Abstract: Surgical risk calculators can estimate risk probabilities for postoperative outcomes utilizing patient-specific risk factors. They provide meaningful information for obtaining informed consent. The aim of the present paper was to evaluate the predictive value of the surgical risk calculators by the American College of Surgeons in German patients undergoing total pancreatectomy. Methods Data for patients who underwent total pancreatectomy between 2014 and 2018 were acquired from the Study, Documentation, and Quality Center of the German Society for General and Visceral Surgery. Risk factors were entered manually into the surgical risk calculators and calculated risks were compared with actual outcomes. Results Of the 408 patients analysed, predicted risk was higher in patients with complications except for the prediction of re-admission (P = 0.127), delayed gastric emptying (P = 0.243), and thrombosis (P = 0.256). In contrast, classification of patients into below, above, or average risk by the surgical risk calculators only produced meaningful results for discharge to nursing facility (P & lt; 0.001), renal failure (P = 0.003), pneumonia (P = 0.001), serious complications, and overall morbidity (both P & lt; 0.001). Assessment of discrimination and calibration showed poor results (scaled Brier scores 8.46 per cent or less). Conclusion Overall surgical risk calculator performance was poor. This finding promotes the development of a specific surgical risk calculator applicable to the German healthcare system.

Abstract: Introduction: Immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG), cyclosporine A (CsA) and Eltrombopag (Epag) has recently been established as standard of care in adult patients (pts.) with severe (sAA) or very severe (vsAA) aplastic anemia & gt; 40-50 years or ineligible for transplant for other reasons. ATG works via immunosuppressive properties including T-cell depletion and induction of immune tolerance. Horse ATG (hATG) is applied for 4 days with 40 mg/kg/day based on the patient's current body weight. Thus, obese pts., defined by a body mass index (BMI) ≥ 30, receive higher absolute hATG dosages than non-obese pts. (BMI & lt; 30). To date, it is unknown whether increased hATG dosages in obese pts. might have beneficial or adverse effects on AA treatment. To address the role of obesity in AA, we investigated (1) the prevalence of obesity in 334 pts. with (suspected) AA and (2) compared the overall survival (OS) and response of 89 obese and non-obese AA pts. to the treatment with hATG/CsA ±Epag. Methods: Retrospective analysis of data from pts. enrolled in the German Registry for Aplastic Anemia and Bone Marrow Failure (AA-BMF). 334 pts. with (suspected) AA and available BMI data (49% (n=164) male/ 51% (n=170) female, 83% (n=278) BMI & lt; 30, 17% (n=56) BMI ≥ 30) were identified of which 89 pts. (43 male/ 46 female, mean age 50 ± 17 years, 75 BMI & lt; 30/ 14 BMI ≥ 30 at hATG administration) with confirmed diagnosis of AA (4 mAA/ 49 sAA/ 18 vsAA/ 14 AA not otherwise specified/ 4 AA-PNH Overlap) and treatment with hATG/CSA were analyzed in detail. 14 pts. received hATG/CSA/Epag (all BMI & lt; 30). Follow-up data were compiled over 35 ± 38.5 months between 2000 and 2023, whereby follow-up data of 12 pts. were incomplete. Results are given as mean ± standard deviation. Results: Analysis of the age distribution of the 343 pts. with (suspected) AA showed a mean age of 50 ±17 years with a biphasic peak at age approx. 25 and 65 years. The average BMI stratified by age (20-30y: 22.9, 31-40y: 24.5, 41-50y: 26.8, 51-60y: 26.4, 61-70y: 27.5, & gt;70y: 27.8) corresponded to the BMI distribution of the German population surveyed by the German Federal Statistical Office. In accordance with the expected survival rates, the 89 AA pts. treated with hATG/CSA (including 14 pts. with Epag) revealed a 5-year overall survival (OS) of 93%/ 86%/ 67 % at & lt; 40/ 40-60/ & gt; 60 years. Regarding BMI, no significant difference was observed in 5-year OS between obese (BMI ≥ 30, 5y-OS 67%) and non-obese pts. (BMI & lt; 30, 5y-OS 85%, p = 0.51). In pts. responding to IST, hematological response at six months after ATG was reached in 67 % (n=7/11) of the obese and 63 % (n=21/33, in 9 pts. exact timepoint not available) of the non-obese pts. (p = 0.85). The proportion of primary IST refractory pts. was numerically lower in obese (21 %, n=3/14) than in non-obese pts. (32 %, n=21/65, p=0.53). Among all 53 responders (2 pts. had incomplete follow-up to assess relapse), a significantly lower relapse rate of 9 % (n=1/11) in obese (median follow-up: 16 months, range 3 to 120 months) compared to 55 % (n=22/40) in non-obese pts. was observed (median follow-up: 19 months, range 1 to 87 months, p=0.008). Conclusion: BMI distribution of AA pts. by age is comparable to that of the general population with a higher rate of obesity in older pts.. Pts. with a BMI ≥ 30 thus receiving higher ATG dosages do appear to have comparable OS and hematological response rates compared to pts. with BMI & lt;30. However, pending validation in a larger patient cohort, we hypothesize, based on our analysis, that a higher cumulative total ATG dose may have a beneficial impact on relapse rates in pts. with BMI ≥ 30 compared to those with BMI & lt; 30.

Abstract: First‐line treatment in patients with acute myeloid leukemia (AML) unfit for intensive therapy is the combination of a hypomethylating agent (HMA) with venetoclax (VEN). However, retrospective data confirming the benefits of this regimen outside of clinical trials have shown conflicting results. Methods We performed a multicenter retrospective analysis of outcomes with first‐line HMA–VEN versus HMA in AML patients unfit for intensive chemotherapy. Results A total of 213 patients were included from three German hospitals (125 HMA–VEN, 88 HMA). Median overall survival in the HMA–VEN cohort was 7.9 months (95% confidence interval [CI], 5.1–14.7) versus 4.9 months (3.1–7.1) with HMA. After 1 year, 42% (95% CI, 33–54) and 19% (12–30) of patients were alive, respectively (hazard ratio [HR] for death, 0.64; 95% CI, 0.46–0.88). After adjusting for clinical and molecular baseline characteristics, treatment with HMA–VEN remained significantly associated with both prolonged survival (HR, 0.48; 95% CI, 0.29–0.77) and time to next treatment (HR, 0.63; 95% CI, 0.47–0.85). Patients who achieved recovery of peripheral blood counts had a favorable prognosis (HR for death, 0.52; 95% CI, 0.33–0.84). Discussion These data align with findings from the pivotal VIALE‐A trial and support the use of HMA–VEN in patients unfit for intensive therapy.

Abstract: Cranial imaging (CI) is a widely used diagnostic procedure, especially in acute myeloid leukemia (AML) patients with suspected bleeding or infection. However, common clinical decision rules to guide CI do not apply to AML patients and the diagnostic yield and outcomes of CI for AML patients are largely unknown. We retrospectively evaluated all CI from newly diagnosed non-promyelocytic AML patients receiving intensive induction or consolidation chemotherapy between 2007 and 2019 for imaging indications, diagnostic yield, and consequences. A total of 110 of 462 patients (24%) received CI for 152 imagings in distinct clinical situations. Forty-four patients (40%) had at least one new and acute pathological finding. Main indication was focal neurologic deficit, craniocerebral trauma, and suspected cerebral hypertension. The most common new finding was intracranial hemorrhage (13% of all imagings), followed by sinusitis (9%). CI led to therapy change in 21 patients. There were no clear associations between indications, laboratory values, and a positive imaging. Positive imaging was associated with adverse overall survival. Our study suggests that the overall rate of ordered CI was appropriate and that CI should generally be performed at a low threshold. A systematized approach to CI may further increase diagnostic yield but is complicated by variable clinical presentation.

Abstract: BI 836826 is a chimeric immunoglobulin G1 antibody targeting CD37, a tetraspanin transmembrane protein predominantly expressed on normal and malignant B cells. This phase I, open-label study used a modified 3 + 3 design to evaluate the safety, maximum tolerated dose (MTD), pharmacokinetics, and preliminary activity of BI 836826 in patients with relapsed/refractory B cell non-Hodgkin lymphoma (NHL; NCT01403948). Eligible patients received up to three courses comprising an intravenous infusion (starting dose: 1 mg) once weekly for 4 weeks followed by an observation period of 27 (Course 1, 2) or 55 days (Course 3). Patients had to demonstrate clinical benefit before commencing treatment beyond course 2. Forty-eight patients were treated. In the dose escalation phase (1–200 mg) involving 37 Caucasian patients, the MTD was 100 mg. Dose-limiting toxicities occurred in four patients during the MTD evaluation period, and included stomatitis, febrile neutropenia, hypocalcemia, hypokalemia, and hypophosphatemia. The most common adverse events were neutropenia (57%), leukopenia (57%), and thrombocytopenia (41%), and were commonly of grade 3 or 4. Overall, 18 (38%) patients experienced infusion-related reactions, which were mostly grade 1 or 2. Preliminary evidence of anti-tumor activity was seen; three patients responded to treatment, including one complete remission in a Korean patient with diffuse large B cell lymphoma. BI 836826 plasma exposure increased more than proportionally with increasing doses. BI 836826 demonstrated preliminary activity; the most frequent adverse events were hematotoxicity and infusion-related reactions which were manageable after amending the infusion schedule. Although BI 856826 will not undergo further clinical development, these results confirm CD37 as a valid therapeutic target in B cell NHL.

Abstract: Introduction Selinexor is an exportin-1 (XPO1) inhibitor which forces the nuclear retention and functional activation of tumor suppressor proteins, inducing apoptosis in cancer cells. Overexpression of XPO-1 is common in many tumors, including acute myeloid leukemia (AML). A phase II study, "SAIL", of selinexor with cytarabine and idarubicin in patients with relapsed/refractory AML was conducted by Fiedler et al. showing a high remission rate. To identify molecular predictors of response and survival we evaluated the molecular mutations and their course in selinexor treated patients. Methods All 42 patients treated in the SAIL trial were eligible to participate in this translational study. The main criterion for inclusion in the present study was availability of DNA from bone marrow or peripheral blood at 3 time points: initial AML diagnosis, screening for the SAIL trial and first response assessment on day 28 of cycle 1. A custom TruSight myeloid sequencing panel was used to identify molecular mutations at diagnosis. Molecular response was defined as variant-allele frequency (VAF) & lt;1% in the follow-up sample after SAIL treatment independent of morphologic remission. Minimal residual disease (MRD) under selinexor maintenance treatment was quantified by error-corrected NGS with a limit of detection of 0.02%. Results Eighteen patients were included for whom DNA was available for all three time points. The median age was 47.5 years (29-72), median prior therapies was 3 (1-9). 13 patients had de novo and 5 secondary/therapy-related AML. ELN risk at first diagnosis was favorable in eight, intermediate in five and adverse in three patients. Only one course of SAIL treatment was administered to all patients. 8 patients achieved morphologic complete remission (CR) or CR with incomplete hematologic recovery (CRi). 13 patients proceeded to allogeneic hematopoietic cell transplantation (alloHCT) or donor lymphocyte infusion. The median overall survival was 0.69 years. The molecular profile showed a predominance of secondary AML-type mutations. No clear pattern was found between mutation status and morphologic CR or CRi (Figure 1). Molecular response to the SAIL induction treatment was found in 6 of 14 patients who had a molecular marker. Mutations in FLT3 (FLT3-TKD=1, FLT3-ITD=2), SF3B1 and TP53 were associated with molecular response, whereas mutations in GATA2, CUX1, TET2, BCOR, DNMT3A, RAD21, ASXL1, SRSF2, and WT1 were associated with resistance. When comparing the molecular characteristics of patients achieving CR/CRi (n=8) and all other patients (n=10), a trend to achieve CR was observed among patients with NPM1 mutations (P=0.094), whereas mutations in ASXL1 (P=0.09) and SRSF2 (P=0.09) were associated with refractoriness. One of the responding patients received selinexor as maintenance therapy for four years. The patient was diagnosed with de novo AML with normal cytogenetics, with SF3B1 and SRSF2 mutations. The patient received an HLA-identical transplant after myeloablative conditioning, but relapsed 6 years after alloHCT. One cycle of selinexor/chemotherapy was administered and the patient achieved CR. The patient continued selinexor maintenance treatment with 60 mg selinexor twice a week. SF3B1 and SRSF2 mutations were still present at the time of relapse and declined under SAIL treatment (Figure 2). The patient received one course of DLI (1x10 7CD3 +), which was tolerated well without signs of GvHD. MRD remained detectable 17 days after DLI. At 30 days after DLI treatment both MRD markers were negative. Under continued selinexor maintenance treatment MRD remained negative until last follow-up at 4.9 years after SAIL treatment. The patient tolerated selinexor well with short-term nausea and dysgeusia after selinexor intake. Selinexor maintenance treatment was stopped 4 years after SAIL treatment and the patient remains in CR 14 months after the end of maintenance. Conclusion In this small series, we found a correlation between FLT3, TP53 and SF3B1 mutation status and molecular response to selinexor/chemotherapy (SAIL). NPM1 mutations were associated with morphologic response to SAIL by trend. Finally, selinexor maintenance may have contributed to long-term disease control in a patient with relapsed AML, and long term therapy with selinexor is feasible. Figure 1 Figure 1. Disclosures Fiedler: Servier: Consultancy, Other: Meeting attendance, Preparation of information material; Stemline: Consultancy; Daiichi Sanyko: Consultancy, Other: Meeting attendance, Preparation of information material; Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Honoraria; MorphoSys: Consultancy, Honoraria; Jazz: Consultancy, Honoraria, Other: Meeting attendance, Preparation of information material; Celgene: Consultancy, Honoraria; Ariad/Incyte: Honoraria; Amgen: Consultancy, Honoraria, Other: Meeting attendance, Preparation of information material, Patents & Royalties, Research Funding; Abbvie: Consultancy, Honoraria, Other: Meeting attendance, Preparation of information material. Modemann: Servier: Honoraria, Other: Travel accomodation; Incyte: Other: Travel accomodation; Gilead: Other: Travel accomodation; Jazz Pharmaceuticals: Other: Travel accomodation; Novartis: Other: Travel accomodation; Teva: Other: Travel accomodation; Pfizer: Other: Travel accomodation; Amgen: Other: Travel accomodation; Daiichi Sankyo: Research Funding; Abbvie: Honoraria, Other: Travel accomodation. Bokemeyer: Merck KGaA: Honoraria; Sanofi: Consultancy, Honoraria, Other: Travel accomodation; Roche: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; BMS: Honoraria, Other: Travel accomodation, Research Funding; AstraZeneca: Honoraria, Research Funding; Merck Sharp Dohme: Consultancy, Honoraria; Lilly/ImClone: Consultancy; Merck Serono: Consultancy, Other: Travel accomodation ; Bayer Schering Pharma: Consultancy; GSO: Consultancy; AOK Health insurance: Consultancy; Abbvie: Research Funding; ADC Therapeutics: Research Funding; Agile Therapeutics: Research Funding; Alexion Pharmaceuticals: Research Funding; Amgen: Research Funding; Apellis Pharmaceuticals: Research Funding; Astellas: Research Funding; BerGenBio: Research Funding; Blueprint Medicine: Research Funding; Boehringer Ingelheim: Research Funding; Celgene: Research Funding; Daiichi Sankyo: Research Funding; Eisai: Research Funding; Gilead Sciences: Research Funding; Gylcotope GmbH: Research Funding; GlaxoSmithKline: Research Funding; Inside: Research Funding; IO Biotech: Research Funding; Isofol Medical: Research Funding; Janssen-Cilag: Research Funding; Karyopharm Therapeutics: Research Funding; Lilly: Research Funding; Millenium: Research Funding; MSD: Research Funding; Nektar: Research Funding; Rafael Pharmaceuticals: Research Funding; Springworks Therapeutics: Research Funding; Taiho Pharmaceutical: Research Funding; Pfizer: Other. Ganser: Celgene: Honoraria; Novartis: Honoraria; Jazz Pharmaceuticals: Honoraria. Thol: Astellas: Honoraria; Jazz: Honoraria; Novartis: Honoraria; Pfizer: Honoraria; BMS/Celgene: Honoraria, Research Funding; Abbvie: Honoraria. Heuser: Karyopharm: Research Funding; AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Astellas: Research Funding; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Tolremo: Membership on an entity's Board of Directors or advisory committees; Jazz: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Honoraria; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer Pharma AG: Research Funding; BMS/Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; BergenBio: Research Funding; Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees, Research Funding. OffLabel Disclosure: Selinexor in patients with relapsed or refractory AML

Abstract: Introduction: Aplastic anemia (AA) is an acquired bone marrow failure syndrome (BMFS) mediated by autoreactive T-cells. In adults with severe (s) or very severe (vs) AA & gt;40-50 years or ineligible for transplant for other reasons immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG), cyclosporine A (CsA) and Eltrombopag (Epag) has recently become the actual standard of care. With CsA treatment maintained for 6 to 24 months followed by CsA tapering hematologic response is achieved in 60-70 % of AA patients (pts.), while 30-40 % are primary refractory. Approximately 40% of pts. relapse during CsA tapering and most relapsed AA pts. remain CsA dependent. In vitro data indicate a dose dependent inhibition of T cell activity induced by CsA, suggesting the presence of a therapeutic CsA threshold around 100 ng/mL (Flores et al. Front Immunol 2019). Pts. with CsA related side effects such as renal insufficiency would benefit from an established lowest efficient CsA plasma level preventing relapse and reducing CsA related toxicity. As data about correlation of CsA plasma levels and the occurrence of relapse during tapering are sparse, we analyzed data from our registries including CsA plasma levels of 20 s/vsAA pts. with and without relapse during CsA tapering after treatment with horse ATG/CsA. Methods: Descriptive retrospective analysis of 20 AA pts. (17 sAA/ 3 vsAA) from the AA-BMF/Basel AA registry treated with horse ATG/CsA and sufficient clinical data during CsA tapering. Results are given as mean ± standard deviation. Mean age of the 13 female and 7 male pts. was 53 ± 19 years. Follow-up data over 59 ±17 months were compiled between 2010 and 2023. Results: All 20 pts. achieved a hematological response i.e. partial (PR) or complete remission (CR) (as defined in Peffault de Latour et al., 2022) at 3/6/9 months after ATG as follows: PR 90%/ 75%/ 55% and CR 0%/ 20%/ 45%. Relapse of AA occurred in 60 % (12 pts.) at 24 ± 11 months after ATG, while 40 % (8 pts.) remained relapse-free during a follow up period of 59 ±17 months. In the 8 pts. without relapse, dose reduction was initiated 14 ± 6 months after ATG at a hematological response of CR in 4 pts. and PR in 4 pts. In two pts. with PR, early decrease of CsA was required due to renal insufficiency (1 month after ATG) or CsA related adverse drug reaction (4 months after ATG), respectively. The average time of CsA maintenance was 32 ± 13 months. In pts. with relapse (60%, 12 pts.), dose reduction was started after reaching best hematological response i.e. CR (9 pts.) or PR (3 pts.) at 11 ± 7 months after ATG. Relapse i.e. recurrent thrombocytopenia occurred 12 ± 9 months after start of tapering at CsA plasma levels of 44.0 ± 29.2 ng/mL and a daily CsA dosage of 1.01 ± 0.70 mg/kg. In one case, relapse occurred one month after stopping CsA. No patient with CsA levels continuously & gt; 100 ng/mL relapsed, whereas thrombocytopenia was observed with a latency of 2.8 ± 1.6 months after first decrease below 100 ng/mL CsA in pts. with relapse. While 58% (7 pts.) of the relapsed pts. responded to salvage-therapy with CsA+Epag (age 58 ± 16 years), 42 % (5 pts.) required a second course of ATG/CsA, or transplant (age 44 ± 22 years). Conclusion: In s/vsAA pts. with hematological response to ATG/CsA, closer monitoring for relapse is recommended reaching CsA plasma levels & lt;100 ng/mL, as CsA & lt;100 ng/mL was associated with higher risk of relapse during CsA tapering in line with previous reported in vitro data. Pending prospective validation, CsA plasma levels & gt;100 ng/mL might serve as threshold in pts. requiring accelerated tapering due to renal insufficiency or CsA related side effects.

Abstract: Telomere biology disorders (TBD) result from premature telomere shortening due to pathogenic germline variants in telomere maintenance-associated genes. In adults, TBD are characterized by mono/oligosymptomatic clinical manifestations (cryptic TBD) contributing to severe underdiagnosis. We present a prospective multi-institutional cohort study where telomere length (TL) screening was performed in either newly diagnosed patients with aplastic anemia (AA) or if TBD was clinically suspected by the treating physician. TL of 262 samples was measured via flow-fluorescence in situ hybridization (FISH). TL was considered suspicious once below the 10th percentile of normal individuals (standard screening) or if below 6.5 kb in patients 〉 40 years (extended screening). In cases with shortened TL, next generation sequencing (NGS) for TBD-associated genes was performed. The patients referred fell into 6 different screening categories: (1) AA/paroxysmal nocturnal hemoglobinuria, (2) unexplained cytopenia, (3) dyskeratosis congenita, (4) myelodysplastic syndrome/acute myeloid leukemia, (5) interstitial lung disease, and (6) others. Overall, TL was found to be shortened in 120 patients (n = 86 standard and n = 34 extended screening). In 17 of the 76 (22.4%) standard patients with sufficient material for NGS, a pathogenic/likely pathogenic TBD-associated gene variant was identified. Variants of uncertain significance were detected in 17 of 76 (22.4%) standard and 6 of 29 (20.7%) extended screened patients. Expectedly, mutations were mainly found in TERT and TERC . In conclusion, TL measured by flow-FISH represents a powerful functional in vivo screening for an underlying TBD and should be performed in every newly diagnosed patient with AA as well as other patients with clinical suspicion for an underlying TBD in both children and adults.