Donor matters: Donor selection impact on hematopoietic stem cell transplantation outcomes in Hispanic patients with B-cell acute lymphocytic leukemia: Insights from a myeloablative HSCT study

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a pivotal treatment for high-risk acute lymphocytic leukemia (ALL), although limited by suitable human leukocyte antigen (HLA)-matched sibling donors (MSD). This study evaluates the impact of donor selection on outcomes in post-HSCT Hispanic B-cell ALL patients.

METHODOLOGY

This single-center retrospective study evaluates outcomes in 88 adult Hispanic B-cell ALL patients who underwent haploidentical, MSD, or MUD myeloablative HSCT between 2013 and 2023.

RESULTS

Compared to Haploidentical transplants, MSD exhibited worse cumulative incidence of relapse (CIR) (HR = 3.39; P = 0.014) and disease-free survival (DFS) (HR = 2.44; P = 0.048) whereas MUD outcomes did not differ. This effect persisted even when controlling for pre-HSCT stage and Minimal residual disease (MRD) status. In addition, Ph-like was a significant predictor of worse DFS (HR = 3.60; P=0.014) and CIR (HR = 2.97; P=0.035) on multivariate analysis. Older donor age correlated with worse GVHD-free, relapse-free survival (GRFS) in haploidentical transplants (HR = 1.05; P=0.036).

CONCLUSION

Our data highlights improved outcomes with younger, haploidentical donors among Hispanic B-cell ALL patients undergoing myeloablative HSCT. This underscores the importance of donor selection in optimizing outcomes for ALL patients.

Impact of ethnicity and immune-related adverse events (IRAE) on outcomes for non-small cell lung cancer (NSCLC) patients treated with immune checkpoint inhibitors

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Background: Immune checkpoint inhibitors (ICI) have become the standard systemic therapy for the treatment of non-small cell lung cancers (NSCLC). With increased ICI use, the presence of immune related adverse events (IRAE) has increased and become associated with improved outcomes. However, minority populations are often underrepresented in clinical trials and the impact of ethnic variance on outcomes on ICI is not well defined. Methods: A retrospective analysis was performed on all NSCLC patients treated with ICI from 2014-2020 at Norris Cancer Center, Keck Medical Center, and Los Angeles County hospital. Presence of IRAE were determined by primary Oncology notes and graded per CTCAE v 5.5. Patients were divided by ethnicity/race below. All statistical analysis was performed with R. Results: In total, 186 NSCLC patients were treated with ICIs. The mean age was 66.3 years old (range 35-89) and average BMI was 25.1. Among the 186 patients, 65 (34.9%) were Asian/Pacific Islander (API), 60 (32.2%) non-Hispanic white (NHW), 33 (17.7%) Hispanic/Latino (HIS), 18 (9.7%) Black/African American (AA), and 10 (5.4%) Other. The median PFS and OS for the entire cohort was 7.1 mo and 17.3 mo, respectively. The median PFS and OS for API, NHW, HIS, and AA, were 18.7 and 20.3 mo, 7.37 and 25.3 mo, 4.1 and 11.0 mo, and 7.2 and 24.4 mo, respectively. The Hispanic group had significantly worse PFS (p = 0.01) and OS (p = 0.002), compared to all other groups. The rate of IRAE by patients was (36.0%), among which 46 (68.7%) were CTCAE grades 1-2 and 21 (31.3%) were grade 3 and above. Sixteen (23.9%) of the IRAE patients received steroids. The organ systems most affected by IRAE were Endocrine (28.4%) followed by Dermatologic (19.4%) and GI (17.9%). Among HIS, 24.2% experienced IRAE, compared to 41.5% for API, 41.7% for NHW, and 22.2% for AA. There was no significant difference in presence of IRAE (p = 0.1624) or the use of steroids (p = 0.3844) by ethnicity. Among the entire cohort, the presence of IRAE was significantly associated with improved median PFS (21.9 mo v 5.06 mo, p = 3e^-04) and median OS (47.7 mo v 12.7 mo, p = 4e^-05) when compared to no IRAE. The degree of improvement in OS with IRAE differed by ethnic/racial group and this difference between groups was statistically significant (p = 6e^-04). Comparisons of median OS with IRAE v without by ethnic/racial group, including hazard ratios: HIS (13.8 mo v 10.8 mo, -0.412), API (59.8 v 15.8 mo, -0.769), AA (41.1 mo v 12.5 mo, -0.924), NHW (47.7 mo v 19.3 mo, -0.958). Conclusions: Our data supports growing evidence that ICI outcomes differ by ethnic/racial background. Specifically, worse outcomes have been noted in the Hispanic population. While all groups show improved clinical outcomes from ICI when experiencing IRAE, this benefit appears to be less among the Hispanic population.

Impact of steroid use among patients with renal cell carcinoma (RCC) who develop immune-related adverse events (irAE)

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Background: Immune checkpoint inhibitor (ICI) therapy has become a standard therapy in the treatment of advanced renal cell carcinomas (RCC). This has led to a proportional increase in the frequency of immune related adverse events (irAE), however. While increasing evidence suggests that irAE may be correlated with benefit from ICI, the impact of steroids to mitigate irAE’s remains unclear. Methods: We analyzed records of patients with RCC treated with an ICI at the USC Norris Comprehensive Cancer Center, Keck Hospital of USC, and LAC+USC Hospital from 2015-2021. Statistical analysis was performed using R. The Kaplan-Meier model was used to calculate progression free survival (PFS) and overall survival (OS). A log-rank test was used to determine if differences in PFS/OS were statistically significant. Results: Out of a total 841 cancer patients treated with ICI, 107 RCC patients were identified. The median age was 60 (range 20-91). The two most common represented ethnicities were 48 Hispanic/Latino (44.9%) and 37 Caucasian (34.6%). The patient population include 64 male patients (59.8%) versus 43 female patients (40.2%). Most had metastatic disease (74.8%) versus local disease (25.2%), and most patients (80.4%) received ICI therapy as initial therapy. Only 6 patients (5.6%) were given combination ICI therapy. The three most common systems affected by irAE were endocrine (18.7%), dermatologic (16.8%), and renal (14.0%). Of the irAE that occurred, 21.5% were categorized as CTCAE grade III or higher. The median PFS of the irAE group was 51.8 months (95% CI 10.0 – 51.8) versus 11.2 months (95% CI 2.7 – 13.8) in the no irAE group. The median OS of the irAE group was 55.0 months (95% CI 23.9 – 55.0) versus 15.6 months (95% CI 13.5 – 23.5). The occurrence of irAE was associated with both statistically significantly increased PFS (p = 0.02) and OS (p = 0.007). The median PFS of patients receiving steroids to treat irAE was 6.5 months (95% CI 3.9 – 9.2) compared to 12.5 months (95% CI 10.4 – 12.5) in the group with irAE who did not receive steroids. The use of steroids was associated with statistically significant worse PFS (p = 0.04) and worse OS but not at statistical significance (p = 0.2). Conclusions: The occurrence of irAE was associated with improved PFS and OS in RCC patients treated with ICI. Furthermore, the use of steroids among patients with irAE was associated with worsened PFS, but not OS. Although steroids should still be used as clinically indicated for the management of irAE, clinicians should be judicious as they may blunt tumor response to ICI treatment.

Venous thromboembolism in patients on check point inhibitors

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Background: Checkpoint inhibition (CPI) therapy, including PD-1/PD-L1 and CTLA-4 inhibition strategies, has significantly improved the prognosis for patients with advanced malignancies. Anticancer treatments like chemotherapy and antiangiogenic agents are associated with higher rate of cancer associated thrombosis. However, the association of CPI with venous thromboembolism (VTE) is not well established. Methods: We conducted a retrospective cohort study of patients with advanced malignancy who were started on CPI between 2016 and 2019 at a tertiary care medical center in Southern California. We used descriptive statistics to describe the occurrence of VTE. Logistic regression was used to identify factors that had a significant impact on occurrence of VTE. Results: The cohort comprised 240 patients with median age of 60 years (range 27-96) at initiation of CPI and majority of the patients were males (57%). 45% were Hispanic, followed by Asian (19%), Caucasian (18%) and African American (8%). 80% had metastatic disease and the most common indication for use of CPI was lung cancer (20%), followed by gynecological malignancies (19%) including ovarian, endometrial and cervical cancer, melanoma (15%) and genitourinary malignancies (15%) including renal and urothelial cancer. The most used agent was nivolumab (68%) followed by pembrolizumab (25%), with most patients receiving single agent CPI (94%). Combination CPI and CPI with other agents including chemotherapy or targeted therapy was given to 3% and 4% respectively. The incidence of VTE was 10% (24/240) – pulmonary embolism (5), upper extremity deep vein thrombosis (5), lower extremity deep vein thrombosis (10) and visceral vein thrombosis (4). Patients were also stratified by Khorana score (KS) based on laboratory values and body mass indices at initiation of CPI (median score 1, range 0-4). VTEs occurred in patients on nivolumab in 8.02% of cases and in 18.2% of cases for pembrolizumab. VTEs occurred in 7.04% of patients with initial KS 0; 8.33%, KS 1; 17.5%, KS 2; and 15.4%, KS 3. Logistic regression analysis using a significance level of p < 0.05 showed no significant association between occurrence of VTE and age, sex, race, type of cancer or Khorana score. Conclusions: In our study, VTE risk in patients receiving CPI was similar to that with other systemic therapy. Further larger studies are needed to assess clinical significance of these findings, stratify for risk factors, and account for dose-dependence.

Midtrimester Ultrasound Predictors of Small-for-Gestational-Age Neonates

OBJECTIVES

To determine whether a specific estimated fetal weight (EFW) or abdominal circumference (AC) measurement percentile at the 18-to 24-week ultrasound (US) examination is associated with a small-for-gestational-age (SGA) neonate.

METHODS

A retrospective case-control study was conducted including women with uncomplicated singleton gestations who delivered a term SGA neonate identified as having a birth weight (BW) below the 10th percentile on the Olsen growth curve and had an 18- to 24-week US examination in our database. The study period was October 2011 to January 2018. A similar number of control charts were requested randomly over the same time with BW in the 10th to 90th percentiles, all which had an 18-to 24-week US examination in our database. After all neonates meeting BW criteria were identified, a chart review was performed to specifically evaluate biometric parameters from the US at 18 to 24 weeks to determine a potential correlation with the EFW percentile and AC percentile. Pregnancy, neonatal outcomes, and maternal demographic characteristics were collected.

RESULTS

A total of 549 term neonates with a BW below the 10th percentile, and 593 control term neonates with BW in the of 10th to 90th percentiles were reviewed. Our analyses revealed that the AC and EFW percentiles were poor predictors of BW (<10th percentile; areas under the receiver operating characteristic curves, 0.68 and 0.69, respectively). A similar low ability of AC and EFW to predict BW below the 5th percentile was noted.

CONCLUSIONS

(1) No tipping point or cutoff for the EFW or AC percentile at the 18- to 24-week US examination was identified to predict a term SGA neonate. (2) These data are helpful when counseling women in midgestation about specific parameters, their importance, and the potential need for follow up imaging.

Transscleral diode laser retinopexy in retinal detachment surgery: results of a multicenter trial

PURPOSE

To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial.

METHODS

Seventy-two patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled.

RESULTS

Information from follow-up of 6 months or longer was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch's membrane in 15 eyes, scleral-thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged perhaps to have contributed to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physician's experience in using transscleral laser retinopexy.

CONCLUSIONS

In this multicenter study, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Multicenter trial of transscleral diode laser retinopexy in retinal detachment surgery

PURPOSE

To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial.

DESIGN

67 patients with primary rhegmatogenous retinal detachment underwent scleral buckling surgery, using transscleral diode laser for retinopexy, at five study centers.

STUDY PARTICIPANTS

72 patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. Five eyes were excluded because they required additional nonprotocol treatment at the time of surgery (vitrectomy or supplementary cryotherapy due to probe malfunction).

MAIN OUTCOME MEASURES

Retinal reattachment at six months after one operation. Secondary measures: visual acuity and complications, including choroidal, retinal, and vitreous hemorrhage, inflammation, and scleral damage.

RESULTS

Six months or greater follow-up information was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch is membrane in 15 eyes, scleral thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes, and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged to have contributed possibly to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physicians experience with transscleral laser retinopexy.

CONCLUSION

In this multicenter series, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Extramedullary toxicity of a conditioning regimen containing busulphan, cyclophosphamide and etoposide in 84 patients undergoing autologous and allogenic bone marrow transplantation

Relapse is still a common problem after bone marrow transplant (BMT) and teh value of adding etoposide to standard conditioning agents is being tested. The aim of the study was to assess the extramedullary toxicity which resulted from adding etoposide to busulphan 16 mg/kg and cyclophoshamide 120 mg/kg (BuCY2). Eighty four patients received etoposide 40 mg/kg in addition to BuCY2 as conditioning for autologous and allogeneic BMT for leukemia and lymphoma. The Bearman system of grading extramedullary toxicity was used along with a system of grading skin toxicity that we devised. There were seven acute toxic deaths (8%) and in total 15 patients experienced life-threatening or fatal toxicity. The major finding was a striking increase in pulmonary toxicity with six deaths (five alveolar hemorrhage and one pulmonary embolus). Five of seven of the patients with severe pulmonary toxicity had been given irradiation to the lung fields (P < 0.001). Thirty nine per cent of patients had veno-occlusive disease of the liver but the case fatality rate was low (1 of 33). Dermatologic toxicity was experienced by 82% of patients and was symptomatically troublesome but rapidly reversible. The addition of etoposide to BuCY2 increases non-hematological toxicity. This regimen is associated with severe pulmonary toxicity in patients with a history of prior chest irradiation. A high incidence of skin toxicity was seen; a system for describing this toxicity is proposed.

Penetrating ocular injury from contaminated eating utensils

Although the rate of infectious endophthalmitis following penetrating ocular injury is generally less than 10%, certain settings may carry a greater risk of infection. One such setting is penetrating injury resulting from eating utensils contaminated with oral flora. We reviewed six of these injuries. Culture-positive bacterial endophthalmitis developed in four of the six eyes; only one of the eyes retained reading visual acuity (greater than 20/50) and two eyes lost light perception. The potential for infection and limited visual outcome in this series warrants aggressive prophylaxis and treatment. The unexpected isolation of Haemophilus influenzae in two of the four infections suggests that broad-spectrum antibiotic treatment should be considered in all such injuries since less common organisms may be encountered.

Cohen syndrome with bull's eye macular lesion

The Cohen syndrome is an autosomal recessive disorder which is characterized by hypotonia, obesity, mental deficiency, and facial, oral and ocular anomalies. During a twelve-year period of observation, the authors' patient manifested pigmentary retinal degeneration and a bull's eye macular lesion. The Cohen syndrome must be included in the differential diagnosis of syndromes with retinitis pigmentosa.