Mutations in the alternative complement pathway in multiple myeloma patients with carfilzomib-induced thrombotic microangiopathy

Thrombotic microangiopathy (TMA) has been reported to occur in multiple myeloma (MM) patients in association with treatment with carfilzomib, an irreversible proteasome inhibitor (PI). The hallmark of TMA is vascular endothelial damage leading to microangiopathic hemolytic anemia, platelet consumption, fibrin deposition and small-vessel thrombosis with resultant tissue ischemia. The molecular mechanisms underlying carfilzomib-associated TMA are not known. Germline mutations in the complement alternative pathway have been recently shown to portend increased risk for the development of atypical hemolytic uremic syndrome (aHUS) and TMA in the setting of allogeneic stem cell transplant in pediatric patients. We hypothesized that germline mutations in the complement alternative pathway may similarly predispose MM patients to carfilzomib-associated TMA. We identified 10 MM patients with a clinical diagnosis of TMA in the context of carfilzomib treatment and assessed for the presence of germline mutations in the complement alternative pathway. Ten, matched MM patients exposed to carfilzomib but without clinical TMA were used as negative controls. We identified a frequency of deletions in the complement Factor H genes 3 and 1 (delCFHR3-CFHR1) and genes 1 and 4 (delCFHR1-CFHR4) in MM patients with carfilzomib-associated TMA that was higher as compared to the general population and matched controls. Our data suggest that complement alternative pathway dysregulation may confer susceptibility to vascular endothelial injury in MM patients and predispose to development of carfilzomib-associated TMA. Larger, retrospective studies are needed to evaluate whether screening for complement mutations may be indicated to properly counsel patients about TMA risk with carfilzomib use.

Outcomes of Immune Checkpoint Inhibitor Administration in Hospitalized Patients With Solid Tumor Malignancies

PURPOSE

More oncologists desire to treat their patients with immune checkpoint inhibitors (ICIs) in the inpatient setting as their use has become more widespread for numerous oncologic indications. This is cost-prohibitive to patients and institutions because of high drug cost and lack of reimbursement in the inpatient setting. We sought to examine current practice of inpatient ICI administration to determine if and in which clinical scenarios it may provide significant clinical benefit and therefore be warranted regardless of cost.

METHODS

We conducted a retrospective chart review of adult patients who received at least one dose of an ICI for treatment of an active solid tumor malignancy during hospitalization at a single academic medical center between January 2017 and June 2018. Patient, disease, and admission characteristics including mortality data were examined, and cost analysis was performed.

RESULTS

Sixty-five doses of ICIs were administered to 58 patients during the study period. Nearly 40% and 80% of patients died within 30 days and 180 days of ICI administration, respectively. There was a trend toward longer overall survival in patients with good prognostic factors including positive programmed death-ligand 1 (PD-L1) expression or microsatellite instability-high (MSI-H) status. Slightly over 70% of patients were discharged within 7 days of ICI administration. The total cost of inpatient ICI administration over the 18-month study period was $615,016 US dollars.

CONCLUSION

Inpatient ICI administration is associated with high costs and poor outcomes in acutely ill hospitalized patients with advanced solid tumor malignancies and therefore should largely be avoided. Careful discharge planning to expedite outpatient treatment after discharge will be paramount in ensuring patients with good prognostic features who will benefit most from ICI therapy can be promptly treated in the outpatient setting as treating very close to discharge in the inpatient setting appears to be unnecessary, regardless of tumor features.

Evaluation of clinical use of intravenous iron: Utilization, efficacy, and safety in the management of cancer and chemotherapy-induced anemia in GI oncology

359

Background: National Comprehensive Cancer Network recommends intravenous (IV) iron therapy for management of cancer and chemotherapy induced anemia without mentioning agent preference. Currently at Dana-Farber Cancer Institute (DFCI), all IV iron formulations can be utilized in management of iron deficiency anemia. This study was performed to evaluate the utilization, efficacy, and safety of IV iron formulations in management of cancer and chemotherapy induced iron deficiency anemia in patients with gastrointestinal (GI) cancer. Methods: Retrospective chart review was performed on DFCI patients with GI cancer undergoing palliative or adjuvant chemotherapy who received ferric gluconate, ferumoxytol, or iron sucrose between January 2021 and January 2022. Patients were identified using electronic medical record reports. Data was collected on cancer diagnosis, chemotherapy regimen, total IV iron dose and frequency, infusion reactions, laboratory values including hemoglobin, mean corpuscular volume (MCV), and iron status parameters (serum iron, ferritin, transferrin, iron-binding capacity, transferrin saturation) at baseline and 4-6 weeks after the last dose. The primary outcome was to assess the utilization of different IV iron formulations. Secondary outcomes were efficacy defined as mean absolute change from baseline in Hemoglobin levels and safety defined as incidence of hypersensitivity reactions. Results: 102 patients were evaluated of which 61 received ferumoxytol, 36 ferric gluconate and 5 iron sucrose. All patients had baseline hemoglobin (≤11 g/dL) and MCV collected. 89 patients had baseline iron status parameters (serum iron, ferritin, transferrin, iron-binding capacity, transferrin saturation). Most patients (N = 70) had diagnosis of colorectal cancer and received chemotherapy every 2 weeks. All patients received recommend total dose of IV iron on days of chemotherapy which was outside the recommended schedule of the IV iron formulations. A gradual increase in Hemoglobin concentrations in patients treated with IV iron was observed. Conclusions: Ferumoxytol and Ferric Gluconate were the most utilized IV iron formulation at DFCI GI oncology patients. All patients received recommended IV iron dosing but did not follow the recommended schedule. All patients had hemoglobin and MCV checked before each IV iron therapy. IV iron therapy was well tolerated and effective in treatment of iron-deficiency anemia in patients with gastrointestinal cancer undergoing chemotherapy.[Table: see text]

B-PRISM (Precision Intervention Smoldering Myeloma): A phase II trial of combination of daratumumab, bortezomib, lenalidomide, and dexamethasone in high-risk smoldering multiple myeloma

8040

Background: Early therapeutic intervention with lenalidomide has shown to be effective in delaying progression in patients with high-risk smoldering multiple myeloma (HR-SMM) (Lonial J Clin Oncol 2020). Quadruplet regimen of daratumumab, bortezomib, lenalidomide and dexamethasone (D-RVD) has demonstrated significant activity in multiple myeloma, achieving high rates of minimal residual disease (MRD) negativity (Voorhees Blood 2020). Thus, we proposed to examine the activity and safety of D-RVD in patients with HR-SMM. Methods: This is a phase II single center, single-arm, open label study evaluating the combination of D-RVD in HR-SMM. Eligibility included high risk per Mayo 2018 “20-2-20” model and other previously established criteria including Mayo 2008 criteria, presence of immunoparesis, evolving type of SMM, and high risk FISH. Primary objective is rate of sustained MRD negativity at 2 years. Secondary objectives include PFS, response rates and safety. Treatment duration with modified D-RVD is for total of 2 years (24 cycles). Daratumumab is administered subcutaneously (SQ) per standard dose and schedule, bortezomib given weekly on days 1, 8, 15 for cycles 1-6 and then biweekly until completion of cycle 24. Lenalidomide is administered on days 1-21 and dexamethasone is administered weekly. All eligible patients will undergo stem cell collection after 6 cycles of therapy. Results: At the time of data cut off, 20 patients have been enrolled with a median follow up of 6 months. The median age is 58 years old (range 40-73). Sixteen out of 20 (80%) patients met high risk criteria per Mayo 2018 model with median plasmacytosis of 20%, median M protein value of 2.6 g/dl and median FLC ratio of 28.2. Seven patients had high-risk FISH: 5 with 1q duplication, 2 with t(4;14). Most common toxicities of any grade included neutropenia (65%), WBC decreased (55%) insomnia (50%), constipation (45%) and hypophosphatemia (45%). Most common grade 3 toxicities included neutropenia (15%), ALT increased (5%), thrombocytopenia (5%), hyperglycemia (5%), hypertension (5%), diarrhea (5%), syncope (5%). No patients discontinued therapy due to toxicity. The overall response rate is 90% with 40% PR, 25% VGPR and 25% CR. All patients have achieved at least a MR and 50% achieved VGPR or greater with responses deepening over time. No patients have progressed on treatment. MRD was evaluable in 16 patients and 8 patients have undergone MRD testing, with MRD negativity rate of 50% (4/8) and 25% (2/8) at thresholds of 10-5 and 10-6, respectively. Stem cells were successfully collected in all patients with mean stem cell yield of 5.78 x 106 CD34+/kg cells. Conclusions: D-RVD is well tolerated in patients with HR-SMM demonstrating significant early activity. Responses continue to deepen over time with patients achieving MRD negative disease. Clinical trial information: NCT04775550.

Prevalence of monoclonal gammopathies and clinical outcomes in a high-risk US population screened by mass spectrometry: a multicentre cohort study

BACKGROUND

Prevalence estimates for monoclonal gammopathy of undetermined significance (MGUS) are based on predominantly White study populations screened by serum protein electrophoresis supplemented with immunofixation electrophoresis. A prevalence of 3% is reported for MGUS in the general population of European ancestry aged 50 years or older. MGUS prevalence is two times higher in individuals of African descent or with a family history of conditions related to multiple myeloma. We aimed to evaluate the prevalence and clinical implications of monoclonal gammopathies in a high-risk US population screened by quantitative mass spectrometry.

METHODS

We used quantitative matrix-assisted laser desorption ionisation-time of flight (MALDI-TOF) mass spectrometry and EXENT-iQ software to screen for and quantify monoclonal gammopathies in serum from 7622 individuals who consented to the PROMISE screening study between Feb 26, 2019, and Nov 4, 2021, and the Mass General Brigham Biobank (MGBB) between July 28, 2010, and July 1, 2021. M-protein concentrations at the monoclonal gammopathy of indeterminate potential (MGIP) level were confirmed by liquid chromatography mass spectrometry testing. 6305 (83%; 2211 from PROMISE, 4094 from MGBB) of 7622 participants in the cohorts were at high risk for developing a monoclonal gammopathy on the basis of Black race or a family history of haematological malignancies and fell within the eligible high-risk age range (30 years or older for PROMISE cohort and 18 years or older for MGBB cohort); those over 18 years were also eligible if they had two or more family members with a blood cancer (PROMISE cohort). Participants with a plasma cell malignancy diagnosed before screening were excluded. Longitudinal clinical data were available for MGBB participants with a median follow-up time from serum sample screening of 4·5 years (IQR 2·4-6·7). The PROMISE study is registered with ClinicalTrials.gov, NCT03689595.

FINDINGS

The median age at time of screening was 56·0 years (IQR 46·8-64·1). 5013 (66%) of 7622 participants were female, 2570 (34%) male, and 39 (<1%) unknown. 2439 (32%) self-identified as Black, 4986 (65%) as White, 119 (2%) as other, and 78 (1%) unknown. Using serum protein electrophoresis with immunofixation electrophoresis, the MGUS prevalence was 6% (101 of 1714) in high-risk individuals aged 50 years or older. Using mass spectrometry, we observed a total prevalence of monoclonal gammopathies of 43% (1788 of 4207) in this group. We termed monoclonal gammopathies below the clinical immunofixation electrophoresis detection level (<0·2 g/L) MGIPs, to differentiate them from those with higher concentrations, termed mass-spectrometry MGUS, which had a 13% (592 of 4207) prevalence by mass spectrometry in high-risk individuals aged 50 years or older. MGIP was predominantly of immunoglobulin M isotype, and its prevalence increased with age (19% [488 of 2564] for individuals aged <50 years, 29% [1464 of 5058] for those aged ≥50 years, and 37% [347 of 946] for those aged ≥70 years). Mass-spectrometry MGUS prevalence increased with age (5% [127 of 2564] for individuals aged <50 years, 13% [678 of 5058] for those aged ≥50 years, and 18% [173 of 946] for those aged ≥70 years) and was higher in men (314 [12%] of 2570) compared with women (485 [10%] 5013; p=0·0002), whereas MGIP prevalence did not differ significantly by gender. In those aged 50 years or older, the prevalence of mass spectrometry was significantly higher in Black participants (224 [17%] of 1356) compared with the controls (p=0·0012) but not in those with family history (368 [13%] of 2851) compared with the controls (p=0·1008). Screen-detected monoclonal gammopathies correlated with increased all-cause mortality in MGBB participants (hazard ratio 1·55, 95% CI 1·16-2·08; p=0·0035). All monoclonal gammopathies were associated with an increased likelihood of comorbidities, including myocardial infarction (odds ratio 1·60, 95% CI 1·26-2·02; p=0·00016 for MGIP-high and 1·39, 1·07-1·80; p=0·015 for mass-spectrometry MGUS).

INTERPRETATION

We detected a high prevalence of monoclonal gammopathies, including age-associated MGIP, and made more precise estimates of mass-spectrometry MGUS compared with conventional gel-based methods. The use of mass spectrometry also highlighted the potential hidden clinical significance of MGIP. Our study suggests the association of monoclonal gammopathies with a variety of clinical phenotypes and decreased overall survival.

FUNDING

Stand Up To Cancer Dream Team, the Multiple Myeloma Research Foundation, and National Institutes of Health.

Patient-Centered Diabetes Care of Cancer Patients

PURPOSE OF REVIEW

There is a bidirectional relationship between cancer and diabetes, with one condition influencing the prognosis of the other. Multiple cancer therapies cause diabetes including well-established medications such as glucocorticoids and novel cancer therapies such as immune checkpoint inhibitors (CPIs) and phosphoinositide 3-kinase (PI3K) inhibitors.

RECENT FINDINGS

The nature and severity of diabetes caused by each therapy differ, with some predominantly mediated by insulin resistance, such as PI3K inhibitors and glucocorticoids, while others by insulin deficiency, such as CPIs. Studies have demonstrated diabetes from CPIs to be more rapidly progressing than conventional type 1 diabetes. There remains a scarcity of published guidance for the screening, diagnosis, and management of hyperglycemia and diabetes from these therapies. The need for such guidance is critical because diabetes management in the cancer patient is complex, individualized, and requires inter-disciplinary care. In the present narrative review, we synthesize and summarize the most relevant literature pertaining to diabetes and hyperglycemia in the setting of these cancer therapies and provide an updated patient-centered framework for their evaluation and management.

Improving rates of venous thromboembolism prophylaxis in multiple myeloma patients on immunomodulatory drugs through a pharmacy-based system

INTRODUCTION

Immunomodulatory drugs used to treat multiple myeloma carry an increased risk of venous thromboembolic (VTE) disease. Previously published guidelines outline consensus opinion on how to mitigate this risk.

METHODS

We collected baseline data to analyze how these strategies are utilized at our single institution and sought to improve the rates of anticoagulation for high-risk patients. This was done through a quality improvement project that added pharmacy/haematology oversight to the VTE risk assessment.

RESULTS

Thirty-nine patients newly started on IMiDs were assessed for VTE risk. This information was passed on to the myeloma provider for consideration. Twenty-two patients were classified as high risk for VTE. Of the high-risk patients, 14 (64%) were placed on an anticoagulant for thromboprophylaxis. Eleven (79%) of the 14 used direct oral anticoagulants (DOACs). Eight high-risk patients did not receive an anticoagulant for thromboprophylaxis; 4 of these developed VTE. No patients on anticoagulation developed a VTE. This strategy had rare minor bleeding complications.

CONCLUSION

This quality action verifies guideline-based thromboprophylaxis in multiple myeloma and supports the benefit of pharmacy oversight in improving VTE rates. The use of DOACs in myeloma should be further explored.

Phase I/II trial of the CXCR4 inhibitor plerixafor in combination with bortezomib as a chemosensitization strategy in relapsed/refractory multiple myeloma

We tested the hypothesis that using CXCR4 inhibition to target the interaction between the tumor cells and the microenvironment leads to sensitization of the tumor cells to apoptosis. Eligibility criteria included multiple myeloma (MM) patients with 1-5 prior lines of therapy. The purposes of the phase I study were to evaluate the safety and maximal-tolerated dose (MTD) of the combination. The treatment-related adverse events and response rate of the combination were assessed in the phase II study. A total of 58 patients were enrolled in the study. The median age of the patients was 63 years (range, 43-85), and 78% of them received prior bortezomib. In the phase I study, the MTD was plerixafor 0.32 mg/kg, and bortezomib 1.3 mg/m² . The overall response rate for the phase II study was 48.5%, and the clinical benefit rate 60.6%. The median disease-free survival was 12.6 months. The CyTOF analysis demonstrated significant mobilization of plasma cells, CD34+ stem cells, and immune T cells in response to plerixafor. This is an unprecedented study that examines therapeutic targeting of the bone marrow microenvironment and its interaction with the tumor clone to overcome resistance to therapy. Our results indicate that this novel combination is safe and that the objective response rate is high even in patients with relapsed/refractory MM. ClinicalTrials.gov, NCT00903968.

Outcomes of immunotherapy administration for hospitalized cancer patients

98

Background: With approvals across multiple cancer types and favorable toxicity profiles, oncologists may consider using immunotherapy (IMT) while their patients are hospitalized. Inpatient IMT may be cost-prohibitive to administer for most institutions due to high cost and inpatient payment structure, but little data are available to evaluate outcomes for IMT in hospitalized patients. We investigated the survival benefit of administering IMT to hospitalized patients with cancer at an NCI-designated cancer center. Methods: We conducted a retrospective chart review of all patients receiving ipilimumab, nivolumab, or pembrolizumab during inpatient admission at Dana-Farber Cancer Institute/Brigham & Women’s Hospital in 2017. For each patient, we assessed: total dose, indication for dosing, cancer type, time between dose and discharge, time between discharge and death, and total cost (average wholesale price). Study follow up was January 1, 2017 to July 1, 2018. Results: Fifty doses of IMT were administered to 44 patients. Most patients (40) received 1 dose, 2 patients received 3 doses, 1 patient received 2 doses, and 1 patient received a combination of ipilimumab/nivolumab. The most common cancer types were lung (41%), gastrointestinal (18%), and head and neck (16%). Indications for IMT administration were: patient due for next dose (48%), disease progression (42%), and new diagnosis (11%). The majority of doses (70%) were received within 7 days prior to discharge, with 32% of doses within 1 day of discharge. The majority of patients (86%) died in the study period; 14% of patients died during admission. Average survival between discharge and death was 54 days (range: 0-444 days). Total cost of inpatient IMT administration was $413,370, an average of $9,395 per patient. Conclusions: To our knowledge, this is the largest analysis of outcomes for patients receiving IMT during a hospitalization. Inpatient use of IMT in cancer patients is associated with high cost and poor clinical outcomes. Dosing within one week prior to hospital discharge was common. Clinical factors such as PD-L1 status, disease status, and reason for admission, which may be important to understand which patients may benefit most from inpatient IMT, should be examined.

Structuring clinical pathways: Creating common language where there is none

303

Background: Clinical pathways (PW) consist of Decision Criteria (DC) such as patient and disease characteristics, prior therapy, and genetic tests. Historical Dana-Farber Pathways (DFP) content was unstructured and maintained in static documents. This could lead to inconsistencies across and within PW, limits to the scope of DFP analytics, and potential discrepancies in clinical content. Methods: To transform DFP content into a digitally innovative structure the DFP team created a hierarchical Data Model (DM). The team compiled all unstructured DC in historical PW, organized them into parameters and attributes, and connected them to external ontologies (e.g., ICDO3) where appropriate. The team then applied the structured DC to historical PW to test comprehensiveness; and addressed any gaps identified in PW and the DM. Results: The DPF DM contains 32 parameters (e.g., Diagnosis) and 218 attributes (e.g., Group Stage) that can be combined to represent all 600+ pathway branch points. The comprehensiveness and nuance of the DM improves DFP’s specificity and clinical flexibility: The DM ensures that DFP gathers actionable data across all PW and creates common language that allows for disease-specific nuances; The DM rectifies gaps in historical PW, such as DC that were not mutually exclusive or conflated multiple clinical parameters; The DM creates complex DC to direct specific sub-groups of patients to the correct treatment path, even in cases where treatment recommendations differ within diagnostic groups. Conclusions: Structuring and standardizing PW content is a complex, time-intensive endeavor. However, this work addresses the challenges of managing clinical content and provides significant benefits for future PW development. A structured DM ensures PW are comprehensive, logical, and built on a framework of inter-operability standardization. A DM also allows DFP to connect with the EMR for auto-navigation, which streamlines provider workflow. The ongoing work required to build and maintain a structured PW DM is worth the result: rich actionable data that can illuminate and standardize practice patterns within and across diseases and institutions. It creates an insightful solution to broadly manage the cancer population.

Maintaining clinical pathways: What does it really take?

305

Background: Building pathways to support clinical decision making is one step, maintaining them is a mountain. Dana-Farber Cancer Institute has built 34 medical oncology (MO) pathways (PWs) and 27 radiation oncology (RO) PWs. These PWs are managed by 28 lead MDs, 8 pharmacists, 6 project managers (PMs), 1 data analyst and 1 coordinator. Once PWs are built, attention shifts to platform and content maintenance. Methods: Maintaining PW clinical and informatics content is complicated and laborious. It requires collaboration amongst clinical and non-clinical experts; these resources form the PW team. PW content is updated quarterly or semi-annually, based on the pace of scientific change in a disease. These review meetings serve as a forum for physicians to review, discuss and revise content. Infrastructure support is provided by the PW team. Supporting the meeting requires a pre-meeting, the formal review meeting, a post meeting, and extensive revisions and content validation along the way. To prepare, PW performance data and emerging relevant evidence is reviewed with the lead MD to establish the meeting agenda. In both MO and RO the PW team is responsible for all content management. Results: We reviewed 6 months of data (2/18-7/18) and analyzed the hours and cost to maintain the pathway portfolio. Conclusions: PW maintenance is costly therefore labor efficiency is critical to overall success. There are 4 strategies for success: building trust; MD engagement; data; and program coordination. The MD/PM relationship is the foundation and consistency is key. MD engagement is crucial; having an influential lead MD sets the tone for the disease center overall. Establishing clear expectations and frequent check-ins keeps the lead MD engaged. Actionable, frequent, and transparent data reports give MDs feedback on their practice patterns. The coordinator is a central point of contact and ensures programmatic execution and success. Though PW maintenance is resource intensive, it facilitates standardized decision-making for the dissemination of cutting-edge cancer care.

[Table: see text]

Outcomes of immunotherapy administration for hospitalized cancer patients

e18225

Background: With approvals across multiple cancer types and favorable toxicity profiles, oncologists may consider using immunotherapy (IMT) while their patients are hospitalized. Inpatient IMT may be cost-prohibitive to administer for most institutions due to high cost and inpatient payment structure, but little data are available to evaluate outcomes for IMT in hospitalized patients. We investigated the survival benefit of administering IMT to hospitalized patients with cancer at an NCI-designated cancer center. Methods: We conducted a retrospective chart review of all patients receiving ipilimumab, nivolumab, or pembrolizumab during inpatient admission at Dana-Farber Cancer Institute/Brigham & Women’s Hospital in 2017. For each patient, we assessed: total dose, indication for dosing, cancer type, time between dose and discharge, time between discharge and death, and total cost (average wholesale price). Study follow up was January 1, 2017 to July 1, 2018. Results: Fifty doses of IMT were administered to 44 patients. Most patients (40) received 1 dose, 2 patients received 3 doses, 1 patient received 2 doses, and 1 patient received a combination of ipilimumab/nivolumab. The most common cancer types were lung (41%), gastrointestinal (18%), and head and neck (16%). Indications for IMT administration were: patient due for next dose (48%), disease progression (42%), and new diagnosis (11%). The majority of doses (70%) were received within 7 days prior to discharge, with 32% of doses within 1 day of discharge. The majority of patients (86%) died in the study period; 14% of patients died during admission. Average survival between discharge and death was 54 days (range: 0-444 days). Total cost of inpatient IMT administration was $413,370, an average of $9,395 per patient. Conclusions: To our knowledge, this is the largest analysis of outcomes for patients receiving IMT during a hospitalization. Inpatient use of IMT in cancer patients is associated with high cost and poor clinical outcomes. Dosing within one week prior to hospital discharge was common. Clinical factors such as PD-L1 status, disease status, and reason for admission, which may be important to understand which patients may benefit most from inpatient IMT, should be examined.

Extramedullary Waldenström macroglobulinemia

Disease assessment in Waldenstrom Macroglobulinemia (WM) is dependent on the percent involvement of B-cell neoplasm in the bone marrow and IgM paraprotein in the serum. A subset of patients also demonstrates extramedullary involvement, which is infrequently examined. The role of extramedullary involvement in the diagnosis and prognosis of WM is poorly understood. The purpose of this study is to report the characteristics of WM patients with extramedullary disease (EMD). Nine hundred and eight-five patients with WM were evaluated at one academic center and the presence of EMD was assessed in these patients. Forty-three (4.4%) patients were identified to have EMD. Nine (21%) patients presented with involvement at WM diagnosis, while 34 (79%) developed EMD post-therapy for WM. Most frequent EMD sites involved were pulmonary (30%), soft tissue (21%), cerebrospinal fluid (23%), renal (8%), and bone (9%). The median overall survival at 10 years was 79% (95% CI: 57-90%). This is the first study to describe the clinical characteristics, response and overall survival in patients with extramedullary WM. Further studies to define the molecular characteristics of this entity and mechanisms of its development are warranted.

Waldenström macroglobulinemia: from biology to treatment

Waldenström macroglobulinemia (WM) is distinct B-cell lymphoproliferative disorder primarily characterized by bone marrow infiltration of lymphoplasmacytic cells along with production of a serum monoclonal (IgM). In this review, we describe the biology of WM, the diagnostic evaluation for WM with a discussion of other conditions that are in the differential diagnosis and clinical manifestations of the disease as well as current treatment options. Within the novel agents discussed are everolimus, perifosine, enzastaurin, panobinostat, bortezomib and carfilzomib, pomalidomide and ibrutinib. Many of the novel agents have shown good responses and have a better toxicity profile compared to traditional chemotherapeutic agents, which makes them good candidates to be used as primary therapies for WM in the future.

Live attenuated varicella-zoster vaccine in hematopoietic stem cell transplantation recipients

Hematopoietic stem cell transplantation (HSCT) recipients are at risk for varicella-zoster virus (VZV) reactivation. Vaccination may help restore VZV immunity; however, the available live attenuated VZV vaccine (Zostavax) is contraindicated in immunocompromised hosts. We report our experience with using a single dose of VZV vaccine in 110 adult autologous and allogeneic HSCT recipients who were about 2 years after transplantation, free of graft-versus-host disease, and not receiving immunosuppression. One hundred eight vaccine recipients (98.2%) had no clinically apparent adverse events with a median follow-up period of 9.5 months (interquartile range, 6 to 16; range, 2 to 28). Two vaccine recipients (1.8%) developed a skin rash (one zoster-like rash with associated pain, one varicella-like) within 42 days post-vaccination that resolved with antiviral therapy. We could not confirm if these rashes were due to vaccine (Oka) or wild-type VZV. No other possible cases of VZV reactivation have occurred with about 1178 months of follow-up. Live attenuated zoster vaccine appears generally safe in this population when vaccinated as noted; the overall vaccination risk needs to be weighed against the risk of wild-type VZV disease in this high-risk population.

New insights into the pathogenesis and treatment of Waldenstrom macroglobulinemia

PURPOSE OF REVIEW

Waldenstrom macroglobulinemia is a distinct low-grade lymphoproliferative disease. There have been recent significant advances in understanding the underlying pathogenesis of this disease, including genetic and epigenetic regulators of tumor progression.

RECENT FINDINGS

Current studies have shown that the tumor microenvironment plays a critical role in cell proliferation, dissemination, and drug resistance.

SUMMARY

This review provides an update of the advances in the pathogenesis of factors both intrinsic (in the tumor clone) and extrinsic (in the bone marrow microenvironment) that regulate tumor progression in Waldenstrom macroglobulinemia. We next discuss novel agents that have been recently tested in clinical trials based on the advances observed in the pathogenesis of Waldenstrom macroglobulinemia.

Relative dose intensity (RDI) assessment in an academic center

139

Background: Patients with early breast cancer treated in the adjuvant setting realize maximum benefit as to disease- free and overall survival when they receive their full planned dose of chemotherapy. Due to the aggressive treatment regimens, patients are at increased risk of dose delays and reductions, which result in reduced RDI. Studies have shown that at RDI < 85%, treatment outcomes are compromised. We sought to calculate the RDI attained in our breast cancer clinic and identify factors contributing to decreased RDI.

Methods: We retrospectively reviewed records of 383 patients treated between January 2008 and December 2009. Treatment blocks were reviewed separately to better identify contributing factors to decreased RDI. Regimens were dose-dense doxorubicin and cyclophosphamide (ddAC), dd-paclitaxel (ddT), paclitaxel and trastuzumab (TH), and TH post ddAC. G-CSF support was noted when present. Dose reductions and dose delays (in days) with reason(s) were recorded for patients with RDI < 85%. Patients who switched care or regimen were excluded from this study.

Results: Of the 383 patients, 150 received ddAC; 101 ddT; 67 TH and 65 TH post ddAC. Of these, the percentage of patients with RDI < 85% was 10.4%. RDI was <85% in 8.7%, 6.9%, 14.9%, and 15.4% in the ddAC, ddT, TH, and TH post ddAC regimens, respectively. The major impediments were neutropenia in the anthracycline containing regimen, neuropathy with taxanes, and cardiotoxicity with trastuzumab. No dose delays were seen for administrative issues.

Conclusions: Our results show that 10.4% of treated patients had RDI < 85%. These results were superior when compared to historic data for same regimens. Major reasons for decreased RDI were neutropenia, neuropathy, and cardiotoxicity. Improving risk assessment of neutropenia before initiating treatment could improve RDI in this patient population. Prophylaxis with vitamin B6 may help reduce incidence of neuropathy. Efforts to assure on-schedule treatments should be maintained. This includes comprehensive paramedical support to overcome any hurdles to on-time treatment. Proper education of patients on the importance of RDI can increase awareness of the value of cooperating with the provider and encourage them to persevere with the treatment.