1
|
Sinanidis I, Hochman MJ, Tsai HL, Randall MP, Bonilla B, Varadhan R, Ambinder AJ, Jones RJ, DeZern AE, Karantanos T. Favorable outcomes in MDS and oligoblastic AML-MR after reduced-intensity conditioning allogeneic bone marrow transplantation with post-transplantation cyclophosphamide. Bone Marrow Transplant 2024:10.1038/s41409-024-02299-y. [PMID: 38714755 DOI: 10.1038/s41409-024-02299-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/10/2024]
Affiliation(s)
- Ilias Sinanidis
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Michael J Hochman
- Division of Hematology, Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hua-Ling Tsai
- Division of Quantitative Sciences, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Michael P Randall
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Brandon Bonilla
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Ravi Varadhan
- Division of Quantitative Sciences, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Alexander J Ambinder
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Richard J Jones
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Amy E DeZern
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| | - Theodoros Karantanos
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
2
|
Hochman MJ, DeZern AE. SOHO State of the Art Updates and Next Questions: An Update on Higher Risk Myelodysplastic Syndromes. Clin Lymphoma Myeloma Leuk 2024:S2152-2650(24)00113-7. [PMID: 38594129 DOI: 10.1016/j.clml.2024.03.006] [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] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 04/11/2024]
Abstract
Higher-risk myelodysplastic syndromes (HR-MDS) are clonal myeloid neoplasms that cause life-limiting complications from severe cytopenias and leukemic transformation. Efforts to better classify, prognosticate, and assess therapeutic responses in HR-MDS have resulted in publication of new clinical tools in the last several years. Given limited current treatment options and suboptimal outcomes, HR-MDS stands to benefit from the study of investigational agents.Higher-risk myelodysplastic syndromes (HR-MDS) are a heterogenous group of clonal myeloid-lineage malignancies often characterized by high-risk genetic lesions, increased blood transfusion needs, constitutional symptoms, elevated risk of progression to acute myeloid leukemia (AML), and therapeutic need for allogeneic bone marrow transplantation. Use of blast percentage and other morphologic features to define myelodysplastic neoplasm subtypes is rapidly shifting to incorporate genetics, resulting in a subset of former HR-MDS patients now being considered as AML in presence of leukemia-defining genetic alterations. A proliferation of prognostic tools has further focused use of genetic features to drive decision making in clinical management. Recently, criteria to assess response of HR-MDS to therapy were revised to incorporate more clinically meaningful endpoints and better match AML response criteria. Basic science investigations have resulted in improved understanding of the relationship between MDS genetic lesions, bone marrow stromal changes, germline predispositions, and disease phenotype. However, therapeutic advances have been more limited. There has been import of the IDH1 inhibitor ivosidenib, initially approved for AML; the Bcl-2 inhibitor venetoclax and liposomal daunorubicin/cytarabine (CPX-351) are under active investigation as well. Unfortunately, effective treatment of TP53-mutated disease remains elusive, though preliminary evidence suggests improved outcomes with oral decitabine/cedazuridine over parenteral hypomethylating agent monotherapy. Investigational agents with novel mechanisms of action may help expand the repertoire of treatment options for HR-MDS and trials continue to offer a hopeful therapeutic avenue for suitable patients.
Collapse
Affiliation(s)
- Michael J Hochman
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Amy E DeZern
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
3
|
Hochman MJ, Othus M, Hasserjian RP, Ambinder A, Brunner A, Percival MEM, Hourigan CS, Swords R, DeZern AE, Estey EH, Karp JE. Prognostic impact of secondary versus de novo ontogeny in acute myeloid leukemia is accounted for by the European LeukemiaNet 2022 risk classification. Leukemia 2023; 37:1915-1918. [PMID: 37524919 PMCID: PMC10457181 DOI: 10.1038/s41375-023-01985-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Abstract
Secondary AML (sAML), defined by either history of antecedent hematologic disease (AHD) or prior genotoxic therapy (tAML), is classically regarded as having worse prognosis than de novo disease (dnAML). Clinicians may infer a new AML diagnosis is secondary based on a history of antecedent blood count (ABC) abnormalities in the absence of known prior AHD, but whether abnormal ABCs are associated with worse outcomes is unclear. Secondary-type mutations have recently been incorporated into the European LeukemiaNet (ELN) 2022 guidelines as adverse-risk features, raising the question of whether clinical descriptors of ontogeny (i.e., de novo or secondary) are prognostically significant when accounting for genetic risk by ELN 2022. In a large multicenter cohort of patients (n = 734), we found that abnormal ABCs are not independently prognostic after adjusting for genetic characteristics in dnAML patients. Furthermore, history of AHD and tAML do not confer increased risk of death compared to dnAML on multivariate analysis, suggesting the prognostic impact of ontogeny is accounted for by disease genetics as stratified by ELN 2022 risk and TP53 mutation status. These findings emphasize the importance that disease genetics should play in risk stratification and clinical trial eligibility in AML.
Collapse
Affiliation(s)
- Michael J Hochman
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Alex Ambinder
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew Brunner
- Leukemia Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Christopher S Hourigan
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ronan Swords
- Division of Hematology/Medical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Amy E DeZern
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Judith E Karp
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
4
|
Gurbuxani S, Hochman MJ, DeZern AE, Shimamura A. The Times, They Are A-Changing: The Impact of Next-Generation Sequencing on Diagnosis, Classification, and Prognostication of Myeloid Malignancies With Focus on Myelodysplastic Syndrome, AML, and Germline Predisposition. Am Soc Clin Oncol Educ Book 2023; 43:e390026. [PMID: 37307513 DOI: 10.1200/edbk_390026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Myeloid malignancies are a manifestation of clonal expansion of hematopoietic cells driven by somatic genetic alterations that may arise in a potential background of deleterious germline variants. As next-generation sequencing technology has become more accessible, real-world experience has allowed integration of molecular genomic data with morphology, immunophenotype, and conventional cytogenetics to refine our understanding of myeloid malignancies. This has prompted revisions in the classification and the prognostication schema of myeloid malignancies and germline predisposition to hematologic malignancies. This review provides an overview of significant changes in the recently published classifications of AML and myelodysplastic syndrome, emerging prognostic scoring, and the role of germline deleterious variants in predisposing to MDS and AML.
Collapse
Affiliation(s)
| | - Michael J Hochman
- Johns Hopkins University School of Medicine, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Amy E DeZern
- Johns Hopkins University School of Medicine, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Akiko Shimamura
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| |
Collapse
|
5
|
Hochman MJ, Smith BD, Karantanos T, Braunstein EM, Gojo I, Jain T, Streiff MB, Moliterno AR, DeZern AE. Chronic myeloid leukemia (CML) evolves from Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) with unexpected frequency. Int J Hematol 2023; 117:456-462. [PMID: 36181657 DOI: 10.1007/s12185-022-03463-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 10/06/2022]
Abstract
Myeloproliferative neoplasms (MPN) are chronic clonal disorders characterized by overproduction of myeloid-lineage blood cells and potential risk of evolution to acute myeloid leukemia (AML). Chronic myeloid leukemia (CML) is distinct from other MPNs in that its pathophysiology stems from the BCR-ABL fusion protein of the Philadelphia chromosome (Ph +). Though there are known cases of Ph- and Ph + MPNs coexisting in a single patient, overall prevalence has never been quantified in a prospective cohort. Here, we review our center's MPN registry, which shows 0.6% of Ph- MPN patients later developed CML. This development occurred no less than 10 and up to 36 years after Ph- MPN diagnosis. This rate of chronic transformation exceeds what is expected, as the incidence of CML in the United States is 2 per 100,000 people-years. The probability of this CML case rate in an average-risk population is less than 0.001%, suggesting there are shared risk factors between Ph- and Ph + MPNs. We speculate that these risk factors may include exposures, genetic predispositions, or be inherent to disease biology. Abrupt-onset leukocytosis heralded post-MPN CML in all cases here and suggests this salient clinical feature should trigger hematologists to consider this diagnosis and perform appropriate testing.
Collapse
Affiliation(s)
- Michael J Hochman
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD, 21287-0013, USA.,Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - B Douglas Smith
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD, 21287-0013, USA
| | - Theodoros Karantanos
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD, 21287-0013, USA
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ivana Gojo
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD, 21287-0013, USA
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD, 21287-0013, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alison R Moliterno
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amy E DeZern
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD, 21287-0013, USA.
| |
Collapse
|
6
|
Hochman MJ, DeZern AE. Myelodysplastic syndrome and autoimmune disorders: two sides of the same coin? Lancet Haematol 2022; 9:e523-e534. [PMID: 35772431 DOI: 10.1016/s2352-3026(22)00138-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/30/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 06/15/2023]
Abstract
Systemic inflammatory and autoimmune diseases and myelodysplastic syndromes have been linked in individual patients and in larger case series for at least 25 years. These associations frequently include thyroid disease, neutrophilic dermatoses, polyarthritis, connective tissue diseases, vasculitis, and autoimmune cytopenias. Studies have found that autoimmune disease (or its therapy) is a risk factor for the development of myelodysplastic syndromes, but such syndromes might also be an instigator of autoimmune disease. Epidemiological studies examining disease risk in myelodysplastic syndromes with and without comorbid autoimmune illness have reached mixed conclusions. The pathophysiology of myelodysplastic syndromes is tightly linked to excessive inflammatory activity in the bone marrow microenvironment, which could promote systemic inflammatory and autoimmune diseases directly or by stimulation of the adaptive immune response. Alternatively, autoimmune diseases could promote clonal evolution and disordered bone marrow growth, promoting the development of myeloid malignancy. Additionally, therapy-related myeloid neoplasms-including myelodysplastic syndromes-have been diagnosed after treatment of autoimmune diseases with immunosuppressant therapies. These associations raise the following question: are myelodysplastic syndromes and systemic inflammatory and autoimmune diseases two sides of the same coin-that is, do they share an underlying disease state that can manifest as a myeloid neoplasm, an autoinflammatory illness, or both? VEXAS syndrome, which was first reported in 2020, is caused by a mutation that affects myeloid-restricted cells and manifests with both myelodysplasia and autoinflammation, and could give insight into this biological possibility. We note that systemic inflammatory and autoimmune diseases are often steroid-dependent; however, studies have also evaluated the roles of other immunomodulating therapies. In this Viewpoint, we critically appraise and review the literature on the epidemiology, pathophysiology, and management of systemic inflammatory and autoimmune diseases that are associated with myelodysplastic syndromes and related diseases.
Collapse
Affiliation(s)
- Michael J Hochman
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy E DeZern
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
7
|
Hochman MJ, Savani BN, Jain T. Examining disease boundaries: Genetics of myelodysplastic/myeloproliferative neoplasms. EJHaem 2021; 2:607-615. [PMID: 35844680 PMCID: PMC9175746 DOI: 10.1002/jha2.264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022]
Abstract
Myelodysplastic/myeloproliferative neoplasms (MDS/MPN) are clonal myeloid malignancies that are characterized by dysplasia resulting in cytopenias as well as proliferative features such as thrombocytosis or splenomegaly. Recent studies have better defined the genetics underlying this diverse group of disorders. Trisomy 8, monosomy 7, and loss of Y chromosome are the most common cytogenetic abnormalities seen. Chronic myelomonocytic leukemia (CMML) likely develops from early clones with TET2 mutations that drive granulomonocytic differentiation. Mutations in SRSF2 are common and those in the RAS-MAPK pathway are typically implicated in disease with a proliferative phenotype. Several prognostic systems have incorporated genetic features, with ASXL1 most consistently demonstrating worse prognosis. Atypical chronic myeloid leukemia (aCML) is most known for granulocytosis with marked dysplasia and often harbors ASXL1 mutations, but SETBP1 and ETNK1 are more specific to this disease. MDS/MPN with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T) most commonly involves spliceosome mutations (namely SF3B1) and mutations in the JAK-STAT pathway. Finally, MDS/MPN-unclassifiable (MDS/MPN-U) is least characterized but a significant fraction carries mutations in TP53. The remaining patients have clinical and/or genetic features similar to the other MDS/MPNs, suggesting there is room to better characterize this entity. Evolution from age-related clonal hematopoiesis to MDS/MPN likely depends on the order of mutation acquisition and interactions between various biologic factors. Genetics will continue to play a critical role in our understanding of these illnesses and advancing patient care.
Collapse
Affiliation(s)
- Michael J. Hochman
- Division of Hematological Malignancies and Bone Marrow TransplantationSidney Kimmel Comprehensive Cancer CenterJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Bipin N. Savani
- Division of Hematology and OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow TransplantationSidney Kimmel Comprehensive Cancer CenterJohns Hopkins UniversityBaltimoreMarylandUSA
| |
Collapse
|
8
|
Hochman MJ, Othus M, Walter RB, Shaw C, Gardner K, Percival MEM, Halpern AB, Hendrie PC, Sandmaier BM, Estey EH. Effect of post-treatment MRD status on subsequent outcomes according to chemotherapy intensity in acute myeloid leukemia (AML). Leuk Lymphoma 2021; 62:1532-1535. [PMID: 33752557 DOI: 10.1080/10428194.2021.1885658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Michael J Hochman
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Megan Othus
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Carole Shaw
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Kelda Gardner
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Anna B Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| |
Collapse
|
9
|
Allan DS, Chakraborty M, Waller GC, Hochman MJ, Poolcharoen A, Reger RN, Childs RW. Systematic improvements in lentiviral transduction of primary human natural killer cells undergoing ex vivo expansion. Mol Ther Methods Clin Dev 2021; 20:559-571. [PMID: 33665226 PMCID: PMC7890427 DOI: 10.1016/j.omtm.2021.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/09/2021] [Indexed: 12/19/2022]
Abstract
Transduction of primary human natural killer (NK) cells with lentiviral vectors has historically been challenging. We sought to evaluate multiple parameters to optimize lentiviral transduction of human peripheral blood NK cells being expanded to large numbers using a good manufacturing practice (GMP)-compliant protocol that utilizes irradiated lymphoblastoid (LCL) feeder cells. Although prestimulation of NK cells with interleukin (IL)-2 for 2 or more days facilitated transduction with vesicular stomatitis virus glycoprotein (VSVG)-pseudotyped lentivirus, there was a subsequent impairment in the capacity of transduced NK cells to proliferate when stimulated with LCL feeder cells. In contrast, incubation of human NK cells with LCL feeder cells plus IL-2 before transduction in the presence of the TBK1 inhibitor BX795 resulted in efficient lentiviral integration (mean of 23% transgene+ NK cells) and successful subsequent proliferation of the transduced cells. Investigation of multiple internal promoter sequences within the same lentiviral vector revealed differences in percentage and level of transgene expression per NK cell. Bicistronic lentiviral vectors encoding both GFP and proteins suitable for the isolation of transduced cells with magnetic beads led to efficient transgene expression in NK cells. The optimized approaches described herein provide a template for protocols that generate large numbers of fully functional and highly purified lentivirus-transduced NK cells for clinical trials.
Collapse
Affiliation(s)
- David S.J. Allan
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Mala Chakraborty
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Giacomo C. Waller
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Michael J. Hochman
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Akkapon Poolcharoen
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Robert N. Reger
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Richard W. Childs
- Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Corresponding author: Richard W. Childs, Laboratory of Transplantation Immunotherapy, Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
| |
Collapse
|
10
|
Hochman MJ, Martin DB. Coincidence of autoimmune hemolytic anemia and pure red cell aplasia in a patient with CLL. Ann Hematol 2020; 100:579-580. [PMID: 32548659 DOI: 10.1007/s00277-020-04091-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/13/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Michael J Hochman
- Department of Medicine, University of Washington Medical Center, 825 Eastlake Ave E, Seattle, WA, 98109, USA
| | - Daniel B Martin
- Department of Medicine, University of Washington Medical Center, 825 Eastlake Ave E, Seattle, WA, 98109, USA. .,Seattle Cancer Care Alliance, 825 Eastlake Ave E, Seattle, WA, 98109, USA.
| |
Collapse
|
11
|
Hochman MJ, Yu Y, Wolf SP, Samsa GP, Kamal AH, LeBlanc TW. Comparing the Palliative Care Needs of Patients With Hematologic and Solid Malignancies. J Pain Symptom Manage 2018; 55:82-88.e1. [PMID: 28887271 PMCID: PMC5921902 DOI: 10.1016/j.jpainsymman.2017.08.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT Hematologic cancer patients use palliative care services less frequently than their solid tumor counterparts. Prior work suggests that these patients have a sizable symptom burden, but comparisons between hematologic and solid tumor patients near the end of life are limited. OBJECTIVES To compare unmet symptom needs in a cohort of hematologic and solid tumor patients referred to specialty palliative care services. METHODS Using a novel data registry of initial palliative care encounters, we performed a cross-sectional analysis of cancer patients receiving care across 17 sites within the Global Palliative Care Quality Alliance. We compared clinically-significant symptoms (rated as four or greater in severity) between hematologic and solid tumor patients and performed multivariate logistic regression analyses examining the relationship between symptom burden and tumor type. RESULTS We identified 1235 cancer patients, 108 of which had hematologic malignancies. Pain, dyspnea, nausea, and anorexia burden were as high among patients with hematologic as those with solid malignancies. Blood cancer patients had higher rates of clinically-significant tiredness (51% vs. 42%; P = 0.03) than solid tumor patients. Finally, blood cancer patients had greater odds of being tired (odds ratio 2.19; CI 1.22-3.91) and drowsy (odds ratio 1.81; CI 1.07-3.07) than solid tumor patients independent of age, gender, race, and performance status. CONCLUSIONS Hematologic and solid tumor patients have significant symptom burden at time of referral to palliative care services. Blood cancer patients may have unique concerns warranting targeted attention, including substantial drowsiness and tiredness. Our findings suggest a need to optimize palliative care usage in the hematologic cancer population.
Collapse
Affiliation(s)
| | - Yinxi Yu
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven P Wolf
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Greg P Samsa
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| |
Collapse
|
12
|
Wysham NG, Hochman MJ, Wolf SP, Cox CE, Kamal AH. Performance of Consultative Palliative Care Model in Achieving Quality Metrics in the ICU. J Pain Symptom Manage 2016; 52:873-877. [PMID: 27697569 PMCID: PMC5944339 DOI: 10.1016/j.jpainsymman.2016.05.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/24/2016] [Accepted: 05/27/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT Quality metrics for intensive care unit (ICU)-based palliative care have been proposed, but it is unknown how consultative palliative care can contribute to performance on these measures. OBJECTIVES Assess adherence to proposed quality metrics of ICU-based palliative care by palliative care specialists. METHODS Surrogates for 9/14 patient-level quality metrics were assessed in all patients who received an initial palliative care specialist consult while in an ICU from 10/26/2012 to 1/16/2015 in the Global Palliative Care Quality Alliance, a nationwide palliative care quality registry. RESULTS Two hundred fifty-four patients received an initial palliative care consultation in an ICU setting. Mean (SD) age was 67.5 (17.3) years, 52% were female. The most common reasons for consultation were symptom management (33%) and end-of-life transition (24%). Adherence to ICU quality metrics for palliative care was variable: clinicians documented presence or absence of advance directives in 36% of encounters, assessed pain in 52.0%, dyspnea in 50.8%, spiritual support in 62%, and reported an intervention for pain in 100% of patients with documented moderate to severe intensity pain. CONCLUSION Palliative care consultations in an ICU setting are characterized by variable adherence to candidate ICU palliative care quality metrics. Although symptom management was the most common reason for palliative care consultation, consultants infrequently documented symptom assessments. Palliative care consultants performed better in offering spiritual support and managing documented symptoms. These results highlight specific competencies of consultative palliative care that should be complimented by ICU teams to ensure high-quality comprehensive care for the critically ill.
Collapse
Affiliation(s)
- Nicholas G Wysham
- Duke University School of Medicine, Durham, North Carolina, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | | | - Steven P Wolf
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Durham, North Carolina, USA
| | - Christopher E Cox
- Duke University School of Medicine, Durham, North Carolina, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
13
|
Hochman MJ, Kamal AH, Wolf SP, Samsa GP, Currow DC, Abernethy AP, LeBlanc TW. Anticholinergic Drug Burden in Noncancer Versus Cancer Patients Near the End of Life. J Pain Symptom Manage 2016; 52:737-743.e3. [PMID: 27663186 PMCID: PMC5472041 DOI: 10.1016/j.jpainsymman.2016.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/18/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Anticholinergic drugs can cause several side effects, impairing cognition and quality of life (QOL). Cancer patients are often exposed to increasing cumulative anticholinergic load (ACL) as they approach death, but this burden has not been examined in patients with nonmalignant diseases. OBJECTIVES To determine ACL and its impact in noncancer versus cancer palliative care patients. METHODS We performed a secondary analysis of 244 subjects enrolled in a randomized controlled trial. ACL was quantified with the Anticholinergic Drug Scale. We used multivariable regression to calculate the effect of ACL on key outcomes, including drowsiness, fatigue, and QOL. Patients were stratified by diagnosis, and drugs were grouped as symptom management (SM) or disease management (DM). RESULTS Overall, ACL in cancer and noncancer patients was not significantly different (2.6 vs. 2.4; P = 0.23). SM drugs caused greater anticholinergic exposure than DM drugs in both cancer and noncancer patients (2.3 vs. 0.5, and 1.5 vs. 1.3, respectively; both P < 0.05); however, DM drugs exposed noncancer patients to relatively more ACL than cancer patients (1.2 vs. 0.6, P < 0.0001). ACL was associated with worse fatigue (odds ratio, 1.08; CI, 1.002-1.17) and worse QOL (odds ratio, 0.89; CI, 0.80-0.98). CONCLUSIONS ACL is associated with worse fatigue and QOL and may not differ significantly between cancer and noncancer patients nearing end of life. SM drugs are more responsible for ACL in cancer and noncancer patients, although DM drugs contribute significantly to ACL in the latter group. We recommend more attention to reducing anticholinergic use in all patients with life-limiting illness.
Collapse
Affiliation(s)
| | - Arif H Kamal
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven P Wolf
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Greg P Samsa
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - David C Currow
- Discipline, Palliative and Supportive Services and Department of Medicine, Flinders University, Adelaide, South Australia, Australia
| | | | - Thomas W LeBlanc
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| |
Collapse
|
14
|
Hochman MJ, Wolf S, Zafar SY, Portman D, Bull J, Kamal AH. Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations. J Pain Symptom Manage 2016; 51:1033-1039.e3. [PMID: 27046299 DOI: 10.1016/j.jpainsymman.2015.12.338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/11/2015] [Accepted: 12/22/2015] [Indexed: 11/26/2022]
Abstract
CONTEXT Palliative care (PC) consultation services are available in most hospitals; outpatient services are rapidly growing to meet the needs of patients at earlier stages of the disease trajectory. OBJECTIVES We aimed to compare the unmet needs of PC patients by location of care to better characterize these populations. METHODS This cross-sectional secondary analysis examined patients receiving hospital and outpatient-based PC across 10 community and academic organizations in the Global Palliative Care Quality Alliance. We identified unmet symptom, advance care planning, and functional needs within our database from October 23, 2012 to January 22, 2015. Kruskal-Wallis, chi-square, and Fisher exact tests were performed. RESULTS We evaluated 633 unique patients. Inpatients (n = 216) were older than outpatients (n = 417; 73 vs. 64 years, P < 0.0001). Seventy-six inpatients (38%) had a Palliative Performance Scale score ≤30%; no outpatients did (P < 0.0001). More inpatients rated their quality of life as poor compared with outpatients (39% vs. 21%, P = 0.0001). We found that outpatients presented with more unresolved pain than inpatients (58.5% vs. 4.1%, P < 0.0001). Conversely, more inpatients presented with unresolved anorexia (52.3% vs. 35.8%, P = 0.002) and dysphagia (28.1% vs. 5.4%, P < 0.0001) than outpatients. We found that inpatient setting was independently associated with lower performance status (odds ratio = 0.068, 95% confidence interval = 0.038-0.120, P < 0.0001). CONCLUSION Compared with inpatients, outpatients are more burdened by pain at first PC encounter yet experience higher quality of life and better performance status. These findings suggest different clinician skillsets, and assessments are needed depending on the setting of PC consultation.
Collapse
Affiliation(s)
| | - Steven Wolf
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Syed Yousuf Zafar
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Diane Portman
- Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Janet Bull
- Four Seasons Compassion for Life, Hendersonville, North Carolina, USA
| | - Arif H Kamal
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| |
Collapse
|