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Zayac AS, Landsburg DJ, Hughes ME, Bock AM, Nowakowski GS, Ayers EC, Girton M, Hu M, Beckman AK, Li S, Medeiros LJ, Chang JE, Stepanovic A, Kurt H, Sandoval-Sus J, Ansari-Lari MA, Kothari SK, Kress A, Xu ML, Torka P, Sundaram S, Smith SD, Naresh KN, Karimi YH, Epperla N, Bond DA, Farooq U, Saad M, Evens AM, Pandya K, Naik SG, Kamdar M, Haverkos B, Karmali R, Oh TS, Vose JM, Nutsch H, Rubinstein PG, Chaudhry A, Olszewski AJ. High-grade B-cell lymphoma, not otherwise specified: a multi-institutional retrospective study. Blood Adv 2023; 7:6381-6394. [PMID: 37171397 PMCID: PMC10598493 DOI: 10.1182/bloodadvances.2023009731] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
In this multi-institutional retrospective study, we examined the characteristics and outcomes of 160 patients with high-grade B-cell lymphoma, not otherwise specified (HGBL-NOS)-a rare category defined by high-grade morphologic features and lack of MYC rearrangements with BCL2 and/or BCL6 rearrangements ("double hit"). Our results show that HGBL-NOS tumors are heterogeneous: 83% of patients had a germinal center B-cell immunophenotype, 37% a dual-expressor immunophenotype (MYC and BCL2 expression), 28% MYC rearrangement, 13% BCL2 rearrangement, and 11% BCL6 rearrangement. Most patients presented with stage IV disease, a high serum lactate dehydrogenase, and other high-risk clinical factors. Most frequent first-line regimens included dose-adjusted cyclophosphamide, doxorubicin, vincristine, and etoposide, with rituximab and prednisone (DA-EPOCH-R; 43%); rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; 33%); or other intensive chemotherapy programs. We found no significant differences in the rates of complete response (CR), progression-free survival (PFS), or overall survival (OS) between these chemotherapy regimens. CR was attained by 69% of patients. PFS at 2 years was 55.2% and OS was 68.1%. In a multivariable model, the main prognostic factors for PFS and OS were poor performance status, lactate dehydrogenase >3 × upper limit of normal, and a dual-expressor immunophenotype. Age >60 years or presence of MYC rearrangement were not prognostic, but patients with TP53 alterations had a dismal PFS. Presence of MYC rearrangement was not predictive of better PFS in patients treated with DA-EPOCH-R vs R-CHOP. Improvements in the diagnostic criteria and therapeutic approaches beyond dose-intense chemotherapy are needed to overcome the unfavorable prognosis of patients with HGBL-NOS.
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Affiliation(s)
- Adam S. Zayac
- Division of Hematology/Oncology, The Warren Alpert Medical School Medical School of Brown University, Providence, RI
| | | | | | | | | | - Emily C. Ayers
- Division of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | - Mark Girton
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, VA
| | - Marie Hu
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Amy K. Beckman
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Shaoying Li
- Division of Pathology and Laboratory Medicine, Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L. Jeffrey Medeiros
- Division of Pathology and Laboratory Medicine, Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Julie E. Chang
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Adam Stepanovic
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Habibe Kurt
- Department of Pathology and Laboratory Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Jose Sandoval-Sus
- Department of Malignant Hematology and Cellular Therapy, Moffitt Cancer Center at Memorial Healthcare System, Pembroke Pines, FL
| | | | - Shalin K. Kothari
- Division of Hematology, Yale University School of Medicine, New Haven, CT
| | - Anna Kress
- Division of Hematology, Yale University School of Medicine, New Haven, CT
| | - Mina L. Xu
- Department of Pathology and Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Pallawi Torka
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Suchitra Sundaram
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Stephen D. Smith
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Medical Oncology, University of Washington, Seattle, WA
| | | | - Yasmin H. Karimi
- Division of Hematology-Oncology, University of Michigan Health, Ann Arbor, MI
| | | | - David A. Bond
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Umar Farooq
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Mahak Saad
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Andrew M. Evens
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Karan Pandya
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Seema G. Naik
- Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA
| | - Manali Kamdar
- Division of Hematology, Hematologic Malignancies and Stem Cell Transplantation, University of Colorado, Denver, CO
| | - Bradley Haverkos
- Division of Hematology, Hematologic Malignancies and Stem Cell Transplantation, University of Colorado, Denver, CO
| | - Reem Karmali
- Division of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Timothy S. Oh
- Division of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Julie M. Vose
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Heather Nutsch
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Paul G. Rubinstein
- Department of Medicine, Section of Hematology-Oncology, University of Illinois, Chicago, IL
| | - Amina Chaudhry
- Department of Medicine, Section of Hematology-Oncology, University of Illinois, Chicago, IL
| | - Adam J. Olszewski
- Division of Hematology/Oncology, The Warren Alpert Medical School Medical School of Brown University, Providence, RI
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2
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Ollila TA, Masel RH, Reagan JL, Lu S, Rogers RD, Paiva KJ, Taher R, Burguera-Couce E, Zayac AS, Yakirevich I, Niroula R, Barth P, Olszewski AJ. Seroconversion and outcomes after initial and booster COVID-19 vaccination in adults with hematologic malignancies. Cancer 2022; 128:3319-3329. [PMID: 35811461 PMCID: PMC9349722 DOI: 10.1002/cncr.34354] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [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: 03/25/2022] [Revised: 05/04/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022]
Abstract
Background Patients with hematologic malignancies have impaired humoral immunity secondary to their malignancy and its treatment, placing them at risk of severe coronavirus disease‐19 (COVID‐19) infection and reduced response to vaccination. Methods The authors retrospectively analyzed serologic responses to initial and booster COVID‐19 vaccination in 378 patients with hematologic malignancy and subsequently tracked COVID‐19–related outcomes. Results Seroconversion occurred in 181 patients (48%) after initial vaccination; patients who had active malignancy or those who were recently treated with a B‐cell–depleting monoclonal antibody had the lowest rates of seroconversion. For initial nonresponders to vaccination, seroconversion after a booster dose occurred in 48 of 85 patients (56%). The seroconversion rate after the booster was similar for patients on (53%) and off (58%) active therapy (p = .82). Thirty‐three patients (8.8%) developed a COVID‐19 infection, and there were three COVID‐19–related deaths (0.8%). Although no significant association was observed between postvaccination seroconversion and the incidence of COVID‐19 infection, no patient with seroconversion died from COVID‐19, and no patient who received tixagevimab/cilgavimab (N = 25) was diagnosed with a COVID‐19 infection. Conclusions Booster vaccinations can promote seroconversion in a significant proportion of patients who are seronegative after the initial vaccination course regardless of the specific vaccine or on/off treatment status at the time of revaccination. Although postvaccination seroconversion may not be associated with a decrease in any (including asymptomatic) COVID‐19 infection, the authors' experience suggested that effective vaccination (including a booster), supplemented by passive immunization using tixagevimab/cilgavimab in case of lack of seroconversion, effectively eliminated the risk of COVID‐19 death in the otherwise high‐risk population. Lay summary Patients with hematologic malignancy, especially lymphoma, have an impaired response to coronavirus disease 2019 (COVID‐19) vaccination. In this single‐institution review, less than one half of the patients studied made detectable antibodies. For those who did not make detectable antibodies after initial vaccination, over one half (65%) were able to produce antibodies after booster vaccination. By the end of February 2022, 33 of the original 378 patients had a documented COVID‐19 infection. The only deaths from COVID‐19 were in those who had undetectable antibodies, and no patient who received prophylactic antibody therapy developed a COVID‐19 infection.
Hematologic malignancies and their treatments impaired humoral immunity from coronavirus disease 2019 vaccination, and booster vaccine overcame a lack of initial response in 58% of patients, including 63% those on active therapy. The findings indicated that booster vaccinations should be strongly encouraged; however, even with boosters, many remain unprotected, which should inform infection prevention and treatment strategies.
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Affiliation(s)
- Thomas A Ollila
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rebecca H Masel
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - John L Reagan
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Shaolei Lu
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ralph D Rogers
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Infectious Disease, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kimberly J Paiva
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rashida Taher
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ella Burguera-Couce
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adam S Zayac
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Inna Yakirevich
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rabin Niroula
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Peter Barth
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adam J Olszewski
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
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3
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Hsu A, Kurt H, Zayac AS, Olszewski AJ. CD5 expression in marginal zone lymphoma predicts differential response to rituximab or bendamustine/rituximab. Leuk Lymphoma 2021; 63:31-42. [PMID: 34467833 DOI: 10.1080/10428194.2021.1973670] [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: 01/28/2023]
Abstract
We examined outcomes of 244 patients with marginal zone lymphoma (MZL) diagnosed in 2010-2020, of which 25 (10%) expressed CD5. CD5 expression was present in 22% of splenic, 8% of nodal, and 5% of extranodal MZL, and showed frequent blood/bone marrow involvement, elevated lactate dehydrogenase, and TP53 deletions. CD5 expression was not associated with progression-free or overall survival, but it conferred a significantly higher risk of histologic transformation (22% versus 4% at 5 years, p = 0.002). Among patients receiving first-line rituximab monotherapy, CD5 expression was associated with lower response rate (30% versus 77%, p = 0.006), PFS (25% versus 45% at 3 years, p = 0.003) and OS (44% versus 77%, p = 0.010), whereas CD5 status did not significantly affect outcomes of patients receiving bendamustine with rituximab (P for interaction = 0.012 for progression-free survival). CD5-positive MZL may have a propensity to leukemic dissemination, histologic transformation, and may derive benefit from first-line bendamustine/rituximab rather than rituximab alone.
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Affiliation(s)
- Andrew Hsu
- Division of Hematology/Oncology, Lifespan Cancer Institute, Providence, RI, USA.,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Habibe Kurt
- Department of Pathology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam S Zayac
- Division of Hematology/Oncology, Lifespan Cancer Institute, Providence, RI, USA
| | - Adam J Olszewski
- Division of Hematology/Oncology, Lifespan Cancer Institute, Providence, RI, USA.,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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4
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Zayac AS, Evens AM, Danilov A, Smith SD, Jagadeesh D, Leslie LA, Wei C, Kim SH, Naik S, Sundaram S, Reddy N, Farooq U, Kenkre VP, Epperla N, Blum KA, Khan N, Singh D, Alderuccio JP, Godara A, Yazdy MS, Diefenbach C, Rabinovich E, Varma G, Karmali R, Shao Y, Trabolsi A, Burkart M, Martin P, Stettner S, Chauhan A, Choi YK, Straker-Edwards A, Klein A, Churnetski MC, Boughan KM, Berg S, Haverkos BM, Orellana-Noia VM, D'Angelo C, Bond DA, Maliske SM, Vaca R, Magarelli G, Sperling A, Gordon MJ, David KA, Savani M, Caimi P, Kamdar M, Lunning MA, Palmisiano N, Venugopal P, Portell CA, Bachanova V, Phillips T, Lossos IS, Olszewski AJ. Outcomes of Burkitt lymphoma with central nervous system involvement: evidence from a large multicenter cohort study. Haematologica 2021; 106:1932-1942. [PMID: 33538152 PMCID: PMC8252937 DOI: 10.3324/haematol.2020.270876] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Indexed: 11/09/2022] Open
Abstract
Central nervous system (CNS) involvement in Burkitt lymphoma poses a major therapeutic challenge, and the relative ability of contemporary regimens to treat CNS involvement remains uncertain. We describe the prognostic significance of CNS involvement and the incidence of CNS recurrence/progression after contemporary immunochemotherapy using real-world clinicopathological data from adults with Burkitt lymphoma diagnosed between 2009 and 2018 in 30 institutions in the USA. We examined associations between baseline CNS involvement, patients’ characteristics, complete response rates, and survival. We also examined risk factors for CNS recurrence. Of 641 patients (aged 18 to 88 years), 120 (19%) had CNS involvement. CNS involvement was independently associated with human immunodeficiency virus infection, poor performance status, involvement of ≥2 extranodal sites, and bone marrow involvement. Selection of the first-line treatment regimen was unaffected by CNS involvement (P=0.93). Patients with CNS disease had significantly lower rates of complete response (59% vs. 77% for patients with and without CNS involvement, respectively; P<0.001), worse 3-year progression-free survival (adjusted hazard ratio [aHR]=1.53, 95% confidence interval [95% CI]: 1.14-2.06; P=0.004) and overall survival (aHR=1.62, 95% CI: 1.18-2.22; P=0.003). The 3-year cumulative incidence of CNS recurrence was 6% (95% CI: 4-8%) and was significantly lower among patients receiving other regimens (CODOX-M/IVAC, 4%, or hyperCVAD/MA, 3%) compared with DA-EPOCH-R (13%; adjusted sub-distribution HR=4.38, 95% CI:, 2.16-8.87; P<0.001). Baseline CNS involvement in Burkitt lymphoma is relatively common and portends inferior prognosis independently of the first-line treatment regimen selected. In real-world practice, regimens including intravenous systemic agents with pronounced CNS penetrance were associated with a lower risk of CNS recurrence. This finding may be influenced by observed suboptimal adherence to the strict CNS staging and intrathecal therapy procedures incorporated in the DA-EPOCH-R regimen.
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Affiliation(s)
- Adam S Zayac
- Lifespan Cancer Institute, Alpert Medical School of Brown University, Providence, RI
| | - Andrew M Evens
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Alexey Danilov
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Stephen D Smith
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Lori A Leslie
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Catherine Wei
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Seema Naik
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, PA
| | | | | | - Umar Farooq
- University of Iowa Carver College of Medicine, Iowa City, IA
| | | | | | | | - Nadia Khan
- Fox Chase Cancer Center, Philadelphia, PA
| | - Daulath Singh
- Loyola University Medical Center, Loyola University Chicago, Maywood, IL
| | - Juan P Alderuccio
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | | | - Maryam Sarraf Yazdy
- Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
| | | | | | | | | | - Yusra Shao
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Asaad Trabolsi
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | | | | | | | - Ayushi Chauhan
- Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
| | - Yun Kyong Choi
- New York University School of Medicine, Perlmutter Cancer Center, New York, NY
| | | | | | | | | | - Stephanie Berg
- Loyola University Medical Center, Loyola University Chicago, Maywood, IL
| | | | | | | | - David A Bond
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Seth M Maliske
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Ryan Vaca
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, PA
| | - Gabriella Magarelli
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Amy Sperling
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Max J Gordon
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Kevin A David
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Paolo Caimi
- University Hospitals Seidman Cancer Center, Cleveland, OH
| | | | | | - Neil Palmisiano
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | - Craig A Portell
- University of Virginia School of Medicine, Charlottesville, VA
| | | | | | - Izidore S Lossos
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Adam J Olszewski
- Lifespan Cancer Institute, Alpert Medical School of Brown University, Providence, RI.
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5
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Hsu A, Ohnigian S, Chang A, Liu Y, Zayac AS, Olszewski AJ, Reagan JL. Thrombosis in COVID-19: A Narrative Review of Current Literature and Inpatient Management. R I Med J (2013) 2021; 104:14-19. [PMID: 34044431] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
COVID-19 infection has been associated with an increased incidence of thrombotic events leading to poor patient outcomes. Given the rapid rise of the COVID-19 pandemic, the ability to conduct prospective trials has been limited and data regarding the use of standard-dose versus intermediate-dose thromboprophylaxis, use of empiric therapeutic anticoagulation, and use of extended-duration thromboprophylaxis after discharge has been largely based upon observational data without any high-quality prospective data guiding their use. In this article, we will review the incidence and frequency of arterial and venous thrombotic events along with the current literature surrounding the use of intermediate-dose thromboprophylaxis, empiric therapeutic anticoagulation, and use of extended-duration thromboprophylaxis for patients hospitalized with COVID-19.
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Affiliation(s)
- Andrew Hsu
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Sarah Ohnigian
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Augustus Chang
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Yuchen Liu
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Adam S Zayac
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Adam J Olszewski
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI
| | - John L Reagan
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI
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6
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Olszewski AJ, Jakobsen LH, Collins GP, Cwynarski K, Bachanova V, Blum KA, Boughan KM, Bower M, Dalla Pria A, Danilov A, David KA, Diefenbach C, Ellin F, Epperla N, Farooq U, Feldman TA, Gerrie AS, Jagadeesh D, Kamdar M, Karmali R, Kassam S, Kenkre VP, Khan N, Kim SH, Klein AK, Lossos IS, Lunning MA, Martin P, Martinez-Calle N, Montoto S, Naik S, Palmisiano N, Peace D, Phillips EH, Phillips TJ, Portell CA, Reddy N, Santarsieri A, Sarraf Yazdy M, Smeland KB, Smith SE, Smith SD, Sundaram S, Zayac AS, Zhang XY, Zhu C, Cheah CY, El-Galaly TC, Evens AM. Burkitt Lymphoma International Prognostic Index. J Clin Oncol 2021; 39:1129-1138. [PMID: 33502927 PMCID: PMC9851706 DOI: 10.1200/jco.20.03288] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Burkitt lymphoma (BL) has unique biology and clinical course but lacks a standardized prognostic model. We developed and validated a novel prognostic index specific for BL to aid risk stratification, interpretation of clinical trials, and targeted development of novel treatment approaches. METHODS We derived the BL International Prognostic Index (BL-IPI) from a real-world data set of adult patients with BL treated with immunochemotherapy in the United States between 2009 and 2018, identifying candidate variables that showed the strongest prognostic association with progression-free survival (PFS). The index was validated in an external data set of patients treated in Europe, Canada, and Australia between 2004 and 2019. RESULTS In the derivation cohort of 633 patients with BL, age ≥ 40 years, performance status ≥ 2, serum lactate dehydrogenase > 3× upper limit of normal, and CNS involvement were selected as equally weighted factors with an independent prognostic value. The resulting BL-IPI identified groups with low (zero risk factors, 18% of patients), intermediate (one factor, 36% of patients), and high risk (≥ 2 factors, 46% of patients) with 3-year PFS estimates of 92%, 72%, and 53%, respectively, and 3-year overall survival estimates of 96%, 76%, and 59%, respectively. The index discriminated outcomes regardless of HIV status, stage, or first-line chemotherapy regimen. Patient characteristics, relative size of the BL-IPI groupings, and outcome discrimination were consistent in the validation cohort of 457 patients, with 3-year PFS estimates of 96%, 82%, and 63% for low-, intermediate-, and high-risk BL-IPI, respectively. CONCLUSION The BL-IPI provides robust discrimination of survival in adult BL, suitable for use as prognostication and stratification in trials. The high-risk group has suboptimal outcomes with standard therapy and should be considered for innovative treatment approaches.
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Affiliation(s)
- Adam J. Olszewski
- Lifespan Cancer Institute, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Lasse H. Jakobsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Graham P. Collins
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Kirsten M. Boughan
- Adult Hematologic Malignancies and Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, OH
| | - Mark Bower
- National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, United Kingdom
| | - Alessia Dalla Pria
- National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, United Kingdom
| | - Alexey Danilov
- Toni Stephenson Lymphoma Center, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Kevin A. David
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Fredrik Ellin
- Department of Clinical Sciences Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | | | - Umar Farooq
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Tatyana A. Feldman
- John Theurer Cancer Center, Hackensack Meridian Health School of Medicine, Hackensack, NJ
| | - Alina S. Gerrie
- BC Cancer Centre for Lymphoid Cancer and The University of British Columbia, Vancouver, British Columbia, Canada
| | - Deepa Jagadeesh
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Reem Karmali
- Division of Hematology Oncology, Northwestern University, Chicago, IL
| | | | | | - Nadia Khan
- Fox Chase Cancer Center, Philadelphia, PA
| | - Seo-Hyun Kim
- Division of Hematology Oncology, Rush University Medical Center, Chicago, IL
| | - Andreas K. Klein
- Division of Hematology and Oncology, Tufts Medical Center, Boston, MA
| | - Izidore S. Lossos
- Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | | | - Peter Martin
- Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY
| | | | - Silvia Montoto
- Department of Haemato-oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Seema Naik
- Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA
| | - Neil Palmisiano
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | - David Peace
- Division of Hematology/Oncology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL
| | | | | | - Craig A. Portell
- Division of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | | | - Anna Santarsieri
- Department of Haematology, Cambridge University Hospitals NHSFT, Cambridge, United Kingdom
| | | | - Knut B. Smeland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Stephen D. Smith
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Suchitra Sundaram
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Adam S. Zayac
- Lifespan Cancer Institute, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Xiao-Yin Zhang
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Catherine Zhu
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Chan Y. Cheah
- Linear Clinical Research and Sir Charles Gairdner Hospital, Perth, Australia
| | - Tarec C. El-Galaly
- Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Andrew M. Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ,Andrew M. Evens, DO, MSc, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ 08901; e-mail:
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Zayac AS, Hilliard RW, Olszewski AJ, Pelcovits A, Reagan JL, Hsu A, Riley D, Austin M, Ollila TA. Enforcing the "4T": An In-Line Calculator for HIT Antibody Ordering in the Electronic Medical Record. R I Med J (2013) 2020; 103:78-83. [PMID: 33003686] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) remains a difficult clinical diagnosis, even with the under-utilized standardized scoring systems, like the '4T' score, to aid in clinical decision-making. Our quality improvement study sought to assess the use of '4T' score, improve the use of HIT antibody (HITA) testing and improvement management of possible HIT by implementing an in-line calculator with guidance within our electronic medical record (EMR) at our institution. We retrospectively reviewed patient charts between October 2017 and October 2018, assessing practices before and after implementation of the '4T' in-line calculator in April 2018. HITA were ordered inappropriately (for 4T <4) in 141 (67%) of 210 instances (75 before and 66 after). We found no statistically significant difference in positive predictive value (PPV) or 4T documentation in provider notes after its implementation. We were able to identify problematic areas in HIT management, such as the ordering of non-heparin anticoagulants, and implement additional changes addressing these problems.
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Affiliation(s)
- Adam S Zayac
- The Warren Alpert Medical School of Brown University, Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - Ross W Hilliard
- The Warren Alpert Medical School of Brown University, Division of General Internal Medicine, Rhode Island Hospital, Providence, RI
| | - Adam J Olszewski
- The Warren Alpert Medical School of Brown University, Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - Aryeh Pelcovits
- The Warren Alpert Medical School of Brown University, Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - John L Reagan
- The Warren Alpert Medical School of Brown University, Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - Andrew Hsu
- The Warren Alpert Medical School of Brown University, Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - David Riley
- The Warren Alpert Medical School of Brown University, Division of General Internal Medicine, Rhode Island Hospital, Providence, RI
| | - Matthew Austin
- The Warren Alpert Medical School of Brown University, Division of General Internal Medicine, Rhode Island Hospital, Providence, RI
| | - Thomas A Ollila
- The Warren Alpert Medical School of Brown University, Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
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8
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Hsu A, Liu Y, Zayac AS, Olszewski AJ, Reagan JL. Intensity of anticoagulation and survival in patients hospitalized with COVID-19 pneumonia. Thromb Res 2020; 196:375-378. [PMID: 32980620 PMCID: PMC7511207 DOI: 10.1016/j.thromres.2020.09.030] [Citation(s) in RCA: 24] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/31/2020] [Accepted: 09/21/2020] [Indexed: 10/29/2022]
Abstract
BACKGROUND SARS-CoV-2 infection has noted derangements in coagulation markers along with significant thrombotic complications. Post-mortem examinations show severe endothelial injury and widespread thrombotic microangiopathy in the pulmonary vasculature. Early reports describing the use of prophylactic anticoagulation demonstrated improved survival, leading to the adoption of prophylactic and therapeutic anticoagulation guided by D-dimer levels. The clinical usefulness of D-dimer values, trends, and more intensive anticoagulation remains an area of clinical interest. OBJECTIVES Assess the outcomes and laboratory trends in COVID-19 patients stratified by intensity of anticoagulation at time of admission. PATIENTS AND METHODS Retrospectively review the differences in clinical outcomes and laboratory trends in patients hospitalized with COVID-19 in the Lifespan Health System. RESULTS Between 27 February and 24 April 2020, 468 patients were hospitalized. Initial use of high-intensity thromboprophylaxis was associated with improved 30-day mortality (adjusted RR 0.26; 95% confidence interval [CI], 0.07-0.97; p = 0.045) without a significant increased rate of bleeding (p = 0.11). In severe COVID-19, D-dimer significantly increased during hospitalization with standard thromboprophylaxis (p < 0.001) but remained stable or decreased with high-intensity prophylaxis or therapeutic anticoagulation. CONCLUSION Patients who received high-intensity prophylactic anticoagulation had a downtrend in D-dimer levels and improved 30-day mortality. This suggests a role in anticoagulation in mitigating adverse outcomes associated with COVID-19; however, further randomized, prospective studies are needed.
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Affiliation(s)
- Andrew Hsu
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI, United States of America.
| | - Yuchen Liu
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Adam S Zayac
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Adam J Olszewski
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - John L Reagan
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
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Abstract
Gastric and gastroesophageal junction (GEJ) cancer is one of the most common malignancy worldwide. In unresectable or metastatic disease, the prognosis is poor and is generally less than a year. Standard front-line chemotherapy includes two- or three-drug regimens with the addition of trastuzumab in HER2-positive disease. With an increased understanding of the biology of cancer over the past few decades, targeted therapies have made their way into the treatment paradigm of many cancers. They been examined in the first- and second-line settings in the treatment of gastroesophageal cancer though has yielded few viable treatment options. One success is ramucirumab either as monotherapy or in combination with paclitaxel is the preferred choice in second-line therapy. While immunotherapy has been considered a breakthrough in oncology over the past decade, the response rates in gastric and gastroesophageal cancers have been relatively low compared to other cancers, resulting in its limited approval and mostly reserved for second-line therapy or beyond. In this article, we will review the standard first- and second-line treatment regimens. Furthermore, this article will review the use of targeted therapies and immunotherapy in treatment of gastric and gastroesophageal cancers. Lastly, we will touch upon future treatment strategies that are currently under investigation.
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Affiliation(s)
- Andrew Hsu
- Division of Hematology/Oncology, The Warren Alpert Medical School of Brown University, Lifespan Cancer Institute, Rhode Island Hospital, Providence, RI, USA
| | - Adam S Zayac
- Division of Hematology/Oncology, The Warren Alpert Medical School of Brown University, Lifespan Cancer Institute, Rhode Island Hospital, Providence, RI, USA
| | - Aditya Eturi
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Khaldoun Almhanna
- Division of Hematology/Oncology, The Warren Alpert Medical School of Brown University, Lifespan Cancer Institute, Rhode Island Hospital, Providence, RI, USA
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10
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Abstract
Genomic studies have revealed molecular mechanisms involved in the pathogenesis of Burkitt's lymphoma, including the ID3/TCF3-dependent centroblast gene expression program, tonic PI3K-AKT-mTOR signaling, and deregulation of cell cycle and apoptosis through mutations in cyclin D3, CDKN2A, or TP53. Unfortunately, these advances have not been translated into treatment, which relies on dose-intense cytotoxic chemotherapy. While most patients achieve long-term survival, options for relapsed/refractory disease are lacking, as Burkitt lymphoma is often excluded from clinical trials of novel approaches. The lower-intensity, dose-adjusted EPOCH plus rituximab (DA-EPOCH-R) regimen constitutes a major advance allowing for treatment of older and HIV-positive patients but needs augmentation to better address the central nervous system involvement. Furthermore, DA-EPOCH-R provides a platform for the study of targeted or immunotherapeutic approaches while de-escalating cytotoxic agents and their associated adverse effects. In this review we discuss the epidemiology and molecular genetics of BL, first-line treatment considerations, and potential novel treatment strategies.
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Affiliation(s)
- Adam S Zayac
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
| | - Adam J Olszewski
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
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11
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Decker DP, Egan PC, Zayac AS, Treaba DO, Olszewski AJ. Treatment strategies and risk of central nervous system recurrence in high-grade B-cell and Burkitt lymphoma. Leuk Lymphoma 2019; 61:198-201. [PMID: 31432717 DOI: 10.1080/10428194.2019.1654097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Dominic P Decker
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Pamela C Egan
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
| | - Adam S Zayac
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
| | - Diana O Treaba
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Pathology, Rhode Island Hospital, Providence, RI, USA
| | - Adam J Olszewski
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
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12
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Kufel WD, Zayac AS, Lehmann DF, Miller CD. Clinical Application and Pharmacodynamic Monitoring of Apixaban in a Patient with End-Stage Renal Disease Requiring Chronic Hemodialysis. Pharmacotherapy 2016; 36:e166-e171. [DOI: 10.1002/phar.1836] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Wesley D. Kufel
- Department of Pharmacy; Upstate University Hospital; Syracuse New York
| | - Adam S. Zayac
- Department of Medicine; Upstate Medical University; Syracuse New York
| | - David F. Lehmann
- Department of Medicine; Upstate Medical University; Syracuse New York
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