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Schuster J, Sheng IY, Reddy CA, Khorana AA, Nizam A, Gupta S, Gilligan T, Wee CE, Sussman TA, Bonham A, Maroli K, Martin A, Ornstein MC. Risk of Thromboembolism in Patients Receiving Immunotherapy-Based Combinations as Front-Line Therapy for Metastatic Renal Cell Carcinoma. Clin Genitourin Cancer 2024; 22:92-97. [PMID: 37932205 DOI: 10.1016/j.clgc.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Most patients with treatment-naïve metastatic renal cell carcinoma (mRCC) receive combination-based immunotherapy with either 2 immune-oncology checkpoint inhibitors (IO/IO) or an IO agent in combination with a vascular endothelial growth factor receptor (VEGF-R) tyrosine kinase inhibitor (IO/TKI). The rates of thromboembolism (TE) in these cohorts are not clearly described and can potentially impact decision-making between IO/IO and IO/TKI. METHODS We conducted a retrospective investigation of patients with treatment-naïve mRCC treated with IO-based combinations between January 2015 and April 2021 at the Cleveland Clinic. TE events, including venous and arterial, were identified in each group. Competing risk regression was done to identify factors associated with the development of TE following therapy, with all-cause mortality treated as a competing event. RESULTS Of 180 patients identified, 77 (43%) received IO/TKI and 103 (57%) received IO/IO. Median age was 65 years, 75% were male, and 80% had clear cell histology. Baseline characteristics were similar between the 2 groups. At a median follow-up of 22.0 months, 10.0% of all patients had a TE. The one-year incidence of TE was 8.1% (95% CI: 3.3%-15.8%) with IO/TKI and 9.8% (95% CI: 5.0%-16.5%) with IO/IO and was not significantly different between the 2 groups (HR 0.89, 95% CI: 0.35%-2.28%). Occurrence of TE was associated with decreased overall survival regardless of IO/IO or IO/TKI therapy (HR 2.80, 95% CI: 1.57-5.02). There was no difference in incidence of TE based on patient age, gender, prior history of TE, International Metastatic Renal Cell Carcinoma (IMDC) risk group, or Khorana score. CONCLUSIONS Incidence of TE is similar between IO/IO and IO/TKI regimens in treatment-naïve mRCC and is also associated with decreased overall survival. While risk of TE may not guide decision-making in choice of front-line mRCC therapy, careful attention should be given to the high risk of TE in this population.
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Sheng IY, Gupta S, Reddy CA, Angelini D, Funchain P, Sussman TA, Sleiman J, Ornstein MC, McCrae K, Khorana AA. Thromboembolism in Patients with Metastatic Urothelial Cancer Treated with Immune Checkpoint Inhibitors. Target Oncol 2022; 17:563-569. [PMID: 35986816 DOI: 10.1007/s11523-022-00905-x] [Citation(s) in RCA: 4] [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] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Immunotherapy has become one of the mainstays for metastatic urothelial carcinoma treatment. Whether immune checkpoint inhibitor therapy increases thromboembolism (TE) risk is unknown. OBJECTIVE We investigated the incidence of arterial thromboembolism (ATE) and venous thromboembolism (VTE) events and its associated outcomes in patients with metastatic urothelial cancer treated with immune checkpoint inhibitors. METHODS Patients with urothelial cancer treated with immune checkpoint inhibitors at the Cleveland Clinic from 1/1/2015 to 12/31/2019 were identified. The Kaplan-Meier method estimated overall survival and Cox proportional hazards regression evaluated the impact of TE on overall survival. RESULTS Of 279 patients, 72% were men with pure urothelial cancer (62%) who started atezolizumab (40%), nivolumab (3%), or pembrolizumab (57%). At a median follow-up of 5.6 months (range 0.3-51.6), 42 patients developed a TE (VTE n = 37, 13%, ATE n = 5, 2%). The cumulative incidence of TE after immune checkpoint inhibitor therapy was 9.1% (95% confidence interval 6.0-13.0) at 6 months and 13.6% (95% confidence interval 9.6-18.4) at 12 months. Most TE (VTE 62%, ATE 100%) occurred within 6 months of immune checkpoint inhibitor initiation (median doses 5, range 1-59), and the majority (VTE 81%, ATE 100%) resulted in hospitalization (median: 5 days, 4 days, respectively). Thromboembolism (hazard ratio 2.296, p = 0.0004), Bajorin score 1 or 2 (hazard ratio 1.490, p = 0.0315), and Bajorin score 2 (hazard ratio 3.50, p < 0.0001) were associated with worse overall survival. CONCLUSIONS Immune checkpoint inhibitors are associated with a high TE risk. Thromboembolism is associated with worsened survival, among other poor outcomes. Further investigation into the mechanism behind immune checkpoint inhibitor-associated TE is needed.
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Affiliation(s)
- Iris Y Sheng
- Department of Medicine, Beth Israel Lahey Mt. Auburn Hospital, Boston, MA, USA
| | - Shilpa Gupta
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Dana Angelini
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Tamara A Sussman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Joseph Sleiman
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Keith McCrae
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA.
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Sheng IY, Gupta S, Reddy CA, Angelini D, Funchain P, Sussman TA, Sleiman J, Ornstein MC, McCrae K, Khorana AA. Thromboembolism in Patients with Metastatic Renal Cell Carcinoma Treated with Immunotherapy. Target Oncol 2021; 16:813-821. [PMID: 34741719 DOI: 10.1007/s11523-021-00852-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Accepted: 10/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Metastatic renal cell carcinoma (mRCC) is associated with a high risk of thromboembolism (TE). OBJECTIVE We investigated whether immunotherapy (IO) increases the hypercoagulable state in this high-risk population. PATIENTS AND METHODS Patients with mRCC treated with IO between 1 January 2015 and 31 December 2019 at the Cleveland Clinic were identified. Cumulative incidence analysis calculated TE rates over time and Gray's test determined differences in TE rates among groups. The Kaplan-Meier method estimated survival, while Cox proportional hazard regression evaluated the impact of TE on OS. RESULTS Of 351 patients, 75% were men with clear cell mRCC (81%) and International Metastatic Renal Cell Carcinoma (IMDC) intermediate- to poor-risk disease (77%). Patients received single-agent IO (52%), doublet IO (31%), or IO with non-IO therapy (17%). The median number of IO doses was 8 (range 1-81). At a median follow-up of 12.8 months, 12% of patients (n = 43) had a TE event (venous n = 37 [11%], arterial n = 6 [2%]). The cumulative TE incidence at 6 months was 4.4% (95% confidence interval [CI] 2.6-6.9) and 9.8% (95% CI 6.8-13.4) at 12 months. No factors, including IMDC or Khorana score, were identified to predict TE development. Seventy-two percent of TE resulted in hospitalization (9% TE-related mortality and 21% TE-related dose delay). TE (p < 0.0001), poor IMDC score (p < 0.0001), and Khorana score ≥ 2 (p < 0.0001) were associated with worse OS. CONCLUSIONS Patients with mRCC treated with IO had a high incidence of TE. TE was associated with risk of treatment delay, hospitalization, and mortality, while TE, IMDC poor risk, and Khorana score ≥ 2 were associated with worse survival. Further investigations into IO-associated TE are needed to identify benefit from primary thromboprophylaxis.
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Affiliation(s)
- Iris Y Sheng
- Department of Medicine, Beth Israel Lahey Mt. Auburn Hospital, Boston, MA, USA
| | - Shilpa Gupta
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Dana Angelini
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Tamara A Sussman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Joseph Sleiman
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Keith McCrae
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA.
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Sheng IY, Barata P, Alameddine R, Garcia JA. Volume matters and intensification is needed: emerging trends in the management of advanced prostate cancer. Drugs Context 2021; 10:2020-10-2. [PMID: 33796138 PMCID: PMC7968923 DOI: 10.7573/dic.2020-10-2] [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: 10/12/2020] [Accepted: 02/07/2020] [Indexed: 11/21/2022] Open
Abstract
Significant changes in the management of patients with de novo metastatic prostate cancer have led to the use of novel oral agents and docetaxel-based chemotherapy earlier in the natural history of their disease. Our main challenge is the lack of prospective randomized data comparing these regimens. It is clear that treatment intensification is needed. Yet, the heterogeneity of this patient population coupled with the lack of understanding of the specific biology for a given individual makes treatment selection challenging. The aim of this narrative review is to discuss the importance of defining advanced disease by volume, the necessity for treatment intensification, and the current and future landscape of metastatic hormone-sensitive prostate cancer management.
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Affiliation(s)
- Iris Y Sheng
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Pedro Barata
- Department of Internal Medicine, Section of Hematology Oncology, Tulane University Medical School, New Orleans, LA, USA
| | - Raafat Alameddine
- Department of Hematology Oncology, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Jorge A Garcia
- Department of Hematology Oncology, University Hospital Cleveland Medical Center, Cleveland, OH, USA
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Sheng IY, Wei W, Chen YW, Gilligan TD, Barata PC, Ornstein MC, Rini BI, Garcia JA. Implications of the United States Preventive Services Task Force Recommendations on Prostate Cancer Stage Migration. Clin Genitourin Cancer 2020; 19:e12-e16. [PMID: 32800474 DOI: 10.1016/j.clgc.2020.06.006] [Citation(s) in RCA: 4] [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: 03/26/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prostate-specific antigen screening is controversial. In 2008, the United States Preventive Services Task Force recommended against screening men aged ≥ 75 years, and in 2012, expanded this to include all men. The impact of these changes continues to unfold. We hypothesized that these screening changes could delay the diagnosis of advanced prostate cancer. MATERIALS AND METHODS The Surveillance, Epidemiology, and End Results database was used to identify men (age, 55-69 years) diagnosed with prostate cancer in 2004 to 2008 (group 1), 2009 to 2012 (group 2), and 2013 to 2015 (group 3). Groups reflect United States Preventive Services Task Force guideline changes. Descriptive statistics were used to present baseline statistics and the number of patients diagnosed in aforementioned groups. Data was adjusted for population growth. RESULTS A total of 328,586 men were identified (group 1, 135,625; group 2, 117,979; group 3, 74,982). The average number of men diagnosed annually with N1M0 (group 1, 381; group 2, 477; group 3, 660) and M1 (group 1, 523; group 2, 761; group 3, 1037) disease increased. With group 1 as control, there was a decrease in the incidence of localized disease (group 2, 9.2%; group 3, 33.2%). However, the incidence of N1M0 (group 2, 5.3%; group 3, 30.1%) and M1 disease (group 2, 22.6%; group 3, 49.2%) increased. Separate analyses of patients (age 50-75 years) and African Americans showed similar trends. CONCLUSION With each recommendation, there was increased incidence of de novo metastatic prostate cancer. The sequelae of advanced disease include financial, emotional, and physical burden. Future studies are needed to identify screening strategies that reduce the risk of developing metastatic disease without over-diagnosing indolent cancers.
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Affiliation(s)
- Iris Y Sheng
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Wei Wei
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Yu-Wei Chen
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Timothy D Gilligan
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Pedro C Barata
- Department of Internal Medicine, Section of Hematology Oncology, Tulane University Medical School, New Orleans, LA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Brian I Rini
- Department of Internal Medicine, Section of Hematology Oncology, Vanderbilit University, Nashville, TN
| | - Jorge A Garcia
- Department of Hematology Oncology, University Hospitals Seidman Cancer Center. Case Comprehensive Cancer Center, Cleveland, OH.
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Sheng IY, Ornstein MC. Ipilimumab and Nivolumab as First-Line Treatment of Patients with Renal Cell Carcinoma: The Evidence to Date. Cancer Manag Res 2020; 12:4871-4881. [PMID: 32606975 PMCID: PMC7320748 DOI: 10.2147/cmar.s202017] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 02/06/2020] [Accepted: 05/26/2020] [Indexed: 12/18/2022] Open
Abstract
Immunotherapy has revolutionized the management of metastatic renal cell carcinoma with four checkpoint inhibitors (nivolumab, ipilimumab, avelumab, and pembrolizumab) approved either as monotherapy or as combination therapy. The use of ipilimumab and nivolumab for treatment-naïve, intermediate to poor risk, metastatic renal cell carcinoma was the first checkpoint inhibitor-based combination therapy and remains the only dual checkpoint inhibitor combination approved in mRCC. In this article, we review the trials that led to the approval of ipilimumab and nivolumab in this setting. We also highlight the ongoing trials using this combination, its use in special populations, and clinically relevant unanswered questions.
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Affiliation(s)
- Iris Y Sheng
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Center Institute, Cleveland, OH, USA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Center Institute, Cleveland, OH, USA
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Abstract
INTRODUCTION The emergence of novel hormonal therapies and the increase availability of sensitive next-generation imaging techniques has significantly changed the management of recurrent prostate cancer. AREAS COVERED In this review, we summarize the definition, diagnosis, treatment, and ongoing clinical trials in non-metastatic castration resistant prostate cancer (M0CRPC). We have also discussed the role of newer imaging modalities in the detection of advanced prostate cancer. EXPERT OPINION M0CRPC is a disease state in prostate cancer when serologic progression (PSA only disease) occurs despite castrated levels of testosterone and imaging shows no evidence of metastasis. With the availability of next-generation imaging, more patients are migrating from M0CRPC to mCRPC space. This stage migration impacts the treatment options currently available in clinical practice and requires the integration of novel imaging in prospective studies moving forward. Until that data become available men with M0CRPC should be considered for therapy with any of these three novel oral AR inhibitors, with a positive impact in metastasis-free and overall survival. Treatment selection should be based on Quality of Life, side effects, and drug-drug interactions.
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Affiliation(s)
- Ruby Gupta
- Department of Hematology and Medical Oncology, William Beaumont Hospital , Royal Oak, MI, USA
| | - Iris Y Sheng
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute , Cleveland, OH, USA
| | - Pedro C Barata
- Deming Department of Medicine, Section of Hematology Oncology, Tulane University Medical School , New Orleans, LA, USA
| | - Jorge A Garcia
- GU Oncology Research Program, University Hospitals Seidman Cancer Center, Case Western Reserve University , Cleveland, OH, USA
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Affiliation(s)
- Iris Y. Sheng
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Brian I. Rini
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
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Safran H, Leonard KL, Perez K, Vrees M, Klipfel A, Schechter S, Oldenburg N, Roth L, Shah N, Rosati K, Rajdev L, Mantripragada K, Sheng IY, Barth P, DiPetrillo TA. Tolerability of ADXS11-001 Lm-LLO Listeria-Based Immunotherapy With Mitomycin, Fluorouracil, and Radiation for Anal Cancer. Int J Radiat Oncol Biol Phys 2018; 100:1175-1178. [PMID: 29722659 DOI: 10.1016/j.ijrobp.2018.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/02/2017] [Accepted: 01/02/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To obtain safety and preliminary efficacy data of the combination of ADXS11-001, live attenuated Listeria monocytogenes bacterium, with mitomycin, 5-fluorouracil (5-FU), and intensity modulated radiation therapy in locally advanced anal cancer. PATIENTS AND METHODS Eligibility included patients with previously untreated, nonmetastatic anal cancer with a primary tumor >4 cm or node-positive disease. Patients received 2 cycles of mitomycin and 5-FU concurrent with 54.0 Gy intensity modulated radiation therapy. One intravenous dose of ADXS11-001 (1 × 109 colony-forming units) was administered before chemoradiation; 3 additional monthly doses were given after chemoradiation. RESULTS Ten patients were treated, including 1 with N2 and 4 with N3 disease. Two patients had grade 3 acute toxicities after the initial dose of ADXS11-001, including chills/rigors (n = 2), back pain (n = 1), and hyponatremia (n = 1). All ADXS11-001 toxicities occurred within 24 hours of administration. There was no apparent increase in chemoradiation toxicities or myelosuppression. One patient had a grade 5 cardiopulmonary event shortly after beginning 5-FU treatment. All 9 assessable patients had complete clinical responses by sigmoidoscopy. Eight of 9 patients (89%) are progression-free at a median follow-up of 42 months. CONCLUSIONS Preliminary data show that ADXS11-001 can be safely administered with standard chemoradiation for anal cancer. Further studies of listeria-based immunotherapy with radiation are warranted.
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Affiliation(s)
- Howard Safran
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island.
| | - Kara-Lynne Leonard
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Kimberly Perez
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Matthew Vrees
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Adam Klipfel
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Steven Schechter
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Nicklas Oldenburg
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Leslie Roth
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Nishit Shah
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Kayla Rosati
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Lakshmi Rajdev
- The Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Kalyan Mantripragada
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Iris Y Sheng
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Peter Barth
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
| | - Thomas A DiPetrillo
- The Department of Medicine, The Brown University Oncology Research Group, Providence, Rhode Island
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Sheng IY, Treaba DO, Bishop KD. Infiltrative Rash Secondary to Leukemic-Phase Diffuse Large B-Cell Lymphoma With t(14;18), CDKN2A and MLL Deletion. J Hematol 2017; 6:90-95. [PMID: 32300400 PMCID: PMC7155845 DOI: 10.14740/jh327w] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 07/31/2017] [Indexed: 11/25/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous and highly aggressive subtype of non-Hodgkin’s lymphoma. It commonly presents as rapidly-growing, painless lymphadenopathy (LAD). DLBCL presenting in leukemic-phase is rare, with fewer than 40 cases published. Chemotherapy remains the standard approach, although selecting the correct regimen has become more perplexing in patients with CDKN2A mutations. Patients with MLL- and CDKN2A-positive DLBCL may benefit from therapy with a dose-adjusted regimen of rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH) compared to traditional rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP). Herein, we report a case of leukemic-phase DLBCL presenting as a cutaneous eruption of the bilateral lower extremities, which has not been previously reported in the literature.
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Affiliation(s)
- Iris Y Sheng
- Department of Internal Medicine, Rhode Island Hospital and Warren Alpert Medical School, 593 Eddy Street, Providence, RI 02903, USA
| | - Diana O Treaba
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital and Warren Alpert Medical School, 593 Eddy Street, Providence, RI 02903, USA
| | - Kenneth D Bishop
- Department of Hematology and Oncology, Sturdy Hospital, 211 Park St, Attleboro, MA 02703, USA
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Kolomeyer AM, Nayak NV, Simon MA, Szirth BC, Shahid K, Sheng IY, Xia T, Khouri AS. Feasibility of retinal screening in a pediatric population with type 1 diabetes mellitus. J Pediatr Ophthalmol Strabismus 2014; 51:299-306. [PMID: 25020279 DOI: 10.3928/01913913-20140709-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 04/28/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE To study the feasibility of using a nonmydriatic camera to screen children with type 1 diabetes mellitus (DM1) as young as 2 years for diabetic retinopathy. METHODS Prospective pilot imaging study involving children with DM1 aged 2 to 17 years. The screening consisted of: (1) intake form; (2) measurement of blood pressure, pulse, and oximetry; (3) assessment of visual acuity (SIMAV, Padova, Italy); and (4) nonmydriatic color imaging (Canon CX-1 45° 15.1 megapixel camera; Canon Corp., Tokyo, Japan). Images were assessed for signs of diabetic retinopathy and graded for quality on a scale of 1 to 5 by two clinicians. Kappa coefficient was calculated to determine inter-observer agreement. RESULTS One hundred four of 106 (98%) children underwent imaging (mean age: 11.1 years, 51% male, 88% white). One (1%) child had nonproliferative diabetic retinopathy and 2 (1.9%) had incidental findings. Only 62% of children had an eye examination within the past year, with children with DM1 for more than 5 years significantly more likely to have done so (P = .03). Children who had an eye examination within the past year were significantly older than their counterparts (P = .01). Images of high quality (grades 4 and 5) were acquired in 178 (86%) eyes, and images of some clinical value (grades ≥ 2) were obtained in 207 (99.5%) eyes. Inter-observer agreement for image quality was 0.896. CONCLUSIONS The feasibility of using a nonmydriatic camera to screen children as young as 2 years for changes related to diabetic eye disease was demonstrated. Nonmydriatic imaging may supplement standard dilated clinical ophthalmology examinations for select patient populations.
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