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Dillon LW, Gui G, Ravindra N, Andrew G, Mukherjee D, Wong ZC, Huang Y, Gerhold J, Holman M, D’Angelo J, Miller J, Higgins J, Salk JJ, Auletta JJ, El Chaer F, Devine SM, Jimenez-Jimenez AM, De Lima MJG, Litzow MR, Kebriaei P, Saber W, Spellman SR, Zeger SL, Page KM, Hourigan CS. Measurable Residual FLT3 Internal Tandem Duplication Before Allogeneic Transplant for Acute Myeloid Leukemia. JAMA Oncol 2024:2818452. [PMID: 38696205 PMCID: PMC11066770 DOI: 10.1001/jamaoncol.2024.0985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/07/2023] [Indexed: 05/05/2024]
Abstract
Importance Persistence of FLT3 internal tandem duplication (ITD) in adults with acute myeloid leukemia (AML) in first complete remission (CR) prior to allogeneic hematopoietic cell transplant (HCT) is associated with increased relapse and death after transplant, but the association between the level of measurable residual disease (MRD) detected and clinical outcome is unknown. Objective To examine the association between pre-allogeneic HCT MRD level with relapse and death posttransplant in adults with AML in first CR. Design, Setting, and Participants In this cohort study, DNA sequencing was performed on first CR blood from patients with FLT3-ITD AML transplanted from March 2013 to February 2019. Clinical follow-up was through May 2022. Data were analyzed from October 2022 to December 2023. Exposure Centralized DNA sequencing for FLT3-ITD in pre-allogeneic HCT first CR blood using a commercially available kit. Main Outcomes and Measures The primary outcomes were overall survival and cumulative incidence of relapse, with non-relapse-associated mortality as a competing risk post-allogeneic HCT. Kaplan-Meier estimations (log-rank tests), Cox proportional hazards models, and Fine-Gray models were used to estimate the end points. Results Of 537 included patients with FLT3-ITD AML from the Pre-MEASURE study, 296 (55.1%) were female, and the median (IQR) age was 55.6 (42.9-64.1) years. Using the variant allele fraction (VAF) threshold of 0.01% or greater for MRD positivity, the results closely aligned with those previously reported. With no VAF threshold applied (VAF greater than 0%), 263 FLT3-ITD variants (median [range] VAF, 0.005% [0.0002%-44%]), and 177 patients (33.0%) with positive findings were identified. Multivariable analyses showed that residual FLT3-ITD was the variable most associated with relapse and overall survival, with a dose-dependent correlation. Patients receiving reduced-intensity conditioning without melphalan or nonmyeloablative conditioning had increased risk of relapse and death at any given level of MRD compared with those receiving reduced-intensity conditioning with melphalan or myeloablative conditioning. Conclusions and Relevance This study provides generalizable and clinically applicable evidence that the detection of residual FLT3-ITD in the blood of adults in first CR from AML prior to allogeneic HCT is associated with an increased risk of relapse and death, particularly for those with a VAF of 0.01% or greater. While transplant conditioning intensification, an intervention not available to all, may help mitigate some of this risk, alternative approaches will be necessary for this high-risk population of patients who are underserved by the current standard of care.
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Affiliation(s)
- Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Zoë C. Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | | | | - Jesse J. Salk
- TwinStrand Biosciences, Seattle, Washington
- University of Washington School of Medicine, Seattle
| | - Jeffery J. Auletta
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- The Ohio State University College of Medicine, Columbus
| | | | - Steven M. Devine
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | | | | | | | - Wael Saber
- Medical College of Wisconsin, Milwaukee
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Scott L. Zeger
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristin M. Page
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- Medical College of Wisconsin, Milwaukee
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Virginia Tech Fralin Biomedical Research Institute Cancer Research Center, Washington, DC
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Shah M, El Chaer F, Ho DY, El Boghdadly Z. Managing infectious challenges in the age of molecular-targeted therapies for adult hematological malignancies. Transpl Infect Dis 2024:e14283. [PMID: 38698640 DOI: 10.1111/tid.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 05/05/2024]
Abstract
Over the last decade, the therapeutic landscape for hematological malignancies (HMs) has witnessed a remarkable surge in the development of novel biological and small-molecule-targeted immunomodulatory agents. These therapies have drastically improved survival, but some come at the cost of increased risk of bacterial, viral, and/or fungal infections and on-target off-tumor immunological side effects. To mitigate such risks, physicians must be well informed about infectious complications and necessary preventive measures, such as screening, vaccinations, and antimicrobial prophylaxis. Furthermore, physicians should be vigilant about the noninfectious side effects of these agents that can mimic infections and understand their potential drug-drug interactions with antimicrobials. Strengthening and harmonizing the current surveillance and reporting system for drug-associated infections in real-world settings is essential to better ascertain the potential infections associated with these agents. In this review, we aimed to summarize the infection risks associated with novel agents used for specific HMs and outline recommended strategies for monitoring and prophylaxis.
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Affiliation(s)
- Manan Shah
- Division of Hematology and Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, Virginia, USA
| | - Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, Virginia, USA
| | - Zeinab El Boghdadly
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
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Raghuwanshi JS, Roberts N, Loughran TP, El Chaer F, Girton M, Moulder G. Plurality Over Parsimony: When Two Diagnoses Are More Likely Than One. J Gen Intern Med 2024:10.1007/s11606-023-08585-7. [PMID: 38409513 DOI: 10.1007/s11606-023-08585-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/20/2023] [Indexed: 02/28/2024]
Affiliation(s)
| | - Nathan Roberts
- Division of Hematology & Oncology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Thomas P Loughran
- Division of Hematology & Oncology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Firas El Chaer
- Division of Hematology & Oncology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Mark Girton
- Division of Clinical Pathology, Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Glenn Moulder
- Division of General, Geriatric, Palliative and Hospital Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
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Lantz J, Pham N, Jones C, Reed D, El Chaer F, Keng M. Blinatumomab in Practice. Curr Hematol Malig Rep 2024; 19:1-8. [PMID: 38060085 DOI: 10.1007/s11899-023-00714-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW Acute lymphoblastic leukemia (ALL) is a rare hematologic neoplasm in adults, with most cases defined by pathology related to abnormal B cell proliferation known as B-cell ALL. The course is challenging, with less-than-optimal survival outcomes, even with aggressive multiagent chemotherapy and consideration for stem cell transplantation. Novel therapies focused on targetable pathways are being investigated to improve outcomes while simultaneously decreasing toxicity. In our review, we aim to evaluate the utilization of blinatumomab in B-cell ALL and provide insight on how this guides our management. RECENT FINDINGS Blinatumomab is a bispecific T-cell engager (BiTE) immunotherapy that neutralizes malignant cells by instigating CD3-positive T cells to target CD19-positive B cells. However, this therapy targets both malignant and non-malignant lymphocytes with potentially severe side effects such as cytokine release syndrome or neurotoxicity. Evidence evaluating utilization in the relapsed or refractory setting has been most supported; however, newer trials have also indicated improved survival in the frontline treatment of B-cell ALL. As this therapy is relatively new, the treatment team may include members who are less experienced with the typical treatment course and drug mechanics. This review synthesized available data investigating the effectiveness of blinatumomab effectiveness and its adverse events in addition to providing guidance on safe administration methods utilizing a multidisciplinary healthcare team. When care is coordinated in these settings, serious side effects can be recognized early, allowing for necessary intervention leading to improved quality of life and overall survival. Future research will continue to evaluate blinatumomab in different lines of therapy and expand its way into community settings.
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Affiliation(s)
- Jeffrey Lantz
- Division of Hematology and Oncology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Natalie Pham
- Division of Internal Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Caroline Jones
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel Reed
- Division of Hematology and Oncology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Michael Keng
- Division of Hematology and Oncology, Department of Medicine, University of Virginia, Charlottesville, VA, USA.
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5
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El Chaer F, Kaul DR, Englund JA, Boeckh M, Batista MV, Seo SK, Carpenter PA, Navarro D, Hirsch HH, Ison MG, Papanicolaou GA, Chemaly RF. American Society of Transplantation and Cellular Therapy Series: #7 - Management of Respiratory Syncytial Virus Infections in Hematopoietic Cell Transplant Recipients. Transplant Cell Ther 2023; 29:730-738. [PMID: 37783338 DOI: 10.1016/j.jtct.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/04/2023]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transplant Infectious Disease Special Interest Group (TID-SIG) to update the 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A new approach was adopted to better serve clinical providers by publishing each standalone topic in the infectious disease series in a concise format of frequently asked questions (FAQ), tables, and figures. Experts in HCT and infectious diseases identified FAQs and then provided answers based on the strength of the recommendation and the level of supporting evidence. In the seventh guideline in the series, we focus on the respiratory syncytial virus (RSV) with FAQs addressing epidemiology, clinical diagnosis, prophylaxis, and treatment. Special consideration was given to RSV in pediatric, cord blood, haploidentical, and T cell-depleted HCT and chimeric antigen receptor T cell therapy recipients, as well as to identify future research directions.
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Affiliation(s)
- Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia, Charlottesville, Virginia.
| | - Daniel R Kaul
- Division of Infectious Disease, University of Michigan Medical School, Ann Arbor, Michigan
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, Washington
| | - Michael Boeckh
- Clinical Research and Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Center and Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Marjorie V Batista
- Department of Infectious Diseases, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - Susan K Seo
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, and Department of Microbiology, School of Medicine, University of Valencia, Valencia & Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Hans H Hirsch
- Clinical Virology Laboratory, Laboratory Medicine, University Hospital Basel, Basel, Switzerland; Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Michael G Ison
- Respiratory Disease Branch, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Shallis RM, Daver N, Altman JK, Komrokji RS, Pollyea DA, Badar T, Bewersdorf JP, Bhatt VR, de Botton S, de la Fuente Burguera A, Carraway HE, Desai P, Dillon R, Duployez N, El Chaer F, Fathi AT, Freeman SD, Gojo I, Grunwald MR, Jonas BA, Konopleva M, Lin TL, Mannis GN, Mascarenhas J, Michaelis LC, Mims AS, Montesinos P, Pozdnyakova O, Pratz KW, Schuh AC, Sekeres MA, Smith CC, Stahl M, Subklewe M, Uy GL, Voso MT, Walter RB, Wang ES, Zeidner JF, Žučenka A, Zeidan AM. Standardising acute myeloid leukaemia classification systems: a perspective from a panel of international experts. Lancet Haematol 2023; 10:e767-e776. [PMID: 37572683 DOI: 10.1016/s2352-3026(23)00159-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/23/2023] [Accepted: 05/19/2023] [Indexed: 08/14/2023]
Abstract
The existence of two acute myeloid leukaemia classification systems-one put forth by WHO and one by the International Consensus Classification in 2022-is concerning. Although both systems appropriately move towards genomic disease definitions and reduced emphasis on blast enumeration, there are consequential disagreements between the two systems on what constitutes a diagnosis of acute myeloid leukaemia. This fundamental problem threatens the ability of heath-care providers to diagnose acute myeloid leukaemia, communicate with patients and other health-care providers, and deliver appropriate and consistent management strategies for patients with the condition. Clinical trial eligibility, standardised response assessments, and eventual drug development and regulatory pathways might also be negatively affected by the discrepancies. In this Viewpoint, we review the merits and limitations of both classification systems and illustrate how the coexistence, as well as application of both systems is an undue challenge to patients, clinicians, hematopathologists, sponsors of research, and regulators. Lastly, we emphasise the urgency and propose a roadmap, by which the two divergent classification systems can be harmonised.
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Affiliation(s)
- Rory M Shallis
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica K Altman
- Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Daniel A Pollyea
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Talha Badar
- Division of Hematology & Medical Oncology, Mayo Clinic Cancer Center, Jacksonville, FL, USA
| | - Jan P Bewersdorf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vijaya R Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Hetty E Carraway
- Leukemia Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pinkal Desai
- Division of Hematology and Oncology, Weill Cornell Medical College, New York, NY, USA
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, UK
| | - Nicolas Duployez
- Laboratory of Hematology, Centre Hospitalier Universitaire Lille, Lille, France
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Amir T Fathi
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ivana Gojo
- Division of Hematologic Malignancies, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Brian A Jonas
- Department of Internal Medicine, Division of Malignant Hematology, Cellular Therapy and Transplantation, University of California Davis, Davis, CA, USA
| | - Marina Konopleva
- Montefiore Einstein Cancer Center & Albert Einstein College of Medicine, New York, NY, USA
| | - Tara L Lin
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas, Kansas City, KS, USA
| | - Gabriel N Mannis
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura C Michaelis
- Division of Hematology and Oncology, Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alice S Mims
- Division of Hematology, Department of Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Pau Montesinos
- Hospital Universitari I Politecnic La Fe, Valencia, Spain
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Keith W Pratz
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Andre C Schuh
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Mikkael A Sekeres
- Division of Hematology, Sylvester Cancer Center, University of Miami, Miami, FL, USA
| | - Catherine C Smith
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Maximilian Stahl
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Geoffrey L Uy
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, Tor Vergata University, and Neuro-Oncohematology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia, Rome, Italy
| | - Roland B Walter
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Eunice S Wang
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Joshua F Zeidner
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Andrius Žučenka
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania and Institute of Clinical Medicine, Vilnius, Lithuania
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine and Yale Cancer Center, New Haven, CT, USA.
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Gui G, Dillon LW, Ravindra N, Hegde PS, Andrew G, Mukherjee D, Wong Z, Auletta J, El Chaer F, Chen E, Chen YB, Corner A, Devine SM, Iyer S, Jimenez Jimenez AM, De Lima MJG, Litzow MR, Kebriaei P, Spellman SR, Zeger SL, Page KM, Hourigan CS. Measurable Residual IDH1 before Allogeneic Transplant for Acute Myeloid Leukemia. medRxiv 2023:2023.07.28.23293166. [PMID: 37577695 PMCID: PMC10418565 DOI: 10.1101/2023.07.28.23293166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Measurable residual disease (MRD) in adults with acute myeloid leukemia (AML) in complete remission is an important prognostic marker, but detection methodology requires optimization. The persistence of mutated NPM1 or FLT3-ITD in the blood of adult patients with AML in first complete remission (CR1) prior to allogeneic hematopoetic cell transplant (alloHCT) has been established as associated with increased relapse and death after transplant. The prognostic implications of persistence of other common AML-associated mutations, such as IDH1, at this treatment landmark however remains incompletely defined. We performed testing for residual IDH1 variants (IDH1m) in pre-transplant CR1 blood of 148 adult patients undergoing alloHCT for IDH1-mutated AML at a CIBMTR site between 2013-2019. No post-transplant differences were observed between those testing IDH1m positive (n=53, 36%) and negative pre-transplant (overall survival: p = 0.4; relapse: p = 0.5). For patients with IDH1 mutated AML co-mutated with NPM1 and/or FLT3-ITD, only detection of persistent mutated NPM1 and/or FLT3-ITD was associated with significantly higher rates of relapse (p = 0.01). These data, from the largest study to date, do not support the detection of IDH1 mutation in CR1 blood prior to alloHCT as evidence of AML MRD or increased post-transplant relapse risk.
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Affiliation(s)
- Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Pranay S Hegde
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Zoë Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Jeffery Auletta
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- The Ohio State University College of Medicine, Columbus, OH
| | | | - Evan Chen
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Steven M Devine
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Sunil Iyer
- Columbia University Irving Medical Center, New York, NY
| | | | | | | | - Partow Kebriaei
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- National Marrow Donor Program, Minneapolis, MN
| | - Scott L Zeger
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin M Page
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- Medical College of Wisconsin, Milwaukee, WI
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
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El Chaer F, Hourigan CS, Zeidan AM. How I treat AML incorporating the updated classifications and guidelines. Blood 2023; 141:2813-2823. [PMID: 36758209 PMCID: PMC10447497 DOI: 10.1182/blood.2022017808] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
The European LeukemiaNet recently revised both the clinical (2022) and measurable residual disease testing (2021) guidelines for acute myeloid leukemia (AML). The updated World Health Organization and International Consensus Classification for myeloid neoplasms were also published in 2022. Together, these documents update the classification, risk stratification, prognostication, monitoring recommendations, and response assessment of patients with AML. Increased appreciation of the genetic drivers of AML over the past decade and our increasingly sophisticated understanding of AML biology have been translated into novel therapies and more complex clinical treatment guidelines. Somatic genetic abnormalities and germ line predispositions now define and guide treatment and counseling for the subtypes of this hematologic malignancy. In this How I Treat article, we discuss how we approach AML in daily clinical practice, considering the recent updates in the context of new treatments and discoveries over the past decade.
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Affiliation(s)
- Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, Yale University, New Haven, CT
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Dillon LW, Gui G, Page KM, Ravindra N, Wong ZC, Andrew G, Mukherjee D, Zeger SL, El Chaer F, Spellman S, Howard A, Chen K, Auletta J, Devine SM, Jimenez Jimenez AM, De Lima MJG, Litzow MR, Kebriaei P, Saber W, Weisdorf DJ, Hourigan CS. DNA Sequencing to Detect Residual Disease in Adults With Acute Myeloid Leukemia Prior to Hematopoietic Cell Transplant. JAMA 2023; 329:745-755. [PMID: 36881031 PMCID: PMC9993183 DOI: 10.1001/jama.2023.1363] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/28/2023] [Indexed: 03/08/2023]
Abstract
Importance Preventing relapse for adults with acute myeloid leukemia (AML) in first remission is the most common indication for allogeneic hematopoietic cell transplant. The presence of AML measurable residual disease (MRD) has been associated with higher relapse rates, but testing is not standardized. Objective To determine whether DNA sequencing to identify residual variants in the blood of adults with AML in first remission before allogeneic hematopoietic cell transplant identifies patients at increased risk of relapse and poorer overall survival compared with those without these DNA variants. Design, Setting, and Participants In this retrospective observational study, DNA sequencing was performed on pretransplant blood from patients aged 18 years or older who had undergone their first allogeneic hematopoietic cell transplant during first remission for AML associated with variants in FLT3, NPM1, IDH1, IDH2, or KIT at 1 of 111 treatment sites from 2013 through 2019. Clinical data were collected, through May 2022, by the Center for International Blood and Marrow Transplant Research. Exposure Centralized DNA sequencing of banked pretransplant remission blood samples. Main Outcomes and Measures The primary outcomes were overall survival and relapse. Day of transplant was considered day 0. Hazard ratios were reported using Cox proportional hazards regression models. Results Of 1075 patients tested, 822 had FLT3 internal tandem duplication (FLT3-ITD) and/or NPM1 mutated AML (median age, 57.1 years, 54% female). Among 371 patients in the discovery cohort, the persistence of NPM1 and/or FLT3-ITD variants in the blood of 64 patients (17.3%) in remission before undergoing transplant was associated with worse outcomes after transplant (2013-2017). Similarly, of the 451 patients in the validation cohort who had undergone transplant in 2018-2019, 78 patients (17.3%) with residual NPM1 and/or FLT3-ITD variants had higher rates of relapse at 3 years (68% vs 21%; difference, 47% [95% CI, 26% to 69%]; HR, 4.32 [95% CI, 2.98 to 6.26]; P < .001) and decreased survival at 3 years (39% vs 63%; difference, -24% [2-sided 95% CI, -39% to -9%]; HR, 2.43 [95% CI, 1.71 to 3.45]; P < .001). Conclusions and Relevance Among patients with acute myeloid leukemia in first remission prior to allogeneic hematopoietic cell transplant, the persistence of FLT3 internal tandem duplication or NPM1 variants in the blood at an allele fraction of 0.01% or higher was associated with increased relapse and worse survival compared with those without these variants. Further study is needed to determine whether routine DNA-sequencing testing for residual variants can improve outcomes for patients with acute myeloid leukemia.
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MESH Headings
- Female
- Humans
- Male
- Middle Aged
- Hematopoietic Stem Cell Transplantation
- Leukemia, Myeloid, Acute/blood
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/therapy
- Neoplasm, Residual/blood
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/genetics
- Nuclear Proteins/genetics
- Preoperative Care
- Retrospective Studies
- Sequence Analysis, DNA
- Recurrence
- Survival Analysis
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Affiliation(s)
- Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristin M. Page
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- Medical College of Wisconsin, Milwaukee
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Zoë C. Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Scott L. Zeger
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Stephen Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Alan Howard
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Karen Chen
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Jeffery Auletta
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- The Ohio State University College of Medicine, Columbus
| | - Steven M. Devine
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | | | | | | | - Wael Saber
- Medical College of Wisconsin, Milwaukee
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Daniel J. Weisdorf
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- University of Minnesota, Minneapolis
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, Maryland
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10
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Varadarajan I, Pierce E, Scheuing L, Morris A, El Chaer F, Keng M. Post-Hematopoietic Cell Transplantation Relapsed Acute Lymphoblastic Leukemia: Current Challenges and Future Directions. Onco Targets Ther 2023; 16:1-16. [PMID: 36685611 PMCID: PMC9849790 DOI: 10.2147/ott.s274551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 12/14/2022] [Indexed: 01/15/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) represents an important and potentially curative treatment option for adult patients with acute lymphoblastic leukemia. Relapse continues to remain the most important factor influencing overall survival post allo-HCT. We discuss early identification, clinical manifestations, and management of relapsed disease. Routine evaluation of measurable residual disease (MRD) and change in donor chimerism play a crucial role in early detection. Pivotal clinical trials have led to FDA approval of multiple novel agents like blinatumomab and inotuzumab. Combining targeted therapy with cellular immunotherapy serves as the backbone for prolonging overall survival in these patients. Donor lymphocyte infusions have traditionally been used in relapsed disease with suboptimal outcomes. This review provides insight into use of cellular therapy in MRD positivity and decreasing donor chimerism. It also discusses various modalities of combining cellular therapy with novel agents and discussing the impact of chimeric antigen receptor T-cell therapy in the setting of post allo-HCT relapse both as consolidative therapy and as a bridge to second transplant.
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Affiliation(s)
- Indumathy Varadarajan
- Department of Medicine, Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Eric Pierce
- Department of Medicine, Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Lisa Scheuing
- Department of Medicine, Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Amy Morris
- Department of Pharmacy Services, University of Virginia, Charlottesville, VA, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Michael Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA,Correspondence: Michael Keng, Division of Hematology & Oncology, University of Virginia Comprehensive Cancer Center, West Complex Room 6009, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA, Tel +1 434 924 4257, Fax +1 434- 243 6068, Email
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11
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El Chaer F, Ballen KK. Measurable residual disease for secondary acute myeloid leukemia prior to allogeneic hematopoietic cell transplantation: does it make a difference? Bone Marrow Transplant 2022; 57:1473-1474. [PMID: 35902643 DOI: 10.1038/s41409-022-01765-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Firas El Chaer
- Division of Hematology/Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen K Ballen
- Division of Hematology/Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA.
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12
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Mort J, Wells L, DiBenedetto S, Morse E, Mautner B, Ghamsari F, Pierce E, Morris A, Keng MK, El Chaer F. Comparison of different treatment modalities for favorable risk acute myeloid leukemia: Standard-dose anthracycline versus high-dose anthracycline versus addition of gemtuzumab ozogamicin. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e19016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19016 Background: The standard remission induction regimen for medically fit patients with AML consists of a backbone of cytarabine & an anthracycline (“7+3” therapy). However, the choice & dose of the anthracycline varies between institutions & practitioner preference, particularly in patients with favorable risk cytogenetics. Gemtuzumab ozogamicin (GO) may improve outcomes in this patient population but is associated with increased toxicities. Methods: We performed a retrospective analysis on medically fit patients ≥ 18 yo with favorable risk AML from 2015-2020 treated with 7+3 at the University of Virginia. Patients were stratified based on standard dose (45 or 60 mg/m2 daunorubicin) (SD) vs higher dose (90 mg/m2 daunorubicin or 12 mg/m2 idarubicin) (HD) of anthracycline vs the addition of GO. Measures included rates of remission, EFS, RFS, and OS as well as rates of treatment-related complications. Results: In total, 58 patients were identified, of which 33 received induction with SD, 19 received HD, & 6 received GO. The majority (75%) of patients were < 60 years old & 93% had de novo AML. The rates of complete remission in the SD, HD & GO groups were 90.9%, 89.5% & 100%, respectively (p = 0.57). EFS at 2-years was 43.9%, 36.7%, & 66.7%, respectively (p = 0.85). RFS at 2-years was 53.0%, 39.0%, & 100%, respectively (p = 0.18). OS at 2-years was similar between all groups (58.9%, 56.9%, & 66.7%, p = 0.92). The rate & duration of cytopenias after induction were similar among all groups (median duration 29 days), however cytopenias were more common in the GO group following consolidation. The rates of major bleeding, admission to the intensive care unit (ICU), and new onset cardiomyopathy (EF < 50%) were higher in the GO group (major bleeding: 0% in SD, 5.3% in HD, 33.3% in GO; ICU admission: 12.1% in SD, 21.1% in HD, 33.3% in GO; cardiomyopathy: 12.1% in SD, 26.3% in HD, 33.3% in GO). The rate of infection, liver dysfunction, & acute renal injury were similar among all groups. No patients developed veno-occlusive disease. Conclusions: Patients receiving GO had a trend toward improved EFS & RFS, however with a similar OS at the expense of higher rates of cytopenias, major bleeding, ICU admission, & cardiotoxicity. Patients receiving HD had a trend toward worse outcomes than those who received SD. A major limitation of our study is the small sample size & single institution experience, however multi-institutional analysis is ongoing for further investigation.[Table: see text]
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Affiliation(s)
- Joseph Mort
- University of Virginia Health System, Charlottesville, VA
| | - Leah Wells
- University of Virginia, Charlottesville, VA
| | | | - Emily Morse
- University of Virginia Health System, Charlottesville, VA
| | - Ben Mautner
- University of Virginia Health System, Charlottesville, VA
| | - Farid Ghamsari
- University of Virginia School of Medicine, Charlottesville, VA
| | | | - Amy Morris
- University of Virginia, Charlottesville, VA
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13
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Mautner B, Pierce E, Mort J, DiBenedetto S, Wells L, Ghamsari F, Morse E, Morris A, Keng MK, El Chaer F. The risks of thrombotic and bleeding events in patients receiving PEGylated asparaginase for treatment of acute lymphoblastic leukemia. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e19015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19015 Background: The prognosis of adult patients with acute lymphoblastic leukemia (ALL) has improved with the adoption of pediatric-inspired chemotherapy regimens. PEGylated asparaginase (PEG-Asp) is essential to these regimens. Although PEG-Asp is associated with an increased risk of coagulopathy, venous thromboembolism, and depletion of antithrombin III (AT3), there is limited data evaluating the risk of thrombosis and bleeding and optimal antithrombotic interventions in these patients are unknown. Methods: We performed a single-center retrospective study of patients ≥ 18 years-old who received PEG-Asp for B- or T-ALL at the University of Virginia between 2015 and 2020. The primary outcomes were the incidence of thrombosis and bleeding events. All patients received prophylactic AT3 repletion for activity level <60% & cryoprecipitate for fibrinogen <100mg/dL. None received prophylactic anticoagulation. All received prednisone during induction at a median daily dose of 1 mg/kg. Results: We identified 57 patients who received PEG-Asp for ALL. Median age was 32 years (range 18-63). Five patients (8.8%) had a thrombotic event during induction versus five (16%) during post-induction. Four patients (7%) had a bleeding event during induction versus five (10%) during post-induction. The most common type of thrombosis was deep venous thrombosis, with the majority being catheter-associated. Pulmonary embolism and CNS thrombosis were less common. During induction, the median time to thrombotic event was 18 days after last PEG-Asp administration. 60% and 80% of patients received AT3 and cryoprecipitate, respectively. During post-induction, the median time to thrombotic event was 58 days after last PEG-Asp administration. 38% and 63% of the patients received AT3 and cryoprecipitate, respectively. There was one episode of major bleeding during induction and six during post-induction. Conclusions: Though the increase in thrombotic risk in adult patients receiving PEG-Asp is well-characterized, rates of reported thromboses vary widely. Studies examining bleeding risk associated with PEG-Asp regimens are even scarcer and with variable outcomes. There was a significant occurrence of both thrombotic and bleeding events associated with administration of PEG-Asp. More investigation into the relative thrombotic and bleeding risks associated with PEG-Asp is needed to determine optimal antithrombotic interventions in adult patients with ALL.[Table: see text]
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Affiliation(s)
- Ben Mautner
- University of Virginia Health System, Charlottesville, VA
| | | | - Joseph Mort
- University of Virginia Health System, Charlottesville, VA
| | | | - Leah Wells
- University of Virginia, Charlottesville, VA
| | - Farid Ghamsari
- University of Virginia School of Medicine, Charlottesville, VA
| | - Emily Morse
- University of Virginia Health System, Charlottesville, VA
| | - Amy Morris
- University of Virginia, Charlottesville, VA
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14
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Hourigan CS, Dillon LW, Gui G, Ravindra N, Wong Z, Andrew G, Mukherjee D, El Chaer F, Yoon C, Spellman S, Howard A, Auletta J, Devine SM, Jimenez Jimenez AM, De Lima MJ, Litzow MR, Kebriaei P, Saber W, Weisdorf DJ, Page K. Pre-MEASURE: Multicenter evaluation of the prognostic significance of measurable residual disease testing prior to allogeneic transplantation for adult patients with AML in first remission. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.7006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7006 Background: Measurable residual disease (MRD) prior to allogeneic hematopoietic cell transplantation (alloHCT) is associated with increased relapse and death in patients with acute myeloid leukemia (AML) in cytomorphological complete remission (CR). We recently demonstrated AML MRD detected in pre-alloHCT blood by DNA-sequencing was associated with increased relapse and decreased overall survival in patients randomized to reduced intensity conditioning (RIC) versus myeloablative conditioning (MAC). The clinical utility of such ultra-deep next-generation sequencing (NGS-MRD) had not yet been reported in a large multi-center cohort. Methods: Patients aged 18 or older who underwent first alloHCT between 2013-2017 for AML in first CR (CR1), reported to be FLT3, NPM1, IDH1, IDH2 and/or Kit mutated at diagnosis, with a pre-conditioning remission blood sample available in the CIBMTR biobank were eligible for this study. Ultra-deep anchored multiplex PCR-based NGS-MRD for the above mutations was performed on 500ng gDNA with error-corrected variant calling as previously described. The pre-specified statistical analysis plan was registered on OSF. Results: Of 457 patients with a sample available, 448 had sufficient clinical annotation and DNA for analysis. 147 of these 448 patients (33%) experienced relapse at a median of 5.6 months post-alloHCT. NGS-MRD was positive in 129 pre-alloHCT patient samples (29%), averaging 1.35 mutation(s)/patient (range: 1-4). 173 mutations were detected with a median VAF of 0.18% (range: 0.0054-62%), most frequently FLT3-ITD (n = 43 patients), NPM1 (n = 48), and IDH2 (n = 46). Testing positive by NGS-MRD prior to alloHCT was associated with a 3yr RFS of 36% (95% CI: 28-45%) compared with 56% (51-62%) in those testing negative (p < 0.001). Detection of NPM1 and/or FLT3-ITD mutations prior to alloHCT was associated with a 3yr relapse probability of 55% (43-67%) and RFS of 26% (16-37%). NGS-MRD impact was modified by conditioning intensity: positive patients receiving RIC/NMA had the highest relapse of 57% at 3yr, testing negative followed by RIC/NMA had the same relapse rate at 3yr (35%) as those who tested positive but received MAC (p < 0.001). At three years, those positive for FLT3-ITD and/or NPM1 mutations prior to RIC/NMA alloHCT had a relapse probability of 67% (50-83%) with a RFS of 19% (8-33%). HR for relapse if NGS-MRD positive pre-alloHCT in CR1 was 2.3 (p < 0.001, 95% CI 1.6-3.1) when adjusting for conditioning intensity and age group. Conclusions: In this largest cohort of NGS-MRD testing prior to alloHCT for AML reported to date, we confirm the ability to identify patients in CR1 but at high-risk of subsequent relapse. This evidence provides the foundation for future precision medicine approaches to reduce post-transplant AML relapse.
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Affiliation(s)
- Chris S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Laura Williams Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Zoë Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | - Chris Yoon
- National Marrow Donor Program, Milwaukee, WI
| | - Stephen Spellman
- (CIBMTR) Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Alan Howard
- National Marrow Donor Program, Minneapolis, MN
| | | | | | - Antonio Martin Jimenez Jimenez
- Division of Transplantation and Cell Therapy, Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL
| | - Marcos J.G. De Lima
- Adult Hematologic Malignancies and Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Cleveland, OH
| | | | - Partow Kebriaei
- The University of Texas MD Anderson Cancer Center, Department of Stem Cell Transplantation & Cellular Therapy, Houston, TX
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI
| | - Daniel Jordan Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Kristin Page
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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15
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Pierce E, Mautner B, Mort J, Blewett A, Morris A, Keng M, El Chaer F. MRD in ALL: Optimization and Innovations. Curr Hematol Malig Rep 2022; 17:69-81. [PMID: 35616771 DOI: 10.1007/s11899-022-00664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Measurable residual disease (MRD) is an important monitoring parameter that can help predict survival outcomes in acute lymphoblastic leukemia (ALL). Identifying patients with MRD has the potential to decrease the risk of relapse with the initiation of early salvage therapy and to help guide decision making regarding allogeneic hematopoietic cell transplantation. In this review, we discuss MRD in ALL, focusing on advantages and limitations between MRD testing techniques and how to monitor MRD in specific patient populations. RECENT FINDINGS MRD has traditionally been measured through bone marrow samples, but more data for evaluation of MRD via peripheral blood is emerging. Current and developmental testing strategies for MRD include multiparametric flow cytometry (MFC), next-generation sequencing (NGS), quantitative polymerase chain reaction (qPCR), and ClonoSeq. Novel therapies are incorporating MRD as an outcome measure to demonstrate efficacy, including blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor T (CAR-T) cell therapy. Understanding how to incorporate MRD testing into the management of ALL could improve patient outcomes and predict efficacy of new therapy options.
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Affiliation(s)
- Eric Pierce
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Benjamin Mautner
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Joseph Mort
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Anastassia Blewett
- Department of Pharmacy Services, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Amy Morris
- Department of Pharmacy Services, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Michael Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA.
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16
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Courville EL, Shantzer L, Vitzthum von Eckstaedt HC, Mellot H, Keng M, Sen J, Morris A, Williams E, El Chaer F. Variant Acute Promyelocytic Leukemia Presenting Without Auer Rods Highlights the Need for Correlation with Cytogenetic Data in Leukemia Diagnosis. Lab Med 2021; 53:95-99. [PMID: 34268555 DOI: 10.1093/labmed/lmab051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Variant acute promyelocytic leukemia (vAPL) is a rare leukemia characterized by rearrangement between RARα and a non-PML partner gene. This type of leukemia can be difficult to recognize by histomorphologic evaluation, particularly in patients with few or no Auer rods, and by flow cytometry, but it can be identified by distinct cytogenetic features. Herein, we report on a patient with vAPL with t(11;17)(q23;q21) who presented an initial diagnostic challenge. Detailed flow cytometry findings are presented for this rare entity. Our case study also presents novel treatment (chemotherapy in combination with venetoclax) chosen based on mechanistic data from preclinical studies.
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Affiliation(s)
- Elizabeth L Courville
- Department of Pathology, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Lindsey Shantzer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | | | - Holly Mellot
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Michael Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Jeremy Sen
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Amy Morris
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Eli Williams
- Department of Pathology, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, US
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17
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Riley DO, Schlefman JM, Vitzthum Von Eckstaedt V HC, Morris AL, Keng MK, El Chaer F. Pegaspargase in Practice: Minimizing Toxicity, Maximizing Benefit. Curr Hematol Malig Rep 2021; 16:314-324. [PMID: 33978914 DOI: 10.1007/s11899-021-00638-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The incorporation of pegaspargase in chemotherapy regimens has significantly improved the prognosis of ALL in adults. However, pegaspargase use poses many challenges due to its unique toxicity profile. Here, we review pegaspargase's most clinically significant toxicities, and provide guidance for their prevention and management in order to avoid unnecessary drug discontinuation and achieve maximum clinical benefit. RECENT FINDINGS Clinically significant toxicities of pegaspargase include thrombosis, hypersensitivity and inactivation, hepatotoxicity, pancreatitis, and hypertriglyceridemia. The majority of these toxicities are temporary, nonfatal, and can be managed supportively without permanent pegaspargase discontinuation. Special attention should be paid to inactivation, which can lead to treatment failure, as well as pancreatitis, which necessitates complete cessation of asparaginase therapy. The question of how to best proceed in patients who cannot tolerate pegaspargase remains unanswered, and is an important area of future investigation. Pegaspargase is an essential component of the pediatric-inspired regimens that have improved survival in adult ALL. Although pegaspargase's toxicity profile is unique, it is also highly manageable and should not be a barrier to achieving maximum clinical benefit using this drug.
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Affiliation(s)
- David O Riley
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Jenna M Schlefman
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Amy L Morris
- Department of Pharmacy Services, UVA Health, Charlottesville, VA, USA
| | - Michael K Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA.
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18
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Holtzman NG, Xie H, Bentzen S, Kesari V, Bukhari A, El Chaer F, Lutfi F, Siglin J, Hutnick E, Gahres N, Ruehle K, Ahmad H, Shanholtz C, Kocoglu MH, Badros AZ, Yared JA, Hardy NM, Rapoport AP, Dahiya S. Immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy for lymphoma: predictive biomarkers and clinical outcomes. Neuro Oncol 2021; 23:112-121. [PMID: 32750704 PMCID: PMC7850044 DOI: 10.1093/neuonc/noaa183] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND CD19-directed chimeric antigen receptor (CAR) T-cell therapy (CAR-T) has emerged as effective for relapsed/refractory large B-cell lymphoma (R/R LBCL). The neurologic toxicity seen with CAR-T, referred to as immune effector cell-associated neurotoxicity syndrome (ICANS), is poorly understood. To better elucidate the clinical characteristics, treatment outcomes, and correlative biomarkers of ICANS, we review here a single-center analysis of ICANS after CAR T-cell therapy in R/R LBCL. METHODS Patients (n = 45) with R/R LBCL treated with axicabtagene ciloleucel (axi-cel) were identified. Data regarding treatment course, clinical outcomes, and correlative studies were collected. Patients were monitored and graded for ICANS via CARTOX-10 scoring and Common Terminology Criteria for Adverse Events (CTCAE) v4.03 criteria, respectively. RESULTS Twenty-five (56%) patients developed ICANS, 18 (72%) of whom had severe (CTCAE grades 3-4) ICANS. Median time to development of ICANS was 5 days (range, 3-11). Elevated pre-infusion (day 0 [D0]) fibrinogen (517 vs 403 mg/dL, upper limit of normal [ULN] 438 mg/dL, P = 0.01) and D0 lactate dehydrogenase (618 vs 506 units/L, ULN 618 units/L, P = 0.04) were associated with ICANS. A larger drop in fibrinogen was associated with ICANS (393 vs 200, P < 0.01). Development of ICANS of any grade had no effect on complete remission (CR), progression-free survival (PFS), or overall survival (OS). Duration and total dose of steroid treatment administered for ICANS did not influence CR, PFS, or OS. CONCLUSIONS ICANS after CAR-T with axi-cel for R/R LBCL was seen in about half of patients, the majority of which were high grade. Contrary to previous reports, neither development of ICANS nor its treatment were associated with inferior CR, PFS, or OS. The novel finding of high D0 fibrinogen level can identify patients at higher risk for ICANS.
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Affiliation(s)
- Noa G Holtzman
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Hao Xie
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Soren Bentzen
- Department of Epidemiology and Biostatistics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vivek Kesari
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ali Bukhari
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Firas El Chaer
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Forat Lutfi
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Siglin
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Hutnick
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Natalie Gahres
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kathleen Ruehle
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Haroon Ahmad
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Carl Shanholtz
- Division of Critical Care, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mehmet H Kocoglu
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashraf Z Badros
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jean A Yared
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nancy M Hardy
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron P Rapoport
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Saurabh Dahiya
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
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19
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Kashanian SM, Li AY, Mustafa Ali M, Sutherland ME, Duong VH, Hambley BC, Zacholski K, El Chaer F, Holtzman NG, Imran M, Patzke CL, Cornu J, Duffy A, Dezern AE, Gojo I, Norsworthy KJ, Levis MJ, Smith BD, Baer MR, Ghiaur G, Emadi A. Increased body mass index is a risk factor for acute promyelocytic leukemia. ACTA ACUST UNITED AC 2021; 2:33-39. [PMID: 33693438 PMCID: PMC7943182 DOI: 10.1002/jha2.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction Obesity has become increasingly prevalent worldwide and is a risk factor for many malignancies. We studied the correlation between body mass index (BMI) and the incidence of acute promyelocytic leukemia (APL), non‐APL acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and control hospitalized patients without leukemia in the same community. Methods Multicenter, retrospective analysis of 71 196 patients: APL (n = 200), AML (n = 437), ALL (n = 103), nonleukemia hospitalized (n = 70 456) admitted to University of Maryland and Johns Hopkins Cancer Centers, and University of Maryland Medical Center. Results Patients with APL had a significantly higher unadjusted mean and median BMI (32.5 and 30.3 kg/m2) than those with AML (28.3 and 27.1 kg/m2), ALL (29.3 and 27.7 kg/m2), and others (29.3 and 27.7 kg/m2) (P < .001). Log‐transformed BMI multivariable models demonstrated that APL patients had a significantly higher adjusted mean BMI by 3.7 kg/m2 (P < .001) or approximately 10% (P < .01) compared to the other groups, when controlled for sex, race, and age. Conclusions This study confirms that when controlled for sex, age, and race there is an independent association of higher BMI among patients with APL compared to patients with ALL, AML, and hospitalized individuals without leukemia in the same community.
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Affiliation(s)
- Sarah M Kashanian
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Andrew Y Li
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Moaath Mustafa Ali
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Mark E Sutherland
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Vu H Duong
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Bryan C Hambley
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Kyle Zacholski
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Firas El Chaer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD.,Present address: Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Noa G Holtzman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD.,Present address: Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mohammad Imran
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Ciera L Patzke
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Jonathan Cornu
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Alison Duffy
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD.,University of Maryland School of Pharmacy, Baltimore, MD
| | - Amy E Dezern
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Ivana Gojo
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Kelly J Norsworthy
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Mark J Levis
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - B Douglas Smith
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Gabriel Ghiaur
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Ashkan Emadi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD.,Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD
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20
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Dholaria B, Savani BN, Hamilton BK, Oran B, Liu HD, Tallman MS, Ciurea SO, Holtzman NG, Ii GLP, Devine SM, Mannis G, Grunwald MR, Appelbaum F, Rodriguez C, El Chaer F, Shah N, Hashmi SK, Kharfan-Dabaja MA, DeFilipp Z, Aljurf M, AlShaibani A, Inamoto Y, Jain T, Majhail N, Perales MA, Mohty M, Hamadani M, Carpenter PA, Nagler A. Hematopoietic Cell Transplantation in the Treatment of Newly Diagnosed Adult Acute Myeloid Leukemia: An Evidence-Based Review from the American Society of Transplantation and Cellular Therapy. Transplant Cell Ther 2021; 27:6-20. [PMID: 32966881 DOI: 10.1016/j.bbmt.2020.09.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022]
Abstract
The role of hematopoietic cell transplantation (HCT) in the management of newly diagnosed adult acute myeloid leukemia (AML) is reviewed and critically evaluated in this evidence-based review. An AML expert panel, consisting of both transplant and nontransplant experts, was invited to develop clinically relevant frequently asked questions covering disease- and HCT-related topics. A systematic literature review was conducted to generate core recommendations that were graded based on the quality and strength of underlying evidence based on the standardized criteria established by the American Society of Transplantation and Cellular Therapy Steering Committee for evidence-based reviews. Allogeneic HCT offers a survival benefit in patients with intermediate- and high-risk AML and is currently a part of standard clinical care. We recommend the preferential use of myeloablative conditioning in eligible patients. A haploidentical related donor marrow graft is preferred over a cord blood unit in the absence of a fully HLA-matched donor. The evolving role of allogeneic HCT in the context of measurable residual disease monitoring and recent therapeutic advances in AML with regards to maintenance therapy after HCT are also discussed.
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Affiliation(s)
- Bhagirathbhai Dholaria
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Bipin N Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Betul Oran
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hien D Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | | | | | - Noa G Holtzman
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | | | - Steven M Devine
- National Marrow Donor Program and Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Gabriel Mannis
- Department of Medicine, Division of Hematology, Stanford University, Stanford, California
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Frederick Appelbaum
- Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington
| | - Cesar Rodriguez
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Firas El Chaer
- Division of Hematology/Oncology, University of Virginia, Charlottesville, Virginia
| | - Nina Shah
- Division of Hematology-Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | | | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - AlFadel AlShaibani
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Yoshihiro Inamoto
- Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington; Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Tania Jain
- Sidney Kimmel Cancer Center, John Hopkins Hospital, Baltimore, Maryland
| | - Navneet Majhail
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Miguel-Angel Perales
- Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mohamad Mohty
- Saint Antoine Hospital, INSERM UMR 938, Université Pierre et Marie Curie, TC, Paris, France; EBMT Paris Study Office, Paris, France
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul A Carpenter
- Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington
| | - Arnon Nagler
- EBMT Paris Study Office, Paris, France; Chaim Sheba Medical Center, Tel Hashomer, Israel
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21
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Abstract
PURPOSE OF REVIEW Rearrangements of the histone lysine [K]-MethylTransferase 2A gene (KMT2A) gene on chromosome 11q23, formerly known as the mixed-lineage leukemia (MLL) gene, are found in 10% and 5% of adult and children ALL cases, respectively. The most common translocated genes are AFF1 (formerly AF4), MLLT3 (formerly AF9), and MLLT1 (formerly ENL). The bimodal incidence of MLL-r-ALL usually peaks in infants in their first 2 years of life and then declines thereafter during the pediatric/young adult phase until it increases again with age. MLL-rearranged ALL (MLL-r-ALL) is characterized by hyperleukocytosis, aggressive behavior with early relapse, relatively high incidence of central nervous system (CNS) involvement, and poor prognosis. RECENT FINDINGS MLL-r-ALL cells are characterized by relative resistance to corticosteroids (due to Src kinase-induced phosphorylation of annexin A2) and L-asparaginase therapy, but they are sensitive to cytarabine chemotherapy (due to increased levels of hENT1 expression). Potential therapeutic targets include FLT3 inhibitors, MEK inhibitors, HDAC inhibitors, BCL-2 inhibitors, MCL-1 inhibitors, proteasome inhibitors, hypomethylating agents, Dot1L inhibitors, and CDK inhibitors. In this review, we discuss MLL-r-ALL focusing on clinical presentation, risk stratification, drug resistance, and treatment strategies, including potential novel therapeutic targets.
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Affiliation(s)
- Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Michael Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Karen K Ballen
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA.
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22
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Li AY, Kashanian SM, Hambley BC, Zacholski K, Baer MR, Duong VH, El Chaer F, Holtzman NG, Norsworthy KJ, Levis MJ, Smith BD, Kamangar F, Ghiaur G, Emadi A. Clustered incidence of adult acute promyelocytic leukemia in the vicinity of Baltimore. Leuk Lymphoma 2020; 61:2743-2747. [PMID: 32536282 DOI: 10.1080/10428194.2020.1775209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Andrew Y Li
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah M Kashanian
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bryan C Hambley
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Kyle Zacholski
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Vu H Duong
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Firas El Chaer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Noa G Holtzman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Kelly J Norsworthy
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Mark J Levis
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - B Douglas Smith
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Farin Kamangar
- Department of Biology, School of Computer, Mathematical, and Natural Sciences, Morgan State University, Baltimore, MD, USA
| | - Gabriel Ghiaur
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Ashkan Emadi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA.,Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, USA
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23
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El Chaer F, Siegel A, Holtzman NG, Bukhari A, Lutfi F, Shah NG, Yared JA, Rapoport AP, McCurdy MT, Dahiya S. Severe dysautonomia as a manifestation of neurotoxicity after CAR-T cell therapy for diffuse large B-cell lymphoma. Am J Hematol 2020; 95:E146-E148. [PMID: 32233094 DOI: 10.1002/ajh.25794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Ariel Siegel
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Noa G. Holtzman
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Ali Bukhari
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Forat Lutfi
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Nirav G. Shah
- Division of Pulmonary & Critical Care, Department of MedicineUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Jean A. Yared
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Aaron P. Rapoport
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Michael T. McCurdy
- Division of Pulmonary & Critical Care, Department of MedicineUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Saurabh Dahiya
- Division of Hematology and Oncology, Department of Medicine, Greenebaum Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland USA
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24
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El Haddad L, Ariza-Heredia E, Shah DP, Jiang Y, Blanchard T, Ghantoji SS, El Chaer F, El-Haddad D, Prayag A, Nesher L, Rezvani K, Shpall E, Chemaly RF. The Ability of a Cytomegalovirus ELISPOT Assay to Predict Outcome of Low-Level CMV Reactivation in Hematopoietic Cell Transplant Recipients. J Infect Dis 2020; 219:898-907. [PMID: 30295846 DOI: 10.1093/infdis/jiy592] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/04/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infections in hematopoietic cell transplant (HCT) recipients cause substantial morbidity and mortality. CMV cell-mediated immunity (CMV-CMI) can be determined by levels of interferon gamma (IFN-γ) production using an enzyme-linked immunospot (ELISPOT) CMV assay (T-SPOT.CMV assay). In this study, we evaluated the ability of this assay to predict the outcome of low-level CMV reactivation in HCT recipients. METHODS We followed 55 HCT recipients with low-level CMV reactivation up to 8 weeks from enrollment. Progression to clinically significant CMV infection (CS-CMVi) was defined as a CMV load >1000 IU/mL or > 500 IU/mL in patients receiving matched related/autologous or matched unrelated transplants, respectively, and initiation of antiviral treatment. RESULTS Progression to CS-CMVi occurred in 31 (56%) of the HCT recipients. Spot counts of CMV-specific pp65 and IE1 antigens were significantly lower in patients who had CS-CMVi than in patients who did not. On multivariate analysis, the ELISPOT CMV responses and steroids use were the only predictors of progression to CS-CMVi. CONCLUSIONS A strong association between low CMV-CMI and progression to CS-CMVi was observed in HCT recipients. The implementation of serial monitoring of CMV-CMI may identify patients at risk of progression to CS-CMVi that require antiviral therapy.
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Affiliation(s)
- Lynn El Haddad
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Ella Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Dimpy P Shah
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Ted Blanchard
- Oxford Immunotec Incorporation, Marlborough, Massachusetts
| | - Shashank S Ghantoji
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Firas El Chaer
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Danielle El-Haddad
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Amrita Prayag
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Lior Nesher
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Katy Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
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25
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Holtzman NG, El Chaer F, Baer MR, Ali O, Patel A, Duong VH, Sausville EA, Singh ZN, Koka R, Zou YS, Etemadi A, Emadi A. Peripheral blood blast rate of clearance is an independent predictor of clinical response and outcomes in acute myeloid leukaemia. Br J Haematol 2019; 188:881-887. [PMID: 31804722 DOI: 10.1111/bjh.16261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/01/2019] [Indexed: 11/29/2022]
Abstract
The day 14 bone marrow aspirate and biopsy (D14BM) is regularly used to predict achievement of complete remission (CR) with induction chemotherapy in acute myeloid leukemia (AML), however its utility has been questioned. Clearance of peripheral blood blasts (PBB) may serve as an early measure of chemosensitivity. PBB rate of clearance (PBB-RC) was calculated for treatment-naive AML patients (n = 164) undergoing induction with an anthracycline and cytarabine (7+3) and with detectable PBB at diagnosis. PBB-RC was defined as the percentage of the absolute PBB count on the day of diagnosis that was cleared with each day of therapy, on average, until D14 or day of PBB clearance. Each 5% increase in PBB-RC approximately doubled the likelihood of D14BM clearance (OR = 1·81; 95% CI: 1·24-2·64, P < 0·005). PBB-RC was also associated with improved CR rates (OR per 5% = 1·97; 95% CI: 1·27-3·01, P < 0·005) and overall survival (OS) [hazard ratio (HR) per 5% = 0·67; 95% CI: 0·52-0·87]. African American patients had poorer OS adjusted for PBB-RC (HR = 2·18; 95% CI: 1·13-4·23), while race was not associated with D14BM or CR rate. PBB-RC during induction chemotherapy is predictive of D14BM clearance, CR, and OS, and can therefore serve as a prognostic marker for clinical outcomes in AML.
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Affiliation(s)
- Noa G Holtzman
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Firas El Chaer
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Maria R Baer
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Omer Ali
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ameet Patel
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vu H Duong
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Edward A Sausville
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zeba N Singh
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rima Koka
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ying S Zou
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Arash Etemadi
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Ashkan Emadi
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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El Chaer F, Ballen KK. Treatment of acute leukaemia in adult Jehovah's Witnesses. Br J Haematol 2019; 190:696-707. [PMID: 31693175 DOI: 10.1111/bjh.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/18/2019] [Indexed: 01/28/2023]
Abstract
Since Jehovah's Witness (JW) patients diagnosed with leukaemia refuse blood transfusions, they are often denied intensive chemotherapy for fear they could not survive myeloablation without blood transfusion support. Treatment of JW patients with acute leukaemia is challenging and carries a higher morbidity and mortality; however, the refusal of blood products should not be an absolute contraindication to offer multiple treatment modalities including haematopoietic stem cell transplantation. In this review we discuss their optimal management and describe alternative modalities to blood transfusions to provide sufficient oxygenation and prevent bleeding.
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Affiliation(s)
- Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen K Ballen
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Kmeid J, Kulkarni PA, Batista MV, El Chaer F, Prayag A, Ariza-Heredia EJ, Mulanovich VE, Chemaly RF. Active Mycobacterium tuberculosis infection at a comprehensive cancer center, 2006-2014. BMC Infect Dis 2019; 19:934. [PMID: 31694567 PMCID: PMC6836382 DOI: 10.1186/s12879-019-4586-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 10/21/2019] [Indexed: 01/10/2023] Open
Abstract
Background Morbidity and mortality from Mycobacterium tuberculosis (Mtb) infection remain significant in cancer patients. We evaluated clinical characteristics, management, and outcomes in patients with active Mtb infection at our institution who had cancer or suspicion of cancer. Methods We retrospectively examined medical records of all patients with laboratory-confirmed active Mtb infection diagnosed between 2006 and 2014. Results A total of 52 patients with laboratory-confirmed active Mtb infection were identified during the study period, resulting in an average rate of 6 new cases per year. Thirty-two (62%) patients had underlying cancer, while 20 (38%) patients did not have cancer but were referred to the institution because of suspicion of underlying malignancy. Among patients with cancer, 18 (56%) had solid tumors; 8 (25%) had active hematologic malignancies; and 6 (19%) had undergone hematopoietic-cell transplantation (HCT). Patients with and without cancer were overall similar with the exception of median age (61 years in cancer patients compared to 53 years in noncancer patients). Pulmonary disease was identified in 32 (62%) patients, extrapulmonary disease in 10 (19%) patients, and disseminated disease in 10 (19%) patients. Chemotherapy was delayed in 53% of patients who were to receive such treatment. Eleven patients (all of whom had cancer) died; 3 of these deaths were attributable to Mtb infection. Conclusions Although not common, tuberculosis remains an important infection in patients with cancer. Approximately one-third of patients were referred to our institution for suspicion of cancer but were ultimately diagnosed with active Mtb infection rather than malignancy.
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Affiliation(s)
- Joumana Kmeid
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prathit A Kulkarni
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Marjorie V Batista
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Firas El Chaer
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, Baltimore, MD, USA
| | - Amrita Prayag
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ella J Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Victor E Mulanovich
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Bukhari A, El Chaer F, Koka R, Singh Z, Hutnick E, Ruehle K, Lee ST, Kocoglu MH, Shanholtz C, Badros A, Hardy N, Yared J, Rapoport AP, Dahiya S. Rapid relapse of large B-cell lymphoma after CD19 directed CAR-T-cell therapy due to CD-19 antigen loss. Am J Hematol 2019; 94:E273-E275. [PMID: 31342556 DOI: 10.1002/ajh.25591] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/19/2019] [Accepted: 07/20/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Ali Bukhari
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Firas El Chaer
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Rima Koka
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Zeba Singh
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Elizabeth Hutnick
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Kathleen Ruehle
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Seung Tae Lee
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Mehmet H. Kocoglu
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Carl Shanholtz
- Department of MedicineUniversity of Maryland School of Medicine Baltimore Maryland
| | - Ashraf Badros
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Nancy Hardy
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Jean Yared
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Aaron P. Rapoport
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
| | - Saurabh Dahiya
- Department of MedicineUniversity of Maryland School of Medicine and Marlene and Stewart Greenebaum Comprehensive Cancer Center Baltimore Maryland
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Bathini S, Holtzman NG, Koka R, Singh Z, Wilding E, Zou Y, Ruehle K, Kocoglu MH, Badros A, Hardy N, Yared J, Rapoport AP, Fontaine M, Emadi A, El Chaer F, Dahiya S. Refractory postallogeneic stem cell transplant pure red cell aplasia in remission after treatment with daratumumab. Am J Hematol 2019; 94:E216-E219. [PMID: 31120638 DOI: 10.1002/ajh.25515] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/15/2019] [Accepted: 05/21/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Srilakshmi Bathini
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Noa G. Holtzman
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Rima Koka
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Zeba Singh
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Emily Wilding
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Ying Zou
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Kathleen Ruehle
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Mehmet H. Kocoglu
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Ashraf Badros
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Nancy Hardy
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Jean Yared
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Aaron P. Rapoport
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Magali Fontaine
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Ashkan Emadi
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Firas El Chaer
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
| | - Saurabh Dahiya
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer CenterUniversity of Maryland School of Medicine Baltimore Maryland
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Sirous R, Bukhari AA, El Chaer F, Yared J, Hardy NM, Kocoglu MH, Badros AZ, Borogovac A, Hutnick E, Gahres N, Ruehle K, Rapoport A, Saboury B, Dahiya S. Early imaging biomarker assessment to predict long-term responses for large B-cell lymphoma (LBCL) after CAR-T therapy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.7560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7560 Background: Axicabtagene Ciloleucel (Axi-cel), an anti-CD19 CART cell therapy, achieved 58% complete response (CR) rate, in patients with relapsed refractory (r/r) LBCL on the ZUMA-1 study (Neelapu, NEJM 2017). Early response assessment (PET-CT) at day 30 is a common clinical practice. Patients with partial response (PR) at day 30 pose a therapeutic dilemma. ZUMA-1 analysis showed 1/3rd PR patients would convert to a CR. No biomarkers exist to predict eventual response. We report comprehensive PET-CT biomarker analysis on patients with PR at day 30 treated with Axi-cel for r/r LBCL. Methods: Ten patients with PR based on PET-CT imaging at day 30 were retrospectively assessed. Day 30 PET-CT was compared to baseline and a day 90 PET-CT. Global burden of disease of each patient at every time-point were quantified using Total Tumor Glycolysis (TTG) methodology as the imaging biomarker. Using adaptive-thresholding method, each lesion on FDG PET image was segmented and the following parameters were quantified: metabolic-volume (MV), SUVmax, SUVpeak, Partial-Volume-Corrected SUVmean and five other imaging biomarkers. To evaluate the effect of baseline and early imaging biomarkers to predict the subsequent burden of disease multiple regression analysis was performed (STATA 15). Results: Day 90 PET-CT assessment revealed, 4 patients had progressive disease (PD), 4 had CR, and 2 had PR. TTG of patients with PD at day 90 was 900 vs. 29 in patients with non-PD (CR, PR). The Global-SUVmean of the patients with PD at day 90 was 725 vs. 86 in patient with non-PD. Regression analysis showed early-TTG as a significant predictor of subsequent-TTG (beta-coefficient = 1.26 (0.39-2.13); P-value = 0.02; adjusted-R-squared = 0.97), while the baseline-TTG didn’t have any effect on subsequent-TTG (P-value = 0.3). Additionally, the regression analysis didn’t show any significant predictive value in SUVmean and SUVmax of baseline and day 30 scans to predict subsequent burden of disease (TTG or Global-SUVmean) with P-values > 0.8. Conclusions: Early post-axi-cel TTG, rather than baseline, can predict subsequent response to treatment. None of the SUV indices, commonly used in daily practice, were predictive of eventual response.
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Affiliation(s)
- Reza Sirous
- University of Maryland Medical Center, Baltimore, MD
| | | | - Firas El Chaer
- University of Maryland Greenebaum Comprehensive Cancer Center (UMGCCC), Baltimore, MD
| | - Jean Yared
- University of Maryland Greenebaum Comprehensive Cancer Center, Towson, MD
| | | | | | | | | | | | | | - Kathleen Ruehle
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | | | - Babak Saboury
- University of Maryland Medical Center, Baltimore, MD
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31
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El Chaer F, El Sahly HM. Vaccination in the Adult Patient Infected with HIV: A Review of Vaccine Efficacy and Immunogenicity. Am J Med 2019; 132:437-446. [PMID: 30611828 DOI: 10.1016/j.amjmed.2018.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 12/20/2022]
Abstract
Patients infected with HIV remain at increased risk of mortality and morbidity from diseases that are preventable with vaccines partly due to the persisting immunopathology that results in impaired responses to vaccination despite virologic suppression. Because data on clinical effectiveness in patients who are immunocompromised remain limited, undervaccination of individuals with HIV poses a major concern. Multiple societies have published recommendations on vaccination in individuals infected with HIV. Many of these recommendations are based on extrapolation of data from clinical trials that usually exclude patients with HIV, although there is a growing body of data from patients infected with HIV as well. In this review, we describe the available literature on vaccine response in the adult patient with HIV as measured by immunogenicity or vaccine efficacy.
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Affiliation(s)
- Firas El Chaer
- Department of Medicine, University of Maryland School of Medicine, Baltimore; University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore
| | - Hana M El Sahly
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Tx.
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32
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Holtzman NG, Chaer FE, Mohindra P, Badros A, Dahiya S, Hardy NM, Kocoglu MH, Law J, Yared JA, Lee ST, Neelapu SS, Rapoport AP. Relapsed Diffuse Large B-Cell Lymphoma after Allogeneic CAR T-Cell Therapy Successfully Treated with PD1 Inhibition. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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El Chaer F, Holtzman NG, Sausville EA, Law JY, Lee ST, Duong VH, Baer MR, Koka R, Singh ZN, Hardy NM, Emadi A. Relapsed Philadelphia Chromosome-Positive Pre-B-ALL after CD19-Directed CAR-T Cell Therapy Successfully Treated with Combination of Blinatumomab and Ponatinib. Acta Haematol 2019; 141:107-110. [PMID: 30695783 DOI: 10.1159/000495558] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/24/2018] [Indexed: 12/24/2022]
Abstract
Adults with relapsed or refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL) treated with conventional chemotherapy have dismal outcomes. Novel immunotherapies targeting CD19, including the bispecific T-cell engager blinatumomab and chimeric antigen-receptor T (CAR-T) cells, have revolutionized the treatment of R/R B-ALL. Robust response rates to CAR-T cell therapy after blinatumomab have recently been reported, but it is unknown whether blinatumomab can be effective following failure of anti-CD19 CAR-T cell therapy. Herein, we describe a patient with Philadelphia chromosome-positive B-ALL who relapsed after CD19-directed CAR-T therapy, but subsequently responded to the combination of blinatumomab and the tyrosine kinase inhibitor ponatinib, with the achievement of a complete remission lasting 12 months.
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Affiliation(s)
- Firas El Chaer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Noa G Holtzman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Edward A Sausville
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Jennie Y Law
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Seung Tae Lee
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Vu H Duong
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Rima Koka
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zeba N Singh
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nancy M Hardy
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Ashkan Emadi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA,
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34
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El Chaer F, Ali OM, Sausville EA, Law JY, Lee ST, Duong VH, Baer MR, Koka R, Singh ZN, Wong J, Yared JA, Griffiths EA, Emadi A. Treatment of CD19-positive mixed phenotype acute leukemia with blinatumomab. Am J Hematol 2019; 94:E7-E8. [PMID: 30328137 DOI: 10.1002/ajh.25317] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/07/2018] [Accepted: 10/15/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Firas El Chaer
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
| | - Omer M. Ali
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
| | - Edward A. Sausville
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
| | - Jennie Y. Law
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
| | - Seung Tae Lee
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
| | - Vu H. Duong
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
| | - Maria R. Baer
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
| | - Rima Koka
- Departments of Pathology; University of Maryland School of Medicine; Baltimore Maryland
| | - Zeba N. Singh
- Departments of Pathology; University of Maryland School of Medicine; Baltimore Maryland
| | - Jerry Wong
- Department of Pathology; Roswell Park Comprehensive Cancer Center; Buffalo New York
| | - Jean A. Yared
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
| | | | - Ashkan Emadi
- Departments of Medicine; University of Maryland School of Medicine; Baltimore Maryland
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore; Baltimore Maryland
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Artau A, Aitken SL, Batista M, Chaer FE, Prayag A, Haddad LE, Mulanovich V, Ariza-Heredia E, Chemaly R. 1561. Outcomes of Resistant or Refractory CMV Infection in Recipients of Allogeneic Hematopoietic Cell Transplant. Open Forum Infect Dis 2018. [PMCID: PMC6252448 DOI: 10.1093/ofid/ofy210.1389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Resistant or refractory CMV infections are not well defined and may be associated with high morbidity and mortality in allogeneic hematopoietic cell transplant (allo-HCT) recipients. Suspicion of resistant CMV infections is usually based on suboptimal responses to antiviral agents. Methods We performed a single-center retrospective chart review (January 2010 to September 2017) of Allo-HCT recipients who had CMV genotypic testing performed for suspected antiviral resistance. Based on the results, we categorized patients as either having refractory CMV (defined as CMV viremia that fails to decrease after at least 2 weeks of appropriately dosed and delivered antiviral therapy; and in the absence of known genetic mutations to the available antiviral agents) or resistant CMV infection (defined as refractory infection with identification of genetic mutations in the UL97 and/or UL54 genes correlating with in vitro antiviral resistance). Primary outcome was all-cause mortality. Results CMV genotypic resistance analysis was performed in 97 patients. Of those, 23 had resistant (11 had UL54 gene, 10 had UL97 gene, and two had both UL54 and 97) and 74 had refractory CMV infections. The majority of patients had AML (53%), underwent matched unrelated donor transplantation (43%), and received ATG during conditioning (64%). Patients with resistant CMV infections had a greater number of prior episodes when compared with those with refractory infections and had a longer time from transplant to suspicion of resistance (P < 0.01; each). Overall, the incidence of CMV disease was 41% (25% vs. 58% affecting the lungs and 56% vs. 17% the GI tract, in resistant vs. refractory infections, respectively). All-cause mortality was 57% (61% resistant vs. 55% refractory) and CMV-attributable mortality was 11% (9% resistant vs. 12% refractory). Conclusion Our data showed that resistant CMV infections are associated with a higher rate of CMV disease. However, both resistant and refractory CMV infections had increased all-cause mortality and similar CMV-attributable mortality. There was no difference in outcomes between allo-HCT recipients who had resistant or refractory CMV infections. New treatment strategies for resistant or refractory CMV infections are needed. Disclosures S. L. Aitken, Merck: Speaker’s Bureau, Consulting fee. E. Ariza-Heredia, Oxford Immunotec: Grant Investigator, Research grant. R. Chemaly, Merck: Consultant, Research grant; Chimerix: Consultant, Research grant; Novartis: Investigator, Research grant; Oxford Immunotec: Consultant, Research grant.
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Affiliation(s)
- Annette Artau
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marjorie Batista
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas El Chaer
- University of Maryland Greenebaum Cancer Center, Baltimore, Maryland
| | - Amrita Prayag
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lynn El Haddad
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Roy Chemaly
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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Kulkarni P, Kmeid J, Batista M, El Chaer F, Ariza-Heredia E, Graviss EA, Mulanovich VE, Chemaly RF. 789. Comparison of Interferon-γ Release Assays (IGRAs) for Diagnosis of Latent or Active Tuberculosis in Cancer Patients. Open Forum Infect Dis 2018. [PMCID: PMC6254052 DOI: 10.1093/ofid/ofy210.796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Patients with certain types of cancer are at increased risk for progression from latent tuberculosis infection (LTBI) to active tuberculosis (ATB) because of immunosuppression. The purpose of this study was to compare the utility of the two commonly used IGRAs, QuantiFERON-TB Gold® (QFT) and T-spot.TB® (T-spot.TB), for diagnosis of LTBI or ATB in cancer patients. Methods We identified patients who had an initial IGRA during 2013 and 2014 at our institution. Along with demographic information, collected clinical data included type of underlying cancer or other condition, reason for testing, diagnosis of ATB following testing, and absolute lymphocyte count (ALC) at the time of testing. IGRA results (positive, negative, borderline, or indeterminate/invalid) were compared between patients who underwent testing with either QFT or T-spot.TB. Results A total of 356 patients had 411 QFT tests done, while 737 patients had 853 T-spot.TB tests performed. The most common underlying malignancies in the QFT and T-spot.TB groups were acute myeloid leukemia (30% and 25%, respectively) and solid tumors (28% vs. 30%, respectively). The most common reasons for testing were pre-hematopoietic-cell transplantation (HCT) screening (42% with QFT and 31% with T spot.TB) or suspected pulmonary ATB (34% with QFT and 42% with T spot.TB). In the QFT group, 145/411 (35%) tests were indeterminate, while only 96/853 (11%) tests in the T-spot.TB group were invalid (P <0.001). The median ALC was 650 cells/µL in patients with an indeterminate result in the QFT group and 90 cells/µL in patients with an invalid test in the T-spot.TB group. A total of four patients were diagnosed with ATB at 1 year after testing. Figure 1 provides a flowchart describing IGRA testing results and development of ATB. Conclusion The frequency of an inconclusive test result is significantly higher with QFT as compared with T-spot.TB for diagnosis of LTBI or ATB in cancer patients. A low ALC is likely a contributing factor in indeterminate QFT and invalid T spot.TBresults. ![]()
Disclosures E. Ariza-Heredia, Oxford Immunotec: Grant Investigator, Research grant. R. F. Chemaly, Oxford Immunotec: Consultant and Grant Investigator, Research grant.
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Affiliation(s)
- Prathit Kulkarni
- Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, Houston, Texas
| | - Joumana Kmeid
- Infectious Diseases, MD Anderson Cancer Center, Houston, Texas
| | - Marjorie Batista
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas El Chaer
- University of Maryland Greenebaum Cancer Center, Baltimore, Maryland
| | | | | | - Victor E Mulanovich
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
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37
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Singh ZN, Duong VH, Koka R, Zou Y, Sawhney S, Tang L, Baer MR, Ambulos N, El Chaer F, Emadi A. High-Risk Acute Promyelocytic Leukemia with Unusual T/Myeloid Immunophenotype Successfully Treated with ATRA and Arsenic Trioxide-Based Regimen. J Hematop 2018; 11:67-74. [PMID: 30294391 DOI: 10.1007/s12308-018-0329-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We describe two patients with acute promyelocytic leukemia (APL) with an unusual immunophenotype with co-expression of myeloperoxidase (MPO) with cytoplasmic CD3 (cCD3) representing myeloid and T-lineage differentiation. Both harbored FLT3-ITD mutations. One additionally had a deletion in the PML gene affecting the primer binding site, thus limiting measurable residual disease (MRD) analysis during follow-up. Both patients achieved durable remission with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO)-based therapy, thus mitigating the need for repetitive conventional chemotherapy cycles and allogeneic stem cell transplantation. Our report highlights the complexity and challenge of diagnosis and management of APL due to the variant immunophenotype and genetics, and underscores the importance of synthesizing information from all testing modalities. The association of the unusual immunophenotype and FLT3-ITD mutation illustrates the plasticity of the hematopoietic stem cell and the pathobiology of leukemia with mixed lineage or lineage infidelity.
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Affiliation(s)
- Zeba N Singh
- Department of Pathology, University of Maryland School of Medicine
| | - Vu H Duong
- Department of Medicine, University of Maryland School of Medicine.,University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, MD, USA
| | - Rima Koka
- Department of Pathology, University of Maryland School of Medicine
| | - Ying Zou
- Department of Pathology, University of Maryland School of Medicine
| | - Sameer Sawhney
- Department of Pathology, University of Maryland School of Medicine
| | - Li Tang
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, MD, USA
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine.,University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, MD, USA
| | - Nicholas Ambulos
- University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, MD, USA
| | - Firas El Chaer
- Department of Medicine, University of Maryland School of Medicine.,University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, MD, USA
| | - Ashkan Emadi
- Department of Medicine, University of Maryland School of Medicine.,Department of Pharmacology, University of Maryland School of Medicine.,University of Maryland Greenebaum Comprehensive Cancer Center Baltimore, MD, USA
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El Chaer F, Singh ZN, Zou Y, Mohindra P, Baer MR, Law JY. Acute Onset Unilateral Proptosis. Am J Med 2018; 131:e337-e338. [PMID: 29660350 DOI: 10.1016/j.amjmed.2018.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Firas El Chaer
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore; Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Zeba N Singh
- Department of Pathology, University of Maryland School of Medicine, Baltimore
| | - Ying Zou
- Department of Pathology, University of Maryland School of Medicine, Baltimore
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore
| | - Maria R Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore; Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Jennie Y Law
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore; Department of Medicine, University of Maryland School of Medicine, Baltimore.
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39
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Singh ZN, Richards S, El Chaer F, Duong VH, Gudipati MA, Waters EO, Koon S, Webley M, Pitel B, Hoppman NL, Baer MR, Zou YS. Cryptic ETV6–PDGFRB fusion in a highly complex rearrangement of chromosomes 1, 5, and 12 due to a chromothripsis-like event in a myelodysplastic syndrome/myeloproliferative neoplasm. Leuk Lymphoma 2018; 60:1304-1307. [DOI: 10.1080/10428194.2018.1480774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Zeba N. Singh
- Department of Pathology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Stephanie Richards
- Department of Pathology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Firas El Chaer
- Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Vu H. Duong
- Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Mary A. Gudipati
- Department of Pathology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Elizabeth O. Waters
- Department of Pathology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Sarah Koon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Matthew Webley
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Beth Pitel
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Nicole L. Hoppman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Maria R. Baer
- Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Ying S. Zou
- Department of Pathology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
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40
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El Chaer F, Holtzman NG, Baer MR, Zimrin AB, Law JY. Sickle Cell Disease Complicated by Iron Overload: An Under-Recognized Risk Factor for Vibrio vulnificus Infection. Acta Haematol 2018; 139:199-200. [PMID: 29734168 DOI: 10.1159/000488754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/24/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Firas El Chaer
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Noa G Holtzman
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Maria R Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ann B Zimrin
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennie Y Law
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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41
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McCusker MG, El Chaer F, Duffy A, Emadi A, Duong VH. Combination of Blinatumomab and Vincristine Sulfate Liposome Injection for Treatment of Relapsed Philadelphia Chromosome Positive B-cell Acute Lymphoblastic Leukemia. Am J Leuk Res 2018; 2:1010. [PMID: 29953129 PMCID: PMC6018018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Relapsed Philadelphia chromosome (Ph) positive Acute Lymphoblastic Leukemia (ALL) is an aggressive lymphoid malignancy with a poor prognosis and no randomized studies demonstrating superiority of any single salvage regimen. We present the case of a 33-year-old woman with relapsed Ph positive precursor (pre) B-cell ALL with rapidly rising peripheral blasts while on blinatumomab monotherapy initially, but ultimately responded with the addition of Vincristine Sulfate Liposome Injection (VSLI). Ponatinib was added later when it became available for the patient, and she ultimately achieved a complete remission. Further study is warranted to explore mechanisms of potential synergy, and the safety and efficacy of the combination of blinatumomab and VSLI.
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Affiliation(s)
| | | | - Alison Duffy
- University of Maryland School of Medicine, USA
- University of Maryland School of Pharmacy, USA
| | | | - Vu H. Duong
- University of Maryland School of Medicine, USA
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42
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Artau A, Aitken SL, El Chaer F, Prayag A, El Haddad L, Mulanovich VE, Shah DP, Ariza-Heredia EJ, Chemaly RF. Outcomes of Resistant or Refractory CMV Infection in Recipients of Allogeneic Hematopoietic Cell Transplant. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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43
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Royse KE, El Chaer F, Amirian ES, Hartman C, Krown SE, Uldrick TS, Lee JY, Shepard Z, Chiao EY. Disparities in Kaposi sarcoma incidence and survival in the United States: 2000-2013. PLoS One 2017; 12:e0182750. [PMID: 28829790 PMCID: PMC5567503 DOI: 10.1371/journal.pone.0182750] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/23/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Geographic and racial disparities may contribute to variation in the incidence and outcomes of HIV-associated cancers in the United States. METHOD Using the Surveillance, Epidemiology, and End Results (SEER) database, we analyzed Kaposi sarcoma (KS) incidence and survival by race and geographic region during the combined antiretroviral therapy era. Reported cases of KS in men from 2000 to 2013 were obtained from 17 SEER cancer registries. Overall and age-standardized KS incidence rates were calculated and stratified by race and geographic region. We evaluated incidence trends using joinpoint analyses and calculated adjusted hazard ratios (aHR) for overall and KS-specific mortality using multivariable Cox proportional hazards models. RESULTS Of 4,455 KS cases identified in men younger than 55 years (median age 40 years), the annual percent change (APC) for KS incidence significantly decreased for white men between 2001 and 2013 (APC -4.52, p = 0.02). The APC for AA men demonstrated a non-significant decrease from 2000-2013 (APC -1.84, p = 0.09). Among AA men in the South, however, APC has significantly increased between 2000 and 2013 (+3.0, p = 0.03). In addition, compared with white men diagnosed with KS during the same time period, AA men were also more likely to die from all causes and KS cancer-specific causes (aHR 1.52, 95% CI 1.34-1.72, aHR 1.49, 95% CI 1.30-1.72 respectively). CONCLUSION Although overall KS incidence has decreased in the U.S., geographic and racial disparities in KS incidence and survival exist.
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Affiliation(s)
- Kathryn E. Royse
- Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
| | - Firas El Chaer
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - E. Susan Amirian
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
| | - Christine Hartman
- Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
| | - Susan E. Krown
- AIDS Malignancy Consortium, New York, New York, United States of America
| | - Thomas S. Uldrick
- HIV and AIDS Malignancy Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Jeannette Y. Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Zachary Shepard
- Department of Undergraduate Education, Baylor College of Medicine, Houston, Texas, United States of America
| | - Elizabeth Y. Chiao
- Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States of America
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El Chaer F, Shah DP, Kmeid J, Ariza-Heredia EJ, Hosing CM, Mulanovich VE, Chemaly RF. Burden of human metapneumovirus infections in patients with cancer: Risk factors and outcomes. Cancer 2017; 123:2329-2337. [PMID: 28178369 PMCID: PMC5459658 DOI: 10.1002/cncr.30599] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 12/27/2016] [Accepted: 01/06/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Human metapneumovirus (hMPV) causes upper and lower respiratory tract infections (URIs and LRIs, respectively) in healthy and immunocompromised patients; however, its clinical burden in patients with cancer remains unknown. METHODS In a retrospective study of all laboratory‐confirmed hMPV infections treated at the authors’ institution between April 2012 and May 2015, clinical characteristics, risk factors for progression to an LRI, treatment, and outcomes in patients with cancer were determined. RESULTS In total, 181 hMPV infections were identified in 90 patients (50%) with hematologic malignancies (HMs), in 57 (31%) hematopoietic cell transplantation (HCT) recipients, and in 34 patients (19%) with solid tumors. Most patients (92%) had a community‐acquired infection and presented with URIs (67%), and 43% developed LRIs (59 presented with LRIs and 19 progressed from a URI to an LRI). On multivariable analysis, an underlying HM (adjusted odds ratio [aOR], 3.11; 95% confidence interval [CI], 1.12‐8.64; P = .029), nosocomial infection (aOR, 26.9; 95% CI, 2.79‐259.75; P = .004), and hypoxia (oxygen saturation [SpO2], ≤ 92%) at presentation (aOR, 9.61; 95% CI, 1.98‐46.57; P = .005) were identified as independent factors associated with LRI. All‐cause mortality at 30 days from hMPV diagnosis was low (4%), and patients with LRIs had a 10% mortality rate at day 30 from diagnosis; whereas patients with URIs had a 0% mortality rate. CONCLUSIONS hMPV infections in patients with cancer may cause significant morbidity, especially for those with underlying HM who may develop an LRI. Despite high morbidity and the lack of directed antiviral therapy for hMPV infections, mortality at day 30 from this infection remained low in this studied population. Cancer 2017;123:2329–2337. © 2017 American Cancer Society. Human metapneumovirus infections in patients with cancer may cause significant morbidity, especially in those with underlying hematologic malignancies who may develop a lower respiratory infection. Despite high morbidity and the lack of directed antiviral therapy for human metapneumovirus infections, mortality from this infection at day 30 and day 90 remains low in the studied population.
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Affiliation(s)
- Firas El Chaer
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dimpy P Shah
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joumana Kmeid
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ella J Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra M Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor E Mulanovich
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Shah D, Ariza-Heredia E, Chaer FE, Haddad LE, El-Haddad D, Prayag A, Nesher L, Rezvani K, Shpall E, Chemaly RF. The ability of CMV–specific ELISPOT assay to predict outcome of low level CMV reactivation in hematopoietic cell transplant recipients. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Dimpy Shah
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ella Ariza-Heredia
- Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas El Chaer
- Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Lynn El Haddad
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Danielle El-Haddad
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amrita Prayag
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lior Nesher
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel
| | - Katy Rezvani
- Stem Cell Transplantation, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth Shpall
- Stem Cell Transplantation, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy F. Chemaly
- Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas
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Taremi M, Shah D, El-Haddad D, Chaer FE, Haddad LE, Prayag A, Rondon G, Hosing C, Ariza-Heredia E, Chemaly RF. Rhinovirus Infections (RhVI) in 233 Hematopoietic Cell Transplant (HCT) Recipients: A Single Center Experience. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mahnaz Taremi
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dimpy Shah
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Danielle El-Haddad
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas El Chaer
- Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Lynn El Haddad
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amrita Prayag
- Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Stem Cell Transplantation Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Stem Cell Transplantation Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ella Ariza-Heredia
- Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy F. Chemaly
- Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas
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47
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El-Haddad D, El Chaer F, Vanichanan J, Shah DP, Ariza-Heredia EJ, Mulanovich VE, Gulbis AM, Shpall EJ, Chemaly RF. Brincidofovir (CMX-001) for refractory and resistant CMV and HSV infections in immunocompromised cancer patients: A single-center experience. Antiviral Res 2016; 134:58-62. [DOI: 10.1016/j.antiviral.2016.08.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/23/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
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48
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El Chaer F, Mori N, Shah D, Oliver N, Wang E, Jan A, Doan V, Tverdek F, Tayar J, Ariza-Heredia E, Chemaly RF. Adjuvant and salvage therapy with leflunomide for recalcitrant cytomegalovirus infections in hematopoietic cell transplantation recipients: A case series. Antiviral Res 2016; 135:91-96. [PMID: 27594527 DOI: 10.1016/j.antiviral.2016.08.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/07/2016] [Accepted: 08/08/2016] [Indexed: 10/21/2022]
Abstract
Cytomegalovirus (CMV) reactivation is a clinically significant complication in hematopoietic stem cell transplant (HCT) recipients. Alternative therapy for multidrug-resistant CMV is limited and often fails. Leflunomide has been used to treat resistant CMV infections, however, data on efficacy, safety, and guidance for therapeutic drug level monitoring are lacking. In this report, we describe 3 HCT recipients with multi-drug resistant CMV infections who received leflunomide as adjuvant and salvage therapy. The therapeutic effect of leflunomide as an anti-CMV agent based on virologic responses and therapeutic drug monitoring were evaluated.
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Affiliation(s)
- Firas El Chaer
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Internal Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Nobuyoshi Mori
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dimpy Shah
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nora Oliver
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Wang
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anna Jan
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vi Doan
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frank Tverdek
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean Tayar
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ella Ariza-Heredia
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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49
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El Chaer F, Amirian ES, Hartman C, Chiao E. Disparities in AIDS-related Kaposi sarcoma incidence and survival. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e18072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Christine Hartman
- Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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50
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Shah DP, Ghantoji SS, Azzi J, Avadhanula V, Kmeid J, El Chaer F, Ariza-Heredia EJ, Shah N, Mulanovich VE, Hosing C, Piedra PA, Chemaly RF. An Open Label, Block-Randomized, Ribavirin Efficacy Trial for Management of RSV Infections in Hematopoietic Cell Transplant (HCT) Recipients: Clinical and Economic Implications. Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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