ABSTRACT:Frailty has emerged as a key component of allo-HCT candidate assessment and is closely associated with transplant outcomes. Exercise-based prehabilitation may improve transplant candidacy, yet real-world implementation is limited. Our institution implemented a structured Frailty Program (FP) to assess frailty and introduce prehabilitation interventions. This study describes the program's evolution and evaluates the impact of prehabilitation. Between April 2021 and April 2025, 185 consecutive allo-HCT candidates were included in 3 sequential FP phases. In the first phase (No-Prehab, n = 76), patients underwent frailty assessment only. In the second phase (Pilot-Prehab, n = 59), patients received a home-based, nonsupervised prehabilitation program. In the third phase (Tele-Prehab, n = 50), patients participated in the HCT Pre-App Program, a structured digital telemedicine intervention supervised by rehabilitation physicians. Frailty was assessed at first consultation and HCT admission using the HCT Frailty Scale. Median prehabilitation duration was 6 weeks. Adherence was high across frailty groups (76%-88%), with no adverse events. Prehabilitation improved frailty status: fit patients increased from 22% to 42% in the Pilot-Prehab cohort (P = .009) and from 34% to 56% in the Tele-Prehab cohort (P = .001). Tele-Prehab independently increased the odds of being fit at admission (odds ratio [OR], 3.86; P = .001) and reduced frailty incidence (OR, 0.17; P = .031). One-year OS and NRM were comparable across cohorts (OS, 74.5%, 84.5%, and 78.1%; P = .367) with a trend toward lower NRM among prehabilitated patients (NRM, 14.6%, 5.1%, and 5.6%; P = .075). Frailty is dynamic in allo-HCT candidates, and results support how home-based digital prehabilitation improves fitness before transplantation.

TP53 gene alterations remain one of the major determinants of poor prognosis in multiple myeloma (MM). However, p53 dysfunction can also arise through non-genetic mechanisms, like post-translational modifications (PTMs). Indeed, phosphorylation and acetylation play essential roles in modulating p53 stability and activity, but their functional relevance in primary MM samples has not been systematically explored. Here, we quantified the expression of four key p53 PTMs, phosphorylation at S15, S20, and T55, and acetylation at K382, using capillary nanoimmunoassay, in 127 newly diagnosed MM patients. We also evaluated the DNA damage marker γ-H2AX, the kinase Chk2, and the phosphatases PP1A and PP2A-C. We found that p53 PTM expression was highly heterogeneous among patients. p-p53 T55 and Ac-p53 K382 were the most frequently expressed, detected in more than 70% of samples. Patients with double-hit TP53 showed significantly lower p-p53 S20 and p-p53 T55 levels compared with those with normal TP53. Low p53 phosphorylation at S20, S15 and T55 was correlated with higher progression risk (HR = 2.39, p = 0.02; HR = 2.14, p = 0.04; and HR = 2.13, p = 0.005, respectively). We also identified deregulated expression of Chk2 and phosphatases, suggesting upstream regulatory imbalances. This is the first study to quantify p53 PTMs in a large set of MM patients, revealing that post-translational dysregulation contributes to p53 impairment independently of TP53 gene alterations. Characterizing p53 PTMs sheds light on the mechanisms underlying its dysfunction, particularly in patients with an intact TP53 gene, but dysfunctional p53 protein regulation.

Distribution of B-cell differentiation stages.

Differentially expressed genes in non-clonotypic cells.

Clinical and tumor microenvironmental characteristics of untreated, newly diagnosed active MM patients having normal (n = 129) vs mutant HPC (n = 38). P-value is calculated using corrected χ2 for dichotomous variables, and Kruskal-Wallis for numerical variables.

Overview illustrating a graphical representation of gating strategy used to detect bone marrow CD34+ hematopoietic progenitor cells (HPC) and plasma cells (PCs) using fluorescence activated cell sorting (BD FACSDiva v 8.0.2). Panels show bivariate dot plots representations in which HPC were gated using conventional manual analysis strategy.

List of somatic mutations detected in normal cells.

Oligoclonal expansions in non-clotypic cells.

This study evaluates the incidence and clinical impact of late- onset non-infectious pulmonary complications (LONIPCs) in adults undergoing allo-HCT with post-transplant cyclophosphamide (PTCy). In addition, it assesses the prognostic value of pre-transplant pulmonary function tests (PFTs) for overall mortality in this population. A total of 317 consecutive adults transplanted between 2014 and 2024 were retrospectively included. LONIPC occurred in 10.6% of patients. The most frequent diagnoses were cryptogenic organizing pneumonia (COP, 4.1%), bronchiolitis obliterans syndrome (BOS, 5.9%), and pulmonary thromboembolism (0.6%). Risk factors for LONIPC included smoking history, pre-existing bronchial asthma, mismatched donors, and grade III-IV acute GVHD. The diagnosis of LONIPC was strongly associated with adverse outcomes in both univariate (OS: HR 9.37, P < 0.001; NRM: HR 4.19, P = 0.001) and multivariate analyses (OS: HR 8.07, P < 0.001; NRM: HR 3.19, P = 0.033). Based on pre-transplant PFTs and the HCT-CI scoring system, patients were classified into low- (24.3%), moderate- (35.0%), or high-risk groups (40.7%). High-risk patients had significantly poorer overall survival (OS) (3-year OS: 58.8% vs. 72.0% and 70.0%, P = 0.027) and higher non-relapse mortality (NRM) (3-year NRM: 19.0% vs. 7.9% and 15.1%) compared with those in the low- and intermediate-risk groups. No differences were observed regarding pre-transplant PFTs between patients developing LONIPC and those who did not. In conclusion, the incidence of LONIPC occurs in 10% of adults undergoing allo-HCT with PTCy. Its diagnosis, as well as the presence of significant pre-transplant PFT abnormalities, were associated with worse outcomes, underscoring their prognostic importance in the contemporary PTCy-based allo-HCT setting.

Genetic relationship between mutant HPC and tumor cells. Concordance between the mutational landscape of hematopoietic progenitor cells (HPC) and patient-paired tumor cells (n = 42) used as filtering criteria for mutations observed in RAS genes. All mutated genes in HPC are shown, whereas in tumor cells only the genes that were mutated and were mapped in the myeloid gene panel are shown. Samples were collected at different moments of treatment: in untreated patients (i.e., at diagnosis), after induction, intensification, or end of treatment (EoT). Cytogenetic alterations were determined by FISH during diagnostic procedures. HPC and tumor cell illustrations were created with BioRender.com.

Differentially expressed genes in clonotypic cells.

Clinical characteristics of MM patients who develop SPM (n = 29) vs those who have not (n = 279). P-value is calculated using corrected χ2 for dichotomous variables, and Kruskal-Wallis for numerical variables.

Infection remains a leading cause of morbidity in multiple myeloma. Preventing infections is paramount and immune profiling could reflect the cumulative effect of host, tumor and treatment-related immunosuppression. However, current understanding of immune dysfunction and its association with infection is limited. To address this gap in knowledge and identify immune biomarkers of increased infection risk, we performed immune profiling using next-generation flow cytometry in bone marrow and peripheral blood samples from 1,786 patients at various disease stages and treatment scenarios. Patients developing infection had significantly lower percentages of CD27+ B cells and CD27- NK cells, as well as increased CD27-/CD27+ T-cell ratio in bone marrow. These immune risk factors were validated in three independent datasets. An immune score was developed to stratify patients with ≤1 vs ≥2 of the aforementioned risk factors, which was associated with higher infection incidence (35% vs 60%, P <.001). The immune score (odds ratio: 2.31, P <.001), disease stage and CD38, BCMA or GPRC5D targeted therapy were independently associated with infection incidence. All cell types detectable in bone marrow and peripheral blood were significantly correlated, suggesting that immune biomarkers of increased infection risk could be monitored using minimally-invasive methods that are available in routine laboratories.

Mutational landscape of HPC according to a variant allele frequency (VAF) ≥2% among untreated patients with MM. Frequencies are calculated according to all patients with BM HPC at diagnosis (n = 232).

Double- and triple-refractory multiple myeloma (RRMM) still represents a considerable clinical challenge. Pomalidomide, cyclophosphamide and dexamethasone (PCd) remain a valid treatment option in this setting. This retrospective, multicentric study evaluated the activity and safety of PCd in patients with RRMM treated following standard clinical practice. A total of 179 patients were included. The median age was 72 years; most were triple-refractory (59.8%), being 162 patients (90.5%) refractory to lenalidomide and 117 (65.4%) to anti-CD38. The overall response rate (ORR) was 59.8% (95% CI: 52.2-67.0). Triple-refractory patients had an ORR of 52.3% (95% CI: 42.5-62.1). The median progression-free survival (PFS) and overall survival (OS) were 7.9 months (95% CI: 6.8-10.1) and 16.1 months (95% CI: 12.8-20.5), respectively. Patients refractory to lenalidomide and anti-CD38 had a median PFS of 7.6 months (95% CI: 5.8-9.4) and 7.6 months (95% CI: 5.8-9.4), respectively. Most frequent grade 3-4 adverse events were neutropenia (57.5%), anaemia (30.7%) and thrombocytopenia (29.6%). PCd demonstrated effectiveness in double- and triple-refractory RRMM patients, including those refractory to anti-CD38 and is a viable treatment option for these patients.

Allogeneic haematopoietic stem cell transplantation (allo-HSCT) is potentially curative for high-risk haematological diseases but may lead to persistent cytopenias such as poor graft function (PGF) or graft failure (GF). Thrombopoietin receptor agonists (TPO-RAs) like eltrombopag or romiplostim are effective but have pharmacologic and practical limitations. This retrospective study evaluated avatrombopag, a novel oral TPO-RA, in 11 adult patients with persistent thrombocytopenia following allo-HSCT (8 with PGF and 3 with GF). Avatrombopag was initiated at 20 mg/day orally, escalated to 40 mg/day after a median of 21 days and up to 60 mg/day after a median of 36 days as the maximum dose in patients who did not achieve an adequate response. The median time to response was 55 days, with a median treatment duration of 134 days. A haematological response was achieved in all eight patients with PGF, with significant improvements in platelet counts and other haematopoietic lineages. In contrast, no response was documented in patients with GF. No severe adverse events or complications were reported. Notably, these findings suggest that avatrombopag is a promising alternative for PGF, offering practical advantages over other TPO-RAs, although prospective studies are needed with a larger sample size of patients to confirm these results.

Frequency of non-clonotypic clones.

LINKER-MM1 (NCT03761108) is a Phase 1/2 study of linvoseltamab, a human BCMA×CD3 bispecific antibody for patients with relapsed/refractory multiple myeloma (RRMM) who are triple-class exposed (TCE) with ≥ 3 prior lines of therapy (3L+), or triple-class refractory (TCR). To contextualize efficacy data from LINKER-MM1, the Phase 2 linvoseltamab 200 mg cohort (N = 105) was compared with an international external control arm (ECA) comprising 203 patients from participating International Myeloma Working Group sites who met LINKER-MM1 eligibility criteria based on chart reviews. The ECA reflected real-world standard-of-care (RW SOC). An independent data review committee assessed data relevance, quality, and cohort comparability, while a separate independent central review committee evaluated response data. Inverse probability of treatment weighting was used to balance baseline characteristics between the linvoseltamab arm and the ECA. Linvoseltamab had a higher objective response rate (weighted odds ratio 3.0 [95% confidence interval (CI): 1.9-4.1]) and longer median progression-free survival (weighted hazard ratio [wHR] 0.33 [95% CI: 0.28-0.40]), time to next treatment (wHR 0.34 [95% CI: 0.29-0.44]), and overall survival (wHR 0.72 [95% CI: 0.58-0.98]) than RW SOC. These findings highlight linvoseltamab's potential as an effective treatment for 3L+ and TCE/TCR RRMM.

The clinical significance of one or two measurable residual disease (MRD) assessments is established in multiple myeloma (MM). However, how to stratify patients according to ≥3 MRD assessments remains unknown. The traits of MRD resistance and if treatment of persistent MRD vs relapse could improve outcomes also remains unknown. MRD dynamics were computed using next-generation flow cytometry and Connector in 539 newly-diagnosed MM patients with ≥3 assessments in the GEM2012MENOS65/GEM2014MAIN and GEM2017FIT trials. Molecular and immune profiling were performed in matched diagnostic and MRD samples. The survival impact of treating persistent MRD vs relapse was investigated with anti-BCMA CAR T cells in MIcγ1huCRBN mice. Computed MRD dynamics based on 3,610 MRD assessments identified five subgroups with different survival. Patients with late-sustained MRD response had excellent outcomes, similar to those with early-sustained MRD response. Patients with volatile results and those with primarily and resurgent MRD resistance had dismal survival. MRD dynamics outperformed transplant-eligibility and the R-ISS. These results were validated in 249 MM patients treated in routine practice. Multiomics characterization of MRD dynamics in patients and mouse models of MRD resistance revealed genomic evolution, transcriptional adaption and a pro-inflammatory tumor-immune microenvironment. Increasing clonality and exhaustion of endogenous T cells throughout disease progression urged investigating if MRD interception with anti-BCMA CAR-T cells could improve outcomes. Infusion at MRD resistance prolonged mouse survival compared to identical treatment at relapse. Altogether, MRD dynamics is the strongest predictor of progression and may help tailoring treatment to prevent additional tumor and immune alterations prior to relapse.