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Zhou C, Chan HP, Dong Q, Couriel DR, Pawarode A, Hadjiiski LM, Wei J. Quantitative Analysis of MR Imaging to Assess Treatment Response for Patients with Multiple Myeloma by Using Dynamic Intensity Entropy Transformation: A Preliminary Study. Radiology 2015; 278:449-57. [PMID: 26192897 DOI: 10.1148/radiol.2015142804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To develop a quantitative measure of bone marrow changes in magnetic resonance (MR) images and investigate its capability for assessment of treatment response for patients with multiple myeloma (MM). MATERIALS AND METHODS This study was retrospective, institutional review board approved, and HIPAA compliant. Informed consent was waived. Patients (n = 64; mean age, 58.8 years [age range, 27-75 years]) who were diagnosed with MM and underwent autologous bone marrow stem cell transplantation (BMT) were evaluated. A pair of spinal MR examinations performed before and after BMT was collected from each patient's records. A three-dimensional dynamic intensity entropy transformation (DIET) method was developed to transform MR T1-weighted signal voxel by voxel to a quantitative entropy enhancement value (qEEV), from which predictor variables were derived to train a linear discriminant analysis classifier by using a leave-one-out method. The output of the linear discriminant analysis provided a qEEV-based response index for quantitative assessment of treatment response. The performance of quantitative response index for the discrimination of responder and nonresponder patients was evaluated by receiver operating characteristic curve analysis. RESULTS Among the 46 and 18 clinically diagnosed responder and nonresponder patients, the quantitative response index at a chosen decision threshold correctly identified 42 responder and 17 nonresponder patients. The agreement between the DIET method and the clinical outcome reached 0.922 (59 of 64; κ = 0.816; area under the receiver operating characteristic curve, 0.886 ± 0.042). CONCLUSION This study demonstrated the feasibility of quantitative response index to differentiate responder and nonresponder patients and had substantial agreement with clinical outcomes, which indicated that this quantitative measure has the potential to be an image biomarker to assess MM treatment response.
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Affiliation(s)
- Chuan Zhou
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Heang-Ping Chan
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Qian Dong
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Daniel R Couriel
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Attaphol Pawarode
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Lubomir M Hadjiiski
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Jun Wei
- From the Departments of Radiology (C.Z., H.C., Q.D., L.M.H., J.W.) and Internal Medicine (D.R.C., A.P.), University of Michigan Health System, Med Inn Building C479, 1500 E Medical Center Dr, Ann Arbor, MI 48109
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Magenau JM, Braun T, Reddy P, Parkin B, Pawarode A, Mineishi S, Choi S, Levine J, Li Y, Yanik G, Kitko C, Churay T, Frame D, Riwes MM, Harris A, Bixby D, Couriel DR, Goldstein SC. Allogeneic transplantation with myeloablative FluBu4 conditioning improves survival compared to reduced intensity FluBu2 conditioning for acute myeloid leukemia in remission. Ann Hematol 2015; 94:1033-41. [PMID: 25784222 DOI: 10.1007/s00277-015-2349-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/04/2015] [Indexed: 01/01/2023]
Abstract
The optimal intensity of conditioning for allogeneic hematopoietic stem cell transplantation (HCT) in acute myeloid leukemia (AML) remains undefined. Traditionally, myeloablative conditioning regimens improve disease control, but at the risk of greater nonrelapse mortality. Because fludarabine with myeloablative doses of intravenous busulfan using pharmacokinetic monitoring has excellent tolerability, we reasoned that this regimen would limit relapse without substantially elevating toxicity when compared to reduced intensity conditioning. We retrospectively analyzed 148 consecutive AML patients in remission receiving T cell replete HCT conditioned with fludarabine and intravenous busulfan at doses defined as reduced (6.4 mg/kg; FluBu2, n = 63) or myeloablative (12.8 mg/kg; FluBu4, n = 85). Early and late nonrelapse mortality (NRM) was similar among FluBu4 and FluBu2 recipients, respectively (day + 100: 4 vs 0 %; 5 years: 19 vs 22 %; p = 0.54). NRM did not differ between FluBu4 and FluBu2 in patients >50 years of age (24 vs 22 %, p = 0.75). Relapse was lower in recipients of FluBu4 (5 years: 30 vs 49 %; p = 0.04), especially in patients with poor risk cytogenetics (22 vs 59 %; p = 0.02) and those >50 years of age (28 vs 51 %; p = 0.02). Overall survival favored FluBu4 recipients at 5 years (53 vs 34 %, p = 0.02), a finding confirmed in multivariate analysis (HR: 0.57; 95 % CI: 0.34-0.95; p = 0.03). These data suggest that myeloablative FluBu4 may provide equivalent NRM, reduced relapse, and improved survival compared to FluBu2, emphasizing the importance of busulfan dose in conditioning for AML.
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Affiliation(s)
- John M Magenau
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA,
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Kitko CL, Braun T, Schuler C, Choi SW, Yanik G, Pawarode A, Magenau J, Taylor A, Ferrara JL, Couriel DR, Levine J. Phase II Clinical Trial of Etanercept Plus Extracorporeal Photopheresis GVHD Prophylaxis Following Unrelated Donor Reduced Intensity Transplant. Biol Blood Marrow Transplant 2015. [DOI: 10.1016/j.bbmt.2014.11.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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54
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Smith CA, Churay TL, Justman HA, Yu JK, Pawarode A, Hanauer D, Magenau J, Goldstein SC, Riwes MM, Parkin B, Levine J, Couriel DR. The Graft-Versus-Lymphoma Effect in Diffuse Large B-Cell Lymphoma. Biol Blood Marrow Transplant 2015. [DOI: 10.1016/j.bbmt.2014.11.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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55
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Brown NA, Ross CW, Gudjonsson JE, Wale D, Pawarode A, Maillard I, Hristov AC. Subcutaneous panniculitis-like T-cell lymphoma with bone marrow involvement. Am J Clin Pathol 2015; 143:265-73. [PMID: 25596253 DOI: 10.1309/ajcpvzyb19nedxxz] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES To describe a rare case of subcutaneous panniculitis-like T-cell lymphoma (SPTCL) with morphologic and immunophenotypic evidence of bone marrow involvement. METHODS Biopsy specimens of skin and subcutis and bone marrow were examined using H&E-stained sections. Immunohistochemical studies for CD2, CD3, CD4, CD5, CD7, CD8, CD20, CD30, CD56, and granzyme B were reviewed. In addition, T-cell receptor γ gene rearrangement studies were performed. RESULTS A bone marrow core biopsy demonstrated several lymphohistiocytic aggregates containing atypical, cytotoxic T cells that rimmed adipocytes and were associated with karyorrhexis. These T cells were morphologically and immunophenotypically identical to a concurrent SPTCL, expressing CD2, CD3, CD7, CD8, and granzyme B but with diminished CD5 expression. CONCLUSIONS SPTCL may rarely involve the bone marrow. Bone marrow infiltrates show a similar morphologic and immunophenotypic appearance to those in the subcutaneous fibroadipose tissue, including rimming of adipocytes by neoplastic lymphocytes.
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Affiliation(s)
- Noah A. Brown
- Department of Pathology, University of Michigan, Ann Arbor
| | | | | | - Daniel Wale
- Department of Radiology, University of Michigan, Ann Arbor
| | | | - Ivan Maillard
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Life Sciences Institute, University of Michigan, Ann Arbor
| | - Alexandra C. Hristov
- Department of Pathology, University of Michigan, Ann Arbor
- Department of Dermatology, University of Michigan, Ann Arbor
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56
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Gatza E, Braun T, Levine JE, Ferrara JLM, Zhao S, Wang T, Chang L, Harris A, Pawarode A, Kitko C, Magenau JM, Yanik GA, Couriel DR, Goldstein S, Connelly J, Reddy P, Paczesny S, Choi SW. Etanercept plus topical corticosteroids as initial therapy for grade one acute graft-versus-host disease after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1426-34. [PMID: 24892263 DOI: 10.1016/j.bbmt.2014.05.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 04/18/2014] [Accepted: 05/22/2014] [Indexed: 12/12/2022]
Abstract
Clinical diagnosis of grade 1 acute graft-versus-host disease (GVHD) marks the beginning of a potentially progressive and fatal course of GVHD after hematopoietic stem cell transplantation (HSCT). However, interventional studies to treat early GVHD are lacking. We conducted a single-arm prospective phase II trial to test the hypothesis that treatment of newly diagnosed grade 1 acute GVHD with etanercept and topical corticosteroids would reduce progression to grade 2 to 4 within 28 days. Study patients (n = 34) had a median age of 51 years (range, 10 to 67 years) and had undergone unrelated (n = 22) or related (n = 12) donor HSCT. Study patients were treated with etanercept (.4 mg/kg, maximum 25 mg/dose) twice weekly for 4 to 8 weeks. Ten of 34 patients (29%) progressed to grade 2 to 4 acute GVHD within 28 days. The cumulative incidence of grade 2 to 4 and grade 3 to 4 acute GVHD at 1 year was 41% and 3%, respectively. Nonrelapse mortality was 19% and overall survival was 63% at 2 years. Among a contemporaneous control cohort of patients who were diagnosed with grade 1 acute GVHD and treated with topical corticosteroids but not etanercept during the study period, 12 of 28 patients (43%) progressed to grade 2 to 4 GVHD within 28 days, with a 1-year incidence of grade 2 to 4 GVHD and grade 3 to 4 GVHD of 61% (41% versus 61%, P = .08) and 18% (3% versus 18%, P = .05), respectively. Patients treated with etanercept also experienced less increase in GVHD plasma biomarkers suppression of tumorigenicity 2 (P = .06) and regenerating islet-derived 3-alpha (P = .01) 28 days after grade 1 acute GVHD diagnosis compared with contemporaneous control patients. This study was terminated early because of poor accrual. Future prospective studies are needed to identify patients with grade 1 acute GVHD at risk of swift progression to more severe GVHD and to establish consensus for the treatment of grade 1 acute GVHD. This trial is registered with ClinicalTrials.gov, number NCT00726375.
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Affiliation(s)
- Erin Gatza
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Thomas Braun
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - John E Levine
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - James L M Ferrara
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Shuang Zhao
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Tianyi Wang
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Lawrence Chang
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Andrew Harris
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carrie Kitko
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - John M Magenau
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Daniel R Couriel
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Steven Goldstein
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - James Connelly
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Pavan Reddy
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sophie Paczesny
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Sung Won Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
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Pawarode A, Braun T, Magenau J, Choi SW, Kitko CL, Yanik G, Goldstein SC, Couriel DR. Allogeneic Hematopoietic Cell Transplant (Allo-HCT) for Advanced Diffuse Large B-Cell Non-Hodgkin's Lymphoma: The University of Michigan Experience. Biol Blood Marrow Transplant 2014. [DOI: 10.1016/j.bbmt.2013.12.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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58
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Raser K, McNulty ML, Yanik G, Goldstein SC, Magenau J, Pawarode A, Kitko CL, Hanauer D, Levine J, Couriel DR. Routine Prophylaxis of Pneumocystis Jirovecii Pneumonia in Recipients of Autologous Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2014. [DOI: 10.1016/j.bbmt.2013.12.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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59
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Churay TL, Justman HA, Skurka NL, Goldstein SC, Pawarode A, Magenau J, Couriel DR. The Impact of Mold Infections after Allogeneic Transplantation. Biol Blood Marrow Transplant 2014. [DOI: 10.1016/j.bbmt.2013.12.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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60
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Choi SW, Braun T, Chang L, Ferrara JLM, Pawarode A, Magenau JM, Hou G, Beumer JH, Levine JE, Goldstein S, Couriel DR, Stockerl-Goldstein K, Krijanovski OI, Kitko C, Yanik GA, Lehmann MH, Tawara I, Sun Y, Paczesny S, Mapara MY, Dinarello CA, DiPersio JF, Reddy P. Vorinostat plus tacrolimus and mycophenolate to prevent graft-versus-host disease after related-donor reduced-intensity conditioning allogeneic haemopoietic stem-cell transplantation: a phase 1/2 trial. Lancet Oncol 2013; 15:87-95. [PMID: 24295572 DOI: 10.1016/s1470-2045(13)70512-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute graft-versus-host disease (GVHD) remains a barrier to more widespread application of allogeneic haemopoietic stem-cell transplantation. Vorinostat is an inhibitor of histone deacetylases and was shown to attenuate GVHD in preclinical models. We aimed to study the safety and activity of vorinostat, in combination with standard immunoprophylaxis, for prevention of GVHD in patients undergoing related-donor reduced-intensity conditioning haemopoietic stem-cell transplantation. METHODS Between March 31, 2009, and Feb 8, 2013, we did a prospective, single-arm, phase 1/2 study at two centres in the USA. We recruited adults (aged ≥18 years) with high-risk haematological malignant diseases who were candidates for reduced-intensity conditioning haemopoietic stem-cell transplantation and had an available 8/8 or 7/8 HLA-matched related donor. All patients received a conditioning regimen of fludarabine (40 mg/m(2) daily for 4 days) and busulfan (3.2 mg/kg daily for 2 days) and GVHD immunoprophylaxis of mycophenolate mofetil (1 g three times a day, days 0-28) and tacrolimus (0.03 mg/kg a day, titrated to a goal level of 8-12 ng/mL, starting day -3 until day 180). Vorinostat (either 100 mg or 200 mg, twice a day) was initiated 10 days before haemopoietic stem-cell transplantation until day 100. The primary endpoint was the cumulative incidence of grade 2-4 acute GVHD by day 100. This trial is registered with ClinicalTrials.gov, number NCT00810602. FINDINGS 50 patients were assessable for both toxic effects and response; eight additional patients were included in the analysis of toxic effects. All patients engrafted neutrophils and platelets at expected times after haemopoietic stem-cell transplantation. The cumulative incidence of grade 2-4 acute GVHD by day 100 was 22% (95% CI 13-36). The most common non-haematological adverse events included electrolyte disturbances (n=15), hyperglycaemia (11), infections (six), mucositis (four), and increased activity of liver enzymes (three). Non-symptomatic thrombocytopenia after engraftment was the most common haematological grade 3-4 adverse event (nine) but was transient and all cases resolved swiftly. INTERPRETATION Administration of vorinostat in combination with standard GVHD prophylaxis after related-donor reduced-intensity conditioning haemopoietic stem-cell transplantation is safe and is associated with a lower than expected incidence of severe acute GVHD. Future studies are needed to assess the effect of vorinostat for prevention of GVHD in broader settings of haemopoietic stem-cell transplantation. FUNDING Merck, Leukemia and Lymphoma Society, National Institutes of Health, St Baldrick's Foundation, Michigan Institute for Clinical and Health Research.
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Affiliation(s)
- Sung Won Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Thomas Braun
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Lawrence Chang
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - James L M Ferrara
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - John M Magenau
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Guoqing Hou
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Jan H Beumer
- Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - John E Levine
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Steve Goldstein
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Daniel R Couriel
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Carrie Kitko
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Gregory A Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Michael H Lehmann
- Department of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Isao Tawara
- Hematology-Oncology, Mie University Hospital, Mie, Japan
| | - Yaping Sun
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Sophie Paczesny
- Pediatric Hematology Oncology, Indiana University, Indianapolis, IN, USA
| | - Markus Y Mapara
- Blood and Marrow Transplantation Program, Columbia University, New York, NY, USA
| | - Charles A Dinarello
- Department of Medicine, University of Colorado, Aurora, CO, USA; Department of Medicine, University Medical Center Nijmegen, Netherlands
| | - John F DiPersio
- Department of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Pavan Reddy
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA.
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Magenau J, Pawarode A, Couriel DR, Yanik G, Mineishi S, Braun T, Reddy P, Ferrara JL, Frame D, Choi SW, Harris AC, Kitko CL, Connelly JA, Levine J, Goldstein SC. Impact of Dose Intensification of FluBu2 to FluBu4 on Transplant Related Mortality, Relapse, and Survival After Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia in Remission. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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62
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Harris AC, Ferrara JL, Braun T, Couriel DR, Choi S, Kitko CL, Goldstein SC, Magenau J, Paczesny S, Pawarode A, Reddy P, Yanik G, Taylor A, Connelly JA, Byersdorfer CA, Levine JE. A Combination of Clinical Characteristics and Day 7 Biomarker Concentrations Predicts Graft-Versus-Host Disease Following Hematopoietic Cell Transplantation From Related Donors. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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63
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Abedin S, Yanik G, Magenau J, Pawarode A, Goldstein SC, Kitko CL, White E, Couriel DR. The Use of Early Spirometric Changes and IGF-1 Levels for the Detection of Patients at Risk for BOS. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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64
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Kitko CL, Saliba R, Choi SW, Reddy P, Goldstein SC, Magenau J, Pawarode A, Kennel M, Levine JE, White E, Couriel DR. Biomarkers of Extracellular Matrix Remodeling in Chronic GVHD. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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65
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Harris AC, Kitko CL, Couriel DR, Braun TM, Choi SW, Magenau J, Mineishi S, Pawarode A, Yanik G, Levine JE. Extramedullary relapse of acute myeloid leukemia following allogeneic hematopoietic stem cell transplantation: incidence, risk factors and outcomes. Haematologica 2012. [PMID: 23065502 DOI: 10.3324/haematol.2012.073189.] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Extramedullary relapse after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia is a contributor to post-transplant mortality but risk factors for, and outcomes of, this condition are not well characterized. We analyzed 257 consecutive patients undergoing allogeneic stem cell transplantation for acute myeloid leukemia at our institution to characterize extramedullary relapse, identify predictive variables and assess outcomes. The 5-year cumulative incidence of isolated extramedullary or bone marrow relapse was 9% and 29%, respectively. Extramedullary relapse occurred later than marrow relapse and most frequently involved skin and soft tissue. Factors predictive of extramedullary relapse after transplantation included previous extramedullary disease, French-American-British classification M4/M5 leukemia, high risk cytogenetics, and advanced disease status at the time of transplantation. Children were more likely than adults to develop extramedullary relapse, a finding probably explained by an overrepresentation of extramedullary disease prior to transplantation and M4/M5 leukemia in children. Acute graft-versus-host disease was not protective against relapse. Unlike medullary relapse, chronic graft-versus-host disease was not protective against extramedullary relapse. The survival rate after extramedullary relapse was 30% at 1 year and 12% at 2 years. Extramedullary relapse is a significant contributor to mortality after allogeneic transplantation for acute myeloid leukemia and appears to be resistant to the immunotherapeutic effect of allogeneic grafting. Effective strategies for patients with extramedullary relapse are needed to improve outcomes after transplantation.
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Affiliation(s)
- Andrew C Harris
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA.
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66
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Harris AC, Kitko CL, Couriel DR, Braun TM, Choi SW, Magenau J, Mineishi S, Pawarode A, Yanik G, Levine JE. Extramedullary relapse of acute myeloid leukemia following allogeneic hematopoietic stem cell transplantation: incidence, risk factors and outcomes. Haematologica 2012; 98:179-84. [PMID: 23065502 DOI: 10.3324/haematol.2012.073189] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Extramedullary relapse after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia is a contributor to post-transplant mortality but risk factors for, and outcomes of, this condition are not well characterized. We analyzed 257 consecutive patients undergoing allogeneic stem cell transplantation for acute myeloid leukemia at our institution to characterize extramedullary relapse, identify predictive variables and assess outcomes. The 5-year cumulative incidence of isolated extramedullary or bone marrow relapse was 9% and 29%, respectively. Extramedullary relapse occurred later than marrow relapse and most frequently involved skin and soft tissue. Factors predictive of extramedullary relapse after transplantation included previous extramedullary disease, French-American-British classification M4/M5 leukemia, high risk cytogenetics, and advanced disease status at the time of transplantation. Children were more likely than adults to develop extramedullary relapse, a finding probably explained by an overrepresentation of extramedullary disease prior to transplantation and M4/M5 leukemia in children. Acute graft-versus-host disease was not protective against relapse. Unlike medullary relapse, chronic graft-versus-host disease was not protective against extramedullary relapse. The survival rate after extramedullary relapse was 30% at 1 year and 12% at 2 years. Extramedullary relapse is a significant contributor to mortality after allogeneic transplantation for acute myeloid leukemia and appears to be resistant to the immunotherapeutic effect of allogeneic grafting. Effective strategies for patients with extramedullary relapse are needed to improve outcomes after transplantation.
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Affiliation(s)
- Andrew C Harris
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA.
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Choi SW, Stiff P, Cooke K, Ferrara JLM, Braun T, Kitko C, Reddy P, Yanik G, Mineishi S, Paczesny S, Hanauer D, Pawarode A, Peres E, Rodriguez T, Smith S, Levine JE. TNF-inhibition with etanercept for graft-versus-host disease prevention in high-risk HCT: lower TNFR1 levels correlate with better outcomes. Biol Blood Marrow Transplant 2012; 18:1525-32. [PMID: 22469883 DOI: 10.1016/j.bbmt.2012.03.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/25/2012] [Indexed: 01/20/2023]
Abstract
Graft-versus-host disease (GVHD) causes most non-relapse mortality (NRM) after alternative donor (unrelated and mismatched related) hematopoietic cell transplant (HCT). We previously showed that increases in day +7 TNF-receptor-1 (TNFR1) ratios (posttransplantation day +7/pretransplantation baseline) after myeloablative HCT correlate with outcomes including GVHD, NRM, and survival. Therefore, we conducted a phase II trial at 2 centers, testing whether the addition of the TNF-inhibitor etanercept (25 mg twice weekly from start of conditioning to day +56) to standard GVHD prophylaxis would lower TNFR1 levels, reduce GVHD rates, and improve NRM and survival. Patients underwent myeloablative HCT from a matched unrelated donor (URD; N = 71), 1-antigen mismatched URD (N = 26), or 1-antigen mismatched related donor (N = 3) using either total body irradiation (TBI)-based conditioning (N = 29) or non-TBI-based conditioning (N = 71). Compared to historical controls, the increase in posttransplantation day +7 TNFR1 ratios was not altered in patients who received TBI-based conditioning, but was 40% lower in patients receiving non-TBI-based conditioning. The latter group experienced relatively low rates of severe grade 3 to 4 GVHD (14%), 1-year NRM (16%), and high 1-year survival (69%). These findings suggest that (1) the effectiveness of TNF-inhibition with etanercept may depend on the conditioning regimen, and (2) attenuating the expected rise in TNFR1 levels early posttransplantation correlates with good outcomes.
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Affiliation(s)
- Sung W Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI 48109-5942, USA
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Paczesny S, Braun T, Vander Lugt M, Harris A, Fiema B, Hernandez J, Choi S, Kitko C, Magenau J, Yanik G, Peres E, Pawarode A, Mineishi S, Whitfield J, Jones D, Couriel D, Pavan R, Hanash S, Ferrara J, Levine J. A Three Biomarker Panel at Days 7 and 14 Can Predict Development of Grade II-IV Acute Graft-Versus-Host Disease. Biol Blood Marrow Transplant 2011. [DOI: 10.1016/j.bbmt.2010.12.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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69
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Harris A, Ferrara J, Levine J, Braun T, Hogan J, Crawford J, Pitteri S, Wang H, Chin A, Zhang Q, Granger J, Vander Lugt M, Byersdorfer C, Magenau J, Gomez A, Choi S, Kitko C, Yanik G, Peres E, Pawarode A, Mineishi S, Reddy P, Couriel D, Hanash S, Paczesny S. Reg3α Is a Biomarker of Graft Versus Host Disease of the Gastrointestinal Tract. Biol Blood Marrow Transplant 2011. [DOI: 10.1016/j.bbmt.2010.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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70
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Pawarode A, Wallace PK, Ford LA, Barcos M, Baer MR. Long-term safety and efficacy of cyclosporin A therapy for T-cell large granular lymphocyte leukemia. Leuk Lymphoma 2010; 51:338-41. [PMID: 20038217 DOI: 10.3109/10428190903470851] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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71
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Choi S, Stiff P, Braun T, Ferrara J, Cooke K, Khaled Y, Kitko C, Lay-Luskin J, Mineishi S, Nickoloff B, Paczesny S, Pawarode A, Peres E, Reddy P, Richardson J, Rodriguez T, Smith S, Yanik G, Whitfield J, Levine J. TNF-Inhibition With Etanercept For GVHD Prevention In Alternative Donor HCT: Lower TNFR1 Levels Correlate With Better Outcomes. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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72
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Harris A, Mageneau J, Braun T, Kitko C, Choi S, Ferrara J, Mineishi S, Pawarode A, Peres E, Reddy P, Yanik G, Levine J. Extramedullary Relapse In Acute Leukemia Following Allogeneic Hematopoietic Stem Cell Transplantation: Incidence, Risk Factors And Outcomes. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Attaphol Pawarode
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
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74
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Pawarode A, Sait SNJ, Nganga A, Coignet LJ, Barcos M, Baer MR. Acute myeloid leukemia developing during imatinib mesylate therapy for chronic myeloid leukemia in the absence of new cytogenetic abnormalities. Leuk Res 2007; 31:1589-92. [PMID: 17391756 DOI: 10.1016/j.leukres.2007.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 01/17/2007] [Accepted: 01/18/2007] [Indexed: 10/23/2022]
Abstract
The BCR/ABL tyrosine kinase inhibitor imatinib mesylate produces a high rate of cytogenetic responses in patients with Philadelphia (Ph)-positive chronic myeloid leukemia (CML), but secondary clonal chromosome abnormalities may develop in Ph-negative cells, and acute myeloid leukemia (AML) has been reported in patients with secondary chromosome abnormalities. We report a patient who developed AML during imatinib treatment of Ph-positive CML despite a cytogenetic response and absence of secondary chromosome abnormalities. Thus, development of AML as a rare event in CML patients with cytogenetic responses to imatinib therapy does not depend on the development of secondary cytogenetic abnormalities.
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MESH Headings
- Adult
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Base Sequence
- Benzamides
- DNA Primers
- DNA, Complementary
- Female
- Humans
- Imatinib Mesylate
- In Situ Hybridization, Fluorescence
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myeloid, Acute/chemically induced
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/genetics
- Piperazines/adverse effects
- Piperazines/therapeutic use
- Pyrimidines/adverse effects
- Pyrimidines/therapeutic use
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Affiliation(s)
- Attaphol Pawarode
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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Pawarode A, Hahn T, Battiwalla M, McCarthy P. 318: Extracorporeal photopheresis (ECP) for the treatment of steroid-refractory or -intolerant chronic graft-versus-host disease (cGVHD) following allogeneic hematopoietic stem cell transplant (HSCT). Biol Blood Marrow Transplant 2007. [DOI: 10.1016/j.bbmt.2006.12.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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76
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Pawarode A, Shukla S, Minderman H, Fricke SM, Pinder EM, O'Loughlin KL, Ambudkar SV, Baer MR. Differential effects of the immunosuppressive agents cyclosporin A, tacrolimus and sirolimus on drug transport by multidrug resistance proteins. Cancer Chemother Pharmacol 2006; 60:179-88. [PMID: 17031644 DOI: 10.1007/s00280-006-0357-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Accepted: 09/11/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE We sought to determine the effects of the immunosuppressants, cyclosporin A (CsA), tacrolimus and sirolimus, on drug transport by the ATP-binding cassette proteins, P-glycoprotein (Pgp; ABCB1), multidrug resistance protein-1 (MRP-1; ABCC1) and breast cancer resistance protein (BCRP; ABCG2), and the major vault protein lung resistance protein (LRP). METHODS Cellular content of mitoxantrone, a Pgp, MRP-1 and BCRP substrate, was measured by flow cytometry in cells overexpressing these proteins following incubation with and without CsA, tacrolimus or sirolimus. Interaction of BCRP with these compounds was studied by photolabeling and ATPase assays. Nuclear-cytoplasmic distribution of doxorubicin was studied by confocal microscopy in cells overexpressing LRP. RESULTS CsA increased cellular drug uptake in cells overexpressing Pgp, MRP-1 or BCRP and nuclear drug uptake in cells overexpressing LRP at the clinically achievable concentration of 2.5 microM. Tacrolimus enhanced cellular drug uptake at 1 microM, but not at 0.08 microM, its clinically achievable concentration, and did not enhance nuclear drug uptake. Sirolimus enhanced cellular drug uptake in cells overexpressing Pgp, MRP-1 and BCRP with optimal effects at 2.5 microM, but was effective at its clinically achievable concentration of 0.25 microM if cells were pre-incubated for at least 30 min before drug exposure, and also enhanced nuclear drug uptake at 0.25 microM. BCRP modulation by all three immunosuppressive agents was associated with competitive binding to the drug transport sites. CONCLUSIONS CsA, tacrolimus and sirolimus modulate drug transport by Pgp, MRP-1 and BCRP and CsA and sirolimus modulate drug transport by LRP at concentrations that differ from immunosuppressive concentrations and maximum tolerated concentrations.
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Affiliation(s)
- Attaphol Pawarode
- Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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Pawarode A, Finlay E, Sait SNJ, Barcos M, Baer MR. Isochromosome 1q in a myelodysplastic syndrome after treatment for acute promyelocytic leukemia. ACTA ACUST UNITED AC 2006; 167:155-60. [PMID: 16737916 DOI: 10.1016/j.cancergencyto.2005.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [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: 07/25/2005] [Revised: 11/23/2005] [Accepted: 11/29/2005] [Indexed: 12/26/2022]
Abstract
A growing body of literature reports therapy-related myelodysplastic syndrome (t-MDS) and acute myeloid leukemia (t-AML) in patients treated successfully for acute promyelocytic leukemia (APL). We report a t-MDS with an isochromosome 1q as a sole abnormality, 47,XY,+1,i(1)(q10), in a 46-year-old man with APL 14 years after he was treated with cytosine arabinosine and daunorubicin. The literature on t-MDS/t-AML after APL therapy and on isochromosome 1q is reviewed.
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Affiliation(s)
- Attaphol Pawarode
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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78
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Pawarode A, Baer MR, Padmanabhan S, Wallace PK, Barcos M, Sait SNJ, Block AW, Wetzler M, Battiwalla M. Simultaneous presentation of acute monoblastic leukemia and mantle cell lymphoma: case report and review of the literature. Leuk Lymphoma 2005; 46:1813-8. [PMID: 16263586 DOI: 10.1080/10428190500244258] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This paper reports a 73-year old woman with simultaneous presentation of acute monoblastic leukemia (acute myeloid leukemia (AML), French-American-British (FAB) type M5a) and mantle cell lymphoma. The patient presented with wasting, generalized lymphadenopathy, an extensive infiltrative rash and pancytopenia. Bone marrow and lymph node histopatholology showed extensive infiltration by leukemic monoblasts. Marrow cytogenetics revealed a complex karyotype, including t(8;16)(p11;p13). Flow cytometric immunophenotyping of peripheral blood, lymph node and bone marrow demonstrated two populations, expressing CD5, CD19, CD20 and CD22 and CD45, HLA-DR, CD13, CD33, CD14 and CD38, respectively. A focus of abnormal lymphocytes in the lymph node biopsy demonstrated BCL1 expression and t(11;14)(p11;p13) by fluorescence in situ hybridization and immunoglobulin heavy chain gene rearrangement by the polymerase chain reaction. The patient received infusional cytarabine, daunorubicin and etoposide chemotherapy, with complete remission of both the AML and the mantle cell leukemia. To the authors' knowledge, this is the first report of simultaneous presentations of AML, FAB M5a and mantle cell lymphoma. The case is discussed and the literature is reviewed.
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MESH Headings
- Aged
- Antigens, CD/blood
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biopsy
- Female
- Humans
- Leukemia, Monocytic, Acute/complications
- Leukemia, Monocytic, Acute/drug therapy
- Leukemia, Monocytic, Acute/pathology
- Lymphocytes/pathology
- Lymphoma, Mantle-Cell/complications
- Lymphoma, Mantle-Cell/drug therapy
- Lymphoma, Mantle-Cell/pathology
- Treatment Outcome
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Affiliation(s)
- A Pawarode
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York 14263, USA
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79
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Abstract
Renal dysfunction is common after liver transplantation. However, there are only limited data on the predictors and natural history of renal dysfunction after liver transplantation. In this study, we determined independent predictors and the natural history of renal dysfunction in 172 consecutive liver transplant recipients. Survival and time to development of permanent renal dysfunction (renal dysfunction defined as a sustained decrease in estimated glomerular filtration rate (GFR) of > 30 mL/min/1.73 m(2) from baseline for at least 6 months, severe renal failure defined as absolute GFR <30 mL/min/1.73 m(2) for at least 6 months) were determined using the Kaplan-Meier method. Cox regression analysis was used to test the independent effect of a given set of variables on time to development of such an event. Nine percent of patients required immediate dialysis, 35% developed permanent renal dysfunction, and 7% developed severe renal failure. The rate of decline in renal dysfunction was maximal, 6.5 mL/min/1.73 m(2) /mo, at 1 month after liver transplantation. Pre-existing diabetes mellitus, major surgical infection, and waiting time on the transplant list were independent risk factors for immediate dialysis. Presence of serum creatinine > 1.2 mg/dL at any time before liver transplantation and a baseline GFR <70 mL/min/1.73 m(2) were independent predictors of permanent renal dysfunction. Diabetes mellitus, coronary artery disease, and primary graft nonfunction predicted the development of severe renal failure. GFR stabilized around 9 months, and presence of decreased GFR > 30mL/min/1.73 m(2) from baseline at 9 months predicted development of permanent renal dysfunction. An absolute GFR of <30mL/min/1.73 m(2) occurring as early as 3 months after liver transplantation predicted severe renal failure. Severe renal failure was associated with a significantly lower survival by Cox regression analysis. We have identified risk factors and the natural history of permanent renal dysfunction and severe liver failure in liver transplant recipients. These observations may be useful in the development of nonnephrotoxic immunosuppressive regimens for high-risk liver transplant recipients.
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Affiliation(s)
- Attaphol Pawarode
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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80
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Abstract
BACKGROUND AND AIMS Primary hepatocellular carcinoma (HCC) is common in Thailand and its prognosis is extremely poor. Hepatic resection and liver transplantation are modes of curative therapy and various therapies have been developed to treat inoperable HCC. This study was performed to determine the outcome of therapy and to identify prognostic factors for survival among Thai patients with HCC. METHODS Three hundred and sixty-eight patients with tissue-proven or serodiagnosed HCC were studied. Differences in laboratory investigations, patient survival, treatment outcomes and prognostic factors were analysed. The Kaplan-Meier method and the log-rank test were used to calculate and compare survival of patients receiving different therapies. RESULTS Of the 368 patients 317 were males (86.1%, M: F ratio 6.2:1). The median age of all patients was 52 years range (2-85 years). Fifty-nine patients were specifically treated and 209 were conservatively treated. Among those tested, 70% had hepatitis B virus-related HCC. The overall median survival (range) after diagnosis and that of the treated and untreated patients were 5.6 (0-92.1), 9.0 (0-92.1) and 2.3 (0-25.9) months, respectively. More than 50% of the Okuda I patients survived beyond 30 months. The Okuda II and III patients had a median survival (range) of 5.7 (0.1-75.2) and 1.6 (0.1-25.9) months, respectively. Those patients treated by surgery, transcatheter oil chemoembolization and systemic chemotherapy had a better survival rate than did the conservatively managed patients. Surgery was found to be a better treatment than systemic chemotherapy. However, no differences between other pairs of treatment groups were identified. Subgroup analysis of the Okuda II group patients revealed the same results. Independent predictors of death were multiple lesions, advanced Okuda stage and treatment modality. CONCLUSION Despite various kinds of therapy, the treatment outcomes for Thai HCC patients remain poor and largely depend on the disease extent and treatment received. Most Thai HCC patients are at an advanced stage at diagnosis. Thai patients who received disease-specific treatment other than intraarterial chemotherapy had a better survival rate than did supportive treatment patients.
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Affiliation(s)
- A Pawarode
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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81
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Pawarode A, Voravud N, Sriuranpong V, Kullavanijaya P, Patt YZ. Natural history of untreated primary hepatocellular carcinoma: a retrospective study of 157 patients. Am J Clin Oncol 1998; 21:386-91. [PMID: 9708639 DOI: 10.1097/00000421-199808000-00014] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.8] [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: 12/13/2022]
Abstract
Primary hepatocellular carcinoma (HCC) is a common malignancy with a dismal prognosis; new modalities of treatment as alternatives to surgery have been developed for unresectable patients. The authors obtain baseline data for the natural history of HCC so that the efficacy of new treatments may be evaluated. A retrospective study of 157 untreated patients with tissue-proven or serodiagnosed HCC was conducted. Clinical characteristics including laboratory investigation, treatment received, survival from the time of diagnosis, and prognostic factors were evaluated. There were 129 men and 28 women (ratio, 4.6:1). Median age was 50.9 years (range, 14.1-85.3 years). The most common symptoms and signs were weight loss (68.2%), abdominal fullness (62.5%), abdominal pain (51.6%), hepatomegaly (73.7%), ascites (45.2%), and jaundice (40.6%). Eighteen percent had extrahepatic metastases of which the lungs were the most common site. Seventy percent were hepatitis B virus related. Overall median survival was 8.7 weeks after the time of diagnosis. Survivals by stages were: TNM II, 16.6 weeks; TNM III, 7.3 weeks; TNM IVA, 9.7 weeks; TNM IVB, 7.6 weeks; Okuda II, 10.7 weeks; and Okuda III, 7.3 weeks. Multivariate analysis revealed serum total bilirubin and albumin as independent prognostic factors of survival. Common causes of death were upper gastrointestinal hemorrhage (34.1%), cancer-related causes (cachexia, HCC rupture, metastatic disease, 31.8%), and hepatic failure (25.0%). Patients with HCC were diagnosed at late stages of their disease and the advanced nature of the tumor precluded effective therapy. Earlier tumor detection at a time when patients are better candidates for treatment may be aided by an active surveillance program of high risk groups.
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Affiliation(s)
- A Pawarode
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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82
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Pawarode A, Voravud N. Ruptured primary hepatocellular carcinoma at Chulalongkorn University Hospital: a retrospective study of 32 cases. J Med Assoc Thai 1997; 80:706-14. [PMID: 9385767] [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: 02/05/2023]
Abstract
Rupture of Primary hepatocellular carcinoma (HCC) is relatively common in high incidence areas including Thailand. There have been attempts to establish a standard treatment to manage this phenomenon. We retrospectively reviewed the records of patients with HCC from January 1989 to June 1997, and ten per cent (32/306) had tumor rupture during the course of the disease. Overall median survival of the patients with tumor rupture was 2.7 months [95% confidence interval (CI), 0-5.9 months] that was not significantly different from that of the patients without rupture (median 6.6 months; 95% CI, 4.0-9.1 months) (P = 0.4605). Among the ruptured group, the patients treated with surgical intervention survived longer than those receiving supportive care alone (median = 15.5 months; 95% CI, 8.7-22.2 months and median = 0.4 months; 95% CI, 0.2-0.5 months, P = 0.0027). The resectional and non-resectional surgical subgroups also had better survival than the supportive group (P = 0.0300 and P = 0.0209, respectively). In conclusion, surgical intervention, if applicable, should be performed in managing ruptured HCC.
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Affiliation(s)
- A Pawarode
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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