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Haran A, Even-Zohar NG, Haran M, Lebel E, Aumann S, Shaulov A, Gatt M, Nachmias B. Impact of Folinic Acid Dosing on Efficacy and Toxicity of High-Dose Methotrexate in Central Nervous System Lymphoma. Clin Lymphoma Myeloma Leuk 2024; 24:187-193.e1. [PMID: 38008594 DOI: 10.1016/j.clml.2023.10.012] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION High-dose methotrexate (HDMTX)-based regimens are the treatment of choice in primary central nervous system lymphoma (PCNSL). Folinic acid (FA) rescue is used to mitigate the toxic effects of MTX on normal cells. However, the optimal dosing of FA in PCNSL remains uncertain. METHODS We analyzed the relationship between FA dosing and treatment efficacy and toxicity in a cohort of 36 PCNSL patients treated at our institute between the years 2014 and 2022. A combination of univariate and multivariate analyses using known prognostic factors were used to determine the association between FA dosing and treatment outcomes. RESULTS We found that higher per-treatment cumulative FA doses were associated with inferior progression-free survival (PFS), with a hazard ratio (HR) of 2.2 for each 100 mg/m2 increase in FA dose. We identified a threshold of 350 mg/m2/treatment, above which there was a significant reduction in PFS. Notably, lower FA doses did not result in increased toxicity. CONCLUSION Our findings suggest that optimizing FA dosing to avoid very high rescue doses may improve treatment outcomes in PCNSL patients receiving HDMTX. Further prospective studies are warranted to validate these findings.
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Affiliation(s)
- Arnon Haran
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel.
| | - Noa Gross Even-Zohar
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Michal Haran
- Department of Hematology, Kaplan Medical Center, Rehovot, Israel
| | - Eyal Lebel
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Shlomzion Aumann
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Moshe Gatt
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
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Nachmias B, Krichevsky S, Gatt ME, Gross Even-Zohar N, Shaulov A, Haran A, Aumann S, Vainstein V. Standardization of Molecular MRD Levels in AML Using an Integral Vector Bearing ABL and the Mutation of Interest. Cancers (Basel) 2023; 15:5360. [PMID: 38001621 PMCID: PMC10670136 DOI: 10.3390/cancers15225360] [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: 10/11/2023] [Revised: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Quantitative PCR for specific mutation is being increasingly used in Acute Myeloid Leukemia (AML) to assess Measurable Residual Disease (MRD), allowing for more tailored clinical decisions. To date, standardized molecular MRD is limited to typical NPM1 mutations and core binding factor translocations, with clear prognostic and clinical implications. The monitoring of other identified mutations lacks standardization, limiting its use and incorporation in clinical trials. To overcome this problem, we designed a plasmid bearing both the sequence of the mutation of interest and the ABL reference gene. This allows the use of commercial standards for ABL to determine the MRD response in copy number. We provide technical aspects of this approach as well as our experience with 19 patients with atypical NPM1, RUNX1 and IDH1/2 mutations. In all cases, we demonstrate a correlation between response and copy number. We further demonstrate how copy number monitoring can modulate the clinical management. Taken together, we provide proof of concept of a novel yet simple tool, which allows in-house MRD monitoring for identified mutations, with ABL-based commercial standards. This approach would facilitate large multi-center studies assessing the clinical relevance of selected MRD monitoring.
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Burstein R, Aviv A, Even-Zohar NG, Nachmias B, Haran A, Braun M, Rottenberg Y, Shaulov A. Comparing end-of-life care of hematologic malignancy versus solid tumor patients in a tertiary care center. Eur J Haematol 2023; 111:528-535. [PMID: 37385825 DOI: 10.1111/ejh.14035] [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: 03/13/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To compare end-of-life (EOL) care for solid tumor and hematologic malignancy (HM) patients. METHODS We collected data on the last 100 consecutive deceased HM and 100 consecutive deceased solid tumor patients who died prior to June 1st 2020, treated at a single center. We compared demographic parameters, cause of death as ascertained by review of medical records by two independent investigators, and EOL quality indicators including: place of death, use of chemotherapy or targeted/biologic treatment, emergency department visits as well as hospital, inpatient hospice and Intensive Care Unit admissions and the time spent as inpatient over the last 30 days of life; mechanical ventilation and use of blood products during the last 14 days of life. RESULTS In comparison with solid tumor patients, HM patients more commonly died from treatment complications (13% vs. 1%) and unrelated causes (16% vs. 2%, p < .001 for all comparisons). HM patients died more frequently than solid tumor patients in the intensive care unit (14% vs. 7%) and the emergency department (9% vs. 0%) and less frequently in hospice (9% vs. 15%, p = .005 for all comparisons). In the 2 weeks prior to death HM patients were more likely than solid tumor patients to undergo mechanical ventilation (14% vs. 4%, p = .013), receive blood (47% vs. 27%, p = .003) and platelet transfusions (32% vs. 7%, p < .001); however, no statistical difference was found in use of either of chemotherapy (18% vs. 13%, p = .28) or targeted treatment (10% vs. 5%, p = .16). CONCLUSIONS HM patients were more likely than solid tumor patients to undergo aggressive measures at EOL. Rarity of HM deaths, frequently caused by complications of treatment and unrelated causes, may affect treatment choices at EOL.
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Affiliation(s)
- Rachel Burstein
- School of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Aviv
- Department of Hematology, HaEmek Medical Center, Afula, Israel
| | - Noa Gross Even-Zohar
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Arnon Haran
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Braun
- Breast Oncology Unit, Sharett Institute of Oncology, Hadassah Medical Center, Jerusalem, Israel
- School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
| | - Yakir Rottenberg
- Department of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Canaani J, Frisch A, Pollyea DA, Schwartz M, Aumann S, Ganzel C, Haran A, Even-Zohar NG, Shaulov A, Vainstein V, Moshe Y, Ofran Y, Wolach O, Nachmias B. Venetoclax-based salvage therapy for adult patients with relapsed/refractory acute lymphoblastic leukemia. Eur J Haematol 2023. [PMID: 37254665 DOI: 10.1111/ejh.14015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Dysregulation of BCL-2 family members has been reported in acute lymphocytic leukemia (ALL), with various BH3-dependencies of the leukemic clone. We conducted a multicenter retrospective cohort of patients with relapsed/refractory B or T ALL, with ven-chemotherapy or ven-navitoclax combinations, to assess efficacy and safety. METHODS Seventeen patients were included in the analysis, median age was 32 years, with 6 B-ALL and 11 T-ALL patients. Nine patients received venetoclax combined with chemotherapy, and 13 patients received venetoclax in combination with navitoclax, vincristine and asparaginase, of which 5 were already exposed to venetoclax in previous lines. RESULTS ORR was 55% and 46% among the ven-chemotherapy and the ven-navitoclax-chemotherapy, respectively. Most of the responders proceeded to an allogenic bone marrow transplant in both cohorts. The most common adverse effects of the ven-navitoclax combination were infectious complications and hepatotoxicity. CONCLUSIONS Our data demonstrated the possible efficacy of ven-chemotherapy and ven-navitoclax in r/r ALL with moderate toxicity.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Avraham Frisch
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, and Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Daniel A Pollyea
- Division of Hematology, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Marc Schwartz
- Division of Hematology, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Shlomzion Aumann
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Chezi Ganzel
- The Hematology Department, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel, Jerusalem, Israel
| | - Arnon Haran
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Noa Gross Even-Zohar
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Vladimir Vainstein
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yakir Moshe
- Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yishai Ofran
- The Hematology Department, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel, Jerusalem, Israel
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Lebel E, Nachmias B, Pick M, Gross Even-Zohar N, Gatt ME. Understanding the Bioactivity and Prognostic Implication of Commonly Used Surface Antigens in Multiple Myeloma. J Clin Med 2022; 11:jcm11071809. [PMID: 35407416 PMCID: PMC9000075 DOI: 10.3390/jcm11071809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/19/2022] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
Multiple myeloma (MM) progression is dependent on its interaction with the bone marrow microenvironment and the immune system and is mediated by key surface antigens. Some antigens promote adhesion to the bone marrow matrix and stromal cells, while others are involved in intercellular interactions that result in differentiation of B-cells to plasma cells (PC). These interactions are also involved in malignant transformation of the normal PC to MM PC as well as disease progression. Here, we review selected surface antigens that are commonly used in the flow cytometry analysis of MM for identification of plasma cells (PC) and the discrimination between normal and malignant PC as well as prognostication. These include the markers: CD38, CD138, CD45, CD19, CD117, CD56, CD81, CD27, and CD28. Furthermore, we will discuss the novel marker CD24 and its involvement in MM. The bioactivity of each antigen is reviewed, as well as its expression on normal vs. malignant PC, prognostic implications, and therapeutic utility. Understanding the role of these specific surface antigens, as well as complex co-expressions of combinations of antigens, may allow for a more personalized prognostic monitoring and treatment of MM patients.
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Srebnik N, Gross Even-Zohar N, Salama A, Sela HY, Hirsch HJ, Gross-Tsur V, Eldar-Geva T. Recognizing the unique prenatal phenotype of Prader-Willi Syndrome (PWS) indicates the need for a diagnostic methylation test. Prenat Diagn 2020; 40:878-884. [PMID: 32297338 DOI: 10.1002/pd.5712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 03/12/2020] [Accepted: 04/04/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Prader-Willi syndrome (PWS) is a neurogenetic disorder characterized by mental retardation, morbid obesity, and endocrine and behavior disorders. We previously showed in a small group of patients that PWS may have a unique prenatal phenotype. We aimed to characterize clinical and ultrasonic features in a larger series of pregnancies with a PWS fetus. METHODS We retrospectively interviewed all mothers of children with PWS followed in the Israel national multidisciplinary PWS clinic. We compared details of the PWS pregnancy with the pregnancies of healthy siblings and with data from the general population. Medical records including ultrasound reports, obstetric records, and genetic results were analyzed. RESULTS Distinct prenatal features of PWS pregnancies included abnormal fetal growth [fetal growth restriction (FGR) (37.3%), increased head to abdominal circumference ratio (44.8%), decreased abdominal circumference (49.2%)], markedly decreased fetal movements (DFM) (80.4%), and polyhydramnios (42.0%) (P < 0.001 for all). The combination of abnormal growth accompanied by polyhydramnios or DFM was highly suggestive for PWS. CONCLUSIONS Recognition of the unique PWS phenotype should alert obstetricians to consider the possibility of PWS, perform the diagnostic methylation test, provide appropriate counseling, and plan optimal management of the affected pregnancy.
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Affiliation(s)
- Naama Srebnik
- Shaare Zedek Medical Center, Obstetrics and Gynecology, Jerusalem, Israel.,Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Noa Gross Even-Zohar
- Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel.,Internal Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Abdalla Salama
- Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Hen Y Sela
- Shaare Zedek Medical Center, Obstetrics and Gynecology, Jerusalem, Israel.,Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Harry J Hirsch
- Shaare Zedek Medical Center Pediatrics, Jerusalem, Israel
| | - Varda Gross-Tsur
- Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel.,Pediatric Neurology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Talia Eldar-Geva
- Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel.,Reproductive Endocrinology and Genetics unit, Shaare Zedek Medical Center, Jerusalem, Israel
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