BACKGROUND AND OBJECTIVE:Acute Leukemia (AL) diagnosed during pregnancy is uncommon, and the management of AL complicated by pregnancy is a poorly studied area that faces a therapeutic dilemma. METHOD:23 cases diagnosed with AL during pregnancy were collected from our center between 2012 and 2022. Additionally, we summarized 17 clinical studies on AL diagnosed during pregnancy. RESULT:Sixteen AML and seven ALL patients were diagnosed during pregnancy in our center; most patients diagnosed during the first or second trimester tended to receive chemotherapy after abortion. All patients diagnosed during the third trimester opted to defer therapy until after delivery. The rate of overall response rate (ORR) was 77.3%, which was found to be similar to that of the general population. A Short delay in initiating anti-leukemia treatment is not associated with a negative impact on prognosis. We conducted a meta-analysis of the literature, and the summary relative complete remission (CR) rate was 76.9% (95%CI 69.1-84.6%) (Random Effects Model I^2 = 66%, p <0.001). We included four Chinese studies comprising 135 participants for further analysis. For non-M3 AL patients, CR rate of the chemotherapy-first cohort was 63.6%, compared with 68.6% in the treatment-after-delivery or abortion cohort (p = 0.657). For M3 patients, the rate was 100 and 83.3%, respectively (p < 0.001). CONCLUSION:Our findings suggest that for non-M3 AL patients can sometimes be managed during pregnancy. For M3 patients, early treatment potentially yield favorable outcomes for both the mother and fetus, using ATRA-based regimens without arsenic trioxide (in the second and third trimester) or standard chemotherapy (in the second trimester) may be considered a treatment option.

Background: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been regarded as the most effective curative therapy for T-cell acute lymphoblastic leukemia/lymphoma (T-ALL/LBL), a highly aggressive hematological malignant. And the conditioning regimen is a crucial component of allo-HSCT. Exploring new conditioning regimens to reduce relapse without increasing transplant-related mortality is of great significance for improving the prognosis of T-ALL/LBL patients. In consideration of the synergistic anti-leukemia effect of cladribine (CLAD) and cytarabine (Ara-c), our center added CLAD and medium-dose Ara-C on the basis of busulfan plus cyclophosphamide to intensify the conditioning regimen (CBAC). Our previous clinical data have suggested that CBAC regimen may reduce relapse without increasing non-relapse mortality (NRM), improving the prognosis of high-risk B-ALL patients. In this study, we implemented the CBAC regimen in T-ALL/LBL transplantation to investigate its potential efficacy benefits, conducting a comparative retrospective study against the TBI-Cy based regimen. Methods: Clinical data of T-ALL/LBL patients underwent allo-HSCT after receiving CBAC conditioning regimen (CLAD (5mg/m2/d, days -8 to -4), Ara-C (2g/m2/d, days -8 to -4), Bu (0.8mg/kg, Q6h, days -8 to -5), cyclophosphamide (CTX) (1.8g/m2/d, days -3 to -2). The medication sequence involved intravenous infusion of CLAD over 3 hours, followed by Ara-C through continuous intravenous drip over 3 hours, with a 4-hour interval) at Xiangya Hospital, Central South University were retrospectively reviewed. Additionally, data of T-ALL/LBL patients received traditional TBI-Cy based conditioning regimen were collected as a control group. We then analyzed the engraftment, transplant-related complications, relapse, and survival outcomes among different conditioning regimen groups. Results: The data were collected for a total of 44 T-ALL/LBL patients, divided into CBAC group (20 patients) and TBI-Cy group (24 patients). The two groups were similar in terms of age, gender, MRD/CR status at HSCT, IPI score, infused mononuclear cell count, infused CD34+ cell count and donor source (p>0.05). There was also no significant difference in either incidence or severity of GVHD, median time of neutrophil/platelet engraftment, incidence of CMV/EBV reactivation and bacterial/ fungal infection between the two groups (p>0.05). The 3-year non-relapse mortality (NRM), cumulative incidence of relapse (CIR), disease-free survival (DFS) and overall survival (OS) of CBAC and TBI-Cy group were 25.0% vs. 21.1% (p=0.786), 15.8% vs. 21.8% (p= 0.557), 59.2% vs. 57.2% (p =0.796), 64.2% vs. 65.8% (p= 0.956), respectively. Conclusion: The CBAC regimen achieved comparable efficacy to TBI-Cy-based regimen and can serve as an alternative to some extent in T-ALL/LBL patients.

Background Despite CD19-directed chimeric antigen receptor T (CAR-T) therapy achieving remarkable remission rates in relapsed/refractory B-cell acute lymphoblastic leukemia (R/R B-ALL), long-term survival remains constrained by T-cell exhaustion and immunosuppressive microenvironments. Dasatinib, a tyrosine kinase inhibitor (TKI), has been shown to alleviate T cell exhaustion and enhance CAR-T cell persistence, demonstrating therapeutic synergy in newly diagnosed ALL. However, it may also suppress CAR-T cytotoxicity and is ineffective against BCR-ABLT315I mutations. Third-generation TKIs, including ponatinib and olverembatinib, effectively overcome T315I-mediated resistance, yet their impact on CAR-T cell function and immune modulation remains insufficiently defined. Methods and Results: We first established in vitro co-culture models of CD19 CAR-T cells with the B-ALL cell line NALM6 to evaluate the effects of dasatinib, ponatinib and olverembatinib on resting and tumor antigen-activated CAR-T cells. At clinically relevant concentrations, none of the TKIs affected resting CAR-T viability. In contrast, upon activation, all three TKIs significantly inhibited CAR-T activation, cytotoxicity, and cytokine secretion (IL-2, TNF-α, IFN-γ), while reducing activation-induced CAR-T cell apoptosis. TKIs treatment also downregulated exhaustion markers (eg. PD-1, TIM3, LAG3) and promoted differentiation toward naïve (TN) and central memory (TCM) subsets, while reducing terminal effector T cells. After the drug elution, CAR-T cells regained their cytolytic function in response to tumor targets. Notably, ponatinib-treated CAR-T cells exhibited higher levels of IFN-γ, TNF-α and IL-2 post-washout compared to other groups. Importantly, the TN/TCM phenotype and low exhaustion marker expression were preserved after washout in all TKI-treated groups. Transcriptomic profiling of CAR-T cells in vitro revealed that all three TKIs downregulated key exhaustion-associated genes, including PDCD1, HAVCR2, CTLA4 and NR4A1, along with upregulation of stemness- and memory-associated genes (eg. CCR7, TCF7, LEF1, IL7R). Gene set enrichment analysis showed inhibition of T-cell activation, apoptosis, glycolysis, and TGF-β signaling by all TKIs. Remarkably, ponatinib uniquely activated the IFN-γ pathway, suggesting superior immunostimulatory effects. Mechanistically, all three TKIs suppressed the phosphorylation of AKT, p38 MAPK, and NF-κB p65, indicating shared inhibition of downstream TCR signaling. Based on these findings, we evaluated ponatinib in a clinical setting. A prospective study (No. ChiCTR2000036350) enrolled three R/R B-ALL patients with the BCR-ABLT315I mutation. All the patients received CD19 CAR-T cell therapy followed by ponatinib maintenance, initiated two months post-infusion. All three patients remained progression-free during ponatinib maintenance. Notably, the DNA copies of CAR-T cells remained detectable at months 5 and 9 after ponatinib treatment in two patients, respectively. To further explore the in vivo effects of ponatinib on T cells and other immune cells,peripheral blood mononuclear cells were collected from these patients before and one month after ponatinib initiation for single-cell RNA sequencing. Ponatinib exposure led to an increased proportion of CD8+T cells and a decreased abundance of myeloid cells subsets. Within T cells, effector cells expanded while Tregs and exhausted T cells decreased. Differential gene analysis showed suppression of activation, adhesion, apoptosis, and PD-1/PD-L1 signaling, aligning with in vitro results. Functional scoring revealed enhanced cytotoxicity, IFN-γ responses, and reduced glycolysis, exhaustion, TGF-β, and Treg signatures. Furthermore, analysis of NK cell subsets showed enhanced cytolytic scores and enrichment of proliferation and immune activation pathways, suggesting that ponatinib preserves innate immune responses in vivo. Conclusions: This study provides preclinical and preliminary clinical evidence that third-generation TKIs, particularly ponatinib, can effectively alleviate CAR-T cell exhaustion, promote memory phenotypes, and remodel the immune microenvironment. Compared to dasatinib and olverembatinib, ponatinib uniquely enhances effector cytokine production and activates the IFN-γ pathway. These findings support ponatinib as a promising combinatorial agent with CAR-T therapy, offering a rational strategy for improving outcomes in patients with T315I-mutated R/R B-ALL.

Background: The patient-reported health-related quality-of-life (HRQoL) is an important indicator for measuring the clinical outcome of lymphoma, however, the evaluation of HRQoL in real-world clinical practice is often lacking. Instead, the Eastern Cooperative Oncology Group performance status (ECOG-PS) is commonly employed by the clinicians to assess the physical abilities of lymphoma patients. This study aimed to evaluate the association between clinician-assessed ECOG-PS and patient-reported HRQoL in lymphoma patients. Methods: Lymphoma patients were recruited from a leading tertiary hospital in China. Demographic and clinical information were retrieved from the medical records. Two clinicians independently assessed the ECOG-PS of all patients who in turn completed the EuroQoL-5 Dimensions-5 Levels (EQ-5D-5L) questionnaire to obtain the self-reported HRQoL. Variables were compared among ECOG-PS ratings using ANOVA and Chi-squared test. The relationship of clinician-assessed ECOG-PS and patient-reported HRQoL were further evaluated by regression analysis. Results: Of the 381 lymphoma patients, 268, 72, and 41 were ECOG-PS of 1, ECOG-PS of 2, ECOG-PS of 3 or 4, respectively. Patient-reported EQ-5D-5L utility scores (P < 0.001) and EQ-VAS scores (P < 0.001) varied significantly across different ECOG-PS ratings. The EQ-5D-5L dimensions also significantly correlated with ECOG-PS (all P < 0.001). The clinician-assessed ECOG-PS and patient-reported HRQoL were associated with the same clinical characteristics, including relapsed or refractory disease, second or later lines of treatment, prior hematopoietic stem cell transplantation, and comorbidities. Moreover, regression analysis observed that worse clinician-assessed ECOG-PS significantly predicted lower patient-reported HRQoL (P < 0.001). Conclusion: The clinician-assessed ECOG-PS relates strongly with the patient-reported HRQoL, especially the physical functioning aspects.

Background: For patients with B-cell acute lymphoblastic leukemia (B-ALL), extramedullary relapse after allogeneic hematopoietic stem cell transplantation (allo-HSCT) carries an extremely unfavorable prognosis. As a new immunotherapy, chimeric antigen receptor T (CAR-T) cell therapy has shown remarkable effects in refractory or relapsed B-ALL (r/r B-ALL). However, there is still a lack of evidence for its efficacy and safety in patients with extramedullary relapse after allo-HSCT. The aim of this study was to evaluate the safety and efficacy of allogeneic CAR-T in such high-risk populations. Method: We conducted a prospective clinical study, during which 7 patients with B-ALL who experienced extramedullary relapse after allo-HSCT were enrolled between October 2019 and January 2025. These patients all received allogeneic CD19 CAR-T cell therapy. We prospectively evaluated the safety, efficacy, and survival outcomes following CAR-T treatment. This study was registered at www.chictr.org.cn (No. ChiCTR2000036350). Results: This study included 7 patients with extramedullary relapse after allo-HSCT. Median age was 21 years (range: 15 - 46 years), and the median follow-up time was 415 days (range: 130 - 1320 days). The last follow-up was conducted until July 5, 2025. All the patients were classified as high-risk patients before transplantation. Four of them were Philadelphia chromosome/BCR-ABL positive (Ph+). The sites of extramedullary relapse included: 5 cases of central nervous system (among which 2 cases were accompanied by BCR-ABL molecular relapse in the bone marrow), 1 case of testicular relapse, and 1 case of extensive extramedullary relapse. The median interval from transplantation to extramedullary relapse was 628 days (44 - 1225 days). All patients received chemotherapy, radiotherapy or targeted therapy to reduce tumor burden before infusion. The infusion dose of CAR-T cells was 4 - 10 × 10⁶/kg. After infusion, one patient developed grade 3 cytokine release syndrome (CRS) and grade 4 immune effector cell-related neurotoxicity syndrome (ICANS), while the remaining patients did not experience grade 2 or higher CRS or ICANS. No patients developed graft-versus-host disease (GVHD), and all adverse events were resolved. In terms of therapeutic efficacy, one patient was considered unresponsive at the first assessment after infusion (54 days after infusion). The remaining 6 patients all achieved complete remission (CR) efficacy. The median duration of CR was 275 days (range: 120 - 1305 days). During the follow-up period, one patient suffered from central nervous system relapse again at 275 days post-infusion, while the other 5 maintained a continuous CR. The expansion of CAR-T cells in peripheral blood peaked between days 8 to 15 post-infusion, with a median peak of 1.90E+05 copies/μg DNA (range: 1.78E+04 – 3.18E+05 copies/μg DNA), and the longest duration of detectable expansion was 1320 days. Furthermore, CAR-T cells were detected in the cerebrospinal fluid of three patients, indicating their capability for targeted migration and central nervous system infiltration. Conclusion: Overall, allogeneic CAR-T therapy has demonstrated excellent safety and durable anti-leukemia effects in high-risk ALL patients with extramedullary relapse after transplantation.

The hypercoagulable state is a hallmark for patients with multiple myeloma (MM) and is associated with disease progression. Activated platelets secrete exosomes and promote solid tumor growth. However, the role of platelet-derived exosomes in MM is not fully clear. We aim to study the underlying mechanism of how platelet-derived exosomes promote MM cell growth. Flow cytometry, Western blot, proteome analysis, co-immunoprecipitation, immunofluorescence staining, and NOD/SCID mouse subcutaneous transplantation model were performed to investigate the role of exosomal LRG1 on multiple myeloma cell growth. Peripheral blood platelets in MM patients were in a highly activated state, and platelet-rich plasma from MM patients significantly promoted cell proliferation and decreased apoptotic cells in U266 and RPMI8226 cells. Leucine-rich-alpha-2-glycoprotein 1 (LRG1) was significantly enriched in MM platelet-derived exosomes. Blocking LRG1 in recipient cells using LRG1 antibody could significantly eliminate the proliferation-promoting effect of platelet-derived exosomes on MM cells. And high exosomal LRG1 was associated with poor prognosis of patients with MM. Mechanistic studies revealed that LRG1 interacted with Olfactomedin 4 (OLFM4) to accelerate MM progression by activating the epithelial-to-mesenchymal transition (EMT) signaling pathway and promoting angiogenesis. Our results revealed that blocking LRG1 is a promising therapeutic strategy for the treatment of MM.

Background DACT gene is a potential Wnt antagonist and tumor suppressor gene. However, the expression of DACT gene in acute myeloid leukemia (AML) and its role are still unknown. Methods In this study, we first multidimensionally analyzed the expression of DACT gene in AML through RNA seq, qRT-PCR and Western blotting analysis as well as TCGA database analysis. Then DACT3 was identified as playing a critical role in AML, and its clinical significance was further explored. The molecular mechanism of DACT3 down-regulation in AML from aspects of DNA methylation and histone acetylation were inquired. Finally, the biological functions of DACT3 in AML were investigated by cell models in vitro and animal experiments in vivo . Results Compared with DACT1 and DACT2, DACT3 was the most differentially expressed DACT family member in AML, suggesting that DACT3 plays the major role. The mRNA and protein expression levels of DACT3 were significantly decreased and positively correlated in AML. Moreover, low expression of DACT3 is associated with no remission disease status and poor prognosis in AML patients. In addition, down-regulation of DACT3 in AML was not completely dependent on promoter methylation, but also affected by histone deacetylation. We found that loss of DACT3 in AML is related to activation of Wnt signaling pathway. Furthermore, DACT3 inhibits the growth of AML cells in vitro and in severe immunodeficiency (SCID) mice. Importantly, DACT3 improved the sensitivity of adriamycin in treating AML cells. Further research showed that co-treatment of chidamide and azacytidine up-regulates DACT3 expression and promotes cell apoptosis via inhibiting Wnt/β-catenin signaling in AML, suggesting a promising therapeutic prospects in FLT3-mutant AML. Conclusion This is the first study revealing the epigenetic regulatory molecular mechanism of the down regulated expression of DACT3 in AML. Our data also shows that DACT3 is a candidate gene for therapeutic target and targeting DACT3 has the potential to validate the combination therapy of DNMT inhibitors and HDAC inhibitors.

Gene editing to disrupt the GATA1-binding site at the +58 BCL11A erythroid enhancer could induce γ-globin expression, which is a promising therapeutic strategy to alleviate β-hemoglobinopathy caused by HBB gene mutation. In the present study, we report the preliminary results of an ongoing phase 1/2 trial (NCT04211480) evaluating safety and efficacy of gene editing therapy in children with blood transfusion-dependent β-thalassemia (TDT). We transplanted BCL11A enhancer-edited, autologous, hematopoietic stem and progenitor cells into two children, one carrying the β 0 /β 0 genotype, classified as the most severe type of TDT. Primary endpoints included engraftment, overall survival and incidence of adverse events (AEs). Both patients were clinically well with multilineage engraftment, and all AEs to date were considered unrelated to gene editing and resolved after treatment. Secondary endpoints included achieving transfusion independence, editing rate in bone marrow cells and change in hemoglobin (Hb) concentration. Both patients achieved transfusion independence for >18 months after treatment, and their Hb increased from 8.2 and 10.8 g dl −1 at screening to 15.0 and 14.0 g dl −1 at the last visit, respectively, with 85.46% and 89.48% editing persistence in bone marrow cells. Exploratory analysis of single-cell transcriptome and indel patterns in edited peripheral blood mononuclear cells showed no notable side effects of the therapy.

Osteolytic bone disease is a hallmark of multiple myeloma (MM). A significant fraction (~20%) of MM patients do not develop osteolytic lesions (OLs). The molecular basis for the absence of bone disease in MM is not understood. We combined PET-CT and gene expression profiling (GEP) of purified BM CD138+ MM cells from 512 newly diagnosed MM patients to reveal that elevated expression of cystatin M/E (CST6) was significantly associated with the absence of OL in MM. An enzyme-linked immunosorbent assay revealed a strong correlation between CST6 levels in BM serum/plasma and CST6 mRNA expression. Both recombinant CST6 protein and BM serum from patients with high CST6 significantly inhibited the activity of the osteoclast-specific protease cathepsin K and blocked osteoclast differentiation and function. Recombinant CST6 inhibited bone destruction in ex vivo and in vivo myeloma models. Single-cell RNA-Seq showed that CST6 attenuates polarization of monocytes to osteoclast precursors. Furthermore, CST6 protein blocks osteoclast differentiation by suppressing cathepsin-mediated cleavage of NF-κB/p100 and TRAF3 following RANKL stimulation. Secretion by MM cells of CST6, an inhibitor of osteoclast differentiation and function, suppresses osteolytic bone disease in MM and probably other diseases associated with osteoclast-mediated bone loss.

Immune thrombocytopenia (ITP) is an acquired disease characterized by isolated thrombocytopenia, which is one of the most common causes of thrombocytopenia during pregnancy. Women with ITP who have severe thrombocytopenia are at an increased risk for life-threatening obstetric complications. Therefore, we established this consensus statement on the diagnosis and management of ITP during pregnancy (detailed information is available in the Supplementary File, https://links.lww.com/CM9/A978). Recommendations for diagnosis of ITP in pregnancy 1. Patients with suspected ITP prior to pregnancy or those with a platelet count <100 × 109/L should be assessed for ITP. 2. The recommended examinations for all patients include the following: a detailed patient and family history; a physical examination; complete blood count panels; reticulocyte and reticulated platelet counts; a peripheral blood smear; coagulation screening; human immunodeficiency virus, hepatitis B virus, and hepatitis C virus testing; liver and renal function tests; thyroid function tests; anti-nuclear antibody; and anti-phospholipid antibody tests. 3. Detection of Helicobacter pylori infection should be considered in patients with digestive symptoms and in those from areas of high prevalence. Polymerase chain reaction for cytomegalovirus and Epstein-Barr virus is also recommended, when clinically indicated. 4. Direct anti-globulin test combined with haptoglobin, lactate dehydrogenase, and bilirubin tests should be considered to assess hemolysis. 5. A bone marrow examination is not routinely recommended unless there are atypical features in the peripheral blood counts or peripheral blood smears that are inconsistent with isolated thrombocytopenia. 6. Anti-platelet antibody and testing of thrombopoietin levels are not routinely recommended. Recommendations for preconception counseling Preconception counseling should be performed for women diagnosed with ITP before pregnancy. Details of the diagnosis of ITP, history of bleeding, previous medical treatment, splenectomy, response to treatment, and obstetric history, including a previous neonate platelet count, should be explored during this counseling. Recommended timing for intervention 1. Patients with a platelet count >30 × 109/L, without bleeding or any risk factor for bleeding who can be observed and followed up until delivery is imminent. 2. In patients with a platelet count <30 × 109/L, treatment should be considered in order to achieve a safe platelet level. 3. Patients with active bleeding symptoms should be treated regardless of the degree of thrombocytopenia. 4. The platelet count should be raised to a target level when a medical procedure or surgery is planned. 5. Late in the third trimester, the platelet count should be maintained at >50 × 109/L for vaginal delivery and at >80 × 109/L for cesarean section and spinal/epidural anesthesia in patients with otherwise normal coagulation. 6. Pregnancy may complicate the management of ITP. A multidisciplinary team including a hematologist, an obstetrician, a neonatologist, and an anesthetist, if necessary, is recommended for the treatment of ITP during pregnancy. Recommended platelet levels for patients undergoing medical procedures Dentistry: a platelet count ≥20 × 109/L Tooth extractions and regional dental block: a platelet count ≥30 × 109/L Minor surgery: a platelet count ≥50 × 109/L Major surgery: a platelet count ≥80 × 109/L Anticoagulant therapy: a platelet count ≥50 × 109/L Recommendations for first-line treatment 1. Prednisone started at a dose of 10 to 20 mg/day is recommended for initial treatment. It can be tapered subsequently to the minimum maintenance dose (5–10 mg/day) to maintain a target platelet count. The dosage should be tapered rapidly to discontinuation in patients who do not respond to prednisone. 2. Intravenous immunoglobulin (IVIg) is recommended for patients who fail to respond to prednisone, for those with severe adverse effects, or for those with an urgent need for elevated platelet counts. A dose of 400 mg/kg per day for 3 to 5 days, or 1000 mg/kg for 1 to 2 days, is recommended; this protocol may be repeated after 1 or 2 weeks, if necessary. 3. In consideration of the safety of the fetus, prednisone is recommended for use in the second and third trimesters of pregnancy. Prednisone should be used with caution during the first trimester. IVIg can be considered when treatment is needed in the first trimester. Recommendations for emergency treatment 1. Emergency treatment is needed for severe thrombocytopenia, which is defined as severe, life-threatening bleeding with a platelet count <10 × 109/L, to rapidly stop bleeding and improve the platelet count, raising it to a relatively safe level. 2. High-dose methylprednisolone (1000 mg/day for 3 days) and IVIg (1000 mg/kg per day for 1-2 days), either alone or in combination, with platelet transfusions are recommended for emergency treatment. If used in combination with high-dose methylprednisolone, which can contribute to increased catabolism, a reduced dosage of IVIg at 400 mg/kg per day for 3 to 5 days could be considered in women who have an increased risk of acute kidney injury. 3. Other therapeutic measures include discontinuing medications that may have an antiplatelet or anticoagulation effect and controlling hypertension. Recommendations for second-line treatment 1. Prednisone or high-dose methylprednisolone combined with IVIg is recommended for patients who fail to respond to initial treatment. 2. Recombinant human thrombopoietin could be considered a second-line alternative for patients who are refractory to corticosteroids and IVIg, ideally in the third trimester and only at an experienced center. 3. Thrombopoietin receptor agonists could be considered in pregnancy only in extremely severe cases when the benefits outweigh the potential harm or when other treatments have failed or are not accessible. 4. Splenectomy is rarely performed during pregnancy. When a splenectomy is deemed necessary, it is best carried out in the second trimester by laparoscopy, if possible. 5. Other cytotoxic and immunosuppressive drugs not listed in these recommendations should be avoided in pregnancy. Recommendations for platelets transfusion 1. When delivery is approaching, platelet transfusion should be prepared in patients whose platelet counts are still below the recommended level despite standard treatment. 2. When pregnant patients with ITP undergo surgery or a procedure, or when they have active bleeding, platelet transfusion can be used to achieve a safe platelet count and rapidly stop bleeding. 3. A combination of IVIg and/or corticosteroids may improve the effectiveness of platelet transfusion. Recommendations for delivery 1. ITP is not an indication for cesarean section. The mode of delivery should be considered based on obstetrical indications. 2. In the third trimester, as delivery nears, an adequate platelet count should be maintained to reduce the risk for maternal hemorrhage. Vaginal delivery is generally considered safe at platelet counts above 50 × 109/L. A platelet count >80 × 109/L is required for cesarean sections with epidural anesthesia. 3. Platelet infusion in combination with IVIg or corticosteroids can be used to rapidly increase platelet levels in emergency situations. Assessment of postpartum hemorrhage (PPH) We recommend evaluating PPH risk for ITP patients routinely to prevent life-threatening events associated with ITP by using the MONITOR model (maternal complication, World Health Organization bleeding score, antepartum platelet transfusion, placental abnormalities, platelet count, previous uterine surgery, and primiparity). Recommendations for the management of neonates born to women with ITP 1. The fetal platelet levels cannot be predicted by measuring the maternal platelet counts. Neonates who have a sibling with previous thrombocytopenia are more likely to experience thrombocytopenia at or after birth. 2. The umbilical cord platelet count should be examined at delivery, if possible. 3. Neonatal platelet counts should be closely monitored after delivery. Repeat platelet monitoring as required based on platelet levels, trends in the count, and response to treatment (if any). 4. It should be considered that the incidence of pseudothrombocytopenia is high in neonates due to the difficulty of collecting blood. 5. Cranial ultrasound should be performed to rule out intracranial hemorrhage if the platelet count is below 50 × 109/L at birth. 6. For neonates with a platelet level <30 × 109/L or with symptomatic bleeding, IVIg at a dose of 1 g/kg can be administered, and can be repeated if necessary. If bleeding is severe and uncontrollable, platelet transfusion can be considered. 7. For neonates with thrombocytopenia, fetal/neonatal alloimmune thrombocytopenia should be considered and differentiated. Funding This work was supported by grants from the National Key Research and Development Program of China (No. 2017YFA0105503), the National Natural Science Foundation of China (No. 81970113), the Key Program of National Natural Science Foundation of China (No. 81730004), and the Beijing Natural Science Foundation (No. H2018206423). Conflicts of interest None.

Silicosis is caused by inhalation of crystalline silica dust particles and known as one of the most serious occupational diseases worldwide. However, little is known about intrinsic factors leading to disease susceptibility. Single-cell sequencing of bronchoalveolar lavage fluid cells of mine workers with silicosis and their co-workers who did not develop silicosis revealed that the impaired interferon (IFN)-γ signaling in myeloid cells was strongly associated with the occurrence of silicosis. Global or myeloid cell-specific deletion of interferon γ receptor (IFN-γR) markedly enhanced the crystalline silica-induced pulmonary injury in wild-type but not in NLRP3 deficient mice. In vitro, IFN-γ priming of macrophages suppressed the crystalline silica-induced NLRP3 inflammasome activation partly by inducing the formation of spacious phagosomes with relatively reduced ratio of crystalline silica/phagosomal areas volumes to resistant crystalline silica-induced lysosomal membrane damage. Thus, these findings provide molecular insights into the intricate mechanisms underlying innate immunity-mediated host responses to environmental irritants.

Introduction Current treatment of severe haemophilia A includes prophylaxis with factor VIII (FVIII) replacement. The supply of plasma-derived FVIII is short in China. Purpose To evaluate the efficacy and safety of a new B-domain deleted (BDD) recombinant FVIII (TQG202) produced by human-derived cells for prophylaxis in severe haemophilia A patients and compare the bioequivalence with Xyntha. Methods This multicentre, clinical trial consisted of an open-label, randomized, two-period cross-over trial assessing single-dose pharmacokinetics (PK), and a single-arm clinical trial evaluating the efficacy and safety of 24 weeks of TQG202 prophylaxis, and repeated PK were assessed after prophylaxis phase. The single-dose was 50 IU/kg in PK assessment, and the initial dose was 30 +/- 5 IU/kg for prophylaxis. The primary endpoints of prophylaxis were the annualized bleeding rate (ABR) and the incremental recovery rate of the first administration. Adverse events (AEs) were recorded. Results Twenty-six participants were enrolled in the PK assessment and 81 participants in the prophylaxis phase. Mean age was 25.9 +/- 10.8 years and all participants were male. The results of PK assessment showed TQG202 is bioequivalent to Xyntha. The total ABR was 2.0 (95% CI: 1.2-2.9) in prophylaxis phase. The mean incremental recovery rate of the first administration was .027 (95% CI: .026-.028) (IU/ml)/(IU/kg). AEs occurred in 42 participants, with an incidence of 51.9%. One severe AE not related to TQG202 occurred. No participants developed FVIII inhibitors. Conclusion TQG202 shows bioequivalence with Xyntha. The promising efficacy and tolerability in the severe haemophilia A prophylaxis support the use of TQG202in clinical practice.

Chimeric antigen receptor T-cell (CAR-T) therapy has greatly improved the disease remission rate and longterm survival rate of patients with relapsed/refractory hematological malignancies.[1-3] Currently, several commercial CAR-T products are available in the market and numerous CAR-T clinical trials have been conducted. Attention should be paid to the safety of CAR-T therapy. The main adverse effects of CAR-T therapy are cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).[4] Moreover, CAR-T therapy-associated coagulopathy (CARAC) is also prominent [Supplementary Table 1].[5-16] Among the patients with hematological malignancies, including B-cell acute lymphoblastic leukemia (B-ALL), non-Hodgkin lymphoma (NHL), and multiple myeloma (MM), more than half of them experienced thrombocytopenia or showed at least one abnormal coagulation parameter after CAR-T therapy.[13-15] Approximately 19.6% of coagulopathy patients experienced clinically significant bleeding and 14–50% of coagulopathy patients further developed disseminated intravascular coagulation (DIC); 6.7–42.9% of the DIC patients died.[13-14,17] The current international grading criteria and treatment guidelines for CAR-T therapy-related adverse events only focus on CRS and ICANS, while CARAC has not been systematically summarized. [18-21] In order to standardize the management of CARAC and promote the safe application of CAR-T therapy, experts from Thrombosis and Hemostasis Group, Chinese Society of Hematology (CSH) and Biotherapeutics Committee, Chinese Research Hospital Association (CRHA) formulated this consensus based on worldwide clinical experience and research progress.

Multiple myeloma (MM) is a genetically heterogeneous disease characterized by genomic chaos making it difficult to distinguish driver from passenger mutations. In this study, we integrated data from whole genome gene expression profiling (GEP) microarrays and CytoScan HD high-resolution genomic arrays to integrate GEP with copy number variations (CNV) to more precisely define molecular alterations in MM important for disease initiation, progression and poor clinical outcome. We utilized gene expression arrays from 351 MM samples and CytoScan HD arrays from 97 MM samples to identify eight CNV events that represent possible MM drivers. By integrating GEP and CNV data we divided the MM into eight unique subgroups and demonstrated that patients within one of the eight distinct subgroups exhibited common and unique protein network signatures that can be utilized to identify new therapeutic interventions based on pathway dysregulation. Data also point to the central role of 1q gains and the upregulated expression of ANP32E, DTL, IFI16, UBE2Q1, and UBE2T as potential drivers of MM aggressiveness. The data presented here utilized a novel approach to identify potential driver CNV events in MM, the creation of an improved definition of the molecular basis of MM and the identification of potential new points of therapeutic intervention.

Multiple myeloma (MM), a terminally differentiated B cell malignancy, remains difficult to cure. Understanding the molecular mechanisms underlying the progression of MM may identify therapeutic targets and lead to a fundamental shift in treatment of the disease. Deubiquitination, like ubiquitination, is a highly regulated process, implicated in almost every cellular process. Multiple deubiquitinating enzymes (DUBs) have been identified, but their regulation is poorly defined. Here, we determined that TRIP13 increases cellular deubiquitination. Overexpression of TRIP13 in mice and cultured cells resulted in excess cellular deubiquitination by enhancing the association of the DUB USP7 with its substrates. We show that TRIP13 is an oncogenic protein because it accelerates B cell tumor development in transgenic mice. TRIP13-induced resistance to proteasome inhibition can be overcome by a USP7 inhibitor in vitro and in vivo. These findings suggest that TRIP13 expression plays a critical role in B cell lymphoma and MM by regulating deubiquitination of critical oncogenic (NEK2) and tumor suppressor (PTEN, p53) proteins. High TRIP13 identifies a high-risk patient group amenable to adjuvant anti-USP7 therapy.

Diffuse large B cell lymphoma (DLBCL) heterogeneity promotes recurrence and anti-CD20-based therapeutic resistance. Previous studies have shown that downregulation of MS4A1/CD20 expression after chemoimmunotherapy with rituximab leads to rituximab resistance. However, the mechanisms of CD20 loss remain unknown. We identified that pyruvate dehydrogenase kinase 4 (PDK4) is markedly elevated in DLBCL cells derived from both patients and cell lines with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) resistance. We found that overexpression of PDK4 in DLBCL cells resulted in cell proliferation and resistance to rituximab in vitro and in vivo. Furthermore, loss of PDK4 expression or treatment with the PDK4 inhibitor dichloroacetate was able to significantly increase rituximab-induced cell apoptosis in DLBCL cells. Further studies suggested PDK4 mediates a metabolic shift, in that the main energy source was changed from oxidative phosphorylation to glycolysis, and the metabolic changes could play an important role in rituximab resistance. Importantly, by knocking down or overexpressing PDK4 in DLBCL cells, we showed that PDK4 has a negative regulation effect on MS4A1/CD20 expression. Collectively, this is the first study showing that targeting PDK4 has the potential to overcome rituximab resistance in DLBCL.

Background Prickle planar cell polarity protein 1 (PRICKLE1), a core component of the non-canonical Wnt/planar cell polarity (PCP) pathway, was recently reported to be upregulated and correlated with poor prognosis in solid cancers. However, the effect of PRICKLE1 on acute myeloid leukemia (AML) remains unknown. This study aims to characterize the prognostic significance of PRICKLE1 expression in patients with AML. Methods RNA-seq was performed to compare mRNA expression profiles of AML patients and healthy controls. qRT-PCR and western blotting were used to analyze the expression of PRICKLE1 in AML patients and cell lines, and two independent datasets (TCGA-LAML and TARGET-AML) online were used to validate the expression results. The correlations between the expression of PRICKLE1 and clinical features were further analyzed. Results Our data showed that PRICKLE1 expression levels were markedly high in AML patients at the time of diagnosis, decreased after complete remission and increased again at relapse. Of note, PRICKLE1 was highly expressed in drug resistant AML cells and monocytic-AML patients. High PRICKLE1 expression was found in FLT3/DNMT3A/IDH1/IDH2-mutant AML and associated with poor prognosis. Furthermore, high expression of PRICKLE1 may be correlated with migration and invasion components upregulation in AML patients. Conclusions These results indicated that high PRICKLE1 expression may be a poor prognostic biomarker and therapeutic target of AML.

Abstract Background: Diffuse large B cell lymphoma (DLBCL) heterogeneity promotes the recurrence and anti-CD20-based therapeutic resistance. In previous studies, it has been demonstrated that the downregulation of MS4A1/CD20 expression after chemoimmunotherapy with rituximab can lead to rituximab resistance. However, the the mechanisms of CD20-loss remains unknown. Methods: The expression levels of PDK4 were investigated in DLBCL patients and cell lines by RNA-seq, qRT-PCR, western blotting and immunofluorescence analysis. Lentiviral infection was used to regulate the level of PDK4 in DLBCL cells. The effects of PDK4 on apoptosis, drug sensitivity and proliferation of DLBCL cells were evaluated by flow cytometry and cell-counting kit-8 (CCK-8) assay, as well as being assessed in a murine model. Cell metabolism was conducted by measurement of glucose consumption, lactate production, ATP levels, ECAR and OCR with corresponding assay kit. Results: Our data showed that PDK4 expression levels elevated significantly in DLBCL cells derived from both the patients and cell lines with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone regimen) resistant. We further found that the overexpression of PDK4 in DLBCL cells can lead to cell proliferation and rituximab resistance both in vitro and in vivo. Furthermore, the loss of PDK4 expression or treatment with the PDK4 inhibitor dichloroacetate is effective in increasing the rituximab-induced cell apoptosis in DLBCL cells. According to the mechanism studies, PDK4 mediated a metabolic shift that the main energy source was changed from OXPHOS to glycolysis. More importantly, with the knockdown or overexpression of PDK4 in DLBCL cells leads to a reverse MS4A1/CD20 expression. Conclusion: Our data identify a metabolic reprogramming role of PDK4 in rituximab resistance of DLBCL and highlight the unique function of PDK4 as an attractive therapeutic target.

Background: Lenalidomide, an immunomodulatory drug (IMiD), is an effective therapy for the treatment of multiple myeloma (MM). However, prolonged treatment may be accompanied by toxicity, second primary malignancies, and drug resistance. There is an inherent vulnerability in MM cells that high rates of immunoglobulin synthesis resulting in the high level of reactive oxygen species (ROS). This provides a therapeutic potential for MM. Materials and Methods: The intracellular ROS levels, H2O2 production and glutathione (GSH) levels were measured using detection kit. Cell viability was evaluated using cell-counting kit-8 (CCK-8) and soft agar colony formation assay. Apoptosis was determined in whole living cells using flow cytometry. Chidamide and its anti-myeloma efficacy in combination with lenalidomide were characterized in MM cell lines in vitro and in a mouse xenograft model. Moreover, Western blotting, immunofluorescence and immunohistochemical studies were performed. Results: ROS levels increased in a time-and dose-dependent manner with chidamide treatment. Moreover, the GSH levels were decreased and the mRNA level of SLC7A11 downregulated after chidamide treatment. The co-treatment with chidamide and lenalidomide increased apoptosis and proliferation inhibition, with combination index (CI) in the synergistic range (0.2-0.5) using the Chou-Talalay method. The cooperative anti-myeloma efficacy was confirmed in the murine model, and immunohistochemical studies also supported this potentiation. Chidamide enhanced the effect of lenalidomide-induced degradation of IKZF1 and IKZF3 by elevating H2O2. In addition, co-treatment with chidamide and lenalidomide increased biomarkers of caspase and DNA damage. Conclusion: Elevated ROS production may constitute a potential biochemical basis for antimyeloma effects of chidamide plus lenalidomide. The results of this study confirm the synergistic effect of chidamide and lenalidomide against MM and provide a promising therapeutic strategy for MM.

Caspase-11, a cytosolic lipopolysaccharide (LPS) receptor, mediates lethal immune responses and coagulopathy in sepsis, a leading cause of death worldwide with limited therapeutic options. We previously showed that over-activation of caspase-11 is driven by hepatocyte-released high mobility group box 1 (HMGB1), which delivers extracellular LPS into the cytosol of host cells during sepsis. Using a phenotypic screening strategy with recombinant HMGB1 and peritoneal macrophages, we discovered that FeTPPS, a small molecule selectively inhibits HMGB1-mediated caspase-11 activation. The physical interaction between FeTPPS and HMGB1 disrupts the HMGB1-LPS binding and decreases the capacity of HMGB1 to induce lysosomal rupture, leading to the diminished cytosolic delivery of LPS. Treatment of FeTPPS significantly attenuates HMGB1- and caspase-11-mediated immune responses, organ damage, and lethality in endotoxemia and bacterial sepsis. These findings shed light on the development of HMGB1-targeting therapeutics for lethal immune disorders and might open a new avenue to treat sepsis.