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Ram R, Amit O, Adler A, Bar-On Y, Beyar-Katz O, Avivi I, Shasha D, Ben-Ami R. Early Antibiotic Deescalation and Discontinuation in Patients with Febrile Neutropenia after Cellular Therapy: A Single-Center Prospective Unblinded Randomized Trial. Transplant Cell Ther 2023; 29:708.e1-708.e8. [PMID: 37591446 DOI: 10.1016/j.jtct.2023.08.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
The optimal duration of empiric antimicrobial therapy of febrile neutropenia in patients after cellular therapy is unclear. Early deescalation has been suggested by some authorities; however, data are lacking for cellular therapy recipients. We performed a randomized controlled study of cellular therapy recipients with febrile neutropenia to evaluate the safety and noninferiority of an early deescalation and discontinuation antibiotic strategy (EDD arm) versus standard broad-spectrum antibiotic treatment until recovery of neutropenia (standard duration arm). The primary outcome was the fraction of antibiotic-free neutropenia days. We randomized 110 patients to the standard duration arm (n = 51) or EDD arm (n = 59). The fraction of antibiotic-free neutropenia days was higher in the EDD arm compared to the standard duration arm (median, .8 [interquartile range (IQR), .62 to .86] versus .51 [IQR, .17 to .86]; P = .016). This was true for the per-protocol, allogeneic hematopoietic cell transplantation (HCT), autologous HCT, and anti-CD19 chimeric antigen receptor T cell therapy subgroups. Treatment success rate, subsequent fever, death within 30 days, and other common cellular therapy-related toxicities were all similar between the 2 study arms. An EDD antibiotic strategy in patients after cellular therapy was safe and associated with a substantial reduction in broad-spectrum antibiotic utilization without compromising cellular therapy outcomes.
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Affiliation(s)
- Ron Ram
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Odelia Amit
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Adler
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bar-On
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofrat Beyar-Katz
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Shasha
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Katz OB, Perry C, Greenzaid SG, Ofir DY, Luttwak E, Avni B, Zuckerman T, Sdayoor I, Stepensky P, Harlev SR, Bar-On Y, Libster D, Sharvit L, Amit O, Greenbaum U, Gold R, Herishanu Y, Benyamini N, Avivi I, Ram R. Response Rates of Extra-Nodal Diffuse Large B Cell Lymphoma to anti CD19-CAR T Cells - a Real Word Retrospective Multi-Center Study. Eur J Haematol 2023. [PMID: 36964939 DOI: 10.1111/ejh.13968] [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: 01/18/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/27/2023]
Abstract
Chimeric antigen receptor T-cells (CAR-T) are widely used for the treatment of relapsed/refractory Diffuse large B cell lymphoma (DLBCL). The data for CAR-T cell therapy in patients with extra-nodal(EN) lymphoma is restricted. We included 126 consecutive patients with DLBCL treated with commercially available CAR-T cells (tisagenlecleucel, n=100, 79.4% and axicabtagene ciloleucel, n=26, 20.6%). At lymphodepletion, 72/126(57%) had EN disease, 42/126(33%) patients had nodal disease (ND)-only and 12/126(10%) showed no disease assessed by PET-CT. There were no significant differences in CAR-T related toxicities and in the median PFS between EN patients and ND [10.76(95% CI: 7.8-13.6) vs 14.1 (95% CI:10-18.1) months, p =0.126)]. Similarly, median OS was not significantly different [15.36 (95% CI 12.5-18.2) vs. 18.4 (95% CI 14.8-22.1) months, p =0.100]. Subgroup analysis according to the number of EN involved sites showed that median PFS and OS were significantly higher in patients with <3 EN sites [12.3 months (95% CI 9-15.5)] vs 4.28 months (95% CI 0.6-7.9), p=0.010] compared to patients with >2 EN sites, respectively [16.5 months (95% CI 13.4-19.6) vs 8.7 months (95% CI 4.6-12.8), p=0.05]. In multivariate cox regression analysis, increased number sites of EN disease and high LDH at lymphodepletion negatively impacted PFS (p=0.021 and <0.001, respectively), while sex, type of product administered, age and performance status did not predict PFS and OS. Of note, all the patients with involvement of gastrointestinal tract (n= 9), urinary tract (n= 9), or pharynx (n= 3) at lymphodepletion, progressed or had an early relapse. In conclusions, patients with >2 EN sites at lymphodepletion have significantly worse clinical outcomes compared to patients with < 3 EN sites. Patients with specific sites of EN disease may demonstrate grim prognosis.
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Affiliation(s)
- Ofrat Beyar Katz
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Chava Perry
- Department of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Grisariu Greenzaid
- Department of Bone Marrow Transplantation & Cancer Immunotherapy Hadassah Medical Center Jerusalem
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dana Yehudai Ofir
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Efrat Luttwak
- Department of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Batia Avni
- Department of Bone Marrow Transplantation & Cancer Immunotherapy Hadassah Medical Center Jerusalem
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Inbal Sdayoor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Polina Stepensky
- Department of Bone Marrow Transplantation & Cancer Immunotherapy Hadassah Medical Center Jerusalem
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shimrit Ringelstein Harlev
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yael Bar-On
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bone Marrow Transplant and cellular therapy, Tel Aviv, Israel
| | - Diana Libster
- Department of Bone Marrow Transplantation & Cancer Immunotherapy Hadassah Medical Center Jerusalem
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Liat Sharvit
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Odelia Amit
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bone Marrow Transplant and cellular therapy, Tel Aviv, Israel
| | - Uri Greenbaum
- Department of Hematology, Soroka University Medical center and Faculty of Health and Science, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Ronit Gold
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bone Marrow Transplant and cellular therapy, Tel Aviv, Israel
| | - Yair Herishanu
- Department of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Benyamini
- Department of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Department of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bone Marrow Transplant and cellular therapy, Tel Aviv, Israel
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Wolach O, Frisch A, Shargian L, Yeshurun M, Apel A, Vainstein V, Moshe Y, Shimony S, Amit O, Bar-On Y, Ofran Y, Raanani P, Nachmias B, Ram R. Venetoclax in combination with FLAG-IDA-based protocol for patients with acute myeloid leukemia: a real-world analysis. Ann Hematol 2022; 101:1719-1726. [PMID: 35732976 DOI: 10.1007/s00277-022-04883-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/01/2022] [Indexed: 11/24/2022]
Abstract
Venetoclax in combination with intensive therapies is explored in both the upfront and relapse/refractory (R/R) setting, and available data suggest that such regimens are effective albeit with added hematological and infectious toxicity. We conducted a multicenter retrospective cohort study of patients with acute myeloid leukemia (AML) treated with venetoclax in combination with FLAG-IDA protocol. Twenty-five patients were included in this analysis (median age 53.4 years). Most patients were treated for R/R AML (n = 24, 96%) with a median of one (range 0-3) previous lines of therapy and 44% of patients (n = 11) having prior allogeneic hematopoietic cell transplantation (HCT). Median follow-up was 10 (range, 4-26) months. Platelet and neutrophil recovery were observed at a median of 31 (95% CI 17.6-38.3) and 23 (95% CI 20-28) days, respectively. The most common adverse events were infectious (blood stream infections, 48% and invasive fungal infections, 32%). Thirty-day mortality was 12%. Composite complete remission (CRc) was 72% for the entire cohort and 91% in patients treated for post-HCT relapse. Incidences of relapse-free and overall survival at 12 months were 67% (95% CI 58-76%) and 50% (95% CI 31-69%), respectively. Real-world data show that the addition of venetoclax to FLAG-IDA protocol is effective in patients with high-risk AML, most notably in the post-HCT relapse setting. Prophylaxis and surveillance for infections are crucial.
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Affiliation(s)
- Ofir Wolach
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Jabotinsky 39, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Avraham Frisch
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Jabotinsky 39, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Jabotinsky 39, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arie Apel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Shamir Medical Center (Formerly Assaf Harofe Medical Center), Be'er Ya'akov, Israel
| | - Vladimir Vainstein
- Department of Hematology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yakir Moshe
- Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shai Shimony
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Jabotinsky 39, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Leukemia department, Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Odelia Amit
- Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Bar-On
- Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yishai Ofran
- The Hematology Department, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Jabotinsky 39, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ron Ram
- Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Ram R, Freund T, Halperin T, Ben-Ami R, Amit O, Bar-On Y, Beyar-Katz O, Eilaty N, Gold R, Kay S, Glait-Santar C, Hagin D. Immunogenicity of a third dose of the BNT162b2 mRNA Covid-19 Vaccine in Patients with impaired B cell reconstitution after cellular therapy - a Single Center Prospective Cohort Study. Transplant Cell Ther 2022; 28:278.e1-278.e4. [PMID: 35182795 PMCID: PMC8848544 DOI: 10.1016/j.jtct.2022.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
Patients with delayed B-cell reconstitution/B-cell aplasia after cellular therapy show decreased immunogenicity to the BNT162b2 mRNA COVID-19 vaccine. We prospectively evaluated both humoral and cellular immune response to a third vaccine dose in patients after allogeneic HCT (n = 10) or CD19-based chimeric antigen receptor T cells (CAR-T) therapy (n = 6) with low absolute B cell numbers and who failed to mount a humeral response after 2 vaccine doses. Humoral response was documented in 40% and 17% after allogeneic HCT and CAR-T therapy, respectively. None of the patients with complete B-cell aplasia developed anti-vaccine antibodies. Cellular response was documented in all patients after allogeneic HCT and in 83% of the patients after CAR-T. T-cell subclasses levels were not predictive for response, while a longer duration from infusion of cells was associated with a better cellular response. We conclude that cellular response develops with repeated vaccine doses even in patients with B-cell aplasia or delayed B-cell reconstitution, and these patients should therefore be vaccinated. These results should be considered in future studies analyzing immunogenicity in this population. Larger and longer follow-up studies are required to confirm whether cellular immunogenicity translates into vaccine efficacy.
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Affiliation(s)
- Ron Ram
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tal Freund
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Allergy and Clinical Immunology Unit, Department of Medicine, Tel Aviv Sourasky Medical Center, Israel
| | - Tami Halperin
- Laboratory for HIV diagnosis, the AIDS Center, Tel Aviv Sourasky Medical Center, Israel
| | - Ronen Ben-Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Israel
| | - Odelia Amit
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bar-On
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofrat Beyar-Katz
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nili Eilaty
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Gold
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel
| | - Sigi Kay
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chen Glait-Santar
- BMT Unit, Tel Aviv Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hagin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Allergy and Clinical Immunology Unit, Department of Medicine, Tel Aviv Sourasky Medical Center, Israel
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5
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Ram R, Hagin D, Kikozashvilli N, Freund T, Amit O, Bar-On Y, Beyar-Katz O, Shefer G, Moshiashvili MM, Karni C, Gold R, Kay S, Glait-Santar C, Eshel R, Perry C, Avivi I, Apel A, Benyamini N, Shasha D, Ben-Ami R. Safety and Immunogenicity of the BNT162b2 mRNA COVID-19 Vaccine in Patients after Allogeneic HCT or CD19-based CART therapy-A Single-Center Prospective Cohort Study. Transplant Cell Ther 2021; 27:788-794. [PMID: 34214738 PMCID: PMC8242200 DOI: 10.1016/j.jtct.2021.06.024] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 12/20/2022]
Abstract
Data are scarce regarding both the safety and immunogenicity of the BNT162b2 mRNA COVID-19 vaccine in patients undergoing immune cell therapy; thus, we prospectively evaluated these two domains in patients receiving this vaccine after allogeneic hematopoietic cell transplantation (HCT; n = 66) or after CD19-based chimeric antigen receptor T cell (CART) therapy (n = 14). Overall, the vaccine was well tolerated, with mild non-hematologic vaccine-reported adverse events in a minority of the patients. Twelve percent of the patients after the first dose and 10% of the patients after the second dose developed cytopenia, and there were three cases of graft-versus-host disease exacerbation after each dose. A single case of impending graft rejection was summarized as possibly related. Evaluation of immunogenicity showed that 57% of patients after CART infusion and 75% patients after allogeneic HCT had evidence of humoral and/or cellular response to the vaccine. The Cox regression model indicated that longer time from infusion of cells, female sex, and higher CD19+ cells were associated with a positive humoral response, whereas a higher CD4+/CD8+ ratio was correlated with a positive cellular response, as confirmed by the ELISpot test. We conclude that the BNT162b2 mRNA COVID-19 vaccine has impressive immunogenicity in patients after allogeneic HCT or CART. Adverse events were mostly mild and transient, but some significant hematologic events were observed; hence, patients should be closely monitored.
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Affiliation(s)
- Ron Ram
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - David Hagin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Allergy and Clinical Immunology Unit, Department of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nino Kikozashvilli
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Freund
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Allergy and Clinical Immunology Unit, Department of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Odelia Amit
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bar-On
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofrat Beyar-Katz
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabi Shefer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Endocrinology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Miguel Morales Moshiashvili
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Endocrinology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Chen Karni
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Gold
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Sigi Kay
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chen Glait-Santar
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rinat Eshel
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chava Perry
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arie Apel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Hematology Ward, Shamir Medical Center (Assaf Haraofeh), Zerifin, Israel
| | - Noam Benyamini
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Shasha
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Bone Marrow Transplantation Unit, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel; Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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6
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Shimony S, Yeshurun M, Wolach O, Ram R, Rozovski U, Shargian L, Zukerman T, Amit O, Bar-On Y, Krayem B, Avni B, Peretz G, Raanani P, Pasvolsky O. Post-transplantation maintenance with sorafenib or midostaurin for FLT3 positive AML patients - a multicenter retrospective observational study. Leuk Lymphoma 2021; 62:2475-2481. [PMID: 33879026 DOI: 10.1080/10428194.2021.1913145] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The role of post allogeneic stem-cell transplantation (AlloSCT) FLT3 inhibition for acute myeloid leukemia in the real-world setting is unclear, especially in the era of widespread pre-transplant use of tyrosine kinase inhibitors (TKIs). In a multicenter nationwide study, we assessed 41 patients who were treated with post-transplant TKIs (sorafenib, n = 23, midostaurin, n = 18). The majority also received TKIs pre-transplant (n = 32, 79%). After a median follow up of 10 months post-transplant (range 3-53.6), 29 patients (71%) were alive and in complete remission. Similar results were seen in a subgroup analysis of pre-transplant TKI recipients (78%). In Univariate analysis, HCT-CI score < 4 and Type of TKI (sorafenib versus midostaurin) predicted longer overall survival. Seventeen patients (41%) suffered from side effects and seven patients (17%) stopped TKI therapy due to adverse events. Overall, our data suggest that post-transplant use of TKIs is safe and effective in an era of their widespread use prior to AlloSCT.
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Affiliation(s)
- Shai Shimony
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 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
| | - Ron Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tsila Zukerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, and Rappaport Faculty of Medicine - Technion, Haifa, Israel
| | - Odelia Amit
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Bar-On
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Baher Krayem
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, and Rappaport Faculty of Medicine - Technion, Haifa, Israel
| | - Batya Avni
- Institute of Hematology, Hadassah Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Galit Peretz
- Department of Hematology and Bone Marrow Transplantation, Soroka Medical center and Faculty of Medicine, Beer Sheva, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Luttwak E, Hagin D, Perry C, Wolach O, Itchaki G, Amit O, Bar-On Y, Freund T, Kay S, Eshel R, Avivi I, Ram R. Anti-CD19 CAR-T therapy for EBV-negative posttransplantation lymphoproliferative disease-a single center case series. Bone Marrow Transplant 2020; 56:1031-1037. [PMID: 33230187 DOI: 10.1038/s41409-020-01145-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 11/09/2022]
Abstract
Posttransplantation lymphoproliferative disease (PTLD) is a potentially fatal disorder arising after solid organ or hematopoietic cell transplantation. Survival rates of PTLD with diffuse large B-cell lymphoma (DLBCL) phenotype have improved due to the introduction of rituximab, however, reports on curative management of refractory PTLD are scarce. Here, we describe successful management of three patients with refractory EBV-negative PTLD with chimeric antigen receptor T-cell (CAR-T) therapy. All patients continued calcineurin inhibitors throughout the whole course of treatment. T-cell immunophenotyping was performed on both the apheresed cells and CAR-T product to investigate the T-cell compartment subpopulations. All three patients responded to a single infusion of tisagenlecleucel and two of them achieved CR. Toxicity profile was similar to other patients with non-PTLD DLBCL treated with CAR-T. No transplanted graft dysfunction was observed during the course of therapy. To our knowledge, this is the first report demonstrating that patients with EBV-negative refractory PTLD may benefit from CAR-T therapy, similarly to other patients with relapse/refractory DLBCL. A larger cohort of patients is needed to further establish proof-of-concept.
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Affiliation(s)
- Efrat Luttwak
- BMT Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - David Hagin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Immunology Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel
| | - Chava Perry
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel
| | - Ofir Wolach
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Gilad Itchaki
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Odelia Amit
- BMT Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bar-On
- BMT Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Freund
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Immunology Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel
| | - Sigi Kay
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel
| | - Rinat Eshel
- BMT Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel
| | - Ron Ram
- BMT Unit, Tel Aviv (Sourasky) Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ram R, Amit O, Zuckerman T, Gurion R, Raanani P, Bar-On Y, Avivi I, Wolach O. Venetoclax in patients with acute myeloid leukemia refractory to hypomethylating agents-a multicenter historical prospective study. Ann Hematol 2019; 98:1927-1932. [PMID: 31187237 DOI: 10.1007/s00277-019-03719-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Abstract
Patients with acute myeloid leukemia (AML) who progress after exposure to hypomethylating agents (HMA) have a dismal prognosis. We hypothesized that the addition of venetoclax, a BCL-2 inhibitor, to AML patients who previously failed HMA might overcome resistance. Adult patients (≥ 18 years) with AML were eligible if leukemia relapsed after, or was refractory to HMA. In general, in addition to venetoclax, patients continued HMA or other low-intensity therapies. Patients who previously underwent allogeneic hematopoietic cell transplantation (HCT) were also eligible. Data were analyzed in November 2018. Twenty-three patients were treated between October 2016 and October 2018 and were eligible for this study. Median age was 76 years and 6 patients had leukemia that relapsed post allogeneic HCT. None of the patients experienced tumor lysis syndrome and toxicities were as expected and manageable. Febrile neutropenia was the most common toxicity (78% of patients). Median hospitalization time was 13 days. Forty-three percent of the patients achieved CR/CRi. Overall survival (OS) was 74% at 6 months and median OS in patients who achieved remission was 10.8 months. Higher number of blasts in both bone marrow and peripheral blood was associated with lower chances of CR, while higher WBC, LDH, and bone marrow or peripheral blasts were associated with increased mortality rate. The addition of venetoclax to patients with HMA-refractory AML may result in a substantial anti-leukemic activity, specifically in those achieving complete remission. This should be further tested in a well-designed prospective trial.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antimetabolites, Antineoplastic/administration & dosage
- Antineoplastic Agents/therapeutic use
- Azacitidine/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Chemotherapy-Induced Febrile Neutropenia/etiology
- Chemotherapy-Induced Febrile Neutropenia/mortality
- Chemotherapy-Induced Febrile Neutropenia/pathology
- Decitabine/administration & dosage
- Drug Administration Schedule
- Drug Resistance, Neoplasm/drug effects
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Male
- Middle Aged
- Prospective Studies
- Remission Induction
- Sulfonamides/therapeutic use
- Survival Analysis
- Transplantation, Homologous
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Affiliation(s)
- Ron Ram
- BMT Unit, Tel Aviv Medical Center, 6 Weizman St., Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Odelia Amit
- BMT Unit, Tel Aviv Medical Center, 6 Weizman St., Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Ronit Gurion
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center Petah Tiqva, Institute of Hematology, Petah Tikva, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center Petah Tiqva, Institute of Hematology, Petah Tikva, Israel
| | - Yael Bar-On
- BMT Unit, Tel Aviv Medical Center, 6 Weizman St., Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- BMT Unit, Tel Aviv Medical Center, 6 Weizman St., Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Wolach
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center Petah Tiqva, Institute of Hematology, Petah Tikva, Israel
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Gendelman O, Amital H, Bar-On Y, Ben-Ami Shor D, Amital D, Tiosano S, Shalev V, Chodick G, Weitzman D. Time to diagnosis of fibromyalgia and factors associated with delayed diagnosis in primary care. Best Pract Res Clin Rheumatol 2018; 32:489-499. [DOI: 10.1016/j.berh.2019.01.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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10
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Ben-Ami Shor D, Weitzman D, Dahan S, Gendelman O, Bar-On Y, Amital D, Shalev V, Chodick G, Amital H. Adherence and Persistence with Drug Therapy among Fibromyalgia Patients: Data from a Large Health Maintenance Organization. J Rheumatol 2017; 44:1499-1506. [DOI: 10.3899/jrheum.170098] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2017] [Indexed: 02/08/2023]
Abstract
Objective.To assess 1-year persistence and adherence rates with drug therapy among patients with fibromyalgia (FM) and to identify factors associated with therapy discontinuation.Methods.This retrospective, cohort study included members ≥ 21 years old from the Maccabi Healthcare Services, a large health maintenance organization in Israel, who were diagnosed with FM from 2008 through 2011. Medications of interest included the anticonvulsant pregabalin, antidepressants [selective serotonin reuptake inhibitor (SSRI), serotonin/norepinephrine reuptake inhibitor (SNRI)], and tricyclic antidepressants (TCA). Time to treatment discontinuation and proportion of days covered (PDC) with FM-specific therapies during the year from first dispensed were analyzed. PDC < 20% was considered low adherence and PDC ≥ 80% was considered high adherence. Logistic regression models were constructed for multivariable analyses.Results.Overall, 3932 patients with FM were included; 88.7% were female. Pre-diagnosis use of medication of interest was documented in 41% of the study population. Of the remaining 2312 patients, 56.1% were issued a prescription, 45.0% were dispensed at least 1 medication in the year following diagnosis, and only 28.8% had prescriptions filled twice within the first year from diagnosis. Among newly prescribed patients, 1-year discontinuation was highest for TCA (91.0%) and lowest for SSRI/SNRI antidepressants (73.7%). Over half of the patients (60.5%) had fewer than 20% of the days covered by any medication during the year and only 9.3% were very adherent (PDC ≥ 80%).Conclusion.This study clearly shows that in an Israeli “real-life” population of patients with FM, persistence and adherence with FM therapy in the year following diagnosis is remarkably low.
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Bar-On Y, Shalev V, Weitzman D, Chodick G, Amital H. Old obstacles but new hopes: trying to understand the fibromyalgia construct. Isr Med Assoc J 2014; 16:625-626. [PMID: 25438449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Abstract
OBJECTIVE To assess whether laser Doppler flowmetry could detect differences in the cutaneous response to postischemic reactive hyperemia between patients with non-insulin-dependent diabetes mellitus (NIDDM) and nondiabetic controls and among subgroups of NIDDM patients. RESEARCH DESIGN AND METHODS We measured the cutaneous blood flow on the forearms during the postischemic reactive hyperemia test in diabetic patients and nondiabetic controls. Subjects were 25 patients with NIDDM from the outpatient clinics of dermatology, ophthalmology, and endocrinology and 25 nondiabetic volunteers matched for sex and age. Of the patients with NIDDM, 14 had proliferative retinopathy, and 13 were obese. Cutaneous postischemic reactive hyperemia test monitored by measuring the cutaneous blood flow with laser Doppler flowmetry was used. Peak blood flow (P) after arterial occlusion, the time required to reach this peak (Tp) and the ratio (K) between these two quantities (K = P/Tp) were measured. RESULTS In diabetic patients, P was significantly lower (P less than 0.02) than in nondiabetic control subjects. In diabetic patients with proliferative retinopathy, K was lower (P less than 0.05) than in diabetic patients without retinopathy. Diabetic patients with a body mass index (BMI; wt/ht2) less than 25 kg/m2 had a longer Tp (P less than 0.002), whereas the control group BMI did not affect this parameter. The combination of retinopathy and BMI less than 25 gave the longest Tp values (P less than 0.0001). CONCLUSIONS Postischemic hyperemia tests in diabetic patients reveal cutaneous microcirculatory changes in the forearm (lower P). Advanced retinopathy is associated with functional disturbances (lower K), especially when combined with a low BMI (less than 25; longer Tp).
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Affiliation(s)
- E Tur
- Department of Dermatology, Ichilov Medical Center, Tel Aviv, Israel
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