Objectives:To investigate the clinical characteristics and risk factors of invasive fungal disease (IFD) in patients with hematological disorders. Methods:From January 2023 to January 2025, 67 patients with blood diseases hospitalized at the Hematology Department who were suspected of infection with IFD underwent metagenomic next-generation sequencing (mNGS) and fungal pathogen detection. Their clinical characteristics and laboratory examinations were retrospectively analyzed. Results:A cohort of 67 patients was enrolled in the study, among which 32 cases were diagnosed with IFD through mNGS and etiological culture, while no fungal pathogens were detected in the remaining 35 cases. The diagnostic yield of mNGS for fungal infection detection (47.76%) demonstrated superior sensitivity compared to conventional pathogenic microbial culture (14.93%), β-D-glucan assay (11.94%), and galactomannan assay (2.99%). Within the IFD cohort, Candida species constituted the most prevalent etiology (46.88%, n = 15), followed by Aspergillus (18.75%, n = 6), Penumocystis (12.5%, n = 4), and Rhizomucor (12.5%, n = 4), with other fungal species accounting for the remaining cases (9.37%, n = 3). Multivariate logistic regression analysis revealed six independent risk factors associated with IFD in patients with hematological disorders: cluster of differentiation 4+ T cell count <400 cells/µL (odds ratio [OR] = 9.45, P = 8.9×10-5), elevated C-reactive protein (OR = 3.18, P = 0.027), elevated interleukin (IL)-6 (OR = 5.75, P = 0.001), elevated IL-10 (OR = 3.31, P = 0.033), hypoproteinemia (OR = 42.17, P = 0.013), and neutropenia lasting for more than 10 days (OR = 4.11, P = 0.015). Conclusions:mNGS has high sensitivity in detecting IFD in patients with hematological diseases. Cluster of differentiation 4+ cell count below 400/uL, increased level of C-reactive protein, IL-6, and IL-10, hypoproteinemia, and neutropenia lasting for more than 10 days are independent risk factors for IFD in patients with hematological diseases.

Large granular lymphocyte leukemia (LGLL) is a rare lymphoproliferative disorder where somatic STAT3 mutation is common. Although LGLL has been described as an underlying condition associated with pure red cell aplasia (PRCA), the clinical characteristics and therapeutic response of LGLL − associated PRCA are largely unclear. We evaluated a set of 81 patients with LGLL − associated PRCA. Comparative analysis was performed on the clinical characteristics, responses to immunosuppressive therapy, and survival outcomes in patients with STAT3 mutation. Among the 81 LGLL − associated PRCA patients, 21 cases (26

OBJECTIVE:This study aims to unravel the relationship between apolipoprotein C1 (APOC1) levels, prognostic nutritional index (PNI), and clinicopathological characteristics in patients with diffuse large B-cell lymphoma (DLBCL) and their prognostic predictive value. METHODS:This study retrospectively analyzed clinical data from 55 DLBCL patients and 50 healthy screening volunteers. APOC1 levels and the PNI were compared between groups, along with their association with DLBCL's clinicopathological features. Patients were stratified into favorable and poor prognosis groups based on the International Prognostic Index (IPI), with APOC1 and PNI compared between subgroups. Kaplan-Meier curves were used to analyze the impact of high and low expression levels of APOC1 and PNI on progression-free survival (PFS) and overall survival (OS) in DLBCL patients. Multivariate logistic regression identified risk factors for poor prognosis, while Receiver Operating Characteristic (ROC) curves assessed the predictive value of APOC1 and PNI for DLBCL outcomes. RESULTS:DLBCL patients had higher APOC1 levels and lower PNI than controls. Patients with advanced-stage (III-IV) disease showed significantly increased APOC1 and decreased PNI compared to early-stage (I-II) cases. DLBCL patients with high APOC1 expression and low PNI showed left-shifted PFS and OS curves (P < 0.05). Both elevated APOC1 and reduced PNI were independent risk factors for poor prognosis, with Area Under the Curve (AUC)s of 0.836 and 0.779, respectively. Their combined predictive value improved, suggesting potential utility in prognosis assessment. CONCLUSION:APOC1 levels and PNI are significantly correlated with higher disease risk in DLBCL, and their combined evaluation may help improve risk assessment.

Objective To explore the testing performance of metagenomic next-generation sequencing (mNGS) in identifying pathogenic microbes in febrile patients with hematological disease and its significant role in guiding clinical treatment. Methods The data of pathogens from the blood cultures of neutropenic patients with hematological disease and/or febrile patients with bloodstream infection (BSI) were summarized and the features of infection were analyzed, through a retrieval of the WoS, PubMed, CNKI, Wanfang, and VIP databases. A retrospective study was conducted on 96 febrile patients with hematological disease (104 specimens) presented to our hospital between May 2022 and May 2024. These patients underwent both routine and mNGS tests for a comparison of the testing performance, and were assigned to mNGS-positive and mNGS-negative groups according to the mNGS results, respectively. Based on an analysis of the data and indexes of the two groups, the contributing factors of mNGS positivity were determined using the univarient and the logistic regression while a prediction model was developed to assess predictive value and summarize the prognosis information using the Receiver Operating Characteristic Curve (ROC). Results According to the included six papers, among totally 3614 isolates from positive blood cultures, Gram-negative bacteria, Gram-positive bacteria, and fungi accounted for 66.66%, 31.02%, and 2.05%, respectively. In this retrospective study, out of 104 peripheral blood tests using mNGS technology, pathogens were detected in 71 tests, with a positive detection rate of 68.27%, which was substantially higher than that of blood culture (7.69%) and routine test (16.35%). Out of 131 isolated pathogenic microbes, viruses held the maximum ratio (60.74%). The identification rate of combined infections by the mNGS test exceeded those by complete blood count (CBC) and routine test. When clinical diagnosis was employed as the gold standard, mNGS test had greater values of sensitivity, positive prediction and negative prediction than those of routine test. The univariant analysis revealed that the mNGS-positive group had higher incidences of pulmonary infection and neutropenia and lower natural killer (NK) cell levels, compared with the mNGS-negative group. The multivariate analysis result of logistic regression model showed that contributing factors of mNGS positivity in febrile patients with hematological disease included pulmonary infection [Odds ratio (OR): 2.389; 95%confidence level (CI): 1.199–4.763)], neutropenia (OR: 4.092; 95% CI: 1.179–14.209), and low NK cell levels (OR: 1.127; 95% CI: 1.117–1.139). According to the analysis result of the ROC curve, the area under curve (AUC) values used for single and combined predictive values of mNGS positivity in febrile patients with hematological disease ranged from 0.623 to 0.849, with the maximum value of 0.849 for combined prediction. The sensitivity and specificity values were 78.79% and 93.33%, respectively. Following relevant guidelines, physicians modified medication for patients with poor disease management based on mNGS results, achieving a survival rate of 75.0%. Conclusion mNGS allows a more comprehensive and accurate identification of pathogenic microbes in patients with hematological disease. However, the positive rate of mNGS test may be affected by pulmonary infection, neutropenia, and low NK cell levels. Therefore, appropriate timing of the mNGS use can provide critical information for the formulation of clinical protocol and enables individualized and accurate treatment.

Background COVID-19 is an ongoing pandemic posing a big threat to public health and economy. Novel variants are constantly emerging with different transmissibility and pathogenicity. This study aimed to explore the hematological characteristics of COVID-19 delta variant during the outbreak in July 2021, Nanjing. Methods This study retrospectively analyzed demographic and clinical parameters of 80 patients diagnosed with COVID-19 delta variant infection. Patients were classified into mild, moderate and severe/critical group according to the guideline. Characteristics of each group were compared. Results The percentage of elderly and patients with comorbidities was significantly higher in the severe/critical group. Vaccination rate was significantly lower in this group. Decreased lymphocyte number, especially CD4+ and CD8+ T cells, elevated fibrinogen, CRP, PCT and IL-6 were associated with disease severity (P<0.05). Severe or critical cases tended to have higher viral load shown by lower CT values of ORF1ab and N gene (P=0.08, P=0.06) and lower specific IgG antibody level (P=0.15) but it did not reach statistical significance. Conclusions Increasing vaccination rate in the elderly and population with comorbidities might improve the prognosis of COVID-19 delta variant. Mechanism study of immune evasion of COVID-19 and methods to booster our immune system was urgently needed.

Background: The bortezomib (BTZ) resistance mechanisms in mantle cell lymphoma (MCL) are complex, involving various genes and signaling pathways. This study used bioinformatical tools to identify and analyze differentially expressed genes (DEGs) associated with BTZ resistance. Methods: Gene chip datasets containing MCL BTZ-resistant and normal control cohorts (GSE20915 and GSE51371) were selected from the Gene Expression Omnibus (GEO) database. GEO2R was used to identify the upregulated DEGs in the microarray datasets, using a significance threshold of P<0.05. Subsequently, these DEGs were subjected to a Gene Ontology (GO) functional analysis, a Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, and a protein-protein interaction (PPI) network assessment. Additionally, 40 MCL patients who underwent second-line BTZ treatment were included in this study. The patients were categorized into resistant and sensitive groups based on treatment response. The enzyme- linked immunosorbent assay (ELISA) technique was employed to evaluate the expression levels of specific DEGs in the serum of the patients in both groups. Results: In the GSE20915 dataset, 144 upregulated genes were identified as DEGs. Similarly, in the GSE51371 dataset, 219 upregulated genes were identified as DEGs. By employing a Venn diagram to compare the upregulated DEGs from both datasets, we identified 11 DEGs linked to BTZ resistance in MCL. The enrichment analysis of the KEGG signaling pathways revealed that the DEGs were predominantly enriched in key biological processes (BP), including the cell cycle, cellular senescence, the p53 signaling pathway, the interleukin 17 (IL-17) signaling pathway, and the nuclear factor kappa-B (NF-kappa B) signaling pathway. A distinct cluster was revealed by creating a PPI network and performing a module analysis of a set of typical DEGs. This cluster comprised four candidate genes; that is, cyclin-dependent kinase inhibitor 1A ( CDKN1A ), CDKN1C, , midkine (MDK), MDK ), and TNF alpha induced protein 3 ( TNFAIP3 ). Among these genes, MDK was found to be the key gene. The serum concentration of MDKin in the resistant group [1,539 (1,212, 2,023) ng/L] was significantly higher than that in the sensitive group [1,175 (786, 1,502) ng/L] (P<0.05). Conclusion: Identifying the key gene MDK and its associated signaling pathways extends our understanding of the molecular processes that underlie resistance to BTZ in MCL. This discovery establishes a theoretical framework for future investigations of targeted therapy in clinical settings.

目的 评估真实世界伊沙佐米治疗多发性骨髓瘤(MM)的疗效和安全性.方法 回顾性分析2019年1月至2021年1月来自中国贫血东部协作组单位(无锡市人民医院等)伊沙佐米治疗72例MM患者的血液学、细胞遗传学及疗效、安全性等数据.结果 难治/复发MM(RRMM)患者接受伊沙佐米的中位治疗周期为6.0(3.0,7.0)个,总体有效率(ORR)为56.5％;新诊断MM(NDMM)患者中位治疗周期为4.5(4.0,9.5)个,总体有效率为85.8％;转换维持治疗组患者中位治疗周期为5.0(3.0,8.0)个,其中25.8％的患者缓解程度加深;不良事件(AEs)的总体发生率为26.5％.结论 在真实世界中,伊沙佐米对RRMM、NDMM或是维持转换MM患者,具有良好的疗效和安全性.

Background Large granular lymphocyte leukemia (LGLL) is a rare disease frequently complicated with pure red cell aplasia (PRCA) [1, 2]. STAT3 mutations have been describled in 30-40% of LGLL patients [3]. The aim of this work was to evaluate whether STAT3 mutations might be associated with specific clinical features and outcomes in LGLL-associated PRCA. Methods and results From January 2016 to July 2023, 81 patients with LGLL-associated PRCA were enrolled in the China Eastern Cooperation Group for Anemia (CECGA) database (ChiCTR2100043485). As an initial step in the STAT3 mutational analysis, we screened all patients with Sanger sequencing or Next-generation sequencing (NGS). The initial dose of CsA was 3-5mg/kg/day, and the serum concentration was adjusted to be 150-200ng/mL based on adverse reactions. After 12 months of maintenance, the dosage was slowly reduced. Cyclophosphamide combined with prednisone (CP) regimen was used as a salvage therapy for patients who failed to CsA. The initial dose of cyclophosphamide and prednisone were 100mg/day and 0.5-1mg/kg/day, respectively. Among the 81 cases, 26% of them were positive for STAT3 mutations. The clinical characteristics of patients with or without STAT3 mutation were summarized in Table 1. Patients with STAT3 mutations had a higher reticulocyte percentage (0.88% vs 0.28%, P=0.039) and red cell distribution width-coefficient of variation (18.8% vs 15.8%, P=0.008) than patients without STAT3 mutations. Y640F mutation were found in 9 of 21 cases. Subgroup analysis showed that patients with Y640F mutation were associated with younger age (44 vs 65 years old, P=0.007) and higer lymphocyte percentage in peripheral blood (63.7% vs 34.4%, P=0.033). Deep sequencing of rearranged T-cell receptor Vβ complementarity-determining region 3 by NGS was conducted in 61 patients. The predominant V-gene of LGLL clonotypes belonged to the TRBV06 family gene was detected in 12 (25%) patients. The expression of TRBV06 family gene was a litter lower in patients with STAT3 mutation than non-mutant groups (8% vs 31%, P=0.189). The complete response rate (CRR) [31% (5/16) vs 33% (19/58), P=0.909] and overall response rate (ORR) [56% (9/16) vs 50% (29/58), P=0.658] of cyclosporine (CsA) treatment were similar in patients with STAT3 mutations or not. In STAT3 mutant group, the CRR [54% (7/13) vs 31% (5/16), P=0.274] and ORR [85% (11/13) vs 56% (9/16), P=0.130] of CP regimen tended to be better than CsA . 6 patients (67%) relapsed among the 9 patients who responded to CsA in STAT3 mutant group. In patients without STAT3 mutation, 19 of 29 (66%) CsA-responders relapsed. There was no siginificant difference in the relapse-free survival between the two group (Figure 1). Discussion/Conclusions In summary, STAT3 mutation was frequently recognized in LGLL-associated PRCA, and the hotspot site was Y640F. Patients with STAT3 mutations responded to CsA as well as those without the mutation. CP regimen could be used as a salvage therapy for patients who failed to CsA. Reference 1. Balasubramanian SK, Sadaps M, Thota S, et al. Rational management approach to pure red cell aplasia. Haematologica. 2018, 103(2): 221-230. 2. Wu X, Cheng L, Liu X, et al. Clinical characteristics and outcomes of 100 adult patients with pure red cell aplasia. Ann Hematol. 2022, 101(7):1493-1498. 3. Barilà G, Teramo A, Calabretto G, et al. Stat3 mutations impact on overall survival in large granular lymphocyte leukemia: a single-center experience of 205 patients. Leukemia. 2020, 34: 1116-1124.

目的 观察阿扎胞苷联合维奈克拉在地西他滨治疗失败骨髓增生异常综合征中的应用效果.方法 10例地西他滨治疗失败的骨髓增生异常综合征患者,采用阿扎胞苷联合维奈克拉治疗:阿扎胞苷75 mg/m2皮下注射7 d,每28天为一个疗程,阿扎胞苷治疗同时开始口服维奈克拉400 mg(1次/日),最少14 d.随访并判定疗效,分别于治疗前、后抽取患者骨髓3 mL检测25个MDS常见突变基因后测算等位基因突变频率VAF(Variant allele fraction,VAF),观察并记录治疗中不良事件发生情况.结果 10例患者用维奈克拉联合阿扎胞苷治疗1～6个周期,中位治疗2.5个周期,治疗后ORR 5例、CR 2例、CRi 1例、PR 1例及NR 1例.与治疗前比较,治疗后10例患者VAF降低(P均<0.5.10例患者治疗过程中不良事件为血小板水平降低17例次、肺部感染11例次、电解质紊乱20例次及胃肠道症状15例次等.10例患者中肺部感染死亡1例、脑出血死亡1例.结论 阿扎胞苷联合维奈克拉用于地西他滨治疗失败的骨髓增生异常综合征患者效果较好,可有效降低患者等位基因突变频率,改善患者预后,但易发生不良事件.

Topic: 12. Bone marrow failure syndromes incl. PNH - Clinical Background: T-large granular lymphocyte leukemia (T-LGLL) is a common cause of secondary pure red cell aplasia (PRCA). Considering the cytotoxicities of cyclophosphamide (CTX) and methotrexate (MTX), cyclosporine (CsA) is proposed as first-line treatment. Due to the rarity of this disease, few studies of subsequent therapy for patients failed to CsA have been reported. Aims: In order to propose therapeutic algorithms that may be helpful in guiding the management of CsA-refractory/relapsed T-LGLL associated PRCA patients. Methods: From January 2016 to December 2022, 65 patients with T-LGLL associated PRCA were enrolled. CsA was administered at a dose of 3–5mg/kg/day with a minimum concentration of 150–200ng/ml. CP regimen consisted of CTX and prednisone. CTX was initiated at a daily dose of 100mg, maintained to response. CTX was discontinued when lymphocyte percentage was lower than 50% of normal level or granulocyte count was less than 0.5×109/L. Prednisone was initiated at a dose of 0.5–1mg/kg/day and gradually typered to discontinuation after four weeks. Results: The median age at presentation was 60 (22–89) years, with 34 cases (52%) over 60 years old. Of the 65 patient cohort treated with CsA, 28 (43%) achieved response. The median time to optimum effect was 3 (1–11) months. The cumulative effect curve showed that 89% of all remission occurred within 9 months (Figure 1). 37 patients did not respond to CsA during a median duration time of 6(1–18) months. 24 patients refractory or resistant to CsA had switched to CP regimen. This yielded an overall response rate (ORR) of 79% (19/24) and complete response rate (CRR) of 63% (15/24). ORR (79% vs 43%, P=0.002) and CRR (63% vs 23%, P<0.001) were higher in CP regimen than in CsA. 90% of all response obtained within 3 months based on the cumulative effect curve of CP regimen (Figure 1). The median time to best response was 2 (0.5–7) months in CP group, which was shorter than in CsA (P=0.001). Out of 60 patients, STAT3 and STAT5b mutations were found in 13 (22%) and 1 (2%), respectively. Only one had more than one mutation. The most frequent mutation was Y640F, found in 7 cases (54%). Patients with STAT3/5b mutation were younger than those with STAT3/5b wild type (48 vs 61 years old, P=0.002). ORR for STAT3/5b mutated versus wild-type with CsA and CP were 6/14(43%) versus 21/46(46%) (P=0.854), 8/9(89%) versus 11/15(73%) (P=0.615), respectively. Response to CP was better than CsA in STAT3/5b- mutated patients (89% vs 43%, P=0.04). T-cell receptor (TCR) repertoire deep sequencing was conducted in 42 patients, 33of them showed predominant leukemic clones. 33% of the T-LGLL clones express the TRBV06 gene. The ORR of CsA in patients with TRBV06 gene expression (2/11) was markedly lower than in them without it (18/32) (18% vs 56%, P=0.029). CP regimen was equally effective in both positive (4/6) and negative (13/14) TRBV06-expressived cases (67% vs 93%, P=0.201). It seemed that CP responded better than CsA in patients showed TRBV06 gene (67% vs 18%, P=0.109), and more cases need to be added to confirm this difference. Binary-Logistic regression model was conducted in cases received CsA and CP therapy. In univariate and multivariate analysis, both leukemic clones belonged to TRBV06 family (P=0.023; P=0.013) and treated by CsA (P=0.004; P=0.005) had worse response (Table 1). Summary/Conclusion: Our results indicated that CP regimen was effective for patients who failed to CsA. The response rate of CsA in patients with STAT3/5b mutation or not was similar. Leukemic clones with TRBV06 gene were frequently detected in T-LGLL associated PRCA, which may related to CsA-refractory or resistant cases. The identification of TRBV06 gene may be useful for appropriately managing patients with T-LGLL associated PRCA.Keywords: Large granular lymphocytic leukaemia, Immune therapy, T cell repertoire, Pure red cell aplasia

Topic: 12. Bone marrow failure syndromes incl. PNH - Clinical Background: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, complement-mediated hemolytic anemia resulting from a somatic phosphatidylinositol glycan class A (PIGA) mutation on the X chromosome of hematopoietic stem cells. PNH mainly presents as hemolytic anemia, bone marrow failure, and thrombosis. Targeting the terminal complement inhibitor, such as eculizumab, could not only controls hemolytic anemia, thrombosis and transfusion, and prevents the deterioration of renal function in PNH patients. However, eculizumab has not yet entered China market, glucocorticoid is still used for the first-line treatment in China. Due to the rarity of PNH patients, there currently lack systematic studies evaluating the long-term effects of glucocorticoids. Aims: The purpose is to identify the efficacy of glucocorticoid maintenance therapy in PNH. Methods: This prospective study was conducted by the Chinese Eastern Collaboration Group of Anemia (ChiCTR2100050945) from September 2020 to April 2022, including three centers: Jiangsu Province Hospital, Jiangning Hospital, the Second Hospital of Nanjing. 26 PNH patients with high disease activity (HAD), which means an increase in lactate dehydrogenase (LDH) ≥ 1.5 times the upper limit of normal (ULN), with at least one of the following signs or symptoms: fatigue, hemoglobinuria, abdominal pain, dyspnea, anemia with hemoglobin (Hb) < 100 g/L), major vascular adverse events (including thromboembolic events), dysphagia, or erectile dysfunction, were enrolled in the study (Table 1). Oral prednisone was initiated at a dose of 1mg/kg/day and gradually reduced to discontinuation after four weeks. Clinical characteristics before treatment, and 1st, 3rd, and 6th after treatment were compared. Results: The level of hemoglobin was improved at 1st month, and stable at 3rd month, and 6th month: (69.12±14.83) vs (77.50±18.11), p＜0.05；(69.12±14.83) vs (74.15±18.23), p=0.15；(69.12±14.83) vs (75.54±19.91), p=0.09; but the stratification of anemia (>90g/L, 60-90g/L, <60g/L) showed no difference: p=0.082, p=0.344, p=0.247; the reticulocyte percentage also had no difference: (6.76±3.92) vs (6.23±4.08) vs (6.62±3.92) vs (7.11±4.73), p=0.457. 25 patients (25/26, 96.15%) required blood transfusion before treatment, and there were 19 patients (19/26, 73.08%), 22 patients (22/26, 84.62%), 21 patients (21/26, 80.77%) were transfusion dependent at 1st, 3rd, and 6th months. No marked changes happened in the proportion of patients with transfusion dependent (p=0.031; p=0.375; p=0.219) at each time points, and there was an additional patient with transfusion dependent at three time points. No one achieved hemolysis control (LDH < 1.5 ⅹULN), and no marked improvement were achieved in lactate dehydrogenase and indirect bilirubin (p=0.436, p=0.881). Before treatment, level of D-dimer elevated (>0.55mg/L) in 7 patients, and in 6 patients, 5 patients, 7 patients, respectively at 1st, 3rd, and 6th months, and no marked improvement of D-dimer were achieved (p=0.263). Before treatment, 1 patient suffered renal insufficiency, and there was an additional patient with renal function deterioration at three time point of 1st, 3rd, and 6th months, respectively. Glomerular filtration rate before treatment was (114.15±42.98) ml/min/1.73m2, it was (117.79±37.69) ml/min/1.73m2, (120.85±44.05) ml/min/1.73m2, (110.30±36.58) ml/min/1.73m2 at 1st, 3rd, and 6th months respectively, and was similar (p=0.42, p=0.43, p=0.41). Summary/Conclusion: It was preliminarily showed that prednisone maintenance therapy for PNH could not control hemolysis, improve anemia, thrombosis and renal function. Long-term glucocorticoid maintenance therapy for PNH was not recommend.Keywords: Paroxysmal nocturnal hemoglobinuria (PNH), Hemolysis, Therapy, Anemia

We reported a rare case with metastatic prostate cancer complicated with hemorrhagic syndrome caused byprimary hyperfibrinolysis.The correct diagnosis of bleeding disorders is a prerequisite for choosing the correct treatment.Tranexamic acid can be used as the preferred treatment for patients with bleeding caused by primary hyperfibrinolysis. In this case, the combination of antifibrinolytics and antiandrogen therapy effectively controlled the severe bleeding symptoms caused by primary hyperfibrinolysis in metastatic prostate cancer. Appropriate treatment after early diagnosis is essential to prevent bleeding and improve prognosis.

Excessive NOD-like receptor thermal protein domain associated protein 3 (NLRP3) inflammasome activation has an important function in the pathogenesis of Sjögren's syndrome (SS). Increased and dysfunctional myeloid-derived suppressor cells (MDSCs) promoted SS. However, NLRP3 inflammasome activation of MDSCs in SS and its regulated components are unclear. Splenic MDSCs were purified by immunomagnetic beads and cultured. Western blot was used to assess NLRP3 inflammasomes. Interleukin-1β (IL-1β) and IL-18 were measured using enzyme-linked immunosorbent assay. Here we showed that the NLRP3 inflammasome was activated in non-obese diabetic (NOD) mice with SS-like manifestations. We found that NLRP3 inflammasome activation was augmented in MDSCs of SS mice and NLRP3 inflammasome activation was suppressed in IL-27-deficient NOD mice. Consistent with findings of SS mice in vivo, we observed that NLRP3 inflammasome activation by adenosine triphosphate and lipopolysaccharide was remarkably intensified in MDSCs with IL-27 treatment in vitro. Collectively, our data highlighted that IL-27 regulates NLRP3 inflammasome activation of MDSCs in experimental SS.

Topic: 12. Bone marrow failure syndromes incl. PNH - Clinical Background: There no suitable definite treatment for transfusion-dependent non-severe aplastic anemia (TD-NSAA). Aims: This study aimed to evaluate the efficacy and safety of avatrombopag combined with CsA in patients with transfusion-dependent non-severe aplastic anaemia (TD- NSAA). Methods: From March 2021 to March 2023, 12 patients with TD- NSAA treated with CsA combined with avatrombopag in Nanjing Jiangning Hospital, Jiangsu Province Hospital and Second Hospital of Nanjing were enrolled. Avatrombopag was taken at a dose of 40 mg per day. CsA was initiated at 3~5 mg/kg daily and then adjusted according to side effects, to maintain the target concentration between 150 and 250 μg/L. Complete the blood counts，biochemical indexes and adverse events during avatrombopag treatment were recorded. The data was collected by prospective registration in the Chinese Eastern Collaboration Group of Anemia (ChiCTR2100045895). Results: Among the 12 patients with TD- NSAA, the median age was 58 (8-78) years, 5 were male and 7 were female (Table 1). Two patients did not respond to previous CsA combined with TPO-RA (eltrombopag/ haitrombopag). Three patients had abnormal hepatic function. The median duration of treatment with avatrombopag was 5.5 (2-20) months. Ten patients (83.3%) obtained trilineage HR [one cases of complete treatment response (CTR), four case of good treatment response (GPR), and four cases of partial treatment response (PR),one case of partial no treatment response (NR)]. Two patient was not included in the outcome assessment due to the short duration of treatment. The median interval time for patients to achieved response was 62 days （range 27-174 days）. White blood cell count（P=0.021）, and platelet count（P=0.003）,absolute neutrophil count(P=0.039),increased significantly after treatment with avatrombopag by pair test (Figure 1). Five patients achieved transfusion independent. Of the two TPO-RA (eltrombopag/ haitrombopag) converted patients, one obtained GPR, one patient PR. No avatrombopag-related grade 2 or higher adverse events, and no thrombotic events and hepatic or renal insufficiency occurred during avatrombopag treatment. Summary/Conclusion: This preliminary study showed that avatrombopag is an effective option for patients with transfusion-dependent non-severe aplastic anemia (TD- NSAA). Table 1 Comparison of data before and after the use of avatrombopag - Before avatrombopag therapy After avatrombopag therapy P value Gender, n (%) / Male 5 (41.67%) Female 7 (58.33%) Median age (range) (year) 58 (8, 78) / Classification, n (%) / complete treatment response (CTR) 1 (8.33%) Good treatment response (GPR) 4(33.33%) treatment response (PR) 4(33.33%) No treatment response (NR) 1(8.33%) WBC (×109/L) (range) 2.21 (1.12, 4.61) 3.88 (2.6,.17) 0.021 ANC (×109/L) (range) 0.92 (0.17, 0.88) 2.38 (1.06, 14.64) 0.039 RBC (×1012/L) (range) 2.05 (1.04, 3.12) 2.43 (1.33, 3.32) 0.312 Hb (g/L) (range) 81 (52, 128) 96(66, 126) 0.299 BPC (×109/L) (range) 11(1, 37) 48.5(21, 137) 0.003 RET (%) (range) 1.84(0.031,3.03) 2.44 (1.66, 3.79) 0.077 LDH (U/L) (range) 216(172, 271) 228 (179, 337) 0.153 Abbreviations: WBC, white blood cell count; ANC, absolute neutrophil count; RBC, red blood cell count; Hb, hemoglobin; BPC, blood platelet count; LDH, lactate dehydrogenase;RET reticulation red blood cells Figure 1 After avatrombopag therapy, the white blood cell count (2.21×109/L vs 3.88×109/L, p=0.021), absolute neutrophil count (0.92×109/L vs 2.38×109/L, p=0.039) and blood platelet count (11×109/L vs 48.5×109/L, p=0.003) improved significantly. Keywords: Treatment, Aplastic anemia, Cyclosporin A, TPO

Topic: 12. Bone marrow failure syndromes incl. PNH - Clinical Background: Intensive immunosuppressive therapy (IST) combined with eltrombopag contributes to improving hematopoiesis in patients with severe aplastic anemia (SAA). Eltrombopag, however, is associated with elevations in alanine aminotransferase and bilirubin. As a small molecule TPO receptor agonist, avatrombopag can be administered orally with food with no significant hepatotoxicity. Aims: We evaluated efficacy and safety of avatrombopag in patients with SAA refractory or intolerant to IST combined with eltrombopag. Methods: 20 SAA patients switched from eltrombopag to avatrombopag at a dose of 40 mg/day in Jiangsu Province Hospital and Second Hospital of Nanjing from October 2020 to February 2023. The hematologic response and safety were analyzed in this study. The data was collected by prospective registration in the Chinese Eastern Collaboration Group of Anemia (ChiCTR2100045895). Results: The median age was 20(3–74) years old. A total of four patients who did not respond to IST combined with eltrombopag within a median time of 13(4–16) months. 15 cases (75%) obtained at least one lineage hematologic response [2 cases (10%) of complete response (CR) and 13cases (65%) of partial response (PR)]. The median time to first response was 42(14–207) days. 13 (65%) patients had a platelet response, with a median increase in platelet count of 21×109/L (range: 11–109). 10 patients who had platelet transfusions requirement became transfusion-independent within a median avatrombopag duration of 35(11–80) days. 9 patients (45%) had erythroid responses, with a median increase in hemoglobin level of 18g/L (range: 12–47). 7 patients had been dependent on packed red cell transfusions, and 6 of them (86%) no longer required transfusions at a median time of 41(14–72) days after avatrombopag. A total of 12 patients (60%) had a neutrophil response, with a median increase of 1.2×109/L (range: 0.3–2.1). No avatrombopag-related grade 2 or more adverse events occurred during the administration, and no thrombotic events occurred. Summary/Conclusion: Our research indicated avatrombopag had certain efficacy and good tolerance in patients with SAA refractory or intolerant to IST combined with eltrombopag, which deserved further exploration.Keywords: Severe aplastic anemia, Immunosuppressive therapy

Addition of eltrombopag (E-PAG) to intensive immunosuppressive therapy (IST) contributes to restoring hematopoiesis in patients with severe aplastic anemia (SAA). Used at relatively low doses in the East Asian population, the efficacies of E-PAG and the predictors for efficacy are not clear. We conducted a retrospective, multicenter study to analyze the efficacy and the possible predicting factors at 6 months in 58 adult SAA patients with rabbit ATG-based IST and E-PAG. The response rate and complete response rate at 6 months were 76% and 21%, respectively. The baseline reticulocyte percentage [area under a curve (AUC)=0.798, 95% confidence interval (CI) 0.640-0.956, P=0.006], absolute reticulocyte count (ARC) (AUC =0.808, 95%CI 0.647-0.970, P=0.004), red cell distribution width – coefficient of variation (RDW-CV) (AUC=0.722, 95%CI 0.494-0.950, P=0.040), and absolute lymphocyte count (ALC) (AUC=0.706, 95%CI 0.522-0.890, P=0.057) were highly predictive of response at 6 months. The tipping values of reticulocyte percentage, ARC, RDW-CV, and ALC were 0.45%, 7.36×109/L, 11.75%, and 1.06×109/L, respectively. The sensitivity and specificity of reticulocyte percentages were 81.6% and 66.7%; ARC were 86.8% and 66.7%, RDW-CV were 94.7% and 55.6%; ALC were 55.3% and 88.9%. At a median follow-up of 15.5 months, the 2-year cumulative overall survival was 92%. The baseline reticulocyte percentage, ARC, RDW-CV, and ALC were potential factors in predicting a favorable effect of rabbit-ATG based IST plus E-PAG in SAA patients of East Asia (ChiCTR2100045895).Clinical Trial Registrationhttp://www.chictr.org.cn/edit.aspx?pid=125480&htm=4, identifier ChiCTR2100045895.

目的:评估环磷酰胺联合泼尼松(CP)方案治疗环孢菌素(CsA)难治/复发的大颗粒淋巴细胞白血病(LGLL)相关纯红细胞再生障碍(PRCA)的疗效及耐受性.方法:回顾性分析登记于中国东部贫血协作组(CEC-GA)数据库的21例CsA治疗无效或复发的LGLL相关PRCA患者临床资料及接受CP方案治疗结果,评估疗效及耐受性.结果:CsA难治/复发患者共21例,其中难治性16例、复发性5例,经CP方案治疗后,15例达完全缓解(CR),3例达部分缓解(PR),3例治疗无效,治疗总有效率为85.7％(18/21),CR率为71.4％(15/21),中位达PR时间为2.2(0.5～6.6)个月,中位达CR时间为2.3(1.3～6.8)个月,中位疗效维持时间17.0(5.0～32.0)个月.8例STAT3突变阳性患者中7例达CR.13例(61.9％)患者在CP方案治疗期间出现不良反应,主要为粒细胞减少和肝功能异常,2例患者因4级粒细胞减少停药.随访期内,无治疗相关死亡事件.3例(14.3％)患者因药物减停出现复发.中位随访20.0(4.0～34.0)个月,15例仍有效,中位无复发生存时间为16.0(3.0～32.0)个月.结论:对于CsA难治/复发的LGLL相关PRCA患者,CP方案疗效确切,且对STAT3突变阳性患者也效果良好.CP方案主要不良反应为骨髓毒性.

Background Eltrombopag (EPAG) could improve the efficacy of immunosuppressive therapy (IST) consisted by antithymocyte immunoglobulin (ATG) and cyclosporin (CsA) in untreated severe aplastic anemia (SAA) patients. This study explored whether patients with SAA could benefit from continuous use of EPAG beyond 6 months. Methods From February 2018 to October 2021, 92 Chinese patients who were 2 years of age or older with a new diagnosis of acquired SAA and were not eligible for front-line hematopoietic stem-cell transplantation were collected in the China Eastern Cooperation Group for Anemia (CECGA). Patients were treated with rabbit ATG (r-ATG) based IST consisting of CsA. Patients over 12 years old and aging 6-11 years old took EPAG orally at dose of 75mg and 37.5mg once daily, respectively; EPAG was administered with 1.25 mg per kilogram per day for patients with age distribution between 2 and 5 years. Generally, all patients were treated with EPAG at least 6 months. The lack of response at 6 months, relapse, HSCT, development of a clonal hematologic disease including myelodysplastic syndrome, and acute myelogenous leukemia, or disease- or treatment-related death are regarded as events in event free survival (EFS). Results The median age was 38 (2-78) years, with 18 patients (20%) under 18 years old and 21 patients (43%) over 60 years old. In the whole cohort, 61 patients (66%) were diagnosed as SAA and 31 patients (34%) with very severe aplastic anemia (vSAA). At 3, 6 and 12 months, the actuarial overall response rates (ORR) were 55% (51 of 92), 73% (67 of 92) and 81% (60 of 74) and complete response (CR) rates were 11% (10 of 92), 20% (18 of 92) and 34% (25 of 74), respectively. 18 patients (20%) who achieved CR within 6 months were under steady state. In 49 patients with PR at 6 months, 14 (35%) of 40 patients who were continuously exposed to EPAG improved to CR within 6.5 (3 ~ 10) months of median time after 6 months. Among 25 patients who failed at 6 months, 11 patients continued to use EPAG, and 5 patients (45%) improved responses with extended median time of 3 (1 ~ 6) months after 6 months (Figure 1). The cumulative effect curve showed that 93% and 58% of all 12 months remission and CR occurred within 6 months. In patients with PR and NR at 6 months, the better 2-year event free survival (EFS) was found in whom continued to use EPAG (75% vs. 26%, P=0.001) (Figure 2). Discussion EPAG plus IST were used to treat previously untreated SAA patients in prospective studies. The ORR and CR rate at 6 months were 68% ~ 94% and 26% ~ 58%, respectively [1, 2]. We found that 93% of all 12 months remission occurred within 6 months for patients treated with IST and EPAG. It is suggested that EPAG should be used in sufficient dosage at least 6 months. It has been reported that patients with CR and PR were present with better OS of 100% and 92%, while OS of non-responders was 47% (P=0.0016), effect was demonstrated as a predictor for 4-year OS [3]. For patients with PR and NR at 6 months in our study, it was found that not only the response rates, but also the 2-year EFS were improved by continuous usage of EPAG, compared to them discontinued EPAG. In conclusion, additional EPAG to IST mainly take effect within 6 months. Continuous administration of EPAG could improve the hematologic response and EFS in patients without achieving CR at 6 months. REFERENCE [1]. Townsley DM, Scheinberg P, Winkler T, et al., Eltrombopag Added to Standard Immunosuppression for Aplastic Anemia. N Engl J Med, 2017. 376(16): p. 1540-1550. [2]. Peffault de Latour R, Kulasekararaj A, Iacobelli S, et al., Eltrombopag Added to Immunosuppression in Severe Aplastic Anemia. N Engl J Med, 2022. 386(1):11-23. [3]. Assi R, Garcia-Manero G, Ravandi F, et al., Addition of Eltrombopag to Immunosuppressive Therapy in Patients with Newly Diagnosed Aplastic Anemia. Cancer, 2018. 124(21):4192-4201. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

目的 探讨不同减低剂量地西他滨治疗骨髓增生异常综合征(MDS)的临床疗效和安全性.方法 2017年1月至2020年12月于南京医科大学第一附属医院,68例MDS患者前瞻性随机分为2组给予不同减低剂量地西他滨皮下注射,低剂量组:20mg/m2,3d,d1～3;超低剂量组:5～7mg/m2,6d,d1～3,d8,d15,d22;每6周为一个疗程.结果 低剂量组的总反应率(ORR)和血液学改善(HI)均优于超低剂量组(60.0％比24.2％,P=0.003;37.1％比15.2％,P=0.04);两组间完全缓解(CR)、部分缓解(PR)、骨髓完全缓解(mCR)分别为2.9％比3.0％(P=0.966),5.7％比0(P=0.163),14.3％比6.1％(P=0.265).IPSSR分组较低危组和较高危组患者在低剂量组的ORR均优于超低剂量组(60.0％比16.7％,P=0.023;60.0％比28.6％,P=0.043).低剂量组等位基因突变频率(VAF)下降程度高于超低剂量组(15.49％比5.98％,P=0.042).多因素分析显示,地西他滨剂量(OR 0.287,P=0.036),女性(OR 6.855,P=0.002)及 IPSSR 分组(OR 1.222,P=0.043)为影响疗效的相关因素.两组出现Ⅲ～Ⅳ级骨髓抑制(15.2％比25.7％,P=0.280)及感染性发热(36.4％比20.0％,P=0.133)的比例相当,而低剂量组肺部感染比例明显低于超低剂量组(8.6％比33.3％,P=0.012).中位随访时间16个月(2～54个月),两组的转白率(24.2％比20.0％,P=0.673),中位转白时间(5.5个月比6.0个月,P=0.879)及中位生存时间(11个月比11个月,P=0.925)比较差异无统计学意义.结论 地西他滨剂量降至极低水平后疗效不佳,女性患者效果优于男性.

目的:探讨芦可替尼治疗SF3B1基因突变的骨髓增生异常综合征（MDS）/骨髓增殖性肿瘤（MPN）伴环状铁粒幼细胞增多和血小板增多（RS-T）、骨髓纤维化（MF）的难治性贫血效果。方法:回顾性分析南通大学附属建湖医院收治的1例SF3B1基因突变MPN/MDS-RS-T伴MF难治性贫血患者的临床资料，并进行文献复习。结果:该患者2016年9月开始先后予以沙利度胺联合糖皮质激素、地西他滨、来那度胺联合糖皮质激素治疗，均无效，严重依赖红细胞输注。2019年10月给予芦可替尼15 mg，2次/d，治疗2周后患者血红蛋白上升，随访3个月后血红蛋白依然稳定，脱离红细胞输注。结论:芦可替尼对SF3B1基因突变的MPN/MDS-RS-T伴MF难治性贫血患者可能有效，值得进一步积累病例进行探索。