1
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Haque T, Cadenas FL, Xicoy B, Alfonso-Pierola A, Platzbecker U, Avivi I, Brunner AM, Chromik J, Morillo D, Patel MR, Falantes J, Leitch HA, Germing U, Preis M, Lenox L, Lauring J, Brown RJ, Kalota A, Mehta J, Pastore F, Gu J, Mistry P, Valcárcel D. Phase 1 study of JNJ-64619178, a protein arginine methyltransferase 5 inhibitor, in patients with lower-risk myelodysplastic syndromes. Leuk Res 2023; 134:107390. [PMID: 37776843 DOI: 10.1016/j.leukres.2023.107390] [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: 07/06/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023]
Abstract
Splicing factor (SF) gene mutations are frequent in myelodysplastic syndromes (MDS), and agents that modulate RNA splicing are hypothesized to provide clinical benefit. JNJ-64619178, a protein arginine methyltransferase 5 (PRMT5) inhibitor, was evaluated in patients with lower-risk (LR) MDS in a multi-part, Phase 1, multicenter study. The objectives were to determine a tolerable dose and to characterize safety, pharmacokinetics, pharmacodynamics, and preliminary clinical activity. JNJ-64619178 was administered on a 14 days on/7 days off schedule or every day on a 21-day cycle to patients with International Prognostic Scoring System (IPSS) Low or Intermediate-1 risk MDS who were red blood cell transfusion-dependent. Twenty-four patients were enrolled; 15 (62.5 %) patients had low IPSS risk score, while 18 (75.0 %) had an SF3B1 mutation. Median duration of treatment was 3.45 months (range: 0.03-6.93). No dose limiting toxicities were observed. The 0.5 mg once daily dose was considered better tolerated and chosen for dose expansion. Twenty-three (95.8 %) patients experienced treatment-emergent adverse events (TEAE). The most common TEAEs were neutropenia (15 [62.5 %]) and thrombocytopenia (14 [58.3 %]). JNJ-64619178 pharmacokinetics was dose-dependent. Target engagement as measured by plasma symmetric di-methylarginine was observed across all dose levels; however, variant allele frequency of clonal mutations in bone marrow or blood did not show sustained reductions from baseline. No patient achieved objective response or hematologic improvement per International Working Group 2006 criteria, or transfusion independence. A tolerable dose of JNJ-64619178 was identified in patients with LR MDS. However, no evidence of clinical benefit was observed.
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Affiliation(s)
| | | | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Germans Trias I Pujol, Badalona, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | - Irit Avivi
- Sourasky Medical Center, Tel Aviv, Israel
| | | | | | - Daniel Morillo
- University Hospital Fundación Jiménez Díaz, START Madrid-FJD early phase unit, Spain
| | - Manish R Patel
- Florida Cancer Specialists/Sarah Cannon Research Institute, Sarasota, FL, USA
| | - Jose Falantes
- Servicio de Hematologia, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS) / CSIC, Universidad de Sevilla, Spain
| | - Heather A Leitch
- St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ulrich Germing
- Universitätsklinikum Düsseldorf, Department of Hematology, Oncology and Clinical Immunology, Düsseldorf, Germany
| | | | | | | | | | | | | | | | | | | | - David Valcárcel
- Hematology Department, Vall d'Hebron Institute Oncology (VHIO), Hospital Universitari Vall d´Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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2
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Buckstein R, Chodirker L, Yee KWL, Geddes M, Leitch HA, Christou G, Banerji V, Leber B, Khalaf D, St-Hilaire E, Finn N, Nevill T, Keating MM, Storring J, Parmentier A, Thambipillai A, Tang D, Westcott C, Cameron C, Spin P. The burden of red blood cell transfusions in patients with lower-risk myelodysplastic syndromes and ring sideroblasts: an analysis of the prospective MDS-CAN registry. Leuk Lymphoma 2023; 64:651-661. [PMID: 36606533 DOI: 10.1080/10428194.2022.2156793] [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] [Indexed: 01/07/2023]
Abstract
Many patients with lower-risk myelodysplastic syndromes (LR MDS) require long-term red blood cell (RBC) transfusions to manage anemia. The consequences of RBC transfusions in LR MDS with ring sideroblasts (LR MDS-RS) are not well known. We estimated the association between cumulative RBC dose density and clinical and patient-reported outcomes using data from the MDS-CAN registry for patients enrolled between January 2008 and December 2018. Outcomes included overall survival, hospitalization, and health-related quality of life (HRQoL). A total of 145 enrolled patients with LR MDS and RS ≥5% had a median follow-up time of 27.1 months; 45 had no transfusions during follow-up, 51 had <1 transfusion per month, and 49 had ≥1 transfusion per month. The cumulative density of RBC transfusions was associated with significantly greater mortality, hospitalization, and inferior HRQoL, suggesting that exposure to RBC transfusion may constitute a significant treatment burden in patients with LR MDS-RS.
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Affiliation(s)
- Rena Buckstein
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Lisa Chodirker
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Karen W L Yee
- Department of Medicine, University of Toronto, Toronto, Canada
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Michelle Geddes
- Department of Medicine, Tom Baker Cancer Centre, Calgary, Canada
| | - Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Grace Christou
- Clinical epidemiology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | | | - Brian Leber
- Hematology Disease Site Team, Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Dina Khalaf
- Hematology Disease Site Team, Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Eve St-Hilaire
- Hematology Services, Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, Canada
| | - Nicholas Finn
- Hematology Services, Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, Canada
| | - Thomas Nevill
- Division of Hematology, Leukemia/Bone Marrow Transplant Program of BC, BC Cancer, University of British Columbia, Vancouver, Canada
| | | | - John Storring
- Hematology Division, McGill University Health Centre, Montréal, Canada
| | - Anne Parmentier
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Aksharh Thambipillai
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Derek Tang
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | - Chris Cameron
- Value and Evidence Division, Marketing and Market Access, EVERSANA™, Sydney, Canada
| | - Paul Spin
- Value and Evidence Division, Marketing and Market Access, EVERSANA™, Sydney, Canada
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3
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Cherniawsky H, Friedmann J, Nicolson H, Dehghan N, Stubbins RJ, Foltz LM, Leitch HA, Sreenivasan GM, Ambler KLS, Nevill TJ, McGinnis E, Wilson L, Beck DB, Chen LYC, Marcon KM. VEXAS syndrome: A review of bone marrow aspirate and biopsies reporting myeloid and erythroid precursor vacuolation. Eur J Haematol 2023; 110:633-638. [PMID: 36788756 DOI: 10.1111/ejh.13944] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 12/02/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
Myeloid and erythroid precursor vacuolation is a common dysplastic finding associated with myeloid malignancies, toxins, drug, and nutritional deficiencies. It has been described as a core morphologic feature in VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. We sought to determine the number of cases attributable to VEXAS syndrome in bone marrow biopsies and aspirates (BAMB) reporting myeloid precursor vacuolation. We reviewed 1318 individual BAMB reports from January 2020 to July 2021 where "vacuole(s)," "vacuolation," or "vacuolated" was reported. Bone marrow biopsies with vacuolation confined to blasts or those completed as routine workup prior to stem cell transplant or post induction chemotherapy for AML (acute myeloid leukemia) were excluded. Myeloid and erythroid precursor vacuolation was noted in 219 reports representing 210 patients. The most common etiology was myelodysplastic syndrome (MDS) (38.6%), AML (16.7%), lymphoproliferative disorders and multiple myeloma (7.6%), drug or toxin exposure (5.2%) myeloproliferative neoplasm (MPN) or MPN/MDS overlap syndrome (4.3%). VEXAS syndrome was determined to be the etiology in 2.9% of patients. Two additional cases of VEXAS syndrome with bone marrow biopsies reported in the specified time frame did not explicitly report myeloid or erythroid precursor vacuolation but were identified based on clinical suspicion and repeat BAMB review. Myeloid and erythroid precursor vacuolation is a dysplastic feature attributable to VEXAS syndrome in at least 2.9% of cases. Standardized reporting of vacuolization, triaging of molecular sequencing and optimal treatment of this disorder are critical issues facing those seeing patients with suspected VEXAS syndrome.
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Affiliation(s)
- Hannah Cherniawsky
- Leukemia/BMT Program of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Jordan Friedmann
- Department of Internal Medicine, University of British Columbia, Vancouver, Canada
| | - Hamish Nicolson
- Department of Pathology, University of British Columbia, Vancouver, Canada
| | - Natasha Dehghan
- Division of Rheumatology, University of British Columbia, Vancouver, Canada
| | - Ryan J Stubbins
- Leukemia/BMT Program of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Lynda M Foltz
- Division of Hematology, University of British Columbia, Vancouver, Canada
| | - Heather A Leitch
- Division of Hematology, University of British Columbia, Vancouver, Canada
| | | | | | - Thomas J Nevill
- Leukemia/BMT Program of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Eric McGinnis
- Department of Pathology, University of British Columbia, Vancouver, Canada
| | | | - David B Beck
- Division of Rheumatology, Department of Medicine, NYU Grossman School of Medicine, New York, USA.,Center for Human Genetics and Genomics, NYU Grossman School of Medicine, New York, USA
| | - Luke Y C Chen
- Division of Hematology, University of British Columbia, Vancouver, Canada
| | - Krista M Marcon
- Department of Pathology, University of British Columbia, Vancouver, Canada
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4
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Buckstein R, Chodirker L, Mozessohn L, Yee KWL, Geddes M, Zhu N, Shamy A, Leitch HA, Christou G, Banerji V, Brian L, Khalaf D, St-Hilaire E, Finn N, Nevill T, Keating MM, Storring J, Delage R, Parmentier A, Thambipillai A, Siddiqui M, Westcott C, Cameron C, Mamedov A, Spin P, Tang D. A natural history of lower-risk myelodysplastic syndromes with ring sideroblasts: an analysis of the MDS-CAN registry. Leuk Lymphoma 2022; 63:3165-3174. [PMID: 36095125 DOI: 10.1080/10428194.2022.2109154] [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] [Indexed: 01/12/2023]
Abstract
Patients with lower-risk (LR) myelodysplastic syndromes (MDS) with ring sideroblasts (RS) have better prognosis than those without RS, but how they fare over time is not fully understood. This study's objective was to assess the natural history of LR MDS with RS ≥5% using MDS-CAN registry individual data. Kaplan-Meier estimates and generalized linear mixed models were used to describe time-to-event outcomes and continuous outcomes, respectively. One hundred and thirty-eight patients were enrolled; median times from diagnosis to enrollment and follow-up were 6.6 and 39.6 months, respectively. Within 5 years of enrollment, 65% of patients had ≥1 red blood cell transfusion dependence episode. Within 5 years of diagnosis, 59% developed iron overload, 38% received iron chelation therapy, 14% progressed to acute myeloid leukemia, and 42% died. Patients exhibited inferior health-related quality of life trends. These first real-world data in LR MDS-RS in Canada indicate a high level of morbidity and mortality over a 5-year period. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02537990.
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Affiliation(s)
- Rena Buckstein
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa Chodirker
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lee Mozessohn
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen W L Yee
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Nancy Zhu
- Division of Hematology, University of Alberta, Edmonton, AB, Canada
| | - April Shamy
- Jewish General Hospital, Montréal, QC, Canada
| | - Heather A Leitch
- St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Grace Christou
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Leber Brian
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Dina Khalaf
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Eve St-Hilaire
- Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, NB, Canada
| | - Nicholas Finn
- Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, NB, Canada
| | - Thomas Nevill
- Division of Hematology, Leukemia/Bone Marrow Transplant Program of BC, BC Cancer, University of British Columbia, Vancouver, BC, Canada
| | | | - John Storring
- McGill University Health Centre, Montréal, QC, Canada
| | - Robert Delage
- CHU de Québec, Hôpital de l'Enfant-Jésus, Centre Universitaire d'Hématologie et d'Oncologie de Québec, Québec, QC, Canada
| | - Anne Parmentier
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aksharh Thambipillai
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mohammed Siddiqui
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Chris Cameron
- Value and Evidence Division, Marketing & Market Access, EVERSANA™, Sydney, NS, Canada
| | - Alexandre Mamedov
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Paul Spin
- Value and Evidence Division, Marketing & Market Access, EVERSANA™, Sydney, NS, Canada
| | - Derek Tang
- Bristol Myers Squibb, Princeton, NJ, USA
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5
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Sanford D, Desjardins P, Leber B, Paulson K, Assouline S, Lembo PMC, Fournier PA, Leitch HA. Real-World Treatment Patterns and Clinical Outcomes in Canadian Patients with AML Unfit for First-Line Intensive Chemotherapy. Curr Oncol 2022; 29:6794-6806. [PMID: 36290812 PMCID: PMC9600019 DOI: 10.3390/curroncol29100535] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 01/13/2023] Open
Abstract
Acute myeloid leukemia (AML) is a hematological malignancy that predominantly affects the elderly. Prognosis declines with age. For those who cannot tolerate intensive chemotherapy, historically established treatment options have been hypomethylating agents (HMAs), low dose cytarabine (LDAC), and best supportive care (BSC). As the standard of care evolves for those unfit for intensive chemotherapy, there is a need to understand established treatment pathways, clinical outcomes and healthcare resource utilization in Canada. The CURRENT study was a retrospective chart review of AML patients not eligible for intensive chemotherapy who initiated first-line treatment between 1 January 2015 and 31 December 2018. Data were collected from 170 Canadian patients treated at six hematology centers, of whom 118 received systemic therapy and 52 received BSC as first-line treatment. Median overall survival was 8.58 months and varied from 2.96 months for BSC to 13.31 months for HMAs. Over 80% of patients had at least one outpatient visit, and 67% of patients receiving systemic therapy and 71% of those receiving BSC had at least one admission to hospital, during their first line of therapy. A total of 96 (81.4%) patients receiving first line systemic therapy and 39 (75.0%) of those receiving first line BSC had at least one red blood cell or platelet transfusion. These findings highlight the unmet need for novel therapies for patients ineligible for intensive chemotherapy.
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Affiliation(s)
- David Sanford
- Vancouver General Hospital, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
- Correspondence:
| | - Pierre Desjardins
- Hémato-Oncologue, Centre Intégré de Cancérologie de la Montérégie, Hôpital Charles LeMoyne, Greenfield Park, QC J4V 2G9, Canada
| | - Brian Leber
- McMaster University Medical Centre, McMaster University, Hamilton, ON L8S 4L7, Canada
| | - Kristjan Paulson
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Sarit Assouline
- Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | | | | | - Heather A. Leitch
- St. Paul’s Hospital, University of British Columbia, Vancouver, BC V6E 1M7, Canada
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6
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Teichman J, Geddes M, Zhu N, Keating MM, Sabloff M, Christou G, Leber B, Khalaf D, St-Hilaire E, Finn N, Shamy A, Yee KW, Storring JM, Nevill TJ, Delage R, Elemary M, Banerji V, Houston B, Mozessohn L, Chodirker L, Zhang L, Siddiqui M, Parmentier A, Leitch HA, Buckstein RJ. High transferrin saturation predicts inferior clinical outcomes in patients with myelodysplastic syndromes. Haematologica 2022; 108:532-542. [PMID: 35979720 PMCID: PMC9890030 DOI: 10.3324/haematol.2022.280723] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 03/18/2022] [Indexed: 02/03/2023] Open
Abstract
Iron overload (IO) reflected by elevated ferritin is associated with increased mortality in myelodysplastic syndromes (MDS), however, ferritin is an imperfect metric. Elevated labile plasma iron correlates with clinical outcomes and transferrin saturation (TSAT) >80%, but is not readily measurable. The trajectory of TSAT, and its association with clinical outcomes remain undefined. Canadian MDS registry patients were evaluated. Mean TSAT, mean ferritin and transfusion dose density (TDD) were determined. Survival was evaluated by TSAT and ferritin (<50%, 50-80%, >80%), (≤500 μg/L, 501-800 μg/L, >800 μg/L). In 718 patients, median age was 74 years; 12%, 31%, 29%, 15% and 13% were IPSS-R very low, low, intermediate, high and very high. TSAT and ferritin were moderately correlated (r=0.63, P<0.0001). TSAT increased over time in transfusion- dependent patients (P=0.006). Higher TSAT and ferritin were associated with inferior 5-year overall (OS), progression- free (PFS), and leukemia-free survival (LFS) (P≤0.008) and higher TDD with inferior 5-year OS. TSAT >80% trended with inferior cardiac death-free survival (P=0.053). In univariate analysis, age, IPSS-R, blast percentage by Eastern Cooperative Oncology Group Performance Status, frailty, Charlson Comorbidity Index, iron chelation (Y/N), TDD, TSAT and ferritin were significantly associated with inferior OS. By multivariable analysis, TSAT >80% (P=0.007) remained significant for OS (R2 30.3%). In MDS, TSAT >80% and ferritin >800 μg/L portended inferior OS, PFS and LFS. TSAT may indicate the presence of oxidative stress, and is readily measurable in a clinical setting. The relationship between TSAT and cardiac death-free survival warrants further study.
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Affiliation(s)
| | | | - Nancy Zhu
- University of Alberta, Edmonton, Alberta
| | | | | | | | | | | | - Eve St-Hilaire
- Dr. Georges-L-Dumont University Hospital Center, Moncton, New Brunswick
| | - Nicholas Finn
- Dr. Georges-L-Dumont University Hospital Center, Moncton, New Brunswick
| | | | | | | | | | | | | | - Versha Banerji
- Sunnybrook Health Sciences Center, Toronto, Ontario,QEII Health Sciences Centre, Halifax, Nova Scotia
| | | | | | | | - Liying Zhang
- Sunnybrook Health Sciences Center, Toronto, Ontario
| | | | | | - Heather A. Leitch
- St. Paul’s Hospital, Vancouver, British Columbia, Canada,HAL and RJB contributed equally as co-senior authors
| | - Rena J. Buckstein
- Sunnybrook Health Sciences Center, Toronto, Ontario,HAL and RJB contributed equally as co-senior authors
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7
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Lai CMB, Setiadi A, Barlas A, Kanani A, Pourshahnazari P, Leitch HA, Metzger DL, Merkeley H, Biggs CM. Targeted treatment of immune thrombocytopenia in CTLA-4 insufficiency: a case report. Br J Haematol 2021; 196:e42-e45. [PMID: 34628649 DOI: 10.1111/bjh.17866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Audi Setiadi
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Angeliki Barlas
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Amin Kanani
- Division of Allergy and Clinical Immunology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Persia Pourshahnazari
- Division of Allergy and Clinical Immunology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Heather A Leitch
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | -
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Daniel L Metzger
- Division of Endocrinology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Hayley Merkeley
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Catherine M Biggs
- Division of Allergy and Clinical Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,BC Children's and St Paul's Hospitals, Vancouver, BC, Canada
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8
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Chan LSA, Gu LC, Leitch HA, Wells RA. Intracellular ROS profile in hematopoietic progenitors of MDS patients: association with blast count and iron overload. ACTA ACUST UNITED AC 2021; 26:88-95. [PMID: 34000978 DOI: 10.1080/16078454.2020.1870373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: Reactive oxygen species (ROS) are under scrutiny as a participant in the pathophysiology of myelodysplastic syndrome (MDS) and the progression of MDS to acute myeloid leukemia (AML). Measurement of intracellular ROS (iROS) is particularly important since iROS is a direct indicator of cellular health and integrity.Methods: We developed a technique to measure standardize iROS (siROS) level in lymphocytes and bone marrow (BM) CD34+ hematopoietic progenitors using the fluorescent probe dichlorofluorescein (DCF). We then quantified the siROS in 38 consecutive BM specimens from 27 MDS patients over the course of 10 months. Disease outcome of these patients were also assessed.Results: High serum ferritin, high blast count and poor IPSS were associated with inferior survival and AML progression in this cohort. High blast MDS patients had lower siROS in their BM CD34+ cells than those of low blast patients, consistent with increased reliance on glycolysis and enhanced ROS defense in high blast MDS. We also observed narrower siROS distribution in the BM CD34+ cells of high blast patients, suggesting that loss of heterogeneity in ROS content accompanies the clonal evolution of MDS. Furthermore, we observed a strong correlation between CD34+ cells siROS and serum ferritin level in high blast patients. In one case, iron chelation therapy (ICT) resulted in parallel decreases in serum ferritin and CD34+ cells siROS.Conclusion: Our findings established the siROS profile in early hematopoietic cells of MDS patients and its relationship with blast count and iron overload.
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Affiliation(s)
- Lap Shu Alan Chan
- Biological Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Lilly ChunHong Gu
- Biological Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, Canada
| | - Richard A Wells
- Biological Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
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9
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Amitai I, Geddes M, Zhu N, Keating MM, Sabloff M, Christou G, Leber B, Khalaf D, Leitch HA, St-Hilaire E, Finn N, Shamy A, Yee K, Storring J, Nevill T, Delage R, Elemary M, Banerji V, Chodirker L, Mozessohn L, Parmentier A, Siddiqui M, Mamedov A, Zhang L, Buckstein R. Patient-reported fatigue refines prognosis in higher-risk myelodysplastic syndromes (MDS): a MDS-CAN study. Br J Haematol 2021; 194:319-324. [PMID: 34060069 DOI: 10.1111/bjh.17537] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 01/25/2021] [Accepted: 04/12/2021] [Indexed: 01/24/2023]
Abstract
The incorporation of patient-reported outcomes with traditional disease risk classification was found to strengthen survival prediction in patients with myelodysplastic syndromes (MDS). In the present Canadian MDS registry analysis, we validate a recently reported prognostic model, the Fatigue-International Prognostic Scoring System among higher-risk patients [FA-IPSS(h)], which incorporates patients' reported fatigue, assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life-Core 30 (QLQ-C30), with a threshold of ≥45 points, in higher IPSS score, stratifying them into distinct subgroups with different survival outcomes. We further validated this concept, using the Revised IPSS >3·5 as cut-off for the definition of higher-risk MDS, and patients' reported fatigue according to Edmonton Symptom Self-Assessment Scale (ESAS) Global Fatigue Scale (GFS), a single-item fatigue rating scale, which is easier to deploy. This emphasises the power of self-reported fatigue at refining overall survival predictions in higher-risk MDS and further bolsters the importance of considering patient-related outcomes in global assessments.
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Affiliation(s)
- Irina Amitai
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Michelle Geddes
- Haematology/Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Nancy Zhu
- Haematology/Oncology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Mary-Margaret Keating
- Haematology/Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Grace Christou
- Haematology/Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Brian Leber
- Haematology/Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Dina Khalaf
- Haematology/Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Heather A Leitch
- Haematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Eve St-Hilaire
- Haematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - Nicholas Finn
- Haematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - April Shamy
- Haematology/Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Karen Yee
- Haematology/Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - John Storring
- Haematology/Oncology, McGill University Health Centre, Royal Victoria Hospital, Montreal, QC, Canada
| | - Thomas Nevill
- Haematology/Oncology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Robert Delage
- Haematology/Oncology, Centre de recherche du CHU de Quebec, Universite Laval, Quebec City, QC, Canada
| | | | - Versha Banerji
- Haematology/Oncology, Cancer Care Manitoba, Winnipeg, MB, Canada
| | - Lisa Chodirker
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lee Mozessohn
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anne Parmentier
- Haematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mohammed Siddiqui
- Haematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Mamedov
- Haematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liying Zhang
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rena Buckstein
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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10
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Leitch HA. Idiopathic multicentric Castleman disease: bringing order to chaos. Lancet Haematol 2020; 7:e180-e181. [PMID: 32027863 DOI: 10.1016/s2352-3026(20)30001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 06/10/2023]
Affiliation(s)
- Heather A Leitch
- Hematology, St Paul's Hospital and the University of British Columbia, Vancouver, BC V6Z 2A5, Canada.
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11
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Starkman R, Alibhai S, Wells RA, Geddes M, Zhu N, Keating MM, Leber B, Chodirker L, Sabloff M, Christou G, Leitch HA, St-Hilaire E, Finn N, Shamy A, Yee K, Storring J, Nevill T, Delage R, Elemary M, Banerji V, Lenis M, Kirubananthaan A, Mamedov A, Zhang L, Rockwood K, Buckstein R. An MDS-specific frailty index based on cumulative deficits adds independent prognostic information to clinical prognostic scoring. Leukemia 2019; 34:1394-1406. [PMID: 31811236 DOI: 10.1038/s41375-019-0666-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/30/2019] [Accepted: 11/17/2019] [Indexed: 12/21/2022]
Abstract
The frailty index (FI) is based on the principle that the more deficits an individual has, the greater their risk of adverse outcomes. It is expressed as a ratio of the number of deficits present to the total number of deficits considered. We developed an MDS-specific FI using a prospective MDS registry and assessed its ability to add prognostic power to conventional prognostic scores in MDS. The 42 deficits included in this FI included measurements of physical performance, comorbidities, laboratory values, instrumental activities of daily living, quality of life and performance status. Of 644 patients, 440 were eligible for FI calculation. The median FI score was 0.25 (range 0.05-0.67), correlated with age and IPSS/IPSS-R risk scores and discriminated overall survival. With a follow-up of 20 months, survival was 27 months (95% CI 24-30.4). By multivariate analysis, age >70, FI, transfusion dependence, and IPSS were significant covariates associated with OS. The incremental discrimination improvement of the frailty index was 37%. We derived a prognostic score with five risk groups and distinct survivals ranging from 7.4 months to not yet reached. If externally validated, the MDS-FI could be used as a tool to refine the risk stratification of current clinical prognostication models.
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Affiliation(s)
- R Starkman
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - S Alibhai
- Geriatric Medicine/Oncology, University Health Network, Toronto, ON, Canada
| | - R A Wells
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Geddes
- Hematology/Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - N Zhu
- Hematology/Oncology, University of Alberta Hospital, Edmonton, AB, Canada
| | - M M Keating
- Hematology/Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - B Leber
- Hematology/Oncology, Juravinski Cancer Center, Hamilton, ON, Canada
| | - L Chodirker
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Sabloff
- Hematology/Oncology, University of Ottawa, Ottawa, ON, Canada
| | - G Christou
- Hematology/Oncology, University of Ottawa, Ottawa, ON, Canada
| | - H A Leitch
- Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - E St-Hilaire
- Hematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - N Finn
- Hematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - A Shamy
- Hematology/Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - K Yee
- Hematology/Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - J Storring
- Hematology/Oncology, McGill University Health Centre-Royal Victoria Hospital, Montreal, QC, Canada
| | - T Nevill
- Hematology/Oncology, Vancouver General Hospital, Vancouver, BC, Canada
| | - R Delage
- Hematology/Oncology, Centre de recherche du CHU de Quebec-Universite Laval, Quebec City, QC, Canada
| | - M Elemary
- Hematology, Saskatoon Cancer Centre, Saskatoon, SK, Canada
| | - V Banerji
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - M Lenis
- Hematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Kirubananthaan
- Hematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Mamedov
- Hematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Zhang
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - K Rockwood
- Geriatric Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - R Buckstein
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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12
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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13
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Wong SA, Dalal BI, Leitch HA. Paroxysmal nocturnal hemoglobinuria testing in patients with myelodysplastic syndrome in clinical practice-frequency and indications. Curr Oncol 2018; 25:e391-e397. [PMID: 30464689 PMCID: PMC6209566 DOI: 10.3747/co.25.4018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 12/29/2022] Open
Abstract
Background Myelodysplastic syndrome (mds) is characterized by peripheral blood cytopenias, with most patients developing significant anemia and dependence on red blood cell (rbc) transfusion. In paroxysmal nocturnal hemoglobinuria (pnh), mutations in the PIGA gene lead to lack of cell-surface glycosylphosphatidylinositol, allowing complement-mediated lysis to occur. Paroxysmal nocturnal hemoglobinuria results in direct antiglobulin test-negative hemolysis and cytopenias, and up to 50% of patients with mds test positive for pnh cells. We wanted to determine whether pnh is considered to be a contributor to anemia in mds. Methods Patients with a diagnosis of mds confirmed by bone-marrow biopsy since 2009 were reviewed. High-resolution pnh testing by flow cytometry examined flaer (fluorescein-labeled proaerolysin) binding and expression of CD14, CD15, CD24, CD45, CD59, CD64, and CD235 on neutrophils, monocytes, and rbcs. Results In 152 patients with mds diagnosed in 2009 or later, the mds diagnosis included subtypes associated with pnh positivity (refractory anemia, n = 7, and hypoplastic mds, n = 4). Of 11 patients who underwent pnh testing, 1 was positive (9.0%). Reasons for pnh testing were anemia (n = 3), new mds diagnosis (n = 2), hypoplastic mds (n = 2), decreased haptoglobin (n= 1), increased rbc transfusion requirement (n= 1), and unexplained iron deficiency (n= 1). Conclusions Testing for pnh was infrequent in mds patients, and the criteria for testing were heterogeneous. Clinical indicators prompted pnh testing in 6 of 11 patients. Given that effective treatment is now available for pnh and that patients with pnh-positive mds can respond to immunosuppressive therapy, pnh testing in mds should be considered. Prospective analyses to clarify the clinical significance of pnh positivity in mds are warranted.
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Affiliation(s)
- S A Wong
- Faculty of Medicine, The Royal College of Surgeons, Dublin, Ireland
| | - B I Dalal
- Department of Hematopathology, Vancouver General Hospital, Vancouver, BC
| | - H A Leitch
- Division of Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC
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14
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Leitch HA, Buckstein R, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Shamy A, Elemary M, Wells RA. Iron overload in myelodysplastic syndromes: Evidence based guidelines from the Canadian consortium on MDS. Leuk Res 2018; 74:21-41. [PMID: 30286330 DOI: 10.1016/j.leukres.2018.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023]
Abstract
In 2008 the first evidence-based Canadian consensus guideline addressing the diagnosis, monitoring and management of transfusional iron overload in patients with myelodysplastic syndromes (MDS) was published. The Canadian Consortium on MDS, comprised of hematologists from across Canada with a clinical and academic interest in MDS, reconvened to update these guidelines. A literature search was updated in 2017; topics reviewed include mechanisms of iron overload induced cellular damage, evidence for clinical endpoints impacted by iron overload including organ dysfunction, infections, marrow failure, overall survival, acute myeloid leukemia progression, and endpoints around hematopoietic stem-cell transplant. Evidence for an impact of iron reduction on the same endpoints is discussed, guidelines are updated, and areas identified where evidence is suboptimal. The guidelines address common questions around the diagnosis, workup and management of iron overload in clinical practice, and take the approach of who, when, why and how to treat iron overload in MDS. Practical recommendations for treatment and monitoring are made. Evidence levels and grading of recommendations are provided for all clinical endpoints examined.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas J Nevill
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brian Leber
- McMaster University, Hamilton, Ontario, Canada
| | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, New Brunswick, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, Quebec, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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15
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Leitch HA. Defining clinically relevant measures of iron overload around haemopoietic stem cell transplantation. Lancet Haematol 2018; 5:e184-e185. [PMID: 29628398 DOI: 10.1016/s2352-3026(18)30033-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Heather A Leitch
- Division of Hematology, St Paul's Hospital, University of British Columbia, Vancouver, BC V6Z 2A5, Canada.
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16
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Wong CAC, Wong SAY, Leitch HA. Iron overload in lower international prognostic scoring system risk patients with myelodysplastic syndrome receiving red blood cell transfusions: Relation to infections and possible benefit of iron chelation therapy. Leuk Res 2018; 67:75-81. [PMID: 29477023 DOI: 10.1016/j.leukres.2018.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 12/26/2017] [Revised: 02/03/2018] [Accepted: 02/06/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND An increased incidence of infections and infectious mortality has been reported in myelodysplastic syndromes (MDS) patients receiving red blood cell (RBC) transfusions. METHODS We examined incidence of infections requiring antibiotics, antifungal or antiviral medications in transfused lower International Prognostic Scoring System (IPSS) risk MDS patients and whether this differed with iron chelation therapy (ICT). RESULTS 138 transfused MDS patients were lower IPSS risk. 59 received ICT; median duration was 13 months. There was no significant difference between groups in neutrophil count at first RBC transfusion or first infection. Infections included: bacterial, n = 88; viral; fungal; and mycobacterial; n = 2 each. In ICT and non-ICT patients, respectively, infections were (number [%]): patients, 23 (40.0%) and 22 (27.8%); episodes (median [range]), 2 (1-6) and 2 (1-5); hospitalizations, 16 (27.1%) and 8 (10.1%); and deaths, 0 (0%) and 1 (1.3%), p = NS for all. Median overall survival (OS) from first RBC transfusion was superior in ICT patients, p = 0.01, and remained significant in a multivariate analysis (MVA), p = 0.003. Median time to first infection (TTI) was 27 and 7.8 months, respectively, p < 0.0001, and ICT remained significant for TTI in an MVA, p = 0.02, hazard ratio 0.3. For ICT patients with blast count <5%, TTI was significantly superior (p = 0.004). CONCLUSIONS In this retrospective analysis, for lower IPSS risk MDS patients receiving RBC transfusions, though number and type of infections were similar between groups and despite similar neutrophil counts, time to first infection was significantly longer in ICT patients (p < 0.0001). These results should be confirmed in larger, prospective analyses.
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Affiliation(s)
| | | | - Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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17
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Alzahrani M, Leitch HA. Castleman disease: delineating the spectrum. Br J Haematol 2018; 180:173-174. [DOI: 10.1111/bjh.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Musa Alzahrani
- Oncology Centre; Department of Haematology; King Saud University; Riyadh Saudi Arabia
| | - Heather A. Leitch
- Department of Hematology; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
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18
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England JT, Dalal B, Leitch HA. Frequency of and reasons for paroxysmal nocturnal haemoglobinuria screening in patients with unexplained anaemia. J Clin Pathol 2017; 71:364-367. [PMID: 29138283 DOI: 10.1136/jclinpath-2017-204724] [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: 08/08/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/04/2022]
Abstract
Referral to hematology for anemia is common. In paroxysmal nocturnal hemoglobinuria (PNH), cells deficient in the glycosylphosphatidyl inositol (GPI) anchor are lysed by complement. Eculizumab improves overall survival and quality of life while reducing hemolysis, transfusion requirements, and thrombosis. We evaluated the frequency of screening for PNH in patients with unexplained anemia. Key clinical features, laboratory data, and investigations were recorded for patients referred for anemia since 2010, without a specific cause found. PNH testing was done by flow cytometry. 540 patients had: anemia not yet diagnosed (NYD, n=318 (including unexplained iron deficiency, n=92; DAT-negative hemolysis, n=9)); anemia of chronic disease, n=173; and pancytopenia NYD, n=49. 82.4% had LDH testing done; 85.0% total bilirubin; 78.7% reticulocyte counts; and 40.6% haptoglobin level; 131 (24.2%) had possible hemolysis. PNH testing was done in 56 (10.4%). Those screened for PNH were more likely to have: younger age (P=0.04); a history of thrombosis (P<0.001); undergone a BMBx (P<0.001); received RBC transfusions (P=0.0018); or evidence of DAT-negative hemolysis (P<0.001). In summary, PNH was tested for in a minority of patients with unexplained anemia (10.4%) despite potential indicators of hemolysis in 24.2%. Increased screening could identify patients who would benefit from treatment and should be considered.
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Affiliation(s)
- James T England
- Internal Medicine, University of British Columbia, Vancouver, Canada
| | - Bakul Dalal
- Division of Laboratory Hematology, Vancouver General Hospital, Vancouver, Canada
| | - Heather A Leitch
- Department of Hematology, St. Paul's Hospital, the University of British Columbia, Vancouver, Canada
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19
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Wong SA, Leitch HA. Iron chelation therapy in lower IPSS risk myelodysplastic syndromes; which subtypes benefit? Leuk Res 2017; 64:24-29. [PMID: 29149650 DOI: 10.1016/j.leukres.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 05/27/2017] [Revised: 09/29/2017] [Accepted: 11/09/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Analyses suggest MDS patients with higher serum ferritin levels (SF) have inferior overall survival (OS), in one study across MDS subtypes. Multiple analyses suggest those with high SF receiving iron chelation therapy (ICT) have superior OS, but which MDS subtypes benefit from ICT remains undefined. METHODS We performed survival analyses of MDS subtypes by receipt of ICT. RESULTS 182 MDS were lower IPSS risk and received red blood cell (RBC) transfusions; 63 received ICT. For the entire cohort, receiving ICT independently predicted superior OS in a multivariate analysis (hazard ratio for death 0.3, p=0.01). Features differing for ICT and non-ICT patients, respectively, were: age; IPSS risk group; number of RBC units transfused; and SF, p≤0.03 for all. At a median follow up of 76.5 and 28.4 months, 65.1% and 63.0% were alive. Median OS (months) for ICT and non-ICT patients was: RA, 140.9 and 36.3, p=0.0008; RARS/RARS-t, 133.4 and 73.3, p=0.02. For RCMD/RCMD-RS, p=NS, however, 3 (20%) had significant erythroid improvement with ICT; other subtypes had small numbers. DISCUSSION In this retrospective analysis, RA and RARS/RARS-t patients receiving ICT had superior OS to non-ICT patients. These findings should be verified and other MDS subtypes examined in larger prospective analyses.
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Affiliation(s)
- Shannon A Wong
- Faculty of Medicine, Royal College of Surgeons, Dublin, Ireland
| | - Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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20
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England JT, Leitch HA. Chronic lymphocytic leukemia in a patient with well-controlled HIV infection: successful treatment with ibrutinib. Leuk Lymphoma 2017; 59:752-754. [PMID: 28728450 DOI: 10.1080/10428194.2017.1349904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- James T England
- a Department of Medicine , University of British Columbia , Vancouver , Canada
| | - Heather A Leitch
- b Division of Hematology , St. Paul's Hospital, University of British Columbia , Vancouver , Canada
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21
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Leitch HA, Parmar A, Wells RA, Chodirker L, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, Sabloff M, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Kew A, Shamy A, Elemary M, Lenis M, Mamedov A, Ivo J, Francis J, Zhang L, Buckstein R. Overall survival in lower IPSS risk MDS by receipt of iron chelation therapy, adjusting for patient-related factors and measuring from time of first red blood cell transfusion dependence: an MDS-CAN analysis. Br J Haematol 2017; 179:83-97. [PMID: 28677895 DOI: 10.1111/bjh.14825] [Citation(s) in RCA: 42] [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: 03/18/2017] [Accepted: 05/25/2017] [Indexed: 01/23/2023]
Abstract
Analyses suggest iron overload in red blood cell (RBC) transfusion-dependent (TD) patients with myleodysplastic syndrome (MDS) portends inferior overall survival (OS) that is attenuated by iron chelation therapy (ICT) but may be biassed by unbalanced patient-related factors. The Canadian MDS Registry prospectively measures frailty, comorbidity and disability. We analysed OS by receipt of ICT, adjusting for these patient-related factors. TD International Prognostic Scoring System (IPSS) low and intermediate-1 risk MDS, at RBC TD, were included. Predictive factors for OS were determined. A matched pair analysis considering age, revised IPSS, TD severity, time from MDS diagnosis to TD, and receipt of disease-modifying agents was conducted. Of 239 patients, 83 received ICT; frailty, comorbidity and disability did not differ from non-ICT patients. Median OS from TD was superior in ICT patients (5·2 vs. 2·1 years; P < 0·0001). By multivariate analysis, not receiving ICT independently predicted inferior OS, (hazard ratio for death 2·0, P = 0·03). In matched pair analysis, OS remained superior for ICT patients (P = 0·02). In this prospective, non-randomized analysis, receiving ICT was associated with superior OS in lower IPSS risk MDS, adjusting for age, frailty, comorbidity, disability, revised IPSS, TD severity, time to TD and receiving disease-modifying agents. This provides additional evidence that ICT may confer clinical benefit.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | | | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lisa Chodirker
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, AB, Canada
| | - Thomas J Nevill
- Division of Hematology, Leukemia/BMT Program of British Columbia, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, NB, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, AB, Canada
| | | | - Andrea Kew
- Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada
| | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, QC, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Martha Lenis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jessica Ivo
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Janika Francis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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22
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Leitch HA, Fibach E, Rachmilewitz E. Toxicity of iron overload and iron overload reduction in the setting of hematopoietic stem cell transplantation for hematologic malignancies. Crit Rev Oncol Hematol 2017; 113:156-170. [PMID: 28427505 DOI: 10.1016/j.critrevonc.2017.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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: 12/17/2016] [Revised: 02/13/2017] [Accepted: 03/04/2017] [Indexed: 01/19/2023] Open
Abstract
Iron is an essential element for key cellular metabolic processes. However, transfusional iron overload (IOL) may result in significant cellular toxicity. IOL occurs in transfusion dependent hematologic malignancies (HM), may lead to pathological clinical outcomes, and IOL reduction may improve outcomes. In hematopoietic stem cell transplantation (SCT) for HM, IOL may have clinical importance; endpoints examined regarding an impact of IOL and IOL reduction include transplant-related mortality, organ function, infection, relapse risk, and survival. Here we review the clinical consequences of IOL and effects of IOL reduction before, during and following SCT for HM. IOL pathophysiology is discussed as well as available tests for IOL quantification including transfusion history, serum ferritin level, transferrin saturation, hepcidin, labile plasma iron and other parameters of iron-catalyzed oxygen free radicals, and organ IOL by imaging. Data-based recommendations for IOL measurement, monitoring and reduction before, during and following SCT for HM are made.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Eitan Fibach
- Hematology Branch, Hadassah - Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
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Williamson BT, Foltz L, Leitch HA. Autoimmune Syndromes Presenting as a Paraneoplastic Manifestation of Myelodysplastic Syndromes: Clinical Features, Course, Treatment and Outcome. Hematol Rep 2016; 8:6480. [PMID: 27499837 PMCID: PMC4961871 DOI: 10.4081/hr.2016.6480] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/30/2016] [Accepted: 05/02/2016] [Indexed: 12/28/2022] Open
Abstract
Autoimmune manifestations (AIM) are reported in up to 10-30% of myelodysplastic syndromes (MDS) patients; this association is not well defined. We present herein a retrospective chart review of single center MDS patients for AIM, a case discussion and a literature review. Of 252 MDS patients examined, 11 (4.4%) had AIM around MDS diagnosis. International Prognostic Scoring System scores were: low or intermediate (int)-1 (n=7); int-2 or high (n=4). AIM were: culture negative sepsis (n=7); inflammatory arthritis (n=3); vasculitis (n=4); sweats; pericarditis; polymyalgia rheumatica (n=2 each); mouth ulcers; pulmonary infiltrates; suspicion for Behcet’s; polychondritis and undifferentiated (n=1 each). AIM treatment and outcome were: prednisone +/- steroid sparing agents, n=8, ongoing symptoms in 5; azacitidine (n=3), 2 resolved; and observation, n=1, ongoing symptoms. At a median follow up of 13 months, seven patients are alive. In summary, 4.4% of MDS patients presented with concomitant AIM. MDS should remain on the differential diagnosis of patients with inflammatory symptoms.
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Affiliation(s)
- Bradley T Williamson
- Departments of Medicine, St. Paul's Hospital and the University of British Columbia , Vancouver, BC, Canada
| | - Lynda Foltz
- Departments of Hematology, St. Paul's Hospital and the University of British Columbia , Vancouver, BC, Canada
| | - Heather A Leitch
- Departments of Hematology, St. Paul's Hospital and the University of British Columbia , Vancouver, BC, Canada
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Alzahrani MF, Radwi M, Leitch HA. Practical Management of Castleman's Disease. Acta Haematol 2016; 136:16-22. [PMID: 27160307 DOI: 10.1159/000444515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/07/2016] [Indexed: 11/19/2022]
Abstract
Castleman's disease (CD) is a rare lymphoproliferative disorder that is most commonly present in multicentric (MCD) form in association with HIV infection. Interleukin-6 (IL-6) and human herpesvirus-8 (HHV-8) play major roles in MCD pathogenesis. Important treatment options have recently become available, particularly with the introduction of IL-6 and IL-6 receptor inhibitors for the treatment of HIV-negative patients with MCD. Though advances in therapy may improve outcomes in some patients, the prognosis remains guarded, and a stratified approach to the management of MCD is needed.
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Affiliation(s)
- Musa Fares Alzahrani
- Hematology Program, St. Paul's Hospital, University of British Columbia, Vancouver, B.C., Canada
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Tsang E, Leitch HA. Pre- and post-treatment serum ferritin levels in patients with higher risk myelodysplastic syndromes receiving azacitidine. Leuk Lymphoma 2016; 57:2709-11. [DOI: 10.3109/10428194.2016.1157878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Buckstein R, Wells RA, Zhu N, Leitch HA, Nevill TJ, Yee KWL, Leber B, Sabloff M, St Hilaire E, Kumar R, Geddes M, Shamy A, Storring J, Kew A, Elemary M, Levitt M, Lenis M, Mamedov A, Zhang L, Rockwood K, Alibhai SMH. Patient-related factors independently impact overall survival in patients with myelodysplastic syndromes: an MDS-CAN prospective study. Br J Haematol 2016; 174:88-101. [PMID: 26991631 DOI: 10.1111/bjh.14033] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [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: 11/12/2015] [Accepted: 01/12/2016] [Indexed: 01/21/2023]
Abstract
UNLABELLED Little is known about the effects of frailty, disability and physical functioning on the clinical outcomes for myelodysplastic syndromes (MDS). We investigated the predictive value of these factors on overall survival (OS) in 445 consecutive patients with MDS and chronic monomyelocytic leukaemia (CMML) enrolled in a multi-centre prospective national registry. Frailty, comorbidity, instrumental activities of daily living, disability, quality of life, fatigue and physical performance measures were evaluated at baseline and were added as covariates to conventional MDS-related factors as predictors of OS in Cox proportional hazards models. The median age was 73 years, and 79% had revised International Prognostic Scoring System (IPSS-R) risk scores of intermediate or lower. Frailty correlated only modestly with comorbidity. OS was significantly shorter for patients with higher frailty and comorbidity scores, any disability, impaired grip strength and timed chair stand tests. By multivariate analysis, the age-adjusted IPSS-R, frailty (Hazard ratio 2·7 (95% confidence interval [CI] 1·7-4·2), P < 0·0001) and Charlson comorbidity score (Hazard ratio 1·8 (95% CI 1·1-2·8), P = 0·01) were independently prognostic of OS. Incorporation of frailty and comorbidity scores improved risk stratification of the IPSS-R by 30% and 5%, respectively. These data demonstrate for the first time, the importance of considering frailty in prognostic models and a potential target for therapeutic intervention in optimizing clinical outcomes in older MDS patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02537990.
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Affiliation(s)
- Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nancy Zhu
- University of Alberta Hospital, Edmonton, AB, Canada
| | - Heather A Leitch
- St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | | | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Brian Leber
- Juravinski Cancer Center, Hamilton Health Sciences Center, Hamilton, ON, Canada
| | - Mitchell Sabloff
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Eve St Hilaire
- Centre Hospitalier Universitaire Dr-Georges-L.-Dumont, Moncton, QC, Canada
| | | | | | - April Shamy
- Jewish General Hospital, Montreal, QC, Canada
| | - John Storring
- McGill University, Health Centre-Royal Victoria Hospital, Montreal, QC, Canada
| | - Andrea Kew
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Max Levitt
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martha Lenis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alex Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Ken Rockwood
- Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
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Tsang E, Leitch HA. Can iron overload in patients with lower-risk myelodysplastic syndromes be reduced using erythropoiesis-stimulating agents? Ann Hematol 2015; 95:73-78. [PMID: 26453076 DOI: 10.1007/s00277-015-2519-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 08/01/2015] [Accepted: 10/01/2015] [Indexed: 01/09/2023]
Abstract
Iron overload (IOL) portends inferior outcome in myelodysplastic syndromes (MDS). Erythropoiesis-stimulating agents (ESA) may reduce red blood cell transfusion requirements. MDS patients receiving ESA were reviewed for characteristics, response to ESA by International Working Group 2006 criteria and ferritin levels. Forty-nine patients received an ESA, had ferritin levels available, and were not receiving iron chelation therapy. Baseline characteristics were not significantly different between ESA responders (ER) and non-responders (ENR; P = NS). The median ESA treatment duration was 6.7 (1.5-85.9) months. Twenty-one (43 %) patients had an ESA response. Median ferritin level in ER was pre-ESA, 473 (range 91-2727) and post-ESA, 801 (130-11,164) ng/mL (P = 0.01), and in ENR pre-ESA, 672 (76-3285) and post-ESA, 1423 (431-6593) ng/mL (P < 0.0001). There was a significant association between ESA response, post-ESA hemoglobin ≥100 g/L, and post-ESA ferritin <1000 ng/mL (P = 0.0003 and 0.03, respectively). At a median follow-up of 28 months, the 2-year overall survival for ER and ENR, respectively, were 80 % and 86 % (P = NS). In lower-risk MDS patients responding to ESA, although an expected decrease in ferritin levels over treatment was not seen, ferritin levels increased less than in non-responders. Whether IOL may be reduced by ESA over a longer treatment duration may require analysis of larger numbers of patients.
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Affiliation(s)
- Erica Tsang
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, 440-1144 Burrard Street, Vancouver, BC, Canada, V6Z 2A5.
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Alzahrani M, Hull MC, Sherlock C, Griswold D, Leger CS, Leitch HA. Human immunodeficiency virus-associated multicentric Castleman disease refractory to antiretroviral therapy: clinical features, treatment and outcome. Leuk Lymphoma 2014; 56:1246-51. [PMID: 25093377 DOI: 10.3109/10428194.2014.935368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/13/2022]
Abstract
Human immunodeficiency virus (HIV)-associated multicentric Castleman disease (MCD) is a lymphoproliferation associated with human herpes virus-8 (HHV-8). Optimal treatment in patients not responding to antiretroviral therapy (ART) is undefined. We report 12 patients with ART refractory HIV-MCD. Patients with HIV-MCD were identified and baseline characteristics, treatment and outcome considered. Median CD4 count at HIV-MCD diagnosis was 295 (60-950) cells/mL. All patients had waxing and waning systemic symptoms, lymphadenopathy and/or splenomegaly, with non-Hodgkin lymphoma (NHL) in three. Treatment included: anti-HHV-8 therapy, n = 8; alone, n = 4; with systemic chemotherapy (CT) ± immunotherapy (IT), n = 4; CT ± IT only, n = 2. Initial median HHV-8 viral load (VL) was 7 × 10(4) copies/mL and at follow-up < 40 in 6/7 survivors; and 403-7.2 × 10(6) in 4/5 who died. One patient developed NHL despite an HHV-8 VL < 40. HIV-MCD is challenging to treat. Suppression of plasma HHV-8 VL did not prevent development of NHL. Anti-HHV-8 therapy should probably be considered adjunctive to cytotoxic therapies.
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Affiliation(s)
- Musa Alzahrani
- Hematology Program, University of British Columbia and King Saud University , Riyadh , Saudi Arabia
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Imran ul-haq M, Hamilton JL, Lai BFL, Shenoi RA, Horte S, Constantinescu I, Leitch HA, Kizhakkedathu JN. Design of long circulating nontoxic dendritic polymers for the removal of iron in vivo. ACS Nano 2013; 7:10704-16. [PMID: 24256569 DOI: 10.1021/nn4035074] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Patients requiring chronic red blood cell (RBC) transfusions for inherited or acquired anemias are at risk of developing transfusional iron overload, which may impact negatively on organ function and survival. Current iron chelators are suboptimal due to the inconvenient mode of administration and/or side effects. Herein, we report a strategy to engineer low molecular weight iron chelators with long circulation lifetime for the removal of excess iron in vivo using a multifunctional dendritic nanopolymer scaffold. Desferoxamine (DFO) was conjugated to hyperbranched polyglycerol (HPG) and the plasma half-life (t1/2) in mice is defined by the structural features of the scaffold. There was a 484 fold increase in t1/2 between the DFO (5 min) versus the HPG-DFO (44 h). In an iron overloaded mouse model, efficient iron excretion by HPG-DFO in the urine and feces was demonstrated (p = 0.0002 and 0.003, respectively) as was a reduction in liver, heart, kidney, and pancreas iron content, and plasma ferritin level (p = 0.003, 0.001, 0.001, 0.001, and 0.003, respectively) compared to DFO. Conjugates showed no apparent toxicity in several analyses including body weight, serum lactate dehydrogenase level, necropsy analysis, and by histopathological examination of organs. These findings were supported by in vitro biocompatibility analyses, including blood coagulation, platelet activation, complement activation, red blood cell aggregation, hemolysis, and cell viability. This nanopolymer-based chelating system would potentially benefit patients suffering from transfusional iron overload.
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Affiliation(s)
- Muhammad Imran ul-haq
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, and ‡Department of Chemistry, University of British Columbia , Life Sciences Centre, 2350 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
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Leitch HA, Buckstein R, Shamy A, Storring JM. The immunomodulatory agents lenalidomide and thalidomide for treatment of the myelodysplastic syndromes: A clinical practice guideline. Crit Rev Oncol Hematol 2013; 85:162-92. [DOI: 10.1016/j.critrevonc.2012.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 07/08/2012] [Accepted: 07/10/2012] [Indexed: 12/27/2022] Open
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Leitch HA, Chan C, Leger CS, Foltz LM, Ramadan KM, Vickars LM. Improved survival with iron chelation therapy for red blood cell transfusion dependent lower IPSS risk MDS may be more significant in patients with a non-RARS diagnosis. Leuk Res 2012; 36:1380-6. [PMID: 22921191 DOI: 10.1016/j.leukres.2012.08.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Revised: 07/31/2012] [Accepted: 08/05/2012] [Indexed: 02/04/2023]
Abstract
Retrospective analyses suggest iron overload is associated with inferior survival (OS) in lower risk MDS and iron chelation therapy (ICT) with improvement. However, an analysis of RARS patients found no such association. We analyzed subtypes of lower risk MDS. Median OS for non-RARS without and with ICT was 44 months and not reached (P<0.001), and for RARS 99 and 134.4 months (P=NS); in red blood cell (RBC) transfusion dependent RARS patients not receiving ICT, median OS was 73.8 months (P=0.025). These results suggest a stronger association between ICT and OS in non-RARS MDS than in RARS, with significantly superior OS in transfusion dependent patients receiving ICT.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
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Ezzat HM, Cheung MC, Hicks LK, Boro J, Montaner JSG, Lima VD, Harris M, Leitch HA. Incidence, predictors and significance of severe toxicity in patients with human immunodeficiency virus-associated Hodgkin lymphoma. Leuk Lymphoma 2012; 53:2390-6. [DOI: 10.3109/10428194.2012.697560] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
The myelodysplastic syndromes (MDS) are characterized by cytopenias and risk of progression to acute myeloid leukaemia (AML). Most MDS patients eventually require transfusion of red blood cells for anaemia, placing them at risk of transfusional iron overload. In β-thalassaemia major, transfusional iron overload leads to organ dysfunction and death; however, with iron chelation therapy, organ function is improved, and survival improved to near normal and correlated with the degree of compliance with chelation. In lower-risk MDS, several nonrandomized studies suggest an adverse effect of iron overload on survival and that lowering iron with chelation may minimize this impact. Emerging data indicate that chelation may improve organ function, particularly hepatic function, and a minority of patients may have improvement in cell counts and decreased transfusion requirements. While guidelines for MDS generally recommend chelation in selected lower-risk patients, data from nonrandomized trials suggest iron overload may impact adversely on the outcome of higher-risk MDS and stem cell transplantation (SCT). This effect may be due to increased transplant-related mortality, infection and AML progression, and preliminary data suggest that lowering iron may be beneficial in this patient group. Other areas of active and future investigation include optimizing the monitoring of iron overload using imaging such as T2* MRI and measures of labile iron and oxidative stress; correlating new methods of measuring iron to clinical outcomes; clarifying the contribution of different cellular and extracellular iron pools to iron toxicity; optimizing chelation by using agents that access the appropriate iron pools to minimize the relevant clinical consequences in individual patients; and incorporating measures of quality of life and co-morbidities into clinical trials of chelation in MDS. It should be noted that chelation is costly and potentially toxic, and in MDS should be initiated after weighing potential risks and benefits for each patient until more definitive data are available. In this review, data on the impact of iron overload in MDS and SCT are discussed; for example, several noncontrolled studies show inferior survival in patients with iron overload in these clinical settings, including an increase in transplant-related mortality and infection risk. Possible mechanisms of iron toxicity include oxidative stress, which can damage cellular components, and the documented impact of lowering iron on organ function with measures such as iron chelation therapy includes an improvement in elevated liver transaminases. Lowering iron also appears to improve survival in both lower-risk MDS and SCT in nonrandomized studies. Selected aspects of iron metabolism, transport, storage and distribution that may be amenable to future intervention and improved removal of iron from important cellular sites are discussed, as are attempts to quantify quality of life and the importance of co-morbidities in measures to treat MDS, including chelation therapy.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St Paul's Hospital and the University of British Columbia, 440–1144 Burrard Street, Vancouver, BC, Canada.
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Leitch HA. Delineating parameters of iron overload in MDS patients treated with deferasirox. Leuk Res 2010; 34:1556-7. [PMID: 20719382 DOI: 10.1016/j.leukres.2010.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 06/30/2010] [Accepted: 06/30/2010] [Indexed: 11/24/2022]
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Cheung MC, Hicks LK, Leitch HA. Excessive Neurotoxicity With ABVD When Combined With Protease Inhibitor–Based Antiretroviral Therapy in the Treatment of AIDS-Related Hodgkin Lymphoma. Clinical Lymphoma Myeloma and Leukemia 2010; 10:E22-5. [DOI: 10.3816/clml.2010.n.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lester R, Li C, Phillips P, Shenkier TN, Gascoyne RD, Galbraith PF, Vickars LM, Leitch HA. Improved Outcome of Human Immunodeficiency Virus-Associated Plasmablastic Lymphoma of the Oral Cavity in the Era of Highly Active Antiretroviral Therapy: A Report of Two Cases. Leuk Lymphoma 2009; 45:1881-5. [PMID: 15223650 DOI: 10.1080/10428190410001697395] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Plasmablastic lymphoma (PBL) is a recently described type of non-Hodgkin's lymphoma (NHL) that occurs in up to 3% of patients with HIV infection. Although the clinical-pathological features of several patients with HIV-associated plasmablastic lymphoma are documented, detailed description of clinical outcome is limited to isolated case reports. Generally, the response to lymphoma therapy is poor and survival is short. Response to highly active anti-retroviral therapy (HAART), however, has also been described. In this report, we describe the clinical course of two patients diagnosed with HIV-associated PBL in the era of HAART. One patient had a complete response to HAART, with a response-duration of 14 months, followed by relapse in the gastrointestinal tract several months after an anti-retroviral holiday. He is currently in complete remission (CR) eight months from diagnosis of relapse after receiving a full course of combination chemotherapy with modified CHOP, and 25 months from initial diagnosis. A second patient responded to brief chemotherapy in conjunction with HAART and is in clinical CR ten months from diagnosis. These cases illustrate that immunologic and virologic control with HAART may be beneficial for treating PBL and may possibly maintain continued CR. We advocate a high index of suspicion for primary PBL or its recurrence in patients with HIV infection, a history of low CD4 counts or high viral load, and oral or gastrointestinal symptoms.
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Affiliation(s)
- Richard Lester
- Department of Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Reece DE, Leitch HA, Atkins H, Voralia M, Canning LA, LeBlanc R, Belch AR, White D, Kovacs MJ. Treatment of relapsed and refractory myeloma. Leuk Lymphoma 2009; 49:1470-85. [DOI: 10.1080/10428190802064941] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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40
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Leitch HA, Chase JM, Goodman TA, Ezzat H, Rollins MD, Wong DH, Badawi M, Leger CS, Ramadan KM, Barnett MJ, Foltz LM, Vickars LM. Improved survival in red blood cell transfusion dependent patients with primary myelofibrosis (PMF) receiving iron chelation therapy. Hematol Oncol 2009; 28:40-8. [DOI: 10.1002/hon.902] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Leitch HA, Vickars LM. Supportive care and chelation therapy in MDS: are we saving lives or just lowering iron? Hematology Am Soc Hematol Educ Program 2009; 2009:664-672. [PMID: 20008252 DOI: 10.1182/asheducation-2009.1.664] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The myelodysplastic syndromes (MDS) are characterized by cytopenias and risk of transformation to acute myeloid leukemia (AML). Although new treatments are available, a mainstay in MDS remains supportive care, which aims to minimize the impact of cytopenias and transfusion of blood products. Red blood cell (RBC) transfusions place patients at risk of iron overload (IOL). In beta-thalassemia major (BTM), IOL from chronic RBC transfusions inevitably leads to organ dysfunction and death. With iron chelation therapy (ICT), survival in BTM improved from the second decade to near normal and correlated with ICT compliance. Effects of ICT in BTM include reversal of cardiac arrhythmias, improvement in left ventricular ejection fraction, arrest of hepatic fibrosis, and reduction of glucose intolerance. It is not clear whether these specific outcomes are applicable to MDS. Although retrospective, recent studies in MDS suggest an adverse effect of transfusion dependence and IOL on survival and AML transformation, and that lowering iron minimizes this impact. These data raise important points that warrant further study. ICT is potentially toxic and cumbersome, is costly, and in MDS patients should be initiated only after weighing potential risks against benefits until further data are available to better justify its use. Since most MDS patients eventually require RBC transfusions, the public health implications both of transfusion dependence and ICT in MDS are considerable. This paper summarizes the impact of cytopenias in MDS and treatment approaches to minimize their impact, with a focus on RBC transfusions and their complications, particularly with respect to iron overload.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
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Leitch HA, Leger CS, Goodman TA, Wong KK, Wong DH, Ramadan KM, Rollins MD, Barnett MJ, Galbraith PF, Vickars LM. Improved Survival in Patients with Myelodysplastic Syndrome Receiving Iron Chelation Therapy. ACTA ACUST UNITED AC 2008. [DOI: 10.3816/clk.2008.n.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- Heather A Leitch
- Department of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
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Fung SS, Hillier KL, Leger CS, Sandhu I, Vickars LM, Galbraith PF, Li CH, Leitch HA. Clinical progression and outcome of patients with monoclonal B-cell lymphocytosis. Leuk Lymphoma 2007; 48:1087-91. [PMID: 17577771 DOI: 10.1080/10428190701321277] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Monoclonal B-cell lymphocytosis (MBL) is a clonal lymphoproliferation with the immunophenotype of chronic lymphocytic leukemia (CLL) but a B-lymphocyte count of less than 5 x 10(9)/l and no lymphadenopathy, organomegaly, cytopenias or symptoms. We performed a retrospective analysis of patients with MBL (n = 46), Rai stage 0 CLL (n = 112) and Rai stage > or =1 CLL (n = 54). Median follow-up and range was 30 (0.1-120) months for MBL, 60 (0.1-309) months for stage 0 CLL and 54 (0.1-309) months for stage > or =1 CLL. None of the MBL patients required treatment compared with 24 of 112 (21%) stage 0 CLL and 28 of 54 (52%) stage > or =1 CLL patients (p < 0.0003). No MBL underwent aggressive transformation compared with 1 of 112 (0.8%) stage 0 CLL and 6 of 54 (11%) stage > or =1 CLL patients (p < 0.0003). Progression-free survival (PFS) appeared improved in MBL compared to stage 0 CLL, although this did not reach statistical significant (p = 0.07) due to the relatively short follow-up in the MBL group; two year PFS was 97.2% for MBL, 93.1% for stage 0 CLL, and 68% for stage > or =1 CLL patients (p < 0.0001 for stage > or =1 CLL compared with MBL and stage 0 CLL). This is the first study of outcome in MBL which demonstrates that patients have an improved disease course compared to stage 0 CLL patients. Over a median 2.5 years of follow-up, no MBL patients required treatment or died of CLL-related causes.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- B-Lymphocytes/pathology
- Disease Progression
- Disease-Free Survival
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphocytosis/diagnosis
- Lymphocytosis/mortality
- Lymphocytosis/pathology
- Lymphocytosis/therapy
- Male
- Middle Aged
- Prognosis
- Retrospective Studies
- Survival Analysis
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Affiliation(s)
- Sarah S Fung
- Faculty of Medicine, University of British Columbia, BC, Canada
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45
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Ezzat H, Filipenko D, Vickars L, Galbraith P, Li C, Murphy K, Montaner JSG, Harris M, Hogg RS, Vercauteren S, Leger CS, Zypchen L, Leitch HA. Improved survival in HIV-associated diffuse large B-cell lymphoma with the addition of rituximab to chemotherapy in patients receiving highly active antiretroviral therapy. HIV Clin Trials 2007; 8:132-44. [PMID: 17621460 DOI: 10.1310/hct0803-132] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Recent trials suggest serious toxicity in HIV-associated non-Hodgkin's lymphoma (NHL) with rituximab (R) and chemotherapy (CT), offsetting the benefit of rituximab. METHOD We retrospectively reviewed experience with CHOP-R vs. CT in 40 patients with HIV-associated diffuse large B-cell lymphoma (DLBCL) diagnosed between December 1992 and February 2006, all of whom were treated with curative intent. RESULTS In a univariate analysis, International Prognostic Index (IPI) score, prior AIDS, HAART, and rituximab were significant for overall survival (OS). In a multivariate analysis, IPI 0-1 (p < .02), no prior AIDS (p < .0002), and receiving CHOP-R (p < .01) were significant for improved OS, and HAART use (p < .09) retained a trend for improved OS. The hazard ratio (HR) for patients with high IPI receiving CHOP-R was 0.3 (95% CI 0.1-0.8). Patients without prior AIDS receiving CHOP-R had an HR of 0.5 (95% CI 0.1-1.7). The OS at 30 months in patients not receiving HAART was 0%. With HAART, OS was 33% for CT and 86% for CHOP-R; HR for CHOP-R was 0.4 (95% CI 0.1-1.2). Toxic deaths were 3 (33%) for CHOP-R and 6 (25%) for CT (p = ns); all toxic deaths with CHOP-R were in patients not receiving HAART. Rituximab-treated patients had a lower death rate from lymphoma (CHOP-R, 2 [16%] vs. CT, 15 [63%]; p < .04), and overall mortality (CHOP-R, 5 [42%] vs. CT, 21 [88%]; p < .01). CONCLUSION These retrospective data suggest that fatal toxicity of rituximab in HIV-NHL is not increased provided HAART is used, that the addition of rituximab to CT improved outcome, and that further prospective trials investigating this issue are warranted.
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Affiliation(s)
- H Ezzat
- Department of Hematology, University of British Columbia, Vancouver, Canada
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46
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Cheung MC, Imrie KR, Leitch HA, Park-Wyllie LY, Buckstein R, Antoniou T, Loutfy MR. Physician perceptions and preferences in the treatment of acquired immunodeficiency syndrome (AIDS)-related lymphoma. Ann Hematol 2007; 86:631-8. [PMID: 17372734 DOI: 10.1007/s00277-007-0284-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 03/05/2007] [Indexed: 11/30/2022]
Abstract
The optimal management of acquired immunodeficiency syndrome-related lymphoma (ARL) in the era of combination antiretroviral therapy (cART) is unclear. We administered a survey to determine physician preferences and perceptions in the management of ARL and to assess the variability in treatment in Canada. Of 196 lymphoma-treating physicians, 117 (63%) responded. The majority of respondents (98%) had a positive attitude towards the treatment of ARL. Most physicians (66%) recommended the concomitant use of cART in the care of their patients with ARL, and a majority (86%) recommended CHOP-like regimens (cyclophosphamide, doxorubicin, vincristine, and prednisone) to form the backbone of chemotherapy. The addition of rituximab was preferred by 43% of physicians, while 39% and 18% would either not use rituximab or were unsure of the agent's role, respectively. In logistic regression analysis, use of rituximab was predicted only by location of practice (province); physicians from the province of British Colombia were much more likely to administer rituximab than practitioners from Ontario (odds ratio 41.8; 95% confidence interval 7.44-235.1, p < 0.001). In the current cART era, physicians have a positive attitude towards the treatment of ARL. The majority prefer to use cART in combination with CHOP for ARL. The use and perceived benefit of rituximab may be influenced by interprovincial formulary differences and regional variation in guideline recommendations.
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Affiliation(s)
- Matthew C Cheung
- Department of Medicine, Division of Hematology/Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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47
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Leitch HA, Connors JM. Vaccine therapy for non-Hodgkin's lymphoma and other B-cell malignancies. Curr Opin Investig Drugs 2005; 6:597-604. [PMID: 15988911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Immunity against tumor antigens, including the passive transfer of humoral (antibody-based) immunity or cellular immunity in the form of cytotoxic T-lymphocyte clones, has been exploited for the treatment of non-Hodgkin's lymphoma and other B-cell malignancies in recent years. In many strategies, the idiotype expressed on B-cell malignancies is the antigen used to induce active immunity. Early studies using purified idiotype, immune adjuvant and cytokines to induce anti-idiotype immunity have demonstrated that these methods are safe and potentially effective, and they are now being tested in prospective, randomized clinical trials. Methods for improvement include recombinant sources of idiotype, DNA vectors, enhancement of antigen delivery and presentation by using dendritic cells, boosting immune help through the use of cytokine delivery or foreign antigens, and blocking negative regulators. The goal of this approach is to induce lasting and individualized immunity against B-cell malignancies that is readily available and cost-effective.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, Department of Medicine, Providence Health Care at St Paul's Hospital, University of British Columbia, 440-1144 Burrard Street, Vancouver, Canada.
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48
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Leenman EE, Panzer-Grümayer RE, Fischer S, Leitch HA, Horsman DE, Lion T, Gadner H, Ambros PF, Lestou VS. Rapid determination of Epstein-Barr virus latent or lytic infection in single human cells using in situ hybridization. Mod Pathol 2004; 17:1564-72. [PMID: 15545957 DOI: 10.1038/modpathol.3800228] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Epstein-Barr (EBV) virus is associated with malignancies such as lymphoma and carcinoma. Infection of cells with EBV may result in either lytic infection with production of viral particles, characterized by the presence of linear DNA forms, or latent infection, characterized by either episomal or integrated DNA forms. To examine whether the different lytic and latent EBV DNA forms can reliably be distinguished in single human cells, in situ hybridization was performed in EBV-positive cell lines. Immunocytochemistry and Southern blot analysis were performed supplementary to in situ hybridization. In latent infection, three in situ hybridization patterns were observed: large-disperse (episomal), small-punctate (integrated) and combined (both), signal types 1, 2 and 3 respectively. These were associated with expression of latent membrane protein 1, but not with Z fragment of Epstein-Barr replication activator or viral capsid antigen. In lytic infection, three additional in situ hybridization patterns were observed: nuclear membrane associated, bubble (filling up the nucleus) and spillover (covering the lysed cells) signals types 4, 5 and 6 respectively. Signal types 4 and 5 were associated with expression of latent membrane protein 1 and Z fragment of Epstein-Barr replication activator but not viral capsid antigen, whereas type 6 was associated with expression of viral capsid antigen only. Southern blot analysis confirmed these results; however, low copy numbers of integrated virus were often missed by Southern blot, confirming that in situ hybridization is more sensitive in determining the presence of all types of EBV DNA. In situ hybridization may prove useful in rapidly screening large series of tissue microarrays and other clinical specimens for the presence of lytic or latent EBV.
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Affiliation(s)
- Elena E Leenman
- Research Institute of Radiology and Roentgenology, St Petersburg, Russia
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49
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Mangel J, Leitch HA, Connors JM, Buckstein R, Imrie K, Spaner D, Crump M, Pennell N, Boudreau A, Berinstein NL. Intensive chemotherapy and autologous stem-cell transplantation plus rituximab is superior to conventional chemotherapy for newly diagnosed advanced stage mantle-cell lymphoma: a matched pair analysis. Ann Oncol 2004; 15:283-90. [PMID: 14760123 DOI: 10.1093/annonc/mdh069] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The outcome of 20 patients with newly diagnosed mantle-cell lymphoma (MCL) treated on a prospective trial of autologous stem-cell transplantation (ASCT) and rituximab immunotherapy was compared with the outcome of 40 matched historical control patients treated with standard combination chemotherapy. PATIENTS AND METHODS Control patients with MCL were identified from a lymphoma database, and pairs were matched with patients receiving ASCT-rituximab for stage of disease, gender and age (+/-5 years). Only patients treated with an anthracycline- or cyclophosphamide-fludarabine-based regimen were included. RESULTS Seventeen of 20 patients who received ASCT-rituximab remain alive in remission at a median of 30 months from diagnosis; one patient relapsed 2 years post-ASCT, and two died at 7 and 11 months post-ASCT without evidence of lymphoma. Of 40 patients treated with conventional chemotherapy, with a median follow-up of 80 months, 33 have relapsed or progressed and 29 have died. Overall (OS) and progression-free (PFS) survival were superior in patients treated with ASCT-rituximab compared with those treated with conventional chemotherapy (PFS at 3 years, 89% versus 29%, P <0.00001; OS at 3 years, 88% versus 65%, P = 0.052). CONCLUSIONS This matched-pair analysis suggests that patients with advanced-stage MCL treated with ASCT-rituximab had statistically significantly better PFS and a trend toward better OS than patients treated with conventional chemotherapy. Longer follow-up will determine response duration and the true impact of this treatment strategy on PFS and OS.
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Affiliation(s)
- J Mangel
- Advanced Therapeutics Program, Toronto Sunnybrook Regional Cancer Centre, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
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50
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Kuruvilla J, Leitch HA, Vickars LM, Galbraith PF, Li CH, Al-Saab S, Naiman SC. Aplastic anemia following administration of a tumor necrosis factor-alpha inhibitor. Eur J Haematol 2004; 71:396-8. [PMID: 14667206 DOI: 10.1034/j.1600-0609.2003.00115.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Upregulation of tumor necrosis factor-alpha (TNF-alpha) has been implicated in the pathogenesis of several inflammatory conditions, including rheumatoid arthritis. Therapeutic agents such as antibodies or soluble TNF-alpha receptor analogs, which block TNF-alpha activity are a recent addition to the therapeutic armamentarium for the conditions. We describe a patient who developed aplastic anemia complicated by sepsis after receiving etanercept, a TNF-alpha receptor analog, for the treatment of rheumatoid arthritis. Pancytopenia resolved within 3 wk of discontinuing etanercept. To our knowledge, this is the first report of aplastic anemia associated with TNF-alpha blockade.
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Affiliation(s)
- John Kuruvilla
- Division of Hematology, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
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