Per- and polyfluoroalkyl substances (PFAS) have become an important focus of research in recent years due to their widespread use and environmental persistence. Perfluorooctanoic acid (PFOA) has attracted considerable attention due to its effects on the reproductive system, yet its molecular mechanisms in testicular cells remain unclear. This study aimed to investigate the effects of PFOA on oxidative stress, mitochondrial function, and interconnected programmed cell death pathways. Mouse Sertoli (TM4) and spermatogonial (GC-1) cells were exposed to PFOA at concentrations of 200-800µM for 24h, and its effects on cell viability and cytotoxicity were evaluated. Oxidative stress levels were determined by measuring reactive oxygen species production, malondialdehyde levels, antioxidant enzyme activities, and mitochondrial membrane potential. In addition, the potential cell death pathways, including apoptosis, autophagy, mitophagy, and ferroptosis, were assessed by analyzing gene and protein expression using RT-qPCR and Western blot. PFOA exposure resulted in a concentration-dependent and significant increase in intracellular ROS levels, accompanied by a significant decrease in mitochondrial membrane potential in both cell lines. The antioxidant defense system and NRF2 signaling were markedly suppressed. PFOA exposure also significantly activated intrinsic apoptotic pathways, as supported by increased apoptotic gene expression and elevated caspase-3 protein levels. A clear increase in autophagy- and mitophagy-related markers was observed, suggesting that cells develop an adaptive response to mitochondrial damage. These findings provide important mechanistic insights into mitochondrial dysfunction and associated cell death processes in PFOA-exposed testicular cells.
Graves' disease (GD) is an autoimmune form of hyperthyroidism. We integrated GD GWAS summary statistics with immune-cell eQTLs to prioritize cell-type-specific genes with potential relevance to GD susceptibility. We analyzed European-ancestry GD GWAS summary statistics from FinnGen Release 12 together with cis-eQTLs from 14 peripheral immune-cell subsets in the OneK1K single-cell resource (982 donors). We prioritized associations using SMR and HEIDI filtering, and Bayesian colocalization (COLOC) analysis was then performed to assess whether eQTL and GD association signals were likely to share a causal variant. Differential expression analysis using GSE71956 was used as additional transcriptomic support. After harmonization, 5,048 instrument-gene pairs were retained. MR identified 173 nonredundant genes (FDR < 0.05); SMR plus HEIDI retained 159 genes across the 14 immune subsets. COLOC highlighted 33 high-confidence colocalized signals (PPH4 > 0.90), including ARID5B in CD4+ naïve/central memory T cells, PRSS16 in CD4+ effector-memory T cells, HIST1H2BI in CD8+ effector-memory T cells, and FCRL3 in NK cells. In GSE71956, several prioritized genes showed differential expression, and ARID5B was expressed at lower levels in GD samples than in controls. Concordant evidence across methods supports these signals, but residual pleiotropy and the European-only design remain important caveats. Differences from prior reports may reflect cell-type context and disease stage. Immune subset-resolved eQTL-GWAS integration points to specific genes and pathways that may contribute to GD susceptibility and helps narrow candidates for follow-up studies.
Rhabdomyosarcoma (RMS), the most common pediatric soft tissue sarcoma, remains difficult to treat in relapsed, metastatic, or refractory disease. Chimeric antigen receptor (CAR) T cell therapy has demonstrated promising results in hematological diseases, but its application to solid tumors including RMS is limited by antigen heterogeneity, on-target/off-tumor toxicity, and insufficient activity against moderate antigen density. We investigated L1 cell adhesion molecule (L1CAM) as a candidate CAR T cell target in RMS by profiling expression in cell lines, patient-derived xenografts, and healthy tissues. Using the CE7-derived single-chain variable fragment, we engineered and compared L1CAM-CAR constructs differing in hinge and costimulatory domains, including the clinically tested 4-1BB-based CE7-CAR configuration. Functional activity was assessed across fusion-positive and fusion-negative RMS models in vitro and in orthotopic mouse models, with B7-H3-CAR T cells included as a benchmark. L1CAM was expressed at variable but specific levels across RMS models, with more prominent expression in fusion-positive RMS and limited expression in healthy tissues. Among constructs, the CD28-based L1CAM.III-CAR showed the strongest cytotoxicity and IFN-γ release, including partial activity in a low-L1CAM model. In vivo, L1CAM.III-CAR T cells improved expansion, delayed tumor progression, and prolonged survival compared with the clinical-reference L1CAM.CT construct, although responses were incomplete and less pronounced than those achieved with B7-H3-CAR T cells. These findings support L1CAM as a rational target for L1CAM-positive RMS cases and demonstrate that CAR optimization can enhance activity against moderate-density antigens. The potent antitumor activity and favorable selectivity profile of L1CAM.III-CAR T cells support their development for pediatric sarcoma immunotherapy.
Chimeric antigen receptor (CAR) T cell therapy has limited efficacy against solid tumors such as neuroblastoma (NB). Key obstacles include extensive tumor burden and the presence of an immunosuppressive tumor microenvironment (TME). We employ targeted radiopharmaceutical therapy (RPT) using [67Cu]Cu-LLP2A and show that it potentiated the anti-tumor activity of CAR T cells in radio-sensitive and radio-resistant NB models via distinct mechanisms. In radio-sensitive NB, RPT is directly tumoricidal while also enhancing CAR T cell efficacy through pro-immune pathways, most notably via the TNF-α pathway, leading to paracrine activation of T cells. In radio-resistant NB, RPT improves CAR T cells by remodeling the myeloid compartment in the TME and increasing the formation of immunological niches of cytotoxic CD8+ GZMB+ and CD4+ GZMB+ CAR T cells. While neither treatment modality alone can effectively treat NB, the combination of VLA-4-targeted RPT and GD2 or B7-H3 CAR T cells augments anti-tumor efficacy, resulting in marked tumor regression in preclinical NB models.
Accurate red cell antibody identification is central to immunohematology, yet reagent red cell variability can compromise test reliability. Factors such as manufacturing differences, reagent composition, and cold-chain instability may alter assay sensitivity and obscure result interpretation. This study, for the first time, reports elution of Lewis antigens from reagent red cell panels, highlighting its role in antibody identification errors and diagnostic ambiguity. Over one year, five cases with inconclusive antibody identification due to reagent variability were analyzed. Comprehensive immunohematology workup was performed using commercially available panels. Root cause analysis, including Ishikawa chart evaluation, examined patient, technical, external, and reagent-related factors. Retesting was done with panels from an alternate manufacturer, and papain-treated reagent cells were assessed for antigenic alterations. Panels from Manufacturer 1 yielded atypical, non-specific reactions. Retesting with Manufacturer 2's panels identified anti-Leᵃ and/or anti-Leᵇ antibodies in all cases. Phenotyping showed absence of Leᵃ and Leᵇ antigens on reagent cells 4-6, contrary to their antigram, leading to false-negative reactions. Papain treatment did not affect reactivity, confirming Lewis antigen loss as the root cause of misidentification. Lewis antigen expression on reagent red cells should be routinely verified, as these plasma-derived antigens may dissociate under variable conditions. Incorporating this check into quality control protocols can enhance assay reliability, reduce diagnostic errors, and improve turnaround time.
Whether and how pyrimidine metabolites promote systemic autoimmunity is unknown. Here, metabolomics and 15N-amide glutamine tracing show enhanced flux through de novo pyrimidine synthesis in systemic lupus erythematosus (SLE)-prone B cells. Temporal inhibition of pyrimidine synthesis dampens SLE-prone but not foreign antigen-specific germinal center (GC), plasma cell (PC), and antibody responses. Uridine monophosphate synthase (UMPS) conditional deletion, however, reveals a B cell-intrinsic requirement of de novo pyrimidine synthesis in foreign antigen-driven and SLE-prone GC, PC, and antibody responses and kidney immune complex deposition. Metabolomics, mitochondrial stress test, metabolic flow cytometry, glycolytic rate assay, and RNA sequencing highlight the importance of pyrimidine synthesis in promoting aerobic glycolysis and oxidative phosphorylation in SLE-prone B cells. De novo pyrimidine synthesis helps SLE-prone B cells maintain heightened metabolic state and expression of metabolic regulator, cMYC. Mechanistically, mTORC1 and S6K1 downstream of TLR7 and CD40 signaling in B cells promote pyrimidine synthesis by activating CAD, a rate-limiting enzyme of this pathway.
Almost 1 million people in the United States suffer from multiple sclerosis (MS). Current therapies suppress protective immunity and are non-curative. Antigen-specific therapies can selectively suppress autoreactive cells, preserving protective immunity. B cell dysregulation, a major driver of MS, remains largely untargeted for antigen-specific tolerance. We hypothesize that targeting B cells with antigen-loaded microparticles will enhance therapeutic efficacy. Here, we demonstrate that antigen-loaded acetalated dextran microparticles (AMP) surface-associate with B cells and enhance IL-10 secretion and MHCII expression, promoting tolerogenic antigen presentation. Leveraging this property, we developed a therapy using myelin oligodendrocyte (MOG35-55) peptide-loaded AMPs associated with B cells (MOG-AMP-B). Administering MOG-AMP-Bs in a late therapeutic model of multiple sclerosis resulted in unprecedented recovery, reducing central nervous system (CNS) inflammation, downregulating activated dendritic cells and macrophages, and increasing regulatory T- and B cells. MOG-AMP-Bs did not reduce the ability of animals to respond to a viral infection, representing a highly effective antigen-specific therapy for restoring immune balance in autoimmunity.
Pediatric-acquired demyelinating syndromes, including multiple sclerosis (MS), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) constitute distinct entities arising during critical periods of neurodevelopment. Early and effective treatment is therefore crucial to prevent long-term disability. Converging evidence supports a central role of B-cells in central nervous system autoimmunity, extending beyond antibody production to include antigen presentation, cytokine production, and T-cell modulation. B-cell-depleting anti-CD20 therapies are increasingly used in this setting, but the strength and consistency of evidence differ substantially across diseases and individual drugs. Available data indicate that anti-CD20 treatment provides significant suppression of relapses and MRI activity in pediatric MS. Rituximab, although used off-label, has shown a significant reduction in annualized relapse rates and inflammatory MRI activity across observational cohorts. Ocrelizumab has the most advanced pediatric evidence among approved anti-CD20 agents, including dose-selection data from OPERETTA I and comparative Phase 3 data from OPERETTA II, where it reduced MRI activity compared with fingolimod and showed sustained B-cell depletion. In contrast, evidence for ofatumumab in pediatric MS remains limited to very small case series, although dedicated pediatric trials are ongoing. No pediatric data are currently available for ocrelizumab or ofatumumab in AQP4+NMOSD or MOGAD. In pediatric AQP4+NMOSD, rituximab remains the best-supported anti-CD20 option, with observational studies showing relapse reduction and a close relationship between CD19-positive B-cell repopulation and breakthrough disease activity. In relapsing MOGAD, responses to rituximab are heterogeneous: some cohorts report reduced relapse frequency during sustained B-cell depletion, whereas others describe continued relapses despite treatment, suggesting that pathogenic mechanisms beyond CD20-positive B-cells, including long-lived plasma cells or non-B-cell immune pathways, may contribute to disease activity. Across pediatric cohorts, anti-CD20 therapies are generally well tolerated. Infusion-related reactions are common but usually mild, infections are typically non-severe, and hypogammaglobulinemia, leukopenia, delayed neutropenia, vaccine-response attenuation, and early B-cell repopulation require individualized monitoring. Upcoming trials of ofatumumab, ublituximab, and rituximab-based strategies in MOGAD will be critical to refine pediatric dosing, define biomarkers of treatment durability, and establish age-specific safety surveillance for the developing immune system. This review summarizes knowledge on B-cell maturation in early life and anti-CD20 treatment outcomes in pediatric patients with these conditions. Safety and tolerability considerations, optimal timing of therapy, and remaining gaps in evidence are also explored, highlighting the need for age-specific biomarkers and prospective studies to better define individualized treatment strategies and to clarify long-term consequences of B-cell-depleting therapies in children.
Three-dimensional (3D) in vitro tumor models are critical for studying transport-limited drug efficacy in solid tumors; however, many existing platforms are technically complex and remain difficult to access. Stacked paper-based tumor models ("cells-in-gel-in-paper", CiGiP) address this challenge by enabling formation of diffusion-limited microenvironments while allowing direct access to cells from distinct tissue depths. Nevertheless, current CiGiP implementations rely on wax or hydrophobic barrier patterning of paper, which has become increasingly inaccessible. Here, we present a wax-printing-free approach for fabricating stacked paper-supported 3D tumor tissues using a simple 3D-printed press-fit enclosure that holds circular paper layers snugly together, thereby enforcing one-dimensional transport without lateral leakage. Using MDA-MB-231 breast cancer cells embedded in Matrigel, we demonstrate the formation of nutrient-limited microenvironments across the tissue depth, as evidenced by layer-dependent cell viability. The platform enables direct quantification of spatial and temporal drug responses, demonstrated using doxorubicin and paclitaxel, both individually and in combination. Layer-dependent cytotoxicity was measured, and combination treatment analysis revealed antagonistic interactions consistent with prior reports. By eliminating the need for hydrophobic patterning, this approach substantially lowers the technical barriers to constructing stacked paper tumor models and is expected to facilitate broader adoption of paper-supported 3D tissues for drug screening and mechanistic studies.
Arsenic, commonly found as an environmental pollutant, poses significant health threats and has become a worldwide public health concern. Extended exposure to arsenic is linked to the development of multiple cancers, particularly bladder cancer. In this study, a rat bladder tumor model was established by combined administration of N-methyl-N-nitrosourea (MNU) and sodium arsenite (NaAsO₂), with MNU serving as a carcinogen and NaAsO₂ as a promoter. Additionally, we constructed arsenic-treated cell model using the SV-HUC-1 human uroepithelial cell line, which was subjected to NaAsO₂ treatment for 40 weeks. This study confirmed that arsenic promoted bladder tumorigenesis induced by MNU in rats. The expression of PLCE1 protein was significantly upregulated in arsenic-treated bladder epithelial cells, and the inhibition of PLCE1 effectively ameliorated the arsenic associated malignant phenotype. Mechanistically, the elevated protein levels of PLCE1 were jointly regulated by OTUD7B-mediated deubiquitination and SENP1-mediated deSUMOylation. Notably, SENP1-mediated deSUMOylation further promoted the deubiquitination modification of PLCE1. Functional experiments demonstrated that either the inactivation of OTUD7B enzyme activity (C194S mutation) or the knockdown of SENP1 significantly alleviated the malignant behavior of bladder epithelial cells induced by inorganic arsenic. This "dual-modification" model provides a new paradigm for studying the carcinogenic mechanisms of environmental toxicants.
Sex differences in immune responses impact cancer outcomes and treatment response, including in glioblastoma (GBM). However, host factors underlying distinct immune-cancer interactions are poorly understood. Here we identify γ-aminobutyric acid (GABA) as a female-specific driver of GBM-promoting immune response. We demonstrated that GABA receptor B (GABBR) signaling enhances the T cell suppressive function of granulocytic myeloid-derived suppressor cells (gMDSCs) from female mice by upregulating the cationic amino acid transporter 2-L-arginine-nitric oxide synthase 2 (NOS2) pathway. GABBR agonism promotes GBM growth in female preclinical models through gMDSCs, while GABBR antagonism extends survival and reduces NOS2 in tumor-infiltrating gMDSCs only in female mice. Immune cells from female participants with GBM have enriched GABA transcriptional signatures and a higher GABA concentration compared to male counterparts. Collectively, these results highlight the sex-specific immunomodulatory role of GABA in tumorigenesis, supporting future assessment of GABA pathway inhibitors for cancer immunotherapy.
Alzheimer's disease (AD) is characterised by severe degeneration of cholinergic neurons within the basal forebrain complex (FBC) which is a key regulator of cognitive function. Cholinergic loss represents a central pathological hallmark of AD; however, the underlying molecular mechanisms remain incompletely understood. Although various in-vitro models are available, many are limited by species-specific differences, high cost, and technical complexity. Human neuroblastoma (SH-SY5Y) cells can be differentiated into neuron-like cells and represent a practical alternative for AD research. This study aimed to optimise retinoic acid (RA)-based differentiation conditions to enhance cholinergic characteristics in SH-SY5Y cells and evaluate their susceptibility to AD-related stressors as a simplified, cost-effective model for preliminary high-throughput AD studies. A structured literature search (2000-2025) was conducted using PubMed and ScienceDirect. After screening based on predefined criteria, 23 relevant studies were analysed for differentiation inducers, serum concentration, duration, neuronal markers, and cholinergic markers. Here, a simplified RA-only protocol was evaluated using 10µM RA with 1% or 3% heat-inactivated foetal bovine serum (1% or 3% HI-FBS) over 3, 5, and 7 days. Neuronal differentiation was assessed by morphological analysis, neurite length measurement, choline acetyltransferase (ChAT) and acetylcholinesterase (AChE) gene expressions, acetylcholinesterase (AChE) activity. Additionally, model relevance was further evaluated using AD-associated stressors such as streptozotocin (STZ), hydrogen peroxide (H₂O₂), lipopolysaccharide (LPS), and aluminium chloride (AlCl₃). Although most protocols generated mature neuron-like cells, only ~ 30% reported cholinergic marker expression, with retinoic acid (RA) and brain-derived neurotrophic factor (BDNF) as the most common inducers. This study reports that differentiation with 1% HI-FBS with 10µM RA for 7 days produced pronounced neuronal morphology, significant neurite extension, and extensive branching. These cells demonstrated a cholinergic-like phenotype, with significant upregulation of ChAT and AChE gene expressions, accompanied by increased AChE enzymatic activity. These neuron-like cells also showed dose-dependent responses to STZ, H₂O₂, and AlCl₃, with time-dependent effects observed for H₂O₂ and AlCl₃. Notably, cells were resistant to LPS-induced cytotoxicity. These findings support the utility of this RA-differentiated SH-SY5Y for neuronal-like cells for cholinergic-like model (1% HI-FBS, 10µM RA) as a practical and cost-effective platform for high-throughput AD drug screening.
Traumatic brain injury (TBI) is a significant contributor to global morbidity and mortality, with limited effective treatment options available. Neural stem cells (NSCs) have shown great potential in the treatment of TBI. However, the relatively low differentiation rate of neurons largely hinders the therapeutic efficacy of brain tissue repair. Here, we found that following TBI, the expression level of YTHDF1 in the hippocampus significantly increased and then decreased. Previous reports have also indicated that YTHDF1 mRNA is preferentially expressed in the mouse hippocampus, a key region involved in spatial learning and memory. Subsequently, we overexpressed or knocked down YTHDF1 in NSCs, and the results demonstrated that YTHDF1 promoted NSC proliferation and neuronal differentiation. In vitro, neuronal injury was induced by H2O2, and co-cultured with YTHDF1-modified NSCs to assess neuronal cell viability, apoptosis, and oxidative stress biomarkers, including the activities of superoxide dismutase (SOD) and catalase (CAT). YTHDF1-modified NSCs significantly reduced neuronal apoptosis and lowered oxidative stress levels. The expression of YTHDF1 in the hippocampus of TBI mice could rescue sensory, motor, and cognitive deficits, promoting neuronal survival. Mechanistically, YTHDF1 may be transcriptionally regulated by MYCN, and exert neuroprotective effects through the PI3K/AKT signaling pathway.
Leber hereditary optic neuropathy (LHON) is a maternally inherited optic neuropathy caused by mutations in mitochondrial DNA. To facilitate disease modeling and the investigation of pathogenetic mechanisms, we generated an induced pluripotent stem cell (iPSC) line, SNUi001-A, derived from the peripheral blood mononuclear cells (PBMCs) of a patient carrying the m.11778G>A mutation in the MT-ND4 gene. The iPSCs were generated using non-integrating episomal vectors. These reprogrammed cells maintained the patient-specific mutation, expressed key pluripotency markers, and demonstrated the potential for multilineage differentiation into all three germ layers.
Langerhans cell histiocytosis (LCH) is a rare neoplasm of immature dendritic cells, usually seen in children. Solitary gastric LCH in adults is uncommon, with only a limited number of reported cases. Optimal management remains unclear, although both endoscopic resection and conservative observation have been described in selected localized cases. We report the case of a man in his 50s who presented with several months of postprandial epigastric discomfort partially relieved by proton pump inhibitors. Endoscopy revealed a small, superficially elevated, discolored lesion in the gastric body resembling early gastric cancer. Histopathology and immunohistochemistry showing S-100, CD1a and langerin positivity confirmed LCH. BRAF V600E testing was positive. Systemic evaluation, including PET-CT, bone marrow biopsy, colonoscopy, and laboratory tests, showed no evidence of multisystem disease. After multidisciplinary review, ESD was performed to achieve complete histological assessment and local disease control. The patient remained asymptomatic, with no evidence of residual or recurrent disease during approximately 10 months of follow-up. This case highlights that solitary gastric LCH may closely resemble early gastric cancer on endoscopy, making targeted biopsy, immunohistochemistry, and systemic assessment essential for diagnosis. In selected localized lesions, ESD may serve as a minimally invasive diagnostic and therapeutic option, particularly when complete histological assessment is needed. Longer-term surveillance remains necessary.
The role of autologous stem cell transplantation (ASCT) is central in AL amyloidosis and continues to be defined in the era of newer therapies. To evaluate contemporary patient selection, practice patterns, and outcomes, we conducted a retrospective, multicenter study across nine tertiary referral centers, including 1047 patients with AL amyloidosis who underwent ASCT between 2010 and 2020. Most patients (67.9%) received full-dose melphalan conditioning, and 66.5% received pre-ASCT induction therapy, predominantly proteasome inhibitor-based regimens. Day-100 all-cause mortality was 3.0%, representing a substantial improvement compared with historical cohorts. Post-ASCT hematological responses were satisfactory in 75.4% of patients. Among patients with paired assessments, ASCT deepened responses in 56.3% who had not achieved a complete response with induction therapy. With a median follow-up of 5.1 years, the median overall survival was 6.3 years. Independent predictors of inferior survival included age ≥60 years, bone marrow plasma cells ≥20%, pre-ASCT dFLC ≥40 mg/L, elevated cardiac biomarkers, lambda-restricted disease, reduced eGFR and reduced-dose conditioning. In this contemporary cohort, ASCT for AL amyloidosis demonstrated low early mortality, high rates of deep hematologic response, and durable survival in carefully selected patients. These findings support its role as an effective consolidative strategy, while its optimal positioning alongside emerging therapies requires further study.
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for the treatment of depressive disorders. Recent clinical reports and studies in animal models have suggested that fluoxetine increases the risk of cardiovascular diseases, but the underlying mechanisms remain unknown. Here, we uncover that fluoxetine disrupts lipid and cholesterol metabolism in primary human endothelial cells (ECs). Fluoxetine triggered an upregulation of cholesterol metabolism genes, leading to the accumulation of lipid droplets in ECs. We find higher levels of cholesterol esters, ceramides, sphingolipids and fatty acids in ECs treated with fluoxetine. The disruption of lipid homeostasis was driven by increased cholesterol biosynthesis, as well as low-density lipoprotein (LDL) uptake and transcytosis via the LDL receptor. Fluoxetine accumulated in ECs in the endoplasmic reticulum (ER), caused ER expansion and reduced protein translation, without inducing ER stress markers. Mechanistically, fluoxetine activated the SREBP2 transcription factor in an INSIG-dependent manner. SREBP2 inhibition attenuated the fluoxetine-mediated upregulation of the LDL receptor and lipid accumulation. Our findings reveal that fluoxetine reprograms lipid metabolism and leads to endothelial dysfunction.
Mature cystic teratomas constitute the most common ovarian neoplasm occurring in childhood. All the components present in mature cystic teratoma are, by definition, mature. Immature teratomas, on the other hand, are malignant, and they constitute a mixture of embryonal and adult tissues derived from all three germ layers. Commonly, the main component is neuroepithelium. The treatment of immature teratoma is surgery and multidrug chemotherapy for grade 2 and 3 tumours. Sometimes only mature components persist in metastatic sites, which may continue to grow (growing teratoma syndrome) following chemotherapy. Emergence of benign or malignant neoplasm with somatic-type features is an uncommon event in mature cystic teratomas. The most common malignant change is squamous cell carcinoma, followed by carcinoid tumour and adenocarcinoma. Other types include melanomas, sarcomas of various types, carcinosarcomas, glioblastoma, etc. Glioblastomas are among extremely rare somatic malignancies arising from mature or immature teratomas. Their etiology is not well understood, and it is still a matter of research whether they share the same genetic alteration as the tumours occurring in the central nervous system. We present a rare case of glioblastoma arising in an immature teratoma in a young female in her early 20s.
Alpha thalassemia major is a severe hemoglobinopathy characterized by absent or markedly reduced alpha-globin production, necessitating lifelong blood transfusions. Chronic simple transfusions can lead to significant iron overload, often requiring iron chelation therapy. However, some patients are unable to tolerate chelation or chelation is insufficient, highlighting the need for alternative strategies for managing iron overload. This study is one of the first to evaluate the feasibility, safety, and efficacy of red blood cell exchange (RBCX) as a therapeutic option for managing iron overload while improving hemoglobin function in an alpha thalassemia major patient with iron overload despite chelation therapy. RBCX therapy was performed approximately every 3 weeks over 1 year, with frequent adjustment of exchange parameters to meet pre-transfusion target levels of functional hemoglobin. Serum ferritin levels, hemoglobin electrophoresis, and functional hemoglobin levels were tracked with each exchange transfusion. For each RBCX treatment, variant hemoglobins decreased by 3.8-fold (from 19.9% to 8.9%) and functional hemoglobin levels increased approximately 3.0 g/dL. RBCX was well tolerated and associated with a marked reduction in systemic iron burden, with serum ferritin declining 7.4-fold (86.4%) over 1 year of therapy, followed by a rise after cessation of RBCX. Cardiac iron remained within normal limits throughout the study period. In contrast, liver iron demonstrated a transient increase shortly after initiation of RBCX, but ultimately declined to levels below baseline after 1 year, even during a period in the absence of iron chelation. These findings suggest that RBCX exerts a meaningful effect on iron homeostasis and raises the possibility of a synergistic benefit when combined with iron chelation. This case highlights that RBCX is a viable therapeutic strategy to treat iron overload in patients with alpha thalassemia major.
LCNEC is a rare high-grade neuroendocrine malignancy with poor prognosis and limited evidence to guide systemic therapy. Prospective, single-arm phase II study of 1st-line durvalumab 1500 mg + cisplatin or carboplatin and etoposide (EP) q3 weeks for 4 cycles, followed by durvalumab 1500 mg q4 weeks, in aLCNEC. The primary endpoint was 12-month PFS (RECIST v1.1, radiologist-assessed); secondary endpoints were ORR, OS, and safety. Sample size followed a single-stage Fleming design (one-sided α = 0.10, power 80%) testing a 12-month PFS rate ≤ 5% (H0) vs ≥ 18% (H1). The study closed early due to slow accrual after twelve of twenty-two planned patients were enrolled. Twelve patients were treated (median age 68y; 66.7% male; 91.7% smokers; 91.7% stage IVB). After median follow-up of 12.8 months (95% CI 8.5-21.3), 92% had progressed and 75% had died. Median PFS was 4.4 months (95% CI 3.1-12.9); 12-month PFS was 25.0% (95% CI 6.0-50.5), exceeding the ≤ 5% null hypothesis (H0) and compatible with the ≥ 18% target (H1). Median OS was 12.8 months (95% CI 5.2-NR); 12-month OS was 58.3% (95% CI 27.0-80.1). ORR was 50.0%, and DCR was 91.7%. All three patients with untreated brain metastases achieved complete intracranial response. Toxicities were mainly grade 1-2; 41.7% had grade 3 adverse events; three discontinued durvalumab for immune-related toxicity; and no treatment-related deaths occurred. This first prospective evaluation of durvalumab + EP in aLCNEC, though underpowered, demonstrates efficacy and safety consistent with design expectations.