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Chai KL, Rowan G, Seymour JF, Burbury K, Carney D, Tam CS. Practical recommendations for the choice of anticoagulants in the management of patients with atrial fibrillation on ibrutinib. Leuk Lymphoma 2017; 58:2811-2814. [PMID: 28504030 DOI: 10.1080/10428194.2017.1315115] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The management of AF represents a major challenge in patients with CLL, especially in elderly patients with multiple comorbidities who are representative of the majority of patients with CLL. This is especially complex in the case of ibrutinib. Many anticoagulants have potential for pharmacological interaction with ibrutinib, and ibrutinib itself has antiplatelet properties. Use of ibrutinib therapy in these patients mandates review and revision of the need for anticoagulation and best anticoagulant to use. Herein, we review the current knowledge of the metabolism of common anticoagulants and how they may interact with ibrutinib.
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Ho PJ, Bajel A, Burbury K, Dunlop L, Durrant S, Forsyth C, Perkins AC, Ross DM. A case-based discussion of clinical problems in the management of patients treated with ruxolitinib for myelofibrosis. Intern Med J 2017; 47:262-268. [PMID: 28260257 DOI: 10.1111/imj.13341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022]
Abstract
Ruxolitinib is a dual janus kinase 1 (JAK1)/JAK2 inhibitor used to treat splenomegaly and symptoms associated with myelofibrosis (MF). Current therapeutic options for symptomatic MF include supportive care, myelosuppressive therapy (such as hydroxycarbamide) and janus kinase (JAK) inhibitors (in particular ruxolitinib). Allogeneic stem cell transplantation remains the only potentially curative treatment for MF, and younger transplant-eligible patients should still be considered for allogeneic stem cell transplantation; however, this is applicable only to a small proportion of patients. There is now increasing and extensive experience of the efficacy and safety of ruxolitinib in MF, both in clinical trials and in 'real-world' practice. The drug has been shown to be of benefit in intermediate-1 risk patients with symptomatic splenomegaly or other MF-related symptoms, and higher risk disease. Optimal use of the drug is required to maximise clinical benefit, requiring an understanding of the balance between dose-dependent responses and dose-limiting toxicities. There is also increasing experience in the use of ruxolitinib in the pre-transplantation setting. This paper aims to utilise several 'real-life' cases to illustrate several strategies that may help to optimise clinical practice.
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Alexander M, Blum R, Burbury K, Coutsouvelis J, Dooley M, Fazil O, Griffiths T, Ismail H, Joshi S, Love N, Opat S, Parente P, Porter N, Ross E, Siderov J, Thomas P, White S, Kirsa S, Rischin D. Timely initiation of chemotherapy: a systematic literature review of six priority cancers - results and recommendations for clinical practice. Intern Med J 2017; 47:16-34. [DOI: 10.1111/imj.13190] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 01/10/2016] [Accepted: 01/11/2016] [Indexed: 12/01/2022]
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Alexander M, Burbury K. A systematic review of biomarkers for the prediction of thromboembolism in lung cancer - Results, practical issues and proposed strategies for future risk prediction models. Thromb Res 2016; 148:63-69. [PMID: 27815968 DOI: 10.1016/j.thromres.2016.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION This review aimed to identify candidate biomarkers for the prediction of thromboembolism (TE) in lung cancer. MATERIALS AND METHODS Systematic review of publications indexed in PubMed or EMBASE databases in the past 5years (01/05/2011-01/05/2016) which evaluated baseline and/or longitudinal biomarker measurements as a predictor of subsequent TE (venous and arterial) in lung cancer patients. RESULTS Of 1105 studies identified, 18 fulfilled predefined inclusion criteria: 6 prospective and 12 retrospective. The 18 studies included 11,262 patients and 36 unique biomarkers. The combined TE rate was 7% (741/10,854), increasing to 11% (294/2612) within prospective studies. All biomarker measurements were baseline only, with no longitudinal assessment reported. The most frequently investigated biomarkers were tumour-related driver mutations, D-dimer, haemoglobin, white cell, and platelet count; as well as biomarker combinations previously used in risk prediction models, such as Khorana risk score. Biomarker thresholds rather than continuous variable analyses were generally applied, however thresholds were not consistent across studies. D-dimer and epidermal growth factor receptor mutation were the strongest and most reproducible predictors of TE. CONCLUSION An important limitation is the lack of prospective data across specific subpopulations of cancer, with correlative, and preferably longitudinal, biomarker assessments. This would provide insight into the pathophysiology, allow patient profiling, and the development of personalised decision-making tools that can be used real-time and throughout the course of the patients' journey, for targeted, risk-adaptive preventative strategies.
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Alexander M, Wolfe R, Ball D, Manser R, McManus M, Riedel B, Solomon B, Westerman D, Burbury K. OC-05 - D-Dimer, fibrinogen and TEG-MA predict thromboembolism in non-small cell lung cancer – interim results from a prospective cohort study. Thromb Res 2016; 140 Suppl 1:S170. [DOI: 10.1016/s0049-3848(16)30122-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Alexander M, Evans SM, Stirling RG, Wolfe R, Officer A, MacManus M, Solomon B, Burbury K, Ball D. The Influence of Comorbidity and the Simplified Comorbidity Score on Overall Survival in Non-Small Cell Lung Cancer-A Prospective Cohort Study. J Thorac Oncol 2016; 11:748-757. [PMID: 26851495 DOI: 10.1016/j.jtho.2016.01.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/21/2016] [Accepted: 01/26/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We addressed the uncertainty of comorbidity as a prognosticator by evaluating comorbidity and the Simplified Comorbidity Score (SCS) as predictors of overall survival in non-small cell lung cancer (NSCLC). METHODS A prospective study included patients in whom NSCLC was diagnosed at an Australian cancer hospital between 2012 and 2014. Patients were assessed for SCS at recruitment and followed up every 3 months until death. RESULTS The cohort included 633 patients; their median age was 67 years (range 28-93), 63% were male, and 86% were ever-smokers. The median SCS at enrolment was 8 (range 0-19); 20% had an SCS higher than 9, and 11% had an SCS of 0. An SCS higher than 9 was associated with male sex, age older than 75 years, an Eastern Cooperative Oncology Group performance status of 2 or higher, and fewer cancer treatments. The 1-year overall survival rate was 62% (95% confidence interval: 58-66). In multivariate analysis, the strongest associations with mortality were metastatic disease (hazard ratio [HR] = 2.8, p < 0.01), Eastern Cooperative Oncology Group performance status of 2 or higher (HR = 2.0, p < 0.01), male sex (HR = 1.6, p < 0.01), more than 10% weight loss at diagnosis (HR = 1.5, p < 0.01), and age older than 75 years (HR = 1.5, p = 0.01). An SCS higher than 9 was not associated with overall survival (HR = 1.0, p = 0.8), and the effect of continuous SCS (HR = 1.1, p < 0.01) was explained by smoking status. CONCLUSIONS In this cohort of patients with NSCLC the SCS was not a clinically significant predictor of overall survival over and above basic patient and disease factors.
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Le Roux PY, Burbury K, Hofman MS, Hicks RJ. Short and long-term prognostic implications of a low embolic burden in oncology patients diagnosed with symptomatic pulmonary embolism. Ann Hematol 2016; 95:651-2. [PMID: 26754636 DOI: 10.1007/s00277-016-2593-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/03/2016] [Indexed: 11/27/2022]
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Byrne TJ, Riedel B, Ismail HM, Heriot A, Dauer R, Westerman D, Seymour JF, Kenchington K, Burbury K. Fast-track rapid warfarin reversal for elective surgery: extending the efficacy profile to high-risk patients with cancer. Anaesth Intensive Care 2016; 43:712-8. [PMID: 26603795 DOI: 10.1177/0310057x1504300608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Periprocedural management of patients on long-term warfarin therapy remains a common and important clinical issue, with little high-quality data to guide this complex process. The current accepted practice is cessation of warfarin five days preoperatively, but this is not without risk and can be complicated, particularly if bridging is required. An alternative method utilising low-dose intravenous vitamin K the day before surgery has been shown previously to be efficacious, safe and convenient in an elective surgical population receiving chronic warfarin therapy. The efficacy and utility of this 'fast-track' warfarin reversal protocol in surgical patients with cancer, who were at high risk of both thromboembolism and bleeding was investigated in a prospective, single-arm study at a dedicated cancer centre. Seventy-one patients underwent 82 episodes of fast-track warfarin reversal (3 mg intravenous vitamin K 18 to 24 hours before surgery). No patient suffered an adverse reaction to intravenous vitamin K, all but one achieved an International Normalized Ratio =1.5 on the day of surgery, and no surgery was deferred. Assays of vitamin K-dependent factor levels pre- and post-vitamin K demonstrated restoration of functional activity to within an acceptable range for surgical haemostasis. While this alternative method requires further validation in a larger prospective randomised study, we have now extended our use of fast-track warfarin reversal using vitamin K to patients with cancer, on the basis of our experience of its safety, convenience, reliability and efficacy.
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Tatarczuch M, Burbury K, Creati L, Januszewicz EH, Seymour JF. Dasatinib therapy can result in significant pulmonary toxicity. Am J Hematol 2015; 90:E224-5. [PMID: 26375182 DOI: 10.1002/ajh.24194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/14/2015] [Indexed: 11/09/2022]
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Campbell B, Callahan J, Bressel M, Simeons N, Everitt S, Hofman M, Hicks R, Burbury K, MacManus M. Age and Gender Differences in the Distribution of Proliferating Bone Marrow in Adults Measured by FLT-PET/CT Imaging With Potential Application for Radiation Therapy Planning. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kostos L, Burbury K, Srivastava G, Prince HM. Gastrointestinal bleeding in a chronic myeloid leukaemia patient precipitated by dasatinib-induced platelet dysfunction: Case report. Platelets 2015; 26:809-11. [PMID: 26029798 DOI: 10.3109/09537104.2015.1049138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Bleeding in patients with chronic myeloid leukaemia (CML) receiving the second-line tyrosine kinase inhibitor (TKI) dasatinib is a well-documented side effect, occurring in up to 24% of patients. In most cases, it is attributed directly to a secondary grade 3 or 4 thrombocytopaenia. Platelet dysfunction precipitated by dasatinib has been demonstrated in multiple in vitro and in vivo studies; however, there is currently no correlative data that definitively associates this with clinically significant bleeding. In this case, we report a patient with chronic-phase CML receiving dasatinib who developed significant gastrointestinal bleeding secondary to angiodysplasia in the absence of a severe thrombocytopaenia or coagulopathy. Platelet function testing on the PFA-100 assay and formal platelet aggregometry demonstrated impaired platelet aggregation, however, upon cessation of dasatinib, platelet function normalised and the bleeding resolved without further intervention. This case demonstrates that dasatinib-induced platelet dysfunction can cause clinically significant bleeding and highlights the need for physicians to be aware of this adverse effect.
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Campbell BA, Callahan J, Bressel M, Simoens N, Everitt S, Hofman MS, Hicks RJ, Burbury K, MacManus M. Distribution Atlas of Proliferating Bone Marrow in Non-Small Cell Lung Cancer Patients Measured by FLT-PET/CT Imaging, With Potential Applicability in Radiation Therapy Planning. Int J Radiat Oncol Biol Phys 2015; 92:1035-1043. [PMID: 26194679 DOI: 10.1016/j.ijrobp.2015.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/10/2015] [Accepted: 04/14/2015] [Indexed: 02/03/2023]
Abstract
PURPOSE Proliferating bone marrow is exquisitely sensitive to ionizing radiation. Knowledge of its distribution could improve radiation therapy planning to minimize unnecessary marrow exposure and avoid consequential prolonged myelosuppression. [18F]-Fluoro-3-deoxy-3-L-fluorothymidine (FLT)-positron emission tomography (PET) is a novel imaging modality that provides detailed quantitative images of proliferating tissues, including bone marrow. We used FLT-PET imaging in cancer patients to produce an atlas of marrow distribution with potential clinical utility. METHODS AND MATERIALS The FLT-PET and fused CT scans of eligible patients with non-small cell lung cancer (no distant metastases, no prior cytotoxic exposure, no hematologic disorders) were reviewed. The proportions of skeletal FLT activity in 10 predefined bony regions were determined and compared according to age, sex, and recent smoking status. RESULTS Fifty-one patients were studied: 67% male; median age 68 (range, 31-87) years; 8% never smokers; 70% no smoking in the preceding 3 months. Significant differences in marrow distribution occurred between sex and age groups. No effect was detected from smoking in the preceding 3 months. Using the mean percentages of FLT uptake per body region, we created an atlas of the distribution of functional bone marrow in 4 subgroups defined by sex and age. CONCLUSIONS This atlas has potential utility for estimating the distribution of active marrow in adult cancer patients to guide radiation therapy planning. However, because of interindividual variation it should be used with caution when radiation therapy risks ablating large proportions of active marrow; in such cases, individual FLT-PET scans may be required.
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Kamel S, Horton L, Ysebaert L, Levade M, Burbury K, Tan S, Cole-Sinclair M, Reynolds J, Filshie R, Schischka S, Khot A, Sandhu S, Keating MJ, Nandurkar H, Tam CS. Ibrutinib inhibits collagen-mediated but not ADP-mediated platelet aggregation. Leukemia 2015; 29:783-7. [PMID: 25138588 DOI: 10.1038/leu.2014.247] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/07/2014] [Accepted: 08/14/2014] [Indexed: 02/03/2023]
Abstract
The BTK (Bruton's tyrosine kinase) inhibitor ibrutinib is associated with an increased risk of bleeding. A previous study reported defects in collagen- and adenosine diphosphate (ADP)-dependent platelet responses when ibrutinib was added ex vivo to patient samples. Whereas the collagen defect is expected given the central role of BTK in glycoprotein VI signaling, the ADP defect lacks a mechanistic explanation. In order to determine the real-life consequences of BTK platelet blockade, we performed light transmission aggregometry in 23 patients receiving ibrutinib treatment. All patients had reductions in collagen-mediated platelet aggregation, with a significant association between the degree of inhibition and the occurrence of clinical bleeding or bruising (P=0.044). This collagen defect was reversible on drug cessation. In contrast to the previous ex vivo report, we found no in vivo ADP defects in subjects receiving standard doses of ibrutinib. These results establish platelet light transmission aggregometry as a method for gauging, at least qualitatively, the severity of platelet impairment in patients receiving ibrutinib treatment.
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Alexander M, Burbury K. Does outpatient status really confer lower thrombotic risk? JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2014. [DOI: 10.1002/jppr.1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cheah CY, Herbert KE, O'Rourke K, Kennedy GA, George A, Fedele PL, Gilbertson M, Tan SY, Ritchie DS, Opat SS, Prince HM, Dickinson M, Burbury K, Wolf M, Januszewicz EH, Tam CS, Westerman DA, Carney DA, Harrison SJ, Seymour JF. A multicentre retrospective comparison of central nervous system prophylaxis strategies among patients with high-risk diffuse large B-cell lymphoma. Br J Cancer 2014; 111:1072-9. [PMID: 25072255 PMCID: PMC4453849 DOI: 10.1038/bjc.2014.405] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/04/2014] [Accepted: 06/23/2014] [Indexed: 01/17/2023] Open
Abstract
Background: Central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) is a devastating complication; the optimal prophylactic strategy remains unclear. Methods: We performed a multicentre, retrospective analysis of patients with DLBCL with high risk for CNS relapse as defined by two or more of: multiple extranodal sites, elevated serum LDH and B symptoms or involvement of specific high-risk anatomical sites. We compared three different strategies of CNS-directed therapy: intrathecal (IT) methotrexate (MTX) with (R)-CHOP ‘group 1' R-CHOP with IT MTX and two cycles of high-dose intravenous (IV) MTX ‘group 2' dose-intensive systemic antimetabolite-containing chemotherapy (Hyper-CVAD or CODOXM/IVAC) with IT/IV MTX ‘group 3'. Results: Overall, 217 patients were identified (49, 125 and 43 in groups 1–3, respectively). With median follow-up of 3.4 (range 0.2–18.6) years, 23 CNS relapses occurred (12, 10 and 1 in groups 1–3 respectively). The 3-year actuarial rates (95% CI) of CNS relapse were 18.4% (9.5–33.1%), 6.9% (3.5–13.4%) and 2.3% (0.4–15.4%) in groups 1–3, respectively (P=0.009). Conclusions: The addition of high-dose IV MTX and/or cytarabine was associated with lower incidence of CNS relapse compared with IT chemotherapy alone. However, these data are limited by their retrospective nature and warrant confirmation in prospective randomised studies.
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Porwit A, van de Loosdrecht AA, Bettelheim P, Brodersen LE, Burbury K, Cremers E, Della Porta MG, Ireland R, Johansson U, Matarraz S, Ogata K, Orfao A, Preijers F, Psarra K, Subirá D, Valent P, van der Velden VHJ, Wells D, Westers TM, Kern W, Béné MC. Revisiting guidelines for integration of flow cytometry results in the WHO classification of myelodysplastic syndromes-proposal from the International/European LeukemiaNet Working Group for Flow Cytometry in MDS. Leukemia 2014; 28:1793-8. [PMID: 24919805 DOI: 10.1038/leu.2014.191] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 04/06/2014] [Accepted: 05/02/2014] [Indexed: 12/22/2022]
Abstract
Definite progress has been made in the exploration of myelodysplastic syndromes (MDS) by flow cytometry (FCM) since the publication of the World Health Organization 2008 classification of myeloid neoplasms. An international working party initiated within the European LeukemiaNet and extended to include members from Australia, Canada, Japan, Taiwan and the United States has, through several workshops, developed and subsequently published consensus recommendations. The latter deal with preanalytical precautions, and propose small and large panels, which allow evaluating immunophenotypic anomalies and calculating myelodysplasia scores. The current paper provides guidelines that strongly recommend the integration of FCM data with other diagnostic tools in the diagnostic work-up of MDS.
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Cheah CY, Dickinson M, Hofman MS, George A, Ritchie DS, Prince HM, Westerman D, Harrison SJ, Burbury K, Wolf M, Januszewicz H, Herbert KE, Carney DA, Tam C, Seymour JF. Limited clinical benefit for surveillance PET-CT scanning in patients with histologically transformed lymphoma in complete metabolic remission following primary therapy. Ann Hematol 2014; 93:1193-200. [PMID: 24595733 DOI: 10.1007/s00277-014-2040-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/15/2014] [Indexed: 11/26/2022]
Abstract
The optimum follow-up of patients with transformed indolent lymphoma (TrIL) is not well defined. We sought to determine the utility of surveillance positron emission tomography-computed tomography (PET-CT) in patients with TrIL achieving complete metabolic remission (CMR) after primary therapy. We performed a retrospective analysis of patients with TrIL treated at Peter MacCallum Cancer Centre between 2002 and 2012 who achieved CMR after primary therapy who had ≥1 subsequent surveillance PET-CT. Of 55 patients with TrIL, 37 (67 %) received autologous stem cell transplantation as consolidation following chemoimmunotherapy. After a median follow-up of 34 (range 3-101) months, the actuarial 3-year progression-free (PFS) and overall survival (OS) were 77 % (95 %CI 62-86 %) and 88 % (75-94 %), respectively. Of 180 surveillance PET-CT scans, there were 153 true negatives, 4 false positives, 1 false negative, 7 indeterminate and 15 true positives. Considering indeterminate scans as false positives, the specificity of PET-CT for detecting relapse was 94 %, sensitivity was 83 %, positive predictive value was 63 % and negative predictive value was 98 %. All seven subclinical (PET detected) relapses were of low-grade histology; in contrast, all nine relapses with diffuse large B cell lymphoma (DLBCL) were symptomatic. In our cohort of patients with TrIL achieving CMR, PET-CT detected subclinical low-grade relapses but all DLBCL relapses were accompanied by clinical symptoms. Thus, surveillance imaging of patients with TrIL achieving CMR is of limited clinical benefit. PET-CT should be reserved for evaluation of clinically suspected relapse.
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Alexander M, Kirsa S, Wolfe R, MacManus M, Ball D, Solomon B, Burbury K. Thromboembolism in lung cancer - an area of urgent unmet need. Lung Cancer 2014; 84:275-80. [PMID: 24679344 DOI: 10.1016/j.lungcan.2014.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 02/12/2014] [Accepted: 02/18/2014] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Thromboembolism is common in lung cancer. Current thromboprophylaxis guidelines lack specific recommendations for appropriate strategies in this high thrombotic risk patient cohort. We profiled lung cancer patients receiving anti-cancer therapy. Thromboembolism incidence and thromboembolism-related mortality rates are reported and we explored patient, disease, and treatment-related risk factors associated with higher thrombotic rates. METHODS Retrospective review of lung cancer patients referred to a Comprehensive Cancer Centre between 01/07/2011 and 30/06/2012 for anti-cancer therapy. Data were collected from medical, pharmacy, pathology and diagnostic imaging electronic records. RESULTS After a median follow up of 10 months (range: 0.03-32 months), 24/222 patients (10.8%) had developed radiologically confirmed thromboembolism; 131 events per 1000 person-years (95%CI 87-195). Thromboembolism occurred equally in patients with non-small cell and small cell lung cancer (10.8% and 10.5% respectively), and more frequently among patients with adenocarcinoma compared to squamous cell carcinoma (14.7% and 5.3% respectively). Chemotherapy-treated patients experienced thromboembolism more often than patients who did not receive chemotherapy (HR 5.7 95%CI 2.2-14.8). Radiotherapy was also associated with more frequent thromboembolism (HR 5.2 95%CI 2.0-13.2). New lung cancer diagnosis, presence of metastatic disease, second primary malignancy and Charlson Index ≥ 5 were also associated with higher rates of thromboembolism. Importantly, pharmacological thromboprophylaxis (P-TP) was not routinely or systematically prescribed for ambulant lung cancer patients during any treatment phase, at this institution. The majority (83%) of thromboembolic events occurred in the ambulatory care setting. CONCLUSION Morbidity and mortality from thromboembolism occurs frequently in lung cancer. Thromboprophylaxis guidelines should be developed for the ambulatory care setting.
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Alexander M, Kirsa S, MacManus M, Ball D, Solomon B, Burbury K. Thromboprophylaxis for lung cancer patients--multimodality assessment of clinician practices, perceptions and decision support tools. Support Care Cancer 2014; 22:1915-22. [PMID: 24573603 DOI: 10.1007/s00520-014-2170-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/10/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to report the opinions and self-reported practices of clinicians, as well as the availability of decision support tools, regarding appropriate thromboprophylaxis for patients with lung cancer to identify variation in practice and/or divergence from evidence-based clinical practice guidelines (CPG). METHODS A computer-generated survey (SurveyMonkey software) was distributed to surgical, radiation and medical oncologists with lung cancer specialisation, via membership of the Australian Lung Cancer Trials Group (ALTG) from May to September 2013. RESULTS Seventy-two clinicians, from public, private, specialist and general hospitals, completed the survey (46% response rate). Hospital-endorsed CPG were widely available (91%); however, these routinely lacked robust recommendations for the ambulatory care setting (98%) and risk stratification tools (65%). Clinicians consistently identified ambulatory care treatment modalities (chemotherapy, alone or in combination with radiotherapy) as having similar (high) thrombotic risk as surgery. Timing and duration of pharmacological thromboprophylaxis prescribing among surgical oncologists varied and were divergent from guideline recommendations. Fifty-eight percent of surveyed clinicians cited a lack of high-quality data to guide preventative strategies in lung cancer patients. CONCLUSION Clinicians consistently identified patients with lung cancer as having a high thromboembolic risk in both ambulatory and surgical settings, but with differences in recommendations and variation in practice. CPG lacked robust recommendations for the ambulatory care setting, the main arena for the multimodality lung cancer treatment paradigm.
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Burbury K. Haemostatic challenges in the cancer patient: Focus on the perioperative period. Best Pract Res Clin Anaesthesiol 2013; 27:493-511. [DOI: 10.1016/j.bpa.2013.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 11/26/2022]
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Cheah CY, Hofman MS, Dickinson M, Wirth A, Westerman D, Harrison SJ, Burbury K, Wolf M, Januszewicz H, Herbert K, Prince HM, Carney DA, Ritchie DS, Hicks RJ, Seymour JF. Limited role for surveillance PET-CT scanning in patients with diffuse large B-cell lymphoma in complete metabolic remission following primary therapy. Br J Cancer 2013; 109:312-7. [PMID: 23807169 PMCID: PMC3721385 DOI: 10.1038/bjc.2013.338] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/14/2013] [Accepted: 06/10/2013] [Indexed: 11/19/2022] Open
Abstract
Background: The usefulness of positron emission tomography with computed tomography (PET–CT) in the surveillance of patients with diffuse large B-cell lymphoma (DLBCL) in complete metabolic remission after primary therapy is not well studied. Methods: We performed a retrospective review of our database between 2002 and 2009 for patients with de novo DLBCL who underwent surveillance PET–CT after achieving complete metabolic response (CMR) following primary therapy. Results: Four-hundred and fifty scans were performed in 116 patients, with a median follow-up of 53 (range 8–133) months from completion of therapy. Thirteen patients (11%) relapsed: seven were suspected clinically and six were subclinical (all within first 18 months). The positive predictive value in patients with international prognostic index (IPI) <3 was 56% compared with 80% in patients with IPI⩾3. Including indeterminate scans, PET–CT retained high sensitivity 95% and specificity 97% for relapse. Conclusion: Positron emission tomography with computed tomography is not useful in patients for the majority of patients with diffuse large B-cell lymphoma in CMR after primary therapy, with the possible exception of patients with baseline IPI ⩾3 in the 18 months following completion of primary therapy. This issue could be addressed by a prospective clinical trial.
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Riedel B, Rafat N, Browne K, Burbury K, Schier R. Perioperative Implications of Vascular Endothelial Dysfunction: Current Understanding of this Critical Sensor-Effector Organ. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0024-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cheah CY, Lew TE, Seymour JF, Burbury K. Rasburicase causing severe oxidative hemolysis and methemoglobinemia in a patient with previously unrecognized glucose-6-phosphate dehydrogenase deficiency. Acta Haematol 2013; 130:254-9. [PMID: 23860572 DOI: 10.1159/000351048] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 03/17/2013] [Indexed: 11/19/2022]
Abstract
Rasburicase is frequently used in tumor lysis syndrome (TLS). Although it is very well tolerated, it can cause severe oxidative hemolytic anemia and methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. We report another case of rasburicase-induced methemoglobinemia in a patient with previously unrecognized G6PD deficiency and review the cases of methemoglobinemia and oxidative hemolysis reported in the literature to date. Patients from ethnicities in which G6PD deficiency is prevalent at high risk of TLS should be screened for G6PD deficiency prior to administration of rasburicase where practical. Asymptomatic decrease in oxygen saturation by oximetry and cyanosis are signs of methemoglobinemia; patients recover with conservative measures including supplemental oxygen and packed red cell transfusion.
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Doo NW, Thompson PA, Prince HM, Seymour JF, Ritchie D, Stokes K, Burbury K, Wolf M, Joyce T, Harrison SJ. Bortezomib with high dose melphalan conditioning for autologous transplant is safe and effective in patients with heavily pretreated and high risk multiple myeloma. Leuk Lymphoma 2012; 54:1465-72. [PMID: 23121086 DOI: 10.3109/10428194.2012.746682] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There are no uniform guidelines for the treatment of relapsed refractory multiple myeloma (MM), however autologous stem cell transplant (SCT) remains an important treatment modality. Although a number of modifications to high dose melphalan (HDM) conditioning have been evaluated, improvement in overall survival has not been demonstrated. We now report our experience of 23 patients with heavily pretreated MM (median lines of prior treatment 3 [range 1-6]) who underwent SCT with bortezomib and high dose melphalan (BorHDM). The overall response rate (at least partial response [PR]) was 65.4%. Median overall survival (OS) was 24 months. A subset of patients who relapsed ≤ 12 months after initial SCT had significantly longer OS after BorHDM SCT compared to a historical control group who received HDM conditioning alone (14.5 vs. 8 months, respectively, p = 0.011). In summary, BorHDM SCT produces very good response rates in heavily pretreated MM, and may increase survival in the salvage setting in patients who relapse early after initial SCT. We propose that its use should be explored as part of a tandem approach in patients undergoing initial SCT who are at high risk of early relapse.
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Khot A, Dickinson M, Stokes K, Harrison S, Burbury K, Fleming S, Wall D, Gambell P, Prince HM, Seymour JF, Ritchie D. A risk-adapted protocol for delayed administration of filgrastim after high-dose chemotherapy and autologous stem cell transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 13:42-7. [PMID: 23146384 DOI: 10.1016/j.clml.2012.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 09/21/2012] [Accepted: 09/26/2012] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The routine use of recombinant human granulocyte-colony stimulating factor (rhG-CSF) after high-dose chemotherapy and autologous stem cell transplantation (auto-SCT) is associated with increased costs. We prospectively explored a strategy that used prophylactic delayed filgrastim only in patients with risk factors. PATIENTS AND METHODS This sequential cohort analysis compared the outcomes of consecutive patients, treated on the risk-adapted protocol (RAP) (risk factors: prior febrile neutropenia; age >60 years; and CD34+ cell infused dose of <2 × 10(6/)/kg), who received filgrastim from day +6 after auto-SCT with a historical cohort (historical day-1 cohort [HD1]), who received filgrastim from day +1. RESULTS Eighty-two patients were treated in the RAP cohort and compared with 115 patients in the HD1 cohort. There were no differences in median age (55 years) or median CD34+ cell dose (5.21 × 10(6)/kg [range, 2-62.2 × 10(6)/kg] vs. 5.24 × 10(6)/kg [range, 2.4-29.8 × 10(6)/kg]). Filgrastim was used for 6 fewer days in the RAP cohort (median 5 days [range, 0-11 days] vs. 11 days [range, 9-47 days]). There was a small absolute but significant difference in median time to neutrophil recovery in the HD1 cohort for the whole group, 10 days (range, 8-46 days) vs. 11 days (range, 9-22 days) (P = .03) and in patients with myeloma; 10 days (range, 9-14 days) vs. 11 days (range, 9-18 days) (P < .0001) as compared to the RAP cohort. There was no difference in median inpatient duration, 13 days (range, 10-26 days) vs. 12 days (range, 1-38 days) (P = .22) and 3-year survival (79% vs. 83% [P = .43]) between HD1 and RAP cohorts respectively. CONCLUSIONS The use of a RAP to identify patients likely to benefit from prophylactic filgrastim is safe and results in cost savings. Patients with myeloma benefit from earlier introduction of filgrastim in terms of neutrophil recovery; this disease-specific observation is an important consideration for future studies.
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