Medicine and Pharmacology

Abstract: Hereditary hemolytic anemias (HHAs) have quite similar clinical manifestations, complicating differential diagnosis and determining treatment, such as splenectomy. For the differential diagnosis of hereditary spherocytosis (HS), pyruvate kinase deficiency (PKD), and hereditary stomatocytosis (HSt), we proposed to measure erythrocyte filterability through membrane filters with a pore diameter of 3 or 3.5 μm. Our modified method provides improved reproducibility reducing the variation in results caused by differences in the filters used. The filterability of erythrocytes significantly differs in patients with HS, HSt and PKD (medians and 1.5 IQR were: 0.045 [0; 0.51] (n=88); 0.685 [0.46; 0.79] (n=12) and 0.75 [0.55; 0.86] (n=28) rel. un., respectively). The specificity of the filterability test for HS diagnosis was 100%, comparable to the best available tests, while its sensitivity (85.2%) was somewhat lower than that of some alternative methods. Only the filterability test could identify a second subgroup in HS patients (14.8%) with higher filterability (close to normal), but their HS diagnosis was confirmed by the decreased filterability by 3-µm pore filter. This subgroup requires further detailed study. The proposed filterability measurement method is promising for diagnosing HS. It has high sensitivity and specificity and can be performed quickly without expensive equipment.

Abstract: Acute myeloid leukemia (AML) produces more molecular, imaging, and clinical data per patient than any hematologist can hold in mind at once, and each revision of the WHO, ICC, and European LeukemiaNet (ELN) frameworks adds to the load. Artificial intelligence (AI) and machine learning (ML) now reach into every stage of AML care. Deep-learning models read therapy-relevant mutations directly from bone-marrow smears; automated flow-cytometry gating reproduces expert calls in under a minute; and the first AI pathology devices for hematology have cleared regulatory review and entered clinical use. Beyond diagnosis, ML captures the age-dependent weight of individual mutations that categorical ELN scoring misses, drug-response prediction for venetoclax–azacitidine has been validated across multiple external cohorts, and large language models are being tested for tumor-board support and trial matching. The next wave, from clonal-architecture modeling and single-cell foundation models to digital twins and reinforcement learning for adaptive dosing, could move AML management from reactive toward predictive, evolution-aware care. This review departs from existing AI-in-hematology surveys in three ways: we (i) restrict scope to AML and organize the field around clinical decision points rather than technology categories, (ii) grade every tool on a five-tier clinical-readiness level (CRL-AML 1–5), which exposes hundreds of models clustered at CRL-AML 1–2 and none yet in prospective clinical evaluation, and (iii) close with a numbered three-year agenda naming the consortia, datasets, and pragmatic trials needed to carry the field from publication to practice.

Abstract:

Background: Multiple myeloma (MM) is a biologically heterogeneous plasma cell malignancy with variable responses to induction therapy that are not fully explained by current risk stratification systems. Mutations in RAS family genes are prevalent in MM, yet contemporary risk stratification systems do not include them despite their oncogenic potential. Our previous findings showed reduced tumor cell sensitivity to bortezomib-containing triplet induction regimens in the presence of RAS mutations. The aim of this study is to identify RAS pathway–related molecular targets and evaluate their relationship with clinical outcomes. Methods: Forty-four patients with newly diagnosed MM received bortezomib-based induction therapy (VCD or PAD/VCD). Bone marrow CD138+ plasma cells were isolated for transcriptome analysis. KRAS and NRAS gene mutations were identified by Sanger sequencing, and RNA sequencing was performed on the Illumina HiSeq 3000 platform. Gene expression was analyzed using Salmon and DESeq2. The clinical endpoints were depth of response, progression-free survival (PFS), and overall survival (OS). Results: Of 66 candidate RAS-pathway genes examined, five—CREM, NRL, IL-6, MMP14 and MEB2B—showed significantly higher expression in samples with KRAS and NRAS gene mutations (t-test, p < 0.05). Lower NRL gene expression was associated with achieving a deep response (CR/VGPR; p = 0.02). Elevated IL6 gene expression correlated with poorer OS (HR 3.18; p = 0.05), while increased CREM gene expression was associated with shorter PFS (HR 2.62; p = 0.01). Conclusions: Increased expression of NRL, CREM, and IL6 genes could serve as potential prognostic biomarkers in MM and may reflect the molecular mechanisms underlying the adverse effects of KRAS and NRAS gene mutations.

Abstract: Fms related receptor tyrosine kinase 3-internal tandem duplication (FLT3-ITD) mutations occur in approximately 20–25% of patients with acute myeloid leukemia (AML) and are associated with increased relapse risk and inferior survival outcomes. Although measurable residual disease (MRD) has become a key prognostic tool for guiding post-remission treatment decisions, FLT3-ITD was historically considered a suboptimal MRD marker because of its subclonal nature, structural heterogeneity and dynamic behavior during disease evolution. Despite its strong diagnostic and prognostic relevance, FLT3-ITD has not yet been fully integrated into routine MRD monitoring also due to methodological limitations, and lack of standardized workflows. Recent evidence supports the use of ultra-high sensitivity (UHS) next-generation sequencing (NGS) approaches to detect FLT3-ITD MRD with improved precision, enabling reliable longitudinal tracking of patient-specific clones at very low variant allele frequencies (VAF), and potentially informing clinical decision-making. Indeed, although MRD evaluation is complicated by clonal heterogeneity and molecular instability, advances in high-sensitivity detection techniques have allowed more accurate monitoring of residual leukemic burden. The present review summarizes the biological underpinnings of FLT3-ITD mutated (FLT3-ITD^mut) AML, discusses the methodological challenges of MRD detection, and critically evaluates the evolving role of MRD in refining relapse prediction, supporting post-remission therapy tailoring, and contributing to a harmonized framework for FLT3-ITD^mut AML management.

Abstract: Background: Leg ulceration is a debilitating complication of thalassaemia syndromes, particularly among patients with non-transfusion-dependent thalassaemia (NTDT). Although chronic anaemia is considered a major contributor, clinically relevant haemoglobin (Hb) thresholds associated with ulcer development remain poorly defined. Methods: We conducted a retrospective longitudinal cohort study of patients managed at a specialised Adult and Adolescent Thalassaemia Care Centre established in 2011. Iterative generalised linear mixed-effects modelling (GLMM) with a logit link function was utilised across 84 patients to systematically identify high-risk longitudinal Hb thresholds for the entire cohort and stratified by genotype. A subsequent multi-exposure GLMM framework evaluated independent clinical risk factors, adjusted for sex and genotype. Results: Iterative threshold testing across the entire cohort identified an optimal biological and statistical cutoff at Hb < 5.0 g/dL, associated with a significant risk of ulceration (partially adjusted OR = 2.87, 95% CI: 1.15 - 7.14, P = 0.024). Genotype-stratified analysis revealed that this threshold effect was predominantly driven by the HbEβ-thalassaemia subpopulation, in which the risk escalated sharply between 4.5g/dL (OR = 33.28, P = 0.001) and 5.5g/dL (OR = 2.42, P = 0.023). In the fully adjusted multivariable model, an Hb < 5.0g/dL remained a robust, independent driver of ulceration (aOR = 2.67, 95%CI: 1.08 - 6.62, P = 0.034). Additionally, active follow-up duration (aOR = 1.17 per year, P < 0.001) and cumulative transfusion burden (aOR = 1.43 per unit, P = 0.004) were identified as independent risk factors. Gender and underlying genotype demonstrated no independent association (P > 0.05). Conclusions: A longitudinal hemoglobin level below 5.0g/dL represents a critical threshold for lower-extremity ulceration in thalassaemia, exhibiting a particularly profound risk in HbE/β-thalassaemia. Proactive clinical management targeted at sustaining Hb levels strictly above this threshold, while managing secondary complications reflected by transfusion burden, may optimise microvascular outcomes.

Abstract: Background: Relapsed/refractory multiple myeloma is marked by frequent triple-class refractoriness and poor survival, whereas bispecific antibodies targeting BCMA, GPRC5D, or FcRH5 show meaningful activity even in heavily pretreated and post-BCMA disease.This meta-analysis evaluates and compares the efficacy and safety of these agents in RRMM using direct and indirect evidence. Methods: We manually searched 7 databases and identified 44 studies for quantitative analysis. Forest plots were created using R 4.1.x software. Results: Versus SOC, odds of ORR were higher with Talquetamab, Teclistamab, Elranatamab, and Linvoseltamab (5.73, 4.86, 3.84, 2.63). PFS improved with Teclistamab (HR 0.50, 95% CI 0.36–0.55), Talquetamab (0.50, 0.36–0.55), Elranatamab (0.45, 0.36–0.55), and Linvoseltamab (0.23, 0.17–0.31). Linoseltamab and Elranatamab showed numerically longer OS relative to SOC ( HR 0.41, 0.24–0.70) and (HR 0.58, 0.43–0.78), but numerically shorter OS with Teclistamab (HR 1.82, 1.37–2.42) and Talquetamab (HR 1.75, 1.20–2.57). In pooled single‑arm data, Talquetamab had the highest ORR (72%) and CRS (68%); Teclistamab showed ORR of 61% with CRS 61% and Linvoseltamab showed ORR of 60% with CRS 51%. Cevostamab and Elranatamab had ORR 49% and 56% with CRS 61% and 52%, respectively. Conclusion: In RRMM, all bispecific antibodies showed superior ORR along with improved PFS as compared to SOC. Linoseltamab and Elranatamab showed numerically longer OS relative to SOC, whereas Talquetamab and Teclistamab showed numerically shorter OS versus SOC, within the constraints of adjusted cross-trial comparisons.

Abstract: The introduction of Bruton tyrosine kinase inhibitors (BTKis) has significantly improved prognosis in the treatment of MCL. BTK inhibitors have demonstrated strong activity in the treatment of relapsed/refractory patients with mantle cell lymphoma (MCL), and several trials indicate that they also have potential as first-line treatment. Furthermore, combining BTKis with immunochemotherapy has enabled time-limited therapy as an alternative for continuous treatment with BTK inhibitors alone. In 2013, ibrutinib became the first BTK inhibitor to be approved by the FDA for previously-treated MCL. The TRIANGLE study found ibrutinib to improve the efficacy of standard immunochemotherapy and reduce the need for autologous stem cell transplantation (ASCT) in younger patients; however, its findings do not conclusively confirm whether ASCT enhanced the activity of the ibrutinib-containing regimen in treatment-naïve patients. The next-generation covalent, irreversible BTK inhibitors acalabrutinib and zanubrutinib demonstrate greater selectivity and better pharmacological characteristics than ibrutinib. The FDA approved acalabrutinib and zanubrutinib as single drugs for the treatment of R/R patients with MCL who have received at least one prior therapy. Acalabrutinib combined with bendamustine and rituximab was also approved for TN MCL unsuitable for ASCT. Pirtobrutinib, a first-in-class noncovalent reversible BTK inhibitor, was approved for the treatment of R/R MCL patients, including those resistant to covalent BTK inhibitors. Several other covalent and non-covalent BTK inhibitors are currently under investigation in MCL. Finally, BTK degraders have entered early clinical trials in B-cell lymphoid malignancies, and some of them in MCL.

Abstract: Obstructive sleep apnoea (OSA) is associated with substantially elevated cardiovascular, neurodegenerative, and metabolic morbidity, yet the mechanistic chain linking nocturnal intermittent hypoxia to these clinical consequences remains incompletely understood. We highlight three apparent contradictions in the existing OSA erythrocyte literature: (i) accelerated erythropoiesis with normal haemoglobin concentration; (ii) unchanged daytime P50 and 2,3-diphosphoglycerate concentrations compared to non-OSA controls; yet (iii) consistently elevated systemic oxidative stress, vascular inflammation, oxidized low-density lipoprotein, and accelerated brain ageing. These observations are not easily reconciled within frameworks that treat OSA erythrocytes as a stable hypoxia-adapted phenotype. We propose the perpetual erythrocyte cohort churning hypothesis: OSA erythrocytes constitute a dynamically mixed population in which newly produced cells attempting to adopt a hypoxia-adapted phenotype are continually subjected to neocytolysis upon return to daytime normoxia. The molecular substrate is the miR-21-mediated catalase suppression demonstrated by Song and Prchal: the same molecular programme that fits cells for nocturnal hypoxia also embeds the antioxidant vulnerability that triggers their daytime clearance. The resulting cycle of production and lysis—occurring each twenty-four hours over years to decades—releases cell-free haemoglobin, free iron, membrane phospholipid fragments, and extracellular vesicles into the systemic circulation, generating a chronic background of oxidative stress that we propose drives the downstream cardiovascular and neurodegenerative consequences. The hypothesis is positioned within the Red Blood Cell Triphenotype Classification (RTC v2.0) as a paradigmatic case of dynamic mixed phenotype—a state in which a single individual harbours multiple coexisting erythrocyte functional phenotypes whose proportions vary diurnally. Four falsifiable predictions are advanced: erythrocyte churning intensity will distinguish OSA from controls and scale with severity; churning will correlate more strongly with downstream oxidative and inflammatory markers than the apnoea-hypopnoea index itself; CPAP therapy will attenuate churning, with residual churning identifying patients at continued cardiovascular risk; and individuals with disproportionately high churning despite moderate AHI will be at elevated long-term morbidity. A multicentre prospective observational study (CSMUH-OSA-RTC-2026-01) has been designed to test these predictions.

Abstract: Erythrocytes are routinely characterized in clinical medicine by three twentieth-century parameters: haemoglobin concentration, haematocrit, and mean corpuscular volume. This framework reflects an outdated view of the red cell as a passive oxygen carrier. Recent landmark findings—including the 2026 demonstration that erythrocytes function as a primary glucose sink during chronic hypoxia, the 2021 elucidation of the band 3 N-terminus as a bidirectional metabolic switch, and the molecular characterization of neocytolysis as an evolutionary retirement mechanism for hypoxia-adapted erythrocytes—collectively reveal a fundamentally different picture: the erythrocyte is a programmable metabolic entity whose functional phenotype is determined by its oxygen exposure history and is dynamically modulated by ongoing physiological state. We propose the Red Blood Cell Triphenotype Classification (RTC), a hypothesis-driven framework that organizes erythrocyte function along three orthogonal axes: Glucose Sink Capacity (GSC), reflecting contribution to systemic glucose disposal; Oxygen Kinetics State (OKS), reflecting position on the oxygen-release-versus-retention spectrum; and Antioxidant Reserve State (ARS), reflecting capacity to withstand oxidative stress. Combining low/medium/high levels along each axis yields ten clinically distinguishable phenotype categories—Types α (baseline) through κ (quantity-quality dissociated)—each linked to specific molecular signatures and clinical contexts spanning altitude adaptation, cyanotic congenital heart disease, chronic mountain sickness, obstructive sleep apnoea, critical illness, sepsis, and rare disorders such as voxelotor-treated sickle cell disease. RTC is intended as both a heuristic for clinical interpretation and a hypothesis generator for empirical research. A Level 1 measurement protocol using existing clinical laboratory infrastructure—flow cytometric GLUT1 quantification, 2,3-diphosphoglycerate, methaemoglobin, and reticulocyte count—is proposed for immediate application. Four testable predictions are advanced. We argue that RTC offers the missing conceptual bridge between molecular erythrocyte biology and the clinical interpretation of haematological, metabolic, and oxygenation data. A planned multi-centre clustering validation study (CSMUH-RTC-2026-01) is described.

Abstract: Background: Hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory syndrome that can mimic sepsis in adults, delaying diagnosis and treatment. Methods: We reviewed three adult patients admitted to a high-complexity referral hospital in Colombia, all initially managed as sepsis, analyzing clinical findings, laboratory results, bone marrow studies, diagnostic approach, and outcomes. Results: All patients had persistent fever, cytopenias, organomegaly, hyperferritinemia, and hypertriglyceridemia, with ongoing inflammation despite appropriate antimicrobial therapy. Bone marrow examination showed hemophagocytosis in all cases. One case was associated with acute myeloid leukemia and had a poor outcome, while two infection-related cases, triggered by disseminated histoplasmosis and visceral leishmaniasis, improved with targeted therapy and supportive care. Conclusions: Persistent inflammation, cytopenias, and markedly elevated ferritin despite standard sepsis treatment should prompt early consideration of hemophagocytic lymphohistiocytosis and investigation of the underlying trigger.

Abstract:

Background/Objectives: Acute Myeloid Leukemia (AML) with myelodysplasia-related gene mutations (AML-MR), often referred to as secondary AML (s-AML) or AML-MRC, is an aggressive form of leukemia that typically arises from an antecedent myelodysplastic syndrome (MDS) but may originate also de novo. It is characterized by mutations in key genes associated with MDS that include some epigenetic regulators (ASXL1, EZH2), splicing factors (SF3B1, SRSF2, U2AF1, ZRSR2) and transcription factors (BCOR, RUNX1, STAG2). The main objective of this review paper consists in analyzing recent studies that have improved the criteria for characterization, definition and classification of AML-MR. Methods: An extensive search of the most recent literature on the topic was performed, selecting and critically analyzing the most relevant studies. Results. The studies carried out in the last years have provided an extensive molecular characterization of AML-MR, supporting more sound criteria for their identification and for a better definition with respect to other AML subtypes, particularly with respect to TP53-mutant AML. Conclusions: A unifying classification of AML-MR is now possible, allowing its identification as a unique, well-defined and separate entity.

Abstract: Background: Diffuse large B-cell lymphoma (DLBCL) with TP53 abnormalities, corresponding to the LymphGen A53 molecular subtype, represents a biologically high-risk group associated with primary resistance to standard R-CHOP therapy. Epigenetic sensitization using hypomethylating agents may enhance chemosensitivity in this setting. We prospectively evaluated the clinical activity and safety of a molecularly adapted DAC-R-CHOP regimen in newly diagnosed A53-DLBCL. Methods: In this single-center prospective pilot cohort study, 70 consecutive patients with newly diagnosed DLBCL underwent targeted next-generation sequencing using a 60-gene panel with integrated copy number variation analysis. Six patients (8.5%) were classified as the A53 subtype. All patients received one cycle of standard R-CHOP. From cycle 2 onward, A53 patients received decitabine (10 mg/m² IV, days 1–5) prior to R-CHOP (DAC-R-CHOP), for a total of six cycles. The primary endpoint was complete metabolic response (CMR) according to Lugano 2014 criteria. Exact 95% confidence intervals (CI) were calculated. Results: The median age of the A53 cohort was 65 years. CMR was achieved in all six patients (100%; 95% CI, 54%–100%). At a median follow-up of 6 months, all patients remained alive in confirmed CMR. Grade III–IV hematologic toxicity occurred in all cases. Febrile neutropenia developed in 100% of patients, requiring mandatory G-CSF support and anti-infective therapy; no treatment-related mortality or permanent dose reductions were observed. Two patients (33%) experienced gastrointestinal bleeding related to local tumor lysis, which was managed conservatively without protocol discontinuation. Conclusions: In this prospective molecularly stratified pilot cohort, integration of decitabine into front-line immunochemotherapy showed promising clinical activity in A53-DLBCL, albeit at the cost of substantial hematologic toxicity requiring intensive supportive care. Given the small sample size, short follow-up, and absence of a comparator arm, these findings should be considered hypothesis-generating and warrant validation in larger multicenter phase II studies with integrated translational biomarker analyses.

Abstract: Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening thrombotic microangiopathy caused by severe ADAMTS13 deficiency due to anti-ADAMTS13 autoantibodies. The resulting persistence of ultra-large von Willebrand factor (VWF) multimers promotes uncontrolled platelet adhesion and aggregation in the microcirculation, leading to thrombocytopenia, microangiopathic hemolytic anemia, and ischemic organ injury. Therapeutic plasma exchange (TPE) has transformed the prognosis of iTTP by removing circulating autoantibodies and replenishing functional ADAMTS13, and it remains a life-saving intervention in acute disease. However, TPE is invasive, resource-intensive, dependent on central venous access and plasma availability, and associated with catheter-related, hemodynamic, metabolic, infectious, and plasma-related adverse events. The therapeutic landscape has changed substantially with the incorporation of immunosuppression and the anti-VWF nanobody caplacizumab. Caplacizumab rapidly blocks VWF-platelet interactions at the effector level, whereas corticosteroids and B-cell-directed therapy target the autoimmune basis of iTTP. Triple therapy with TPE, immunosuppression, and caplacizumab accelerates platelet recovery and reduces unfavorable outcomes. At the same time, accumulating observational evidence and early prospective data suggest that selected patients may achieve remission with caplacizumab plus immunosuppression without routine first-line TPE. This perspective review critically re-evaluates the role of TPE in contemporary iTTP management. We propose that TPE should no longer be viewed exclusively as an obligatory universal first-line intervention, but rather as a contextualized component of individualized, response-adapted care. TPE remains indispensable for severe, unstable, or refractory disease and must be immediately available when TPE-free treatment is attempted. Safe implementation of TPE-sparing strategies requires experienced centers, rapid ADAMTS13 testing, immediate access to caplacizumab and immunosuppression, careful patient selection, and close clinical and laboratory monitoring. Defining which patients can be treated safely without TPE is a central challenge for future trials and guideline development.

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Background/Objectives: A complex karyotype (CK) in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) is defined as the presence of three or more unrelated chromosomal abnormalities in the absence of defining core-binding factor translocations. Frequently involved chromosomes include losses/deletions on chromosomes 5, 7 and 17. It is heavily associated with TP53 mutations, with 70-80% of CK cases in MDS/AML harboring TP53 mutations- Methods: An extensive literature search of the studies carried out in the last two decades has shown a consistent development of experimental and clinical studies aiming to characterize the biological properties and the clinical features of AML and MDS bearing CK and TP53 mutations. Results: These studies have greatly contributed to identify as separate entities AML and MDS bearing CK and or TP53 alterations. Particularly, the improvement in the methods of detection of chromosome aberrations has contributed to define the specific nature of the various chromosome abnormalities and to decipher the mechanisms of catastrophic events leading to gene rearrangements. Two types of CK were identified in AML and MDS, one more frequent associated with TP53 mutations (with poor prognosis) and another less frequent without TP53 mutations (with relatively better prognosis) Conclusions: The treatment of AML and MDS with CK and/or TP53 mutations alterations remains extremely challenging and the prognosis of these patients is dismal. The main aim of the various induction treatments explored in these patients is to bridge patients to allo-HSCT, the only therapeutic approach able to improve the survival of at least a part of these patients.

Abstract: Libraries for next generation sequencing were prepared using primers directed to the framework 2, framework 3 and D and J regions of the rearranged immunoglobulin gene from 50 diagnosis myeloma bone marrow samples. After sequencing and bioinformatic analysis a marker sequence suitable for minimal residual disease analysis by HAT-PCR was obtained for 90% of the 50 samples studied. In 88% of samples a complete VDJ sequence was obtained. Failure to detect a marker sequence was principally due to a low percentage of plasma cells in the marrow sample. The high frequency of detection of a suitable marker sequence indicates that minimal residual disease can be monitored by HAT-PCR in the great majority of instances.

Abstract: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of aggressive non-Hodgkin lymphomas and is characterized by pronounced molecular heterogeneity that is not always fully captured by standard histopathological assessment. At present, analysis of circulating tumor DNA (ctDNA) is regarded as a promising liquid biopsy tool that enables non-invasive molecular tumor profiling, assessment of tumor burden, and dynamic monitoring of minimal residual disease (MRD). Modern analytical platforms, ranging from PCR-based technologies to next-generation sequencing, including CAPP-Seq and PhasED-Seq, have substantially expanded the possibilities of molecular monitoring in DLBCL. This review summarizes data on the biological characteristics of ctDNA and contemporary methods for its analysis, as well as evidence regarding the concordance between ctDNA mutational profiles and tumor tissue. Particular attention is paid to the clinical significance of baseline ctDNA levels, early assessment of molecular eradication of the tumor clone, MRD status after completion of therapy, and molecular monitoring during remission. The principal limitations of clinical integration are also discussed, including insufficient standardization of the analytical workflow, the influence of clonal hematopoiesis, and the absence of completed interventional studies demon-strating improved clinical outcomes when therapy is modified according to molecular status. Thus, ctDNA currently represents a highly informative prognostic biomarker in DLBCL; however, its full implementation in routine clinical practice requires further standardization, validation, and confirmation of its role in treatment selection within personalized strategies.

Abstract: Background/Objectives: Beta-thalassemia (β-thal) is an inherited hemoglobin disorder caused by mutations in the HBB gene. Hb Malay (HBB:c.59A>G, CD19), a missense substitution (AAC→AGC; Asn→Ser) in exon 1 of the β-globin gene causing β⁺-thalassemia, has been mainly described in Southeast Asian populations but remains rarely documented in Indonesia. This study aimed to identify the Hb Malay mutation and investigate its familial segregation in an Indonesian extended family. Methods: Cascade molecular screening was initiated following detection of the mutation in a proband referred for genetic testing. Sixteen family members consented to participate. Genomic DNA was extracted from peripheral blood and a 1.9-kb β-globin gene fragment was amplified by PCR. Mutation screening was performed using the GenoArray Thalassemia Detection Kit (Hybribio) and confirmed by Sanger sequencing. A three-generation pedigree was constructed from molecular results and family interviews.Results: The Hb Malay mutation (HBB:c.59A>G) was identified in 13 of 16 individuals: 12 heterozygous carriers (A/G) and one homozygous individual (G/G, subject KA, aged 15 years). Three individuals showed the normal genotype (A/A). Pedigree analysis demonstrated autosomal recessive inheritance across three generations. No α-globin deletions were detected. Conclusions: This is the first report of a large Indonesian family carrying the Hb Malay variant, confirmed by dual molecular methods. These findings highlight the importance of cascade molecular screening for early carrier identification, particularly where hemoglobin fractionation testing is unavailable.

Abstract: Chronic lymphocytic leukemia (CLL) is a biologically heterogeneous B-cell malignancy in which B-cell receptor signaling, microenvironmental interactions, genomic lesions, and epigenetic deregulation cooperate to shape disease behavior. The imprinted DLK1-DIO3 locus at chromosome 14q32 contains the largest human miRNA cluster and has been implicated in cancer-related regulatory networks; however, its systems-level contribution to CLL remains incompletely defined. In the present study, we investigated the potential involvement of DLK1-DIO3 miRNAs in CLL biology by integrating public transcriptomic datasets with miRNA-centered pathway analysis. GSE70830 was used as a discovery dataset and GSE66117 as a supportive validation cohort to identify genes consistently downregulated in CLL compared with normal B cells. The overlap between the two datasets yielded a 345-gene consensus downregulated CLL signature, which was subsequently used as gene filter input for DIANA-miRPath v3.0 analysis of the expressed DLK1-DIO3 miRNA cluster. This analysis identified eight enriched KEGG pathways, mainly converging on B-cell receptor signaling, NF-kappa B signaling, cell adhesion molecules, leukocyte transendothelial migration, and glycan-related processes. DIANA-miRPath v4.0 was further used as a pathway-centered refinement approach, supporting the involvement of individual DLK1-DIO3 miRNAs in signaling, adhesion, migration, and microenvironment-associated programs. Post hoc annotation also showed that members of an IGHV-associated DLK1-DIO3 miRNA panel were represented within several of these pathway categories. Overall, our findings support a systems-level association between the DLK1-DIO3 miRNA locus and CLL-relevant transcriptional programs, providing a hypothesis-generating framework that warrants further experimental validation.

Abstract: Background/Objectives: Quiescent leukemia stem cells (LSCs) are self-renewing, pluripotent cells that represent a major obstacle to successful curative treatment of chronic myeloid leukemia (CML). LSCs are independent of BCR-ABL1 signaling and persist following tyrosine-kinase inhibitor treatment. The mechanisms that enable LSCs' survival are currently the focus of CML research. The review examines the complex relationship between signaling pathways and discusses recent advancements in research on energy metabolism in the pathogenesis of CML. Methods: This comprehensive narrative review used a systematic approach to selecting studies published in peer-reviewed journals, without year or publication-type limits. Results: Energy metabolism assumes a critical role in the biology of CML LSCs. These cells show dependency on oxidative phosphorylation (OXPHOS) and mitochondrial homeostasis, with fatty acid oxidation as the primary source of ATP. Studies highlight significant alterations in signaling networks with a dynamic interplay among dominant pathways in the CML clone. TGF-β-FOXO signaling is proposed to be crucial for maintaining the self-renewal capacity of quiescent LSCs, unlike the majority of proliferating mature CML cells that exhibit strong activation of the PI3K/AKT pathway and glycolysis. Additionally, unique aspects of LSCs' metabolism underline the contribution of leukemic cell interactions, including the induction of a more permissive microenvironment. Conclusion: Fatty acid oxidation appears critical to the survival and self-renewal of CML LSCs. Adaptation of mitochondrial function is concordant with signaling changes and presumes adjustment of mitochondrial respiration with stimulated OXPHOS. Research findings unveil many potential targets to consider to overcoming survival mechanisms, with disrupting the mitochondrial support as a promising strategy to selectively eradicate CML LSCs.

Abstract: Acute myeloid leukemia (AML) develops within a bone marrow environment that influences leukemic stem-cell behavior, residual disease, and response to therapy. This review examines evidence that the marrow microenvironment is not only a site of leukemic growth, but can actively shape AML initiation, maintenance, and treatment resistance. Clinical observations such as donor cell leukemia after allogeneic transplantation, together with experimental models in which stromal or osteolineage abnormalities induce myeloid disease, suggest that altered niches may contribute to leukemogenesis in selected settings. In established AML, vascular and endosteal compartments provide adhesive, chemokine, inflammatory, and metabolic signals that promote leukemic-cell retention, quiescence, survival, and chemotherapy tolerance. AML cells also remodel the surrounding marrow, suppressing normal hematopoiesis and generating stromal, endothelial, osteoblastic, adipocytic, and immune-cell programs that favor leukemic persistence. These interactions are especially relevant to drug resistance, including resistance to venetoclax-based therapy, where cytokine-mediated changes in apoptotic dependence, fatty-acid metabolism, mitochondrial adaptation, and stromal support may all contribute. Several therapeutic approaches have attempted to disrupt niche-mediated protection, including targeting CXCL12/CXCR4 signaling, adhesion pathways, inflammatory circuits, Hedgehog signaling, and metabolic dependencies. Although early-phase studies have shown activity in some AML subsets, randomized evidence remains limited and results have been inconsistent. We discuss how a better understanding of microenvironmental biology may help define when niche-directed therapy is most likely to complement conventional and molecularly targeted AML treatment.