immunoselective neonatal Fc receptor blocker, reduces circulating IgG levels, including autoantibodies implicated in wAIHA. The phase 2/3, randomized, 24-week, double-blind ENERGY study in participants with wAIHA evaluated nipocalimab 30 mg/kg IV q4w (n=38), 15 mg/kg IV q2w (n=38), and placebo (n=39). The primary endpoint, durable hemoglobin response (hemoglobin ≥10 g/dL and a ≥2 g/dL increase from baseline at 3 consecutive visits [≥28 days] starting by Week 16, without rescue therapy), achieved statistical significance for nipocalimab 30 mg/kg IV q4w (23.7% [9/38]; 1-sided P=0.015) but not 15 mg/kg IV q2w (21.1% [8/38]; P=0.044; not significant) versus placebo (7.7% [3/39]). Improvement in FACIT-Fatigue score at Week 24 (key secondary endpoint) was observed with nipocalimab, with mean (SD) improvement of 3.4 (7.29) points (nominal P=0.007) for 30 mg/kg IV q4w and 1.2 (6.07) (nominal P=0.267) for 15 mg/kg IV q2w versus 0.6 (3.42) for placebo. Mean percent (SD) reduction in average daily prednisone dose (key secondary endpoint) was 15.1% (28.2) for nipocalimab 30 mg/kg IV q4w (nominal P=0.039) and 14.0% (30.4) for 15 mg/kg IV q2w (nominal P=0.055) versus 3.9% (16.33) for placebo. The safety profile was consistent with the known safety profile of nipocalimab and with wAIHA-associated risks. Overall, in the double-blind ENERGY study, nipocalimab demonstrated rapid hemoglobin response and nominal improvements in fatigue that were maintained over 24 weeks, with no new safety findings in wAIHA. NCT04119050.
