In this month’s Pharmacy SIG Literature Update:single-cord blood transplant vs. haploidentical stem cell transplantation for leukemia, tocilizumab for GVHD prophylaxis, and more! Literature summaries are provided as information only. Please refer to the original published articles for complete details on study methodology, results and discussion.
*** Must read. Landmark publication that affects practice
** Recommend reading. Secondary paper that adds to literature
* Consider reading. Cursory importance to the practice
**Castagna L, Dodero A, Patriarca F, et al. Multicenter phase II study on haploidentical bone marrow transplantation using a reduced-intensity conditioning regimen and posttransplantation cyclophosphamide in patients with poor prognosis lymphomas. Transplantation and Cellular Therapy. 2021; 27(4):328e1-e6. https://pubmed.ncbi.nlm.nih.gov/33836877/
- Prospective, multicenter, phase 2 study in Italy for adult patients with poor prognosis lymphomas.
- Patients received RIC with thiotepa 10 mg/kg IV on day -6, fludarabine 30 mg/m2/day IV on days -5 to -2, cyclophosphamide 30 mg/kg IV on day -5, and low-dose (2 Gy) TBI or TMI/TLI on day -1, with haplo HCT (bone marrow source) on day 0.
- GVHD prophylaxis consisted PTCy IV on days +3 and +4, with cyclosporine A or tacrolimus plus MMF starting on day +5. Calcineurin inhibitors tapered starting day +90 to +100, and MMF was stopped on day +35.
- Of 47 patients, the majority had Hodgkin’slymphoma (n = 23, 49%) or DLBCL (n = 7, 14.3%).
- The 6-month incidence of grade 2-4 aGVHD was 26% (13-38%), with only one patient having grade 3-4 aGVHD. The median time to aGVHD was 30 days (16-72), with a 2-year incidence of cGVHD of 16% (5-28%). 81% of patients were off all immunosuppression at last follow-up.
- The 1-year PFS was 60%, with a 4-year PFS and OS of 54% and 64%, respectively. The 4-year relapse rate was 28% (15-41%), with no relapses occurring after the second year. The median time from haplo HCT to relapse was 113 days (18-387).
- While the 1-year incidence of CMV reactivation was 57% (43-72%), this would likely be lower in current state with the availability of letermovir.
- The 1-year incidence of CMV reactivation was 57% (43-72%), with CMV disease detected in two patients (colitis and pneumonia). The 1-year BK virus cystitis rate was 28% (15-41%). The 1-year Monthly Literature Update May 20212 invasive aspergillosis rate was 8.5% (4-17%). The 1-year incidence of bacterial infections was 34% (20-48%)
- In conclusion, an RIC regimen prior to haploidentical transplant with bone marrow source was well-tolerated with a low incidence of GVHD (most being grade 2). Survival plateaued at 2 years.
- It is important to note this study was conducted prior to the availability of novel therapies for relapsed/refractory lymphomas (e.g., CAR-T, polatuzumab vedotin, tafasitamab).
*Shimony S, Yeshurun M, Wolach O, et al. Post-transplantation maintenance with sorafenib or midostaurin for FLT3 positive AML patients - a multicenter retrospective observational study. Leukemia & Lymphoma 2021: April 21 online. https://pubmed.ncbi.nlm.gov/33879026/
- Multicenter retrospective study of 41 FLT3+ AML patients post-alloHCT receiving TKIs (sorafenib [n=23] or midostaurin [n=18]) in a real-world setting. Median time from alloHCT to TKI initiation was 62 days, and median duration of maintenance was 101 days.
- Primary outcomes: mean OS = 37.9 months (CI 95% 30.2-45.6) and RFS = 36.9 months (CI 95% 29.2-44.7). Projected 2-year OS was 64% for entire cohort (74% for sorafenib; 50% for midostaurin).
- After a median follow-up of 10 months, 29 patients (71%) were alive and in CR. Similar results were shown in a subgroup analysis for pre-transplant TKI recipients (78%).
- Univariate analysis predicted longer OS with HCT-CI score < 4 and type of TKI (sorafenib vs midostaurin) whereas multivariate analysis showed only borderline significance (OR 0.32, CI 0.09-1.13, p = 0.07 and OR 0.29, CI 95%, CI 95% 0.08-1.03, p = 0.06, respectively).
- Seventeen patients (41%) experienced adverse effects, while 7 patients (17%) stopped TKIs due to adverse effects.
- The authors concluded that their data suggests that post-transplant use of TKIs is safe and effective (low post-HCT relapse rate of 21%) in an era of their widespread use prior to alloHCT.
*Ribera JM, Morgades M, Ciudad J, et al. Chemotherapy or allogeneic transplantation in high-risk Philadelphia chromosome-negative adult lymphoblastic leukemia. Blood. 2021;137(14):1879-1894. https://pubmed.ncbi.nlm.nih.gov/33150388/
- Prospective study of patients aged 15-60 years with high-risk ALL in a CR (after induction and early consolidation) who were allocated to either delayed consolidation + maintenance therapy for up to 2 years (218 patients) or alloHCT (106 patients) based on MRD levels (HCT for patients with absence of CR after induction or MRD > 0.1%)
- 5-year cumulative incidence of relapse and OS for the chemo and HCT groups were 45% vs 59%, and 40% vs 38%, respectively
- In the chemo group, hematologic toxicity and infections were the most frequent, followed by liver toxicity
- Authors conclude that avoiding alloHCT in patients with high-risk features and adequate MRD does not compromise outcomes after induction and consolidation and better post-remission therapies are needed for patients with MRD
**Konuma T, Kanda J, Yamasaki S, et al. Single cord blood transplantation versus unmanipulated haploidentical transplantation for adults with acute myeloid leukemia in complete remission. Transplantation and Cellular Therapy. 2021; 27(4):334e1-e11. https://pubmed.ncbi.nlm.nih.gov/33836881/
- Retrospective analysis of 1313 intermediate or poor-risk AML in CR in Japan to analyze OS, leukemia-free survival (LFS), and GVHD rate of patients SCBT (n = 1102) and unmanipulated haplo HCT (n = 211).
- Neutrophil recovery at day 30 was lower with SCBT vs haplo-HCT (81% vs 97%; p<0.001) as well as at day 60 (90% vs 97%; p<0.001). The median time to neutrophil recovery was also lower with SCBT (20 vs 15 days; p<0.001). Similarly, cumulative incidence of platelet recovery at day 60 was significantly lower in SCBT recipients compared with haplo-HCT (66% vs. 75%, p < 0.001).
- Grade II-IV aGVHD was higher with SCBT at day +100 (39% vs 30%; p=0.013). Grade III-IV aGVHD was similar between arms at day +100 (11% vs 11%; p=0.82)
- CMV viremia was lower with SCBT (59% vs 70%; p=0.004), although CMV disease was not different between arms (7% vs 8%; p=0.65)
- There was no difference at 3 years between SCBT and haplo HCT for OS (59% vs 59%; p=0.44), LFS (56% vs 58%; p=0.56), GVHD-free and relapse free survival (44% vs 39%; p=0.34), and cGVHD-free and relapse-free survival (48% vs 43%; p=0.26).
- The author’s concluded that, despite a longer time to neutrophil recovery and increased incidence of grade II-IV aGVHD with SCBT, it had a lower rate of CMV viremia, and survival was no different between the arms. Therefore, it is justified to choose haplo HCT or SCBT for AML patients in CR depending on availability of donors and preference of the center.
**Kennedy GA, Tey SK, Buizen L, et al. A phase 3 double-blind study of the addition of tocilizumab vs placebo to cyclosporine/methotrexate GVHD prophylaxis. Blood. 2021;137(14):1970-1979. https://pubmed.ncbi.nlm.nih.gov/33512442/
- Randomized, placebo-controlled, phase 3 trial conducted within 5 Australian centers evaluating the efficacy of tocilizumab in preventing grade 2-4 aGVHD in 145 patients with AML/MDS undergoing MRD or MUD MAC or RIC alloHCT. Patients were randomized 1:1 to receive either cyclosporine/MTX/placebo vs cyclosporine/MTX/tocilizumab for GVHD prophylaxis. Tocilizumab was dosed at 8 mg/kg (max. 800 mg) once on day -1.
- Overall incidence of grade 2-4 aGVHD at day 100 was 36% in the placebo group vs 27% for the tocilizumab group (HR 0.69, P=0.23), and in the MUD group was 45% vs 32%, (HR 0.61, P=0.16). Overall incidence of grade 2-4 aGVHD at day 180 was 40% in the placebo group vs 29% for the tocilizumab group (HR 0.68, P=0.19), and in the MUD group was 48% vs 32%, (HR 0.59, P=0.13).
- No difference noted in severity (grade 3-4) of aGVHD observed either in the placebo vs tocilizumab groups (13% vs 14%, respectively).
- Overall survival (79% vs 71%, P=0.27) and TRM (8% vs 11%, P=0.56) were similar in the placebo vs tocilizumab groups as well as PFS (75% vs 67%, P=0.24). 4
- No differences in incidence of liver toxicity or infectious complications (grade >2) effects were observed. Neutrophil engraftment was delayed in the tocilizumab group by 2-3 days. When comparing infections, the tocilizumab group was noted to have more gram-negative bacteremias (28 isolates vs 10), but less CMV reactivation (11% vs 17%, P=0.016).
- Authors conclude that the addition of tocilizumab demonstrated a non-significant trend toward reduced aGVHD in patients receiving MUD alloHCT, but no improvement in OS
**Rodriguez-Otero P, Ayers D, Cope S, et al. Matching adjusted indirect comparisons of efficacy outcomes for idecabtagene vicleucel (ide-cel, bb2121) versus selinexor + dexamethasone (Sd) and belantamab mafodotin (BM) in relapsed and refractory multiple myeloma. Leukemia & Lymphoma 2021: April 24 online. https://pubmed.ncbi.nlm.gov/33896344
- Matching-adjusted indirect treatment comparisons (MAICs) were performed for triplerefractory MM patients to compare ide-cel vs Sd and BM, in the absence of head-to-head trials.
- Data was used from KarMMa (ide-cel, all cell doses), modified intention-to-treat (mITT) population of STORM part 2 (received at least 1 dose of Sd), and mITT population of DREAMM-2 (all randomized patients receiving BM). For each target dose, weights from KarMMa were estimated to match the patient characteristics in STORM part 2 and DREAMM-2.
- ORR was higher with ide-cel (treated population) compared to Sd (73% vs 26.6%; 95% CI: 3.83- 15.62) and BM 2.5mg/kg (70% vs 31.6%; 95% CI: 2.35-11.13). Ide-cel target dose (450 x 106 ) showed 14-fold improvement in ORR vs Sd (OR 13.97; 95% CI: 3.09-63.23) and 12.6-fold improvement vs BM 2.5mg/kg (OR 12.62; 95% CI: 3.69-43.10) based on the MAIC.
- Based on MAIC, ide-cel showed statistically significant improvement in median PFS (8.1 months vs 3.7 months, HR 0.46 [0.28-0.75]) and median OS (19 months vs 8.6 months, HR 0.23 [0.13- 0.42]) vs Sd. Ide-cel also showed statistically significant improvement in median PFS (10.4 months vs 2.9 months, HR 0.45 [0.27-0.77]) and median OS (19 months vs 9.9 months, HR 0.35 [0.14-0.87]) vs BM 2.5mg/kg.
- The authors concluded that efficacy estimates for ide-cel show a statistically and clinically meaningful benefit over Sd and BM 2.5mg/kg in those patients with triple-refractory MM. Also stated that longer follow-up is required to evaluate the OS benefit, these analyses will need to be updated as the long-term data matures with all 3 included clinical trials.
**Patrick DL, Powers A, Jun MP, et al. Effect of lisocabtagene maraleucel on HRQoL and symptom severity in relapsed/refractory large B-cell lymphoma. Blood Adv. 2021;5(8):2245-2255. https://pubmed.ncbi.nlm.nih.gov/33904895/
- Amendment to the open-label, non-randomized, multicenter, phase 1 TRANSCEND study allowed patients to be assessed for HRQoL, symptoms, and health utility by using the EORTC QLQ-C30 (181 patients) and EQ-5D-5L (186 patients) prior to lymphodepletion, on day 0, and 1, 5 2, 3, 6, 9, 12, 18, and 24 months after cell infusion plus at disease progression/relapse and end of study
- EORTC QLQ-C30: Global health status/quality of life was significant improved compared with baseline from 1 month to 18 months with clinically meaningful improvement observed in 33%, 52%, 60% and 60% at 1 month, 6 months, and 12 months, respectively. Clinically meaningful deterioration occurred in 14%, 10%, and 7% at 1 month, 6 months, 12 months, and 18 months, respectively.
- Physical functioning significantly improved at 2, 9 and 12 months, but with a significant deterioration initially observed at 1 month. Fatigue showed significant improvement compared with baseline at 2 and 18 months. Pain score improvements were not clinically meaningful.
- Higher proportion of treatment responders, compared with non-responders, showed a clinically meaningful improvement at any time point in HRQoL (72% vs 41%), physical functioning (42% vs 23%), fatigue (74% vs 45%), and pain (56% vs 41%)
- EQ-5D-5L: None of the mean index score increases were clinically meaningful. The proportion of patients with clinically significant improvement was 21%, 31%, 37%, and 32% at 1 month, 6 months, 12 months, and 18 months, respectively. The proportion of patients with clinically meaningful deterioration was 30%, 24%, 15%, and 12% at 1 month, 6 months, 12 months, and 18 months, respectively.
- Authors conclude that patients with relapsed-refractory LBCL treat with liso-cel had early, sustained, and clinically significant improvements in HRQoL and symptoms that correlated with antitumor activity
**Higham CS, Collins G, Shimano KA, et al. Transplant-associated thrombotic microangiopathy in pediatric patients: pre-HSCT risk stratification and prophylaxis. Blood Adv. 2021;5(8):2106-2114. https://pubmed.ncbi.nlm.nih.gov/33877298/
- Single-center retrospective pre-post analysis of 257 pediatric patients who underwent alloHCT from January 2012 through October 2019. Prospective TA-TMA risk stratification was implemented in December 2016, and high-risk patients received TMA prophylaxis with eicospentaenoic acid (EPA) 30 mg/kg/day and from at least 2 weeks prior to conditioning through day +100 in addition to N-acetylcysteine (NAC) 70 mg/kg every 8 hours from day +3 through day +42.
- 161 patients underwent HCT before TA-TMA risk stratification and 96 patients afterwards. 16.1% of patients retrospectively assigned were high-risk, and 24% prospectively assigned (P=0.14). Before stratification, there were 11 cases of TA-TMA for a cumulative 1-year incidence of 7.3% vs 4 cases post-stratification for a cumulative 1-year incidence of 4.5% (P=0.42).
- TA-TMA rates by risk stratification were statistically significant. For high-risk patients, poststratification cumulative 1-year incidence was 18.2% s. 28.2% in the pre-stratification patients (P<0.001). Standard-risk patients did not receive prophylaxis, and therefore no difference was 6 noted between the groups. This was reduced to 4.5% cumulative 1-year incidence in the patients who received combination prophylaxis.
- Authors conclude that the novel risk-stratification scoring system with implementation of prophylaxis showed a dramatic decrease in TA-TMA incidence and severity, so should be assessed in a larger randomized trial
*Yamazaki F, Yamasaki K, Kiyotani C, et al. Thiotepa-melphalan myeloablative therapy for high-risk neuroblastoma Pediatr Blood Cancer 2021;68:e28896. https://pubmed.ncbi.nlm.nih.gov/33788375/
- Retrospective review of the safety and efficacy of 41 high-risk neuroblastoma patients who received thiotepa (age >2, 200 mg/m2/day; age 2, 70 mg/m2/day; age <2, 1.5 mg/kg/day) over 1 hour, both given intravenously on Days - 12, -11, -5, and -4.
- All 41 patients received intensive induction chemotherapy with a median of 5 cycles. A third of patients attained CR or VGPR before autologous SCT. Twenty-four (59%) patients received 13-cis retinoic acid and 8 (20%) underwent allogeneic cord SCT after autoHCT.
- The 5-year EFS from treatment start was 41.5 + 7.7% and overall survival 56.1 + 7.8. Patients with MYCN-amplified high-risk neuroblastoma had a significantly improved 5-year EFS of 60.9 + 10.2% (p <0.001). Grade 3-4 mucositis occurred in 80% of patients and capillary leak syndrome in 20% with half requiring intravenous steroids. Three patients died of regimen-related toxicity (infection and TMA).
- The authors conclude that high dose thiotepa and melphalan therapy may be effective for highrisk neuroblastoma but with associated toxicities that warrant close monitoring.
**Miayo K, Terakura S, Ozawa Y, et al. Comparison of transplantation outcomes after foscarnet and ganciclovir administration as first-line anti-cytomegalovirus preemptive therapy. Transplantation and Cellular Therapy. 2021; 27(4):324e2-e10. https://pubmed.ncbi.nlm.nih.gov/33836887/
- Retrospective analysis of allo-HCT patients (n = 847) from unrelated donors who received preemptive anti-CMV therapy. Patients were excluded if they received prophylactic anti-CMV therapy with foscarnet, ganciclovir, or letermovir.
- Foscarnet was given to 86 patients and ganciclovir was given t 446 patients. There was no difference in the CMV status of the recipient between the arms (94% vs 89%; p=0.29), although patients in the foscarnet arm had a lower incidence of donor CMV positivity (15% vs 35%; p<0.001).
- There was no difference in the rate of OS, relapse, aGVHD, NRM or end organ CMV disease between the 2 arms and was not influenced by choice of anti-CMV therapy. The cGVHD rate at 2 years was higher in the ganciclovir arm compared to foscarnet (17% vs 33%; p=0.006), as was the rate of extensive cGVHD (6% vs 21%; p=0.002)
- More patients switched from foscarnet to ganciclovir (27%) versus ganciclovir to foscarnet (10%) (p<0.001). The primary reasons for switching from foscarnet were insufficient effect (14%) and nonhematologic adverse effects, such as renal dysfunction (9%) and rash (5%). The primary reasons for switching from ganciclovir were insufficient effect (6%) and hematologic adverse effects (5%).7
- Authors concluded that either agent can be used as first-line anti-CMV pre-emptive therapy, however selection may influence cGVHD related clinical outcomes in HCT recipients.
*Chen K, Arbona-Haddad E, Cheng MP, et al. Cytomegalovirus events in high-risk allogeneic hematopoietic-cell transplantation patients who received letermovir prophylaxis. Transpl Infect Dis 2021: online April 18. https://pubmed.ncbi.nlm.gov/33866648
- A single-center retrospective cohort study of 60 patients with CMV-seropositive alloHCT recipients who received primary letermovir prophylaxis was performed to determine CMV incidence rate and management strategies during and after prophylaxis.
- Patients had a median age of 61 years (range, 19-73). Letermovir prophylaxis was started a median time of 8 days (range, 0-43 days) after HCT, and duration of therapy was a median of 92 days (range, 10-504 days).
- During prophylaxis, 13 patients (22%) had quantifiable CMV DNAemia (reactivation) a median of 9 days (range, 1-59 days) after starting letermovir. Five (8%) of these patients discontinued prophylaxis and received preemptive therapy (PET) with valganciclovir; 8 (13%) continued letermovir as prophylaxis and CMV DNAemia resolved without PET. No patient developed CMV disease.
- Thirteen (22%) patients had post-prophylaxis CMV reactivation a median of 33 days (range, 14- 109 days) after discontinuing letermovir. In four (7%) of these patients, CMV DNAemia resolved without PET, and 9 (15%) received PET. No patient developed CMV disease.
- The authors concluded that letermovir prophylaxis is both safe and effective in providing CMV protection after alloHCT, especially high-risk patients. Authors found that detection of blips of during letermovir prophylaxis is relatively common, but clinically significant CMV reactivation that requires treatment during this period is uncommon.
*Camargo JF, Mendoza MA, Lin R, et al. Clinical presentation and outcomes of COVID-19 following hematopoietic cell transplantation and cellular therapy. Transpl Infect Dis 2021: online April 25. https://pubmed.ncbi.nlm.gov/33896088
- A single-center retrospective cohort study evaluated outcomes of 28 HCT and cellular therapy patients (autoHCT, n = 12; alloHCT, n = 15; CAR-T, n = 1) with confirmed COVID-19.
- The median age was 57 years (interquartile range [IQR], 50-67); median time from HCT to COVID-19 was 656 days (IQR, 33-1274), and patients were followed for a median of 59 days (IQR, 40-88). Out of 28 patients, 12 (43%), 6 (21%), and 10 (36%) had mild, moderate, and severe/critical disease, respectively.
- Among assessable patients (n = 19), 10 (53%) had documented virological clearance; median time to clearance was 34 days (range, 21-56).
- Overall mortality was 25% (no difference in autoHCT vs alloHCT) and exclusively in hospitalized patients, older than 50 years of age with severe disease. 7/10 (70%) patients with severe/critical COVID-19 died whereas none of the patients with mild/moderate disease died (p = 0.0001). 8
- Patients diagnosed with COVID-19 within 12 months of HCT exhibited higher mortality (57% vs 14%; p = 0.04). A higher proportion of patients who died within 30 days of COVID-19 diagnosis (3/4) were receiving ≥ 2 immunosuppressants, compared with patients who survived beyond 30 days (2/24; 75% vs 8%; p = 0.01).
- The authors concluded that their data shows mortality in COVID-19 HCT patients is higher than that of the age-comparable general population and largely dependent on age, disease severity, timing from HCT, and intensity of immunosuppression.
**Baumrin E, Izaguirre NE, Bausk B, et al. Safety and reactogenicity of the recombinant zoster vaccine after allogeneic hematopoietic cell transplantation. Blood Adv. 2021;5(6):1585-1593. https://pubmed.ncbi.nlm.nih.gov/33710336/ PMID: 33710336
- Single-center prospective observational cohort to assess the safety and reactogenicity of the RZV between 9 and 24 months after alloHCT in 158 patients who completed at least 1 dose, and 150 patients who completed 2 doses separated by at least 8 weeks
- 74% of patients received vaccine 1 (V1) 9 to 12 months after transplant. 92% has positive VZV immunoglobulin G serologies with 14% having a history of herpes zoster infection. At the time of V1 and V2, 72% and 60% were on systemic immunosuppression, respectively.
- 2.5% of patients experienced an episode of VZV reactivation at a median of 706 days posttransplant (median of 76.5 days after V1 and 25.5 days after V2). 21.5% of patients discontinued antiviral prophylaxis after receiving both doses of RZV, in which reactivation occurred in 11.8%.
- The cumulative incidence of cGVHD in patients who received V1 within 9-12 months posttransplant was 0.45, 0.57, and 0.60 at 9, 12, and 15 months, respectively, as compared to 0.42, 0.56, and 0.6 in the historical control group. There was no difference in relapse rate or mortality as compared to historical controls.
- Reactions to the RZV occurred in 91% of patients with majority (86%) due to injection-site pain (grade 3, 16%). Fatigue (70.2%) and myalgia (50.7%) were the most common general symptoms reported. Of note, RZV was co-administered with other post-HCT vaccines in majority of patients.
- Authors conclude that two doses of RZV demonstrated safety and tolerability in alloHCT recipients without increased rates of cGVHD, relapse, or death with overall low breakthrough reactivation rates
aGVHD: acute graft-versus-host disease
ALL: acute lymphoblastic leukemia AML: acute myeloid leukemia
alloHCT: allogeneic hematopoietic cell transplantation
autoHCT: autologous hematopoietic cell transplantation
BM: belantamab mafodotin
CAR: chimeric antigen receptor
cGVHD: chronic graft-versus-host disease
EORTC: European Organisation for Research and Treatment of Cancer
EPA: eicospentaenoic acid
FLT3: fms-like Receptor Tyrosine Kinase 3
GVHD: graft-versus-host disease
haplo HCT: haploidentical hematopoietic cell transplantation
HRQoL: health-related quality of life
HCT-CI: Hematopoietic Cell Transplantation-specific Comorbidity Index
Ida-cel: idecabtagene vicleucel
LFS: leukemia-free survival
mITT: modified intention-to-treat
MRD: minimal residual disease
MUD: matched unrelated donor
NRM: non-relapse mortality
ORR: overall response rate
OS: overall survival
PFS: progression-free survival
PTCy: post-transplant cyclophosphamide
RFS: relapse-free survival
RIC: reduced-intensity conditioning
RZV: recombinant zoster vaccine
SCBT: single-cord blood transplant
Sd: Selinexor + dexmamethasone
TA-TMA: transplant-associated thrombotic microangiopathy
TBI: total body irradiation
TKI: tyrosine kinase inhibitor
TLI: total lymphoid irradiation
TMI: total marrow irradiation
TRM: treatment-related mortality
VGPR: very good partial remission
ASTCT Pharmacy SIG Research Working Committee: Jennifer Collins, Kelly Gaffney, Katie Gatwood, Arpita Gandhi, Jitesh Kawedia, Binni Kunvarjee, Andrew Lin, Dennis Marjoncu, Jonathan Ptachcinski, Julianna Roddy, Lily Yan