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Introduction: Chimeric antigen receptor T cell (CAR-T) therapy harnesses a patient’s own immune system to target cancer. Cardiotoxicity occurs in up to 25% of patients treated with CAR-T. There are limited data characterizing the association between the development of cardiotoxicity after CAR-T and mortality among patients following CAR T cell therapy. Hypothesis: We hypothesized that cardiotoxicity following CAR-T treatment would be associated with a higher rate of mortality. Cardiotoxicity was a composite outcome defined as the development of heart failure, cardiogenic shock, or myocardial infarction. Methods: We included the first 202 adult patients entered into a multicenter registry receiving anti-CD 19 CAR-T for lymphoma or acute lymphoblastic leukemia (ALL). Of these, 108 died and 94 survived. Covariates included standard baseline cardiovascular and cancer parameters, the occurrence of cardiotoxicity and mortality. Results: Those that did and did not die after CAR-T were similar in age, sex, and pre-lymphodepletion chemotherapy regiment. Death after CAR-T was more common in patients with than without hypertension (66% vs. 47%, p=0.009) or ALL (66% vs. 48%, p=0.02), and less common with baseline coronary artery disease (25 vs. 56%, p=0.04). There was no difference in mean cytokine release syndrome (CRS) grade, rate of ≥2 CRS, or in the use of tocilizumab or steroids between those who did and did not die after CAR-T. During a mean follow-up of 372±284 days, 33 (16%) patients experienced cardiotoxicity. Patients with vs. without cardiotoxicity died more often (76% vs. 49%, OR 3.2, CI 1.4 - 7.6, p=0.005). In a Cox model adjusted for covariates identified in univariate analyses, occurrence of cardiotoxicity with CAR-T was independently associated with an increased risk of mortality (adjusted HR: 1.85, 95% CI: 1.17-2.92, p=0.009). Conclusions: CAR-T recipients who experience cardiotoxicity have higher mortality.

The MYD88 L265P somatic variant (MYD88) has a high prevalence in Waldenstrom’s Macroglobulinemia (WM), a form of lymphoplasmacytic lymphoma (LPL) associated with monoclonal IgM. Although the role of MYD88 in WM was initially reported in 2012, it was not until 2016 that MYD88 testing was included in the National Cancer Care Network (NCCN) Guidelines. We present a case illustrating the utility of MYD88 status in distinguishing atypical forms of WM from marginal zone lymphoma (MZL) and in selecting second-line therapy with ibrutinib. In 2012, a 64-year-old male presented with dyspnea on exertion, a hemoglobin of 5.6 g/dL, a platelet count of 86,000, and monoclonal IgM kappa on serum immunofixation but no detectable M-spike. Bone marrow biopsy revealed 95% monoclonal B-lymphocytes with lymphoplasmacytic differentiation favoring a diagnosis of LPL/WM over MZL, with a favorable response to chemotherapy. This diagnosis was called into question 3 years later following relapse, and MZL was favored based on the lack of MYD88 mutation. One year later, however, repeat bone marrow biopsy detected the MYD88 mutation and therapy with ibrutinib yielded a favorable response. The distinction between certain lymphomas can be problematic and in this case MYD88 was helpful in clarifying a diagnosis of atypical LPL/WM from MZL and in selecting effective second-line therapy.

Thrombomodulin (TM) is an essential cofactor for the physiologic activation of the anticoagulant protein C by thrombin. We have observed that the expression of TM mRNA in response to retinoic acid was markedly increased in human U937 monoblast-like cells, and human MEG01 megakaryocyte-like cells, but not in human umbilical vein cells, murine hemangioma cells, human K562 erythroblast-like cells, and murine HSD fibroblast-like cells. TM activity in U937 cells and MEG01 cells was not detectable in untreated cells, but developed rapidly after treatment with retinoic acid. In endothelial cells there was minimal change in TM activity in response to retinoic acid treatment. We have isolated clones for the genes for murine and human TM and have identified potential retinoic acid response elements in the 5'-flanking region of the human gene. In U937 cells the increase in mRNA levels was associated with increased transcription, and transient transfection studies with reporter plasmids demonstrate functional retinoic acid response elements present in the 5'-flanking region of the gene. Deletion of, and mutations introduced into, the potential retinoic acid response element confirm the functional response in transient transfections.

Thrombomodulin (TM) is an essential cofactor for the physiologic activation of the anticoagulant protein C by thrombin. We have observed that the expression of TM mRNA in response to retinoic acid was markedly increased in human U937 monoblast-like cells, and human MEG01 megakaryocyte-like cells, but not in human umbilical vein cells, murine hemangioma cells, human K562 erythroblast-like cells, and murine HSD fibroblast-like cells. TM activity in U937 cells and MEG01 cells was not detectable in untreated cells, but developed rapidly after treatment with retinoic acid. In endothelial cells there was minimal change in TM activity in response to retinoic acid treatment. We have isolated clones for the genes for murine and human TM and have identified potential retinoic acid response elements in the 5'-flanking region of the human gene. In U937 cells the increase in mRNA levels was associated with increased transcription, and transient transfection studies with reporter plasmids demonstrate functional retinoic acid response elements present in the 5'-flanking region of the gene. Deletion of, and mutations introduced into, the potential retinoic acid response element confirm the functional response in transient transfections.

A monoclonal antibody, designated 3.2.3, which recognizes a novel Mr 60,000 disulfide-linked lytic triggering structure present on rat large granular lymphocytes and natural killer (NK) cells was recently described (W. H. Chambers et al., J. Exp. Med., 169: 1373-1389, 1989). The present study describes the use of 3.2.3 to identify the in situ tissue distribution of large granular lymphocytes/NK cells in different organs from normal and tumor-bearing F344 rats. Frozen tissue sections were prepared and stained with monoclonal antibody 3.2.3 using an avidinbiotin immunoperoxidase technique. 3.2.3+ NK cells were easily identified using this technique, and quantitative analysis of various tissues of normal rats demonstrated that (a) in the spleen, most NK cells were located, sometimes as aggregates, in the red pulp (12.4% of total nucleated cells in that organ compartment) with relatively few noted in the white pulp (0.2-2.3%); (b) in the liver, 3.2.3+ cells were rare, sparsely distributed, and located primarily in the sinusoids (1.2%); (c) in the lungs, 3.2.3+ cells were located in the interstitium (3.7%); (d) in the thymus, 3.2.3+ cells were found primarily in the medulla (1.8%) adjacent to the cortex but not in the cortex itself (0.2%); (e) in the lymph node, most 3.2.3+ cells were contained in the paracortex (6.9%); and finally (f) in the small bowel, 3.2.3+ cells were present in the lamina propria (8.6%) and as aggregates in the interfollicular zone of Peyer's patches (0.7%). To study the distribution of 3.2.3+ NK cells in developing tumor metastases, we induced liver metastases by intrasplenic injection of MADB106 mammary adenocarcinoma cells and prepared frozen tissue sections of the liver 10-14 days later. We found that the frequency of 3.2.3+ cells in the developing liver metastases was 3-6 times higher than in the surrounding normal liver tissue. Moreover, the frequency of 3.2.3+ NK cells was equivalent to the frequency of tumor-infiltrating CD5+ T-cells identified in the same tumor lesions. This suggests specific infiltration of 3.2.3+ NK cells in early developing metastatic lesions. These results indicate that monoclonal antibody 3.2.3 will be valuable in analyzing the involvement of NK cells in various pathological states.