Identification of a dynamic gene regulatory network required for pluripotency factor-induced reprogramming of mouse fibroblasts and hepatocytes.

The generation of induced pluripotent stem cells (iPSCs) from somatic cells provides an excellent model to study mechanisms of transcription factor-induced global alterations of the epigenome and genome function. Here, we have investigated the early transcriptional events of cellular reprogramming triggered by the co-expression of Oct4, Sox2, Klf4, and c-Myc (OSKM) in mouse embryonic fibroblasts (MEFs) and mouse hepatocytes (mHeps). In this analysis, we identified a gene regulatory network composed of nine transcriptional regulators (9TR; Cbfa2t3, Gli2, Irf6, Nanog, Ovol1, Rcan1, Taf1c, Tead4, and Tfap4), which are directly targeted by OSKM, in vivo. Functional studies using single and double shRNA knockdowns of any of these factors caused disruption of the network and dramatic reductions in reprogramming efficiency, indicating that this network is essential for the induction and establishment of pluripotency. We demonstrate that the stochastic co-expression of 9TR network components occurs in a remarkably small number of cells, approximating the percentage of terminally reprogrammed cells as a result of dynamic molecular events. Thus, the early DNA-binding patterns of OSKM and the subsequent probabilistic co-expression of essential 9TR components in subpopulations of cells undergoing reprogramming steer the reconstruction of a gene regulatory network marking the transition to pluripotency.

Daratumumab in first-line treatment of patients with light chain amyloidosis and Mayo stage IIIb improves treatment response and overall survival.

Treatment of patients with Mayo stage IIIb light chain (AL) amyloidosis is still challenging, and the prognosis remains very poor. Mayo stage IIIb patients were excluded from the pivotal trial leading to the approval of daratumumab in combination with bortezomib-cyclophosphamide-dexamethasone. This retrospective, multicenter study evaluates the addition of daratumumab to first-line therapy in patients with newly diagnosed stage IIIb AL amyloidosis. In total, data from 119 consecutive patients were analyzed, 27 patients received an upfront treatment including daratumumab, 63 a bortezomibbased regimen without daratumumab, eight received therapies other than daratumumab or bortezomib and 21 pretreated patients or deceased prior to treatment were excluded. In the daratumumab group, median overall survival was not reached after a median follow-up time of 14.5 months, while it was significantly worse in the bortezomib- and the otherwise treated group (6.6 and 2.2 months, respectively) (P=0.002). Overall hematologic response rate at 2 and 6 months was better in the daratumumab group compared to the bortezomib group (59% vs. 37%, P=0.12, 67% vs. 41%, P=0.04, respectively). Landmark survival analyses revealed a significantly improved overall survival in patients with partial hematologic response or better, compared to non-responders. Cardiac response at 6 months was 46%, 21%, 0% in the daratumumab-, bortezomib- and otherwise treated groups, respectively (P=0.04). A landmark survival analysis revealed markedly improved overall survival in patients with cardiac very good partial response vs. cardiac non-responders (P=0.002). This study demonstrates for the first time the superiority of an upfront treatment with daratumumab over standard-of-care in stage IIIb AL amyloidosis.

Moderate Continuous and Modified High-Intensity Interval Training in Patients With Left Ventricular Assist Devices: The Prospective Train-the-LVAD Trial.

BACKGROUND: High-intensity interval training (HIIT) of 4 minutes at 80%-90% of peak oxygen consumption (VO2peak) has been shown to be feasible in patients with left ventricular assist devices (LVADs). The effect of shorter bouts of HIIT, which reduce the anaerobic burden, has not been investigated compared to moderate continuous training (MCT). METHODS AND RESULTS: We conducted a prospective, monocentric study (NCT05121077) randomizing patients with LVADs into 20 minutes of MCT (n = 10) or short bouts (≤ 90 seconds) of HIIT (n = 10) following cardiopulmonary exercise testing at 50%-60% and 80%-90% of VO2peak. Each of the 18 supervised sessions (3×/week, t0-t1) included 10 minutes of strengthening training. The primary outcome was the increase of VO2peak in the 2 groups between t0 and t1. Secondary outcomes were changes in the 12-item Kansas City Cardiomyopathy Questionnaire, the 6-minute walk distance and the percentage of VO2peak at the first ventilatory threshold. VO2peak significantly increased with HIIT (13.0 ± 4.6mL/kg/min vs 14.6 ± 4.3mL/kg/min; P = 0.037), but not with MCT (11.8 ± 3.3mL/kg/min vs 13.1 ± 3.3mL/kg/min; P = 0.322), without between-group differences (P = 0.853). Secondary outcomes improved from t0-t1 in MCT and HIIT, without differences between the groups. CONCLUSIONS: Short bouts of HIIT are feasible, and they improved VO2peak and functional parameters in patients in this pilot prospective study.

Improved survival of patients with primary plasma cell leukemia with VRd or daratumumab-based quadruplets: A multicenter study by the Greek myeloma study group.

We evaluated the efficacy and prognostic impact of bortezomib-lenalidomide triplet (VRd) or daratumumab-based quadruplets (DBQ) versus previous anti-myeloma therapies, that is, bortezomib standard combinations (BSC) or conventional chemotherapy (CT), in a large cohort of patients with primary plasma cell leukemia (pPCL), including those fulfilling the revised diagnostic criteria, that is, circulating plasma cells (cPCS): ≥5%; 110 pPCL patients (M/F: 51/59; median age 65 years, range: 44-86) out of 3324 myeloma patients (3%), registered in our database between 2001 and 2021, were studied; 37% had cPCS 5%-19%; 89% received novel combinations including DBQ (21%), VRd (16%) and BSC (52%); 35% underwent autologous stem cell transplantation. 83% achieved objective responses. Treatment with VRd/DBQ strongly correlated with a higher complete response rate (41% vs. 17%; p = .008). After a median follow-up of 51 months (95% CI: 45-56), 67 patients died. Early mortality was 3.5%. Progression-free survival was 16 months (95% CI: 12-19.8), significantly longer in patients treated with VRd/DBQ versus BSC/CT (25 months, 95% CI: 13.5-36.5 vs. 13 months 95% CI: 9-16.8; p = .03). Median overall survival (OS) was 29 months (95% CI: 19.6-38.3), significantly longer in patients treated with VRd/DBQ versus BSC/CT (not reached vs. 20 months, 95% CI: 14-26; 3-year OS: 70% vs. 32%, respectively; p < .001; HzR: 3.88). In the multivariate analysis VRd/DBQ therapy, del17p(+) and PLT <100.000/µL, independently predicted OS (p < .05). Our study has demonstrated that in the real-world setting, treatment with VRd/DBQ induces deep and durable responses and is a strong prognostic factor for OS representing currently the best therapeutic option for pPCL.

Quantitative 99mTc-DPD-SPECT/CT assessment of cardiac amyloidosis.

INTRODUCTION: Transthyretin (ATTR) amyloidosis is responsible for the majority of cardiac amyloidosis (CA) cases and can be reliably diagnosed with bone scintigraphy and the visual Perugini score. We aimed to implement a quantification method of cardiac amyloid deposits in patients with suspected cardiac amyloidosis and to compare performance to visual scoring. METHODS AND MATERIALS: 136 patients received 99mTc-DPD-bone scintigraphy including SPECT/CT of the thorax in case of suspicion of cardiac amyloidosis. Imaging phantom studies were performed to determine the scaling factor for standardized uptake value (SUV) quantification from SPECT/CT. Myocardial tracer uptake was quantified in a whole heart volume of interest. RESULTS: Forty-five patients were diagnosed with CA. A strong relationship between cardiac SUVmax and Perugini score was found (Spearman r 0.75, p < 0.0001). Additionally, tracer uptake in bone decreased with increasing cardiac SUVmax and Perugini score (p < 0.0001). ROC analysis revealed good performance of the SUVmax for the detection of ATTR-CA with AUC of 0.96 ± 0.02 (p < 0.0001) with sensitivity 98.7% and specificity 87.2%. CONCLUSION: We demonstrate an accessible and accurate quantitative SPECT approach in CA. Quantitative assessment of the cardiac tracer uptake may improve diagnostic accuracy and risk classification. This method may enable monitoring and assessment of therapy response in patients with ATTR amyloidosis.

Multi-center study of inter-rater reproducibility, image quality, and diagnostic accuracy of CZT versus conventional SPECT myocardial perfusion imaging.

BACKGROUND: Cadmium-zinc-telluride (CZT)-based detectors exhibit higher diagnostic sensitivity in myocardial perfusion imaging (MPI) than conventional Anger-MPI for detection of coronary artery disease (CAD); however, reduced specificity and diagnostic accuracy of CZT-MPI were observed. This study aims to compare these different camera systems and to examine the degree of inter-rater reproducibility among readers with varying experience in MPI. METHODS: 83 patients who underwent double stress/rest examinations using both a CZT and conventional SPECT cameras within one visit were included. Anonymized and randomized MPI-images were distributed to 15 international readers using a standardized questionnaire. Subsequent coronary angiography findings of ten patients served as a reference for analysis of sensitivity and specificity. RESULTS: Image quality was significantly better in CZT-MPI with significantly lower breast attenuation (P < 0.05). CZT-MPI exhibited higher sensitivity than Anger-MPI (87.5% vs. 62.5%) and significantly reduced specificity (40% vs. 100%). Readers experienced with both camera systems had the highest inter-rater agreement indicating higher reproducibility (CZT 0.54 vs. conv. 0.49, P < 0.05). CONCLUSIONS: Higher diagnostic sensitivity of CZT-MPI offers advantages in detection of CAD yet potentially of at the cost of reduced specificity, therefore it requires special training and a differentiated evaluation approach, especially for non-experienced readers with such camera systems.

Exercise oscillatory ventilation in patients with advanced heart failure with and without left ventricular assist device.

BACKGROUND: Exercise oscillatory ventilation (EOV), indicating pathological fluctuations on pulmonary arterial pressure, is associated with mortality in patients with heart failure (HF). Whether left ventricular assist device (LVAD)-induced ventricular unloading can reverse EOV and may prevent short-term rehospitalization has not been investigated. METHODS: We performed a retrospective single-center in- and outpatient analysis of patients with (n = 20, LVAD) and without (n = 27, HF) circulatory support and reduced ejection fraction (EF, 22.8 ± 7.9%). The association of cardiopulmonary exercise testing (CPET) variables and 3 months-rehospitalization (3MR) as a primary outcome was analyzed. Furthermore, CPET variables were compared regarding the presence of EOV (+/-). RESULTS: Lower VO2peak (11.6 ± 4.9 ml/kg/min vs. 14.4 ± 4.3 ml/kg/min, p = 0.039), lower increase of PETCO2 (CI = 0.049-1.127; p = 0.068), and higher VE/VCO2 (43.8 ± 9.5 vs. 38.3 ± 10.6; p = 0.069) were associated with 3MR. Flattening of O2 pulse (CI = 0.139-2.379; p = 0.487) had no impact on 3MR. EOV was present in 59.5% (n = 28/47) of patients, without a significant difference between LVAD and HF patients (p = 0.959). Patients with HF/EOV+ demonstrated significantly lower VO2peak compared with HF/EOV- (p = 0.039). LVAD/EOV+ displayed significantly lower EF (p = 0.004) and fewer aortic valve opening than LVAD/EOV- (p = 0.027). CONCLUSIONS: Lower VO2peak , but not EOV, was associated with 3MR. EOV occurred at a similar rate in LVAD and HF patients, which may illustrate insufficient unloading during exercise in chronic LVAD therapy and may contribute to the limited exercise capacity following LVAD implantation. Simultaneous CPET and right heart catheterization studies are needed to elucidate whether EOV may serve as a non-invasive predictor of insufficient LV unloading necessitating LVAD reprograming.

18F-flutemetamol positron emission tomography in cardiac amyloidosis.

PURPOSE: Bone-tracer scintigraphy has an established role in diagnosis of cardiac amyloidosis (CA) as it detects transthyretin amyloidosis (ATTR). Positron emission tomography (PET) with amyloid tracers has shown high sensitivity for detection of both ATTR and light-chain (AL) CA. We aimed to investigate the accuracy of 18F-flutemetamol in CA. METHODS: We enrolled patients with CA or non-amyloid heart failure (NA-HF), who underwent cardiac 18F-flutemetamol PET/MRI or PET/CT. Myocardial and blood pool standardized tracer uptake values (SUV) were estimated. Late gadolinium enhancement (LGE) and T1 mapping/ extracellular volume (ECV) estimation were performed. RESULTS: We included 17 patients (12 with CA, 5 with NA-HF). PET/MRI was conducted in 13 patients, while PET/CT was conducted in 4. LGE was detected in 8 of 9 CA patients. Global relaxation time and ECV were higher in CA (1448 vs. 1326, P = 0.02 and 58.9 vs. 33.7%, P = 0.006, respectively). Positive PET studies were demonstrated in 2 of 12 patients with CA (AL and ATTR). Maximal and mean SUV did not differ between groups (2.21 vs. 1.69, P = 0.18 and 1.73 vs. 1.30, P = 0.13). CONCLUSION: Although protein-independent binding is supported by our results, the diagnostic yield of PET was low. We demonstrate here for the first time the low sensitivity of PET for CA.

A novel TTR mutation (p.Ala65Val) underlying late-onset hereditary transthyretin (ATTRv) amyloidosis with mixed cardiac and neuropathic phenotype: a case report.

BACKGROUND: Hereditary transthyretin (ATTRv) amyloidosis is a rare, genetically heterogeneous and phenotypically variable systemic disease characterized by deposition of misfolded transthyretin fibrils in various tissues. ATTRv cardiomyopathy and progressive axonal polyneuropathy are the most common manifestations, leading to severe disability and ultimately death within approximately ten years. As disease-modifying treatment options evolve, timely diagnosis and treatment initiation are crucial to prevent rapid disease progression. CASE PRESENTATION: Here, we report on a 73-year old patient initially diagnosed with cardiac wild-type ATTR (ATTRwt) amyloidosis by endomyocardial biopsy. Molecular genetic analysis revealed a novel TTR sequence variant (p.Ala65Val) that is highly likely to be amyloidogenic in light of previously reported TTR mutations and the patient's clinical presentation and family history. CONCLUSIONS: Our findings expand the spectrum of known pathogenic TTR mutations and underline the importance of a thorough diagnostic workup in amyloidosis patients including careful genetic testing to avoid misdiagnosis and missing of treatment opportunities and to enable cascade testing and tracking of carriers.

Impact of severe mitral regurgitation on postoperative outcome after durable left-ventricular assist device implantation.

BACKGROUND: Mitral valve regurgitation (MR) is a common finding in patients with end-stage heart failure. The aim of the study was to analyze the impact of preoperative moderate-to-severe MR on postoperative outcomes and survival after durable left-ventricular assist device (LVAD) implantation. METHODS: From August 2010 to May 2021, 246 patients underwent a durable LVAD implantation. We stratified the patients into two groups: Group A (n = 109) presented with MR 0-I°, and Group B presented with MR II-III° (n = 137). MR II-III° was defined according to the current recommendations (i.e., vena contracta ≥ 7 mm, regurgitation volume ≥ 30 ml or effective regurgitation orifice area ≥ 20 mm2 ). RESULTS: Significantly more patients in Group B suffered from pulmonary hypertension and presented with chronic obstructive lung disease. We observed significantly higher rates of tricuspid regurgitation (TR) II-III° in Group B (76.1%) versus Group A (14.8%) (p < 0.001) and TR III° in Group B (30.4%) versus Group A (3.7%) (p < 0.001). There was no difference in the incidence of right heart failure between the groups. Within our cohort, the in-hospital, 1-year, 3-year, and 5-year mortality was 22.4%, 32.1%, 50.7%, and 64.4%, respectively. Group B showed significantly worse overall survival (p = 0.05). Patients with preoperative TR II-III° had a significantly worse survival than those with TR 0-I° (p = 0.048). In patients presenting with MR II-III°, we discovered that TR III° seems to predict both in-hospital and mid-term mortality. CONCLUSION: MR II-III° negatively affects the outcomes in patients requiring LVAD implantation. Persisting MR II-III° is an independent predictor of mortality. Patients with concomitant preoperative TR II-III° are at increased risk of developing postoperative major adverse events. Addressing the MR might be considered for these patients.

Impact of time to diagnosis on Mayo stages, treatment outcome, and survival in patients with AL amyloidosis and cardiac involvement.

OBJECTIVE: To study the impact of time to diagnosis on cardiac Mayo stages, treatment outcome, and overall survival. METHODS: We retrospectively analyzed 77 consecutive patients diagnosed between 2015 and 2020 with AL amyloidosis and cardiac involvement. Medical history was recorded in standardized form with the help of a questionnaire. RESULTS: Time from onset of symptoms of cardiac failure to diagnosis was correlated with the severity of cardiac involvement in modified Mayo 2004 and revised Mayo 2012 staging systems (rs  = 0.30, 95% CI: 0.07-0.50, P = .007 and rs  = 0.25, 95% CI: 0.01-0.45, P = .03). Patients with advanced Mayo 2004 stages received reduced-intensity regimens and had a lower probability to achieve adequate hematologic- and cardiac response after first-line treatment than patients with early stages (rs  = 0.28, 95% CI: 0.04-0.48, P = .01 and rs  = 0.72, 95% CI: 0.55-0.82, P < .0001) and poorer overall survival (P = .0004). Compared with patients diagnosed within the first year, patients diagnosed after 13-18 or ≥19 months from first symptoms had a 3- to 5 times higher risk of dying. Our data indicate that there is a 12-month window within which the diagnosis of AL amyloidosis needs to be established to avoid early deterioration and death. CONCLUSIONS: Sensitizing physicians and raising awareness for the disease are crucial for timely diagnosis and may improve the outcome of the disease.

Outcomes of left ventricular assist device implantation for advanced heart failure in critically ill patients (INTERMACS 1 and 2): A retrospective study.

The use of left ventricular assist devices (LVADs) for advanced heart failure is becoming increasingly common. However, optimal timing and patient selection remain controversial. The aim of this study was to investigate outcomes of LVAD implantation for advanced heart failure in critically ill patients (INTERMACS 1 and 2). Between August 2010 and January 2020, 207 consecutive patients underwent LVAD implantation. Overall survival, major adverse events, and laboratory parameters were compared between patients in INTERMACS 1-2 (n = 107) and INTERMACS 3-5 (n = 100). Preoperative white blood cells, C-reactive protein, procalcitonin, bilirubin, alanine transaminase, and lactate dehydrogenase were all significantly higher in INTERMACS 1-2 when compared to INTERMACS 3-5 (P < .05). During hospitalization following LVAD implantation, patients in INTERMACS 1-2 were more likely to develop major infections (41.1% vs. 23.0%, P = .005), respiratory failure (57.9% vs. 25.0%, P < .001), mild (20.6% vs. 8.0%, P = .010), and moderate (31.8% vs. 7.0%, P < .001) right heart failure, and acute renal dysfunction (56.1% vs. 6.0%, P < .001). During a median follow-up of 2.00 years (interquartile range (IQR) 0.24-3.39 years), they had a higher incidence of thoracic (15.9% vs. 4.0%, P = .005) and gastrointestinal bleeding (21.5% vs. 11.0%, P = .042), as well as right heart failure (18.7% vs. 1%, P < .001). Risk of death was significantly higher in the INTERMACS 1-2 group (hazards ratio (HR) 1.64, 95% CI 1.12-2.40, P = .011). LVAD implantation in critically ill patients is associated with increased morbidity and mortality. Our results suggest that decision for LVAD should be not be delayed until INTERMACS 1 and 2 levels whenever possible.

Publisher Correction to: 18F-florbetaben positron emission tomography detects cardiac involvement in systemic AA amyloidosis.

The correct title for this paper should be: 18F-florbetaben positron emission tomography detects cardiac involvement in systemic AA amyloidosis.

Prediction of acute kidney injury after left ventricular assist device implantation: Evaluation of clinical risk scores.

Acute kidney injury (AKI) is frequent in patients scheduled for implantation of a left ventricular assist device (LVAD) and associated with increased mortality. Although several risk models for the prediction of postoperative renal replacement therapy (RRT) have been developed for cardiothoracic patients, none of these scoring systems have been validated in LVAD patients. A retrospective, single center analysis of all patients undergoing LVAD implantation between September 2013 and July 2016 was performed. Primary outcome was AKI requiring RRT within 14 days after surgery. The predictive capacity of the Cleveland Clinic Score (CCS), the Society of Thoracic Surgeons Score (STS), and the Simplified Renal Index Score (SRI) were evaluated. 76 patients underwent LVAD implantation, 19 patients were excluded due to preoperative RRT. RRT was associated with a prolonged ventilation time, length of stay on the ICU and 180 day mortality (14(60.9%) vs 6(17.6%), P < .01). Whereas the Thakar Score (7.43 ± 1.75 vs 6.44 ± 1.44, P = .02) and the Mehta Score (28.12 ± 15.08 vs 21.53 ± 5.43, P = .02) were significantly higher in patients with RRT than in those without RRT, the SRI did not differ between these groups (3.96 ± 1.15 vs 3.44 ± 1.05, P = .08). Using ROC analyses, CCS, STS, and SRI showed moderate predictive capacity for RRT with an AUC of 0.661 ± 0.073 (P = .040), 0.637 ± 0.079 (P = .792), and 0.618 ± 0.075 (P = .764), respectively, with comparable accuracy in the Delong test. Using univariate logistic regression analysis, only the De Ritis Ratio (OR 2.67, P = .034) and MELD (OR 1.11, P = .028) were identified as predictors of postoperative RRT. Risk scores which are predictive in general cardiac surgery cannot predict RRT in patients after LVAD implantation. Therefore, it seems to be necessary to develop a specific risk score for this patient population.

Circulating macrophage migration inhibitory factor (MIF) in patients with heart failure.

BACKGROUND: Heart failure (HF) is characterized by impaired systolic ejection capacity and/or diastolic filling of the heart, leading to a multisystem disorder. Remote organ failure, systemic inflammation or pulmonary hypertension (PH) are hallmarks of the pathophysiological changes in HF. The Macrophage migration inhibitory factor (MIF) is a pro-inflammatory cytokine that is involved in a variety of cardiovascular and inflammatory diseases. Circulating MIF levels and their potential role as a disease marker in the different subgroups of HF have not been investigated yet. We here aimed to unravel a potential role of MIF in HF. METHODS AND RESULTS: MIF plasma levels were assessed in 249 consecutive patients with HF. MIF was detectable in all investigated subjects and showed no difference with regard to the nature of HF (preserved or reduced ejection fraction). Spearman correlation revealed an association with inflammatory biomarkers (white blood cell count r = 0.18, p = 0.005; c-reactive protein r = 0.20, p = 0.003). MIF was associated with higher pulmonary artery systolic pressure (PASP) as assessed by echocardiography (r = 0.23, p < 0.001). Log-transformed PASP was also independently associated with MIF in a multivariable linear regression model (p = 0.02). Follow-up (FU) data after 180 days revealed that patients with increased MIF values (in ng/ml) were more likely to reach the endpoint all-cause mortality (HR 1.01, 95% CI 1.004-1.02, p = 0.005, per unit change). CONCLUSION: MIF is detectable in the circulation of patients with HF and might be associated with clinical endpoints in HF, markers of inflammation and PH. These promising results should stimulate further research to elucidate the role of MIF in the multisystem disorder of HF.

Long-term outcomes of total body irradiation plus cyclophosphamide versus busulfan plus cyclophosphamide as conditioning regimen for acute lymphoblastic leukemia: a comparative study.

The role of total body irradiation (TBI) in allogeneic hematopoietic stem cell transplantation (HCT) for adult acute lymphoblastic leukemia (ALL) remains controversial. Therefore, we investigated long-term treatment outcomes of transplanted ALL patients aiming to identify prognostic factors and the impact of conditioning. We enrolled consecutive ALL patients transplanted from 1990 to 2016, following TBI- or busulfan (Bu)-based conditioning regimen. We studied 151 ALL patients transplanted in first complete remission (CR) (60), other CR (33), or relapsed/refractory disease (58) from sibling (87), and HLA-matched (42) or mismatched (17) unrelated and alternative donors (5). High-dose fractionated TBI-based conditioning was administered in 84. No differences were observed in baseline characteristics, except for disease stage at transplant, donor type, and graft source. With a follow-up of 19.0 (0.5-170.5) in TBI and 14.5 (1.2-319.1) months in non-TBI patients, there was no difference in acute (grades II-IV) or chronic GVHD, thrombotic microangiopathy, and bacterial or fungal infections. Only viral infections were significantly increased in the non-TBI group. There was no significant difference in the cumulative incidence (CI) of treatment-related or relapse mortality and disease-free or overall survival (OS). In the multivariate analysis, unfavorable pre-transplant predictors of OS were age (p = 0.024), advanced disease stage (p = 0.007), and female-to-male donor (p = 0.006). Interestingly, TBI patients younger than 40 years had significantly higher OS (55.1%, p = 0.023) and DFS (48.6%, p = 0.020). In conclusion, high-dose TBI is feasible in younger patients providing better survival. The choice between TBI- or Bu-conditioning regimens remains challenging.

Lack of survival improvement with novel anti-myeloma agents for patients with multiple myeloma and central nervous system involvement: the Greek Myeloma Study Group experience.

Involvement of the central nervous system (CNS) is a rare complication of multiple myeloma (MM). Herein, we have described the incidence, characteristics, prognostic factors for post CNS-MM survival, and outcome of CNS-MM and explored the efficacy of novel agents (NA) (thalidomide, bortezomib, lenalidomide) in this setting. Between 2000 and 2013, 31 (0.9 %) out of 3408 newly diagnosed symptomatic MM patients, consecutively diagnosed and treated during the same period in 12 Greek centers, developed CNS-MM (M/F 15/16, median age 59 years, range 20-96 years; newly diagnosed/relapsed-refractory 2/29; median time to CNS-MM diagnosis 29 months). Clinical and laboratory characteristics were retrospectively recorded. Twenty-six percent of patients had circulating plasma cells (PCs) or plasma cell leukemia (PCL) at CNS-MM and 39 % had skull-derived plasmacytomas, suggesting hematological and contiguous spread. Treatment for CNS-MM was offered in 29/31 patients and 11/29 responded (NA 18/29, additional radiotherapy 9/28, intrathecal chemotherapy 13/29). The median post CNS-MM survival was 3 months (95 % CI 1.9-4.1) and did not differ between patients treated with NA and/or radiotherapy vs. others. In the multivariate analysis, prior treatment of MM with NA, extramedullary disease (EMD) during MM course (i.e., plasmacytomas, circulating PCs, or documented PCL) and abnormally high LDH at MM diagnosis were independent prognostic factors, whereas treatment of CNS-MM with NA did not predict for post CNS-MM survival. Despite the relatively limited number of patients due to the rarity of CNS-MM, our results suggest that NA do not seem to improve post CNS-MM survival. Patients with EMD display shortened post CNS-MM survival and should be followed thoroughly.

Towards unravelling the kinetics of an acute myeloid leukaemia model system under oxidative and starvation stress: a comparison between two- and three-dimensional cultures.

A great challenge when conducting ex vivo studies of leukaemia is the construction of an appropriate experimental platform that would recapitulate the bone marrow (BM) environment. Such a 3D scaffold system has been previously developed in our group [1]. Additionally to the BM architectural characteristics, parameters such as oxygen and glucose concentration are crucial as their value could differ between patients as well as within the same patient at different stages of treatment, consequently affecting the resistance of leukaemia to chemotherapy. The effect of oxidative and glucose stress-at levels close to human physiologic ones-on the proliferation and metabolic evolution of an AML model system (K-562 cell line) in conventional 2D cultures as well as in 3D scaffolds were studied. We observed that the K-562 cell line can proliferate and remain alive for 2 weeks in medium with glucose close to physiological levels both in 20 and 5% O2. We report interesting differences on the cellular response to the environmental, i.e., oxidative and/or nutritional stress stimuli in 2D and 3D. Higher adaptation to oxidative stress under non-starving conditions is observed in the 3D system. The glucose level in the medium has more impact on the cellular proliferation in the 3D compared to the 2D system. These differences can be of significant importance both when applying chemotherapy in vitro and also when constructing mathematical tools for optimisation of disease treatment.

A treacherous case of primary non-Hodgkin lymphoma of the bone: appearances can be deceptive.

INTRODUCTION: Primary lymphoma of the bone constitutes an extremely rare but distinctive clinical entity, accounting for approximately 3% of all primary bone malignancies and less than 1% of all non-Hodgkin lymphomas. CASE PRESENTATION: We report a rare case of a male patient with an atypical clinical presentation of non-Hodgkin primary lymphoma of the bone, initially misdiagnosed as ankylosing spondylitis. To our knowledge, this is the first case in the literature in which magnetic resonance imaging was contra-indicated. The atypical radiological imaging of the tumor, despite its aggressiveness, rendered the diagnostic approach a challenging but strenuous process. CONCLUSION: Plain radiographs and even computerized tomography images of primary lymphoma of the bone may appear as normal, but other imaging modalities should be used including radionuclide scans, especially when imaging techniques of greater accuracy such as magnetic resonance imaging are contraindicated. A patient-centred approach with emphasis on the main symptoms is the key to the diagnostic challenge of revealing the extremely unusual cases of primary lymphoma of the bone.