Trial by Fire
Transplantasia
Having a blast yet?
Paging Dr. V
MU-scellaneous
100
A phase 3 clinical trial studying axicabtagene ciloleucel vs SOC for high risk large B cell lymphoma.
What is ZUMA-23?
100
Your patient is Day 0 of her syngenic transplant. What does this mean about her donor?
The donor is the patient's identical twin. 
100
Name the following cells:
Photo credit: MYSELF
What are schistocytes?
___________________________
- Helmet, crescent, or triangle shaped
- RBC injury from damaged endothelium
-Seen in MAHA/TMA
100
Your patient has CMV reactivation of 450 copies and will be admitted to the hospital for a while. What are your two IV treatment options and major side effect of each?
(you already tried IVIG because Dr. Kodali was on, and it didn't work :‑) )
Foscarnet - Renal dysfunction, electrolyte abnormalities
Ganciclovir - Marrow suppression
100
If you are looking at a clinically stable patient with an unremarkable EKG, but serum potassium is returning critical at 7+, name two ways to ascertain a proper potassium reading.
1) ABG Potassium
2) Draw BMP in a "gold top".
___________________________________
Why? In vitro release of K from leukocytes undergoing lysis during the clotting process (in processing)
200
You see a new patient, a 78yo male with newly diagnosed acute myeloid leukemia. He has stable chronic angina, but no history of CHF, and he could be a good candidate for this clinical trial.
What is the ICT01-101 (ImCheck) Trial?
-ICT01 is an anti-BTN3A antibody for activating Vγ9Vδ2 T cell-mediated antitumor immune response.
-In combo with Aza/Ven, given on Day 1 only of a 28 day cycle.
200
This is what we call a transplant when the donor's blood type is O+ and the recipient's blood type is B+.
What is a minor ABO mismatch?
200
Identify these cells.
What is a blast?
___________________
Typically large (compared to RBC), large nucleus
Scant cytoplasm
None or few cytoplasmic granules
Large nucleolus
Auer Rods?
200
You take a phone call from pathology and your patient's BAL appears to be growing fungus. It will take DAYS to grow out. What can help you guess the species faster?
The angle of hyphae, and presence of septations.
_________________________________________
Aspergillus approx 45* angle and many septations, while mucor has few septations and broader hyphae (up to 90*)
200
This is the osmolality of normal saline.
*cries in hyponatremia*
308 mOsm/L
300
You have a new 38yo patient who is healthy and works as a construction worker. Only PMHx is history of HSV-1 reactivation each winter. EF is 65% with out diastolic dysfunction. He has a new diagnosis of AML with a WBC of 40, Hgb 10.4, Plt 37. What two things preclude him (at least initially) from the ImCheck (ICT01-101) trial?
He is eligible for induction chemotherapy and his WBC is >25.
-Hydrea, Leukapheresis, and/or low dose ARA-C can be used to decrease WBC to <25 in appropriate patient population.
300
A condition in post-SCT or solid organ transplant patients where B-cells or plasmacytic cells grow unchecked, AND the commonly associated infection.
(condition and infection)
What is PTLD (post transplant lymphoproliferative disorder) and EBV?
______________________________________
Many different classifications of PTLD, about 80% of them are EBV positive.
Benign polycolonal proliferations -->Florid follicular hyperplasia --> Polymorphic PTLD-->Monomorphic PTLD (most commonly DLBCL)
300
Name the following cells:
What is a spherocyte?
___________________________
-Round RBC, no central pallor, typically smaller than normal RBC-Seen in Hereditary Spherocytosis and Autoimmune Hemolytic Anemia
300
Your neutropenic patient is septic, febrile, and unstable in the ICU. Dr. John is pressuring you to add an antibiotic to your current regimen of meropenem, zyvox. Dr V is not picking up his phone! (would never happen). All you have is a 2/2 blood culture positive for heavy growth GPC that has yet to be speciated. What would you like to add?
Clindamycin!
(will reluctantly accept an aminoglycoside, although not the point of the question)
________________________________________
-Clindamycin decreases production of exotoxins that underlie many manifestations of invasive group A streptococcal infections and improve survival
(DON'T forget to pull the line)
300
Previously it was thought that biallelic CEPBA mutations conferred a positive prognosis in AML. How has this been redefined in recent years?
Patients with a mutation in the bZip (CEPBA basic leucine zipper) region appear to have a better prognosis.
_____________________________________
-82.5% of bZip will be biallelic.
-"Patients with CEBPA-dm and CEBPA-bZip experienced identical event-free survival (EFS) of 64% and similar overall survival (OS) of 81% and 89%, respectively; this compared favorably to EFS of 46% and OS of 61% in patients with CEBPA-wild-type (CEBPA-WT) (both P < .001)."
400
A patient with AML who has already progressed through three lines of therapy with the following mutations: ASXL1, FLT3, DNMT3 could be a good candidate for *this* clinical trial, but would need to have *this* drug in hand.
What is Oryzon FRIDA, and Gilteritinib?
__________________________________
-Phase 1b trial studying iadademstat given as liquid in a 5 days on, 2 days off pattern.
-Must have gilteritinib in hand in order to start but can NOT have previously been refractory to gilteritinib.
400
This is the ethnic background that is LEAST likely to find a match on on the NMDP registry.
Black/African American
400
Both of these images represent the same disease, please name it.
What is APL?
Left side: Hypergranular with Auer Rods (can obscure nucleus)
Right side: Hypogranular, bilobed nuclei
Start ATRA!
400
This is a gram negative rod that can cause respiratory distress and is historically resistant to meropenem.
What is Stenotrophomonas maltophilia?
________________________________
-The most common carbapenem-resistant gram-negative bacterial cause of bloodstream infections in US hospitals
-Typically treat with Bactrim
400
Other than limiting the DMSO....
(1g/kg/day #neverforget)
...what other limitation can we place on autologous transplants to minimize toxicity, specifically Grade 3-5 SAEs?
Total Nucleated Cells
TNC dose of <1.63 × 109 TNC/kg/day
(goal is to reduce grans)
500
These are the two mutations that can be targeted using the drug Ziftomenib if the patient has R/R AML.
What are FLT3 and NPM1?
-On the KO-MEN-008 protocol.
500
What is a monosomal karyotype and what is the prognostic significance?
Two autosomal monosomies OR one monosomy plus one or more structural aberrations (not including loss of a chromosome)
Often associated with TP53.
"Several recent studies have revealed that AML with the MK are at the extreme end of the unfavorable risk category, and its presence is predictive of the worst possible outcome."
"4-year overall survival (OS) of 4%, compared with a 21% 4-year OS in patients with other unfavorable karyotypes but without MK" (SWOG)
500
What are these cells:
What are neutrophils?
___________________________________
-Multilobed nucleus, with 3 to 5 lobes joined by slender strands of genetic material
-The cytoplasm of neutrophils contains numerous purplish granules
-Typically smallest granulocyte
500
This is standard treatment for a MAC (Mycobacterium Avium Complex) infection.
Macrolide (azithromycin, clarithromycin)
AND
Ethambutol
AND
Rifampin
500
What are the three DAT mutations and what is their prognostic significance?
DNMT3A, ASXL1, TET2.
Minimal prognostic significance.
Seen often in CHIP (clonal hematopoesis of indeterminate significance)