ABSTRACT:The Acute Promyelocytic Leukemia (APL) Asian Consortium analyzed a contemporaneous cohort of newly diagnosed patients with APL treated with and without frontline arsenic trioxide (ATO) in 6 centers. The objectives were to define the impact of ATO on early deaths and relapses and its optimal positioning in the overall treatment strategy. In a 21.5-year period, 324 males and 323 females at a median age of 45.5 years (range, 18.1-91.8; low/intermediate risk, n = 448; high risk, n = 199) were treated. Regimens included frontline all-trans retinoic acid (ATRA)/chemotherapy and maintenance with/without ATO (n = 436), ATRA/IV-ATO/chemotherapy (ATRA/IV-ATO; n = 61), and ATRA/oral-ATO/ascorbic acid with ATO maintenance (oral-AAA; n = 150). The ATRA/chemotherapy group had significantly more frequent early deaths within 60 days (8.3% vs 3.3%; P = .05), inferior 60-day survival (91.7% vs 98.4%/96%; P < .001), inferior 5-year relapse-free survival (RFS; 76.9% vs 92.8%/97.8%; P < .001), and inferior 5-year overall survival (OS; 84.6% vs 91.4%/92.3%; P = .03) than ATO-containing groups (ATRA/IV-ATO and oral-AAA). The addition of oral-ATO maintenance partly mitigated the inferior 5-year RFS resulting from the omission of ATO during induction (ATRA/chemotherapy/non-ATO maintenance vs ATRA/chemotherapy/ATO maintenance vs ATRA/IV-ATO vs oral-AAA, 71.1% vs 87.9% vs 92.8% vs 97.8%; P < .001). The favorable survival impacts of ATO were observed in all risk groups. In conclusion, ATO decreased early deaths, improved 60-day survival, and resulted in significantly superior RFS and OS. This trial was registered at www.clinicaltrials.gov as #NCT04251754.

Background Approximately 50% of patients with myelofibrosis (MF) discontinue ruxolitinib after 3 years, mostly due to disease progression, suboptimal response or cytopenia. Outcome after ruxolitinib discontinuation is poor with a median overall survival (OS) of approximately 14 months. Lysine-specific demethylase-1 (LSD1) is a histone demethylase critical for self-renewal of malignant hematopoietic stem cells and for maturation of progenitor cells. Bomedemstat is an oral LSD1 inhibitor clinically active in patients with myeloproliferative neoplasms (MPN) and has shown clinical activity as a single-agent in patients with MF. Aims This is an ongoing, open-label, Phase 2 study of the combination of bomedemstat and ruxolitinib in treatment-naïve patients with MF or those with a sub-optimal response to ruxolitinib. The objectives of this are to evaluate the safety and tolerability of the combination, the optimal dosing of bomedemstat in this regimen, and to assess the efficacy of the combination as assessed by spleen size reduction and symptom reduction using the Myelofibrosis Symptom Assessment Form (MFSAF). Methods Cohort A is comprised of patients with a sub-optimal response to an adequate trial of ruxolitinib defined as splenomegaly not reduced by >35% from baseline or symptoms scores that have not improved by >50%. Cohort A patients must have been on a stable dose of ruxolitinib for ≥8wks. Cohort B is comprised of treatment-naïve patients with MF who require treatment per guidelines. Patients in Cohort A remain on the entry dose of ruxolitinib while Cohort B patients received a starting ruxolitinib dose of 10 mg twice per day throughout the study. All patients received concomitantly, a starting dose of bomedemstat of 0.4mg/kg/d. Dose adjustments up were allowed every 4 weeks to achieve a target platelet count of 50 x 109/L. Down titrations could be made at any time in the interest of patient safety. Results Between 1 December 2022 to 31 December 2023, 24 men and 19 women with a median age of 64 (range: 47-81) years were enrolled. Case distribution was PMF, N=26 (60.5%); PPV-MF, N=10 (23.3%); and PET-MF, N=7 (16.3%). Mutational profile of driver genes was JAK2V617F, N=33 (76.7%); JAK2 exon 12, N=1 (2.3%); and CALR mutations, N=8 (18.6%). Six patient (14%) harbored high-molecular risk (HMR) mutations (ASXL, N=4; EZH2, N=2). At enrollment, the mean (standard error) white blood cell count (WBC), hemoglobin (Hb), platelet count, and lactate dehydrogenase (LDH) were 12.83 x 109/L (1.61), 9.7 g/dL (0.3), 317 x 109/L (36) and 607 IU/L (63), respectively. Ten patients (23.3%), 23 patients (53.5%) and 10 patients (23.3%) belonged to the Dynamic International Prognostic Scoring System (DIPSS) high, intermediate-2 and intermediate-1 risk categories, respectively. Thirty patients and 13 patients were enrolled in Cohort A and Cohort B respectively. At the data cut-off of 30 June 2024, the median duration of ruxolitinib + bomedemstat was 61.7 (range: 27.4-80.4) weeks. In 40 evaluable patients at Week 24, 11 patients (27.5%) had ≥50% reduction in MF-SAF Total Symptom Score (TSS) (Cohort A: 7/27, 25.9%; Cohort B: 4/13, 30.7%) and 7 patients (17.5%) had ≥ 35% spleen volume reduction (SVR) (Cohort A: 2/27, 7.4%; Cohort B: 5/13, 38.5%). At Week 24, 20 patients (50%) had stable (≤ 1g/dL absolute change in Hb) or improved Hb (Cohort A: 14/27, 51.9%; Cohort B: 6/13, 46.3%). The most common non-hematologic adverse events (AEs) were diarrhea, N=13 (30.2%) (Grade 1-2, N=12; Grade 3-4, N=1); edema, N=11 (25.5%) (Grade 1-2, N=11; Grade 3-4, N=0) malaise, N=9 (20.9) (Grade 1-2, N= 9; Grade 3-4, N=0); and dysgeusia, N=7 (16.2) (Grade 1-2, N=7; Grade 3-4, N=0). There were no safety signals, or deaths related to drug. Updated data on exploratory outcomes including changes in mutant allele frequencies (MAF) of driver gene mutations, cytokine profiles and bone marrow fibrosis will be presented. Conclusions These results suggest that the addition of bomedemstat to a ruxolitinib regimen is well tolerated, improves splenomegaly and symptom scores, and stabilizes hemoglobin both in the frontline and second-line setting. ClinicalTrials.gov Identifier: NCT05569538

Clonal hematopoiesis (CH) is associated with an increased risk of developing myeloid neoplasms (MNs) such as myelodysplastic neoplasm (MDS) and acute myeloid leukemia (AML). In general, CH comprises clonal hematopoiesis of indeterminate potential (CHIP) and clonal cytopenia of undetermined significance (CCUS). It is an age-related phenomenon characterized by the presence of somatic mutations in hematopoietic stem cells (HSCs) and hematopoietic stem and progenitor cells (HSPCs) that acquire a fitness advantage under selection pressure. Individuals with CHIP have an absolute risk of 0.5–1.0% per year for progressing to MDS or AML. Inflammation, smoking, cytotoxic therapy, and radiation can promote the process of clonal expansion and leukemic transformation. Of note, exposure to chemotherapy or radiation for patients with solid tumors or lymphomas can increase the risk of therapy-related MN. Beyond hematological malignancies, CH also serves as an independent risk factor for heart disease, stroke, chronic obstructive pulmonary disease, and chronic kidney disease. Prognostic models such as the CH risk score and MN-prediction models can provide a framework for risk stratification and clinical management of CHIP/CCUS and identify high-risk individuals who may benefit from close surveillance. For CH or related disorders, therapeutic strategies targeting specific CH-associated mutations and specific selection pressure may have a potential role in the future.

Background Most patients with primary myelofibrosis (PMF) in pre-/early fibrotic stage (pre-PMF) and at low or intermediate-1 risk by the dynamic international prognostic scoring system (DIPSS) will progress to higher risks or overt MF. There is currently no consensus on the optimal treatment for these patients. Ropeginterferon alfa 2b (ropeg) is a next-generation monopegylated interferon alfa-2b developed specifically to treat myeloproliferative neoplasms (MPN). Aims P1101MF is an on-going multicenter phase 2 study of ropeg in patients with pre-PMF and DIPSS low/intermediate-risk PMF. Methods Key eligibility included morphologically confirmed pre-PMF, overt PMF, post-polycythemia vera MF (PPV-MF) or post-essential thrombocythaemia MF (PET-MF), DIPSS low/intermediate-1 risk, and the need for cytoreduction. The primary outcome were responses in haemoglobin (Hb, from 10 g/dL to upper reference range), white blood cell (WBC, < 10 x 10 9/L) and platelet (≤ 400 x 10 9/L) at 24 and 48 weeks. Secondary outcomes included adverse events (AEs), changes in mutant allele frequencies (MAF) of driver and non-driver genes as assessed by droplet digital polymerase chain reaction (ddPCR), quality-of-life (QOL), cytokine profiles and bone marrow morphology. Patients received ropeg at a dose of 250 mcg at week 1, followed by 350 mcg at week 2 and 500 mcg every 2 weeks from week 4 onwards. Results At the data cut-off of 30 June 2023, 37 men and 29 women with a median age of 59 (range: 30-86) years were enrolled. The diagnoses were pre-PMF (=46, 69.6%); overt PMF (N=6, 9.1%); PPV-MF (N=5, 7.5%); and PET-MF (N=9, 13.6%). Mutational profile of driver genes was JAK2V617F (N=46, 69.6%); CALR mutations (type 1/type-1 like, N=13, 19.7%; type 2/type 2-like, N=4, 6.1%); MPL mutation (N=1, 1.5%); and triple-negative (N=3, 4.5%). The median time from diagnosis to treatment was 5.8 (1-271) months. The median baseline parameters were white blood cell count (WBC): 6.49 (3.25-33.95) x 10 9/L; haemoglobin (Hb): 12.5 (7.1-15.9) g/dL; platelet count: 495 (113-1114) x 10 9/L; and lactate dehydrogenase: 277 (136-1146) IU/L. The median follow-up was 69 (4-69) weeks, with 61 patients (92%) and 51 patients (77%) having completed 24 and 48 weeks of treatment respectively. Responses in Hb, WBC and platelet were 75%, 82% and 74% respectively at 24 weeks, and 82%, 80% and 71% respectively at 48 weeks. Reduction of MAF at 24 and 48 weeks was achieved for JAK2V617F in 50% (19/38) of patients (≥50%, N=10, 26%; complete, N=3, 8%) and 79% (22/28) of patients (≥50%, N=6, 21%; complete, N=1, 4%) respectively; and for CALR in 44% (7/16) of patients (≥50%, N=1, 6%) and 50% (5/10) of patients (≥50%, N=1, 10%) respectively. Forty-six patients (69.6%) had bone marrow biopsies serially performed, with 42 patients (91%) having stable/improved marrow fibrosis. Eight patients (17.4%) had resolution of marrow fibrosis by 48 weeks. There were 5 discontinuations (personal reasons, N=1; intractable pruritus, N=1; symptom/spleen size progression, N=3). Disease progression (pre-PMF to overt PMF; development of accelerated/blast phase) was not observed. Non-haematological AEs included transaminitis (grade 1-2, N=34); malaise (grade 1-2, N=27; grade 3-4, N=1) and hair loss (grade 1-2, N=21). The most common haematological AE was anaemia (grade 1-2, N=15; grade 3-4, N=6). Conclusion: Ropeg was well-tolerated, effective in cytoreduction and induced molecular and morphologic responses in patients with pre-PMF and low/intermediate-1-risk MF.

Background: Pure oral arsenic trioxide (oral-ATO) solution (Arsenol ®) was first formulated in Hong Kong. It achieves a bioavailability comparable to that of intravenous ATO (i.v.-ATO). Oral-ATO, used in combination with all trans retinoic acid (ATRA) and ascorbic acid (the AAA regimen) has been shown to highly effective in the frontline induction/consolidation of newly-diagnosed acute promyelocytic leukaemia (APL) in combination with chemotherapy. Aims: The objectives of this ongoing multi-centre phase 2 study of newly-diagnosed APL patients were: 1. to evaluate the efficacy and safety of an entirely oral AAA-induction in a risk-adapted strategy with no chemotherapy and minimal chemotherapy in low-risk and high-risk (presentation leucocyte ≤ 10 x 109/L and > 10 x 109/L) cases; 2. to evaluate the molecular responses during treatment with oral-AAA-based induction/consolidation/maintenance. Methods: Patients with newly-diagnosed APL received oral-AAA induction that comprised oral ATO (Arsenol ®, Jacobson Pharma, Hong Kong) (10mg/day, or 0.16mg/kg in patients < 18 years old, days 1-42), ATRA (45mg/m2/day, or 25mg/m2/day in patients <18 years old, in 2 divided doses, days 1-42), and oral ascorbic acid (1g/day, or 15mg/kg/day in patients <18 years old, days 1-42). Daunorubicin (50mg/m2/day intravenously for 3 days) was administered to patients < 65 years old with high-risk disease. On reaching first complete remission (CR1) consolidation treatment comprising oral-AAA (days 1-14) every 28 days for 2 cycles was given, followed by maintenance with oral-AAA (days 1-14) every 8 weeks for 12 cycles. Real-time quantitative polymerase chain reaction for PML:RARA was performed weekly during induction, every 4 weeks during consolidation, every 8 weeks during maintenance and every 12 weeks for 2 years thereafter. The primary outcomes were overall survival (OS, time from presentation to death), and relapse-free survival (RFS, time from CR1 to molecular/haematologic relapse or death), and safety. The secondary outcome was molecular response. Data were censored on February 28, 2023. Results: Between January 1, 2018 to January 31, 2023, 41 men and 64 women with a median age of 49 years (range: 3-91 years) were accrued, with 77 patients (73.3%) and 28 patients (26.7%) belonging to the low-risk and high-risk groups. Seven patients (6.7%) died at presentation before induction (intracranial haemorrhage, N=6; differentiation syndrome, DS, N=1). Ninety-eight patients received oral-AAA-based induction (AAA alone, N=77; AAA+daunorubicin, N=21). All treated patients achieved CR1. At 8 weeks, all patients achieved a MRD ratio of <0.01. On completion of AAA maintenance, all evaluable patients achieved an MRD ratio of <0.0001. The median duration of follow-up was 27 months (interquartile range: 7-44 months), with 40 patients having completed 2 years of AAA maintenance at data censoring. During the study period, only one patient had molecular relapse 12 months after the completion of AAA maintenance, followed by haematologic relapse 2 weeks later and died from refractory APL. This patient harboured the A216V variant on the PML B2 domain conferring resistance to ATO. One patient died in remission due to gastrointestinal bleeding unrelated to treatment. The 3-year OS and RFS were 98.9% and 97.1% respectively. Cardiotoxicity and grade 3/4 hepatotoxicity related to oral-ATO were not observed. APL-DS occurred in 59 patients (60%) after initiation of AAA (all within the first 14 days), all responding fully to dexamethasone. Summary/Conclusion: The use of an entirely oral AAA-based induction in a risk-adapted strategy that minimized chemotherapy was highly effective and safe in newly-diagnosed APL of all risk categories, and induced deep molecular responses.Keywords: ALL-trans retinoic acid (ATRA), Oral, Arsenic trioxide, Acute promyelocytic leukemia

Background Approximately 50% of patients with myelofibrosis (MF) discontinue ruxolitinib after 3 years, mostly due to disease progression, suboptimal response or cytopenia. Outcome after ruxolitinib discontinuation is poor with a median overall survival (OS) of approximately 14 months. Lysine-specific demethylase-1 (LSD1) is a histone demethylase critical for self-renewal of malignant hematopoietic stem cells and for maturation of progenitor cells. Bomedemstat is an oral LSD1 inhibitor clinically active in patients with myeloproliferative neoplasms (MPN) and has shown clinical activity as a single-agent in patients with MF. Aims This is an ongoing, open-label, Phase 2 study of the combination of bomedemstat and ruxolitinib in treatment-naïve patients with MF or those with a sub-optimal response to ruxolitinib. The objectives of this are to evaluate the safety and tolerability of the combination, the optimal dosing of bomedemstat in this regimen, and to assess the efficacy of the combination as assessed by spleen size reduction and symptom reduction using the Myelofibrosis Symptom Assessment Form (MFSAF). Methods Cohort A is comprised of patients with a sub-optimal response to an adequate trial of ruxolitinib defined as splenomegaly not reduced by >35% from baseline or symptoms scores that have not improved by >50%. Cohort A patients must have been on a stable dose of ruxolitinib for ≥8wks. Cohort B is comprised of treatment-naïve patients with MF who require treatment per guidelines. Patients in Cohort A remain on the entry dose of ruxolitinib while Cohort B patients received a starting ruxolitinib dose of 10 mg BID throughout the study. All patients received concomitantly, a starting dose of bomedemstat of 0.4mg/kg/d. Dose adjustments up were allowed every 4 weeks to achieve a target platelet count of 50 x 10 9/L (40-90 x 10 9/L range) Down titrations could be made at any time in the interest of patient safety. Results At the data cut-off of 30 June 2023, 16 men and 16 women with a median age of 64 (range: 47-81) years were enrolled. Case distribution was PMF, N=19 (59.4%); PPV-MF, N=7 (21.9%); and PET-MF, N=6 (18.8%). Mutational profile of driver genes was JAK2 V617F, N=24 (75%); JAK2 exon 12, N=1 (3.1%); and CALR mutations, N=7 (21.9%). Six patient (18.8%) harbored high-molecular risk (HMR) mutations ( ASXL N =4; EZH2, N=2). At enrollment, the median white blood cell count (WBC), hemoglobin (Hb), platelet count, and lactate dehydrogenase (LDH) were 10.21 x 10 9/L (2.4-50.8 x 10 9/L), 9.4 g/dL (6.7-12.1g/dL), 215 x 10 9/L (100-906 x 10 9/L) and 504 IU/L (107-2174 UL), respectively. Ten patients (31.2%), 19 patients (59.4%) and 3 patients (9.4%) belonged to the Dynamic International Prognostic Scoring System (DIPSS) high, intermediate-2 and intermediate-1 risk categories, respectively. The median spleen size was 5cm (5-16cm) below left costal margin (BLCM). Twenty-four patients were enrolled in Cohort A with a median treatment duration of ruxolitinib of 128 (13-668) weeks. Cohort B has enrolled 8 patients. The median duration of ruxolitinib + bomedemstat was 12 (1-26) weeks. In 20 evaluable patients at Week 12 (Cohort A, N=17; Cohort B, N=3), 12 patients (60%) had stable ( ∆<± 1.0 g/dL) or improved Hb (>1.0 g/dL) (Cohort A: 11/17, 64.7%; Cohort B: 1/3, 33.3%), 5 patients (25%) had ≥50% reduction in MF-SAF Total Symptom Score (TSS) (Cohort A: 4/17, 23.5%; Cohort B: 1/3, 33.3%) and 18 patients (65%) had ≥ 30% spleen length reduction (Cohort A: 15/17, 88.2%; Cohort: 3/3, 100%) (Figure 1A-C). In six patients evaluable for molecular responses by droplet-digital polymerase chain reaction at Week 12, 4 patients (67%) had reductions in JAK2 V617F allele frequencies with 1 patient (17%) having ≥50% reduction. The most common non-hematologic adverse events (AEs) were diarrhea (Grade 1-2, N=16; Grade 3-4, N=0); malaise (Grade 1-2, N= 6; Grade 3-4, N=0); oedema (Grade 1-2, N=7; Grade 3-4, N=0) and dysgeusia (Grade 1-2, N=5; Grade 3-4, N=0). There were no safety signals, dose-limiting toxicities, or deaths related to drug. Conclusions These early results suggest that the addition of bomedemstat to a ruxolitinib regimen is well tolerated, improves splenomegaly and symptom scores, and stabilizes hemoglobin both in the frontline and second-line setting. Enrollment in ongoing.

Background: In Asia, treatment decisions in myelodysplastic neoplasms (MDS) are conventionally based on the Revised International Prognostic Scoring system (IPSS-R). A unique clinical-molecular prognostic model, the IPSS-molecular (IPSS-M), has been developed based on 2957 patients with de-novo MDS, therapy-related MDS, and MDS/myeloproliferative neoplasm (MPN) overlap syndrome. The IPSS-M comprises haematological parameters, karyotypic abnormalities and somatic mutations in a 31-gene panel. Validation of the IPSS-M in large multicentre studies in Asian has however not been performed. Hence, prognostic models taking into account the unique clinical-molecular characteristics of Asian MDS patients remain undefined. Aims: The objectives of this multicenter cohort study were: 1. to define the haematological, cytogenetic and molecular characteristics of Asian MDS patients; and 2. to develop a prognostic model based on these characteristics. Methods: Consecutive MDS patients in Hong Kong, Singapore and Taiwan diagnosed between 2004 to 2021 were studied. Data were censored on 17 September 2022. Patients with MDS/MPN overlap syndrome were excluded. A panel of 54 myeloid-related genes was sequenced in the diagnostic bone marrow by next-generation sequencing. Hematological, pathological, cytogenetic and molecular variables were evaluated for their association with overall survival (OS), leukemia-free survival (LFS), and time to progression to secondary acute myeloid leukemia (TTP-sAML). Variable selection was performed to determine the confounding variable and independent prognostic variables. The relative weights of the selected variables were estimated using a Cox multivariable model adjusted for confounders. According to the weights of each prognostic variable, individual patient-specific prognostic scores were calculated. Based on the scores of the entire cohort, six prognostic subgroups were defined. The statistical predictive power of this prognostic model was assessed by the concordance index (C-index). The prognostic model was validated with publicly available data from the IPSS-M cohort. Results: Seven hundred and seventy-eight men (63.5%) and 447 women (36.5%) at a median age of 68.4 (interquartile range, IQR: 57-77) years were studied. After a median follow-up of 2.85 (IQR: 0.97-7.06) years, there were 693 deaths (56.6%) and 284 transformations to sAML (23.2%). Three-hundred and ninety-four patients (32.2%) received hypomethylating agents (azaciticine, N=367; decitabine, N=27), and 158 patients (12.9%) underwent allogeneic haematopoietic stem cell transplantation. All patients showed at least one genetic alteration in the 54-gene panel (Figure 1A). Prognostic scoring systems (each with 6 prognostic subgroups) were established for OS (C-index: 0.72) (Figure 1A), LFS (C-index:0.71) (Figure 1B) and TTP-sAML (C-index: 0.74) (Figure 1C). Genomic factors significantly associated with inferior outcomes were monosomy 7, del(5q), and mutations in GNAS and TP53 for OS; trisomy 19, del(5q), monosomy 7, and mutations in GNAS, PTPN11 and TP53 for LFS, and i(17q), del(5q), and mutations in NPM1, NRAS, GNAS, IDH2, SF3B1, and RUNX1 for TTP-sAML. Using the IPSS-M publically available dataset as the validation cohort, our prognostic model gave C-indices of 0.70, 0.71 and 0.74 for OS, LFS and TTP-sAML respectively. Finally, this prognostic model had superior prognostic power as compared with the IPSS-R and IPSS-M for the current Asian cohort (Figure 1D). Conclusion: Combining genomic with hematological and cytogenetic parameters, the Asian clinical-molecular prognostic model improved the risk stratification of patients with MDS in Asia, potentially improving clinical decision-making.

Background: Most patients with primary myelofibrosis (PMF) in early/pre-fibrotic stage (pre-PMF) with dynamic international prognostic scoring system (DIPSS) low or intermediate-1 risks progress to higher risks or overt MF. There is currently no consensus on the optimal treatment for these patients. Ropeginterferon alfa 2b (P1101) is a next-generation monopegylated interferon alfa-2b developed specifically to treat myeloproliferative neoplasms (MPN). Aims: P1101MF is an on-going multicenter phase 2 study of P1101 in patients with pre-PMF and DIPSS low/intermediate-risk PMF. Methods: Key eligibility included morphologically confirmed pre-PMF, overt PMF, post-polycythemia vera MF (PPV-MF) or post-essential thrombocythaemia MF (PET-MF), DIPSS low/intermediate-1 risks, and the need for cytoreduction. The primary outcome were haematologic responses at 24 and 48 weeks. Secondary outcomes included adverse events (AEs), changes in allele burden of driver and non-driver gene mutations, quality-of-life (QOL), cytokine profiles and bone marrow morphology. Patients received P1101 at a starting dose of 250mcg followed by 350mcg at week 2 and 500mcg every 2 weeks from week 4 onwards. Results: At the data cut-off of 27 February 2023, 36 men and 26 women with a median age of 59 (range: 30-86) years were enrolled. Case distribution was pre-PMF, N=44 (71%): overt PMF, N=6 (9.7%);PPV-MF, N=5 (8.1%); and PET-MF, N=7 (11.3%). Mutational profile of driver genes was JAK2V617F, N=43 (69.4%); CALR mutations (Type 1/type-1 like, N=13; Type 2/type 2-like, N=4), MPL mutation, N=1 (1.6%). Next-generation sequencing (NGS) of non-driver mutations showed haboured high molecular risk mutations, N=8 (12.9%)(ASXL1, N=3; EZH2, N=2; IDH2, N=2; SFSF2, N=1). One triple-negative pre-PMF case showed the TP53 p.Arg248Gln variant. The median time from diagnosis to treatment was 5 months (range: 1-266 months). At baseline, the median white blood cell count (WBC), haemoglobin (Hb), platelet count, and lactate dehydrogenase were 7 x 109/L (range: 3.3-33.95 x 109/L), 12.6 g/dL (range: 7.1-15.9 g/dL), 500 x 109/L (range: 113-1114 x 109/L) and 277 IU/L (range: 136-1146) respectively. The baseline median MPN Symptom Assessment Form Total Symptom Score was 16 (range:0-49). The median follow-up was 55 (9-61) weeks, with 56 patients (90%) and 35 patients (56%) having completed 24 and 48 weeks of treatment respectively. At 24 weeks, responses in Hb (defined as 10g/dL to upper limit normal), WBC (WBC < 10 x 109/L) and platelet (defined as platelet count ≤ 400 x 109/L) were 76.6%, 87.2% and 78.7% respectively. Furthermore, 36 (92%) of 39 evaluated JAK2V617F mutated patients had stable or improved JAK2V617F allele burden by droplet digital polymerase reaction. Three patients (8%) had >50% reduction in the JAK2V617F allele burden with one patients achieving undetectable JAK2V617F from week 16 onwards. There were 3 discontinuations (personal reasons, N=2; symptom progression, N=1). None of the pre-PMF cases progressed to overt PMF. Progression to blast phase was not observed. The most common AEs were malaise (N=29, 47%; Grade 1-2, N=28; Grade 3-4, N=1), anaemia (N=26, 42%; Grade 1-2, N=22; Grade 3-4, N=4), and hair loss (N=23, 37%; Grade 1-2, N=23; Grade 3-4; N=0). Eight patients (13%) had asymptomatic derangement thyroid function. Neuropsychiatric disorders and other autoimmune disorders were not observed. Summary/Conclusion: In summary, P1101 was generally well-tolerated, effective in cytoreduction and induced molecular responses early in JAK2V617F-mutated patients with pre-PMF and low/intermediate-1-risk PMF. Keywords: Ropeg-Interferon, Myelofibrosis

Background: Pure oral arsenic trioxide (oral-ATO) solution (Arsenol ®) was first formulated in Hong Kong. It achieves a bioavailability comparable to that of intravenous ATO (i.v.-ATO). Oral-ATO, used in combination with all trans retinoic acid (ATRA) and ascorbic acid (the AAA regimen) has been shown to highly effective in re-induction of relapsed acute promyelocytic leukaemia (APL), and in the frontline induction, consolidation and maintenance of newly-diagnosed APL. However, the relative outcomes of APL treated with regimens based on ATRA/chemotherapy, i.v.-ATO/ATRA, and oral-ATO/ATRA have not been critically appraised. Aims: The objectives of this multicentre retrospective cohort analysis were: 1. to define the clinicopathologic features of APL in Asia; 2. to compare the outcomes in newly-diagnosed APL treated with regimens based on ATRA/chemotherapy, i.v.-ATO/ATRA, and oral-ATO/ATRA/ascorbic acid (AAA). Methods: Patients with newly-diagnosed APL treated in 14 centres (Hong Kong:9; Taipei: 1; Thailand: 1; Singapore: 1; Malaysia: 2) between 1 January 2001 to 30 July 2022 were identified. Information on the clinicopathologic features, treatment and outcomes were collected. Primary outcomes were 60-day survival (time from presentation to death, censoring at day 60), overall survival (OS, time from presentation to death or last follow-up), and relapse-free survival (RFS, time from first complete remission, CR1, to relapse, death or last follow-up). Data were censored on August 30, 2022. Survivals (60-day survival, OS, RFS) were analyzed with the Kaplan-Meier method, difference between groups determined with the log-rank test and Cox proportional hazard model. Results: There were 334 men and 332 women at a median age of 44 (range: 3-91) years, with 460 patients (69.1%) in the standard-risk (presenting leucocyte ≤ 10 x 109/L) and 206 patients (30.9%) in the high-risk (presenting leucocyte > 10 x 109/L) groups. According to induction/consolidation/maintenance regimens, patients were divided into four groups: ATRA/chemotherapy based induction/consolidation/maintenance, N=324; ATRA/chemotherapy based induction/consolidation + AAA maintenance, N=127; i.v.-ATO/ATRA-based induction/consolidation, N=61; and AAA-based induction/consolidation/maintenance, N=154. Notably, 49% of patients did not receive ATO because of drug access problems. After a median follow-up of 74.5 months (interquartile range: 29-132 months), there were 112 deaths (16.8%). The 60-day survival was 91.6%. On multivariate analysis, inferior 60-day survival was associated with age > 50 years (P=0.02), central nervous system (CNS) involvement at presentation (P<0.001) and non-ATO (oral or i.v.)-based induction (P<0.001). The 5-year OS was 87%. On multivariate analysis, inferior OS was associated with age > 50 years (P=0.001), CNS involvement at presentation (P<0.001) and APL differentiation syndrome (DS) (P<0.001); and the use of ATRA/chemotherapy-based induction/consolidation and CR1 AAA maintenance (5-year OS: 93.5%; P=0.04) and AAA-based induction/consolidation/maintenance (5-year OS: 92.4%; P=0.002).. The 5-year RFS was 82.4%. On multivariate analysis, inferior RFS was associated with male sex (P=0.04) and CNS involvement at presentation (P<0.001); and the use of i.v.-ATO/ATRA-based induction/consolidation (5-years RFS: 92.8%; P=0.005), ATRA/chemotherapy-based induction/consolidation and CR1 AAA maintenance (5-year RFS: 88%; P<0.001), and AAA-based induction/consolidation/maintenance (5-year RFS: 97.8%; P<0.001). Summary/Conclusion: The use of AAA-based regimens in newly-diagnosed APL significantly improved early deaths, OS and RFS independent of conventional risk grouping.Keywords: Acute promyelocytic leukemia, Oral, Arsenic trioxide, ALL-trans retinoic acid (ATRA)

Relapse after allogeneic haematopoietic stem cell transplantation (HSCT) is one of the key determinants of outcome in myelofibrosis (MF) and remains an important unmet need. In this retrospective single-centre study, we evaluated 35 consecutive patients with MF receiving allogeneic HSCT. At 30 days post-HSCT, full donor chimerism was achieved in 31 patients (88.6

Background: Pure oral arsenic trioxide (oral-ATO) solution (Arsenol ®) was first formulated in Hong Kong. It achieves a bioavailability comparable with that of intravenous ATO (i.v.-ATO). Oral-ATO combined with all-trans retinoic acid (ATRA) and ascorbic acid (the AAA regimen) combined with chemotherapy is highly efficacious in relapsed and newly-diagnosed APL. To reduce treatment-related toxicities and long-term risks of second primary cancers, a chemotherapy-free approach is increasingly favoured. Aims: The objectives of this prospective multicentre study in newly diagnosed APL patients were: 1. to evaluate the efficacy and safety of an entirely oral AAA-induction in a risk-adapted strategy; 2. to evaluate the molecular responses during oral-AAA-based induction/consolidation/maintenance. Methods: Newly-diagnosed APL patients were stratified by presentation leucocyte count into standard-risk (≤ 10 x 10 9/L) and high-risk (> 10 x 10 9/L) groups. Standard-risk patients and high-risk patients ≥ 65 years old received AAA induction comprising oral-ATO (Arsenol ®, Jacobson Pharma Corporation, Hong Kong) (10 mg/day, or 0.16 mg/kg in patients < 18 years old, days 1-42), ATRA (45 mg/m 2/day, or 25 mg/m 2/day in patients <18 years old, in 2 divided doses, days 1-42), and oral ascorbic acid (1 g/day, or 15mg/kg/day in patients <18 years old, days 1-42). High-risk patients < 65 years old received in addition daunorubicin (50 mg/m 2/day i.v. for 3 days). On reaching first complete remission (CR1), consolidation with AAA (days 1-14) every 28 days for 2 cycles was given, followed by maintenance with AAA (days 1-14) every 8 weeks for 12 cycles. Real-time quantitative polymerase chain reaction for PML:: RARA with a sensitivity of 10 -5 was performed (weekly during induction, every 4 weeks during consolidation, every 8 weeks during maintenance and thereafter every 12 weeks for 2 years). For molecular response, the normalized copy number ratio was defined as PML::RARA copy number/ ABL copy number. Primary outcomes were overall survival (OS, time from presentation to death or last follow-up), and relapse-free survival (RFS, time from CR1 to molecular or haematological relapse, death or last follow-up), and safety (according to the Common Toxicity Criteria for Adverse Events (AE) version 5.0). The secondary outcome was molecular response. Data were censored on July 22, 2023. Results: Between January 1, 2018 to July 22, 2023, 5 paediatric/adolescent patients (male, N=2; female, N=3) at a median age of 12 (3-15) years and 116 adult (> 18 years old) patients (male, N=47 ; female, N=69) at a median age of 49 (19-91) years were accrued (standard risk: paediatric/adolescent, N=3; adults, N=87; high-risk: paediatric/adolescent, N=2; adults, N=29). Seven patients (all high-risk adults) died at presentation before induction (intracranial haemorrhage, N=6; severe APL differentiation syndrome, DS, with leucocyte >100 x10 9/L, N=1). One-hundred and fourteen patients received oral-AAA-based induction (AAA alone, N=90; AAA+daunorubicin, N=24), all achieving CR1. For PML:: RARA normalized copy number, all treated patients at week 8 achieved a ratio of <0.01; and on completion of AAA maintenance, all evaluable patients (N=56) achieved a ratio of <0.0001. The median follow-up was 29 (IQR: 8-47) months, with 56 patients (49%) having completed 2 years of AAA maintenance. There was only one relapse, occurring in an adult patient 12 months after completion of AAA maintenance. Molecular analysis showed a PML B2 domain A216V mutation that conferred resistance to ATO. One adult patient died of an unrelated gastrointestinal bleeding while in CR1. The 3-year OS was 99.1% (paediatric/adolescent: 100%; adult: 99%). The 3-year RFS was 97.9% (paediatric/adolescent: 100%; adult: 97.9%). The most common non-haematological AEs (all grade 1-2) were transaminitis (N=54, 47.3%) and headache (N=32, 28%) Notably, no cardiotoxicity (arrhythmias/cardiac failure) was observed. APL-DS occurred in 67 patients (58.7%) after initiation of AAA, all responding fully to intravenous dexamethasone. There were no treatment discontinuations. Conclusion: The use of an entirely oral AAA-based induction in a risk-adapted strategy that minimized chemotherapy was highly effective and safe in newly-diagnosed APL of all risk categories and age groups. Early deaths remained an obstacle to realizing a cure-for-all in APL.

In myelodysplastic syndrome (MDS), resistance to hypomethylating agents (HMA) portends a poor prognosis, underscoring the importance of understanding the molecular mechanisms leading to HMA-resistance. In this study, P39 and Kasumi-1 cells and their azacitidine-resistant and decitabine-resistant sublines were evaluated comparatively with transcriptomic and methylomic analyses. Expression profiling and genome-wide methylation microarray showed downregulation of PTEN associated with DNA hypermethylation in P39 cell lines resistant to azacitidine and decitabine. This pattern of PTEN dysregulation was also confirmed in a cohort of patients failing treatment with HMA. DNA hypomethylation of MDM2 was detected with downregulation of MDM2 in HMA resistant cell lines. Long-read sequencing revealed significant RNA hypomethylation of MDM2 resulting in alternative splicing and production of a truncated MDM2 transcript in azacitidine-resistant P39 cells. The expression of this MDM2 truncated transcript was also significantly increased in HMA-resistant patients compared with HMA-responsive patients. In conclusion, epigenetic and epi-transcriptomic dysregulation of PTEN and MDM2 were associated with resistance to hypomethylating agents.

Most patients with early/pre-fibrotic primary myelofibrosis (pre-PMF) and dynamic international prognostic scoring system (DIPSS) low or intermediate-1 risk myelofibrosis (MF) progress to overt PMF or higher risk MF. There is currently no consensus on the optimal treatment strategies in these patients. Ropeginterferon alfa 2b (P1101) is a next generation monopegylated interferon alfa-2b developed specifically to treat myeloproliferative neoplasms (MPN). The P1101MF study is a multicenter phase 2 study of P1101 for patients with pre-PMF and DIPSS low/intermediate-1 risk MF (NCT04988815). Key eligibility included the need for cytoreduction, morphologically confirmed pre-PMF, overt PMF, post-polycythemia vera MF (PPV-MF) or post-essential thrombocythemia MF (PET-MF), and DIPSS low/intermediate-1 risk category. The primary outcome was the clinicohematologic complete response (CHCR) rate at 24 and 48 weeks. Secondary outcomes included adverse events (AEs), changes in allele burden of driver genes and other non-driver mutations, changes in quality-of-life (QOL), changes in cytokine profiles and changes in bone marrow morphology. Patients received P1101 at a starting dose of 250mcg followed by 350mcg at week 2 and 500mcg every 2 weeks from week 4 onwards. At the data cut-off of 28 July 2022, 56 patients (33 men, 23 women) with a median age of 58 (range: 30-87) were enrolled. Thirty eight patients (68%) had pre-PMF, 5 (9%) had overt PMF, 3 (5%) had PPV-MF and 10 (18%) had PET-MF. Next-generation sequencing (NGS) in 53 patients showed JAK2V617F in 39 patients (74%), CALR mutations in 13 patients (25%) and MPL mutation in 1 patient (2%). On day 1, the mean white blood cell (WBC) count, hemoglobin concentration, platelet count, and lactate dehydrogenase (LDH) level were 9.4 x 109/L (range: 3.3-33.95), 12.5 g/dL (range: 7.1-15.9), 520 x 109/L (range: 113-1038) and 359 IU/L (range: 136-1146) respectively. The median duration of follow-up was 24 (2-28) weeks. Forty-six and 30 patients completed 12 and 24 weeks of treatment respectively. At 12 and 24 weeks the CHCR rate was 74% and 67%, respectively. At 24 weeks, 36 (92%) of 39 JAK2V617F mutated patients had stable or improved JAK2V617F allele burden by droplet digital polymerase reaction (ddPCR). Three patients (8%) had >50% reduction in the JAK2V617F allele burden with one patient achieving undetectable JAK2V617F from week 16 onwards. Disease progression or blastic transformation were not observed during the study. The most common AEs were malaise (N=22, 39%; Grade 1-2, N=21; Grade 3-4, N=1), anemia (N=12, 21%; Grade 1-2, N=8; Grade 3-4, N=4), muscle pain (N=11, 20%; Grade 1-2, N=11; Grade 3-4, N=0) and hair loss (N=10, 18%; Grade 1-2, N=10; Grade 3-4; N=0) . There were no treatment discontinuations, safety signals or deaths related to treatment. In summary, P1101 was well-tolerated, effective in cytoreduction and induced molecular responses. The recruitment of patients is ongoing.

Myelodysplastic syndrome (MDS) is a clonal myeloid neoplasm characterized by ineffective hematopoiesis, cytopenia, dysplasia, and clonal instability, leading to leukemic transformation. Hypomethylating agents are the mainstay of treatment in higher-risk MDS. However, treatment resistance and disease transformation into acute myeloid leukemia (AML) is observed in the majority of patients and is indicative of a dismal outcome. The residual cell clones resistant to therapy or cell clones acquiring new genetic aberrations are two of the key events responsible for drug resistance. Bulk tumor sequencing often fails to detect these rare subclones that confer resistance to therapy. In this study, we employed a single-cell DNA (sc-DNA) sequencing approach to study the clonal heterogeneity and clonal evolution in two MDS patients refractory to HMA. In both patients, different single nucleotide variations (SNVs) or insertions and deletions (INDELs) were detected with bulk tumor sequencing. Rare cell clones with mutations that are undetectable by bulk tumor sequencing were detected by sc-DNA sequencing. In addition to SNVs and short INDELs, this study also revealed the presence of a clonal copy number loss of DNMT3A, TET2, and GATA2 as standalone events or in association with the small SNVs or INDELs detected during HMA resistance and disease progression.

In myelodysplastic syndrome (MDS), resistance to hypomethylating agents (HMA) portends a poor prognosis, underscoring the importance of understanding the molecular mechanisms leading to HMA-resistance. In this study, P39 and Kasumi-1 cells and their azacitidine-resistant and decitabine-resistant sublines were evaluated comparatively with transcriptomic and methylomic analyses. Expression profiling and genome-wide methylation microarray showed downregulation of PTEN associated with DNA hypermethylation in P39 cell lines resistant to azacitidine and decitabine. This pattern of PTEN dysregulation was also confirmed in a cohort of patients failing treatment with HMA. DNA hypomethylation of MDM2 was detected with downregulation of MDM2 in HMA resistant cell lines. Long-read sequencing revealed significant RNA hypomethylation of MDM2 resulting in alternative splicing and production of a truncated MDM2 transcript in azacitidine-resistant P39 cells. The expression of this MDM2 truncated transcript was also significantly increased in HMA-resistant patients compared with HMA-responsive patients. In conclusion, epigenetic and epi-transcriptomic dysregulation of PTEN and MDM2 were associated with resistance to hypomethylating agents.

Myelodysplastic syndrome (MDS) is a heterogeneous, clonal hematological disorder characterized by ineffective hematopoiesis, cytopenia, morphologic dysplasia, and predisposition to acute myeloid leukemia (AML). Stem cell genomic instability, microenvironmental aberrations, and somatic mutations contribute to leukemic transformation. The hypomethylating agents (HMAs), azacitidine and decitabine are the standard of care for patients with higher-risk MDS. Although these agents induce responses in up to 40–60% of patients, primary or secondary drug resistance is relatively common. To improve the treatment outcome, combinational therapies comprising HMA with targeted therapy or immunotherapy are being evaluated and are under continuous development. This review provides a comprehensive update of the molecular pathogenesis and immune-dysregulations involved in MDS, mechanisms of resistance to HMA, and strategies to overcome HMA resistance.

Despite therapeutic advances, early death (ED) remains a major factor curtailing survival of acute promyelocytic leukemia (APL). Studies examining factors that cause early death (ED; within 30 days of admission) and the correlation of survival with the timing of administration of all-trans retinoic acid (ATRA) and hemostatic parameters are scarce. We performed a cohort analysis of nonselect patients with newly diagnosed APL who presented to the health care system in Hong Kong, where oral arsenic trioxide was used. From 1 January 2007 to 30 April 2020, 358 patients (median age, 47 [1-97] years) with newly diagnosed APL were identified. ED occurred in 56 patients (16%): 11 (3%) died in the first 2 days after admission (intracranial hemorrhage [ICH], n = 6; APL-differentiation syndrome [APL-DS], n = 4; infection, n = 1); 22 (6%) died within 3 to 7 days (ICH, n = 12; APL-DS, n = 8; infections, n = 2), and 23 (6%) died within 8 to 30 days (ICH, n = 7; APL-DS, n = 11; infection, n = 5). Factors significantly associated with ED by multivariate analysis included male sex (P = .01); presenting leukocyte count ≥10 × 109/L (P = .03); fibrinogen <1.5 g/L (P = .02); and ATRA administration >24 hours after hospital admission (P < .001). After a median follow-up of 47 (0-166) months, the 5- and 10-year overall survival (OS) was 68.6% and 61.2%, respectively. Excluding EDs, the 5- and 10-year post-30-day OS improved to 81.3% and 72.5%. Early administration of ATRA (<24 hours) and vigorous correction of hemostatic abnormalities, including hypofibrinogenemia, are key to reducing ED.

Introduction:Real-world data of responses, quality-of-life (QOL) changes and adverse events in patients with myeloproliferative neoplasms (MPN) on conventional therapy (hydroxyurea +/- anagrelide), pegylated interferon alpha-2A (PEG-IFN alpha-2A) or ruxolitinib are limited. Methods:We prospectively studied MPN patients receiving conventional therapy, PEG-IFN alpha-2A or ruxolitinib. Next-generation sequencing of 69 myeloid-related genes was performed. Clinicohematologic responses, adverse events, and QOL (determined by the Myeloproliferative Neoplasm Symptom Assessment Form Total Symptom Score, MPN-SAF TSS) were evaluated. Results:Seventy men and fifty-five women with polycythemia vera (PV) (N = 23), essential thrombocythemia (ET) (N = 56) and myelofibrosis (MF) (N = 46) were studied for a median of 36 (range: 19-42) months. In PV, responses were comparable for different modalities.CREBBPmutations were associated with inferior responses. In ET, PEG-IFN alpha-2A resulted in superior clinicohematologic complete responses (CHCR) (P = 0.045). In MF, superior overall response rates (ORR) were associated with ruxolintib (P = 0.018) andJAK2V617F mutation (P = 0.04). For the whole cohort, ruxolitinib led to rapid and sustained reduction in spleen size within the first 6 months, and significant improvement of QOL as reflected by reduction in MPN-SAF TSS (P < 0.001). Adverse events of grades 1-2 were observed in 44%, 62% and 20% of patients receiving conventional therapy, PEG-IFN alpha-2A and ruxolitinib respectively; and of grade 3-4 in 7% and 9% of patients receiving PEG-IFN alpha-2A and ruxolitinib. Conclusions:Conventional therapy, PEG-IFN alpha-2A and ruxolitinib induced responses in all MPN subtypes. PEG-IFN alpha-2A led to superior CHCR in ET; whereas ruxolitinib resulted in superior ORR in MF, and significant reduction in spleen size and improvement in QOL.

Abstract Clofarabine is active in refractory/relapsed acute myeloid leukemia (AML). In this phase 2 study, we treated 18‐ to 65‐year‐old AML patients refractory to first‐line 3 + 7 daunorubicin/cytarabine induction or relapsing after 3 + 7 induction and high‐dose cytarabine consolidation, with clofarabine (30 mg/m2/d, Days 1‐5), cytarabine (750 mg/m2/d, Days 1‐5), and mitoxantrone (12 mg/m2/d, Days 3‐5) (CLAM). Patients achieving remission received up to two consolidation cycles of 50% CLAM, with eligible cases bridged to allogeneic hematopoietic stem cell transplantation (allo‐HSCT). The mutational profile of a 69‐gene panel was evaluated. Twenty‐six men and 26 women at a median age of 46 (22‐65) years were treated. The overall response rate after the first cycle of CLAM was 90.4% (complete remission, CR: 69.2%; CR with incomplete hematologic recovery, CRi: 21.2%). Twenty‐two CR/CRi patients underwent allo‐HSCT. The 2‐year overall survival (OS), relapse‐free survival (RFS), and event‐free survival (EFS) were 65.8%, 45.7%, and 40.2%, respectively. Multivariate analyses showed that superior OS was associated with CR after CLAM (P = .005) and allo‐HSCT (P = .005), and superior RFS and EFS were associated with allo‐HSCT (P < .001). Remarkably, CR after CLAM and allo‐HSCT resulted in 2‐year OS of 84.3% and 90%, respectively. Karyotypic aberrations and genetic mutations did not influence responses or survivals. Grade 3/4 neutropenia/thrombocytopenia and grade 3 febrile neutropenia occurred in all cases. Other nonhematologic toxicities were mild and uncommon. There was no treatment‐related mortality and the performance of allo‐HSCT was not compromised. Clofarabine, cytarabine, and mitoxantrone was highly effective and safe in refractory/relapsed AML. This study was registered at ClinicalTrials.gov (NCT02686593).

Introduction Renal relapses adversely affect the long-term outcomes of patients with lupus nephritis (LN), but the pathogenic mechanisms remain elusive. B cell signatures of miR-148a, BACH1, BACH2, and PAX5 expression are relevant to the regulation of B lymphocyte homeostasis. It is unknown whether B cell signature is related to the relapse of LN. Methods We compared B lymphocyte subsets and cellular signatures during disease quiescence between LN patients with multiple relapses (MR, ≥3 LN relapses within 36 months) and those with no relapse (NR). Also, circulating B lymphocytes were isolated from treatment-naïve patients with active LN and treated with antagomir-148a in vitro to investigate the relationship between miR-148a, BACH1, BACH2, and PAX5. Results MR patients (n = 19), when compared with NR (n = 14), showed significantly lower percentage of circulating naïve B cells and higher memory B cell-to-naïve B cell ratio. MR patients also showed higher miR-148a levels in sera and B cells, and lower BACH1, BACH2, and PAX5 expression in naïve and memory B cells. Antagomir-148a upregulated BACH1, BACH2, and PAX5 expression, and reduced B cell proliferation upon stimulation, in naïve and memory B cells isolated from treatment-naïve active LN patients. Conclusion Altered B cell subsets and cellular signatures of miR-148a, BACH1, BACH2, and PAX5 may be associated with distinct patient phenotypes related to the risk of LN relapse.