Single-center pediatric experience with venetoclax and azacitidine as treatment for myelodysplastic syndrome and acute myeloid leukemia

BACKGROUND

The BCL-2 inhibitor venetoclax (ven) has revolutionized the treatment of acute myeloid leukemia (AML) in elderly adults, leading to its recent FDA approval for this population in combination regimens. Although extensive data exist for adult myeloid malignancies, there are limited preclinical data on the efficacy and/or dosing of venetoclax for pediatric myelodysplastic syndrome (MDS) or AML and thus little information to guide use of this regimen in pediatric patients. Our objective was to describe our single-center experience with venetoclax in combination with the hypomethylating agent 5-azacitidine (aza) in pediatric patients with MDS or AML.

PROCEDURE

We conducted a retrospective chart review of patients treated at Children's Hospital Colorado prior to March 2020 with at least one cycle of ven/aza. Patients were included if between the ages of 1 and 25 years with a diagnosis of high-grade MDS or AML. AML patients had relapsed or primary refractory disease or were deemed poor candidates for standard chemotherapy.

RESULTS

Eight patients received ven/aza, two for high-grade MDS and six for AML. Ven/aza was well tolerated by all patients. The most common adverse events seen with this regimen were gastrointestinal and hematologic. Morphologic responses were seen in six patients including both patients with MDS. All four AML responders became minimal residual disease negative. Three responders have thus far proceeded to allogeneic hematopoietic stem cell transplant following ven/aza.

CONCLUSIONS

Our clinical experience suggests that ven/aza is a safe and promising regimen that should be further explored with late-phase clinical trials.

Progress: Targeted Therapy, Immunotherapy, and New Chemotherapy Strategies in Advanced Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) is one of the most aggressive subtypes of breast cancer, accounting for approximately 15% of cases, and is defined by the lack of expression of hormone receptors (estrogen and progesterone receptors) and lack of amplification or overexpression of human epidermal growth receptor 2 (HER2). Due to the lack of targets of hormone receptors and HER2, treatment of TNBC or advanced TNBC relies on conventional chemotherapeutic agents, but their efficacy and prognosis are poor. In patients with advanced TNBC, poorer outcomes are observed. Recently, with the launch of clinical trials and advancements in molecular studies, targeted therapy for signaling transduction pathways, immunotherapy for immune checkpoints, and new chemotherapy strategies have provided feasible or potential therapeutic options for advanced TNBC. This review aimed to summarize recent progress in targeted therapy, immunotherapy, and chemotherapy for advanced TNBC.

Potential survival benefit for patients receiving autologous hematopoietic stem cell transplantation after checkpoint inhibitors for relapsed/refractory Hodgkin lymphoma: A real-life experience

In recent years, novel drugs are available for the patients with relapsed/refractory Hodgkin lymphoma (HL), like immune checkpoint inhibitors (CPi). These drugs have been able to rescue a cohort of patients who subsequently could receive an allogeneic stem-cell transplant (SCT). No data were reported for subsequent autologous SCT (ASCT) after CPi. Here, we report our real-life experience in heavily pretreated HL patients undergoing ASCT as consolidation approach after CPi treatment. A retrospective observational study was conducted. Patients had CPi therapy in the context of clinical trials (n = 6) or in the named patient program (n = 7) between July 2014 and November 2019: 9 out of 13 received pembrolizumab and the remaining four underwent nivolumab. A median of 12 cycles (range, 3-16) of CPi therapy were infused. Thirteen patients underwent ASCT after CPi: 11 (84.6%) patients obtained a complete response (CR) and 2 had progression of disease, with an overall response rate of 84.6%. With a median follow-up of 3.3 years (range, 1.1-5.5), only one CR patient had disease relapse after 3.9 months from ASCT, leading to an estimated disease-free survival of 87.5% at 56.9 months. The estimated 5-year progression-free survival was 73.4% and overall survival was 92.3% at 4.8 years, respectively. No unexpected or cumulative toxicity was observed. Our results indicated that ASCT may represent a further effective therapeutic option as consolidation in HL after CPi treatment that today represents the last conventionally recognized therapeutic line.

Psychogenic Non-Epileptic Status as Refractory, Generalized Hypertonic Posturing: Report of Two Adolescents

Psychogenic non-epileptic seizures (PNES) or dissociative seizures are found under the umbrella headings of functional/dissociative neurological disorders (FND) in psychiatric classifications (DSM-5; ICD-11). PNES are not characterized by any specific ictal or postictal EEG abnormalities. Patients with PNES can present with motor or non-motor symptoms, frequently associated with a change in the level of consciousness. PNES duration is variable, often longer than that of epileptic seizures. Prolonged PNES, sometimes termed PNES status, involve continuous or repetitive events that exceed 30 min. Prolonged PNES are often misdiagnosed as an epileptic event and are often inappropriately treated with high doses of antiseizure drugs. In this report, we describe two adolescent patients who presented with prolonged PNES characterized by generalized hypertonic posturing and low levels of consciousness. Despite multiple presentation to the Emergency department, and multiple normal video-EEG, the patients were misdiagnosed with epilepsy and were inappropriately treated with antiseizure medications. Both patients presented psychiatric comorbidity, consisting of a major depressive disorder, obsessive-compulsive symptoms, social withdrawal, difficulty of social interaction, and anxious-perfectionist personality traits. The episodes of prolonged PNES gradually declined within 18 months in both patients.

Gilteritinib use in the treatment of relapsed or refractory acute myeloid leukemia with a FLT3 mutation

The prognosis of patients with relapsed or refractory acute myeloid leukemia (R/R AML) is dismal with salvage standard approaches, and mutations of FMS-like tyrosine kinase 3 (FLT3) gene, occurring in around 30% of AML patients may confer even poorer outcomes. Several targeted tyrosine kinase inhibitors have been developed to improve FLT3-mutated AML patient´s survival. Gilteritinib, a highly specific second-generation class I oral FLT3 inhibitor, has demonstrated superiority to salvage chemotherapy (SC) in R/R FLT3 mutated AML based on significantly longer OS in the gilteritinib arm than in the SC arm. Gilteritinib is generally well tolerated, but some clinically relevant adverse events should be monitored, especially myelosuppression, QTc prolongation and differentiation syndrome, usually manageable (dose reductions, interruption or discontinuation) and reversible. We discuss clinical development, efficacy, safety and mechanisms of resistance of gilteritinib in the treatment of R/R patients with FLT3 mutated AML.

Intravenous Ketamine Administered as Patient Controlled Analgesia and Continuous Infusion for Central Pain Syndrome

Treatment of Central Pain Syndrome (CPS) is known to be extremely challenging. Current therapies are unsatisfactory as patients report only mild to moderate pain relief. We report a case of using ketamine as a patient-controlled analgesia (PCA) for the treatment of CPS. A 58-year-old male with CPS presented with severe generalized body pain refractory to multiple pharmacological interventions. He was started on a basal infusion rate at 0.3 mg/kg/h with a ketamine PCA bolus of 10 mg with a 10-minute lockout period. Over the next 7 days, the basal infusion rate was titrated up to 2.1 mg/kg/h relative to the number of times the patient pressed the PCA. At the end of the trial, the patient reported 0/10 pain with lightheadedness on the first day being the only side effect reported. He was discharged home with his regular pain regimen, with significant decrease in pain over the next few months. Rather than trying to establish a "one size fits all" protocol for ketamine infusions, this case illustrates a shift in pain management focus by allowing patients to self-titrate and demonstrates the potential for using ketamine PCA as a treatment option for CPS.

Outcomes of Inhaled Amikacin and Clofazimine-Containing Regimens for Treatment of Refractory Mycobacterium avium Complex Pulmonary Disease

Limited data are available regarding optimal treatment for refractory Mycobacterium avium complex-pulmonary disease (MAC-PD). We evaluated outcomes of inhaled amikacin (AMK) with clofazimine (CFZ) regimens as an add-on salvage therapy for refractory MAC-PD. We retrospectively analyzed 52 patients with refractory MAC-PD, characterized by persistently positive sputum cultures despite >6 months of treatment. Thirty-five (67%) patients had M. intracellulare-PD, and 17 (33%) patients had M. avium-PD. Twenty-seven (52%) patients received the salvage therapy for ≥12 months, whereas 25 (48%) patients were treated for <12 months due to adverse effects or other reasons. Seventeen (33%) patients had culture conversion: 10 (10/27) in the ≥12-month treatment group and seven (7/25) in the <12-month treatment group (p = 0.488). Microbiological cure, defined as maintenance of culture negativity, was achieved in 12 (23%) patients; six (6/12) with accompanying symptomatic improvement were considered to have reached cure. Clinical cure, defined as symptomatic improvement with <3 consecutive negative cultures, was achieved in three (6%) patients. Overall, 15 (29%) patients achieved favorable outcomes, including microbiological cure, cure, and clinical cure. Inhaled AMK with CFZ may provide favorable outcomes in some patients with refractory MAC-PD. However, given the adverse effects, more effective strategies are needed to maintain these therapeutic regimens.

The Value of Serum MicroRNA Expression Signature in Predicting Refractoriness to Bortezomib-Based Therapy in Multiple Myeloma Patients

Bortezomib is the first-in-class proteasome inhibitor, commonly used in the treatment of multiple myeloma (MM). The mechanisms underlying acquired bortezomib resistance in MM are poorly understood. Several cell-free miRNAs have been found to be aberrantly regulated in MM patients. The aim of this pilot study was to identify a blood-based miRNA signature that predicts bortezomib-based therapy efficacy in MM patients. Thirty MM patients treated with bortezomib-based regimens were studied, including 19 with refractory disease and 11 who were bortezomib sensitive. Serum miRNA expression patterns were identified with miRCURY LNA miRNA miRNome PCR Panels I+II (Exiqon/Qiagen). Univariate analysis found a total of 21 miRNAs to be differentially expressed in patients with MM according to bortezomib sensitivity. Multivariate logistic regression was created and allowed us to discriminate refractory from sensitive patients with a very high AUC of 0.95 (95%CI: 0.84-1.00); sensitivity, specificity and accuracy were estimated as 0.95, 0.91, and 0.93. The model used expression of 3 miRNAs: miR-215-5p, miR-181a-5p and miR-376c-3p. This study is the first to demonstrate that serum expression of several miRNAs differs between patients who are bortezomib refractory and those who are sensitive which may prove useful in studies aimed at overcoming drug resistance in MM treatment.

An analysis of 20 clinical cases of refractory mycoplasma pneumonia in children

BACKGROUND

Refractory mycoplasma pneumonia (RMPP) is one of the important pathogens of community-acquired pneumonia (CAP) in children. Its treatment is difficult. The aims of this study were to analyze the clinical manifestations, diagnosis, and treatment of 20 cases of RMPP in children in order to provide a reference for the diagnosis and treatment of RMPP.

METHODS

The clinical data of 20 patients with RMPP admitted to the Pediatrics Department of the First Affiliated Hospital of Guangzhou Medical University in the recent three years were retrospectively analyzed. The clinical data of 36 patients with common mycoplasma pneumonia in the same period were compared. The clinical manifestations, laboratory examinations, and imaging characteristics of RMPP were discussed. Intrapulmonary and extrapulmonary complications and treatment were also analyzed in order to provide assistance in the diagnosis and treatment of RMPP.

RESULTS

There were significant differences between the refractory group and the general group in terms of heat duration, hospitalization time, hypoxemia, lung rales, CRP, ESR, PCT, LDH, ALT, PLT, WBC, D dimer and other laboratory examinations, intrapulmonary and extrapulmonary complications, and treatment (all P<0.05). There was no significant difference in the age, sex, and wheezing between the two groups (P>0.05).

CONCLUSIONS

Long duration of fever, tachycardia, and lung rale protrusion may be the clinical characteristics of RMPP. Unilateral pulmonary shadow and atelectasis should be paid more attention, which may be a high-risk factor for the development of RMPP. The inflammation index of RMPP cases increased and there were many complications inside and outside the patients' lungs. It was necessary to give enough macrolides to fight the infection by using Glucocorticoid and Intravenous immunoglobulin reasonably while liver, heart, and fiberoptic bronchoscopy was completed to improve the effectiveness of the diagnosis and treatment.

Treatment approaches in relapsed or refractory peripheral T-cell lymphomas

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of rare and aggressive non-Hodgkin’s lymphomas. Clinical staging, prognostic scoring, and initial treatment strategies have historically been based on paradigms developed in B-cell lymphomas. Despite primary treatment protocols that are typically anthracycline-based and frequently involve consolidative autologous stem cell transplantation in first remission, many patients develop disease progression. There remains a high unmet medical need for improved treatment strategies in the relapsed or refractory setting. Salvage chemotherapy and stem cell transplantation in those who are suitable has traditionally been the accepted approach, but this remains a minority of the total patient population. As increasing knowledge is gleaned regarding the biological heterogeneity within the various PTCL subtypes, newer targeted agents have been developed, studied, and approved in this small, heterogeneous population of relapsed or refractory disease. Given its success and tolerability in this pretreated population, brentuximab vedotin, an anti-CD30 antibody drug conjugate, was brought earlier in the disease course and is a model for advances in the targeted treatment of PTCL. As others undergo further development in the relapsed setting and successes are brought earlier in the disease course, the outcome for PTCL patients is likely to improve. However, innovative clinical trial designs are crucial for the assessment of targeted agents in this highly heterogeneous population. This review explores the current treatment environment for patients with relapsed and refractory PTCL, including newer strategies such as targeted agents and immunotherapy.

Definition of Uveitis Refractory to Treatment: A Systematic Review in the Absence of a Consensus

PURPOSE

To evaluate the different definition of refractoriness in uveitis in the literature.

METHODS

We systematically searched the literature in order to identify definitions of refractory noninfectious uveitis in adult patients. A search strategy in the databases of MEDLINE and Scopus was used to find articles published between January 2005 and October 2018.

RESULTS

Definitions of corticosteroids-refractoriness were related to two main concepts: persistence of inflammation despite the use of corticosteroid and recurrences above a dosage threshold. In terms of immunomodulatory therapy and biologic agents, we observed a great variety of definitions: persistence of inflammation, number of attacks, side effects or complications, symptoms, and best-corrected visual acuity.

CONCLUSIONS

The results of this systematic review demonstrate the current lack of consensus on the definition for refractory uveitis, regardless of the treatment being used and revealed a new terminology based on a comprehensive and operational definition for each specific category of refractoriness.

Treatment with daratumumab in patients with relapsed/refractory AL amyloidosis: a multicentric retrospective study and review of the literature

Management of patients with relapsed or refractory (R/R) AL amyloidosis is complex. Some initial reports have shown positive results with daratumumab in heavily pre-treated AL amyloidosis patients. In this retrospective multicentric study, 38 patients (mean age 64 ± 9 years) with R/R AL amyloidosis treated with daratumumab were included. Cardiac and renal involvement was present in 76 and 74% of patients, and 42% had ≥3 organs involved. Median number of previous lines of therapy was 2 (range 1-8). Overall hematological response was 72%, including 28% complete responses. The median time to first hematological response was 2 weeks. A high-quality response (≥very good partial response) was obtained in 65% of patients who had never achieved such depth of response previously. Hematological responses were more frequent among patients receiving daratumumab as second-line therapy compared to subsequent therapies (92 vs. 61%). Cardiac and renal organ response rates were 37 and 59%. At 12 months, overall and progression-free survival were 59% (95%CI: 0.36-0.77) and 52% (95%CI: 0.29-0.70), respectively. Daratumumab is a safe and effective drug in the treatment of R/R AL amyloidosis and should be considered early in the course of the disease.

Transcranial direct current stimulation for refractory auditory hallucinations in schizophrenia: Acute and 16-week outcomes

BACKGROUND

Transcranial direct current stimulation (tDCS) has demonstrated efficacy against antipsychotic-refractory auditory verbal hallucinations (AVH) in schizophrenia. The duration of persistence of benefit is not well characterized.

MATERIALS AND METHODS

Thirty-one adults with schizophrenia and medication-refractory AVH were treated with 2-3 mA tDCS in 30 min sessions, twice a day, 6 days a week, for 2-4 weeks. The anode was sited over F3 and the cathode midway between T3 and P3 in the 10-20 EEG system. Patients were assessed until a 4-month study endpoint using two auditory hallucination rating scales and the Positive and Negative Syndrome Scale (PANSS-N).

RESULTS

Auditory hallucinations were moderately reduced by tDCS with 25%-29% improvement evident by the end of the 2^nd week and another 10% improvement between week 2 and 4 months. There was no loss of benefit at the end of the 4-month study. There was also a small (11%) but statistically significant improvement in PANSS-N scores.

CONCLUSIONS

Although this study is limited by the nonblind, uncontrolled design, the results suggest that tDCS, as delivered, holds promise for treating refractory AVH in schizophrenia; the benefits persist beyond the short term.

Outcomes of patients with relapsed or refractory acute myeloid leukemia: a population-based real-world study

With standard therapies for patients with acute myeloid leukemia (AML), many patients either do not achieve complete response (CR) or relapse after CR. There are a scarcity of real-world data on outcomes of unselected patients with relapsed/refractory acute myeloid leukemia (RR-AML). We retrospectively evaluated treatment patterns and survival outcomes of unselected patients aged ≥18 years diagnosed with RR-AML identified from the Alberta Cancer Registry, Alberta, Canada, between January 2013 and December 2016. We included 199 patients who met predefined criteria for RR-AML. Following RR-AML diagnosis, 23% of patients received intensive therapy (IT), 33% non-intensive therapy (NIT), and 44% best supportive care (BSC). The unadjusted median overall survival (OS) of the study cohort was 5.3 months from the time of RR-AML diagnosis, with a 5-year OS rate of 12.6% (95% confidence interval 7.5-21.1). According to treatment intensity after RR-AML, the median OS outcomes were 13.6, 9.4, and 2.0 months for IT, NIT, and BSC groups, respectively (P<0.001). Patients who received treatment (IT or NIT) had better survival than those who received only BSC. This study emphasizes the need for newer therapy options for patients with RR-AML.

Refractory lupus panniculitis treated successfully with rituximab: Two cases

Lupus panniculitis is usually difficult to treat, and the patient is often put on multiple immunosuppressives with variable clinical response and relapses, notwithstanding the long-term side effects. We describe two cases of refractory lupus panniculitis which have been treated successfully with rituximab which is a chimeric anti-CD20 antibody. It reduces the number of circulating mature B-cells, thereby reducing the autoantibodies and the mediators of inflammation. Rituximab is a good alternative to patients who are not responsive to conventional treatment options for lupus panniculitis. There have been few side effects reported by the patients, but the clinical response and psychological well-being clearly outweigh them.

Low-dose pembrolizumab and nivolumab were efficacious and safe in relapsed and refractory classical Hodgkin lymphoma: Experience in a resource-constrained setting

The efficacy and safety of low-dose anti-PD1 antibodies in relapsed/refractory classical Hodgkin lymphoma (cHL) require confirmation. Pembrolizumab (100 mg every 3 weeks, Q3W) or nivolumab (40 mg Q2W) were administered to patients with relapsed/refractory cHL. In the pembrolizumab cohort (N = 11), who had failed a median of three (1-6) therapies (brentuximab vedotin [BV]: 91%; autologous hematopoietic stem cell transplantation [auto-HSCT]: 18%), the overall response rate (ORR) by positron emission tomography-computed tomography was 100% (metabolic complete response [mCR]: 73%; partial response [PR]: 27%). Median cumulative dose for achieving best response was 400 (300-800) mg. Median progression-free survival (PFS) was 35 months. Median overall survival (OS) was not reached. Adverse events (AEs) of grade 1-2 were observed in three patients. In the nivolumab cohort (N = 6), who had failed a median of three (2-6) therapies (BV: 50%; auto-HSCT: 17%; allogeneic HSCT: 34%), the ORR was 100% (mCR: 67%; PR: 17%; indeterminate response: 17%). Median cumulative dose for achieving best response was 160 (160-360) mg. Median PFS was 33 months. Median OS was not reached. AEs of grade 1-2 were observed in four patients, two of whom had pre-existing autoimmune conditions. Five patients with Epstein-Barr virus (EBV) positive Reed-Sternberg cells underwent monitoring of plasma EBV DNA, which became negative in four mCR patients but remained positive in one PR patient who died ultimately from refractory lymphoma. Low-dose pembrolizumab and nivolumab were highly efficacious and safe in relapsed/refractory cHL. These observations have significant financial implications in resource-constrained settings.

A phase I study of CAR-T bridging HSCT in patients with acute CD19+ relapse/refractory B-cell leukemia

Chimeric antigen receptor (CAR)-T cell therapy is a novel cellular immunotherapy for relapsed/refractory(R/R) B acute lymphoblastic leukemia (B-ALL). However, the survival duration of CAR-T cells in vivo is noteworthy, and in some cases recurrence occurs following CAR-T cell therapy. There is controversy over the benefits of bridging to allo-HSCT after CAR-T cell therapy. The present study explored the efficacy and safety of CD19 chimeric antigen receptor (CAR) T-bridged allogeneic hematopoietic stem cell transplantation (allo-HSCT) treatment in relapsed/refractory B-cell acute lymphocytic leukemia (R/R B-ALL). A total of 9 patients with B-ALL treated at The First Affiliated Hospital of Wenzhou Medical University between December 2016 and November 2017 were included. The results demonstrated that the total response rate on day 28 after receiving CD19-CAR T-cell therapy was 100% (9/9) and all patients exhibited complete remission. The 1-year overall survival (OS) rate for 5 patients who received CAR-T bridged HSCT was 100%, the 1-year DFS rate was 100%; the 1-year OS rate for the 4 patients who received CAR-T therapy was 75%, and the 1-year DFS rate was 75%. Patients who received CAR-T bridged to HSCT had no significant prolongation of myeloid and platelet engraftment median time compared with patients who received CAR-T alone, and the incidence of acute graft-versus-host disease or extensive chronic graft-versus-host disease did not increase. Overall, the present clinical trial demonstrated that CAR-T therapy bridging to HSCT is a feasible, safe and effective method to treat adult patients with R/R B-ALL.

Fabrication of Refractory Materials from Coal Fly Ash, Commercially Purified Kaolin, and Alumina Powders

Coal fly ash and kaolin are ceramic compounds utilized as raw materials in the production of refractories. Fly ash is an environmental pollutant that emanates abundantly from coal thermal power plants. The management of the large amounts of fly ash produced has been very challenging, with serious economic and environmental consequences. Kaolin, on the other hand, is a natural and synthetic clay material used in medicines, paper, plastics, and cosmetic preparations. In this research, refractory materials (cordierite (Mg₂Al₄Si₅O₁₈), mullite (3Al₂O₃·2SiO₃), and kyanite (Al₂SiO₅)) were fabricated in four different experiments, and an assessment was made of the strength of each of the materials. Coal fly ash and kaolin were each blended with alumina as starting materials. MgO and AlF₃·3H₂O were each applied as additives to the reacting materials. The mixtures were molded and sintered at temperatures between 1000 °C and 1200 °C for three hours in a muffle furnace, and characterized by SEM and XRD. The analysis revealed the evolution of cordierite, mullite, and kyanite alongside other crystalline compounds. The formation of kyanite in experiment C, due to the addition of AlF₃·3H₂O, is unprecedented and phenomenal. The XRD figures show the corundum phases crystallize at 1100 °C in experiments A and B, and disappear at 1200 °C.

Effective treatment of refractory acquired pure red blood cell aplasia with eltrombopag and sirolimus: a case report

Acquired pure red cell aplasia (aPRCA) is a kind of anemia characterized by severe reticulocytopenia and reduced bone marrow erythroblastic cells. For patients who are refractory to the first-line therapy (cyclosporin A with/without glucocorticoids), second-line therapy is considered less effective. We report on a patient with primary aPRCA who was refractory to cyclosporin A, glucocorticoids, and several second-line regimens. The patient was treated with sirolimus for 10 months with no improvement in hemoglobin but complete response was achieved after adding eltrombopag at a dosage of 25 mg/day. Eltrombopag was well tolerated with no evidence of clonal evolution at the end of follow up. This case provided a new attempt at treating patients with refractory/relapse aPRCA with eltrombopag, probably in combination with sirolimus.

Resolution of refractory chylothorax with a combination of talc pleurodesis and CPAP

Chylothorax is an uncommon cause of pleural effusion. Recurrent chylous effusions are often resistant to conservative treatment and many need surgical intervention. We report a 69‐year‐old woman with refractory idiopathic chylothorax resistant to medium‐chain triglyceride diet and intermittent thoracentesis. Lymphangiography and lymphoscintigraphy failed to identify the site of leakage. We initiated continuous positive airway pressure (CPAP) 12 h before and 48 hours after talc pleurodesis. Chest drain was removed at day 3 and she was discharged at day 5. To our knowledge, this is the first case of successful resolution of idiopathic refractory chylothorax with CPAP ventilation used in tandem with talc pleurodesis.

Second autologous stem cell transplantation for relapsed/refractory Hodgkin lymphoma after a previous autograft: a study of the lymphoma working party of the EBMT

The purpose of this study was to analyze the results of second autologous hematopoietic stem cell transplantation (ASCT2) for patients with relapsed/refractory Hodgkin lymphoma (HL) after a first transplantation (ASCT1). Outcomes for 56 patients receiving an ASCT2 registered in the EBMT database were analyzed. The 4-year cumulative incidences of non-relapse mortality and disease relapse/progression were 5% and 67%, respectively. The 4-year overall survival (OS) and progression-free survival (PFS) were 62% and 28%. In univariate analysis, relapse of HL within 12 months of ASCT1 was associated with a worse OS (35% versus 76%, p = 0.01) and PFS (19% versus 29%, p = 0.059). Chemosensitivity at ASCT2 predicted better outcomes (4-year OS 72% versus 29%, p = 0.002; PFS 31% versus 12%, p = 0.015). This series shows that ASCT2 is a safe procedure and a relatively effective option for patients with late relapses after ASCT1 and with chemosensitive disease who are not eligible for an allogeneic transplant.

An evaluation of subcutaneous daratumumab for the treatment of multiple myeloma

INTRODUCTION

A subcutaneous formulation of daratumumab, a human immunoglobulin G1 kappa monoclonal antibody targeting CD38, recently achieved FDA approval for both newly diagnosed and relapsed refractory multiple myeloma amid promises to decrease infusion times and rates of infusion reactions in myeloma patients.

AREAS COVERED

In this article the biology behind subcutaneous administration of oncologic antibody therapies is reviewed and the subcutaneous formulation of daratumumab is covered in depth. The most recent results from the PAVO, COLUMBA, and PLEIADES clinical trials evaluating subcutaneous daratumumab as a single agent, and in combination, in both newly diagnosed, and relapsed and refractory myeloma patients are summarized. The efficacy, safety, and PK data from these trials are reviewed, and the potential of the subcutaneous formulation to improve quality of life in myeloma patients and decrease healthcare resource use is discussed.

EXPERT OPINION

Subcutaneous daratumumab is non-inferior to conventional intravenous daratumumab with lower risk of infusion-related reactions and decreased administration time. Based on these data, and the recent FDA and European Commission approvalsthe widespread use of the subcutaneous formulation for both conventional and investigational practice is supported.

Complete Remission in a Patient with Treatment Refractory Bullous Pemphigoid after a Single Dose of Omalizumab

Bullous pemphigoid (BP) is an autoimmune disorder known to be mediated by immunoglobulin G (IgG) autoantibodies. The role of immunoglobulin E (IgE) antibodies is being investigated as their presence has been described in severe cases. Herein, we report a patient of BP who was refractory to most conventional agents and developed hypotension after rituximab but achieved lasting remission after a single dose of the anti-IgE monoclonal antibody omalizumab.

Factors Associated with Refractory Nasal Congestion Following Adenoidectomy

OBJECTIVE

The objective of this study was to better characterize factors associated with refractory rhinitis in pediatric patients who underwent adenoidectomy compared to those who had symptom resolution.

METHODS

The authors conducted a case series of patients younger than 18 years old who underwent adenoidectomy at Boston Medical Center from October 2012 to December 2018. Patients who underwent tonsillectomy and adenoidectomy or who underwent adenoidectomy for indications other than rhinitis were excluded. Patients who had refractory rhinitis symptoms postoperatively were compared to those who had resolution of their symptoms using Chi-square analysis and t-tests.

RESULTS

One hundred three patients who had refractory symptoms following adenoidectomy were compared to 139 patients who had resolution of symptoms. Patients who had refractory symptoms had significantly higher proportion of use (89.3%, P = .0011) and higher mean number of preoperative (1.50, P = .0226) and postoperative (1.10, P < .0001) medications, including nasal saline, intranasal steroids, antihistamines, and/or antibiotics. They were more likely to receive postoperative allergy evaluations (50%, P = .0068) and repeat surgery (30.1%, P < .0001), and had a higher proportion of reported history of allergies (24.3%, P = .0089).

CONCLUSION

Use and number of preoperative medications, reported history of allergies, and postoperative allergy evaluation were significantly higher in patients with refractory chronic rhinitis following adenoidectomy. This study identified differences in patients who developed refractory symptoms that may help clinical decision making for surgical management.

Bispecific Antibodies: A New Era of Treatment for Multiple Myeloma

Despite the introduction of novel agents such as proteasome inhibitors, immunomodulatory drugs, and autologous stem cell transplant, multiple myeloma (MM) largely remains an incurable disease. In recent years, monoclonal antibody-based treatment strategies have been developed to target specific surface antigens on MM cells. Treatment with bispecific antibodies (bsAbs) is an immunotherapeutic strategy that leads to an enhanced interaction between MM cells and immune effector cells, e.g., T-cells and natural killer cells. With the immune synapse built by bsAbs, the elimination of MM cells can be facilitated. To date, bsAbs have demonstrated encouraging results in preclinical studies, and clinical trials evaluating bsAbs in patients with MM are ongoing. Early clinical data show the promising efficacy of bsAbs in relapsed/refractory MM. Together with chimeric antigen receptor-modified (CAR)-T-cells, bsAbs represent a new dimension of precision medicine. In this review, we provide an overview of rationale, current clinical development, resistance mechanisms, and future directions of bsAbs in MM.