Background: Therapy options are limited for COVID-19 patients with hematological disease, cancer, immunosuppression or advanced age. Even though no benefit was observed for convalescent plasma in unselected patients with COVID-19, retrospective data suggest that it could be effective in patients unable to mount a sufficient immune response upon SARS-CoV-2 infection. Plasma from vaccinated donors has not been systematically assessed for COVID-19 treatment. Aims: We conducted a randomized clinical trial to address plasma efficacy in patients at high risk for an adverse outcome. Methods: COVID-19 patients with confirmed SARS-CoV-2 infections and oxygen saturation <=94% were randomized (NCT05200754). Patients received convalescent or vaccinated SARS-CoV-2 plasma in two bags (238 - 337 ml plasma each) from different donors on day 1 and 2 (PLASMA) or standard of care (CONTROL). Randomization was stratified according to four clinical patient groups, hematological/solid cancer (group-1), treatment or disease associated immunosuppression (group 2), high risk disease by standard parameters (group-3) or age >=75 years (group-4). Mechanically ventilated patients were not eligible. Plasma was obtained from donors with high level neutralizing activity (titer >=1:80) either after SARS-CoV-2 infection (convalescent) or after vaccination with at least two doses of mRNA vaccines (vaccinated). Crossover for the control group was allowed at day 10. The primary endpoint was time to improvement as two points on a seven-point ordinal scale or live discharge from the hospital (IMPROVEMENT) with prespecified analyses of subgroups (Janssen M, et al. Trials 2020 Oct 6;21(1):828). Results: A total of 133 patients were randomized with 68 receiving PLASMA with a median age of 68 years (range 36-95) or CONTROL (n=65, of which n=10 (15.4%) crossed over at day 10) with a median age of 70 years (range 38-90). The distribution of the four predefined groups was group-1, n=53; group-2, n=18; group-3, n=35; and group-4, n=27. The intention to treat analysis revealed a non-significant shorter time to IMPROVEMENT for patients in PLASMA (median 12.5 days, 95%-CI [10; 16]) compared to patients in CONTROL (median 18 days, 95%-CI [11; 28]), hazard ratio 1.24, 95% confidence interval [0.83; 1.85], p=0.29). Overall, 27 patients died (PLASMA, n=12; CONTROL, n=15; p=0.80). Predefined subgroup analysis revealed a clinically significant benefit in patients with hematological malignancies, other cancers or immunosuppression (group-1, group-2, n=71). With a median time to improvement of 13 days (95%-CI [9; 19]) for PLASMA and 32 days (95%-CI [17; 57]) for CONTROL(HR 2.03, 95%-CI [1.17; 3.6], p=0.01). A sensitivity analysis revealed that IMPROVEMENT appeared to be seen even earlier with vaccinated (median 10 days, 95%-CI [8; 14]) compared to convalescent SARS-CoV-2 plasma (median 13 days, 95%-CI [6; 38]) and CONTROL. Within group-1 and group-2, six patients in PLASMA (18.2%) and 10 in CONTROL (28.6%) died. No significant differences in improvement were observed in group-3 and group-4 with a HR of 0.72 (95%-CI [0.41; 1.28], p=0.26). Within group-3 and group-4, six patients in PLASMA (18.8%) and five in CONTROL (16.7%) died. No previously unknown side effects of plasma therapy emerged within the trial. Image:Summary/Conclusion: Plasma from convalescent and particularly vaccinated donors improved outcome of COVID-19 patients with an underlying hematological disease /cancer or other reasons of impaired immune response. Plasma did not improve outcome in immune-competent patients with other risk factors and/or older age.

Loss of p53 —a tumor suppressor gene located on the short arm of chromosome 17 (band 17p13.1)—was detected in 105 out of 2272 (5%) adult acute myeloid leukemia (AML) patients who took part in the Study Alliance Leukemia AML96 and AML2003 multi center trials. There were 85 patients with 17p ( p53 ) deletion with multiple aberrations and 20 patients with a 17p ( p53 ) deletion as single aberration or with only one additional chromosomal abnormality. None of the p53 -deleted patients displayed additional low-risk aberrations, like t(8;21) or inv(16). Significant positive association between p53 deletion and other high-risk factors was identified for del(5q) ( P <0.001), −5 ( P <0.001) and −7 ( P <0.05). The molecular risk factors FLT3-ITD and NPM1 mutation showed an inverse correlation to the p53 deletion in complex aberrant patients ( P <0.001). The multivariate analysis revealed p53 deletion without multiple aberrations as an independent negative prognostic factor for disease-free survival ( P <0.001), relapse risk ( P =0.028) and overall survival ( P <0.001). Thus, the single p53 deletion should be considered as a high-risk aberration for future risk-adapted treatment strategies in AML.

Acute myeloid leukaemia (AML) represents a heterogeneous group of early stem cell malignancies characterized by an uncontrolled expansion of malignant cells blocked at certain stages of myeloid differentiation. Several genetic abnormalities have been described, including translocations involving genes of the CBF family, as well as activating mutations of signal transduction proteins, e.g. N-RAS, K-RAS or the Flt3- receptor tyrosine kinase (RTK). More recently, mutations in the SHP-2 protein, a tyrosine phosphatase involved in RTK signal transduction, have been described in patients with juvenile myelomonocytic leukaemia (JMML) as well as paediatric patients with AM. Only limited data on this aberration are available in older patients. In order to investigate the prevalence and the prognostic relevance of this gene in adults, we analyzed the mutational status of SHP-2 in a cohort of patients with AML.

Partial tandem duplication (PTD) of the MLL gene and internal tandem duplication (ITD) of the juxtamembrane region of the FLT3 receptor tyrosine kinase gene have been described in acute myeloid leukemia (AML) patients, preferentially in those with normal cytogenetics. These alterations have been associated with a poor prognosis. In our study, we analyzed the prevalence and the potential prognostic impact of these aberrations in a large unselected and well‐defined cohort of 956 patients with AML. Results were correlated with cytogenetic data and clinical outcome. MLL PTD was detected by RT‐PCR, subsequent nucleotide sequencing, and Southern blotting. The overall incidence was found to be 5.0% (48/956), whereas FLT3 ITD was detected in 19.2% (184/956). Sixteen cases were positive for both alterations. The rate of MLL PTD in FLT3 ITD positive patients was significantly higher than that in FLT3 ITD negative patients [16/184 (8.7%); 32/772 (4.1%); P = 0.025]. However, both aberrations were highly increased in patients with normal karyotype (MLL PTD 35/431, P = 0.004; FLT3 ITD 132/334, P < 0.001). When restricted to this subgroup, the rate of MLL PTD in patients with FLT3 mutations was not significantly increased. No statistically significant differences were detected between patients positive for MLL PTD and patients negative for MLL PTD in the rate of complete remissions or the overall survival, although we did see a significantly shorter disease‐free survival in patients age 60 or younger. In conclusion, although there is an overlap in the mutational spectrum in AML with FLT3 ITD and MLL PTD mutations, our data do not support a common mechanistic basis. Although associated with inferior disease‐free survival, the results of this study do not unequivocally support the notion that MLL PTD mutations represent an independent prognostic factor. © 2003 Wiley‐Liss, Inc.

Allelic variants of the MDR-1 gene have been shown recently to influence protein expression and P-glycoprotein (P-gp) function in healthy volunteers. Therefore, 405 acute myeloid leukemia patients were investigated for somatic genotypes of the three most frequent single nucleotide polymorphisms (SNPs) in exons 12, 21, and 26. In all three loci, homozygous wild-type alleles were classified as genotype A, heterozygous as B, and homozygous mutant (alternative) allele as C. Patients with the C genotype in exons 12 and 26 showed a lower median age (both P < 0.05). Additionally, the C genotype in exons 12 and 26 was associated with cytogenetic poor risk aberrations (both P < 0.05). A possible regulatory impact of the SNPs on MDR1 mRNA expression was investigated by a Real time-PCR assay. MDR1 expression was strongly correlated with a decreased complete remission rate (P = 0.01) but failed to predict decreased overall survival (OS). There was a significant association of the A genotype in exons 21 (P = 0.05) and 26 (P < 0.05) with lower MDR1 expression, whereas the B variants showed highest MDR1 values at all three investigated gene loci. The A genotype in exon 26 was associated with lower OS (P < 0,01). In these patients, worse OS is likely attributable to an increased risk of relapse (P < 0.001). We were able to detect a linkage disequilibrium of the investigated SNPs, indicating combined polymorphisms that could affect the regulation of MDR1 expression. The A genotype of all SNPs demonstrated both lowest MDR1 values and significantly decreased OS (P < 0.05) with a high probability of relapses (P < 0.01). These observations indicate that allelic variants of the MDR1 gene may influence therapy outcome by additional mechanisms, different from P-gp expression on acute myeloid leukemia blasts, possibly involving pharmacokinetic effects of P-gp.

BACKGROUND AND OBJECTIVES Treatment outcome in elderly patients with acute myeloid leukemia (AML) is still disappointing. However, some trials showed that increasing the dosage of anthracyclines within induction therapy improved treatment outcome substantially. We, therefore, tried to escalate induction therapy further in a group of young elderly AML patients. DESIGN AND METHODS In a multicenter trial 33 patients aged 61-65 years with de novo or secondary AML were treated with double induction therapy including high dose mitoxantrone, etoposide and ara-C (MAV) in the first course and m-amsacrine together with high dose ara-C (MAMAC) in the second course. Treatment results were compared to those in 39 AML patients older than 65 years receiving conventional double induction therapy including daunorubicin and ara-C (DA I and DA II) within the same time period. RESULTS Compared to results achieved with conventional induction therapy, intensified double induction therapy did not significantly improve CR rates, overall or disease-free survival. Hematologic toxicity was not different between the two groups, but non-hematologic toxicity was significantly higher with MAV/MAMAC. This was mainly due to gastro-intestinal or liver toxicity. The rate of early mortality (death within the first 12 weeks) was 42% in the group receiving intensified therapy and 18% in that given conventional induction therapy (p=0.04). INTERPRETATION AND CONCLUSION Intensification of double induction therapy using high dose mitoxantrone and high dose ara-C in AML patients aged 61-65 years did not lead to improved treatment outcome and conferred an unacceptable early death rate due to high non-hematologic toxicity. Risk-adapted or alternative treatment strategies are needed to improve treatment outcome in these young elderly AML patients.

Constitutive activation of the FLT3 receptor tyrosine kinase, either by internal tandem duplication (ITD) of the juxtamembrane region or by point mutations in the second tyrosine kinase domain (TKD), has been described in patients with acute myelogenous leukemia (AML). We analyzed the prevalence and the potential prognostic impact of FLT3 mutations in 979 AML patients. Results were correlated with cytogenetic data and the clinical response. FLT3-ITD mutations were found in 20.4% and FLT3-TKD mutations in 7.7% of the patients. Each mutation was associated with similar clinical characteristics and was more prevalent in patients with normal karyotype. Significantly more FLT3 aberrations were found in patients with FAB M5, and fewer were found in patients with FAB M2 and M6. Although less frequent in patients with cytogenetic aberrations, FLT3-ITDs were found in 13 of 42 patients with t(15;17) and in 9 of 10 patients with t(6;9). The prevalence of the ITD allele on the DNA level was heterogeneous, ranging from faint mutant bands in some patients to predominant mutant bands in others. Based on quantitative analysis, the mutant-wild-type (wt) ratio ranged from 0.03 to 32.56 (median, 0.78). Patients with a high mutant/wt ratio (ie, greater than 0.78) had significantly shorter overall and disease-free survival, whereas survival in patients with ratios below 0.78 did not differ from those without FLT3 aberrations. Multivariate analysis confirmed a high mutant/wt ratio to be a strong independent prognostic factor. Taken together, these data confirm that FLT mutations represent a common alteration in adult AML. Constitutive activation may be associated with monocytoid differentiation. A high mutant/wt ratio in ITD-positive patients appears to have a major impact on the prognostic relevance.

Two patients with high-risk acute myeloid leukemia (AML) whose bone marrow aspirates showed more than 25% blasts between 2 and 4 weeks after the first induction chemotherapy immediately received modified conditioning therapy with intravenous busulfan at 50% of the usual dose and fludarabine, before hematologic recovery occurred. Unmanipulated G-CSF mobilized peripheral blood stem cells from an HLA-identical sibling donor were transfused and haematopoietic recovery was achieved in both recipients. Both of them are in continuing hematological remission with full donor chimerism 12 and 22 months after transplantation. Early treatment intensification with allogeneic cell therapy during marrow aplasia might cure high-risk AML patients who are unlikely to achieve remission with conventional chemotherapy protocols.

There is an increasing demand for platelet transfusions and it remains an ongoing challenge for most blood centers to maintain an adequate platelet inventory. Platelet transfusions doubled in the US and in Canada from 1980 to 1987[1-3]. Between 1989 and 1992 the number of platelet concentrates decreased in the US by 8.9 % while the number of apheresis platelets administered increased by 75 %

BACKGROUND AND OBJECTIVES:There is growing evidence that altered expression of genes belonging to the BcL-2 family of apoptosis regulators might influence chemotherapy-induced apoptosis in malignant cells and therefore could confer multidrug resistance. So far expression studies of apoptosis-regulating genes on acute myeloid leukemia (AML) have mainly focused on Bcl-2 itself and most of them have not included other factors involved in drug resistance or apoptosis as parameters determining response to chemotherapy, disease progression and survival. DESIGN AND METHODS:We therefore examined Bcl-2, Bcl-XL and Bax gene expression in 235 adult patients with de novo or secondary myeloid leukemia. The expression levels were correlated with established prognostic factors such as age, cytogentic aberrations, mdr1 gene expression and clinical outcome in a multivariate analysis. RESULTS:Bcl-2 and Bcl-XL positive patients had a much lower white blood cell count than negative patients (p<0.001 and p=0.003, respectively). Bcl-2 expression correlated with FAB subtype M0 (p=0.03), Bax with M5b (p=0.02) and Bcl-XL with M6 (p=0.005). Mdr1 expression was more frequently seen in Bcl-2 and Bcl-XL positive patients (p=0.03 and p=0.02, respectively). Remarkably Bax was significantly less frequently expressed in de novo AML patients with high risk cytogenetics (p=0.007). No difference in expression was recognized for Bcl-2 or Bcl-XL when statistical analyses were done for cytogenetic risk groups. However, in the multivariate analysis regarding the group of de novo AML patients < or =60 years with intermediate risk cytogenetics, Bcl-XL expression was found to be an independent negative prognostic factor for response to induction therapy (p=0.04). In contrast, no prognostic impact of Bcl-XL expression on treatment response was seen within the group of patients with high risk cytogenetic findings. Neither Bcl-2 nor Bax nor Bcl-XL expression had a significant influence on overall or disease-free survival. INTERPRETATION AND CONCLUSIONS:These data indicate that the prognostic value of Bcl-XL gene expression for treatment response in AML patients < or =60 years is dependent on cytogenetics.

Mutations in ras genes have been found to be the most frequent genetic aberrations in adult myeloid leukaemia (AML). Some reports have shown an improved outcome of ras-mutated AML. In order to understand the biology of ras mutation in AML, we studied a cohort of patients treated in a prospective multicentre trial for ras mutational status and resistance gene expression. Blast samples from 162 adult patients with de novo or secondary AML were examined for resistance gene expression (mdr1, mrp1 and lrp) and ras mutations using reverse transcription-polymerase chain reaction and protein nucleic acid-competitive polymerase chain reaction strategies respectively. Ras mutations were confirmed using DNA sequencing. Ras mutations leading to an exchange of amino acids were found in 40 (25%) patients. Thirty AML patients had N-ras mutations and nine patients had K-ras mutations. One patient showed both N-ras and K-ras mutations. Resistance gene expression was positive for mdr1 in 30%, for mrp1 in 43% and for lrp in 62% of patients. There was a strong inverse correlation between the presence of ras mutation and mdr1 expression (P = 0.005). However, no significant difference was seen between patients with or without ras mutations and mrp1 or lrp expression. Whereas mdr1 expression was associated with a lower complete remission rate (P < 0.04), ras mutations had no significant influence on remission status. Neither ras mutation nor mdr1 expression had a significant impact on overall or disease-free survival to date. For the first time, there is evidence that activated ras genes are associated with lower mdr1 expression in AML.

Spectral karyotyping (SKY) was performed in patients with acute myeloid leukemia (AML; n = 25), secondary AML (s-AML; n = 7), myelodysplastic syndrome (MDS; n = 6) and s-MDS ( n = 1) to complement conventional cytogenetic investigations. According to the results of conventional cytogenetics the patients were subdivided into three groups: group 1, normal karyotype, n = 19 cases, median age = 64 years; group 2, patients displaying either one or two single aberrations, n = 10 cases, median age = 54 years; group 3, patients with ⩾3 independent aberrations, n = 10 cases, median age = 61.5 years. SKY identified no abnormal metaphases in group 1. In one patient of group 2 a hidden translocation t(7;14)(q3?1;q2?2) could be revealed with SKY. Conventional cytogenetics had only shown trisomy 8. A similar t(7;14) was also detected in one patient of group 3. SKY was helpful for the delineation of marker chromosomes and additional material. Furthermore, SKY could distinguish between partial and total monosomies or real existing and apparent deletions. The combination of G-banding, FISH and SKY was found very useful for the precise delineation of the karyotype. As a result of our study we recommend SKY investigation as an important additional tool for accurate chromosome analysis. The detected t(7;14) might represent a novel recurrent translocation in acute myeloid leukemias.