ABSTRACT:CPX-351, a novel liposomal formulation of cytarabine and daunorubicin, represents the standard of care in fit patients with acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) and therapy-related AML (t-AML). Considering its better safety profile than conventional intensive chemotherapy, we investigated its cost-to-benefit ratio, in terms of overall survival and of mortality, in a large multicentric series of AML-MRC and t-AML receiving CPX-351 outside clinical trials between 2019 and 2022. Patients were classified as fit or unfit for intensive chemotherapy through a comprehensive evaluation of age, comorbidities, and performance status by adopting Italian Society of Hematology/Italian Society of Experimental Hematology/Gruppo Italiano per il Trapianto di Midollo Osseo (SIE/SIES/GITMO) criteria. Disease risk was defined according to the European LeukemiaNet 2017 classification. Before treatment start, 328 of 403 (81.4%) patients were classified as fit and 75 of 403 (18.6%) as unfit. Three hundred and ninety-six had a full genetic/cytogenetic profile, with 17 (4%) being categorized as favorable risk, 162 (41%) intermediate risk, and 217 (55%) adverse risk according to European LeukemiaNet 2017. After induction, 230 of 403 (57.1%) patients achieved complete remission, with no differences between fit (57.3%) and unfit (56%) patients. However, the 2 groups significantly differed in terms of survival (median overall survival, 18 months vs 8 months for fit and unfit patients, respectively) and of 28- and 100-day mortality (4.6% vs 10.7% at 28 days and 14.3% vs 32% at 100 days for fit and unfit patients, respectively). In conclusion, the SIE/SIES/GITMO criteria distinguished patient subgroups with different short- and long-term outcomes after treatment with CPX-351. The update or design of dedicated fitness criteria could represent a future and valid strategy to optimize the use of this specific treatment.

ABSTRACT:Secondary myelofibrosis (SMF) represents a late stage of polycythemia vera (PV) and essential thrombocythemia (ET), with overall survival (OS) currently defined by the myelofibrosis secondary to PV and ET prognostic model (MYSEC-PM). To identify additional myeloid neoplasm-associated cancer gene variants (CGVs) associated with SMF outcome, we evaluated next-generation sequencing panel testing in 644 patients within the MYSEC cohort. Overall, 429 (66.6%) patients reported at least 1 CGV, with ASXL1, TET2, and DNMT3A being the most frequently involved. Specific molecular profiles affected OS (P< .001): U2AF1, TP53, or SRSF2 variants (UTS; 9.3%; median OS, 4.1 years) and ASXL1 without UTS (25.3%; median OS, 8.4 years). By integrating these genetic signatures within the MYSEC-PM through penalized Cox regressions, we identified the following independent predictors (P< .0001 to .02): hemoglobin level <11 g/dL (1 point), circulating blasts ≥3% (2 points), platelet count <150 × 109/L (2 points), age (0.21 points/y), ASXL1 without UTS mutations (1 point), and any UTS mutations (3 points). Finally, we developed the MYSEC-molecular prognostic model (MYSEC-mPM) allocating 582 patients with SMF into 4 categories with different OS (P < .001): low (median OS, 18.0 years; score <14), intermediate-1 (8.8. years; score, 14-16), intermediate-2 (4.6 years; score, 17-18), and high risk (1.9 years; score ≥19). Additionally, in 381 patients with SMF and available cytogenetics, the MYSEC-mPM was implemented with complex/monosomal karyotype, generating the karyotype-enhanced MYSEC-kmPM. Our study shows that genomic and cytogenetic profiling improves survival prediction in SMF, outperforming the MYSEC-PM.

We studied platelet recovery in 93 patients with myelofibrosis, following an allogeneic hemopoietic stem cell transplant (HSCT). The primary end point of the study was achieving a platelet count of 50x109/L within day +100 post transplant, which occurred in 62 patients (67%), predicted 5-year non-relapse mortality (NRM) (5% vs. 55%, P=0.0009) and 5-year actuarial survival (85% vs. 38%, P<0.00001); relapse was unaffected. The cumulative incidence of strong platelet recovery was predicted by a matched sibling donor (MSD) compared to alternative donors (90% vs. 60%, P=0.001), by the dose of CD34(+) cells (cut off 8.68x10(6)/kg; 83% vs. 61%, P=0.01), recipient age (cut off 63 years; 72% vs. 48%, P=0.01), and splenectomy (86% vs. 63%, P=0.04). In multivariate Cox analysis, significant predictors of platelet recovery were a MSD (P=0.003), a high CD34 cell dose (P=0.02), splenectomy (P=0.003), and younger patient age (P=0.02). Patients with slow platelet recovery have significantly lower platelet counts long term, combined with chronic graft-versus-host disease. In conclusion, strong post-HSCT platelet recovery in MF patients is mainly predicted by donor type, together with CD34 cell dose and patient age, and is strongly associated with NRM and survival.

Systemic mastocytosis (SM) is a rare hematological neoplasm characterized by infiltration of tissue by clonal mast cells (MCs) and pleiotropic clinical presentation. When SM is clinically aggressive, patients necessitate treatment with tyrosine kinase inhibitors (TKIs). Response to therapy may be unsatisfactory, especially for younger patients, and the possibility of allogeneic transplant should be discussed.

Background. Cytokine release syndrome (CRS) is the most frequent toxicity after chimeric antigen receptor T-cell (CAR-T) therapy and typically presents as a systemic inflammatory syndrome. In recent years, a localized form of CRS (L-CRS), most commonly involving the craniocervical region, has been increasingly recognized. L-CRS may occur with or without overt local tumor involvement and can progress to airway impairment, requiring prompt recognition and treatment. Case presentation. We report two cases of patients with refractory diffuse large B-cell lymphoma (DLBCL) treated with anti-CD19 CAR-T therapy who developed abrupt, painful bilateral parotid and/or submandibular gland swelling (left predominance) early after infusion, following systemic CRS treated with tocilizumab. Infectious, obstructive, and autoimmune causes were excluded; ultrasound findings were compatible with inflammatory glandular changes. Given rapid progression and concern for airway patency, corticosteroids were administered with prompt clinical resolution. Literature review and diagnostic alert. We provide an overview of published L-CRS with craniocervical presentations (Table 1). Similar acute swelling temporally related to tocilizumab has been reported in other settings. In such cases, differential diagnostics of L-CRS vs. a tocilizumab-associated infusion-related/hypersensitivity reaction needs to be carried out. Conclusion. L-CRS is a clinically relevant and potentially severe complication of CAR-T therapy that may involve salivary glands even without cervical tumor burden. Clinicians should also consider drug-related reactions, particularly when cervical swelling occurs shortly after tocilizumab administration.

Objectives: Digital morphology (DM) systems assisted by artificial intelligence are increasingly being introduced into hematology laboratories; however, data on their performance in routine clinical practice for bone marrow aspirates (BMA) remain limited. We evaluated the automated pre-classification generated by a full-field DM system in a large series of BMA samples from patients with onco-hematological disorders. Methods: We analyzed 350 BMA samples during routine diagnostic activity; they were evaluated using the Siemens Scopio X100 HT system. Automated results were compared with conventional optical microscopy (OM), which served as the reference method for bone marrow differential counts. Results obtained in pre-classification and post-classification were analyzed separately across major cellular lineages and clinically relevant blast thresholds. Results: Sixteen markedly hypercellular samples could not be quantitatively evaluated. In the 334 evaluable BMA samples, the granulocytic series showed very strong correlation between DM and OM at pre-classification (r = 0.85, 95% CI 0.82-0.88), with further improvement after post-classification (r = 0.93, 95% CI 0.91-0.94). Erythroblast percentage showed strong correlation at pre-classification (r = 0.78, 95% CI 0.74-0.82) and very strong correlation after post-classification (r = 0.93, 95% CI 0.92-0.95). Lymphocyte percentage showed moderate correlation at pre-classification (r = 0.55, 95% CI 0.47-0.62) and strong correlation after post-classification (r = 0.78, 95% CI 0.73-0.82). Blast percentage showed strong correlation overall at pre-classification (r = 0.73, 95% CI 0.67-0.77), with very strong correlation in samples with < 5% blasts (r = 0.91, 95% CI 0.88-0.93), but lower correlation in samples with > 5% blasts (r = 0.59, 95% CI 0.48-0.68), improving after post-classification (r = 0.84, 95% CI 0.78-0.88). Low-frequency cell populations and challenging hypercellular smears remained more problematic and required expert morphologic review. Conclusions: In routine BMA evaluation, the Scopio DM system provided good overall performance for the major marrow lineages, with clear improvement after expert post-classification. Its main value lies in supporting a supervised diagnostic workflow rather than replacing expert microscopic assessment, particularly in challenging samples and in low-frequency or morphologically heterogeneous cell populations.

Introduction: Autologous stem cell transplantation (ASCT) is regaining interest as a consolidation strategy for acute myeloid leukemia (AML) patients with favorable/intermediate risk and measurable residual disease (MRD) negativity. In fit older adults, its role remains debated due to concerns regarding toxicity and stem cell collection. Aim: To evaluate the long-term outcomes of ASCT in AML patients aged ≥60 years in first complete remission (CR1). Methods: We retrospectively analyzed 43 non-M3 AML patients (median age 64, range 60-72) who underwent ASCT in CR1 across five centers (2000-2024). Risk was stratified by ELN 2017. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Results: The cohort included 22 favorable-risk and 21 intermediate-risk patients. Most (88%) achieved CR1 after one induction course. Median neutrophil and platelet engraftment occurred at 13 and 15 days, respectively. Grade III/IV infections were observed in 28% of patients; transplant-related mortality was low at 4%. At a median follow-up of 77 months, 5-year OS and DFS were 51% (95% CI: 37-70%) and 47% (95% CI: 34-65%), respectively. OS was significantly superior in favorable- versus intermediate-risk patients (68% vs. 35%, p = 0.027), with a similar trend for DFS (57% vs. 35%, p = 0.07). The number of consolidation cycles did not impact survival outcomes. Conclusions: This multicenter study confirms that ASCT is a feasible and effective consolidation strategy for selected fit AML patients aged ≥60. The low mortality and encouraging survival, particularly in favorable-risk subgroups, support ASCT as a valid alternative to prolonged chemotherapy or maintenance.

Background FLT3-mutant acute myeloid leukemia (AML) is associated with aggressive disease biology, high relapse rates, and heterogeneous responses to chemotherapy and FLT3-targeted therapies. Although FLT3 mutations represent a key oncogenic driver, they coexist with multiple co-mutations affecting epigenetic regulation, transcription, and signaling pathways. This complexity suggests that clinical behavior may be better explained by the organization of gene interaction networks rather than individual genomic alterations. Methods We performed gene co-occurrence network analysis in patients with FLT3-mutant AML. Networks were constructed using weighted associations between recurrently mutated genes and analyzed across clinically relevant subgroups, including overall survival (> 18 vs < 18 months), response to induction chemotherapy (complete remission [CR] vs progressive disease [PD]), response to FLT3 inhibitor–based therapy, age at diagnosis (< 60 vs ≥ 60 years), and pre-transplant relapse. Network topology was assessed in terms of centrality, modularity, and connectivity. Results 35 patients were included in the network analysis. An overall conserved core network was identified, centered on FLT3, RUNX1, TP53, and TET2, supported by epigenetic (DNMT3A, EZH2) and transcriptional (CEBPA, GATA2) modules. Clinical outcomes were associated with distinct network configurations. Favorable survival and response to chemotherapy were characterized by modular and hierarchically organized networks, incorporating differentiation and metabolic regulators such as CEBPA, IDH1, SF3B1, and CUX1. In contrast, poor survival and resistance were associated with highly interconnected and redundant networks, enriched in stemness and transcriptional regulators, including ASXL1, MECOM, GATA2, and ANKRD26. Response to FLT3 inhibitor–based therapy was associated with preservation of network complexity, whereas resistance was characterized by network contraction toward a minimal survival circuitry, with emergence of KIT as a bypass signaling node. Age-related analyses revealed more structured networks in younger patients, while older patients exhibited increased transcriptional and splicing complexity. Relapse was associated with network rewiring, including the emergence of CUX1, suggesting increased regulatory plasticity. Conclusions FLT3-mutant AML is a disease in which clinical behavior is determined by network architecture rather than single mutations. Modular networks are associated with therapeutic sensitivity, whereas redundant and rewired networks underlie resistance and relapse. These findings support the development of network-based biomarkers and therapeutic strategies to optimize treatment in FLT3-mutant AML.

Supplementary Table 3 – Summary of real-world data

BACKGROUND:Chimeric antigen receptor (CAR)-T cell therapy has revolutionized outcomes in relapsed/refractory lymphomas, yet nonrelapse mortality (NRM) has emerged as a notable concern, with older age and infections identified as major determinants of NRM in real-life studies. OBJECTIVE:The aim of the present study was to describe the rate and causes of NRM after CAR-T cells and identify risk factors. STUDY DESIGN:Within the framework of the prospective, multicenter, observational CART‑SIE study, we analyzed causes and determinants of NRM in a large real-world cohort of lymphoma patients receiving CAR‑T cells from 2019 to 2025. Associations between NRM and clinical or biological factors were assessed using Fine and Gray subdistribution hazard models. RESULTS:From 2019 to 2025, 1132 patients were enrolled in the CART-SIE Study; among those, 932 were evaluable for outcomes, with a median follow-up of 17.8 months (IQR 6.3-25.4). In this cohort, 305 deaths were observed, mainly occurring after disease progression (n = 258); overall, 47 deaths were solely attributable to NRM (5%), either early (≤28 days, 40.4%), late (29-90 days, 23.4%) or very late (>90 days, 36.2%). The 1- and 2-year cumulative incidence of NRM were 5.5% and 8.8%. Infections were the leading cause (51%), followed by CAR-T acute toxicities (CRS, ICANS, and HLH/MAS; 30%), and secondary malignancies (11%). In univariable analysis, age > 60 gt; 60 years, diabetes, atrial fibrillation, high CAR-HEMATOTOX score, elevated ferritin, baseline cytopenias, CRS grade ≥3, any-grade or grade ≥3 ICANS and infectious events were risk factors for NRM. Multivariable models revealed that, among pre-infusion factors, only high ferritin levels (HR 3.23, 95% CI: 1.37-7.62, P = .007) and diabetes (HR 3.93, 95% CI: 1.28-12.1, P = .017) independently predicted NRM, while only severe CRS, ICANS, and infections remained strong post-infusion predictors. CONCLUSIONS:These findings emphasize the role of host-related factors and inflammation in shaping CAR-T outcomes. Optimized patient selection, rigorous management of acute toxicities, tailored infectious prophylaxis and long-term oncologic surveillance are essential components of long-term survivorship care, aiming to mitigate NRM and sustain long-term benefits of CAR-T cells. Clinical trial registration ClinicalTrials.gov ID: NCT06339255.

INTRODUCTION:The objective of this study was to analyze outcomes associated with letermovir for CMV primary prophylaxis in adult CMV-seropositive allo-HCT recipients in a multicenter real-world scenario. METHODS:This retrospective real-world international study involved 481 adults undergoing allo-HCT between 2018 and 2020 who received letermovir for primary prophylaxis. Outcomes included clinically significant CMV infection (csCMVi), graft-versus-host disease, opportunistic infections, all-cause mortality, hospitalizations, and ICU admissions. The median follow-up was 33.8 months. RESULTS:The median start time of letermovir was 3 days after transplant, with a median duration of prophylaxis of 100 days. The cumulative incidence of csCMVi was 2.7% (95% CI = 1.5-4.5) at 3 months, 13.1% (95% CI = 10.3-16.3) at 6 months, and 17.1% (95% CI = 13.9-20.6) at 12 months. The median time from HCT to csCMVi was 142 days. In multivariate analysis, four factors contributed to development of csCMVi: reduced-intensity conditioning (HR = 1.90; 95% CI = 1.17-3.08; p = 0.009), peripheral blood as cell source (HR = 2.92; 95% CI = 1.00-8.50; p = 0.0495), pretransplant CMV serostatus D-/R+ (HR = 2.24; 95% CI = 1.42-3.53; p = 0.0005), use of alemtuzumab (HR = 3.91; 95% CI = 1.60-9.59; p = 0.003). There was no difference in the cumulative incidence of csCMVi in the first 100 days between patients who started letermovir ≤ 5 versus > 5 days after transplant. Factors adversely contributing to overall survival: age as a continuous variable, 10-year effect (HR = 1.23; 95% CI = 1.08-1.41; p = 0.002), patient male sex (HR = 1.48; 95% CI = 1.02-2.13; p = 0.038), status > CR1 of disease at transplant (HR = 1.97; 95% CI = 1.36-2.85; p = 0.0004), PB as stem cell source (HR = 1.81; 95% CI = 1.04-3.15; p = 0.04), acute leukemia diagnosis (HR = 1.61; 95% CI = 1.10-2.34; p = 0.01), CMV high-risk patients (HR = 1.52; 95% CI = 1.02-2.27; p = 0.04). CONCLUSIONS:An analysis of real-world use of letermovir in CMV prophylaxis after allo-HCT showed a low incidence of csCMVi compared to previously published information.

CPX-351 for the treatment of acute myeloid leukemia (AML) has demonstrated better efficacy compared with standard chemotherapy regimens, with an excellent safety profile. We aimed to assess the determinants of response, relapse, and survival in patients treated with CPX-351 as the first-line therapy for AML. In this retrospective monocentric study, we analyzed 60 consecutive patients treated with CPX-351 for therapy-related AML or AML with myelodysplastic-related changes. We observed a 61% overall response rate, with 58% complete response. The presence of complex karyotype at diagnosis predicted lower response rates. Among patients who achieved complete response, the relapse rate was 50%, with a median relapse-free survival of 154 days. The median overall survival was 412 days. We found that the biological profile at diagnosis is associated with survival. Leukocytosis at diagnosis, complex karyotype, and mutations of IDH1 and SRSF2 were correlated with lower survival in the univariable analysis. In the multivariable analysis, leukocytosis and complex karyotype retained their statistical significance.

OBJECTIVES:Baseline systemic inflammation has emerged as a determinant of outcome after CD19-directed CAR-T therapy. We evaluated the prognostic performance of the recently developed INFLAmmation MIXture Model (InflaMix) in an independent bicentric cohort of patients with large B-cell lymphoma (LBCL) receiving commercial CAR-T cells, focusing on treatment-related toxicities. METHODS:We retrospectively analyzed 212 consecutive patients with relapsed/refractory LBCL treated with axi-cel, tisa-cel, or liso-cel between 2020 and 2026. Patients were classified according to the InflaMix inflammatory phenotype. Progression-free survival (PFS), CAR-T-related toxicities, ICU admission, and concordance with CAR-HEMATOTOX and mEASIX were assessed. RESULTS:An inflammatory InflaMix phenotype was identified in 21% of patients and was associated with inferior PFS (12-month PFS: 30% vs. 56%; p < 0.001). While overall grade 2-4 CRS and ICANS rates were comparable, inflammatory patients showed higher rates of grade 3-4 CRS (11.1% vs. 1.8%; OR 3.18) and ICU admission (24.4% vs. 5.6%; OR 3.00). No association with ICAHT was observed. Concordance was poor with CAR-HEMATOTOX and moderate with mEASIX. CONCLUSIONS:InflaMix was externally validated as a predictor of inferior PFS, severe CRS, and ICU admission after CAR-T therapy, and candidates as a practical tool for pre-infusion risk stratification and as a complement to existing scores.

Chimeric antigen receptor T-cell (CAR-T) therapies targeting CD19 have revolutionized the treatment of B-cell malignancies, but their use is frequently complicated by immune effector cell-associated neurotoxicity syndrome (ICANS). The underlying mechanisms include endothelial dysfunction, blood–brain barrier disruption, and neuroinflammation. Circulating biomarkers of neuronal and astroglial injury, such as neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP), may provide insight into ICANS pathophysiology and serve as predictive tools. We conducted a retrospective study of 34 adult patients treated with anti-CD19 CAR-T cells for B-cell malignancies. Serum NfL and GFAP were measured at infusion (day 0) and day 7 using ultrasensitive immunoassays. Baseline GFAP and NfL levels correlated with endothelial activation markers, including mEASIX and lactate dehydrogenase, but not with demographic variables. ICANS of any grade occurred in 34

BACKGROUND:Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) relapse is the most frequent cause of allogeneic stem cell transplantation (allo-SCT) failure. The utility of post-relapse therapy is controversial due to the high incidence of toxicity and the low efficacy. METHODS:This sub-analysis of the Gruppo Italiano Trapianto di Midollo Osseo (GITMO) AML/MDS relapse study focuses on 647 AML/MDS relapsing after allo-SCT performed between 2015 and 2021. Following the relapse, these patients were treated with either hypomethylating agents (HMAs)-based therapy (n = 308) or other treatments (n = 339), including intensive chemotherapy, FLT3-inhibitors, and second allo-SCT. RESULTS:HMAs-based therapies were more frequently used in older patients, transplanted not in CR following a reduced-intensity conditioning regimen. The overall response rate (ORR) with or without HMA-based salvage treatment was 33% and 40%, respectively (P = .006). The complete remission (CR) rate was 23% and 33% in the two groups, respectively (P < .001). The long-term OS and TRM of the two groups were superimposable. Independently from the type of salvage, an advantage in OS was observed when donor lymphocytes infusion (DLI) was included (P < .001). Relapse within 12 months after SCT, low disease burden at relapse, and the CR status at transplant confirmed their independent strong prognostic impact on both HMA and non-HMA-based group (HR 0.05, 0.44, and 0.49 and HR 0.19, 0.32, and 0.53, respectively). CONCLUSIONS:Despite the lower ORR observed with HMA-based therapy, the long-term OS was comparable to that observed with other therapies. The immune control of the disease relapse with DLI is of benefit, independently from the salvage therapy. .