The treatment of myeloma has undergone extraordinary improvements in the past half century. These advances have been accompanied by a concern for secondary primary malignancies (SPMs). It has been known for decades that extended therapy with alkylating chemotherapy agents, such as melphalan, carries an increased risk of therapy-related myelodysplastic syndrome and/or acute myeloid leukemia (t-MDS/AML), with a cumulative risk as high as 10–15%. High-dose chemotherapy with autologous stem cell support became widely accepted for myeloma in the 1990s. Despite the use of high doses of melphalan, the risk of t-MDS/AML with this procedure is estimated to be less than 5%, with much of this risk attributable to pretransplant therapy. Recently, lenalidomide has come under scrutiny for its possible association with SPMs. It is too soon to declare a causal relationship at this time, but there appears to be an increased number of SPMs in reports from several studies using lenalidomide maintenance. Current studies should be amended and future studies planned to better define the risk of SPMs and the risk factors and mechanisms for its development. Patients should be educated regarding this potential concern but the current use of lenalidomide should not generally be altered until further data are available.

Recent progress in the molecular genetics of acute myeloid leukemia (AML) has shown this disease to be more heterogeneous than previously realized. Recurrent cytogenetic and mutational changes in leukemic blasts have been confirmed to have high prognostic significance. High-throughput techniques to analyze the AML genome in greater depth have revealed novel mutations with putative roles in leukemogenesis. The use of prognostic biomarkers has allowed for a more detailed categorization of AML based on risk. Despite this tremendous progress, the understanding of the mechanisms by which these changes influence leukemia growth and response to treatment is still limited, which in turn has hindered the development of rationally targeted therapies for AML. The integration of clinical, cytogenetic and molecular data will be essential to translate the current research momentum into better outcomes for patients with AML.

Background/Objectives: Myeloid sarcoma (MS) is a rare extramedullary manifestation of myeloid blasts, with limited systematic data, particularly regarding molecular (NGS) concordance between MS tissue and bone marrow. We hypothesized that clonal heterogeneity may exist between these sites due to their distinct biological environments. Methods: We conducted a systematic review and meta-analysis of 85 studies encompassing 7241 MS patients, to evaluate clinical characteristics, mutational profiles, treatment patterns, and outcomes. Mutational concordance or discordance between MS and bone marrow was assessed in a subset of 112 patients. Results: Male predominance (59%) and skin/soft tissue localization (31%) were most common. NPM1 (25%) and FLT3 (20%) were the most frequently reported mutations. Among 112 patients with paired sequencing, 56% showed discordance in mutational profiles. NPM1 was significantly enriched in MS sites compared to bone marrow (35% vs. 21%, p = 0.02) and was associated with skin involvement. Discordance was more frequent in isolated and secondary MS. Venetoclax with hypomethylating agents achieved a 44% response rate, mainly in secondary MS. Post-transplant isolated extramedullary relapse occurred in 46% of relapsed patients and was linked to high rates of graft-versus-host disease. The pooled median overall survival was 12.8 months. Conclusions: MS demonstrates significant molecular heterogeneity. Routine site-specific NGS profiling may guide targeted therapy in this rare disease.

Background: While NPM1-mutated AML in the absence of FLT3-ITD generally carries a favorable prognosis, large registry studies suggest the positive prognostic benefit may not extend to patients > 65 years of age. We examined this preferential, age-dependent prognostic impact through a real-world analysis of 2811 adult AML patients. Results: The median overall survival (OS) was significantly better in NPM1^MT compared to NPM1^WT patients [20.86 vs. 17 mo., p = 0.003]. When stratified by age, NPM1^MT patients had higher OS than NPM1^WT patients in the 55–65-year age group (28.62 vs. 16.3 mo., p ≤ 0.0001). This OS benefit was heterogenous and prevailed most strikingly in the 55–60 (68.3 vs. 15.6 mo., p = 0.002), and up to the 60–65-year group (mOS not estimable vs. 20 mo., p = 0.007), but not beyond 65 y. Notably, the ≤65 cohort was more enriched with dominant NPM1 (21% vs. 15%, p ≤ 0.001), while the >65 cohort was enriched with abnormal karyotype (20% in >65 years vs. 16% in ≤65 years, p = 0.001), and co-occurring SRSF2 and ASXL1 mutations (18.7% vs. 7.5%, p ≤ 0.0001 and 13.5% vs. 4.1%, p ≤ 0.0001 resp.). Conclusions: We demonstrate that in a real-world setting, the prognostic benefit of NPM1 does not extend beyond age 65, underscoring the need for age-adapted risk stratification models. This granular approach could prevent the potential overestimation of prognosis in older patients with NPM1^MT AML and inform therapeutic decision making.

Chronic myeloid leukemia is now a highly treatable leukemia due to the availability of multiple tyrosine kinase inhibitors (TKIs) inhibiting the BCR-ABL1 oncogene. Some patients with CML can displa...