PURPOSE:While survival outcomes in multiple myeloma (MM) have improved with contemporary combination therapies, predicting disease trajectories for individual patients at diagnosis remains a significant challenge. We investigate the prognostic value of a noninvasive biomarker-cell-free DNA (cfDNA)‑derived 5-hydroxymethylcytosine (5hmC) signature-in newly diagnosed MM, aiming to improve risk stratification at diagnosis. MATERIALS AND METHODS:In this prospective cohort study, 321 patients with newly diagnosed MM were enrolled between 2010 and 2017, with follow-up through 2022. We profiled genome-wide 5hmC modifications (gene bodies) in cfDNA collected at diagnosis. We applied elastic net regularization to a Cox proportional hazards model to identify 5hmC signatures associated with overall survival (OS) and progression-free survival (PFS). A weighted prognostic score (wp-score), based on 18 key 5hmC-modified genes, was developed through machine learning and validated in the validation set, controlling for clinical prognostic factors. RESULTS:During a median follow-up of 70.5 months, 127 deaths occurred. The cfDNA 5hmC at diagnosis reflected the 5hmC in bone marrow‑derived tumor cells and differed across clinical subgroups. The wp-score showed strong prognostic ability for OS (hazard ratio [HR], 2.9 [95% CI, 1.7 to 4.9]; P < .0001) and PFS (HR, 1.8 [95% CI, 1.3 to 2.5] P = .00014) in the validation set, controlling for known prognostic factors, including stage, lactate dehydrogenase levels, and treatment type. The wp-score calculated at diagnosis remained associated with OS and PFS at 24-, 48-, and 72-month follow-up periods. CONCLUSION:This prospective study suggests that cfDNA-derived 5hmC signatures at diagnosis provide independent prognostic information for OS and PFS in MM. These findings support further investigation and independent validation of noninvasive epigenomic biomarkers within contemporary MM risk stratification frameworks.

6097 Background: Neoadjuvant immunotherapy is an emerging strategy in head and neck squamous cell carcinoma to enhance systemic antitumor immunity and enable response-adapted de-escalation. In HPV associated oropharyngeal squamous cell carcinoma (OPSCC), virally encoded oncoproteins represent shared, tumor-specific antigens and a rational immunologic target well suited for the neoadjuvant setting in the presence of intact tumor antigen. We conducted a phase I/II trial evaluating neoadjuvant HPV16-specific viral immunotherapy (HB200; HB201 and HB202 HPV16 therapeutic vaccines) plus chemotherapy followed by response-adapted definitive treatment in non-metastatic HPV16+ OPSCC (NCT05108870). Methods: This investigator-initiated phase I/II trial enrolled patients with previously untreated, non-metastatic HPV16+ OPSCC (N1-3 or T3-4; smokers permitted). All patients received three cycles of neoadjuvant HB200 (HB201 alone or alternating HB202/201) with carboplatin/paclitaxel, followed by radiographic response assessment. Patients with T1-2 tonsil or well-lateralized base of tongue tumors achieving ≥50% tumor shrinkage underwent transoral robotic surgery (TORS) alone. Remaining patients received response and risk adapted radiotherapy (50-70Gy based on risk/response) with or without cisplatin. The primary endpoint was deep response rate (DRR; ≥50% tumor shrinkage). Secondary endpoints included survival and toxicity. Exploratory endpoints included circulating tumor HPV-DNA (ctHPV-DNA), HPV16-specific immunity, and spatial transcriptomics. Results: Thirty-five patients were enrolled (median age 58; 89% male); Twelve patients (34%) received HB201 alone and 23 (66%) received alternating HB202/201. Nineteen patients (54%) were current or former smokers, and 49% had stage II-III (AJCC 8 th edition). The DRR was 87.9% (95% CI, 71.8-96.6). Thirty (86%) received de-escalated definitive therapy. At a median follow-up of 23 months, 2-year PFS and OS were 86% and 100% respectively. Most common AEs during neoadjuvant HB200/chemo were fatigue (97%), nausea (91%), and fever (76%). Detectable ctHPV-DNA following treatment was significantly associated with disease recurrence ( p <0.01). HPV16-specific immune responses and spatial transcriptomic analyses will be presented. Conclusions: Neoadjuvant HB200 combined with chemotherapy resulted in high deep response rates, frequent treatment de-escalation, and excellent survival outcomes in locoregionally advanced HPV16+ OPSCC. These findings support further evaluation of HPV directed immune therapy in neoadjuvant setting. Clinical trial information: NCT05108870 .

Introduction: A comprehensive geriatric assessment (CGA) is recommended in older adults (OAs, age>60 years) with acute myeloid leukemia (AML) by the EuropeanLeukemia Net (ELN) 2025 Fitness panel (Venditti, Blood Advances, 2025). The CGA has been evaluated in patients (pts) treated with intensive regimens (Klepin, Blood, 2013) and hypomethylating agents (HMA) (Ritchie, Blood Advances, 2022) though data in the current era with HMA+venetoclax (HMA+ven) as the standard of care are limited. Furthermore, change in pt fitness after induction therapy is poorly described despite unanimous ELN panel agreement on the importance of the topic. Finally, the CGA domain of nutrition is understudied in AML. Specifically, sarcopenia, defined as low muscle mass and strength (Cruz-Jentoft, The Lancet, 2019), has to date not been incorporated into a CGA. To fill these gaps in knowledge, we conducted a prospective observational trial (NCT05458258) of a CGA at diagnosis and at the end of induction therapy in OAs with newly diagnosed AML with the hypothesis that sarcopenia would predict early death (ED). Methods: Our prior Trial in Progress abstract (Yates, Blood, 2023) describes the study schema in full. In brief, pts underwent a CGA prior to and after induction (28-40 days after). The primary outcome, ED, was defined as death within 60 days of treatment initiation or from date of diagnosis for those who aimed to start treatment but died before treatment initiation. Secondary outcomes included length of stay (LOS), unscheduled readmissions, and treatment tolerability (defined as ability to finish 2 cycles of HMA+ven within 3 months of treatment start). Subgroup analyses were conducted among those fit by performance status (ECOG PS<2) and excluding those who died before treatment initiation. Multivariable analyses controlled for age, ELN 2024 Less Intensive risk (ELN 2024), and ECOG PS. Results: We recruited 82 pts between 3/1/2023-4/18/2025 with 79 pts included in the final analysis (2 withdrew, 1 diagnosis changed). Data cut off for this pre-planned interim analysis was 7/8/2025. Median age was 73 years (range, 60-93) with most patients being White (79%) and male (58%). ELN 2024 categories were Favorable (56%), Intermediate (27%), and Adverse (17%). Mutations in TP53 (17%), IDH1/2 (20%), NPM1 (17%), FLT-3 ITD (13%), and NRAS/KRAS (17%) were observed. Most pts were treated with less-intensive regimens (83%), primarily HMA+ven (67%). CGA impairments at diagnosis were prevalent despite 79% of pts having ECOG PS 0-2: functional status (instrumental activities of daily living (IADL), 43%), physical function (short physical performance battery (SPPB), 60%), malnutrition (patient-generated subjective global assessment (PG-SGA), 80%), sarcopenia (skeletal muscle index (kg/m2) at L1 from computed tomography and grip strength; impaired if both low, 24%), comorbidities (Charlson Comorbidity Index (CCI), 61%), and cognition (MOCA, 70%). The ED rate was 28% for the whole cohort and 20% when excluding the 8 pts who died before initiating induction. Median follow up and median OS for the whole cohort was 8 months and 14.7 months, respectively. No CGA variables were associated with increased ED rates in multivariable analyses though sarcopenia (Odds Ratio (OR): OR=2.1, 95% CI 0.69-6.44; p=0.19), 6-minute walk test ((6MWT): (OR=0.99, 95% CI 0.98-1.00; p=0.05), and SPPB (OR=7.41, 95% CI 0.67-82.6; p=0.1) neared statistical significance. In multivariable analysis in the whole cohort and subgroups the Timed Up and Go (TUG) test (OR=2.61; 95% CI 1.05-6.48; p=0.04) was the strongest predictor of OS. In multivariable models sarcopenia and TUG predicted treatment tolerability and unscheduled readmissions while IADLs and MOCA were the strongest predictors of LOS. When comparing CGA variables at diagnosis and post-induction therapy significant changes in ECOG PS (mean change=+0.44; p<0.01) and MOCA (mean change +1.03; p=0.02) were found. Furthermore, evaluable pts had clinically meaningful improvements in 6MWT (>50 meters; Ma, JCO, 2025) (62%) and MOCA (>2 points; Wong, JCN, 2017) (56%) at the end of induction. Conclusions: In a cohort of OAs with AML primarily fit by ECOG PS, a CGA uncovered significant impairments in fitness which were associated with survival, treatment tolerability, LOS, and readmissions independent of age, treatment intensity, or ECOG PS. Fitness, particularly cognition and physical function, may improve upon undergoing induction therapy.

6091 Background: Human papillomavirus-associated (HPV+) oropharyngeal carcinoma (OPC) is linked to favorable survival outcomes, prompting efforts to de-intensify treatment strategies. Circulating tumor HPV-DNA (ctHPV-DNA) is a promising biomarker for assessing treatment response and guiding de-escalation strategies. This study evaluates how patient characteristics influence ctHPV-DNA dynamics during neoadjuvant therapy across two de-escalation clinical trials. Methods: Patients with non-metastatic HPV+ OPC enrolled across two trials of neoadjuvant carboplatin/paclitaxel (NCT04572100) or carboplatin/ nab -paclitaxel/nivolumab (OPTIMA II, NCT03107182), with ctHPV-DNA available at baseline and post-neoadjuvant, were eligible. All participants received three cycles of neoadjuvant therapy followed by response-adapted de-escalated locoregional treatment. ctHPV-DNA values (copies per ml plasma) were measured at baseline and after 2-3 cycles of neoadjuvant therapy, and percentage reductions were calculated. We defined “ctHPV-DNA clearance” as ≥ 95% reduction from baseline and compared data distribution between patients who achieved clearance and those who did not using Kruskal-Wallis, Pearson’s χ2, or Fisher’s exact tests. Overall survival (OS) and progression free survival (PFS) probabilities were compared using log-rank test. Results: The study included 84 patients . The mean age was 60.9 years. 93% of patients with neoadjuvant nivolumab/chemotherapy achieved ctHPV-DNA clearance compared to 82% with chemotherapy alone, p =0.298. Patients with T1-T2 tumors (AJCC 8 th edition) were significantly more likely to achieve ctHPV-DNA clearance compared to those with T3-T4 tumors ( p =0.0254). Age, race/ethnicity, smoking history, tumor site (e.g., tonsil), and risk group were not significantly associated with ctHPV-DNA clearance rates. ctHPV-DNA clearance by cycle 2-3 of neoadjuvant therapy predicted radiographic response per RECIST v1.1 ( p =0.001), and significantly improved OS ( p =0.025) and PFS ( p <0.001). Survival outcomes were similar across OPTIMA II and NCT04572100 as previously reported. Conclusions: Earlier T-stage tumors were associated with rapid ctHPV-DNA clearance by cycle 2 with a trend towards higher clearance rate with neoadjuvant nivolumab/chemotherapy. Rapid clearance predicts radiographic response, OS, and PFS, supporting ctHPV-DNA as a useful biomarker for treatment monitoring with neoadjuvant treatment in HPV+ OPC. Clinical trial information: NCT03107182 . ctHPV-DNA % reduction between baseline and follow up at cycle 2-3. ≥ 95% reductionN (%) < 95% reductionN (%) p Age, (mean ± sd) 60.4 ± 10 61.3 ± 8.5 0.656 Gender (Male) 59 (86.8) 9 (13.2) 1 Race (Caucasian) 54 (86) 9 (14) 0.583 Risk (High) 34 (92) 3 (8) 0.309 T1 stage 12 (75) 4 (25) 0.0254 T2 stage 30 (97) 1 (3) T3 stage 8 (89) 1 (11) T4 stage 3 (60) 2 (40) Tumor shrinkage (median %, range) -64.2 (-23, -100) -42 (-14, -71) 0.001

Neoadjuvant immunotherapy in human papillomavirus (HPV)–negative locoregionally advanced (LA) head and neck squamous cell carcinoma (HNSCC) appears promising, yet its role in nonsurgical treatment for head and neck cancer remains undefined. Neoadjuvant nivolumab plus chemotherapy followed by response-stratified de-escalated chemoradiation therapy (CRT) in HPV-negative LA stage IVa/b HNSCC may improve treatment efficacy while reducing treatment-related toxic effects. To determine the deep response rate and tolerability of neoadjuvant nivolumab plus chemotherapy followed by response-stratified CRT in nonvirally mediated stage IVa/b HNSCC. In this investigator-initiated phase 2 nonrandomized clinical trial conducted at a single academic center, patients with stage IVa/b (American Joint Committee on Cancer Tumor Classification, 8th edition) HPV-negative LA HNSCC were enrolled between 2019 and 2022. Data were analyzed from February 2023 to January 2024. The DEPEND trial evaluated neoadjuvant nivolumab plus carboplatin and paclitaxel, followed by response-stratified CRT. Patients with 50% or greater reduction per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 received de-escalated CRT to 66 Gy with elimination of elective nodal volumes; patients with less than 50% reduction received standard CRT to 70 to 75 Gy. Adjuvant nivolumab was administered for 9 cycles. The primary end point was deep response rate (DRR; 50% or greater shrinkage per RECIST version 1.1) following neoadjuvant nivolumab plus chemotherapy. Secondary end points included progression-free survival (PFS), overall survival (OS), locoregional control, and distant control. Exploratory end points included acute toxic effects in patients who received response-adapted de-escalated CRT. Of 36 included patients, 28 (78%) were male, and the median (range) age was 58.9 (27-77) years. All patients started treatment and were available for analysis. The median (range) follow-up was 20 (13-40) months. The primary end point was met, with a DRR following neoadjuvant nivolumab/chemotherapy of 53% (95% CI, 35-70). The objective response rate was 86% (95% CI, 71-95). A total of 19 received de-escalated CRT and 16 received standard CRT. PFS and OS at 2 years were 66% (95% CI, 34-76) and 73% (95% CI, 52-86), respectively. The most common treatment-emergent adverse events for de-escalated and standard CRT were mucositis (14 of 19 [74%] and 15 of 16 [94%], respectively), radiation dermatitis (13 of 19 [68%] and 14 of 16 [88%], respectively), and dry mouth (7 of 19 [37%] and 10 of 16 [63%], respectively). In this phase 2 nonrandomized clinical trial, neoadjuvant nivolumab/chemotherapy led to deep responses in 53% of patients with HPV-negative LA stage IVa/b HNSCC, and response-adapted de-escalated CRT led to favorable survival with lower acute toxic effects among deep responders. ClinicalTrials.gov Identifier: NCT03944915

Purpose: The hypothesis of this study was that histotripsy, an ultrasound therapy that disrupts tissue mechanically through the action of bubble clouds, increases the short-term rate of acute thrombus clearance for catheter-directed thrombolysis Materials and Methods: Thrombi formed in the femoral vein of pigs were treated with CDT, histotripsy, or CDT and histotripsy (histotripsy+). Ultrasound (B-mode and color Doppler) and contrast fluoroscopy imaging data were scored by 4 observers for semiquantitative evaluation of each arm with ordinal regression models. Further, B-mode images were manually annotated by 3 observers to quantify the thrombus clearance rate. Results: A total of 27 thrombi (2.0 cm [SD +/- 0.4] in length) in 27 animals were considered in this study (N = 8 for CDT, N = 9 for histotripsy, and N =10 for histotripsy+). The mean treatment duration was 20.2 minutes (SD +/- 1.3). The ordinal regression models indicated that the thrombus clearance rate increased for histotripsy+ relative to CDT based on B-mode and color Doppler but not fluoroscopy (P = .015, P = .001, and P = .900, respectively). Manual annotation of B-mode images denoted that histotripsy+ had an increased thrombus clearance rate relative to CDT and histotripsy (P = .001 and P = .022, respectively). Petechial hemorrhage was present in the perivascular soft tissue for 2 cases with histotripsy and 1 case with histotripsy+. Conclusions: The clearance of acute thrombus was similar for treatment with CDT or histotripsy. Combining these individual approaches further increased the rate of thrombus clearance based on multiple imaging metrics.

PURPOSE:Human papillomavirus-associated (HPV+) oropharyngeal carcinoma is associated with excellent survival, yet treatment drives substantial toxicity. Improved biomarkers are needed to select patients for de-escalated treatment. Circulating tumor HPV DNA (ctHPV-DNA) represents a promising noninvasive biomarker to gauge treatment response and surveil for disease recurrence. PATIENTS AND METHODS:A prospective biomarker clinical trial of response-stratified de-escalation was conducted. Eligible patients with non-metastatic HPV+ oropharyngeal carcinoma received neoadjuvant chemotherapy, followed by risk/response-stratified de-escalation with transoral robotic surgery, de-escalated radiation with or without chemotherapy to 50 Gy, or standard chemoradiation to 70 Gy. Deep response (≥50% tumor shrinkage per RECIST v1.1) qualified patients for de-escalation. ctHPV-DNA was measured using HPV-SEQ in plasma at baseline, during neoadjuvant chemotherapy, radiation, and following treatment. The primary endpoint was the correlation of ctHPV-DNA kinetics and radiographic response. RESULTS:Forty-six eligible patients were enrolled, and 488 ctHPV-DNA samples were analyzed (median 11 per patient). The median follow-up was 30 months, and five recurrences were observed (10.9%). Baseline ctHPV-DNA was detected in 95% of evaluable patients. Rapid early ctHPV-DNA clearance after one cycle of neoadjuvant therapy (≥95% reduction) predicted radiographic deep response (P = 0.04). Detection of ctHPV-DNA 3 months or later after treatment was associated with worse progression-free and overall survival (P < 0.001). Sensitivity, specificity, and positive and negative predictive values of longitudinal ctHPV-DNA were 100%. The longest lead time from positive ctHPV-DNA to detection of recurrent disease was 25 months. CONCLUSIONS:Rapid early clearance of ctHPV-DNA during neoadjuvant therapy demonstrates utility in predicting response to treatment. Detectable ctHPV-DNA following treatment is predictive of both disease recurrence and worse survival.

Objective: The allostasis theory states that, as addiction develops, alcohol is consumed to relieve negative affect rather than to produce positive effects. This study aimed to investigate the real-time subjective effects of alcohol in individuals with alcohol use disorder (AUD) and those prone to negative affect by virtue of having comorbid depressive disorder (DEP). Methods: Participants (N=221) completed high-resolution ecological momentary assessments during 3-hour monitoring of one alcohol drinking episode and one non- alcohol drinking episode in their natural environment. Participants also completed daily mood surveys and next- day surveys. Linear mixed-effect models were used to compare drinking behavior and subjective responses (stimulation, sedation, liking, wanting, negative affect) among 120 participants with AUD (AUD+; with depression [DEP+]: N=64, without depression [DEP-]: N=56) and 101 participants without AUD (AUD-; DEP+: N=45, DEP-: N=56). Results: During the monitoring period, participants with AUD consumed an average of 8.5 standard alcohol drinks (estimated blood alcohol concentration [eBAC]=0.115 g/dl) versus 3.7 drinks (eBAC=0.040 g/dl) for non-AUD participants. The AUD group, regardless of comorbid DEP, reported increases in stimulation and rewarding effects that persisted throughout most of the alcohol episode relative to the non- alcohol episode. To a lesser extent, alcohol relieved negative affect but this was not specific to AUD or DEP groups. Conclusions: Contrary to the allostasis model of addiction's emphasis on negative reinforcement drinking, findings demonstrated that people with AUD prone to negative affect displayed positive alcohol reinforcement with pronounced and prolonged sensitivity to alcohol's pleasurable effects, akin to their noncomorbid counterparts. The findings provided critical testing of addiction theories in the natural environment to enhance external validity.

Background & Aims: Total abdominal colectomy (TAC) with a staged ileal pouch-anal anastomosis (IPAA) is a common surgical treatment for ulcerative colitis (UC). However, a significant percentage of patients experience pouch failure, leading to morbidity. This retrospective case-control study identified histopathologic features of the TAC specimen associated with pouch failure and investigated the molecular mechanisms of this susceptibility using single-cell spatial transcriptomics. Methods: We analyzed a cohort of 417 patients who underwent IPAA between 2000 and 2010 at the University of Chicago Medical Center for up to 18 years. Histologic examination of TAC specimens focused on disease activity, depth of inflammation, and specific features, including granulomas and deep ulcers. A subset of patients was profiled using single-cell spatial transcriptomics to map gene expression and immune cell interactions in relation to the risk of pouch failure. Results: The 18-year pouch failure risk was 23%, with post-procedure clinical features of Crohn’s disease as a major risk factor (hazard ratio [HR], 4.3; 95% confidence interval [CI], 2.3–8.1) as well as high-risk histologic features, including deep chronic inflammation (HR, 21; 95% CI, 11–41) and severe disease activity (HR, 14; 95% CI, 5.7–32) in TAC specimens. Spatial transcriptomics showed immune infiltration of T and myeloid cells, reduced myocyte-glial interactions, and cytokine signaling pathways such as interleukin (IL)-10, IL-1β, and type I/II interferons, associated with an increased risk of pouch failure. CD68 immunohistochemistry confirmed that deep CD68+ macrophage infiltration is associated with increased risk of future pouch failure. Conclusion: Histologic features including CD68 immunohistochemisty and spatial molecular profiling are predictive of IPAA failure. These findings support the use of histologic evaluation and targeted molecular analysis of the TAC specimen to identify high-risk patients and improve IPAA outcomes.

199 Background: Anti-EGFR antibodies like cetuximab are ineffective in KRAS mutated (mt) colorectal cancer (CRC) due to constitutive activation of downstream pathways. Avutometinib is a first in class, oral, novel, dual RAF/MEK inhibitor. In patient-derived xenograft models of KRAS mt CRC, the combination of an anti-EGFR antibody with avutometinib conferred stronger tumor growth inhibition than either agent alone. We present results from the dose escalation phase (1b) of an ongoing phase 1b/2 trial evaluating the combination avutometinib plus cetuximab in KRAS mt metastatic (m) CRC. Methods: This is a single-center, open-label, phase 1b/2 study evaluating the safety and combined tolerability of avutometinib and cetuximab. Patients received avutometinib 2.4mg (at DL0) or 3.2mg (at DL1) orally twice a week for 3 weeks out of a 4-week cycle + cetuximab 500mg/m 2 intravenously q2week. Patients with disease progression on, or intolerance to 5-FU, oxaliplatin, and irinotecan, and measurable disease per RECIST v1.1 were enrolled. The primary endpoint for phase 1b was to establish the maximum tolerated dose (MTD) and hence determine the recommended phase 2 dose (RP2D). Dose limiting toxicity (DLT) period was 28 days. A 3+3 dose escalation design was used with dose level (DLs) 0 (2.4mg avutometinib) as the starting level and one dose escalation to DL+1 (3.2mg avutometinib). Results: We report safety results of phase 1b. 10 patients, 7 at DL0 and 3 at DL+1, were enrolled. Median age was 52.5 yrs (range 41 – 75). Any grade (G) treatment related adverse events (TRAEs) were seen in all 10 patients. Most common TRAEs were acneiform rash (100%), chills (30%), diarrhea (30%), and fatigue (30%). G3 TRAEs at DL0 were seen in 4/7 (57.1%) patients and at DL+1 in 2/3 (66.7%) patients. No G4 TRAEs were seen. G3 TRAEs seen at DL0 are noted in the table. One patient from the initial three enrolled was not evaluable due to underdosing. Another patient was later found to not meet eligibility criteria, but they did clear the DLT period. Hence, 6/7 patients at DL0 were evaluated for AE assessment, of which 1 had a DLT. 3 additional patients were enrolled in DL+1. 2/3 patients in DL+1 had grade 3 toxicities (both DLTs) of rash. Hence DL0 was established as the MTD/RP2D. Conclusions: This is the first trial evaluating the combination avutometinib plus cetuximab in KRAS mt mCRC. RP2D for avutometinib was established at 2.4mg orally twice a week for 3 weeks out of a 4-week cycle when used in combination with q2week 500mg/m 2 cetuximab for KRAS mt mCRC. Enrollment continues currently for the dose expansion phase for efficacy assessment. Clinical trial information: NCT05200442 . G3 TRAEs at DL0 attributed to both drugs unless specified. G3 TRAE # of patients Acneiform rash 3/7 (42.9%) Hand-Foot syndrome 1/7 (14.3%) Extremity edema 1/7 (14.3%) Cellulitis 1/7 (14.3%) Sepsis 1/7 (14.3%) Anemia 1/7 (14.3%) Creatine phosphokinase elevation 1/7 (14.3% – avutometinib only)

Importance:Neoadjuvant immunotherapy in human papillomavirus (HPV)-negative locoregionally advanced (LA) head and neck squamous cell carcinoma (HNSCC) appears promising, yet its role in nonsurgical treatment for head and neck cancer remains undefined. Neoadjuvant nivolumab plus chemotherapy followed by response-stratified de-escalated chemoradiation therapy (CRT) in HPV-negative LA stage IVa/b HNSCC may improve treatment efficacy while reducing treatment-related toxic effects. Objective:To determine the deep response rate and tolerability of neoadjuvant nivolumab plus chemotherapy followed by response-stratified CRT in nonvirally mediated stage IVa/b HNSCC. Design, Setting, and Participants:In this investigator-initiated phase 2 nonrandomized clinical trial conducted at a single academic center, patients with stage IVa/b (American Joint Committee on Cancer Tumor Classification, 8th edition) HPV-negative LA HNSCC were enrolled between 2019 and 2022. Data were analyzed from February 2023 to January 2024. Interventions:The DEPEND trial evaluated neoadjuvant nivolumab plus carboplatin and paclitaxel, followed by response-stratified CRT. Patients with 50% or greater reduction per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 received de-escalated CRT to 66 Gy with elimination of elective nodal volumes; patients with less than 50% reduction received standard CRT to 70 to 75 Gy. Adjuvant nivolumab was administered for 9 cycles. Main Outcomes and Measures:The primary end point was deep response rate (DRR; 50% or greater shrinkage per RECIST version 1.1) following neoadjuvant nivolumab plus chemotherapy. Secondary end points included progression-free survival (PFS), overall survival (OS), locoregional control, and distant control. Exploratory end points included acute toxic effects in patients who received response-adapted de-escalated CRT. Results:Of 36 included patients, 28 (78%) were male, and the median (range) age was 58.9 (27-77) years. All patients started treatment and were available for analysis. The median (range) follow-up was 20 (13-40) months. The primary end point was met, with a DRR following neoadjuvant nivolumab/chemotherapy of 53% (95% CI, 35-70). The objective response rate was 86% (95% CI, 71-95). A total of 19 received de-escalated CRT and 16 received standard CRT. PFS and OS at 2 years were 66% (95% CI, 34-76) and 73% (95% CI, 52-86), respectively. The most common treatment-emergent adverse events for de-escalated and standard CRT were mucositis (14 of 19 [74%] and 15 of 16 [94%], respectively), radiation dermatitis (13 of 19 [68%] and 14 of 16 [88%], respectively), and dry mouth (7 of 19 [37%] and 10 of 16 [63%], respectively). Conclusions and Relevance:In this phase 2 nonrandomized clinical trial, neoadjuvant nivolumab/chemotherapy led to deep responses in 53% of patients with HPV-negative LA stage IVa/b HNSCC, and response-adapted de-escalated CRT led to favorable survival with lower acute toxic effects among deep responders. Trial Registration:ClinicalTrials.gov Identifier: NCT03944915.

6068 Background: Human papillomavirus (HPV) positive OPSCC is known to have a favorable prognosis compared to its HPV negative counterparts. It is thus important to limit treatment-related toxicity while preserving functional and survival outcomes. In this pooled study, we report functional and survival outcomes across prospective cohorts treated with chemotherapy-response-adaptive dose and volume de-escalation of radiation. Methods: Patients with non-metastatic HPV positive OPSCC were sequentially treated at an academic center on either an interventional de-escalation trial: OPTIMA 1 (NCT02258659); OPTIMA II (NCT03107182); (NCT04572100 ) or off-protocol in a prospective registry. Eligible patients had N1-3 or T3-4 (AJCC 8 th edition) disease. Very low-risk patients T0-2N0-1 (single lymph node <3cm) were excluded. Patients were stratified as low risk (LR) or high risk (HR) according to T/N stage and smoking history. Following chemotherapy (carboplatin and paclitaxel or nab -paclitaxel) with or without nivolumab, patients received de-escalated treatment with low dose arm (LDA; radiation [RT] alone to 50Gy or transoral robotic surgery), intermediate dose arm (IDA; chemoRT [CRT] to 45-50Gy) or regular dose arm (CRT to 70-75Gy). To analyze functional outcomes, we compared swallowing performance scores (SPS), trismus, percutaneous endoscopic gastrostomy (PEG) tube placement obtained from pre- and post-(C)RT. Comparisons across risk categories and treatment arms using Chi-square, Fisher, and Student t-tests. Survival outcomes were compared using log-rank statistic. Results: Eligible patients (n=242) started treatment between 2014 and 2024: 116 LR and 126 HR patients; 83% received de-escalated treatment (LDA/IDA) and 17% received standard dose (RDA). Post-treatment SPS (p=0.0002) and trismus scores (p=0.0013) was better among de-escalated versus non-de-escalated patients. Lower PEG placement rates were observed among de-escalated patients 33/196 (16.8%) vs 27/39 (69.2%) (p<.0001). With median follow-up of 48 months, no statistically significant differences in overall survival or progression free survival were observed between treatment arms. OS (95.1% (95% CI 90.8%-97.4%) vs 93.7%( 95% CI 77.72%- 98.4%), P=0.185) and PFS (92.2% (95% CI 87.1%-95.2%) vs 90.7% (95% CI 73.9% - 96.9%, p=0.202) were similar in deescalated and non-deescalated patients at 3 years. Low risk individuals also had better OS (97.1% vs 92.1%, p=0.01) and PFS (96.1% vs 88.3%, p=0.004) at three years. Conclusions: Improved functional outcomes including posttreatment swallowing function, trismus, and lower PEG placement rates were observed with chemotherapy-response-adaptive radiation de-escalation with excellent survival in the largest prospective cohort reported to date. Response-adaptive de-escalation warrants further comparative study.

Sensitivity to alcohol’s stimulating and rewarding properties is associated with increased risk for future heavy drinking and the development and maintenance of alcohol use disorder (AUD). Further, pace of alcohol consumption varies across individuals and affects level of intoxication and subjective alcohol responses. The present study used smartphone-based high-resolution ecological momentary assessment (HR-EMA) of a heavy drinking episode in young adult risky drinkers’ natural environments to examine associations between pace of drinking and subjective responses to alcohol. Young adult risky drinkers (N = 248; 42

Background and Significance: In 2021-2023, 40% of adults in the United States were obese (Emmerich, NCHS Data Brief, 2024). Obesity is associated with poor survival in adolescent and young adults (AYAs) with acute lymphoblastic leukemia (ALL) (Stock, Blood, 2019) (Shimony, Blood Advances, 2023). Poorer survival among patients with obesity is multifactorial. Obese patients experience increased treatment toxicities (hepatotoxicity, hyperglycemia, and thromboembolic events) translating into higher non-relapse mortality. Additionally, ALL treatment resistance during induction and maintenance phases, leading to primary induction failures and higher MRD detection rates in those who attain a remission, is seen in those with obesity. The biological basis of these clinical findings has been well described. Adipocytes (1) donate metabolic fuel in the form of asparagine, glutamine, and free fatty acids; (2) reduce chemotherapy-induced oxidative stress; and (3) spur proliferation. Additionally, adipocytes have been shown to protect lymphoblasts from anthracyclines and asparaginase. The Improve Diet and Exercise in ALL (IDEAL) Trial (Orgel, Blood Advances, 2022) showed that a caloric deficit, accomplished jointly by nutritional and exercise interventions with the end goal of minimizing fat mass gain and muscle loss, was feasible and may improve chemotherapy efficacy during induction in pediatric B-ALL patients. This trial, Nutrition and Exercise to Optimize Muscle and Adiposity in Adults with B-ALL (NEOMA, NCT06785324), aims to bring this therapeutic modality to the AYA ALL population. Study Design and Methods: NEOMA is a pilot interventional trial of nutrition and exercise in 15 AYA patients with B-ALL. Patients must be age>18 years-50 years, have Philadelphia chromosome negative (Ph (-)) ALL, and receive a pediatric-inspired induction regimen. Ineligibility criteria include BMI<18.5 kg/m2. The nutrition intervention targets a 10% caloric deficit calculated from each patient's Basal Metabolic Rate (WHO/Schofield) utilizing a high protein (>25%), low fat (<25%), low glycemic index/high fiber (45-55%) diet. The study dietician meets with the patient on day of enrollment to go over the “menu” of dietary options, provide education, and re-assesses the patient every two days for adherence. The exercise intervention targets 200 minutes of moderate intensity physical activity weekly, as defined by Metabolic Equivalents (METs) of 3-6, made up of aerobic and resistance training activities tailored to the patient's preference by working with the study physical therapist (PT). 200 minutes of moderate intensity physical activity achieves an additional 10% caloric deficit weekly. The 3-week NEOMA intervention is in the inpatient setting. The primary aim is to establish feasibility, adherence, and usability. NEOMA will be deemed feasible if >70% of patients eligible for enrollment consent to NEOMA. The dietary intervention will be deemed of acceptable adherence if >75% of patients are categorized as “adherent”, defined as >75% of the patient's dietary assessments consistent with the prescribed diet. The exercise intervention will be deemed of acceptable adherence if >50% of patients are able to meet the exercise goal (200 minutes of 3-6 METs physical activity=600 MET-minutes minimum weekly goal) in 2 out of 3 weeks of induction therapy. Secondary outcomes include body composition and metabolomic changes, end of induction MRD status as assessed by ClonoSEQ® assay, and treatment toxicities. Metabolomics assessments are done on daily serum samples and pre- and post-intervention bone marrow aspirate utilizing a modified folch extraction to measure both lipids and polar metabolites on a dedicated LC-MS system. Changes in visceral adiposity and skeletal muscle are evaluated at the 1st lumbar spinal level from CT scans using the Data Analysis Facilitation Suite, version 3.6.0 (Voronoi Health Analytics Inc) to obtain automated body composition measurements. Current Progress: NEOMA opened on 5/12/2025 with an anticipated enrollment over 1 year. 2 patients have been approached for consent with 1 patient enrolling and 1 screen failure (Ph+). This is the first interventional study in AYAs with ALL aimed to decrease adiposity and improve muscle mass during induction therapy. If the NEOMA intervention is shown to be feasible, useable, and effective, the study would provide preliminary data to inform a randomized clinical trial of the intervention.

Supplemental Table 2. Correlation coefficients (p-values) for ctHPV-DNA kinetics and radiographic response following neoadjuvant chemotherapy.

Abstract Background: Multiple myeloma (MM), a B-cell neoplasm characterized by the infiltration of malignant plasma cells into the bone marrow, is the second most common blood malignancy in the United States. The molecular pathogenesis of MM involves both genetic and epigenetic alterations. While 60-75% of newly diagnosed patients achieve a complete response or better with current modern combination therapies, almost all patients eventually progress largely due to the persistence or re-emergence of minimal residual disease (MRD). Monitoring for MRD has become essential for evaluating treatment efficacy and predicting long-term outcomes in MM patients. We aimed to investigate whether epigenetic changes, particularly 5- hydroxymethylcytosines (5hmC), at diagnosis are associated with MRD status following treatment. Methods: Utilizing 5hmC-Seal, a highly sensitive chemical labeling technique, we profiled genome-wide 5hmC in circulating cell-free DNA (cfDNA) and bone marrow genomic DNA (gDNA) at baseline and after 8 cycles of treatment (C8) from newly diagnosed MM patients (n=25) enrolled in a clinical trial (NCT01816971). MRD testing was performed on bone marrow samples using the clonoSEQ next generation sequencing assay (limit of detection 10-6). Results: The 5hmC modification levels were summarized across various genomic features, revealing enrichment in gene bodies and enhancer regions, consistent with the known regulatory role of 5hmC. We ranked 5hmC-modified genes at baseline by their variability, and found that the number of overlapping genes between cfDNA and gDNA was significantly higher than expected by permutation analysis. Subsequently, we identified the top 100 most variable 5hmC- modified genes in gDNA, which exhibited a higher Pearson correlation with cfDNA within individuals (mean r=0.90) compared to between individuals (mean r=0.82; p<0.05), suggesting that cfDNA has the potential to reflect gDNA in capturing some MM-related variations. Among the 11 patients with MRD+ at C8, a genome-wide scan of 5hmC in cfDNA comparing baseline and C8 identified 1,614 differentially modified genes (p<0.05) after adjusting for age and sex. [BC1] Furthermore, we identified 459 differentially modified genes comparing baseline 5hmC levels between patients who were MRD+ (n=11) and MRD- (n= 14) at C8 (p<0.05), after adjusting for age and sex. These results highlight the differential epigenetic landscape associated with MRD status. Conclusions: Genome-wide 5hmC profiling of cfDNA from blood revealed a similar epigenetic landscape to gDNA from bone marrow in patients with MM, suggesting that cfDNA may offer a less invasive alternative for assessing epigenetic modifications. Moreover, this profiling identified distinct epigenetic changes associated with the achievement of MRD- negativity. These findings provide a foundation for further investigation into the molecular alterations linked to MM disease biology that could potentially lead to MRD negativity. Future directions will focus on identifying biomarkers that could inform personalized treatment strategies. Citation Format: Zhou Zhang, Bei Wang, Krissana Kowitwanich, John Cursio, Daniel Appelbaum, Chuan He, Wei Zhang, Benjamin Derman, Brian Chiu, Andrzej Jakubowiak. Genome-wide 5-hydroxymethylation mapping in cell-free DNA to characterize the epigenetic differences in minimal residual disease of multiple myeloma [abstract]. In: Proceedings of the AACR Special Conference: Liquid Biopsy: From Discovery to Clinical Implementation; 2024 Nov 13-16; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(21_Suppl):Abstract nr B032.

Introduction: Myeloproliferative neoplasms (MPN) carry a variable risk of progression to accelerated phase (AP) or blast phase (BP), which is associated with poor overall survival (OS). Isocitrate dehydrogenase (IDH) mutations are associated with the progression of MPNs to AP/BP and are characterized as high-risk mutations. The IDH1 inhibitors ivosidenib and olutasidenib and the IDH2 inhibitor enasidenib are approved for use in acute myeloid leukemia (AML) and reports have demonstrated the efficacy of IDH inhibition in IDH1/2-mutated MPN AP/BP (Patel et al, BJH 2020; Chifotides et al, Blood Adv 2020, Gangat et al, BJH 2023). Our group previously reported on a cohort of 202 patients (pts) diagnosed with MPN AP/BP with modern myeloid therapies and found a median OS (mOS) of 0.86 years (Patel et al, Blood Adv 2024); here we describe the treatment patterns and survival of pts with IDH1/2-mutated MPN AP/BP. Methods: In this multicenter, retrospective study, adult pts with IDH1/2-mutated MPN AP/BP diagnosed after 1/1/2017 were included. Patient demographic, disease characteristics, treatment, and survival data were collected. Response was characterized by European LeukemiaNet (ELN) 2017 criteria and 2012 MPN-BP criteria. OS was evaluated with Kaplan-Meier analysis. Results: Thirty-five pts with IDH1/2-mutated MPN AP/BP were identified (9 with AP, 26 with BP). Median age was 69.5 years old and 54% were male. Thirty pts had race and ethnicity data, of which 90% identified as White and 4% identified as Hispanic. MPN AP/BP arose from polycythemia vera in 20% of pts, essential thrombocythemia in 26%, primary myelofibrosis in 26%, MPN not otherwise specified in 23% and other in 5%. Regarding incidence of driver mutations, JAK2 was noted in 74% of pts, MPL in 9%, CALR in 9% and 11% were triple-negative. Ten pts (29%) underwent allogeneic stem cell transplant for MPN AP/BP. All pts underwent next generation sequencing (NGS) at diagnosis of MPN AP/BP; 11 (31%) had an IDH1 mutation and 24 (69%) had an IDH2 mutation. Non-driver co-mutations with frequency >10% included SRSF2 (43%), ASXL1 (37%), DNMT3A (17%), TP53 (17%), TET2 (14%), and EZH2 (11%). Thirty pts had at least 1 adverse risk mutation by ELN 2022 criteria. We then analyzed responses based on frontline (1L) treatment approach along with survival for the entire cohort and stratified by 1L treatment. By ELN 2017 criteria a response was characterized as achievement of complete remission (CR), CR with incomplete count recovery (CRi), or partial remission (PR). Ten pts received intensive chemotherapy (IC) with an overall response rate (ORR) of 40% (3 CR, 1 CRi). For hypomethylating agent (HMA) + venetoclax (VEN)-based therapy (HMA+VEN) (n=9) ORR was 67% (2 CR, 4 CRi), for HMA-based therapy (HMA monotherapy or HMA+JAKi) (n=8) ORR was 50% (3 CRi, 1 PR), and for IDH inhibitor (IDHi)-based (HMA+IDHi or IDHi), (n=6) the ORR was 33% (1 CRi, 1 PR). Response by 2012 MPN-BP criteria in pts with available data was also reported. Response was characterized by achievement of complete molecular response (CMR), complete cytogenetic response (CCR), acute leukemia response (ALR)-complete (ALR-C), or ALR-partial (ALR-P). ORR were 57% (1 CCR, 3 ALR-C) with IC (n=7), 57% (3 ALR-C, 1 ALR-P) with HMA + VEN (n=7), 50%(2 ALR-C, 2 ALR-P) with HMA-based (n=8) and 67% (1 ALR-C, 3 ALR-P) with IDHi-based (n=6). Median OS (mOS) for the entire cohort was 2.2 years; of note the mOS for pts (n=30) with 1+ ELN22 adverse-risk co-mutations was 2.6 years. Median OS by frontline therapy was 1.5 years for IC, 1.1 years for HMA + VEN, 2.2 years for HMA-based, and 2 years for IDHi-based with no statistically significant difference (p=0.9976). We also analyzed outcomes of IDHi-based therapy in the relapsed/refractory (R/R) setting. Eight pts received IDHi-based therapy (1 IDH1 and 7 IDH2) with an ORR of 25% by ELN2017 (2 CRi). When using 2012 MPN-BP criteria, ORR was 50% (2 ALR-C, 2 ALR-P). Median OS from time of IDHi initiation in the R/R setting was 1.1 years. Conclusions: In our cohort of pts with IDH1/2-mutated MPN-AP/BP, mOS was 2.2 years and was not impacted by the presence of adverse-risk ELN22 mutations. There was no significant difference in mOS based on frontline treatment, although mOS was numerically longest in the HMA-based and IDH inhibitor based groups. IDH inhibitors also retained efficacy in the R/R setting with an ALR-C/ALR-P rate of 50% and mOS of 1.1 years.

Cytogenetic abnormalities influence the prognosis of multiple myeloma (MM). How these abnormalities associate with overall survival (OS) in European Americans (EAs) and African Americans (AAs) remains unclear. We collected data on fluorescence in situ hybridization (FISH) targeting 17 cytogenetic abnormalities from 181 patients newly diagnosed with MM between 2010-19. Vital status was ascertained using the National Death Index. Baseline clinical data were retrieved from electronic medical records. Established high-risk cytogenetic abnormalities (HRCAs) include t(4;14), t(14;16), t(14;20), del 17p, and gain/amplification of 1q. In each population, we evaluated the associations between cytogenetic abnormalities and OS. Among 55 AAs and 126 EAs, 65 deaths occurred (median follow-up: 5.8 years). The distribution of the abnormalities was similar between EAs and AAs. High-risk MM, characterized by HRCAs, was associated with worse OS in EAs (HR=2.6 [1.3-5.5]), but not AAs. Del 13q was associated with worse OS in both populations. Gain/amplification of 1q was associated with poorer OS in EAs (HR=3.44 [1.3-9.3]) but not AAs, whereas t(4;14) was associated with poorer OS in AAs (HR=14.51 [2.3-92.3]) but not EAs. These associations remained after controlling for prognostic factors or other HRCAs, highlighting the potential of population heterogeneity in the prognostic significance of cytogenetic abnormalities.