ABSTRACT:Bruton tyrosine kinase inhibitors (BTKis) have dramatically changed the therapeutic landscape of chronic lymphocytic leukemia (CLL), with ibrutinib, first-in-class, demonstrating durable efficacy even in high-risk patients. However, off-target adverse events (AEs) have raised concerns, prompting the development of more selective second-generation BTKis, such as zanubrutinib, designed to improve tolerability while maintaining efficacy. Despite encouraging results from clinical trials, real-world data comparing zanubrutinib with ibrutinib remain limited. In this multicenter, retrospective study, we analyzed 934 patients with CLL treated outside clinical trials, including 393 receiving zanubrutinib and 541 receiving ibrutinib. We evaluated time to treatment discontinuation (TTD) and time to next treatment or death (TTNTD) in both the overall cohort and a propensity score-matched population. Patients who were treated with zanubrutinib experienced lower 12-month discontinuation rates (overall: 12.6% vs 21.4%; matched: 12.4% vs 20.2%) and higher 12-month TTNTD rates (overall: 91.9% vs 83.0%; matched: 93.2% vs 83.4%). Multivariable analyses confirmed zanubrutinib as an independent predictor of longer TTD and TTNTD, whereas high-risk features, including age, relapsed/refractory disease, Binet stage C, TP53 disruption, Eastern Cooperative Oncology Group 2 to 3, and congestive heart failure, were consistently associated with poorer outcomes. AEs leading to discontinuation, particularly atrial fibrillation, bleeding, and infections, were less frequent with zanubrutinib, reflecting its favorable safety profile. These findings provide real-world evidence that zanubrutinib offers more durable disease control and improved persistence compared with ibrutinib, reinforcing its clinical value as a preferred second-generation BTKi. Nevertheless, the relatively short follow-up for zanubrutinib warrants cautious interpretation of long-term outcomes, and underscores the need for ongoing observation to fully characterize its durability and safety.

Background/Objectives: Tissue niches, such as those in the spleen, bone marrow, and lymph nodes, are crucial for the survival and growth of leukemic cells in chronic lymphocytic leukemia (CLL). Methods: A growing amount of research over the last 20 years has shown how important the tumor microenvironment (TME) is to the pathophysiology, development, and resistance to treatment of CLL. This protective environment, which is made up of various cell types (including stromal and immune cells), extracellular matrix components, and soluble factors, supports CLL cells and encourages their survival, growth, and drug resistance. Even in the absence of mutations, Notch2 is functionally activated in the CLL system, in addition to the well-known Notch1. This occurs because leukemic cells aberrantly express the ligand Jagged1/2, which activates the Notch2 receptor on both stromal and CLL cells themselves. Notch2 activation on stromal cells leads to the triggering of the Wnt/β-catenin program in CLL cells, whereas the activation of Notch2 in CLL cells promotes the expression of Mcl-1, which confers drug tolerance (especially in cases with trisomy 12). Results: In addition to these mechanisms, Notch2 acts as a transcription factor that directly controls the expression of key targets, such as CD23 and Hes1, that are fundamental for B cell proliferation, differentiation, and survival in CLL. Conclusions: All of these circuits represent important therapeutic targets and help explain the cells' dependence on their niche, the formation of proliferation centers, and resistance to modern targeted agents.

ABSTRACT:The phase 3 CRISTALLO trial compared first-line fixed-duration venetoclax-obinutuzumab (VenO) vs fludarabine, cyclophosphamide, and rituximab (FCR)/bendamustine-rituximab (BR) in patients with chronic lymphocytic leukemia (CLL), using undetectable minimal residual disease (uMRD) as the sole primary end point. Previously untreated patients with a cumulative illness rating scale score ≤6 and creatinine clearance ≥70 mL/min without del(17p)/TP53 mutations were randomized 1:1 to VenO or FCR/BR. The primary end point was uMRD (<10-4) in peripheral blood (PB) using next-generation sequencing at month 15. Key secondary end points included uMRD (<10-4) in PB and bone marrow (BM) at end of treatment (EOT) and progression-free survival (PFS). uMRD at deeper cutoffs were explored. At data cutoff (19 March 2024), 80 patients received VenO, and 86 received FCR/BR. Baseline characteristics were generally balanced across arms. The primary end point was met: 81.3% (VenO) and 54.7% (FCR/BR) achieved uMRD (<10-4) in PB at month 15 (P = .0004). uMRD (<10-4) in PB and BM at EOT was also higher with VenO vs FCR/BR. Short follow-up precluded evaluation of PFS at the first planned interim analysis; however, fewer patients progressed/died with VenO vs FCR/BR (7 vs 13). At month 15, 65.0% (VenO) and 25.6% (FCR/BR) achieved uMRD (<10-6) in PB. The overall safety profile was consistent with the known safety profile of each drug. No patient in the VenO arm was deemed high risk for tumor lysis syndrome (TLS) after obinutuzumab debulking; no clinical TLS occurred. These results confirm and extend the findings from the GAIA-CLL13 trial, validating increased depth of response with VenO vs chemoimmunotherapies. This trial was registered at www.clinicaltrials.gov as NCT04285567.

CONTEXT:Early palliative care (EPC) improves patient-centered outcomes in solid tumors but remain underutilized in acute myeloid leukemia (AML), where evidence on EPC content and implementation is limited. OBJECTIVES:We aimed to characterize the core components...associations with palliative care quality indicators and end-of-life (EOL) care intensity. METHODS:We conducted a single-center retrospective observational study including consecutive adults with AML/HR-MDS receiving outpatient EPC. We reviewed electronic medical records to identify EPC components across all visits. We assessed temporal trends by comparing the first versus last three visits. Mixed-effects logistic regression examined associations between EPC components and quality indicators; univariate models assessed associations with EOL care aggressiveness. RESULTS:A total of 180 patients received 1175 EPC visits (median six visits/patient). EPC components most frequently addressed symptoms (89.9%), coping support (74.6%), and illness understanding (71.2%). Over time, EOL planning increased (11.0% in first vs. 68.3% in last three visits; P < 0.001), as did family engagement (45.2% vs. 61.9%; P = 0.025). In multivariable models, more illness-understanding visits increased prognostic awareness discussions (OR 1.34; 95% CI: 1.16-1.55; P < 0.001), whereas coping-focused visits were associated with lower odds of documented goals-of-care conversations (OR 0.86; 95% CI: 0.78-0.96; P = 0.006). More EOL planning-focused visits increased the likelihood of receiving ≥1 quality indicator (OR 1.65; 95% CI: 1.40-1.94; P < 0.001) and ACP documentation (OR 2.91; 95% CI: 2.25-3.76; P < 0.001). Higher EPC exposure was associated with lower chemotherapy use in the last 30 days of life (OR 0.73; 95% CI: 0.53-1.00; P = 0.049), and coping-focused visits were associated with lower odds of in-hospital death (OR 0.77; 95% CI: 0.60-0.94; P = 0.010). CONCLUSIONS:EPC in AML/HR-MDS has distinct components that vary over time and are associated with established indicators of high-quality care, including EOL outcomes. These findings support a scalable, content-driven EPC model with direct implications for clinical implementation and future trials in hematologic malignancies.

B-cell prolymphocytic leukemia (B-PLL) is a rare B-cell neoplasm that presents splenomegaly, lymphocytosis, minimal or absent lymphoadenopathy, at least 55% of prolymphocytes in peripheral blood and a variable clinical course. Complex/composite karyotype and recurrent structural variants (SVs), including TP53 aberrations (mutations/deletion) and MYC abnormalities (translocation or gain) are genetic features typically seen in B-PLL. We applied the genome-wide technology of optical genome mapping (OGM) in 3 cases with B-PLL, finding multiple genomic aberrations, including SVs, copy number variations (CNVs) and aneuploidies. MYC aberrations were not observed in our cases, whereas all B-PLL showed concomitant deletion 17p and TP53 mutations. TP53-disrupted B-PLL cells showed additional genomic alterations that affect genes implicated in extrinsic and intrinsic apoptotic pathways i.e., TNFRSF10, FAS, MDM2, BCL2, and BCL2L11 and genes involved in cell-cycle regulation i.e., IKBKB, CDK2, CDK4, and RB1, suggesting that a convergent multifactorial pathogenetic mechanism may be involved in B-PLL. Applying the OGM technology on cytogenetically complex rare hematological neoplasia may be useful to improve the genetic definition and differential diagnosis of B PLL/SBLPN and related splenic B cell neoplasms.

Abstract We report the case of a young woman who developed aplastic anemia (AA), following a serologically confirmed primary Epstein–Barr virus (EBV) infection, occurring with fever and pharyngotonsillitis, in the absence of either palpable lymph nodes or enlarged spleen. Pancytopenia persisted after EBV DNA clearance, requiring multiple red blood cell and platelet transfusions. Given the availability of a human leukocyte antigen (HLA)-matched sibling donor (MSD), hematopoietic stem cell transplantation (HSCT) from bone marrow source was performed after a non-myeloablative conditioning regimen with cyclophosphamide and thymoglobulin. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine A and methotrexate. EBV reactivation occurred, one month post-HSCT, peaking at 28,838 DNA copies/ml in peripheral blood, without evidence of post-transplant lymphoproliferative disorder. Two pre-emptive doses of rituximab were administered, resulting in sustained EBV DNA negativity. Subsequent bone marrow evaluation showed normal cellularity and restoration of peripheral counts. After two years of follow-up, the patient remains transfusion-independent, with stable hematologic recovery, no signs of GVHD, and persistent mixed chimerism (70–75% host cells in peripheral blood; about 60% donor CD3 + lymphocytes). To our knowledge, this is the only second reported case of EBV-related AA successfully treated with MSD HSCT. This case underscores the importance of assessing EBV serology in all patients with AA, since EBV infection may be mild or subclinical, and highlights the efficacy of early rituximab administration in high-level EBV DNA reactivation after transplantation.

OBJECTIVES:To describe longitudinal changes in quality of life (QOL) and symptoms among patients with acute myeloid leukaemia (AML) receiving real-world early palliative care (EPC) during the first year after diagnosis. METHODS:This prospective observational study enrolled consecutive adults with AML followed in an outpatient EPC clinic. QOL and symptoms were assessed monthly using the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu), the Edmonton Symptom Assessment Scale (ESAS) and the Hospital Anxiety and Depression Scale (HADS). Scores were analysed through joint modelling, integrating longitudinal and survival data, and sensitivity analyses. RESULTS:Thirty-eight patients contributed 169 FACT-Leu, 151 ESAS and 111 HADS questionnaires. From baseline, median FACT-Leu scores improved from 108.7 to 135.7 at 4 months and remained stable through 8 and 12 months (p≤0.011), while ESAS scores decreased from 25.2 to 5.7 by 4 months and remained low through 12 months (p<0.001), indicating sustained symptom improvement. HADS scores showed no statistically significant changes, although a modest anxiety improvement was noted. Trajectories remained consistent across all sensitivity analyses. CONCLUSIONS:In AML patients receiving EPC in a real-world outpatient setting, QOL and symptom burden showed sustained improvement over time. These descriptive findings highlight the potential effectiveness and clinical relevance of EPC in routine AML care and provide real-world reference data for future controlled studies.

The management of chronic lymphocytic leukemia (CLL) in older patients requires careful balancing of therapeutic efficacy with the risks of treatment intolerance. Frailty assessment is increasingly recognized as a critical determinant of clinical outcomes, but its specific role in guiding therapy with second-generation Bruton tyrosine kinase inhibitors remains poorly defined. We conducted a prospective, multicenter investigation of 326 consecutive CLL patients aged 65 years or older who received zanubrutinib across 52 Italian centers, aiming to evaluate whether the Clinical Frailty Scale (CFS) could predict treatment discontinuation in real-world practice. The cohort was characterized by advanced age (median 78.1 years, range 65.1-94.5), with over half of the patients presenting with Binet stage C disease. Two-thirds were treated in the frontline setting, while the remainder received zanubrutinib as salvage therapy. After a median follow-up of 8 months, 48 patients (14.7%) discontinued treatment, most commonly due to toxicity or disease progression. Receiver operating characteristic curve analysis identified a CFS of 3 as the optimal threshold for predicting discontinuation, with an area under the curve of 0.65 (95% CI 0.56-0.73, p < 0.001). At 12 months, the discontinuation rate was significantly higher among patients with a CFS > 3 (29.2%) compared with those with a CFS ≤ 3 (8.8%) (p < 0.001); among conventional prognostic variables, only relapsed/refractory disease demonstrated an independent association with TTD. These findings highlight the CFS as a simple yet powerful clinical tool that provides incremental prognostic information beyond standard disease-related factors. Incorporating frailty assessment into treatment planning may enhance patient selection and optimize therapeutic strategies for elderly CLL patients in daily practice.

BACKGROUND:Patients with acute leukemia frequently receive aggressive treatments near the end of life (EOL) . Goals-of-care (GOC) conversations may improve EOL quality, yet few studies have investigated their impact in hematological malignancies. OBJECTIVE:To evaluate sociodemographic and clinical factors associated with GOC conversations and the impact of GOC conversations on EOL care. METHODS:A retrospective study was conducted among patients with acute leukemia and high-risk myelodysplastic syndromes, treated over a 15-year period at authors' Institution. RESULTS:Of 390 patients, 44.4% had GOC conversations. Palliative care specialists documented the first GOC discussion in 157 patients. 133 (76.9%) patients received GOC conversations within a program of early palliative care (EPC) . In multivariable analysis, age≥60 (OR 4.85; 95% CI: 2.18-10.78) , ≥2 comorbidities (OR 2.52; 95% CI: 1.03-6.2) , non-White race (OR 7.97; 95% CI: 1.13-56.32) , prior allogeneic transplantation (OR 8.74; 95% CI: 2.09-36.58) , and EPC integration (OR 16.28; 95% CI: 4.21-62.92) were significantly associated with higher likelihood of GOC discussions. Concerning EOL care, GOC conversations were associated with reduced odds of chemotherapy in the last 90 days (OR 0.41; 95% CI: 0.21-0.79) , ICU admission in the last 30 days (OR 0.20; 95% CI: 0.05-0.85) , and in-hospital death (OR 0.35; 95% CI: 0.18-0.69) . CONCLUSIONS:GOC conversations were infrequently performed and the primary factor that increased their likelihood of occurrence was EPC. When GOC conversations took place, patients experienced higher-quality EOL care. These results support increasing EPC for patients with hematologic malignancies to improve GOC conversations and their overall EOL care and, suggest EPC as a prime intervention for trials in this setting.

The colony-stimulating factor 3 receptor (CSF3R) plays an essential role in differentiation, growth, and survival of granulocytes. Driver mutations in CSF3R gene represent a diagnostic marker of chronic neutrophilic leukemia (CNL). Less commonly, these mutations are observed in other myeloid neoplasms but their pathogenetic and prognostic role is still unclear. Here, we analyzed a large cohort of myeloid neoplasms to evaluate the incidence of CSF3R mutations and co-mutational profile. Mutational analysis was performed using targeted NGS myeloid panel in a consecutive cohort of 360 patients with myeloid neoplasms. Mutations in CSF3R were identified in 20/360 (5.6%) cases. A CSF3R gene mutation was present in 13/179 AML cases (7.3%), in 2/27 (7.4%) CMML cases, in 1/94 (1.1%) MDS cases and in 4/60 (6.7%) other myeloid neoplasms. The frequencies of patients with CSF3R mutations lowered to 2.8% in all cases and 3.4% in AML, excluding cases with variants of uncertain significance (VUS). A total of 23 mutations of CSF3R gene were detected, half localized in the extracellular domain, 5 in the transmembrane region (type I) and 6 mutations in the cytoplasmic domain (type II). In AML, CSF3R mutations were more frequent in patients harboring CBF alterations (25.0%) and CEBPA mutations (11.8%). Two cases with AML harboring pathogenic CSF3R variants were primary refractory to induction therapy. CMML cases with T618I variant showed a myeloproliferative phenotype. Overall, our findings support the notion that CSF3R variants, particularly type I and II pathogenic mutations, may modulate the phenotypic features of leukemic cells in myeloid neoplasia.

Treatment-free remission is one of the most important goals of CML treatment but so far, the best treatment to reach this aim is still undefined, even though it is widely accepted that a sustained DMR is the prerequisite to discontinue TKI. Here we report on the depth of the molecular response, the first co-primary end point of the SUSTRENIM study, in a cohort of newly diagnosed CP-CML patients randomized 1:1 to be treated with nilotinib or with imatinib followed by switching to nilotinib in absence of optimal response. Of the 448 enrolled patients, 228 and 220 were randomized to the nilotinib (NIL) and imatinib (IM) arms, respectively, and followed for a median of 45.9 months. Eighty-two (37.2%) of the 220 patients on the IMarm did not fulfill the ELN criteria for optimal response of treatment and switched to nilotinib therapy. At the 24 months of follow-up, 107 of the 448 patients reached an MR4.5 response with a significantly higher frequency within the patients on the nilotinib arm (65 vs 42; p = 0.02). The analysis of the first primary endpoint indicates that, despite the early switch in the IM-randomized patients, NIL therapy is more effective to induce DMR.

ABSTRACT:Octogenarians represent a significant fraction of patients with chronic lymphocytic leukemia (CLL) but, despite the prevalence of the disease in this age group, limited data are available on the safety and efficacy of novel drugs in this subgroup. We conducted a multicenter retrospective study enrolling 120 octogenarian patients who received venetoclax (Ven) regimens in any line. Regarding efficacy, we found Ven to perform similarly to what is reported in younger patients with CLL, with an overall response rate of 91%, a complete response rate of 44%, and median progression-free survival of 44 months. Concerning safety, we report a toxicity profile that is consistent with previous reports, with most high-grade adverse events being of hematologic or infectious nature, given that 37% and 22% of patients experienced neutropenia or infections of grade 3 or higher. As part of our study, we compared the safety and efficacy data we collected with those obtained in a comparable Bruton tyrosine kinase inhibitor (BTKi)-treated population. We found that these 2 treatments were comparable in terms of overall efficacy, barring a higher rate of complete responses with Ven; safety profiles were different among the 2 groups given that BTKi-treated patients had more cardiovascular toxicities (26% vs 4%) and Ven-treated subjects experienced more infectious events (82% vs 49%). Our data point out that Ven-based regimens are safe and effective in octogenarian patients with CLL despite their higher clinical complexity and comorbidity burden and should provide some basis for the design of prospective studies to further evaluate the optimal treatment regimen in this patient population.

ABSTRACT:We investigated the influence of 55 583 autophagy-related single-nucleotide polymorphisms (SNPs) on chronic lymphocytic leukemia (CLL) risk across 4 independent populations comprising 5472 CLL cases and 726 465 controls. We also examined their impact on overall survival (OS), time to first treatment (TTFT), autophagy flux, and immune responses. A meta-analysis of the 4 populations identified, to our knowledge, for the first time, significant associations between CDKN2A (rs3731204) and BCL2 (rs4940571, rs12457371, and rs1026825) SNPs and CLL risk, with CDKN2A showing the strongest association (P = 1.57 × 10-12). We also validated previously reported associations for FAS, BCL2, and BAK1 SNPs with CLL risk (P = 4.73 × 10-21 to 3.39 × 10-9). The CDKN2Ars3731204 and FASrs1926194 SNPs associated with increased CDKN2A and ACTA2 messenger RNA expression levels in the whole blood and/or lymphocytes (P = 5.1 × 10-7, P = 1.58 × 10-21, and P = 7.8 × 10-41), although no significant effect on autophagy flux was observed. However, associations were found between CDKN2A, BCL2, and FAS SNPs and various T-cell subsets, cytokine production, and circulating concentrations of interferon gamma, tumor necrosis factor-related apoptosis-inducing ligand, CD40, chemokine ligand 20, and interleukin-2 receptor subunit β proteins (P ≤ .005). No significant association was detected between autophagy variants and OS or TTFT, suggesting that these variants drive disease initiation rather than progression. In conclusion, this study identified 4 novel associations for CLL and provided insights into the biological pathways that influence CLL development.

We aimed to explore the prognostic value of patient-reported health-related quality of life (HRQoL) data for the achievement of early molecular response (EMR) at 3 months in patients with chronic phase chronic myeloid leukemia (CP-CML). We analyzed HRQoL baseline data of 436 newly diagnosed patients with CML patients enrolled in the GIMEMA Sustrenim trial. HRQoL was assessed by the EORTC QLQ-30 and the QLQ-CML24 questionnaires. In the multivariate analysis, the following factors were found to be independently associated with achievement of EMR: Sokal risk (low vs intermediate risk p=0.046 and low vs high risk p<0.001), nilotinib treatment (p<0.001) and higher patient-reported role functioning (EORTC QLQ-C30) (p<0.001). Current findings suggest the importance of assessing HRQoL at diagnostic workup of patients with CML as it may provide valuable prognostic information.

Background: Venetoclax + an anti-CD20 antibody has shown deep remissions and long-term immune recovery in patients (pts) with relapsed/refractory CLL (Kater et al. Hemasphere 2024). Immunological effects of this combination in 1L CLL are not fully characterized. The CRISTALLO Phase III trial compared the efficacy and safety of fixed duration (FD) VenO vs fludarabine-cyclophosphamide-rituximab/bendamustine-rituximab (FCR/BR) in fit pts with treatment (Tx)-naïve CLL (Sharman et al. ASH 2024). Immune dynamics during and after VenO Tx and correlation of immune recovery patterns with minimal residual disease (MRD) status were explored. Methods: Pts were randomized 1:1 to VenO or FCR/BR. The primary endpoint was undetectable MRD (uMRD; <10-4) rate at Month 15 in peripheral blood (PB). Key secondary endpoints included progression-free survival. Immune profiling was performed at baseline, during Tx, and every 3 months (mos) up to 48 mos post-Tx in pts stratified by MRD status at Month 15 (<10-4) in PB. A flow cytometry panel was developed to identify non-malignant B cells (CD3/CD24/CD56-CD19+ and excluding CD19+CD20dim/negCD5+CD23+CD79bdim/neg) vs CLL cells (CD19+CD20dim/negCD5+CD23+CD79bdim/neg) in PB. Serial measurements included lymphocyte subsets (CD4+/CD8+ T cells and NK cells), immunoglobulin (Ig) levels (IgG, IgA, IgM), and detailed B-cell compartment analysis. Results: Overall, 80 and 86 pts were randomized to VenO and FCR/BR, respectively; 81.3% (VenO) and 54.7% (FCR/BR) achieved uMRD at Month 15. Non-malignant B-cell and CLL cell profiling was performed for 80 pts at baseline and on-Tx in the VenO arm, and 84 pts at baseline in the FCR/BR arm. Lymphocyte subsets (n=72) and Ig profiles (n=77) were assessed pre- and post-VenO up to 48 mos follow-up (FU). At baseline, no significant differences in levels of CLL cells, non-malignant B cells, CD4+ T cells, CD8+ T cells, NK cells, and Igs were observed between Tx arms in both uMRD and MRD+ groups. Analysis of CD19+ cells (capturing CLL and non-malignant B cells) during VenO Tx showed a marked depletion at 12 mos FU. In the uMRD group, CLL cells remained suppressed up to 36 mos FU (median: 3.9 CLL cells/µL). In contrast, in the MRD+ group, CLL cells were not fully depleted at 12 mos FU (median: 28.9 CLL cells/µL) and rebounded rapidly, showing a 10-fold increase by 18 mos FU (median: 315.1 CLL cells/µL). Non-malignant B cells were relatively less depleted with Tx vs CLL cells (median: 66.9 and 51.8 cells/µL in the uMRD and MRD+ groups, respectively). Notably, the MRD+ group showed a faster recovery of non-malignant B cells over time, with median counts rising to 373.3 cells/µL at 24 mos FU vs 127.9 cells/µL in the uMRD group. However, recovery was partial and did not return to baseline in the uMRD group (1127.7 cells/µL). Similar to B-cell recovery kinetics, NK cells showed gradual immune reconstitution after transient depletion at 6 mos FU in the VenO arm. However, recovery of CD4+ and CD8+ T cell counts was delayed and did not return to baseline by 48 mos FU, irrespective of MRD status. Ig levels, including IgG, IgM, and IgA, showed a significant but transient decline after VenO Tx, with the lowest levels seen at 3 mos FU, followed by signs of recovery from 9 mos FU. IgM levels were 0.22 g/L at baseline (n=63), 0.14 g/L at 3 mos FU (n=13), 0.19 g/L at 12 mos FU (n=55), 0.315 g/L at 24 mos FU (n=48), and 0.335 g/L at 36 mos FU (n=28), mirroring non-malignant B-cell recovery patterns. Consistent with the facilitated non-malignant B-cell recovery in the MRD+ group, median IgG, IgA, and IgM levels were all numerically higher in the MRD+ vs the uMRD group across all time points. Additional assessment on the impact of Igs on grade ≥3 infection will be presented. At final data cutoff (19 Mar 2025; median FU: 41 mos), fewer pts had progressed/died with VenO vs FCR/BR (14 vs18; p=0.399). There were no new deaths since the primary analysis and no new safety signals were identified with VenO. Conclusions: CRISTALLO demonstrated that FD VenO causes differential effects on malignant and non-malignant B-cell populations, with sustained CLL cell depletion in pts achieving uMRD alongside B-cell recovery, delayed T-cell recovery and effective Ig reconstitution. Findings extend previous observations and confirm that immune reconstitution can occur while maintaining deep remissions. Furthermore, final analysis results continue to support the efficacy and safety of FD VenO.

Background Today, an important final endpoint in the management of chronic phase chronic myeloid leukemia (CP-CML) patients is the achievement of a sustained and deep molecular response (DMR) for subsequent discontinuation of therapy (treatment free remission - TFR). The selection of first-line TKI when the goal of therapy is TFR is still controversial, particularly in elderly patients with comorbidities in whom therapy with a more potent second-generation TKI could be associated with toxicities due to medium- or long-term off-target effects. The SUSTRENIM study is an international, prospective study comparing not only the rate of DMR but, more importantly, the rate of TFR in newly diagnosed CML patient randomized to receive NIL vs IM frontline followed by systematic switching to NIL in case of non-optimal response (Clinical Trial number 02602314). Methods Patients are stratified at randomization according to the Sokal risk score (high versus intermediate/low risk) and country. All the patients who obtained a reduction greater than 4.0 logs of residual disease (MR4.0) within the first three years of treatment and maintained or improved this level of response in all the subsequent tests up to the end of the fourth years of therapy qualified for treatment discontinuation phase of the study. In the present analysis we compared, in the two arms of the trial, the rate of patients eligible to discontinuation after at 48 months of therapy and of those who showed a successful TFR after 12 months after TKI withdrawal. In addition, the rate of TFR was also analyzed for the patient features (i.e. age, gender, ELTS and Sokal risk, BCR::ABL1 isoform) using Fisher's exact test or Wilcoxon according to variable type. Results Overall, 448 patients consecutively enrolled in the study were randomized to the NIL (N = 228) and IM (N = 220) arms of the study. Of these, 258 patients (58%) were male and 190 (42%) were female, and the median age was 54 years (range, 19-86) with 20% and 28% aged >65 years in the NIL and IM arms, respectively. Overall, the percentage of high-risk patients was 16% according to the Sokal score and 9% for the ELTS score. Of the 448 randomized patients, 151 were eligible for TFR entry after the first 48 mo. of observation (median 58 mo.) at the time of the present analysis and were evenly distributed between the two arms of the trial (77 in the IM and 74 in the NIL arm, respectively). After 6 and 12 mo. of follow-up, 72.1% (95% CI: 64.8-80.3) and 65.2% (95% CI: 57.3-74.1) of these patients were still in TFR. Interestingly, multivariate analysis showed that only two independent factors predict successful TFR: treatment arms (IM vs NIL) and ELTS score (Low vs Int/High) but not the Sokal risk nor age or others. Consistently, 75.0% (95% CI: 65.1-86.5) of patients randomized in the NIL arm were in TFR at 12 mo. vs 55.2% (95% CI: 44.0-69.3) of those in the IMA arm (p<0.02) at K-M analysis. Still more impressive the differences between the TFR rate at 12 mo. between the ELTS low risk patients of the two arms of the study. Indeed, 67.5% of ELTS low patients of the IMA arm vs 86.1% of the NIL arm remained in TFR at 6 months and 58.6% vs 84.0% at 12 months of follow-up (p=0.0041). On the other hands, no differences were observed between the two arms of treatments when we selected only ELTS low/int patients. Noteworthy, severe non-cardiovascular events were rather infrequent and well balanced between the two arms of the study while either vascular and cardiac events were more frequently observed in patients randomized to NIL arm. However, we observed only two cardiac-related deaths, one in the patient treated with NIL and the other in the patient treated with IM. Conclusions This study demonstrates that, if the final goal is TFR an aggressive therapeutic strategy can be pursued in all patients. First-line therapy with second-generation TKIs is feasible and more effective to achieve a deep and early molecular response and, consequently, a higher TFR rate compared to IM despite the optimization with early switch to NIL in case of suboptimal response. This appears to be particularly true in case of low ELTS risk patients, regardless of their age, gender or other baseline features. On the other hand, in patients at intermediate or high ELTS risk, the benefit of NIL frontline is negligible if the aim of the therapy is TFR achievement.

B-cell prolymphocytic leukemia (B-PLL) is a rare lymphoproliferative disorder characterized by splenomegaly, lymphocytosis, and poor prognosis. Treatment options are limited, with modest responses to chemo-immunotherapy. We present two elderly patients with B-PLL treated with Zanubrutinib, a second-generation BTK inhibitor, achieving good disease response and tolerance. Both had TP53 deletion/mutations and high-risk complex karyotype. They obtained partial remission with normalization of hematologic parameters and spleen size. Given the rarity of the disease, further studies are needed to define treatment strategies, but Zanubrutinib appears to be a promising drug in this rare orphan drug disease.

Introduction. Expression of the CD49d integrin chain has prognostic impact on ibrutinib (IB)-treated CLL patients (Tissino et al, J Exp Med, 2018; Tissino et al, Blood 2020). In addition, a 4-factor (4-f) score, based on TP53 aberration, β2-microglobulin (β2M), lactate dehydrogenase (LDH) and previous therapy lines was proposed to identify patients at a higher risk of treatment failure or death during IB therapy (Ahn et al, J Clin Oncol, 2020; Morabito et al, Am J Hematol, 2021). The clinical impact of TP53 disruption was recently refined by demonstrating that only the co-presence of TP53 deletion and mutations, and not the single aberrations, has prognostic value in the IB setting (Bomben et al, Leukemia 2022). The aim here is to integrate these observations in a comprehensive scoring for the management of IB-treated patients. Methods. This study is a retrospective/multicenter analysis of 410 CLL patients treated with IB in the current clinical practice (December/2013-March/2021). Outcome data were updated as of March/2023. Median follow-up from IB treatment was 29.5 months (95% CI 26.7-33.1 months); 57 patients were treatment naïve (0 previous lines), while 353 had ≥1 previous lines. CLL patients were characterized for CD49d expression and for the 4-f variables, TP53 disruption was evaluated by FISH and TP53 mutational status by NGS (low-VAF mutations included). OS or PFS were measured from the date of IB treatment to the date of death (OS), or progression/death (PFS) or last follow-up. Results. 1) The canonical 4-f was applied as previously described, identifying 111 low-, 163 intermediate (int)-, and 136 high-risk patients. Patients in the low-risk group had a longer OS than patients in the int-, and high-risk groups ( P=0.0115 and P=0.0011), while no difference was found comparing patients in the int- vs. high-risk groups (P=0.3036). 2) We generated a modified version of the 4-f score by considering: i) as TP53 disrupted only patients presenting a concomitant TP53 deletion and mutation (n=93); ii) since no difference in terms of OS was found comparing previously untreated patients (n=57) and patients treated with 1 previous line (n=157; P=0.78), these two groups were combined (n=214) and kept separated from patients who had received >1 previous lines of therapy (n=196). Accordingly, the 4-f-modified identified 218 low-, 109 int-, and 83 high-risk patients, the 3 groups presented different OS, the latter model outperforming the canonical 4-f score (C-indices 0.616 vs 0.639; P<0.0001). 3) CD49d-high CLL cases (i.e. CLL with CD49d expression ≥30% and/or with CD49d-bimodal expression; n=268) had shorter OS and PFS intervals ( P=0.0005 and 0.0194, respectively) than CD49d-low cases (n=142). By combining these observations, CD49d remained an independent prognostic factor for OS ( P=0.004) in a multivariable model, which included the 4-f-modified int-risk ( P=0.0585) and high-risk ( P=0.0011) groups. Driven by these findings, we re-analyzed the single parameters of the 4-f score along with CD49d expression. According to a new multivariable analysis (Fig. A), LDH was not included in the final model, which in turn included CD49d expression as independent OS predictor ( P=0.0011). 4) We then redesigned a novel 4-f model excluding LDH data in favor of CD49d expression data (4-factor-CD49d). Each of the four factors contributed one point and stratified patients (n=407/410) into three groups with a significantly different risk for OS probability, merged on a one-to-one risk group comparison basis: score 0-1, low-risk (n=185); score 2-3, int-risk (n=211); score 4, high-risk (n=11; Fig. B). The inclusion of CD49d into this novel 4-f model improved its prediction capability (C-index=0.663; P<0.0001 versus both the original 4-f and the 4-f-modified). Similar results were obtained when considering PFS as clinical readout. Conclusions. Evidence is provided that in the context of CLL patients treated with IB in a real-world setting, variables like B2M, the number of previous lines of therapy and assessment of TP53 disruption remain important tools for identifying patients at a higher risk of relapse/death. Here we emphasize the need of a comprehensive assessment of TP53 aberrations considering TP53 deletions and mutations simultaneously, and propose to add the assessment CD49d expression, integrating these four variables into a novel 4-f-CD49d scoring system. Further validation in independent cohorts is needed.