Anti-CD19 Chimeric Antigen Receptor T-cell (CAR-T) therapy has emerged as a key treatment option for patients with relapsed or refractory large B-cell lymphoma (LBCL). However, data on its effectiveness and safety in elderly populations remain limited, particularly in real-world clinical practice. Moreover, comparative outcomes among different CAR-T products across age groups have not yet been fully characterized. We conducted a nationwide retrospective cohort study using data from the Japanese Society for Transplantation and Cellular Therapy. A total of 908 patients who received CAR-T therapy between January 2019 and September 2024 were included. Patients were categorized as younger (<65 years) or elderly (≥65 years). Subgroup analyses were performed by CAR-T product (tisagenlecleucel, lisocabtagene maraleucel, and axicabtagene ciloleucel). In univariate analysis, 1-year overall survival (OS) and progression-free survival (PFS) were comparable between younger and elderly patients (OS: 69.4% vs. 65.7%, P = 0.40; PFS: 47.9% vs. 54.1%, P = 0.17). In multivariate analysis, age ≥65 showed no significant association with OS (HR: 0.89, 95% CI: 0.65–1.21, P = 0.45). The incidence of immune effector cell-associated neurotoxicity syndrome was significantly higher in elderly patients (12.7% vs. 7.0%, P = 0.005). Compared with tisa-cel, axi-cel and liso-cel were associated with superior PFS, but predominantly in younger patients. Among elderly patients, axi-cel was associated with the higher non-relapse mortality rate compared with tisa-cel. CAR-T therapy is feasible and effective for elderly patients with LBCL. These findings support age-adapted treatment strategies that consider both efficacy and toxicity of each product.

Abstract: Real-world CD19 chimeric antigen receptor (CAR) T-cell therapy for large B-cell lymphoma (LBCL) is characterized by expanded eligibility and evolving management practices. However, the prognostic impact of these changes remains inconsistent, and the specific drivers of outcomes remain unclear. This study analyzed 913 patients with relapsed/refractory (R/R) LBCL from a Japanese registry and compared the outcomes between 2 calendar periods (2019-2021 vs 2022-2024). The 2022-2024 cohort was older, had more adverse baseline features, and was less pretreated. Treatment patterns have shifted toward higher utilization of second-line therapy, a growing preference for axicabtagene ciloleucel (axi-cel) and lisocabtagene maraleucel (liso-cel), and improved disease control before infusion. Accordingly, the 2022-2024 cohort achieved a longer progression-free survival (PFS; 6-month PFS, 63.2% vs 55.2%; P = .005), which persisted after adjusting for baseline characteristics using propensity score matching. Multivariable analysis identified second-line therapy, improved preinfusion disease control, and a shift in product selection from tisagenlecleucel to axi-cel or liso-cel as the primary drivers of this improvement. This benefit was pronounced in high-risk populations, including patients with stable or progressive disease at infusion (6-month PFS, 54.6% vs 43.8%; P = .012) and those who were refractory to first-line therapy (6-month PFS, 51.7% vs 40.3%; P = .013). Despite broader use in higher-risk populations and greater axi-cel exposure, 6-month nonrelapse mortality remained low (2.1% vs 1.5%). Real-world outcomes of CD19 CAR T-cell therapy for R/R LBCL have improved, predominantly driven by second-line therapy, enhanced preinfusion disease control, and increased use of more potent CAR T products.

INTRODUCTION:Chimeric antigen receptor (CAR)-T cell therapies targeting CD19 have shown efficacy against B-cell malignancies. However, they frequently cause immune effector cell-associated neurotoxicity syndrome (ICANS), which can be life-threatening and require intensive care. Even when it is not severe, ICANS can lead to prolonged hospitalization and limit treatment options, especially for elderly patients. Despite its clinical significance, a reliable, early predictive marker for ICANS has not been identified. METHODS:To identify risk factors for ICANS, we retrospectively analyzed B-cell lymphoma patients who received tisagenlecleucel (tisa-cel), lisocabtagene maraleucel (liso-cel), or axicabtagene ciloleucel (axi-cel) at Kyoto University Hospital from 2019 to 2024. RESULTS:Among 106 patients, 76 received tisa-cel, 22 liso-cel, and eight axi-cel. Median age at infusion was 63.5 years (interquartile range, 57-69). Eight patients (8%) had a history of central nervous system (CNS) involvement. ICANS occurred in 17 patients (16%), all with prior cytokine-release syndrome (CRS). Reticulocyte counts at infusion were significantly lower in patients who subsequently developed ICANS (1.57 versus 2.80 × 104/μL, P < 0.01). Multivariate analysis identified a low reticulocyte count at infusion (HR, 3.67; 95% CI, 1.23-11.02; P = 0.02), history of CNS involvement (HR 8.37; 95% CI, 3.04-23.04; P < 0.01), and axi-cel (HR, 4.56; 95% CI, 1.88-11.09; P < 0.01) as independent risk factors. Patients divided by the median reticulocyte count at infusion (2.57 × 104/μL) demonstrated significantly higher 30-day cumulative incidence of ICANS in those with lower counts (25.5% versus 7.8% at 30 days; P = 0.018). CONCLUSION:Reticulocyte counts at infusion, a simple hematological parameter, may help predict ICANS development and guide optimal risk-based management of chimeric antigen receptor (CAR)-T cell therapy.

Cytokine release syndrome (CRS) remains a major toxicity of chimeric antigen receptor (CAR) T-cell therapy in large B-cell lymphoma (LBCL), and robust pre-infusion predictors are needed for risk-adapted management. We retrospectively analysed LBCL patients in the Japanese nationwide registry who underwent CD19 CAR-T-cell therapy between 2019 and 2024. Among 900 patients (median age 62 years), cumulative incidences of CRS within 30 days after infusion were 75.0% for any grade, 20.8% for grade ≥ 2 and 14.0% for grade ≥ 3. In multivariable analysis, lower estimated glomerular filtration rate (eGFR) (adjusted hazard ratio [aHR] 1.108 per 10 mL/min per 1.73 m2 decrease; 95% confidence interval [CI] 1.015-1.209; p = 0.022), higher ferritin (aHR 1.006 per 100 ng/mL; 95% CI 1.001-1.010; p = 0.016), C-reactive protein (CRP) (aHR 1.142 per mg/dL; 95% CI 1.091-1.195; p < 0.001) and lactate dehydrogenase (LDH) (aHR 1.073 per 100 U/L; 95% CI 1.008-1.142; p = 0.028) independently predicted grade ≥ 2 CRS. We then built a four-factor CRS pre-infusion risk evaluation model, cytokine release syndrome-pre-infusion risk evaluation (CRS-PRE), that stratified grade ≥ 2 CRS risk into low, intermediate and high groups with incidences of 2.8%, 26.0% and 50.0% respectively. Decreased eGFR, a surrogate of host renal reserve, with elevated ferritin, CRP and LDH emerged as predictors of high-grade CRS. The CRS-PRE may facilitate risk-adapted monitoring and intervention in clinical practice.

Anti-CD19 chimeric antigen receptor T cell (CAR-T) therapy is highly effective for B cell precursor acute lymphoblastic leukemia (BCP-ALL); however, approximately half of the patients relapse. Thus, there is an urgent need to identify factors that improve efficacy. This study enrolls 19 patients with BCP-ALL (16 children and 3 young adults) who receive tisagenlecleucel. Infusion products, peripheral blood, and bone marrow samples are obtained before and after CAR-T cell infusion. Single-cell analysis reveals that central memory CARpos T cells increase in long-term responders, whereas CXCR3+CD38highPD-1high effector CARpos T cells are enriched in relapsed patients, post-infusion. By contrast, CARpos T cells obtained from infusion products in long-term responders are enriched in the CD38-CD73-Tim-3-HLA-DR+ phenotype, characterized by a decreased ability to produce adenosine, memory-like transcriptomic characteristics, and leveraging of mitochondrial metabolism and oxidative phosphorylation. Our study reveals that the CD38-CD73-Tim-3-HLA-DR+ phenotype contributes to long-term remission in patients with BCP-ALL who receive tisagenlecleucel.

Chimeric antigen receptor (CAR) T-cell therapy is effective for treating relapsed or refractory B-cell lymphoma; however, its outcomes remain heterogeneous. We conducted a nationwide retrospective registry study in Japan to assess whether pretreatment body mass index (BMI) influences outcomes after CD19-directed CAR T-cell therapy. Among 944 patients with relapsed or refractory B-cell lymphoma treated between 2019 and 2024, BMI was categorized as Low (<18.5 kg/m²; n = 166), Normal (18.5 to 24.9 kg/m²; n = 619), or High (≥25 kg/m²; n = 159). The primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), cumulative incidence of relapse or progression (CIR), non-relapse mortality (NRM), and CAR T-cell-related toxicities. Six-month OS rates in the low, normal, and high BMI groups were 73.2%, 83.7%, and 89.3%, respectively (P < .01), and corresponding PFS was 62.3%, 75.6%, and 77.7% (P < .01). CIR was more frequent in the Low-BMI group, whereas NRM did not differ significantly across groups. In the overall cohort, Low-BMI was associated with shortened OS and PFS and higher CIR in multivariable analyses. In a complete-case sensitivity analysis restricted to patients with available disease status data at the time of infusion, these associations were attenuated after adjusting for disease status. Severe CAR T-cell-related toxicities were comparable across BMI groups. Pretreatment BMI may serve as a simple clinical marker associated with early outcomes after CAR T-cell therapy, although this association may be partly explained by disease status at infusion or unmeasured disease burden.

CD19-directed chimeric antigen receptor (CAR) T-cell therapy has markedly improved outcomes for patients with relapsed or refractory B-cell malignancies, although coagulopathy characterized by hypofibrinogenemia has increasingly been recognized as a complication after CAR T-cell therapy. Nevertheless, its contemporary real-world incidence, risk factors, and clinical impact remain incompletely defined. This study aimed to determine the real-world incidence, risk factors, and clinical impact of hypofibrinogenemia following CD19-directed CAR T-cell therapy for relapsed or refractory B-cell lymphoma. This retrospective cohort study included all consecutive adult patients (≥16 years) with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma (FL) who received tisagenlecleucel (tisa-cel), lisocabtagene maraleucel (liso-cel), or axicabtagene ciloleucel (axi-cel) at Kyoto University Hospital between December 2019 and December 2024. We also evaluated detailed CRS severity according to modified CRS grading (m-CRS), in which grade 1 was subdivided into grade 1a (duration of CRS-related symptoms ≤5 days) and grade 1b (duration of CRS-related symptoms >5 days), as previously described; grade 1b CRS was defined as "prolonged CRS." A total of 111 patients (74 tisagenlecleucel [tisa-cel] [67%], 24 lisocabtagene maraleucel [liso-cel] [22%], and 13 axicabtagene ciloleucel [axi-cel] [12%]) were included. Hypofibrinogenemia (fibrinogen ≤150 mg/dL) was observed in 28 patients (25%) within 30 days after infusion (median onset, 10.5 days). FFP was administered to 15 patients (14%). Multivariable analysis revealed that grade ≥1b CRS (adjusted hazard ratio [aHR], 4.59; 95% confidence interval [CI], 1.89 to 11.14; P < .01), lower baseline fibrinogen levels (aHR, 1.07 per 10 mg/dL decrease; 95% CI, 1.02 to 1.14; P = .01), and axi-cel use (versus tisa-cel: aHR, 3.29; 95% CI, 1.38 to 7.83; P < .01) were independently associated with hypofibrinogenemia. In our cohort, no fatal bleeding events occurred. Hypofibrinogenemia was not associated with inferior overall survival or progression-free survival. Prolonged CRS (grade 1b) or grade ≥2 CRS, lower baseline fibrinogen, and use of axi-cel were independently associated with hypofibrinogenemia. Risk-adapted fibrinogen monitoring may help identify patients who could benefit from closer surveillance, and timely fibrinogen replacement may optimize supportive care. Further multicenter studies are warranted to validate these findings and clarify the clinical impact of hypofibrinogenemia, including hemorrhagic outcomes.

Although chimeric antigen receptor (CAR)-T cell therapies are highly effective for B-cell lymphoma, they frequently cause cytokine release syndrome (CRS). High-grade CRS is serious and may require intensive care, yet reliable early predictive markers remain elusive. To identify risk factors for high-grade CRS, we retrospectively analyzed B-cell lymphoma patients who received CD19 CAR-T cell therapy. Of 106 patients analyzed, CRS occurred in 93 (88%), Grade ≥ 2 CRS in 28 (26%), and Grade ≥ 3 CRS in 6 (6%). Reticulocyte counts at infusion were significantly lower in patients who developed Grade ≥ 2 CRS (1.85 vs. 2.80 × 10 4 /µL, p = 0.02). Multivariate analysis identified low reticulocyte count (< 15,000/µL; HR 2.21; 95% CI 1.01–4.86; p = 0.048), high metabolic tumor volume (> 100 mL), and use of axicabtagene ciloleucel as independent risk factors for Grade ≥ 2 CRS. Stratification by the reticulocyte cutoff showed higher 30-day cumulative incidence of CRS in patients with low counts, for both Grade ≥ 2 (42.9% vs. 19.7%, p = 0.012) and Grade ≥ 3 CRS (17.9% vs. 1.3%, p < 0.001). KyoTox-CRS, a risk-scoring system integrating these factors, effectively stratified these CRS risks. Early prediction of high-grade CRS based on the reticulocyte count at infusion may help to guide optimal risk-based management of CAR-T cell therapy.

Patients undergoing hematopoietic stem cell transplantation (HSCT) often receive multiple antibiotics and antifungal agents concurrently, making it crucial to understand potential pharmacokinetic interactions. We report here an interaction between the glycopeptide antibiotic teicoplanin (TEIC) and sulfo-butyl ether-β-cyclodextrin (SBECD), a solubilizing excipient in the intravenous formulation of posaconazole (PSCZ). We performed a single-center retrospective analysis of HSCT patients who received oral and intravenous PSCZ during TEIC therapy. Associations between PSCZ administration and TEIC concentration-to-dose (C/D) ratios were evaluated using linear mixed-effects models. In rats, we examined the effects of intravenous PSCZ and SBECD on TEIC pharmacokinetics by assessing the area under the concentration–time curve (AUC) and urinary excretion of total TEIC and its components. Molecular docking and in vitro protein-binding assays were also conducted to investigate the interaction between TEIC and SBECD. In HSCT patients, TEIC C/D ratios were significantly lower during intravenous PSCZ administration but not during oral PSCZ use. In rats, both intravenous PSCZ and SBECD decreased TEIC AUC and increased urinary excretion, particularly for the A2 group. Docking simulations indicated that the hydrophobic side chain of TEIC A2-2 fit within the SBECD cavity, and in vitro assays confirmed SBECD concentration-dependent increases in TEIC unbound fractions. Co-administration of intravenous PSCZ containing SBECD may reduce TEIC protein binding, thereby enhancing renal elimination.

ABSTRACT Background In febrile neutropenia (FN), the empirical use of anti‐methicillin‐resistant Staphylococcus aureus (MRSA) drugs is recommended, particularly when mucosal damage occurs during fluoroquinolone antibiotic administration. Therefore, the early use of anti‐MRSA drugs may be recommended in many cases of FN after allogeneic hematopoietic cell transplantation (allo‐HCT), but the evidence regarding their efficacy is limited. Objectives To assess the impact of early administration of anti‐MRSA drugs on the resolution of fever in patients undergoing allo‐HCT. Methods We retrospectively analyzed 186 allo‐HCT patients. Patients receiving anti‐MRSA drugs within 3 days of fever onset formed the early‐decision group; those treated on or after Day 4 or untreated formed the late‐decision group. Results The early group showed a significantly shorter fever duration than the late group. (p = 0.044). Multivariate logistic regression analysis showed the late group was negatively associated with fever resolution by Day 7 (OR: 0.45, 95% CI: 0.22–0.92, p = 0.028). No significant correlation was observed between anti‐MRSA drug timing and acute graft‐versus‐host disease (aGVHD) in the entire cohort. However, among patients aged 51 or older, the late group showed increased risk of aGVHD (HR: 2.22, 95% CI: 1.06–4.64, p = 0.034). Conclusions Associations were observed between the timing of anti‐MRSA drug administration and clinical outcomes in allo‐HCT, including fever resolution and the incidence of aGVHD in older patients. Trial registration The authors have confirmed clinical trial registration is not needed for this submission.

Venetoclax-azacitidine chemotherapy is a key treatment for older or medically unfit patients with acute myeloid leukemia (AML). As venetoclax is metabolized via cytochrome P450 3 A, dose adjustments are required when combined with antifungal agents. However, data on venetoclax concentrations and their impact on safety and efficacy remain limited. This study analyzed the association between venetoclax trough levels and treatment outcomes in 152 AML patients (median age: 70 years). The median trough level was 1,518 ng/mL (range: 60-11,328 ng/mL), with significant interindividual variability, even after adjusting for antifungal use. High venetoclax trough levels were significantly associated with elevated creatinine and total bilirubin levels. Patients with trough levels below 1857.3 ng/mL had lower rates of hematologic toxicity during the first treatment cycle (92.9% vs. 100%, P = 0.041). In the second cycle, hematologic toxicity was lower in patients with concentrations below 1,299.3 ng/mL (68% vs. 90%, P = 0.009). In the treatment-naïve group, trough levels above 1857.3 ng/mL were associated with a higher composite complete remission rate (77.3% vs. 47.8%, P = 0.042). These findings highlight the need for venetoclax dose optimization based on drug levels to improve both safety and efficacy in AML treatment.

BACKGROUND:Granulocyte colony-stimulating factor (G-CSF)-based mobilization is essential for peripheral blood stem cell (PBSC) collection for allogeneic transplantation. Conventional daily G-CSF requires repeated dosing and dose adjustment and often necessitates leukapheresis over multiple consecutive days, increasing donor burden. Single-dose pegfilgrastim has emerged as an alternative; however, real-world data on its impact on CD34+ cell collection in healthy donors remain limited. STUDY DESIGN AND METHODS:Healthy related or unrelated donors who received either a single dose of pegfilgrastim or daily filgrastim and subsequently underwent PBSC collection at Kyoto University Hospital between July 2014 and September 2025 were included. CD34+ cell harvest outcomes and donor burden were compared. RESULTS:A total of 39 donors were analyzed (20 pegfilgrastim, 19 filgrastim), with comparable baseline characteristics. At the start of leukapheresis, peripheral blood white blood cell counts were significantly higher in the pegfilgrastim group. Pegfilgrastim achieved greater total CD34+ cell yield (median 398.0 × 106 vs. 302.4 × 106 cells, p = .025) and higher yields per 10 L of processed blood (median 407.8 × 106 vs. 302.4 × 106 cells, p = .032). Single-session leukapheresis was more frequent with pegfilgrastim (95.0% vs. 63.2%, p = .002), and the estimated processing time required to collect 2 × 106/kg CD34+ cells was shorter (median 62.7 vs. 111.1 min, p = .040). No severe adverse events were observed. DISCUSSION:These findings suggest that single-dose pegfilgrastim enables more efficient PBSC collection with reduced donor burden and may represent a practical mobilization strategy in healthy allogeneic donors.

INTRODUCTION:Lysozyme-associated nephropathy (LyN) is an underrecognized cause of kidney dysfunction, commonly associated with chronic myelomonocytic leukemia (CMML). CASE PRESENTATION:We present 2 cases of LyN with distinct clinical manifestations. In Case 1, an 80-year-old man with primary myelofibrosis developed progressive monocytosis, kidney dysfunction, proteinuria, and elevated serum and urinary lysozyme levels. Kidney biopsy revealed lysozyme-positive intracytoplasmic granules within proximal tubular cells, confirming the diagnosis of LyN. Notably, the progressive increase in the number of lysozyme-positive bone marrow cells may serve as an indicator of LyN activity. Treatment with hydroxycarbamide, a cytoreductive agent, and ruxolitinib, a Janus kinase inhibitor, successfully stabilized kidney function. In Case 2, a 63-year-old man with CMML developed acute kidney injury. Although the etiology of kidney dysfunction could not be determined during life, autopsy revealed diagnostic features of LyN. To further investigate LyN pathophysiology, we performed the first mass spectrometry-based proteomic analysis of proximal tubules in 2 cases. LyN samples showed marked lysozyme accumulation and upregulation of proteins involved in lysosomal system, lipid metabolism, cellular stress, and chronic inflammation. These findings suggest that chronic lysozyme overload disrupts intracellular homeostasis and contributes to kidney injury. CONCLUSION:LyN is underdiagnosed as unexplained tubular damage or chronic kidney disease, highlighting the need for awareness of the clinicopathological features.

CD19-directed chimeric antigen receptor T-cell (CAR-T) therapy has transformed the treatment landscape of relapsed or refractory (r/r) B-cell lymphoma. Despite its remarkable efficacy, CAR-T therapy is associated with a spectrum of acute and late toxicities. Among these, hypogammaglobulinemia is a common complication; however, the long-term kinetics of serum immunoglobulin levels and clinical risk factors are not fully understood. We retrospectively analyzed adult patients with r/r B-cell lymphoma who underwent CD19-targeted CAR-T therapy at Kyoto University Hospital. Serum IgG levels were evaluated longitudinally from apheresis to up to two years after infusion. Hypogammaglobulinemia was defined as serum IgG <400 mg/dL or the necessity of immunoglobulin replacement therapy. Seventy-six patients were analyzed. Serum IgG levels declined significantly after infusion, reaching their nadir at 9 months, and remaining suppressed as long as 2 years. Cumulative incidence of hypogammaglobulinemia at six months was 63.9%. 60.5% of patients received immunoglobulin replacement therapy. Multivariable analysis identified the following three independent risk factors for hypogammaglobulinemia: age ≥60 years at infusion, pre-infusion IgG <600 mg/dL, and a pre-infusion CD4/CD8 ratio <0.3, reflecting impaired immune reserve. Hypogammaglobulinemia was not significantly associated with progression-free survival or overall survival in landmark analyses. These findings may help identify patients for whom careful monitoring of immunoglobulin levels and appropriate management of hypogammaglobulinemia and infectious complications are warranted.

BACKGROUND:Chimeric antigen receptor (CAR) T-cell therapy has transformed treatment for patients with relapsed or refractory large B-cell lymphoma (LBCL). However, real-world data in Japan remain limited. METHODS:We retrospectively analyzed 489 LBCL patients treated with tisagenlecleucel (tisa-cel) using a nationwide registry. RESULTS:The median patient age was 62 years, with 89% having undergone ≥3 prior therapies. At infusion, 22% were in a complete response. The estimated 1-year progression-free survival (PFS) and overall survival (OS) rates were 43.2% (95%CI, 37.8-49.3%) and 65.9% (95% CI, 61.0-71.1%), respectively. Multivariable analysis revealed that better Karnofsky performance status, a history of stem cell transplantation, absence of extranodal lesion, higher absolute lymphocyte count, and lower lactate dehydrogenase level prior to lymphodepleting therapy were significantly associated with better PFS and OS. Older age (≥65 years) at infusion was associated with better PFS, while shorter duration from apheresis to infusion (<60 days) was associated with better OS. Cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome occurred in 71% and 5% of patients, respectively. CONCLUSIONS:This study provides the largest real-world dataset on tisa-cel treatment for LBCL. Our results showed real-world outcomes and early safety consistent with prior trials.

BACKGROUND:Mogamulizumab, an anti-CCR4 monoclonal antibody, is approved for relapsed/refractory (r/r) aggressive adult T-cell leukemia/lymphoma (ATL), although durable responses are limited. OBJECTIVE:To identify biomarkers associated with mogamulizumab efficacy, focusing on host immune status and known prognostic factors. METHODS:We retrospectively analyzed 315 patients with r/r aggressive ATL using real-world data from Japan. Clinical and prognostic variables were analyzed for association with overall survival (OS), stratified by mogamulizumab use. RESULTS:Among 315 patients, 97 received mogamulizumab (Moga [+]). One-year OS was higher in Moga (+) than Moga (-) patients (51.2 % vs. 34.0 %, p = 0.006). Multivariate analysis identified age < 70, PS 0-1, cCa < 11 mg/dL, albumin ≥3.5 g/dL, LDH < 265 IU/L, LMR ≥ 2.6, and Moga (+) use as independent predictors of OS. In Moga (+) patients, cCa and LMR remained independent prognostic factors. CONCLUSION:LMR is a novel prognostic factor in r/r ATL and may provide useful information when considering mogamulizumab-based treatment.

Bendamustine is one of the primary chemotherapeutic agents for the treatment of B-cell lymphomas, whereas its toxicity to T cells is associated with a high rate of infectious complications and a potential negative impact on subsequent immunotherapies. Bendamustine has previously been reported to be a potent in vitro inhibitor of HOIP, the catalytic subunit of the linear ubiquitin chain assembly complex (LUBAC). Because LUBAC functions as a checkpoint for tumor necrosis factor receptor superfamily (TNFRSF)-induced cell death, we hypothesized that bendamustine may have specific activity on the CD40 or BAFF-R signaling in B-cell lymphomas. In a cell culture assay, we found that bendamustine not only suppressed CD40L- and BAFF-driven NF-κB signaling in B-cell lymphomas but also induced higher cell death in the presence of these signals, a phenomenon not typical of other chemotherapeutic agents. Bendamustine resistance was shown to be driven by knockout of TRAF3, a mediator of CD40 and BAFF-R signaling. Importantly, the toxic effect of bendamustine on T cells was also found to be associated with another TNFRSF molecule, OX40. Pretreatment with an antibody blocking OX40-OX40L signaling attenuated bendamustine-induced T-cell depletion in mice, whereas preserving the cytotoxic effect of bendamustine on transplanted B-cell lymphoma. In conclusion, both the antilymphoma effect and the T-lymphopenia induced by bendamustine are associated with TNFRSF signaling, and the T-cell toxicity can be separately controlled by blocking OX40 signaling before bendamustine administration.

BACKGROUND:The factor B inhibitor iptacopan improved 24-week outcomes in adult patients with paroxysmal nocturnal haemoglobinuria in the phase 3 APPLY-PNH and APPOINT-PNH trials; the trial extension periods assessed clinical activity and safety up to 48 weeks. Here, we report the final 48-week data from APPLY-PNH and APPOINT-PNH. METHODS:In both APPLY-PNH and APPOINT-PNH trials, patients were aged 18 years or older, with paroxysmal nocturnal haemoglobinuria (red and white blood cell population sizes ≥10%) and without laboratory evidence of bone marrow failure. In APPLY-PNH (an open-label, randomised, phase 3 trial conducted in 39 centres [38 hospitals, one outpatient research clinic] from 12 countries or regions), patients with haemoglobin concentration lower than 10 g/dL on anti-C5 treatment (stable eculizumab or ravulizumab regimen for ≥6 months) were randomly assigned (8:5) via interactive response technology to either receive oral iptacopan 200 mg twice daily (iptacopan group) or to continue their individual intravenous eculizumab or ravulizumab regimen for 24 weeks (anti-C5 group). Randomisation was stratified by type of anti-C5 and receipt of red blood cell (RBC) transfusions in the preceding 6 months. In APPOINT-PNH (an open-label, single-arm, phase 3 trial conducted in 12 hospitals from eight countries), complement inhibitor-naive patients with paroxysmal nocturnal haemoglobinuria and with haemoglobin concentration lower than 10 g/dL and lactate dehydrogenase (LDH) concentration higher than 1·5 times the upper limit of normal received iptacopan 200 mg twice daily for 24 weeks. Both trials had 24-week extension periods in which all patients received iptacopan monotherapy. Primary endpoints were the proportion of patients with an increase from baseline in haemoglobin concentration of 2 g/dL or higher (APPLY-PNH and APPOINT-PNH) and haemoglobin concentration 12 g/dL or higher (APPLY-PNH) between weeks 18 and 24, all in the absence of RBC transfusions between weeks 2 and 24; results for these primary endpoints have been reported previously. We report final activity and safety data at the completion of both trials (week 48). Prespecified endpoints at week 48 included percentage of patients with a haemoglobin increase from baseline of 2 g/dL or higher or haemoglobin 12 g/dL or higher (including post-transfusion data). Efficacy data were analysed per the intention-to-treat principle, and safety was analysed according to the treatment that patients received. APPLY-PNH and APPOINT-PNH are registered with ClinicalTrials.gov, NCT04558918 and NCT04820530, respectively. FINDINGS:In APPLY-PNH, between Jan 25, 2021, and April 8, 2022, 62 patients (43 [69%] female, 19 [31%] male; 48 [77%] White, 12 [19%] Asian, two [3%] Black) were randomly assigned to the iptacopan group and 35 patients (24 [69%] female, 11 [31%] male; 26 [74%] White, seven [20%] Asian, two [6%] Black) to the anti-C5 group; 61 (98%) and 34 (97%), respectively, entered the extension period. At trial completion (March 6, 2023), the median duration of iptacopan treatment was 337 days (IQR 168-338). In APPOINT-PNH, 40 patients were enrolled between July 19, 2021, and May 17, 2022, and received iptacopan (17 [43%] female, 23 [58%] male; 12 [30%] White, 27 [68%] Asian, one [3%] Black); all entered the extension period. At trial completion (April 18, 2023), the median duration of iptacopan treatment was 337 days (IQR 337-344). At week 48, irrespective of RBC transfusions, the number of patients who had an increase in haemoglobin concentration of 2 g/dL or higher was 51 (86%) of 59 in the APPLY-PNH iptacopan group, 21 (72%) of 29 in the APPLY-PNH anti-C5-to-iptacopan group, and 38 (97%) of 39 in APPOINT-PNH. The number of patients who had haemoglobin concentration of 12 g/dL or higher at week 48 was 40 (68%) of 59 in the APPLY-PNH iptacopan group, 17 (59%) of 29 in the APPLY-PNH anti-C5-to-iptacopan group, and 31 (79%) of 39 in APPOINT-PNH. There were no treatment discontinuations because of treatment-emergent adverse events or deaths. Across the 48-week trials, clinical breakthrough haemolysis occurred in seven (7%) of 96 iptacopan-treated patients in APPLY-PNH (including both groups) and two (5%) of 40 in APPOINT-PNH, but it was generally mild or moderate with no iptacopan discontinuation. Three major adverse vascular events occurred in APPLY-PNH by trial completion; all were considered unrelated to iptacopan. The most common treatment-emergent adverse event was COVID-19 in APPLY-PNH (iptacopan: 18/62 patients [29%]; anti-C5-to-iptacopan: 8/34 [24%]) and headache in APPOINT-PNH (12/40 [30%]). Severe and serious treatment-emergent adverse events were experienced by six (10%) and nine (15%) of 62 patients in the APPLY-PNH iptacopan group, respectively; in APPOINT-PNH, these were experienced by four (10%) and eight (20%) of 40 patients, respectively. The most common serious treatment-emergent adverse event was COVID-19, occurring in one (2%) of 62 patients in the APPLY-PNH iptacopan group and two (5%) of 40 patients in APPOINT-PNH. No severe treatment-emergent adverse events occurred in more than one patient. INTERPRETATION:Long-term data indicate durable haemolysis control with iptacopan in paroxysmal nocturnal haemoglobinuria, maintained normal or near-normal haemoglobin, and no new safety concerns. We believe that these data support iptacopan as a potential therapy option, suggesting that we are in a new treatment era for paroxysmal nocturnal haemoglobinuria. FUNDING:Novartis.