Effective communication of multistage cancer treatment trajectories remains a major challenge, particularly for patients with limited health literacy. We present a patient-centered visualization approach for representing complex, phase-based oncology treatments, integrating principles from information visualization, user experience (UX) design, and cognitive psychology. Using acute myeloid leukemia (AML) as a case study, we developed two timeline-based representations: a static, visually simplified trajectory emphasizing structure and hierarchy, and an interactive variant with layered information. We evaluated both approaches in a quantitative survey, measuring comprehension of treatment sequences, perceived confidence, and information quality. Results show that the static visualization significantly improves understanding and clarity, highlighting the importance of visual hierarchy, consistent encoding, and reduced complexity when communicating temporal medical processes compared to the baseline. In contrast, additional interactivity did not improve performance and introduced navigational overhead, suggesting that interaction must be carefully aligned with cognitive demands. Our findings contribute to visualization research by demonstrating how patient-centered design can improve the interpretability of multistage treatment trajectories. We derive design implications for temporal medical visualizations, emphasizing simplicity, structural clarity, and accessibility to support informed decision-making in clinical contexts.

SnoRNAs are highly expressed in AML and play a role in leukemogenesis and leukemic maintenance. SnoRNAs can be further processed into snoRNA-derived RNAs (sdRNAs). Expression and implications of sdRNAs in AML and healthy hematopoiesis, however, remain largely elusive. We characterized sdRNA and snoRNA levels in hematopoietic stem cells (HSCs), healthy peripheral blood cells, and 159 AML patient samples at initial diagnosis. HSCs, healthy WBCs and AML blasts could be differentiated by their sdRNA expression pattern in a cell-type specific manner. In AML, high sd3’-RNA/snoRNA-hostgene ratios were associated with inverse patient outcome. Particularly, in NPM1-mutated patients with favorable risk stratification and good initial therapy response, high sd3’-RNA ratios identified a subgroup with inferior outcome, and could therefore represent biomarkers to identify those at-risk patients. High sd3’-RNA ratios were associated with clear alterations in oncogenic, inflammatory and immune response signalling. Forced expression of single sdRNAs, such as sd3’-SNORD78 and sd5’-SNORD93, enhanced clonogenic potential in AML. Total proteome and transcriptome analyses suggested NUDT21, a reported tumor suppressor with implications in inflammatory and immune response signalling, as novel target of sd3’-SNORD78. Our data introduces sdRNAs as effector molecules in healthy hematopoiesis and AML with mechanistic, diagnostic, as well as potential prognostic and therapeutic implications.

Background: Chimeric antigen receptor (CAR)-T cells are therapeutic breakthroughs against advanced non-Hodgkin lymphomas and myelomas. On the other hand, no CAR-T cell product has been so far clinically approved for therapy of Hodgkin Lymphoma (HL), T cell lymphoma (TCL), or Epstein-Barr-Virus (EBV)-associated lymphoproliferative diseases (EBV-LPDs). CD30 (TNFRSF8) is commonly expressed on HL and on subsets of TCL and EBV-LPDs. CD30CAR-T cells generated via transduction with viral vectors have been tested in clinical trials, showing overall good responses against HL. CAR-T cells produced entirely with locus-specific gene editing methods are emerging as attractive next-generation engineered cell products for ease of multiple seamless cell modifications. Methods: Using CRISPR/Cas9-mediated techniques, we optimized homology-directed repair templates (HDRTs) and performed all-in-one multiplex editing to knock-in (KI) CD30CAR within the TCRα constant ( TRAC ) locus and to simultaneously knock-out (KO) PD-1 or/and β2M. CD30CAR-T cells were tested in CD30 + cell models of HL, TCL, and EBV-LPDs. Results: We compared mouse versus human anti-CD30 scFv designs in HDRTs incorporating TRAC homology arms, FcIg spacer/detection domain, and CD28 / CD3z signaling domains. We obtained an average of 30% TRAC KI CD30CAR-T cells and efficient in vitro cytotoxicity with CD30 + cell targets. CARs incorporating the high-affinity humanized 5F11 scFv showed the highest CAR expression, and the editing templates were further modified to incorporate a truncated CD34 (tCD34) spacer/detection domain. 5F11-CD30CAR-tCD34-T cells showed high CAR-KI rates (approx. 50-80% 12-14 days after editing) and potency in vitro and in vivo . Subsequently, we tested all-in-one CAR KI with additional KOs by co-electroporation of guide RNAs (gRNAs) targeting the genes encoding PD-1 or /and β2M to improve function and allow for improved cell persistence in allogeneic recipients, respectively. Compared with CD30CAR-T cells, CD30CAR-β2M KO -T cells were similarly viable and functional and showed low risk of translocations. PD1 KO enabled CD30CAR-T cells to produce higher levels of cytotoxic features upon exposure to targets. However, simultaneous β2M KO and PD-1 KO compromised the expansion capacity of CD30CAR-T cells and resulted in detectable translocations. Conclusions: Non-virally engineered 5F11-CD30CAR-T cells represent a novel cell therapy modality against CD30 + lymphomas. Multiplex editing remains to be optimized to avoid unwanted genomic alterations and chromosomal translocations.

Supplementary Figure S1 shows enrichment of FBL in LSC, correlation of FBL with LSC signature and rRNA 2'-O-Me in healthy hematopoietic cells. Supplementary Figure S2 shows the association of rRNA 2’-O-Me with LSC and hematopoietic differentiation signatures. Supplementary Figure S3 shows strategy for LSC sorting and distribution of LSC methylation sites on ribosomes. Supplementary Figure S4 shows the effect of FBL knockdown on rRNA 2’-O-methylation and in vitro proliferation of leukemia cells. Supplementary Figure S5 show the effect of FBL overexpression on in vivo engraftment of primary AML cells. Supplementary Figure S6 shows the effect of FBL knockdown on nascent proteome and metabolism of AML cells. Supplementary Figure S7 shows the ribosome footprinting analysis after FBL knockdown. Supplementary Figure S8 shows the association of Gm1447 with LSC signature and the effect of Gm1447 supression on cellular amino acid levels. Supplementary Figure S9 shows regulatory effect of Gm1447 on in vivo leukemic self-renewal.

Relapse in acute myeloid leukemia (AML) is driven by resistant subclones that survive chemotherapy. It is assumed that these resilient leukemic cells can modify their proliferative behavior by entering a quiescent-like state, similar to healthy hematopoietic stem cells (HSCs). These dormant cells can evade the effects of cytostatic drugs that primarily target actively dividing cells. Although quiescence has been extensively studied in healthy hematopoiesis and various solid cancers, its role in AML has remained unexplored. In this study, we applied an HSC-derived quiescence-associated gene signature to an AML patient cohort and found it to be strongly correlated with poor prognosis and active TGF-β signaling. In vitro treatment with TGF-β1 induces a quiescence-like phenotype, resulting in a G0 shift and reduced sensitivity to cytarabine. To find potential therapeutic targets that prevent AML-associated quiescence and improve response to cytarabine, we conducted a comprehensive CRISPR interference (CRISPRi) screen combined with TGF-β1 stimulation. This approach identified TGFBR1 inhibitors, like vactosertib, as effective agents for preventing the G0 shift in AML cell models. However, pretreatment with vactosertib unexpectedly induced complete resistance to cytarabine. To elucidate the underlying mechanism, we performed a multi-faceted approach combining a second CRISPRi screen, liquid chromatography-tandem mass spectrometry (LC-MS/MS), and in silico analysis. Our findings revealed that TGFBR1 inhibitors unintentionally target the nucleoside transporter SLC29A1 (ENT1), leading to reduced intracellular cytarabine levels. Importantly, we found that this drug interaction is not unique to TGFBR1 inhibitors, but extends to other clinically significant kinase inhibitors, such as the FLT3 inhibitor midostaurin. These findings may have important implications for optimizing combination therapies in AML treatment.

Risk stratification in acute myeloid leukemia (AML) is driven by genetics, yet patient age substantially influences therapeutic decisions. To evaluate how age alters the prognostic impact of genetic mutations, we pooled data from 3062 pediatric and adult AML patients from multiple cohorts. Signaling pathway mutations dominated in younger patients, while mutations in epigenetic regulators, spliceosome genes, and TP53 alterations became more frequent with increasing age. Machine learning models were trained to identify prognostic variables and predict complete remission and 2-year overall survival, achieving area-under-the-curve scores of 0.801 and 0.791, respectively. Using Shapley (SHAP) values, we quantified the contribution of each variable to model decisions and traced their impact across six age groups: infants, children, adolescents/young adults, adults, seniors, and elderly. The highest contributions to model decisions among genetic variables were found for alterations of NPM1, CEBPA, inv(16), and t(8;21) conferring favorable risk and alterations of TP53, RUNX1, ASXL1, del(5q), -7, and -17 conferring adverse risk, while FLT3-ITD had an ambiguous role conferring favorable treatment responses yet poor overall survival. Age significantly modified the prognostic value of genetic alterations, with no single alteration consistently predicting outcomes across all age groups. Specific alterations associated with aging such as TP53, ASXL1, or del(5q) posed a disproportionately higher risk in younger patients. These results challenge uniform risk stratification models and highlight the need for context-sensitive AML treatment strategies.

IKZF1 mutations are recurrent alterations in acute myeloid leukaemia (AML), and hotspot point mutation, N159S, has recently been associated with unique gene expression and adverse risk. To better understand the molecular and clinical associations of IKZF1 N159S-mutated AML, we performed a pooled analysis of 4136 AML patients. IKZF1 N159 mutations were found in 39 patients (0.94%) in a dominant clonal constellation, indicating early genetic events. N159S mutations were associated with aberrant karyotype, significantly higher rates of myelodysplasia-related gene mutations, ELN2022 adverse risk and a particularly poor outcome, supporting the classification of IKZF1 N159S-mutated AML as a rare molecular subtype with adverse prognosis.

Introduction Acute myeloid leukemia (AML) is a disease of older patients, with a median age at diagnosis of 68 years. Accumulating evidence has reported the feasibility of allogeneic hematopoietic cell transplantation (allo-HCT) in older patients in first complete remission (CR1). However, the role of allo-HCT and the optimal donor for older patients with AML in CR2 remains to be explored. Methods We retrospectively analyzed data from the European Society for Blood and Marrow Transplantation (EBMT) for older patients (age≥68) with AML who underwent first allo-HCT in CR2 between 2010 and 2022. Donors included a matched sibling (MSD), a haploidentical donor (Haplo) with a T-cell replete graft, or a 10/10 matched/9/10 mismatched unrelated donor (MUD/MMUD). All the enrolled patients were divided into three groups by donor type. Results The analysis comprised 531 patients: 84 in the MSD group, 87 in the Haplo group, and 360 in the MUD/MMUD group. For the entire cohort, the median age was 70 years (IQR 69, 72) and was comparable among the three groups (P=0.66). The median donor age was older in the MSD group (65) than the Haplo (42) and MUD/MMUD (29) groups (P<0.001). Male recipients in the MSD (29.8%) and Haplo (26.4%) groups received grafts from female donors more frequently than those in the MUD/MMUD group (12.5%) (P<0.001). Peripheral blood was used more frequently as the graft source in the MUD/MMUD (97.8%) and MSD (90.5%) groups than in the Haplo group (74.7%) (P<0.001). The MUD/MMUD group had a higher proportion of D-/P- Cytomegalovirus (CMV) serostatus (28.9%) compared to the MSD (14.6%) and Haplo (14.3%) groups (P=0.001). Baseline characteristics such as patient sex, Karnofsky performance status (KPS), and risk classification were similar among the three groups. Reduced-intensity conditioning (RIC) was used for 84.9% of the entire cohort. In the Haplo group, 80.2% of patients received post-transplant cyclophosphamide (PTCy) for graft-versus-host disease (GVHD) prophylaxis. HCT-related cause and original disease were the major causes of death for the three cohorts. In univariate analysis, Haplo-HCT was associated with a lower 1-year overall survival (OS) (MSD 65.7%, Haplo 53.7%, MUD/MMUD 64%), leukemia-free survival (LFS) (MSD 61.6%, Haplo 46.9%, MUD/MMUD 57.3%), GVHD-free, relapse-free survival (GRFS) (MSD 46.8%, Haplo 36.3%, MUD/MMUD 46.2%), higher non-relapse mortality (NRM) (MSD 18.7%, Haplo 33.6%, MUD/MMUD 21.4%), and similar Relapse incidence (RI) (MSD 19.7%, Haplo 19.5%, MUD/MMUD 21.3%). The 180-day cumulative incidence of grade II-IV acute GVHD was higher in Haplo (27.1%) than in MSD (21.1%) or MUD/MMUD (22.6%) recipients. The incidence of grade III-IV acute GVHD was also higher in Haplo (15.5%) than in MSD (6.2%) or MUD/MMUD (7.7%) recipients. Interestingly, the 1-year cumulative incidence of overall chronic GVHD was higher in the MSD group (43.4%) than in the Haplo (21.5%) or MUD/MMUD (24.1%) recipients. In multivariate analysis, the Haplo (HR=2.28, P=0.01) and MUD/MMUD (HR=2.21, P=0.027) groups were associated with worse OS compared to the MSD group. The Haplo (HR=2.02, P=0.02) and MUD/MMUD (HR=2.11, P=0.028) groups were also associated with worse LFS, while no significant difference in GRFS was observed between the three cohorts. NRM was higher for Haplo (HR=4.8, P=0.001) and MUD/MMUD (HR=4.82, P=0.002) recipients compared to MSD recipients. Importantly, there was no significant difference among different donor types with respect to RI. Concerning GVHD, the Haplo (HR=3.01, P=0.022) and MUD/MMUD (HR=3.14, P=0.028) groups were associated with a higher risk of grade II-IV acute GVHD compared to the MSD group. The Haplo (HR=16.35, P=0.014) and MUD/MMUD (HR=12.21, P=0.038) groups were also associated with a higher risk of grade III-IV acute GVHD compared to the MSD group. There was no significant difference among the three groups in the incidence of overall and extensive chronic GVHD. Older patient age was associated with worse LFS (HR=1.92, P=0.047). Older donor age was associated with worse OS (HR=1.23, P=0.015), worse LFS (HR=1.21, P=0.02), higher NRM (HR=1.42, P=0.003), and a higher risk of grade II-IV aGVHD (HR=1.34, P=0.019). CMV serostatus other than D-/R- had a significantly lower risk of RI (HR=0.64, P=0.044). Conclusions For older AML patients in CR2, allo-HCT is feasible, and MSD-HCT remains the best option with prolonged OS and LFS compared to Haplo- and MUD/MMUD-HCT due to lower NRM and comparable RI.

Lysine acetyltransferase 2 A (KAT2A) plays a pivotal role in epigenetic gene regulation across various types of cancer. In colorectal cancer (CRC), increased KAT2A expression is associated with a more aggressive phenotype. Our study aims to elucidate the molecular underpinnings of KAT2A dependency in CRC and assess the consequences of KAT2A depletion. We conducted a comprehensive analysis by integrating CRISPR-Cas9 screening data with genomics, transcriptomics, and global acetylation patterns in CRC cell lines to pinpoint molecular markers indicative of KAT2A dependency. Additionally, we characterized the phenotypic effect of a CRISPR-interference-mediated KAT2A knockdown in CRC cell lines and patient-derived 3D spheroid cultures. Moreover, we assessed the effect of KAT2A depletion within a patient-derived xenograft mouse model in vivo. Our findings reveal that KAT2A dependency is closely associated with microsatellite stability, lower mutational burden, and increased molecular differentiation signatures in CRC, independent of the KAT2A expression levels. KAT2A-dependent CRC cells display higher gene expression levels and enriched H3K27ac marks at gene loci linked to enterocytic differentiation. Furthermore, loss of KAT2A leads to decreased cell growth and viability in vitro and in vivo, downregulation of proliferation- and stem cell-associated genes, and induction of differentiation markers. Altogether, our data show that a specific subset of CRCs with a more differentiated phenotype relies on KAT2A. For these CRC cases, KAT2A might represent a promising novel therapeutic target.

Abstract Purpose An increasing number of international studies demonstrate serious negative effects of the COVID-19 pandemic on the timely diagnosis of cancer and on cancer treatment. Our study aimed to quantitatively and qualitatively evaluate the capacities of German Comprehensive Cancer Centers (CCCs) in different areas of complex oncology care during the first 2 years of the COVID-19 pandemic. Methods Prospective panel survey over 23 rounds among 18 CCCs in Germany between March 2020 and June 2022. Results The COVID-19 pandemic substantially affected the oncological care system in Germany during the first 2 years. Persistent limitations of care in CCCs primarily affected follow-up (− 21%) and psycho-oncologic care (− 12%), but also tumor surgery (− 9%). Substantial limitations were also reported for all other areas of multidisciplinary oncological care. Conclusions This study documents the limitations of oncological care during the COVID-19 pandemic and highlights the need to develop strategies to avoid similar limitations in the future.

Background Immune Thrombocytopenia (ITP) is a rare hematologic autoimmune disease marked by platelet (PLT) destruction and impaired megakaryopoiesis. While most research focuses on B- and T-cell-mediated mechanisms, PLT-intrinsic changes are poorly characterized. Despite lacking nuclei, PLTs preserve a functional transcriptome responsive to external signals and potentially reflecting disease-specific alterations. PLT RNA profiling has revealed mechanistic insights and distinct gene expression patterns in various conditions. However, transcriptome-wide analyses of circulating PLTs in ITP are lacking. We performed RNA sequencing (RNA-seq) of purified PLTs from ITP patients (pts) to assess technical feasibility of PLT transcriptomics in thrombocytopenia and characterize the PLT RNA profile in ITP. Methods Peripheral blood from 6 chronic ITP pts (PLTs 24-45/µl), 6 pts with non-ITP thrombocytopenia matched by PLT count, 6 ITP pts in treatment-free remission, and 8 healthy controls was collected in EDTA tubes and immediately processed. Sampling required ≥ 20/µl PLTs to ensure sufficient RNA yield. PLT-rich plasma was obtained by centrifugation after addition of a PLT inhibition cocktail to prevent ex vivo activation. PLTs were purified by dual leukocyte depletion (filtration and CD45-based magnetic separation). Total RNA was extracted using organic phase separation followed by column purification. Sample purity was confirmed by qPCR for leukocyte- and erythrocyte-specific transcripts. RNA libraries were prepared using Polaris™ rRNA depletion for coding and non-coding transcript detection, and sequenced on a NovaSeq 6000. Reads were aligned to GRCh38 (Ensembl 104) using STAR; only uniquely mapped reads were included. Gene counts were obtained via featureCounts, and differential expression was analyzed using DESeq2 with sex as covariate. Multiple testing correction was applied using Independent Hypothesis Weighting (FDR ≤ 0.05). Results Sufficient RNA was obtained from all samples. Relative to PLT counts, RNA yield per PLT was higher in ITP pts than in controls, indicating increased RNA content. RNA-seq provided high-quality data with low to absent expression of leukocyte- and erythrocyte-specific transcripts. A mean of 60.7 million paired-end reads and a median of 5864 genes per sample (≥1 CPM) were detected. Differential expression analysis between ITP pts and healthy controls identified 3643 upregulated and 3342 downregulated transcripts. Prominently upregulated genes were related to integrin signaling and PLT adhesion (ITGB3, ITGA2B, FLNA, PARVB, P4HB, PPP6R1), as well as granule biogenesis and vesicle trafficking (NBEAL2, PLXNB3, ENO1, MYH9), suggesting a higher proportion of young, activation-primed PLTs. A marked downregulation was observed in numerous mitochondrial transcripts, including components of the respiratory chain (MT-ND1–6, MT-CO1–3, MT-CYB, MT-ATP6/8) and mitochondrial tRNAs. This pattern differs from that of reticulated PLTs described in the literature and may reflect impaired mitochondrial function and increased apoptotic susceptibility. PLT transcriptomes from ITP pts in treatment-free remission resembled healthy controls, consistent with disease resolution and normalized PLT counts. To assess whether the observed transcriptomic changes were ITP-specific or reflected general features of regenerative thrombopoiesis, we included a comparison group of pts with post-chemotherapy thrombocytopenia during hematopoietic recovery. Though PCA revealed clear separation between ITP and post-chemotherapy samples, many transcriptomic features observed in ITP, such as upregulation of cytoskeletal and granule-associated genes and downregulation of mitochondrial transcripts, were also present in the latter group. This overlap suggests that key transcriptomic features in ITP PLTs reflect a general regenerative program triggered by increased PLT demand. Conclusion Our study shows that PLT transcriptome analysis is feasible even in patients with low PLT counts, enabling detailed molecular characterization in this challenging setting. The ITP PLT transcriptome reveals a dominance of young, activation-primed PLTs with signs of impaired maturation. Comparison with post-chemotherapy thrombocytopenia suggests that this profile reflects a general regenerative RNA signature in response to increased PLT demand. In ITP, where this condition is chronically sustained, it may drive persistent PLT activation and functional dysregulation.

Objective This study evaluated the legibility, comprehension, and clinical usability of visual timelines for communicating cancer treatment paths. We examined how these visual aids enhance participants' and patients' understanding of their treatment plans.Materials and Methods The study included 2 online surveys and 1 in-person survey with hematology cancer patients. The online surveys involved 306 and 160 participants, respectively, while the clinical evaluation included 30 patients (11 re-surveyed) and 24 medical doctors. Participants were assessed on their ability to understand treatment paths provided with audio information alone or with visual aids. The study also evaluated the comprehensibility of key treatment terms and the ability of patients to recall their cancer treatment paths.Results Visual representations effectively communicated treatment terms, with 7 out of 8 terms achieving over 85% transparency as pictograms, compared to 5 out of 8 for comics and 4 out of 8 for photos. Visual treatment timelines improved the proportion of correct responses, increased confidence, and were rated higher in information quality than audio-only information. In the clinical evaluation, patients showed good comprehension (mean proportion correct: 0.82) and recall (mean proportion correct: 0.71 after several weeks), and both patients and physicians found the visual aids helpful.Discussion We discuss that visual timelines enhance patient comprehension and confidence in cancer communication. We also discuss limitations of the online surveys and clinical evaluation. The importance of accessible visual aids in patient consultations is emphasized, with potential benefits for diverse patient populations.Conclusion Visual aids in the form of treatment timelines improve the legibility and comprehension of cancer treatment paths. Both patients and physicians support integrating these tools into cancer treatment communication.

Cytomorphological assessment of bone marrow smears (BMS) is essential in the diagnosis of myelodysplastic neoplasms (MDS), yet manual evaluation is prone to inter-observer variability. We trained end-to-end deep learning models to distinguish between MDS, acute myeloid leukemia, and bone marrow donor BMS with high accuracy in internal tests and external validation. Occlusion sensitivity mapping revealed the high importance of nuclear structures beyond canonical dysplasia, demonstrating accurate, interpretable MDS detection without labor-intensive cell-level annotation.

Abstract The B-cell lymphoma 2 inhibitor venetoclax (VEN) in combination with hypomethylating agents has been approved for first-line treatment of patients with acute myeloid leukemia (AML) ineligible for intensive treatment. VEN-containing treatment strategies may also be effective in relapsed/refractory (R/R) AML; however, comparative studies with conventional therapies for fit patients as a bridge-to-transplant strategy are limited. Using propensity score matching (PSM), we compared 37 patients with R/R AML, who received VEN-based salvage therapy as bridge to allogeneic hematopoietic stem cell transplantation (allo-HCT), with 90 patients from the German Study Alliance Leukemia AML registry, who were treated with non–VEN-containing salvage therapy according to their treating physician’s choice (TPC). The overall response rate among VEN patients was higher than the TPC control cohort (62% vs 42%; P = .049). Overall, 73% of VEN-treated patients vs 63% of TPC patients were bridged to allo-HCT (P = .41). After a median follow-up of 34.3 months for the VEN and 21.0 months for the TPC cohort, the median overall survival (OS) were 15.8 months (95% confidence interval [CI], 10.6 to not evaluable) and 10.5 months (95% CI, 6.8-19.6; P = .15), respectively. PSM revealed a trend toward improved OS for VEN patients (hazard ratio, 0.70; 95% CI, 0.41-1.22; P = .20). Median event-free survival was significantly longer in the VEN cohort (8.0 months) than the TPC cohort (3.7 months; P = .006). Our data suggest that VEN-based salvage therapy is a safe and effective bridge to allo-HCT for this difficult-to-treat AML patient population.

Background Allogeneic hematopoietic stem cell transplantation (alloHCT) is increasingly performed in Myelofibrosis (MF), where it remains the only potentially curative treatment. Disease relapse is a major contributor to post-transplant mortality and may occur even several years (yrs) after alloHCT in a relevant subset of patients (pts). Given the limited and heterogeneous data on long-term outcomes and relapse risk - particularly with respect to late relapse - we performed a landmark analysis in a large multicenter MF cohort to explore factors associated with late disease recurrence and post-transplant survival. Methods Clinical data were collected from primary MF (PMF) and secondary MF pts undergoing alloHCT between 2000-2023 at nine German centers. Pts surviving >100 days post-transplant were included for outcome analysis. Longitudinal chimerism data were available for all pts based on centralized short tandem repeat testing. Molecular profiling was performed on pre-transplant and relapse samples using a 60-gene myeloid next-generation sequencing (NGS) panel. Relapse was defined according to established criteria, including clinical, morphological or molecular recurrence prompting therapeutic intervention. Overall survival (OS) and relapse-free survival (RFS) were estimated using the Kaplan-Meier method. Multivariate analysis was performed using Cox regression with stepwise variable selection based on Akaike and Bayesian Information Criteria. Results Among the 234 included pts, median age at transplant was 59 yrs (range, 19-72); 66.7% were male, and 70.9% had PMF. Median follow-up was 74 months (IQR, 44–120). The cumulative incidence of relapse (CIR) was 15.4% at 1 year, 24.7% at 3 yrs, and 27.1% at 5 yrs post-transplant. Among pts alive and relapse-free at 5 yrs, the 5-year CIR from this landmark was 17.7%, indicating notable risk for late relapse. The 5-year OS from the time of relapse was 62% for early (<5 yrs) vs. 67% for late (≥5 yrs) relapse (p=.46). Among relapsed pts, salvage therapy was initiated in 87.5%. Of those, 77.8% achieved second remission, including 55.6% responding to donor lymphocyte infusion or immunosuppression withdrawal alone and 22.2% requiring a second alloHCT. Driver mutations included JAK2 (65%), CALR (21.7%), and MPL (11.5%). Additional mutations primarily affected epigenetic modifiers, with ASXL1 mutated in 52.1%, EZH2 in 13.4% and IDH1/2 in 6%. Spliceosome-related mutations (U2AF1, SRSF2, SF3B1, ZRSR2) were detected in 30.8%, RAS-pathway mutations (e.g., NRAS, KRAS, CBL, PTPN11) in 21.7%, cohesin complex mutations (STAG2, SMC1A, SMC3) in 6.5%, and TP53 mutations in 5.1%. Paired NGS (pre-transplant and at relapse; n=39) revealed stable mutational profiles - including both driver and co-occurring mutations - with no relevant evidence of clonal evolution, even in relapses beyond 10 yrs post-transplant. In univariate analysis, post-transplant survival showed no significant association with disease-related factors, including MF subtype (PMF vs. secondary MF) and pre-transplant risk scores (MIPSS70/MIPSS70+, MYSEC-PM), or transplant-related variables such as donor type, conditioning intensity, prior JAK inhibitor use, time from diagnosis to alloHCT, or transplant year (<2010 vs. ≥2010). Age ≥60 yrs was associated with inferior OS. Long-term mixed chimerism (<99% beyond day +200) predicted shorter RFS, but not OS. Limited chronic GvHD was associated with improved RFS and OS. Mutations in ASXL1 and EZH2 were linked to inferior RFS and OS; mutations in CBL and PTPN11 to shorter RFS. In multivariate analysis, only mutations in ASXL1 (HR 1.53, p=.045), CBL (HR 2.9, p=.003) and PTPN11 (HR 3.9, p<.001), as well as long-term mixed chimerism remained independently predictive for RFS, and only ASXL1 for OS (HR 2.2, p=.007). Conclusions In MF, relapse remains a long-term post-transplant risk and is predominantly observed without clonal evolution, indicating recurrence from residual clones rather than molecular progression. Mutations in ASXL1, CBL, and PTPN11 as well as long-term mixed chimerism were independently associated with inferior long-term outcomes. The favorable impact of limited chronic GvHD and responses to immunomodulatory salvage strategies underscore the potential of immune-mediated disease control in MF. Although limited by its retrospective, multicenter design, this study supports the relevance of molecular monitoring and immune-based interventions in long-term post-transplant care in MF.

Background VEXAS syndrome (vacuoles, E1 enzyme, x-linked, autoinflammatory, somatic) is an acquired hematoinflammatory disorder caused by somatic UBA1 mutations. Since its identification in 2020, treatment has remained largely empirical lacking standardized guidelines. The German VEXAS Registry was established to prospectively collect clinical, therapeutic and outcome data in a national real-world cohort. This report provides initial cohort characterization and outlines current treatment practices in Germany. Methods The German VEXAS Registry was initiated in May 2024. Centers provide standardized data on patient characteristics, treatment, response, complications, and patient-reported outcomes (PRO) at set intervals. Retrospective inclusion is allowed if data are sufficient. Therapeutic response is assessed longitudinally per investigator judgment, including both clinical (major: full control of inflammatory symptoms and daily steroid dose <10 mg; minor: symptom improvement not meeting criteria for major response) and hematologic response (per hematologic disease, e.g., IWG 2023 criteria for myelodysplastic neoplasm [MDS]). By July 2025, 81 pts were enrolled from 12 German centers, both hematologic and rheumatologic. Median follow-up from diagnosis was 17 (range 1–75) months (mo). Results All but one pt were male; median age at diagnosis was 70 (range: 54–91) years. UBA1 mutations predominantly affected codon 41 (75%); others included splice-site and exon 15 variants. Additional mutations were found in 49%, mainly in MDS-associated genes (e.g., DNMT3A, TET2, ASXL1, SRSF2). Cytogenetics were normal in 80%; aberrations included -Y and single cases of +8, del(9q), del(20q), -X (female pt), and complex karyotype. Most frequent inflammatory symptoms were fever (47%), skin lesions (68%), arthritis/arthralgia (70%), polychondritis (32%) and ocular inflammation (30%). Hematologic findings included MDS diagnosed in 66% (82% MDS with low blasts); others had isolated cytopenia or monoclonal gammopathy of undetermined significance. General symptoms, e.g. fatigue (44%), night sweats (31%), and weight loss (46.5%) were also common. As previously reported, clinical manifestations differed by UBA1 mutation type, with p.41Val variants tending to show more fever and pulmonary involvement, splice site mutations presenting with fewer inflammatory and predominant hematologic features, and significantly more cutaneous inflammation observed in p.41Leu pts (p = .007). Median time from first symptoms to diagnosis was 9 mo, with retrospective confirmation up to 10 years after symptom onset. PRO indicated substantial impairment, with 48% reporting moderate to severe limitations on EQ-5D and a median EQ-VAS score of 60. Steroid-sparing therapies included azacytidine (AZA), JAK inhibitors, conventional immunomodulators and cytokine blockers (TNFα, IL-1, IL-6). AZA was used in 34% of pts, all with low-risk MDS; 72% of those treated ≥3 mo showed partial or complete clinical and hematologic responses. Four pts discontinued AZA in remission; one relapsed after 23 mo and resumed therapy. JAK inhibitors (ruxolitinib, upadacitinib, tofacitinib, baricitinib) were given in 27%; 53% were switched due to lack of efficacy after a median duration of 4 mo. Sustained responses ≥3 mo occurred in 21%, all on ruxolitinib. Immunomodulators and/or cytokine blockers were used in 36% (median 2 agents, range 1–4); 40% had at least a minor clinical response, most commonly with methotrexate or anti-IL-1 agents, although all anti-IL-1 treatments were eventually discontinued due to intolerance. Three pts underwent allogeneic hematopoietic stem cell transplantation for refractory autoinflammation after 3–7 prior therapies (immunomodulators, cytokine blockers and JAK inhibitors); all achieved clinical remission by day +100 post-transplant. To date, four deaths have been reported during follow-up, mostly due to severe infections. Conclusion This early analysis of the German VEXAS Registry provides detailed real-world insights into the clinical spectrum and treatment patterns of VEXAS syndrome in a national cohort. Our data confirm the considerable heterogeneity of both disease manifestations and therapeutic responses, highlighting the need to strengthen interdisciplinary collaboration and improve treatment standards. Even though a proportion of patients had a disease onset even before VEXAS was described, time to diagnosis underscores the importance of raising disease awareness.