HIV Associated Lymphomas: A Double-Edged Sword

People with HIV (human immunodeficiency virus) are at higher risk of developing Lymphomas in comparison to people without HIV. The risk of developing lymphomas in patients with HIV continues to persist, even in the HAART era. We retrospectively analysed outcomes of patients with HIV associated lymphomas between Jan 2012 and Oct 2022, with minimum follow up of 6 months. Outcomes have been reported in terms of overall response rate (ORR), overall survival (OS) and event free survival (EFS). Statistical methods such as Kaplan Meier test were used to assess the overall survival and progression free survival, while chi-square test was used to assess factors affecting disease response. Twenty-three patients were identified as HIV associated lymphoma in that duration. Four patients were excluded from the cohort due to insufficient data in the database record. 12 (63.15%) were male and 07 (36.85%) were females with male: female ratio of 1.7:1. Median age was 42 years ranging from 21 to 66 years. 11 (57.9%) patients had stage-4 disease at presentation. Median CD4 counts at diagnosis was 615/µl, ranging from 130 to 1100/µl. DLBCL cases were in majority which showed 60% of CR post 1st line Chemotherapy. At the last follow-up, 04 (21.05%) patients were dead and 15 (78.95%) patients were alive. 10 years Overall survival [OS] and Progression Free Survival [PFS] was found to be 78.95% ± 11 at a median follow up of 42.6 months ranging (1.7-114.3) months. HIV associated lymphomas have an acceptable prognosis, despite majority presenting with stage 4 disease, low median CD4 count at diagnosis, concomitant ART, and treatment with intensive chemotherapy.

Second stem cell transplantation for treatment of relapsed/refractory multiple myeloma after first autologous stem cell transplant: A 15-year retrospective institutional analysis

Background

Multiple myeloma remains an incurable disease, with the majority of patients relapsing after autologous stem cell transplant (ASCT). After relapse, second transplant remains one of the therapeutic options, along with novel agents.

Methods

We reviewed the data of our patients who underwent ASCT for myeloma (N = 202) over the last two decades (2004-2019). Of these, 12 patients underwent a second transplant.

Results

Out of 12 patients, nine underwent second autologous stem cell transplant, whereas three received an allogeneic stem cell transplantation (Allo-SCT). Median progression-free survival (PFS) after the first ASCT was 32 months (5-84 months). Median interval between both the transplants was 35 months (4-159 months). Median age of our cohort which underwent second transplant was 56 years. Overall response rate (ORR) post-second transplant on day +100 was 83.3%, without any transplant-related mortality (TRM). With the use of preemptive plerixafor, none of our patients required a second day for stem cell harvest. Median CD34 dose of stem cells infused was 4.11 × 106/kg. Similar to the first ASCT, the median time to neutrophil and platelet engraftment was 11 and 12 days, respectively. At a median follow-up of 41 months, estimated 3-year PFS and overall survival (OS) was 37% ± 15% and 63% ± 15%, respectively.

Conclusion

">Among all relapsed myeloma patients who were transplant eligible, 11% underwent a second transplant. Second transplant is well tolerated with similar time to engraftment after first ASCT. Hence, we believe that second transplant is a feasible, cost-effective option in a resource-limited setting, which should be more widely utilized.

Attenuated Dose Dasatinib in Newly Diagnosed Chronic Myeloid Leukemia Chronic Phase Patients in India

BACKGROUND

BCR-ABL Tyrosine kinase inhibitors (TKI's) are most successful of targeted therapies and are currently considered the cornerstone in the management of patients with chronic myeloid leukemia (CML). A recent study reported excellent outcomes of Dasatinib 50mg with better sustained response. Therefore, we aim to evaluate the molecular responses and safety of upfront Dasatinib 50mg in Indian CML-Chronic Phase patients.

METHODS

It was an observational single-centre study. CML-CP patients started on Dasatinib 50mg daily were offered to participate in this study. Data of imatinib was collected retrospectively as a comparator group.

RESULTS

Between June 2020 to Feb 2022, fifty patients were included in the dasatinib 50mg once daily group. Median age was 40 yrs. ranging from (19 to73) years. At a median follow up of 9.2 months, 49 patients completed three months treatment, out of which 48 patients were evaluated as one patient stopped medication after a month due to financial constraints. The response rate at three months for dasatinib 50mg daily and Imatinib were 68.75% and 69.7% respectively. At 12 months, 68% and 66.6% patients achieved major molecular response [MMR] in dasatinib 50mg and imatinib groups respectively.

CONCLUSION

In conclusion, low dose dasatinib is safe and effective as an upfront therapy in CML-CP. Early molecular response [EMR] rates were comparable in low dose dasatinib and imatinib arm but deep molecular responses were significantly higher in low dose dasatinib arm. Dasatinib, taken daily at a dose of 50mg, may offer a new, alternative choice as generic versions are available now for frontline therapy in CML-CP.

Busulfan (Bu) and Cyclophosphamide (Cy) based conditioning regimen still holds the promise of being a safe and efficacious regimen for Allogeneic Transplantation in patients with Transfusion Dependent Thalassemia (TDT), even in high risk

BuCy based regimen has been used as a standard myeloablative chemotherapy for haematopoietic stem cell transplantation in thalassemia. However, treosulfan based conditioning regimen has emerged due to concerns of toxicities. We retrospectively analysed the safety and efficacy of Fludrabine/Bu/Cy/ATG vs Treosulfan/Thiotepa/Fludrabine regimens for HSCT in TDT conducted at our institute (2013-2021). In 75 patients, 36 (48%) received Flu/Bu/Cy/ATG whereas 39(52%) received Treo/Thio/Flu. Median age was 6(1-12) and 9 (1-15) years respectively. Number of patients with Class I, II, III were 14, 10, 12 in Flu/Bu/Cy/ATG vs 2, 19, 18 in Treo/Thio/Flu group respectively. Graft was growth factor mobilized bone marrow in Flu/Bu/Cy/ATG vs peripheral blood stem cell in Treo/Thio/Flu group. Mean stem cell dose was 3.82(2.2-9.1) vs 5(1.65-8.01) 10⁶ /kg in Flu/Bu/Cy/ATG vs Treo/ Thio/ Flu group respectively. Neutrophils and platelets engrafted at a median of 16(14-21) and 16 (9-47) days in Flu/Bu/Cy/ATG and 15(10-20) and 13(9-41) days in Treo/ Thio/ Flu group. Median duration of follow-up was 28 (23-32.9) months. Five (6.6%) patients had rejection (all secondary). Venoocclusive disease was observed in 02 (5.7%) vs 04 (10.3%) patients (p=0.047) respectively. Flu/Bu/Cy/ATG had 04(11.4%) patients with acute GVHD vs 15(38.5%) patients which had significant impact on survival (p=0.038). We observed chronic GVHD in 04(11.4%) and 11(28.2%) patients respectively with significant impact on survival (p=0.031). Four (5.1%) patients had TRM in Treo/Thio/ Flu group, in contrast to none in Flu/Bu/Cy/ATG group. Mixed chimerism was common in Flu/Bu/Cy/ATG {20 (57.1%)} vs Treo/Thio/Flu group {12(30.1%)}. 5-year EFS and OS of entire cohort were 87%+4% and 94%+3% respectively. Estimated TFS, EFS, OS of Flu/Bu/Cy/ATG vs Treo/Thio/Flu was 97.1%+2.9% vs 89.2%+5.1%(p=0.251), 97+3% vs 80.7+6% (p=0.041) and 100% vs 90.4+5 % (p=0.067) respectively. In our experience Flu/Bu/Cy/ATG regimen is safe and effective even in high risk TDT. However, one needs to be vigilant for mixed chimerism.

A Retrospective Cohort Study of Upfront Nilotinib in Chronic Myeloid Leukemia: A Single-Center Experience

Context Nilotinib is a second-generation BCR-ABL1 tyrosine kinase inhibitor used in the treatment of chronic myeloid leukemia (CML).

Aims We aim to evaluate the responses and safety of upfront Nilotinib therapy in Indian CML patients.

Setting and Design We retrospectively reviewed the medical records of CML patients who received Nilotinib as an upfront treatment at our center between January 1, 2011 and October 15, 2019.The follow-up was taken till March 31, 2020.

Results Forty One patients ( n = 36 chronic phase and five accelerated-phase CML) received frontline Nilotinib. Median age was 39 years (21–63) with male-to-female ratio of 1.1: 1. At 3 months, 96.9% patients achieved BCR-ABL of ≤10% at international scale. By the end of 12 months, 71.5% patients achieved major molecular response (BCR-ABL ≤0.1%) and 91.4% patients achieved complete cytogenetic response assessed by BCR-ABL polymerase chain reaction of ≤1%. Common toxicities observed were weight gain, thrombocytopenia, corrected QT prolongation, and elevated serum amylase in 14 (34.1%), 7(17.07%), 4(9.7%), and 4(9.7%) patients, respectively. Overall, five patients had loss of response with further progression and death in three patients. At a median of 43.7 months, 38 patients survived with estimated 3 year event-free survival and overall survival of 65 ± 9 and 93 ± 5%.

Conclusion This study showed remarkable good response with upfront Nilotinib in Indian patients with CML.

High Risk Acute Promyelocytic Leukemia - An Enigma for Hematologists: Optimizing Treatment with APML-4 Protocol

Management of Acute Promyelocytic Leukemia (APML) has improved drastically after the introduction of ATRA (All-trans-retinoic acid) and Arsenic trioxide (ATO). The use of APML-4 protocol has shown its effectiveness in Australian population. We know that high-risk APML represents a subset with poor outcomes. There is scarcity of literature reporting outcomes of high-risk APML from India. We present a 5-year retrospective analysis of the safety and efficacy of APML-4 protocol in our 28 high-risk patients. Of 28 patients, there were 8(28.5%) early deaths; all 20 patients (100%) who were alive achieved hematologic complete remission post-induction and molecular complete remission post-consolidation. The 5-year disease free survival, failure free survival (FFS) and overall survival were 100%, 69% and 69% respectively. Factors affecting FFS were age > 45 years (p = 0.008), baseline ECOG-PS > 1 (p < 0.0001), and grade 3-4 differentiation syndrome (p = 0.008). APML-4 protocol in high-risk patients is capable of achieving excellent disease control with less toxicities. While early induction deaths in high-risk APML still remain an issue, protocol modifications (for steroid and anthracyclines) are important considering high frequency of infections at baseline and during induction therapy in our population.

Experience with combination of hydroxyurea and low-dose thalidomide in transfusion-dependent beta thalassemia patients

Hydroxyurea (HU) and thalidomide have been reported to improve clinical and hematological parameters in transfusion-dependent beta thalassemia (TDT). Therefore, we retrospectively analyzed the combination of HU and thalidomide in 140 transplant ineligible TDT, ≥ 10 years old, visiting our thalassemia clinic between October 2014 and November 2019. Responses were defined as maintenance of hemoglobin ≥9gm/dl without transfusion as complete response (CR) and with at least 50% reduction in transfusion burden as partial response (PR). Patients with less than 50% transfusion burden reduction for consecutive 6 months of therapy were defined as non-responders (NR), and treatment was discontinued thereafter. Primary end point was overall response rate (ORR) at last follow-up. At median follow-up of 22.6 (95% CI 16.4-28.7) months, 76 (57.2%) patients achieved CR and 19 (14.3%) achieved PR, accounting to an ORR of 71.5%. Among responders at last follow-up, a significant increase in the post-treatment hemoglobin (0.88±0.37gm/dl, p<0.0001) and drop in serum ferritin (-1490.5ng/ml, p<0.0001) were observed. Median time to CR was 124 (95% CI 75.3-172.6) days. Median longest continuous CR was 791 (95% CI 662.2-919.7) days. Common toxicities observed were sedation (25%), hyperbilirubinemia {(23.57%, grade 3/4 =17 (12.14%)}, and constipation (22.8%). Nearly three-fourth of the patients has responded with majority having CR. Adverse events are a concern; hence, regular close monitoring is a prerequisite.

Study of Three Cases of Primary Refractory T Cell ALL

A significant proportion of T cell acute lymphoblastic leukemia (T-ALL) patients do not achieve complete remission after 4 weeks of induction chemotherapy or relapse early. Salvage chemotherapy for such patients usually results in poor outcome which can be up to 20-30% survival with allogeneic BMT. Nelarabine combined with chemotherapy, in COG AALL0434 study, showed 4-year disease-free survival of 54.8% in patients with primary refractory T ALL. An allogeneic BMT in such patients may further improve outcome. In this report, three patients with primary refractory T cell ALL including a case of ETP-ALL and near ETP-ALL were treated with Nelarabine combined with COG based regime and thereafter an allogeneic stem cell transplantation. All three patients achieved a complete remission with negative minimal residual disease status with one course of therapy, received allo SCT (MSD = 2, Haplo = 1) and are surviving in complete remission at 12 months, 14 months and 25 months of follow up. This report highlights that primary refractory T ALL patient can be successfully treated with Nelarabine in combination with chemotherapy and consolidation with allogeneic SCT to provide maximum chances of long-term survival and cure.

Study of clinical characteristics, risk factors and outcomes for tuberculosis post allogeneic stem cell transplant: never count it out

BACKGROUND

Allogeneic stem cell transplant (AlloSCT) recipients remain at a higher risk of developing tuberculosis (TB), especially in endemic populations. We conducted a retrospective study to identify the incidence, clinical presentation, and risk factors for active TB among our alloSCT recipients.

METHODS

Records of all patients transplanted between 1 January 2012 and 31 July 2020 were reviewed. Patients were followed up for outcome until 30 September 2020. None of the patients received prophylactic anti-tubercular drugs. Proven diagnosis of active TB was considered if Mycobacterium tuberculosis (MTB) was cultured from clinical samples or acid-fast bacilli (AFB) or MTB demonstrated on Ziehl-Neelsen (ZN) staining or histopathology or XPERT MTB, while probable diagnosis of TB was considered if histopathology findings were suggestive of caseation necrosis/epithelioid cell granulomas without any evidence of malignancy or lymphocyte rich exudative effusions (pleural/pericardial) without an alternative cause.

RESULTS

Among 381 alloSCT recipients, 15 patients (3.9%) developed TB at median of 246 (74-279) days post AlloSCT, after being symptomatic for a median of 22 (7-60) days, amounting to a cumulative incidence of 4.9%. All patients were started on four-drug anti tubercular therapy, ATT [Rifampicin, Isoniazid, Ethambutol, Pyrazinamide (RHEZ)], of which five patients developed hepatotoxicity at a median of 12 days after start of ATT, leading to drug modification. At last follow up, TB was cured in 13 (86.67%) patients, one succumbed to disease relapse, while others are still on treatment. Age ⩾ 30 years, immunosuppression for graft versus host disease (GvHD) > 6 months, prior use of tyrosine kinase inhibitors (TKI) and chronic GvHD on univariate analysis and immunosuppression for GvHD > 6 months on multivariate analysis were found to be associated with development of TB.

CONCLUSION

A high index of suspicion with timely workup and treatment of TB is the key in AlloSCT recipients, especially in endemic TB populations.

Primary Bone Lymphoma: A 13 Year Retrospective Institutional Analysis in the Chemo-Immunotherapy Era

Primary Lymphoma of bone (PBL) is an uncommon extranodal tumor accounting for 1% of all malignant lymphomas. The incidence of PBL is so rare that many of its aspects remain unknown. We retrospectively analysed our data in order to know clinical characteristics and treatment outcome in Indian population in chemo-immunotherapy era. We identified 49 patients [2007-2019] (median age 52 years) of which, 35 (71.4%) were males. Nearly one-third patients (n = 18; 36.8%) were elderly (Age > 60). The most common histological subtype was DLBCL. Local pain /swelling (n = 23; 47%) and B symptoms (n = 20; 44.4%) was the most common presentation. Spine was the most frequently involved site (n = 25; 51%) followed by pelvis (n = 17; 34.7%). One third patients had poor ECOG-PS ≥ 2, (n = 16; 32.6). More than 50% of the population presented with IPI score ≥ 2 (n = 25; 55.5%). Majority of the patients presented with Ann-Arbor stage IV disease (n = 31; 63.2%). (n = 32; 71.1%) cases received chemotherapy alone and (n = 13; 28.9%) patients were treated in combination with local radiotherapy. R-CHOP was the most common treatment regimen given to patients (n = 43; 95.5%). Overall, three-fourth patients (n = 36; 80%) achieved a complete response. At a median follow-up of 45 ± 2 (range 3-144) months, 4-year OS (Overall Survival) and PFS (Progression free survival) was 83.1% and 74.5%, respectively, using Kaplan-Meier survival curves. Prognostic factors for OS on multivariate analysis were ECOG-PS 0-1 [p = 0.05], age < 60 [p = 0.03] and achievement of CR [p = 0.001]. PBL in India is usually of DLBCL subtype, with spine as the most common site. It has an excellent prognosis in the R-CHOP era. Chemo-immunotherapy with 6 R-CHOP followed by addition of Radiotherapy if partial response appears to provide good outcomes. However, the exact role of radiation still needs to be confirmed.

Autologous stem cell transplantation in first remission is associated with better progression-free survival in multiple myeloma

Autologous stem cell transplant (ASCT) is standard consolidation therapy in management of multiple myeloma (MM) patients. We reviewed records of all consecutive MM patients who underwent ASCT with high-dose melphalan at our center from year 2002 to 2016. A total of 141 ASCT were conducted (90 males and 51 females) with median age of 55 years (23-68 years). Median time from diagnosis to transplant was 7 months (3-79), with majority of patients underwent transplant in first remission, while 17 (12%) patients received transplant beyond first remission. Eighty-three percent patients obtained CR/VGPR post-ASCT. Transplant-related mortality was 2.1%. At a median follow up of 54 months, mean overall survival (OS) and progression-free survival (PFS) group were 128.3 months (95% C.I. 111.9-144.7 months) and 73.8 months (95% C.I. 57.7-89.9 months), respectively. On univariate analysis, OS was adversely affected by renal insufficiency (p = 0.024), while OS was better with CR/VGPR post-ASCT (p < 0.001) and lenalidomide maintenance therapy (p = 0.009). PFS was affected by CR/VGPR pre-ASCT (p = 0.021), CR/VGPR post-ASCT (p < 0.001), and transplant in first remission (p = 0.034). On multivariate analysis, lenalidomide maintenance (versus thalidomide) (p = 0.007) and CR/VGPR response post-ASCT (p = 0.0003) were found to be predictors for better OS and CR/VGPR response at transplant for better PFS (p = 0.038). Transplant in first remission versus beyond first remission showed a trend for better PFS (p = 0.073).

CONCLUSION

Majority of patients obtained CR/VGPR post-ASCT. Longer PFS was seen with patients who were transplanted in first remission.

Simple and sensitive spectrophotometric determination of ziram, zineb and ferbam in commercial samples and foodstuffs using phenylfluorone

A procedure has been developed for the determination of ziram, zineb and ferbam dithiocarbamate pesticides by converting ziram and zineb into a zinc-phenylfluorone complex and ferbam into an iron phenylfluorone complex, which are then dissolved in water in the presence of cetylpyridinium bromide and pyridine as a surfactant. The method is sensitive, highly selective and can be used for the determination of ziram, zineb and ferbam in commercial samples and in foodstuffs.

Production and characterization of a monoclonal antibody (P6) reactive to Mycobacterium tuberculosis

The production and characterization of a murine monoclonal antibody (P6) to Mycobacterium tuberculosis is described. The specificity of the monoclonal antibody, an IgG1/K type, was tested against sonic extracts obtained from 27 mycobacteria and 39 bacteria by an enzyme-linked immunosorbent assay. Apparently it was highly specific for the virulent form of M. tuberculosis (H37Rv) and did not react with avirulent strains of M. tuberculosis (H37Ra) and M. bovis (BCG). It was devoid of reactivity with all other mycobacteria and bacteria except to a reaction of low extent with Nocardia asteroides (11.8%). The antibody recognized intact M. tuberculosis as well as the sonicate. Various pathogenic strains of M. tuberculosis collected from different geographical locations showed a range of reactivity with this monoclonal antibody. The antibody reacted strongly with M. tuberculosis South Indian (79112) and British strain (wild) and to varying extents with other strains of M. tuberculosis tested. In Western immunoblots, it recognized antigens of 45 and 96 KDa of M. tuberculosis (H37Rv).