Azacitidine/venetoclax is the standard treatment for patients with acute myeloid leukemia (AML) unfit for intensive chemotherapy. Cytochrome P450 3A4 (CYP3A4) is the major metabolizing enzyme for venetoclax, and its inhibition can boost venetoclax. In the HOVON 171 phase 2 trial, patients with AML were treated with azacitidine/venetoclax/cobicistat. This 2-stage, open-label, multicenter phase 2 trial included a crossover run-in phase followed by an ongoing extension phase. In cycle 1, patients received standard-dose azacitidine/venetoclax. In cycle 2, cobicistat was added, and venetoclax was reduced to 50 mg. The primary end point was pharmacokinetic equivalence, defined as 90% confidence interval (CI) of geometric mean ratios (GMRs) >0.8 for area under the curve over 24 hours (AUC0-24h) and maximum plasma concentration (Cmax). Polymorphisms in genes encoding for CYP enzymes were determined. In vitro assays were performed to assess cobicistat's impact on the antileukemic effect of azacitidine/venetoclax in AML cell lines. In 13 evaluable patients, cobicistat-boosted venetoclax at 50 mg achieved higher exposure than standard 400-mg dosing. GMRs were 2.0 (90% CI, 1.4-2.8) for AUC0-24h and 1.4 (90% CI, 1.0-2.0) for Cmax. In the intention-to-treat population, 65% achieved complete remission (CR) or CR with incomplete hematologic recovery. Interpatient variability in venetoclax exposure because of CYP3A4 polymorphisms was reduced by cobicistat. No unexpected toxicities were observed. In in vitro, cobicistat enhanced azacitidine/venetoclax antileukemic effects. In conclusion, cobicistat enhances and optimizes venetoclax exposure, enabling an eightfold dose reduction while maintaining efficacy. The potentiated antileukemic activity positions cobicistat as a promising complementary agent in AML therapy. This trial was registered at www.clinicaltrials.gov as NCT06014489.

BCR::ABL1 digital PCR is a promising technique for the quantification of deep molecular responses (DMRs) in chronic myeloid leukemia. It provides an improved precision and sensitivity compared with conventional real-time quantitative PCR (qPCR), which is particularly relevant in the context of prediction of successful treatment-free remission. This study assessed the feasibility of BCR::ABL1 digital PCR in clinical practice. A total of 168 DMR samples of patients with chronic myeloid leukemia aiming for a treatment-free remission attempt were assessed by both digital PCR and qPCR. Digital PCR was performed with the droplet-based Bio-Rad QXDx BCR-ABL %IS assay, using eight replicates per sample. qPCR was performed with the fully automized Cepheid Xpert BCR-ABL Ultra assay. Various technical and practical aspects of BCR::ABL1 quantification using digital PCR were assessed. The reported limit of detection of the qPCR is molecular response 4.5, requiring an equivalent of 32,000 ABL1 transcripts. Using digital PCR, a median number of ABL1 of approximately 300,000 were obtained. BCR::ABL1 was quantifiable by digital PCR in 68% of the samples below qPCR's limit of detection. In addition, e13a2 and e14a2 BCR::ABL1 transcript types could be discriminated based on the mean fluorescence intensity of BCR::ABL1-positive droplets. BCR::ABL1 digital PCR is feasible for DMR quantification in clinical practice and offers an increased sensitivity over qPCR. (J Mol Diagn 2025, 27: 109-118; https:// doi.org/10.1016/j.jmoldx.2024.11.003)

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.

BACKGROUND & AIMS:Medical nutrition therapy (MNT) is commonly used in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing intensive remission-induction treatment to prevent malnutrition, particularly the loss of fat-free mass (FFM)/muscle mass, as well as associated adverse outcomes. However, studies examining the associations of proactive versus wait-and-see approaches toward MNT with nutritional, physical, and clinical outcomes in these patients are lacking. Therefore, this study aimed to explore the associations of these different MNT approaches with body composition changes, as well as physical and clinical outcomes in AML/MDS patients undergoing intensive remission-induction treatment. Additionally, the study aimed to explore the relationships between body composition changes and physical and clinical outcomes, and whether these associations varied between the proactive and wait-and-see strategies. METHODS:In this multicenter prospective correlational study, newly diagnosed AML/MDS patients undergoing intensive remission-induction treatment were included. Patients were treated in one of five hospitals using a proactive approach toward MNT, initiating MNT when nutritional intake became inadequate, or in the single hospital in the Netherlands that followed a wait-and-see strategy, limiting the use of MNT to exceptional and severe cases only. Body composition was assessed at the start of treatment, weekly during admission and at discharge, and handgrip strength, and patient-reported physical functioning and fatigue at treatment initiation and discharge. Information on number of complications, and duration of fever and hospital length of stay (LOS) was collected from medical records. Within-group changes in body composition and between-group differences were tested using paired or independent t, Wilcoxon signed-rank or two-sample tests, respectively, or chi-square/Fisher's exact tests for proportions. The longitudinal patterns between proactive MNT approach/wait-and-see strategy hospitals were compared by means of linear mixed effects models. Associations between body composition changes and physical and clinical outcomes were explored using multiple linear regression models, and compared between proactive MNT approach/wait-and-see strategy hospitals. RESULTS:In this study, 204 AML/MDS patients (54 % male, mean age: 56.3 ± 13.0 years) were included, of whom 140 underwent treatment in a hospital using a proactive approach toward MNT and 64 in the hospital following a wait-and-see strategy. In the proactive MNT approach hospitals, 57 % of patients received MNT during the first chemotherapy cycle versus 8 % of patients in the wait-and-see hospital (p < 0.0001). Both approaches toward MNT were associated with significant decreases in body weight, FFM/muscle mass, and muscle strength. However, losses in FFM/muscle mass and muscle strength did not differ significantly between the strategies, while body weight loss was lower with the proactive approach (estimated between-group difference during the first cycle: 0.44 kg/week (95 % CI 0.18-0.70 kg/week, p = 0.0008), primarily due to better preservation of fat mass (FM) (p < 0.05). Additionally, the proactive MNT strategy was associated with fewer nutrition impact symptoms (p < 0.0001), fewer complications (p = 0.01), and shorter LOS (33 days (IQR: 27-41) vs 29 days (IQR: 26-34), p = 0.009). Similar results were observed during the second chemotherapy cycle. Furthermore, better maintenance of body weight and indicators of FFM/muscle mass and FM were significantly associated with shorter LOS and fever duration, fewer complications, improved physical functioning and/or reduced fatigue. Several associations differed significantly between the two MNT strategies, given that decreased body composition parameters were associated with worse physical and clinical outcomes in the wait-and-see hospital, while in the proactive MNT approach hospitals these associations were opposite or attenuated and non-significant. CONCLUSION:In AML/MDS patients undergoing intensive remission-induction treatment, a proactive approach toward MNT should be used, as it was associated with fewer nutrition impact symptoms, fewer complications, shorter LOS, and better body weight maintenance, mainly through better preservation of FM, compared to a wait-and-see strategy. Maintenance of body weight, FFM/muscle mass and/or FM was associated with improved physical and clinical outcomes. Given that proactive use of MNT could not prevent loss of FFM/muscle mass and muscle strength, future research should focus on combined nutritional and physical exercise interventions aimed at reducing these losses.

Patient-guided dose reduction, as explored in the RODEO study, offers a promising approach to alleviate the burden of tyrosine kinase inhibitor (TKI) therapy in chronic myeloid leukemia (CML). Supported by shared decision-making (SDM) and a patient decision aid, this strategy aims to reduce TKI toxicity while maintaining effectiveness. This interim analysis evaluates its effectiveness at six months, focusing on intervention failure, i.e., TKI dose re-escalation due to loss of major molecular remission (MMR) of BCR::ABL1 (>0.1%IS) or expected loss of MMR, and patient-reported health-related quality of life (HRQoL) and symptom burden. The SDM-process and decisional conflict are also evaluated. This is a prospective, single-arm, multicenter trial including 148 patients with chronic-phase CML in at least MMR. Patients and their treating hematologists were engaged in an SDM-process and selected a reduced TKI dose. BCR::ABL1 monitoring was conducted regularly; HRQoL and symptom burden was assessed using the scores of the QLQ-C30 and QLQ-CML24 questionnaires, and IL 156 item list. of the European Organisation for Research and Treatment of Cancer (EORTC). SDM and decisional conflict were evaluated via SDM-Q-9, SDM-Q-Doc, and the Decisional Conflict Scale. Of 146 patients analyzed, 2.8% experienced intervention failure at six months. Modest statistically significant improvements were seen in multiple symptom scales. SDM was well-evaluated, with low decisional conflict by patients. Patient-guided dose reduction appears safe and beneficial at six months follow-up.

Sustained remissions off-treatment (SROTs) after tapering of thrombopoietin receptor agonists (TPO-RAs) have been reported in 15%-50% of patients with immune thrombocytopenia (ITP). The STIP (Stop TPO-Receptor Agonist in ITP Patients) study is a prospective trial aimed to investigate the clinical effects of romiplostim tapering. Adult patients (22/40) with ITP ≥3 months received romiplostim for 1 year, were tapered and followed for 1 year. Anti-platelet antibodies (APAs), TPO levels and indium-111 platelet scintigraphy were assessed before, during and after romiplostim. Censored survival analysis showed that the probability of SROT at 1 year after tapering was 23.6% (95% confidence interval: 11.0%-50.5%). Patients with SROT had higher platelet levels on romiplostim (median: 332.5 vs. 84.5 × 109/L) and lower romiplostim doses at the start of tapering (median: 1.0 vs. 4.5 μg/kg) compared to those with a non-sustained response (NSR). APAs were detected in 8/25 patients at baseline, of which 5 showed a substantial decrease during romiplostim. The indium-111 scan revealed an improved platelet survival at the start of tapering for 50% of patients with SROT (2/4, missing n = 1) versus none with an NSR (0/14, missing n = 3). Overall, the STIP study demonstrated a probability of SROT of 23.6% in a diverse and largely chronic group of adult patients with ITP.

Background & aims: Medical nutrition therapy (MNT) is commonly used in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing intensive remission-induction treatment to prevent malnutrition, particularly the loss of fat-free mass (FFM)/muscle mass, as well as associated adverse outcomes. However, studies examining the associations of proactive versus wait-and-see approaches toward MNT with nutritional, physical, and clinical outcomes in these patients are lacking. Therefore, this study aimed to explore the associations of these different MNT approaches with body composition changes, as well as physical and clinical outcomes in AML/MDS patients undergoing intensive remission-induction treatment. Additionally, the study aimed to explore the relationships between body composition changes and physical and clinical outcomes, and whether these associations varied between the proactive and wait-and-see strategies. Methods: In this multicenter prospective correlational study, newly diagnosed AML/MDS patients undergoing intensive remission-induction treatment were included. Patients were treated in one of five hospitals using a proactive approach toward MNT, initiating MNT when nutritional intake became inadequate, or in the single hospital in the Netherlands that followed a wait-and-see strategy, limiting the use of MNT to exceptional and severe cases only. Body composition was assessed at the start of treatment, weekly during admission and at discharge, and handgrip strength, and patient-reported physical functioning and fatigue at treatment initiation and discharge. Information on number of complications, and duration of fever and hospital length of stay (LOS) was collected from medical records. Within-group changes in body composition and between-group differences were tested using paired or independent t, Wilcoxon signed-rank or two-sample tests, respectively, or chi-square/Fisher's exact tests for proportions. The longitudinal patterns between proactive MNT approach/wait-and-see strategy hospitals were compared by means of linear mixed effects models. Associations between body composition changes and physical and clinical outcomes were explored using multiple linear regression models, and compared between proactive MNT approach/wait-and-see strategy hospitals. Results: In this study, 204 AML/MDS patients (54 % male, mean age: 56.3 +/- 13.0 years) were included, of whom 140 underwent treatment in a hospital using a proactive approach toward MNT and 64 in the hospital following a wait-and-see strategy. In the proactive MNT approach hospitals, 57 % of patients received MNT during the first chemotherapy cycle versus 8 % of patients in the wait-and-see hospital (p < 0.0001). Both approaches toward MNT were associated with significant decreases in body weight, FFM/muscle mass, and muscle strength. However, losses in FFM/muscle mass and muscle strength did not differ significantly between the strategies, while body weight loss was lower with the proactive approach (estimated between-group difference during the first cycle: 0.44 kg/week (95 % CI 0.18-0.70 kg/week, p = 0.0008), primarily due to better preservation of fat mass (FM) (p < 0.05). Additionally, the proactive MNT strategy was associated with fewer nutrition impact symptoms (p < 0.0001), fewer complications (p = 0.01), and shorter LOS (33 days (IQR: 27-41) vs 29 days (IQR: 26-34), p = 0.009). Similar results were observed during the second chemotherapy cycle. Furthermore, better maintenance of body weight and indicators of FFM/muscle mass and FM were significantly associated with shorter LOS and fever duration, fewer complications, improved physical functioning and/or reduced fatigue. Several associations differed significantly between the two MNT strategies, given that decreased body composition parameters were associated with worse physical and clinical outcomes in the wait-and-see hospital, while in the proactive MNT approach hospitals these associations were opposite or attenuated and non-significant. Conclusion: In AML/MDS patients undergoing intensive remission-induction treatment, a proactive approach toward MNT should be used, as it was associated with fewer nutrition impact symptoms, fewer complications, shorter LOS, and better body weight maintenance, mainly through better preservation of FM, compared to a wait-and-see strategy. Maintenance of body weight, FFM/muscle mass and/or FM was associated with improved physical and clinical outcomes. Given that proactive use of MNT could not prevent loss of FFM/muscle mass and muscle strength, future research should focus on combined nutritional and physical exercise interventions aimed at reducing these losses. (c) 2025 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

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.

ABSTRACT Approximately 40%–60% of patients reaching a stable deep molecular response during TKI treatment will maintain a state of remission after TKI discontinuation, denoted as treatment‐free remission (TFR). Depth of molecular response assessed by BCR::ABL1 digital PCR prior to TKI discontinuation has demonstrated its significance as a reliable predictive parameter for TFR. A clinically applicable prediction cutoff of 0.0023%IS has been established and externally validated. In this study, BCR::ABL1 digital PCR, as most sensitive and stable assay of its kind, was investigated as a TFR prediction tool in the Netherlands, and evaluated for its predictive value to stop TKI treatment below the aforementioned cutoff. The primary endpoint of molecular recurrence (MolR, BCR::ABL1 > 0.1%IS) at 12 months was prospectively assessed. Overall, 67 discontinued patients below the set BCR::ABL1 digital PCR cutoff were included. The overall MolR probability was 50% (95% CI, 36%–62%). In 38 patients treated for more than 6 years as commonly recommended as desirable treatment duration before TFR attempt, the MolR probability dropped to 36% (95% CI, 18%–50%). Patients attempting an early TKI discontinuation (treated for less than 6 years) had a high MolR probability of 76% (95% CI, 65%–89%). BCR::ABL1 digital PCR was successfully used in Dutch clinical practice. Our study indicates that in patients with a low BCR::ABL1 digital PCR result, a total TKI treatment duration of six or more years remains associated with a lower MolR rate and should generally be pursued. In patients treated for more than 6 years, BCR::ABL1 digital PCR was capable to identify stop candidates with a higher probability of TFR success.

Selected chronic myeloid leukemia (CML) patients may discontinue their tyrosine kinase inihibitor (TKI) in an attempt to achieve sustained treatment-free remission (TFR), which mitigates therapy-related side effects and limits treatment costs. TFR has been extensively studied following the discontinuation of adenosine triphosphate (ATP) – competitive TKI. However, there is minimal data concerning TFR after the discontinuation of the novel TKI asciminib. Here, we present two CML patients intolerant to multiple ATP-competitive TKIs who achieved a deep molecular response (DMR) during asciminib treatment and sustained this remission after asciminib discontinuation. One of the cases developed transient myalgia and arthralgia after asciminib discontinuation consistent with a TKI withdrawal syndrome. Both patients have been free of molecular relapse for more than at least 8 months after TKI discontinuation without increase in molecular BCR::ABL1 signal. These two cases provide proof of principle that sustained TFR after discontinuing asciminib in CML patients is feasible.

Background/Objectives: Patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) often receive medical nutrition therapy (MNT) during intensive remission-induction treatment. Since little is known about changes in nutritional status, specifically body composition, in this patient population, these changes and their associations with physical and clinical outcomes were assessed. Subjects/Methods: In this multicenter prospective observational study, newly diagnosed AML/MDS patients who received intensive remission-induction chemotherapy, routine dietary counseling by a dietician and MNT immediately upon inadequate nutritional intake, were included. At treatment initiation and discharge, nutritional status, including Patient-Generated Subjective Global Assessment (PG-SGA)-scores and body composition, physical outcomes and fatigue were assessed. Associations of nutritional status/body composition with physical outcomes, fatigue, fever duration, number of complications, time to neutrophil engraftment and hospital length of stay (LOS) (collected from medical records) were examined using multiple regression analysis. Results: In >91% of the 126 AML/MDS patients included, nutritional intake was adequate, with 61% receiving MNT. Nevertheless, body weight decreased significantly (p < 0.001) and mainly consisted of a loss of muscle/fat-free mass (FFM) (p < 0.001), while fat mass (FM) remained unchanged (p-value range = 0.71-0.77). Body weight and waist circumference showed significant negative associations with fever duration and/or number of complications. Significant positive associations were found between mid-upper arm muscle circumference (MUAMC) and physical functioning and between PG-SGA-scores and fatigue. Body weight and MUAMC were also negatively associated with LOS. Conclusion: Despite MNT in AML/MDS patients undergoing intensive chemotherapy, muscle/FFM decreased while FM remained unchanged. Maintenance of nutritional status was associated with improved physical and clinical outcomes.

Approximately half of chronic phase (CP) CML patients in a stable deep molecular response (DMR; MR4.0; BCR::ABL1<0.01% on the International Scale [IS]) can safely and durably cease their therapy, entering a treatment-free remission (TFR).1-3 The alternative half of patients will show a molecular recurrence (MolR) requiring restarting TKI therapy.3 A longer total TKI treatment duration and DMR duration have been associated with higher probability of TFR.1, 2, 4 The identification of additional parameters to predict TFR success is clinically important. The depth of molecular remission beyond MR4.0 quantified by standard real-time PCR (RT-PCR) for BCR::ABL1 does not consistently correlate with the chance of sustained TFR.5 However, the depth of molecular response measured by BCR::ABL1 digital PCR, an alternative and more precise quantification technique, has been reported to be associated with TFR outcome in several studies. We aimed to establish the role of BCR::ABL1 digital PCR (dPCR) in TFR prediction, and to assess its relation to other clinical markers. This individual participant data (IPD) meta-analysis was done in adherence with the PRISMA-IPD flow diagram and checklist.6 Peer-reviewed studies were eligible if the predictive value of RNA-based BCR::ABL1 dPCR was assessed for CML patients attempting a first TKI discontinuation (Figure S1). PubMed, EMBASE, and the Cochrane Library databases were searched (Appendix S1). The outcome of interest was time to MolR. MolR was defined as BCR::ABL1>0.1%IS in one assessment or a 1-log BCR::ABL1 increase in two consecutive assessments. The primary objective was to assess MolR prediction with BCR::ABL1 dPCR. The secondary objectives were to assess other parameters for MolR prediction and to build a risk stratification model for MolR. A one-stage statistical approach was used, and the following parameters were analyzed in a Cox proportional hazards model: dPCR, age, sex, treatment duration, DMR duration, Sokal score, ELTS score, BCR::ABL1 transcript type, and TKI generation (see Supplemental Files for full methodology and references of included studies). Tables S1–S3 show the characteristics of the included studies and the final cohort of 635 patients. After TKI discontinuation, 41% of patients experienced MolR. MolR patients had a shorter duration of treatment (6.8 vs. 7.8 years, p = 0.012) and had a numerically, but not statistically significant shorter DMR duration (3.2 vs. 3.6 years, p = 0.245; studies BE, LU, AT) and UDMR duration (2.8 vs. 3.2 years, p = 0.098; studies MO, NI, CO). A total of 459 patients (72%) had a dPCR result below the prediction cut-off (dPCR-low). In these patients, 33% experienced MolR, versus 62% in patients with a dPCR result above the prediction cut-off (dPCR-high), p < 0.001. The e13a2 transcript, e14a2 transcript or both transcripts were detected in 108 (30%), 206 (58%) and 42 (12%) patients, respectively. MolR patients more often had the e13a2 transcript (41% vs. 22%, p < 0.001). No differences were noted in age, sex, TKI type, ELTS, or Sokal score. The 24-month probability of MolR in dPCR-low versus dPCR-high patients was 33% (95% CI, 28%–37%) and 61% (95% CI, 53%–68%), respectively (Figure S2A; p < 0.001). Using the cutoff of 6 years of TKI treatment, patients with a short versus long TKI treatment duration had 24-month MolR probability of 48% (95% CI, 41%–55%) and 36% (95% CI, 31%–41%), respectively (Figure S2B; p = 0.012). The HR of dPCR-high and TKI treatment duration (numeric) for MolR was 3.154 (95% confidence interval [CI], 1.952–5.096, p < 0.001) and 0.956 (95% CI, 0.916–0.999, p = 0.044; Figure S3A), respectively. UDMR duration (in three studies MO, NI, CO) was also significantly associated with TFR outcome with an HR of 0.898 (95% CI, 0.812–0.992, p = 0.034). Harboring the e14a2 transcript had a favorable impact on TFR, associated with a 24-month MolR probability of 34% (95% CI, 28%–41%) compared to 59% (95% CI, 48%–67%) in patients with the e13a2 transcript, and 48% (95% CI, 30%–61%) in patients harboring both transcripts (Figure S2C, p < 0.001). For the subsequent regression analysis, patients harboring both transcripts were grouped with patients harboring the e13a2 transcript alone, in order to clearly distinguish patients having a low MolR (i.e., e14a2 patients). The HR of the e13a2 transcript (or both) for MolR was 1.582 (95% CI, 1.119–2.236, p = 0.009). Both dPCR-high and BCR::ABL1 transcript type remained significantly associated with MolR probability in the multivariable analysis (Figure S3B). The HR of dPCR-high for MolR corrected for TKI treatment duration was 3.211 (95% CI, 2.001–5.154, p < 0.001). In a multivariable model combining dPCR-high, TKI treatment duration <6 years and BCR::ABL1 transcript type (e13a2 or both), their respective HR for MolR were 2.327 (95% CI, 1.548–3.497, p < 0.001), 1.278 (95% CI, 0.921–1.771; p = 0.141) and 1.480 (95% CI, 1.037–2.113; p = 0.031). The Cox proportional hazard assumption was not violated in the presented models. No significant interactions were observed between dPCR-high and other included variables. A sensitivity analysis of the first multivariable model was done using a two-stage random effects Cox regression analysis (Figure S4). The pooled HR of dPCR-low for MolR was 3.120 (95% CI, 1.876–5.189, p < 0.001). A low between-study heterogeneity was observed for treatment duration (I2 = 35%), and a moderate heterogeneity was observed for dPCR-high (I2 = 66%). An explorative analysis of molecular recurrence prediction in various clinical scenarios was described in the Supplemental Files and Figure S5, for example, exploring various subgroups based on time to recurrence, treatment duration, TKI type, and BCR::ABL1 transcript type. Based on our results and prior knowledge of relevant clinical predictive parameters, the parameters BCR::ABL1 dPCR, treatment duration, and BCR::ABL1 transcript type were combined in a composite risk score (Figure 1). The risk parameters were weighted based on the rounding of their HR for MolR (presented in model 2), that is, +2, +1, and +1, respectively (Figure 1). Patients were divided into low (score 0), intermediate (score 1–2), and high (score 3–4) MolR risk category. The model was fitted in three studies (Figure 1A) and validated in a fourth study (Figure 1B). All studies together, this resulted in a 24-month MolR probability of 25% (95% CI, 16%–32%), 45% (95% CI, 37%–52%), and 68% (95% CI, 55%–78%), respectively (see Supplemental Files for details on model validation). In this patient-level meta-analysis, depth of molecular response measured by BCR::ABL1 dPCR was a robust and consistent predictor for MolR, independent of treatment duration, TKI type, and BCR::ABL1 transcript type. BCR::ABL1 dPCR could aid in the timing of a TFR attempt, especially in the context of an "early" attempt in patients treated with a TKI for less than 6 years. Patients who attempted an early discontinuation had a favorable 24-month MolR probability of 39% if their dPCR result was low, compared to 67% if their dPCR result was high. A longer treatment duration in patients with a low dPCR result adds modestly to limiting MolR probability (29%). Patients with the e14a2 transcript more often maintained TFR and conversely, patients with the e13a2 transcript had an inferior probability of sustained TFR, which is in line with previous reports.7 Differential outcomes for both transcripts have already been described in terms of TKI treatment response.7 A technical quantification artifact cannot be excluded completely.8 However, in our study the association of BCR::ABL1 transcript type with a probability of MolR was independent of the dPCR result, which suggests a transcript-specific disease phenotype. One potential explanation might be a differential immunogenicity of e14a2 BCR::ABL1 positive cells as these provoke a cytotoxic T-lymphocyte response, in line with the theory that successful TFR involves immunological mechanisms.9 Based on our results and previous reports, we combined the three most relevant parameters in one risk stratification model, that is, depth of molecular response assessed by BCR::ABL1 dPCR, TKI treatment duration, and BCR::ABL1 transcript type. Patients were classified into low, intermediate, or high-risk categories, having a probability of MolR of 25%, 45%, and 68% at 24 months, respectively. This proposed model could deliver a risk-adapted approach in the decision of TKI discontinuation, as low-risk patients might confidently discontinue their TKI with a good chance of TFR success, and high-risk patients should preferentially continue their TKI treatment. The primary strength of this study is the intercontinental collaboration and assembling of patient-level data thus creating one of the largest discontinuation cohorts assessed to date. A limitation of this study is the heterogeneity of dPCR assays and therefore a dependency on study-specific prediction cutoffs. It was thus not possible to align dPCR results as a numeric variable in the models. We addressed this issue by the addition of a stratification per study and a random effect term in the Cox regression analysis. For further implementation in clinical practice, dPCR assays should undergo standardization for which alignment with the IS would be preferable. Secondly, the optimal TFR prediction cutoff on the IS should still be further validated. Two studies reported quite similar cutoffs on the IS, i.e. 0.0023%IS (NI) and 0.0030%IS (LU). Ongoing research will provide more clarity on this matter. In conclusion, depth of molecular response measured by BCR::ABL1 dPCR is a valuable and robust predictive parameter for successful TKI discontinuation and may be used to identify TKI stop candidates, including patients treated for less than 6 years aiming for an early discontinuation attempt. The combination of BCR::ABL1 dPCR with TKI treatment duration and BCR::ABL1 transcript type, further improved risk stratification for MolR. PW, PV, and CK conceptualized the research idea. PW and CK coordinated the study. Individual Patient Data were provided by SD, FEN, FXM, EA, MM, JR, SBe, DR, MF, SM, CGP, IC, LL, DY, SBr, GC, and MB. CK collected and pooled the data. CK and JR performed the statistical data-analysis. CK visualized the data. PW and CK had full access to the study data and take responsibility for the integrity of the data and the accuracy of the data analysis. PW and CK wrote the first draft of the manuscript. All co-authors revised the manuscript, figures, and tables. All co-authors approved the final version of the manuscript, figures, and tables. This meta-analysis was academically funded by an institutional grant from the Albert Schweitzer Hospital and a grant from ZonMw, a governmental funding agency in the Netherlands. The funders of this meta-analysis had no role in study design, data collection, data analysis, data interpretation, or writing of the report. SD is a speaker for Novartis and Incyte. FEN is a consultant for Novartis, SPARC; board entity for BMS-Celgene, Novartis, Pfizer, Incyte Biosciences, Institutional grants from Novartis, Incyte Biosciences. DY received research funding from Novartis and BMS; and received honoraria from Novartis, Takeda, Pfizer and Amgen. SBr is a member of the advisory boards of Qiagen, Novartis and Cepheid, received honoraria from Qiagen, Novartis, and Cepheid, and research funding from Novartis and Cepheid. PW has received institutional grants from Novartis and BMS-Celgene; and has received speaker fees from BMS-Celgene, Incyte, Novartis, and Pfizer. This individual participant data meta-analysis was conducted using data from previously published studies. Each of these studies had appropriate ethical approvals, and patient consent was obtained according to local and national regulations at the time of data collection. The data used in the current meta-analysis were de-identified and anonymized to protect participant confidentiality. Deidentified Individual Participant Data will be made available upon request to investigators whose proposed use of the data has been approved by our Study Committee with a representative of all included study cohorts. Proposals for access should be sent to [email protected]. Text S1. Methodology. Text S2. exploratory analyses of TFR prediction in various clinical scenarios. Text S3. risk stratification model. Appendix S1. search strategy, collected item list, R script main one-stage model. Table S1. study and BCR::ABL1 digital PCR characteristics. Table S2. baseline patient characteristics and molecular recurrence characteristics, grouped by study. Table S3. baseline characteristics in the pooled patient cohort, with or without molecular recurrence. Figure S1. flow diagram of study identification, screening, and inclusion. Figure S2. Kaplan Meier estimates based on different subgroups. Figure S3. one-stage univariable (A) and multivariable (B) Cox regression analysis presenting the hazard ratios for molecular recurrence. Figure S4. sensitivity analysis of multivariable model 1 using a two-stage approach. Figure S5. one stage multivariable Cox regression analysis in various clinical scenarios. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

The treatment of older patients with acute myeloid leukemia (AML) considered unfit for receiving intensive chemotherapy is challenging. Based on the hypothesis that addition of the broad tyrosine kinase inhibitor (TKI) midostaurin could improve the response to hypomethylating agents, irrespective of FLT3 gene mutational status, we conducted a randomized phase II multicenter study to assess the tolerability and efficacy of the addition of midostaurin to a 10-day schedule of decitabine in unfit (i.e. Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) ≥ 3) AML and higher risk myelodysplasia (MDS) patients (HOVON155 trial). In total, 140 eligible patients were randomly (1:1) assigned to treatment with 10-days of decitabine alone (N = 70) or combined with midostaurin (50 mg bid;starting the day following the last dose of decitabine), (N = 70). Addition of midostaurin was well tolerated and the number of AEs was comparable for both treatment arms. Early death rates (< 30 days) were similar as well (10

Immune thrombocytopenia (ITP) is an auto-immune bleeding disorder characterized by isolated thrombocytopenia due to an accelerated platelet destruction and impaired platelet production. Thrombopoietin receptor agonists (TPO-RAs, e.g. romiplostim) are recommended as a subsequent treatment option for patients who failed first-line therapy with corticosteroids. Long lasting use of TPO-RAs, however, is associated with high costs and a persisting burden for patients. Strikingly, sustained remissions after tapering of TPO-RAs have been reported in 10-50% of the patients with primary ITP. These findings suggest that TPO-RAs, besides stimulating platelet production, may also have an immune modulatory effect via a hitherto unknown mechanism. No distinct clinical factors or biomarkers have been identified that can reliably predict successful tapering of TPO-RAs. The STIP study is a prospective multi-center single-arm intervention trial in the Netherlands aimed to determine the rate of sustained remission off-treatment (SROT) after 1 year of romiplostim treatment. Thirty-nine adult patients with primary ITP lasting for more than 3 months and an indication for second-line treatment received romiplostim for 1 year. Subsequently, romiplostim was tapered within 6 weeks and patients were followed for 1 year. SROT was defined as platelet counts > 30 x 109/L, no bleeding symptoms and no need for treatment. Data about clinical parameters were gathered to identify potential predictors for SROT. Moreover, blood samples were taken at six different time points before, during and after romiplostim treatment. These samples were assessed for anti-glycoprotein (anti-GP) antibodies by monoclonal antibody immobilization of platelet antigen tests and for endogenous TPO levels by an enzyme-linked immunosorbent assay. Indium-111 scans were performed before and after +/- 1 year of romiplostim treatment to assess changes in platelet sequestration sites and clearance rate. Seventy-seven percent (30/39) of the included patients had chronic ITP and 41% (16/39) had received 2 or more treatment lines prior to inclusion. Twenty-nine patients completed the first year of treatment of which 86% (25/29) started the tapering phase. Censored survival analysis showed that 23.6% (95% CI: 11.0-50.5%) had a SROT at 1 year after tapering (n=5, uncensored: 20%). The median time to relapse was 58 days. Only mild bleeding symptoms (WHO scale ≤ 1) were observed in 41% (7/17) of the patients who relapsed. Five of the 17 patients who relapsed did not restart therapy. Hence, romiplostim tapering resulted in a treatment-free response of at least 12 months in 40% (10/25). Patients with SROT at 1 year had higher platelet levels during romiplostim treatment (median: 332.5 vs. 84.5 x109/L) and required lower doses at start tapering (median: 1.0 vs. 4.5 μg/kg) compared to patients who relapsed. Anti-GP antibodies were detected in 8/25 patients at baseline, of which 5 (2/3 patients with SROT and 3/5 with relapse) showed an substantial decrease (OD value ≥ 0.10) in antibody levels. We found that the endogenous TPO levels were similar for patients with SROT and relapse at the start of the tapering (median: 13 vs. 10.5 IE/ml). The indium-111 scan showed for 75.0% (3/4, missing: n= 1) of the patients with SROT compared to only 7.1% (1/14, missing: n= 3) of those who relapsed clearance rates within a normal range at the start of tapering (>62% circulatory platelet-associated radioactivity at 48hrs). The median difference in splenic: liver ratio between scans in patients who relapsed was 0.0 (range: -1.8 - 1.4, data evaluable in n= 13), while in those with SROT a median increase of 0.6 was observed (range: 0.1 - 1.9, n= 5). The STIP study demonstrates a sustained remission rate after romiplostim treatment of 23.6% in a diverse and largely unselected group of patients with ITP. Moreover, we have observed that tapering romiplostim using a standardized protocol is relatively safe, if closely monitored. We observed that patients with SROT tended to use lower romiplostim doses during treatment resulting in higher platelet counts. Normalization of the platelet clearance rate before tapering may be indicative of reaching remission in individual cases. Although more research into the underlying mechanisms leading to immune modulation is needed, these observations can be useful to identify patients who may benefit from TPO-RA treatment and subsequent tapering.

Bariatric surgery is increasingly performed to treat severe obesity. As a result of anatomical and physiological changes in the gastrointestinal tract, the pharmacokinetics (PK) of oral drugs can be altered, affecting their efficacy and safety. This includes the class of tyrosine kinase inhibitors (TKIs) which are used to treat chronic myeloid leukemia (CML). This case series describes the clinical course of four CML cases with a history of bariatric surgery. The patients used various TKIs (nilotinib, dasatinib, bosutinib, ponatinib, and imatinib) for which 15 drug levels were measured. The measured TKI concentrations were in part subtherapeutic, and highly variable when compared to mean levels measured in the general population. Multiple drug levels were measured in these patients, as the clinicians were aware of the possible impact of bariatric surgery. The drug levels were used as additional input for clinical decision-making. All four patients required TKI switches and/or dose modifications to achieve an effective and tolerable treatment. Eventually, adequate clinical and molecular remissions were achieved in all cases. In summary, TKI concentrations of patients undergoing bariatric surgery may be subtherapeutic. Moreover, there is substantial interindividual and intraindividual variation, which may be explained by the complex interference of bariatric surgery and associated weight loss. For clinical practice, therapeutic drug monitoring is advised in patients with a history of bariatric surgery in case of suboptimal response or loss of response.

Precise and reliable predictive parameters to accurately identify chronic myeloid leukemia (CML) patients who can successfully discontinue their tyrosine kinase inhibitor (TKI) treatment are lacking. One promising parameter is depth of molecular response measured by BCR::ABL1 digital PCR (dPCR). The aim of this study was to validate a previously described prediction cutoff of 0.0023%(IS) and to assess the value of dPCR for treatment-free remission (TFR) prediction in relation to other clinical parameters. A droplet-based dPCR assay assessed BCR::ABL1 %(IS) prior to TKI discontinuation. The primary endpoint was molecular recurrence (MolR) by 36 months. A total of 186 patients from Canada, Germany, and the Netherlands were included. In patients with a first TKI discontinuation attempt (n = 163), a BCR::ABL1 dPCR < and >= 0.0023%(IS) had a MolR probability of 33% and 70%, respectively. Patients treated less than 6 years with a BCR::ABL1 dPCR <0.0023%IS had a MolR probability of 31%. After correction for treatment duration, both high dPCR value and the use of imatinib (vs. second-generation TKI) were significantly associated with a higher risk of MolR (HR of 3.66, 95%CI 2.06-6.51, p < .001; and 2.85, 95%CI 1.25-6.46, p = .013, respectively). BCR::ABL1 dPCR was not associated with TFR outcome after second TKI discontinuation, however, with the limitation of a small number of patients analyzed (n = 23). In conclusion, BCR::ABL1 digital PCR based on the cutoff of 0.0023%(IS) is a valuable predictive tool to identify CML patients with a high probability of TFR success after first TKI discontinuation, including patients treated for less than 6 years.

Whether additional mutations in genes other than BCR::ABL1 harbor predictive or prognostic value and whether they should be incorporated in routine diagnostic workups for newly diagnosed CP CML pts is a controversial issue. Most of the currently available data pointing to a potential negative impact of ASXL1 and/or epigenetic genes on response to therapy come from NGS analyses of selected and/or non-homogeneously treated cohorts of pts, with only 2 studies having so far focused on pts enrolled in prospective clinical trials (TIDEL II and TIGER, respectively). We undertook a translational study aimed to investigate the impact of molecular profiling at diagnosis on the likelihood to achieve deep MR and stable TFR in CP CML pts enrolled in the GIMEMA/HOVON CML1415 (‘SUSTRENIM‘), an international prospective clinical trial that randomized pts to receive either NIL or IM with switch to NIL in case of no optimal response (NCT02602314). All the pts achieving ≥MR4 by 36 months (mo) and maintaining it up to 48 mo of therapy qualified for the TFR phase. SUSTRENIM enrolled a total of 448 pts (IM, n=220; NIL, n=228); median follow-up is 56 mo (range, 42-60). One hundred and twenty-four pts who signed the informed consent for participation in this translational study had peripheral blood samples collected at diagnosis and subject to whole exome sequencing (WES). This subset of pts did not differ from the whole population in terms of age, gender, Sokal and ELTS scores, TFR eligibility; 73 of them were randomized to NIL and 67 to IM. Exome capture was performed with the egSEQ Exome Panel (Edinburgh Genetics), followed by 2×150bp paired-end sequencing on a NovaSeq X Plus (Illumina) (48Gb/sample; average sequencing depth, 300X). Raw sequence reads were aligned on the GRCh38 human reference genome and variants called using Dragen v3.9.5 pipeline. Variants labeled as somatic were retained for downstream annotation using VarSeq v2.5.0. For the purpose of the present report, we focused on somatic single nucleotide variants and frameshift indels in ASXL1 and in a comprehensive set of 123 genes compiled using publicly available databases of epigenetic factors and leukemia-associated genes. Strict filtering criteria were adopted, for uniformity with previous NGS studies in CML, to select for variants predicted to be nonsynonymous or to disrupt essential splice donor or acceptor sites and to be either loss of function or damaging according to ≥4 functional prediction tools. Pts with and without mutations were compared using Wilcoxon rank sum test, Fisher's exact test or Pearson's Chi-squared test; cumulative incidences of progression-free survival (PFS) were compared with the Fine and Gray test. ASXL1 mutations were detected in 8/124 (7%) pts. These pts were slightly younger (median, 44 vs 58 years, p=0.059); no correlation was observed with gender, Sokal or ELTS, transcript. Depth of MR at 3, 12, 24, 36 and 48 mo was not significantly different between pts with and without mutations, either stratifying into MR levels at each timepoint or categorizing responses as < or ≥MR3, MR4, M4.5 at a given timepoint (of note: ≥MR3 at 3 mo, 0% vs 13%, p=0.6; ≥MR3 at 12 mo, 80% vs 74%, p>0.9; ≥MR4 at 24 mo, 60% vs 60%, p>0.9; ≥MR4 at 36 mo, 100% vs 75%, p=0.6; ≥MR4 at 48 mo, 100% vs 83%, p>0.9 for pts with and without ASXL1 mutations, respectively). A similar percentage of ASXL1-mutated and -unmutated pts became eligible for TFR as per protocol (43% vs 42%, p>0.9). PFS did not differ between pts with or without ASXL1 mutations (p=0.95). Mutations in epigenetic and leukemia-associated genes were detected in 17/124 (14%) pts. Mutated genes were IKZF1, IDH1, IDH2, DNMT3A, BCOR, BCORL1, NSD2, PHF2, KDM1B. As above, no significant differences were observed between pts with and without mutations in terms of MR depth at different timepoints, TFR eligibility, PFS. In conclusion, presence of an ASXL1 mutation (or of other epigenetic or leukemia-associated gene mutations) did not impact on the depth of MR or on TFR eligibility either in pts treated with NIL or in pts treated with IM with proactive switch to NIL in case of no optimal response. Although algorithms for risk stratification and tailored treatment based on molecular profiling at diagnosis are eagerly awaited, our data warn against the premature incorporation of ASXL1 mutations among high risk features in treatment recommendations, and highlight the need for further studies in prospective series of uniformly treated pts.