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Al-Samkari H. Optimal management of chemotherapy-induced thrombocytopenia with thrombopoietin receptor agonists. Blood Rev 2024; 63:101139. [PMID: 37914568 PMCID: PMC10872905 DOI: 10.1016/j.blre.2023.101139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of antineoplastic therapy, resulting in antineoplastic therapy dose reductions, treatment delays, treatment discontinuation, and morbid bleeding events. Despite several decades of research into thrombopoietic growth factors in CIT, there are presently no available U.S. FDA- or EMA-approved agents to treat CIT. However, a respectable body of evidence has been published evaluating the thrombopoietin receptor agonists (TPO-RAs) for the management and prevention of CIT in patients with solid tumors, and critical studies are ongoing with the TPO-RAs romiplostim and avatrombopag. When employed in the appropriate patient population and used properly, TPO-RAs can successfully and safely manage CIT for extended periods of time with minimal apparent risks. This comprehensive review discusses the evidence for TPO-RAs in CIT in patients with solid tumors, provides detailed guidance for their use in the clinic, and discusses ongoing essential clinical trials in management of CIT.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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2
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Sato D, Takami H, Takayanagi S, Taoka K, Tanaka M, Matsuura R, Tanaka S, Saito N. Lymphoproliferative disorder during temozolomide therapy; a representative case of a formidable complication and management challenges. BMC Neurol 2023; 23:224. [PMID: 37296412 DOI: 10.1186/s12883-023-03274-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Lymphoproliferative disorder represents a heterogeneous clinicopathological spectrum characterized by uncontrolled proliferation of lymphocytes. Immunodeficiency is a major trigger of its development. While induction of immunodeficiency is a well-known adverse effect of temozolomide therapy, development of lymphoproliferative disorder following temozolomide therapy has not previously been described. CASE PRESENTATION A patient with brainstem glioma developed constitutional symptoms, pancytopenia, splenomegaly and generalized lymphadenopathy during the 2nd cycle of maintenance therapy following induction therapy with temozolomide. Epstein-Barr virus-infected lymphocytes were observed histopathologically and "other iatrogenic immunodeficiency-associated lymphoproliferative disorder" (OIIA-LPD) was diagnosed. Although discontinuation of temozolomide led to rapid remission, relapse was observed 4 months later. CHOP chemotherapy was induced, resulting in secondary remission. Vigilant follow-up for another 14 months showed radiologically stable brainstem glioma and no further recurrence of OIIA-LPD. CONCLUSIONS This is the first report documenting OIIA-LPD during temozolomide administration. Timely diagnosis of the disease and discontinuation of the causative agent were considered to be the management of choice. Close monitoring for relapse should be continued. Finding a balance between glioma management and controlling the remission of OIIA-LPD remains to be clarified.
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Affiliation(s)
- Daisuke Sato
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hirokazu Takami
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Shunsaku Takayanagi
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Kazuki Taoka
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Reiko Matsuura
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Shota Tanaka
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
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3
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Sullivan JK, Fahey PP, Agho KE, Hurley SP, Feng Z, Day RO, Lim D. Valproic acid as a radio-sensitizer in glioma: A systematic review and meta-analysis. Neurooncol Pract 2023; 10:13-23. [PMID: 36659976 PMCID: PMC9837785 DOI: 10.1093/nop/npac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Histone deacetylase inhibitors (HDACi) including valproic acid (VPA) have the potential to improve radiotherapy (RT) efficacy and reduce treatment adverse events (AE) via epigenetic modification and radio-sensitization of neoplastic cells. This systematic review and meta-analysis aimed to assess the efficacy and AE associated with HDACi used as radio-sensitizers in adult solid organ malignancy patients. Methods A systematic review utilized electronic searches of MEDLINE(Ovid), Embase(Ovid), The Cochrane Library, and the International Clinical Trials Registry Platform to identify studies examining the efficacy and AEs associated with HDACi treatment in solid organ malignancy patients undergoing RT. Meta-analysis was performed with overall survival (OS) reported as hazard ratios (HR) as the primary outcome measure. OS reported as median survival difference, and AEs were secondary outcome measures. Results Ten studies reporting on the efficacy and/or AEs of HDACi in RT-treated solid organ malignancy patients met inclusion criteria. All included studies focused on HDACi valproic acid (VPA) in high-grade glioma patients, of which 9 studies (n = 6138) evaluated OS and 5 studies (n = 1055) examined AEs. The addition of VPA to RT treatment protocols resulted in improved OS (HR = 0.80, 95% CI 0.67-0.96). No studies focusing on non-glioma solid organ malignancy patients, or non-VPA HDACi met the inclusion criteria for this review. Conclusions This review suggests that glioma patients undergoing RT may experience prolonged survival due to HDACi VPA administration. Further randomized controlled trials are required to validate these findings. Additionally, more research into the use of HDACi radio-adjuvant treatment in non-glioma solid organ malignancies is warranted.
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Affiliation(s)
| | - Paul P Fahey
- School of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Kinglsey E Agho
- School of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Simon P Hurley
- School of Medicine, Flinders University, South Australia, Australia
| | - Zhihui Feng
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Richard O Day
- St Vincent’s Clinical Campus, University of New South Wales, New South Wales, Australia
| | - David Lim
- School of Medicine, Flinders University, South Australia, Australia
- School of Health Sciences, Western Sydney University, New South Wales, Australia
- Centre for Remote Health: A JBI Affiliated Centre, Alice Springs, Australia
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4
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Targeting Glioblastoma via Selective Alteration of Mitochondrial Redox State. Cancers (Basel) 2022; 14:cancers14030485. [PMID: 35158753 PMCID: PMC8833725 DOI: 10.3390/cancers14030485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Glioblastoma is characterized by a pronounced redox imbalance due to elevated glycolytic and mitochondrial oxidative metabolism. New therapeutic strategies have been developed to modulate glioblastoma redox signaling to effectively suppress growth and prolong survival. However, drug selectivity and therapeutic relapse prove to be the major challenges. We describe a pharmacological strategy for the selective targeting and treatment of glioblastoma using the redox active combination drug menadione/ascorbate, which is characterized by tolerance to normal cells and tissues. Menadione/ascorbate treatment of glioblastoma mice suppressed tumor growth and significantly increased survival without adverse side effects. This is accompanied by increased oxidative stress, decreased reducing capacity and decreased cellular density in the tumor alone, as well as increased brain perfusion and decreased regulation of several oncoproteins and oncometabolites, which implies modulation of the immune response and reduced drug resistance. We believe that this therapeutic strategy is feasible and promising and deserves the attention of clinicians. Abstract Glioblastoma is one of the most aggressive brain tumors, characterized by a pronounced redox imbalance, expressed in a high oxidative capacity of cancer cells due to their elevated glycolytic and mitochondrial oxidative metabolism. The assessment and modulation of the redox state of glioblastoma are crucial factors that can provide highly specific targeting and treatment. Our study describes a pharmacological strategy for targeting glioblastoma using a redox-active combination drug. The experiments were conducted in vivo on glioblastoma mice (intracranial model) and in vitro on cell lines (cancer and normal) treated with the redox cycling pair menadione/ascorbate (M/A). The following parameters were analyzed in vivo using MRI or ex vivo on tissue and blood specimens: tumor growth, survival, cerebral perfusion, cellular density, tissue redox state, expression of tumor-associated NADH oxidase (tNOX) and transforming growth factor-beta 1 (TGF-β1). Dose-dependent effects of M/A on cell viability, mitochondrial functionality, and redox homeostasis were evaluated in vitro. M/A treatment suppressed tumor growth and significantly increased survival without adverse side effects. This was accompanied by increased oxidative stress, decreased reducing capacity, and decreased cellular density in the tumor only, as well as increased cerebral perfusion and down-regulation of tNOX and TGF-β1. M/A induced selective cytotoxicity and overproduction of mitochondrial superoxide in isolated glioblastoma cells, but not in normal microglial cells. This was accompanied by a significant decrease in the over-reduced state of cancer cells and impairment of their “pro-oncogenic” functionality, assessed by dose-dependent decreases in: NADH, NAD+, succinate, glutathione, cellular reducing capacity, mitochondrial potential, steady-state ATP, and tNOX expression. The safety of M/A on normal cells was compromised by treatment with cerivastatin, a non-specific prenyltransferase inhibitor. In conclusion, M/A differentiates glioblastoma cells and tissues from normal cells and tissues by redox targeting, causing severe oxidative stress only in the tumor. The mechanism is complex and most likely involves prenylation of menadione in normal cells, but not in cancer cells, modulation of the immune response, a decrease in drug resistance, and a potential role in sensitizing glioblastoma to conventional chemotherapy.
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Garcia CR, Myint ZW, Jayswal R, Wang C, Morgan RM, Butts AR, Weiss HL, Villano JL. Hematological adverse events in the management of glioblastoma. J Neurooncol 2022; 156:153-161. [PMID: 34820776 PMCID: PMC8829911 DOI: 10.1007/s11060-021-03891-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/30/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hematological adverse events (HAEs) are common during treatment for glioblastoma (GBM), usually associated with temozolomide (TMZ). Their clinical value is uncertain, as few investigations have focused on outcomes for HAEs during GBM treatment. METHODS We combined data from two randomized clinical trials, RTOG 0525 and RTOG 0825, to analyze HAEs during treatment for GBM. We investigated differences between chemoradiation and adjuvant therapy, and by regimen received during adjuvant treatment. RESULTS 1454 patients participated in these trials, of which 1154 (79.4%) developed HAEs. During chemoradiation, 44.4% of patients developed HAEs (54% involving more than one cell line), and were most commonly lymphopenia (50.6%), and thrombocytopenia (47.5%). During adjuvant treatment, 45% of patients presented HAEs (78.6% involving more than one cell line), and were more commonly leukopenia (62.7%), and thrombocytopenia (62.3%). Median overall survival (OS) and progression free survival (PFS) were longer in patients with HAEs (OS 19.4 months and PFS 9.9 months) compared to those with other or no adverse events (OS 14.1 months and PFS 5.9 months). There was no significant difference in survival between grade 1 and/or 2 versus grade 3 and/or 4 HAEs. History of HAEs during chemoradiation was a protective factor for presentation of HAEs during adjuvant therapy. CONCLUSION HAEs are common during GBM treatment, and often involve more than one cell line (more likely during adjuvant therapy). HAEs may be associated with prolonged OS and PFS, particularly during adjuvant therapy. HAEs during chemoradiation was a protective factor for HAEs during adjuvant therapy.
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Affiliation(s)
| | - Zin W. Myint
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Division of Medical Oncology, University of Kentucky, Lexington, KY, USA
| | - Rani Jayswal
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Division of Medical Oncology, University of Kentucky, Lexington, KY, USA
| | - Chi Wang
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Division of Cancer Biostatistics, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Rachael M. Morgan
- Department of Pharmacy Services, University of Kentucky, Lexington, KY, USA
| | - Allison R. Butts
- Department of Pharmacy Services, University of Kentucky, Lexington, KY, USA
| | - Heidi L. Weiss
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - John L. Villano
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Division of Medical Oncology, University of Kentucky, Lexington, KY, USA.,Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
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6
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Zhang Y, Qu H, Xue X. Blood-brain barrier penetrating liposomes with synergistic chemotherapy for glioblastoma treatment. Biomater Sci 2021; 10:423-434. [PMID: 34873606 DOI: 10.1039/d1bm01506k] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Glioblastoma multiforme (GBM) is an aggressive and malignant brain tumor with high mortality. The current treatment strategies are still unsatisfactory for this devastating disease. Here, we developed a glucose-functionalized liposome (gLTP) that co-loads temozolomide (TMZ) and pro-apoptotic peptide (PAP) to achieve synergistic efficacy towards GBM. The gLTP can readily penetrate the blood-brain barrier via the glucose-GLUT1 pathway and release the TMZ and PAP in the cells. The PAP destroys the mitochondria and subsequently depletes ATP generation, making the GBM cells more sensitive to TMZ-mediated chemotherapy. gLTP exhibits the best anti-tumor effect on the subcutaneous brain tumor model compared to other treatments, including a single drug (TMZ or PAP) liposome and TMZ and PAP physical mixture. On the highly aggressive intracranial tumor model, gLTP can readily penetrate the BBB and efficiently deliver the drugs into the brain tumor, leading to striking improvements in total survival compared to the other treatments. This strategy potentially inspires new attempts to design more effective anti-GBM formulations.
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Affiliation(s)
- Ying Zhang
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, College of Life Sciences, Northwest University, Xi'an, 710069, China.
| | - Haijing Qu
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Xiangdong Xue
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, College of Life Sciences, Northwest University, Xi'an, 710069, China. .,School of Pharmacy, Shanghai Jiao Tong University, Shanghai, 200240, China
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7
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Al-Samkari H, Parnes AD, Goodarzi K, Weitzman JI, Connors JM, Kuter DJ. A multicenter study of romiplostim for chemotherapy-induced thrombocytopenia in solid tumors and hematologic malignancies. Haematologica 2021; 106:1148-1157. [PMID: 32499239 PMCID: PMC8018116 DOI: 10.3324/haematol.2020.251900] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Indexed: 12/15/2022] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) frequently complicates cancer treatment causing chemotherapy delays, dose reductions, and discontinuation. There is no FDA-approved agent available to manage CIT. This study retrospectively evaluated patients with CIT treated on institutional romiplostim treatment pathways at 4 U.S. centers. The primary outcome was achievement of a romiplostim response [median on-romiplostim platelet count (Plt) ≥75x109/L and ≥30x109/L above baseline]. Secondary outcomes included time to Plt≥100x109/L and rates of the following: Plt<100x109/L, Plt<75x109/L, Plt<50x109/L, thrombocytosis, chemotherapy dose reduction/treatment delay, platelet transfusion, bleeding, and thromboembolism. Multivariable regression was used to identify predictors of romiplostim non-response and compare weekly dosing with intracycle/intermittent dosing. 173 patients (153 solid tumor, 20 lymphoma or myeloma) were treated, with 170 (98%) receiving a median of 4 (range, 1-36) additional chemotherapy cycles on romiplostim. Romiplostim was effective in solid tumor patients: 71% of patients achieved a romiplostim response, 79% avoided chemotherapy dose reductions/treatment delays and 89% avoided platelet transfusions. Median per-patient Plt on romiplostim was significantly higher than baseline (116x109/L vs. 60x109/L, P<0.001). Bone marrow tumor invasion, prior pelvic irradiation, and prior temozolomide predicted romiplostim non-response. Bleeding rates were lower than historical CIT cohorts and thrombosis rates were not elevated. Weekly dosing was superior to intracycle dosing with higher response rates and less chemotherapy dose reductions/treatment delays (IRR 3.00, 95% CI 1.30-6.91, P=0.010) or bleeding (IRR 4.84, 95% CI 1.18-19.89, P=0.029). Blunted response (10% response rate) was seen in non-myeloid hematologic malignancy patients with bone marrow involvement. In conclusion, romiplostim was safe and effective for CIT in most solid tumor patients.
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Affiliation(s)
- Hanny Al-Samkari
- Div of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aric D Parnes
- Hematology Division, Brigham and Womens Hospital, Boston, USA
| | - Katayoon Goodarzi
- Div of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James I Weitzman
- Division of Hematology Oncology, Newton-Wellesley Hospital, Newton, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women Hospital, Harvard Medical School, Boston, USA
| | - David J Kuter
- Div of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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8
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Ata F, Akkam Veettil SF, Gaber M, Omar NE, Madani A, Mah Afifi H, Aldardouri MM, Amer A, Kohla S, Zar Gul AR. Fatal temozolomide induced aplastic anemia in a female with Glioblastoma multiforme : A case report and literature review. Clin Case Rep 2021; 9:1641-1646. [PMID: 33768906 PMCID: PMC7981661 DOI: 10.1002/ccr3.3860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/28/2020] [Accepted: 01/11/2021] [Indexed: 11/16/2022] Open
Abstract
When seeing patients on Temozolomide with pancytopenia, aplastic anemia secondary to the drug should be considered early in the differentials to avoid permanent hematological suppression.
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Affiliation(s)
- Fateen Ata
- Department of Internal Medicine Hamad General Hospital Hamad Medical Corporation Doha Qatar
| | | | - Mohammed Gaber
- Department of Oncology National Center for Cancer Care & Research Hamad Medical Corporation Doha Qatar
| | - Nabil E Omar
- Pharmacy Department National Center for Cancer Care & Research Hamad Medical Corporation Doha Qatar
| | - Ammar Madani
- Department of Oncology National Center for Cancer Care & Research Hamad Medical Corporation Doha Qatar
| | - Hebatalla Mah Afifi
- Pharmacy Department National Center for Cancer Care & Research Hamad Medical Corporation Doha Qatar
| | - Meeloud M Aldardouri
- Department of Oncology National Center for Cancer Care & Research Hamad Medical Corporation Doha Qatar
| | - Aliaa Amer
- Hematopathology Division, Department of Laboratory Medicine and Pathology Hamad Medical Corporation Doha Qatar
| | - Samah Kohla
- Hematopathology Division, Department of Laboratory Medicine and Pathology Hamad Medical Corporation Doha Qatar
| | - Abdul Rehman Zar Gul
- Department of Oncology National Center for Cancer Care & Research Hamad Medical Corporation Doha Qatar
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9
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Ata F, Akkam Veettil SF, Gaber M, Omar NE, Madani A, Mah. Afifi H, Aldardouri MM, Amer A, Kohla S, Zar Gul AR. Fatal temozolomide induced aplastic anemia in a female with Glioblastoma multiforme : A case report and literature review. Clin Case Rep 2021; 9:1641-1646. [DOI: https:/doi.org/10.1002/ccr3.3860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/11/2021] [Indexed: 08/30/2023] Open
Affiliation(s)
- Fateen Ata
- Department of Internal Medicine Hamad General HospitalHamad Medical Corporation Doha Qatar
| | | | - Mohammed Gaber
- Department of Oncology National Center for Cancer Care & ResearchHamad Medical Corporation Doha Qatar
| | - Nabil E. Omar
- Pharmacy Department National Center for Cancer Care & ResearchHamad Medical Corporation Doha Qatar
| | - Ammar Madani
- Department of Oncology National Center for Cancer Care & ResearchHamad Medical Corporation Doha Qatar
| | - Hebatalla Mah. Afifi
- Pharmacy Department National Center for Cancer Care & ResearchHamad Medical Corporation Doha Qatar
| | - Meeloud M. Aldardouri
- Department of Oncology National Center for Cancer Care & ResearchHamad Medical Corporation Doha Qatar
| | - Aliaa Amer
- Hematopathology Division, Department of Laboratory Medicine and Pathology Hamad Medical Corporation Doha Qatar
| | - Samah Kohla
- Hematopathology Division, Department of Laboratory Medicine and Pathology Hamad Medical Corporation Doha Qatar
| | - Abdul Rehman Zar Gul
- Department of Oncology National Center for Cancer Care & ResearchHamad Medical Corporation Doha Qatar
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10
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Villani V, Anghileri E, Prosperini L, Lombardi G, Rudà R, Gaviani P, Rizzato S, Lanzetta G, Fabi A, Scaringi C, Pronello E, Simonetti G, Targato G, Pace A. Adjuvant chemotherapy after severe myelotoxicity during chemoradiation phase in malignant gliomas. Is it feasibile? Results from AINO study (Italian Association for Neuro-Oncology). J Neurol 2021; 268:2866-2875. [PMID: 33609154 DOI: 10.1007/s00415-021-10438-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Malignant gliomas (MG) are aggressive brain tumours in adults. The standard of care is concurrent radiation plus temozolomide (TMZ) [chemo-radiotherapy (CRT)] followed by TMZ maintenance up to 6 months. TMZ is considered to have a low toxicity profile, but several studies reported occurrence of severe myelosuppression, especially during the concomitant phase. Toxicity may be prolonged, thus treatment should be discontinued. PURPOSE To evaluate the risk of recurrente myelotoxicity during adjuvant chemotherapy (CT) in patients who recovered from severe myelotoxicity during CRT. METHODS We retrospectively collected data on patients with MG who developed and recovered from severe myelotoxicity during CRT from eight Italian neuro-oncology centers. RESULTS We included 87 patients. Histology was Glioblastoma (GBM) in 78 patients (89.7%); 60% of patients were female. After myelotoxicity recovery, 54 (62%) received treatment. The majority of them (82%, n = 44) received adjuvant TMZ and 18% (n = 10) others treatments. Out of 44 patients who received adjuvant TMZ, 34% experienced the re-occurrence of grade 3-4 myelotoxicity which required permanent CT discontinuation in 6 (13%) cases. Patients who received TMZ or other treatments had longer overall (OS) (adjusted HR 0.46, p = 0.008) and progression free survival (PFS) (adjusted HR 0.57, p = 0.034) than those who remained untreated. CONCLUSION Our study suggests that after severe myelotoxicity the majority of patients received treatment, particularly with TMZ. Only a fraction of patients experienced toxicity recurrence, suggesting that TMZ is well tolerated and had an impact on PFS and OS.
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Affiliation(s)
- Veronica Villani
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Elena Anghileri
- Molecular Neuroncology Unit Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Luca Prosperini
- Department of Neurosciences, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, City of Health and Science Hospital, Turin, Italy
| | - Paola Gaviani
- Neuro-Oncology Unit Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Simona Rizzato
- Department of Oncology, Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Gaetano Lanzetta
- Oncology Department, Istituto Neurotraumatologico Italiano, Grottaferrata, RM, Italy.,Scientific Institute for Research, Hospitalization and Health Care (IRCCS) Neuromed, Pozzilli, Italy
| | - Alessandra Fabi
- Phase 1 Unit and Precision Medicine-IRCSS Regina Elena National Cancer Institute, Rome, Italy
| | - Claudia Scaringi
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Edoardo Pronello
- Department of Neuro-Oncology, City of Health and Science Hospital, Turin, Italy
| | - Giorgia Simonetti
- Neuro-Oncology Unit Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giada Targato
- Department of Oncology, Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Andrea Pace
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
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11
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Gilbar PJ, Pokharel K, Mangos HM. Temozolomide-induced aplastic anaemia: Case report and review of the literature. J Oncol Pharm Pract 2020; 27:1275-1280. [PMID: 33086908 DOI: 10.1177/1078155220967087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Temozolomide (TMZ) is an oral alkylating agent principally indicated for neurological malignancies including glioblastoma (GBM) and astrocytoma. Most common side effects are mild to moderate, and include fatigue, nausea, vomiting, thrombocytopenia and neutropenia. Severe or prolonged myelosuppression, causing delayed treatment or discontinuation, is uncommon. Major haematological adverse effects such as myelodysplastic syndrome or aplastic anaemia (AA) have rarely been reported. CASE REPORT We report a 68-year old female with GBM treated at a tertiary hospital with short-course radiotherapy and concurrent temozolomide following craniotomy. On treatment completion she was transferred to our hospital for rehabilitation. She was thrombocytopenic on admission. Platelets continued falling with significant pancytopenia developing over the next two weeks. Blood parameters and a markedly hypocellular bone marrow confirmed the diagnosis of very severe AA, probably due to TMZ. MANAGEMENT AND OUTCOME Treatment consisted of repeated platelet transfusions, intravenous antibiotics, antiviral and antifungal prophylaxis, and G-CSF 300 mcg daily. Platelet and neutrophil counts had returned to normal at 38 days following the completion of TMZ treatment. DISCUSSION Whilst most cases of AA are idiopathic, a careful drug, occupational exposure and family history should be obtained, as acquired AA may result from viruses, chemical exposure, radiation and medications. Temozolomide-induced AA is well documented, though only 12 cases have been described in detail. Other potential causes were eliminated in our patient. Physicians should be aware of this rare and potentially fatal toxicity when prescribing. Frequent blood tests should be performed, during and following TMZ treatment, to enable early detection.
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Affiliation(s)
- Peter J Gilbar
- Cancer Care Services, Toowoomba Hospital, Toowoomba, Australia.,Rural Clinical School, Faculty of Medicine, The University of Queensland, Toowoomba, Australia
| | - Khageshwor Pokharel
- Cancer Care Services, Toowoomba Hospital, Toowoomba, Australia.,Rural Clinical School, Faculty of Medicine, The University of Queensland, Toowoomba, Australia
| | - Hilda M Mangos
- Cancer Care Services, Toowoomba Hospital, Toowoomba, Australia
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Shi W, Blumenthal DT, Oberheim Bush NA, Kebir S, Lukas RV, Muragaki Y, Zhu JJ, Glas M. Global post-marketing safety surveillance of Tumor Treating Fields (TTFields) in patients with high-grade glioma in clinical practice. J Neurooncol 2020; 148:489-500. [PMID: 32535723 PMCID: PMC7438370 DOI: 10.1007/s11060-020-03540-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/21/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Tumor Treating Fields (TTFields; antimitotic treatment) delivers low-intensity, intermediate-frequency, alternating electric fields through skin-applied transducer arrays. TTFields (200 kHz) was FDA-approved in glioblastoma (GBM), based on the phase 3 EF-11 (recurrent GBM, rGBM) and EF-14 (newly diagnosed GBM, ndGBM) trials. The most common TTFields-related adverse event (AE) in both trials was array-associated skin irritation. We now report on TTFields-related AEs in the real-world, clinical practice setting. METHODS Unsolicited, post-marketing surveillance data from TTFields-treated patients (October 2011-February 2019) were retrospectively analyzed using MedDRA v21.1 preferred terms, stratified by region (US, EMEA [Europe, Middle East, Africa], Japan), diagnosis (ndGBM, rGBM, anaplastic astrocytoma/oligodendroglioma, other brain tumors), and age (< 18 [pediatric], 18-64 [adults], ≥ 65 [elderly]; years of age). RESULTS Of 11,029 patients, 53% were diagnosed with ndGBM and 39% were diagnosed with rGBM at any line of disease recurrence. Most were adults (73%), 26% were elderly, and the male-to-female ratio was ~ 2:1 (close to published ratios of typical GBM populations). The most commonly reported TTFields-related AE was array-associated skin reaction, occurring in patients with ndGBM (38%), rGBM (29%), anaplastic astrocytoma/oligodendroglioma (38%), and other brain tumors (31%); as well as 37% of pediatric, 34% of adult, and 36% of elderly patients. Most skin AEs were mild/moderate and manageable. Other TTFields-related AEs in patients with ndGBM/rGBM included under-array heat sensation (warmth; 11%, 10%, respectively) and electric sensation (tingling; 11%, 9%, respectively), and headache (7%, 6%, respectively). CONCLUSIONS This TTFields safety surveillance analysis in > 11,000 patients revealed no new safety concerns, with a favorable safety profile comparable with published TTFields/GBM trials. The safety profile remained consistent among subgroups, suggesting feasibility in multiple populations, including elderly patients.
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Affiliation(s)
- Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, 19107, USA.
| | - Deborah T Blumenthal
- Neuro-Oncology Unit, Division of Oncology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery and Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Sied Kebir
- Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- West German Cancer Center, German Cancer Consortium, Partner Site Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Rimas V Lukas
- Department of Neurology, Northwestern University, Chicago, IL, USA
- Lou & Jean Malnati Brain Tumor Institute at the Lurie Comprehensive Cancer Center, Northwestern University, Chicago, USA
| | - Yoshihiro Muragaki
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jay-Jiguang Zhu
- McGovern Medical School and Memorial Hermann Hospital at Texas Medical Center, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- West German Cancer Center, German Cancer Consortium, Partner Site Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Zong Z, Hua L, Wang Z, Xu H, Ye C, Pan B, Zhao Z, Zhang L, Lu J, Mei LH, Rutong Y. Self-assembled angiopep-2 modified lipid-poly (hypoxic radiosensitized polyprodrug) nanoparticles delivery TMZ for glioma synergistic TMZ and RT therapy. Drug Deliv 2019; 26:34-44. [PMID: 30744436 PMCID: PMC6394306 DOI: 10.1080/10717544.2018.1534897] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The addition of temozolomide (TMZ) to radiotherapy (RT) improves survival of patients with glioblastoma (GBM). However, TMZ + RT causes excess toxicity in patients. In this study, we prepared angiopep-2 (A2) modified lipid-poly (hypoxic radiosensitized polyprodrug) nanoparticles for TMZ delivery (A2-P(MIs)25/TMZ) to achieve synergistic effects against glioma. This A2-P(MIs)25/TMZ display highly promising advantages: (1) a hydrophobic P-(MIs)25 core where poorly water-soluble TMZ can be encapsulated; (2) nitro groups of the hydrophobic P-(MIs)25 core that are converted into hydrophilic amino groups (P(NH2s)25) under low oxygen conditions to mimic the oxygen-increased sensitization to RT; (3) a lipid monolayer at the interface of the core and the shell to modify the A2 (a specific ligand for low-density lipoprotein receptor-related protein-1 (LRP-1), which are expressed in the blood-brain barrier (BBB) and human glioma cells), thereby enhancing the drug encapsulation efficiency in glioma. These nanoparticles appear as a promising and robust nanoplatforms for TMZ and hypoxic cell radiosensitization delivery.
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Affiliation(s)
- Zhenkun Zong
- a Nanjing Medical University , Nanjing , China.,b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China.,c Department of Neurosurgery , Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Lei Hua
- a Nanjing Medical University , Nanjing , China.,b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China.,c Department of Neurosurgery , Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Zhen Wang
- b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China
| | - Haoyue Xu
- b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China
| | - Chengkun Ye
- b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China
| | - Bomin Pan
- b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China
| | - Zongren Zhao
- b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China
| | - Longzhen Zhang
- d Department of Radiation Oncology , Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Jun Lu
- e Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province School of Life Science , Jiangsu Normal University , Xuzhou , China
| | - Liu Hong Mei
- b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China.,c Department of Neurosurgery , Affiliated Hospital of Xuzhou Medical University , Xuzhou , China.,f Jiangsu Center for the Collaboration and Innovation of Cancer Biotherapy , Cancer Institute, Xuzhou Medical University , Xuzhou , China
| | - Yu Rutong
- a Nanjing Medical University , Nanjing , China.,b Institute of Nervous System Diseases , Xuzhou Medical University , Xuzhou , China.,c Department of Neurosurgery , Affiliated Hospital of Xuzhou Medical University , Xuzhou , China.,f Jiangsu Center for the Collaboration and Innovation of Cancer Biotherapy , Cancer Institute, Xuzhou Medical University , Xuzhou , China
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Newton SL, Kalamaha K, Fernandes HD. Temozolomide-induced Aplastic Anemia Treated with Eltrombopag and Granulocyte Colony Stimulating Factor: A Report of a Rare Complication. Cureus 2018; 10:e3329. [PMID: 30473962 PMCID: PMC6248811 DOI: 10.7759/cureus.3329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Temozolomide is an alkylating agent used in the treatment for glioblastoma multiforme (GBM), the most frequent primary malignant brain tumor in adults. Temozolomide was approved in March 2005 for treatment of GBM, with the Stupp protocol (radiotherapy and concomitant use of temozolomide). Despite initial studies demonstrating mild and well-tolerated side effects, several recent reports describe severe hematologic adverse effects associated with temozolomide use. We report the case of a 51-year-old female diagnosed with GBM who received the standard treatment protocol of radiotherapy and concomitant temozolomide. The patient developed prolonged pancytopenia. Bone marrow biopsy demonstrated hypocellular bone marrow with diminished trilineage hematopoiesis, suggestive of drug-induced aplastic anemia. Although temozolomide is regarded as a safe drug with few side effects, severe hematologic toxicities have been reported.
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Affiliation(s)
- Shauna L Newton
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
| | - Kadra Kalamaha
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
| | - Hermina D Fernandes
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
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Hogan DJ, Zhu JJ, Diago OR, Gammon D, Haghighi A, Lu G, Das A, Gruber HE, Jolly DJ, Ostertag D. Molecular Analyses Support the Safety and Activity of Retroviral Replicating Vector Toca 511 in Patients. Clin Cancer Res 2018; 24:4680-4693. [DOI: 10.1158/1078-0432.ccr-18-0619] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/03/2018] [Accepted: 06/13/2018] [Indexed: 11/16/2022]
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16
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Wang HC, Lin YT, Lin WC, Ho RW, Lin YJ, Tsai NW, Ho JT, Lu CH. Tumor Volume Changes During and After Temozolomide Treatment for Newly Diagnosed Higher-Grade Glioma (III and IV). World Neurosurg 2018; 114:e766-e774. [DOI: 10.1016/j.wneu.2018.03.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/09/2018] [Indexed: 11/28/2022]
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Liu P, Li P, Lei T, Qu L, Huang H, Mu Q. Acute lymphoblastic leukemia following temozolomide treatment in a patient with glioblastoma: A case report and review of the literature. Oncol Lett 2018; 15:8663-8668. [PMID: 29805603 DOI: 10.3892/ol.2018.8422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/22/2016] [Indexed: 01/24/2023] Open
Abstract
Temozolomide (TMZ) is a second-generation oral alkylating agent that functions against a number of central nervous system neoplasms, and is generally used to treat high-grade gliomas, including anaplastic astrocytoma and glioblastoma multiforme. Therapy-related secondary myelodysplastic syndrome and acute myeloid leukemia have been reported in patients following prolonged exposure to TMZ. However, TMZ-related acute lymphoblastic leukemia (ALL) is extremely rare. The present study describes the case of an 11-year-old boy with a 3-day history of generalized tonic-clonic seizures and a contrast-enhanced lesion in the left temporooccipital region with focal cystic degeneration, as detected by magnetic resonance imaging. The patient underwent craniotomy and gross-total resection andpathological analysis confirmed the diagnosis of giant cell glioblastoma. Postoperatively, the patient received TMZ-based concurrent chemoradiation during radiotherapy, and developed B-cell ALL 6 months following TMZ treatment. A thorough literature search identified only six published cases of TMZ-related ALL. The chemotherapeutic efficacy of TMZ has been identified, however, its leukemogenic potential should be emphasized among practitioners and patients. Further studies are required to determine the specific pathogenic mechanism of TMZ-related ALL. Close hematological monitoring of patients following TMZ treatment is vital and a high index of suspicion is necessary.
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Affiliation(s)
- Pengfei Liu
- Department of Neurosurgery The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China.,Department of Neurosurgery, Hongqi Hospital of Mudanjiang Medical University, Mudanjiang, Heilongjiang 157011, P.R. China.,Department of Neurosurgery, Guangdong 999 Brain Hospital, Guangzhou, Guangdong 510510, P.R. China
| | - Peiwen Li
- Department of Neurosurgery The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ting Lei
- Department of Neurosurgery The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Limei Qu
- Department of Pathology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Haiyan Huang
- Department of Neurosurgery The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Qingchun Mu
- Department of Neurosurgery, Hongqi Hospital of Mudanjiang Medical University, Mudanjiang, Heilongjiang 157011, P.R. China
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18
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Franceschi E, Tosoni A, Minichillo S, Depenni R, Paccapelo A, Bartolini S, Michiara M, Pavesi G, Urbini B, Crisi G, Cavallo MA, Tosatto L, Dazzi C, Biasini C, Pasini G, Balestrini D, Zanelli F, Ramponi V, Fioravanti A, Giombelli E, De Biase D, Baruzzi A, Brandes AA. The Prognostic Roles of Gender and O6-Methylguanine-DNA Methyltransferase Methylation Status in Glioblastoma Patients: The Female Power. World Neurosurg 2018; 112:e342-e347. [PMID: 29337169 DOI: 10.1016/j.wneu.2018.01.045] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Clinical and molecular factors are essential to define the prognosis in patients with glioblastoma (GBM). O6-methylguanine-DNA methyltransferase (MGMT) methylation status, age, Karnofsky Performance Status (KPS), and extent of surgical resection are the most relevant prognostic factors. Our investigation of the role of gender in predicting prognosis shows a slight survival advantage for female patients. METHODS We performed a prospective evaluation of the Project of Emilia Romagna on Neuro-Oncology (PERNO) registry to identify prognostic factors in patients with GBM who received standard treatment. RESULTS A total of 169 patients (99 males [58.6%] and 70 females [41.4%]) were evaluated prospectively. MGMT methylation was evaluable in 140 patients. Among the male patients, 36 were MGMT methylated (25.7%) and 47 were unmethylated (33.6%); among the female patients, 32 were methylated (22.9%) and 25 were unmethylated (17.9%). Survival was longer in the methylated females compared with the methylated males (P = 0.028) but was not significantly different between the unmethylated females and the unmethylated males (P = 0.395). In multivariate analysis, gender and MGMT methylation status considered together (methylated females vs. methylated males; hazard ratio [HR], 0.459; 95% confidence interval [CI], 0.242-0.827; P = 0.017), age (HR, 1.025; 95% CI, 1.002-1.049; P = 0.032), and KPS (HR, 0.965; 95% CI, 0.948-0.982; P < 0.001) were significantly correlated with survival. CONCLUSIONS Survival was consistently longer among MGMT methylated females compared with males. Gender can be considered as a further prognostic factor.
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Affiliation(s)
- Enrico Franceschi
- Department of Medical Oncology, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Alicia Tosoni
- Department of Medical Oncology, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Santino Minichillo
- Department of Medical Oncology, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Roberta Depenni
- Department of Oncology, Hematology, and Respiratory Diseases, University Hospital of Modena, Modena, Italy
| | - Alexandro Paccapelo
- Department of Medical Oncology, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Stefania Bartolini
- Department of Medical Oncology, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Maria Michiara
- Department of Medical Oncology, University Hospital of Parma, Parma, Italy
| | - Giacomo Pavesi
- Department of Neurosurgery, Agostino-Estense Hospital, Modena, Italy; Department of Oncology and Hematology, Romagnolo Scientific Institute for the Study and Treatment of Tumors-IRCCS, Cesena, Italy
| | - Benedetta Urbini
- Clinical Oncology Unit, St. Anna University Hospital, Ferrara, Italy
| | - Girolamo Crisi
- Department of Neuroradiology, University Hospital of Parma, Parma, Italy
| | - Michele A Cavallo
- Department of Neurosurgery, St. Anna University Hospital, Ferrara, Italy
| | - Luigino Tosatto
- Department of Neurosurgery, M. Bufalini Hospital, Cesena, Italy
| | - Claudio Dazzi
- Department of Oncology and Hematology, General Hospital, Ravenna, Italy
| | - Claudia Biasini
- Department of Oncology and Hematology, Oncology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Giuseppe Pasini
- Department of Medical Oncology, Infermi Hospital, Rimini, Italy
| | | | - Francesca Zanelli
- Department of Oncology, Santa Maria Nuova Hospital-IRCCS, Reggio Emilia, Italy
| | - Vania Ramponi
- Department of Neurosurgery, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Antonio Fioravanti
- Department of Neurosurgery, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Ermanno Giombelli
- Department of Special Surgeries, Unit of Neurosurgery, University Hospital of Parma, Parma, Italy
| | - Dario De Biase
- Molecular Diagnostic Unit, Department of Pharmacy and Biotechnology, USL Company of Bologna, University of Bologna, Bologna, Italy
| | - Agostino Baruzzi
- IRCCS Institute of Neurological Sciences, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alba A Brandes
- Department of Medical Oncology, Bellaria Hospital, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy.
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Ozturk Y, Bozkurt I, Yaman ME, Guvenc Y, Tolunay T, Bayram P, Hayirli N, Billur D, Erbay FK, Senturk S, Bozkurt G. Histopathologic Analysis of Tamoxifen on Epidural Fibrosis. World Neurosurg 2018; 111:e941-e948. [DOI: 10.1016/j.wneu.2018.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 12/31/2017] [Accepted: 01/04/2018] [Indexed: 12/14/2022]
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Parasramka S, Talari G, Rosenfeld M, Guo J, Villano JL. Procarbazine, lomustine and vincristine for recurrent high-grade glioma. Cochrane Database Syst Rev 2017; 7:CD011773. [PMID: 28744879 PMCID: PMC6483418 DOI: 10.1002/14651858.cd011773.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Recurrent high-grade glioma (HGG) carries an extremely poor prognosis. There is no current standard of care or guideline-based recommendations. Nitrosourea-based multidrug chemotherapy or PCV - procarbazine, lomustine (CCNU) and vincristine - is one of the treatment options at recurrence. There has been no meta-analysis which looks at the benefits and harms of PCV chemotherapy in adults with recurrent HGG. OBJECTIVES To assess the effectiveness and safety of procarbazine, lomustine, and vincristine (PCV) chemotherapy with other interventions in adults with recurrent high-grade glioma. To investigate whether predefined subgroups of people benefit more or less from chemotherapy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2017), MEDLINE (1946 to 22 May 2017), and Embase (1980 to 22 May 2017). We searched trial registries including the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; apps.who.int/trialsearch) and the National Institutes of Health (NIH; ClinicalTrials.gov). We searched the reference lists of all identified studies; the electronic table of contents of the Journal of Neuro-Oncology (1983 to 2016) and Neuro-Oncology (1999 to 2016); and conference abstracts from the Society for Neuro-Oncology (SNO) and the American Society of Clinical Oncology (ASCO 2004 to 2016). We also searched unpublished grey literature and other regional databases. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-randomised trials (QRCTs), or controlled clinical trials (CCTs) where PCV was used to treat adults with recurrent HGG. Comparison arm included no chemotherapy, other second line chemotherapy or best supportive care. DATA COLLECTION AND ANALYSIS Two review authors extracted the data and undertook a 'Risk of bias' assessment and critical appraisal of the studies. MAIN RESULTS We identified two RCTs meeting our inclusion criteria. The two trials tested different comparisons.One RCT included 35 participants and compared PCV with 'eight drugs in one day' multidrug chemotherapy, which is a combination of drugs with different mechanisms of action. Median survival was 6 months for the PCV group and 6.5 months for the 'eight drugs in one day' group. Adverse event outcomes were not graded or quantified. Progression-free survival (PFS) and quality of life (QoL) were not described in the methods and were not an outcome of interest. The sample size in this study was small, which lead to insufficient statistical power to detect clinical differences. According to the GRADE approach we judged the quality of evidence to be low for survival outcome and very low for chemotherapy toxicityThe second multi-institutional RCT included 447 participants and compared PCV with Temozolomide (TMZ). Participants were randomised into three arms to receive PCV, and two different regimens of TMZ in a 2:1:1 ratio at first recurrence. The trial reported a median overall survival of 6.7 months and 7.2 months for the PCV and TMZ group respectively. It reported a PFS of 3.6 months for the PCV group and 4.7 months for the TMZ group. There was no observed difference of effect on overall survival (hazard ratio (HR) 0.91, 95% CI 0.74 to 1.11; P = 0.35) or PFS (HR 0.89, 95% CI 0.73 to 1.08; P = 0.23) in participants receiving PCV or TMZ chemotherapy. The proportion of people with at least one grade 3 or 4 adverse event was not clinically important at 9.2% versus 12.2% in PCV and TMZ arms respectively. Mean QoL scores calculated at baseline, 12 weeks and 24 weeks was 51.9 versus 59.8 favouring TMZ (P = 0.04) which is statistically but not clinically significant and was less than the pre-defined 10 point change for moderate improvement. We judged the GRADE quality of evidence to be moderate for overall survival, PFS, and chemotherapy toxicity and low for QoL. AUTHORS' CONCLUSIONS Evidence is based on a single large trial analysis as the other trial was small, with inadequate power to detect survival difference. Chemotherapy-naive patients with HGG at first recurrence when treated with PCV or TMZ have similar survival and time-to-progression outcomes. Adverse events are similar and QoL scores are statistically but not clinically significant between TMZ and PCV. Further RCTs should be conducted with adequate power following CONSORT guidelines with emphasis on QoL outcomes.
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Affiliation(s)
- Saurabh Parasramka
- University of Kentucky College of MedicineDepartment of Internal Medicine800 Rose Street, CC447LexingtonKentuckyUSA40536
| | - Goutham Talari
- University of Kentucky College of MedicineDepartment of Internal Medicine800 Rose Street, CC447LexingtonKentuckyUSA40536
| | - Myrna Rosenfeld
- Hospital Clinic /IDIBAPSDepartment of NeurologyVillarroel, 170BarcelonaCatalunyaSpain08036
| | - Jing Guo
- Kentucky ClinicCenter for Health Services Research740 South LimestoneLexingtonUSA40536‐0284
| | - John L Villano
- University of Kentucky College of MedicineDepartment of Internal Medicine800 Rose Street, CC447LexingtonKentuckyUSA40536
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Karremann M, Krämer N, Hoffmann M, Wiese M, Beilken A, Corbacioglu S, Dilloo D, Driever PH, Scheurlen W, Kulozik A, Gielen GH, von Bueren AO, Dürken M, Kramm CM. Haematological malignancies following temozolomide treatment for paediatric high-grade glioma. Eur J Cancer 2017; 81:1-8. [PMID: 28586748 DOI: 10.1016/j.ejca.2017.04.023] [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: 10/19/2016] [Revised: 04/25/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Temozolomide (TMZ) is widely used in high-grade glioma (HGG). There is a major concern of treatment-induced secondary haematological malignancies (SHMs). Due to the poor overall survival of HGG patients, the true incidence is yet elusive. Thus, the aim of this study was to determine the risk of SHMs following TMZ in paediatric HGG. METHODS We analysed 487 patients from the HIT-HGG database of the German-speaking Society of Pediatric Oncology and Hematology with follow up beyond 1 year. RESULTS The incidence of SHM was 7.7 ± 3.2% at 10 years. No SHM occurred in 194 patients after first-line TMZ therapy, but four out of 131 patients treated with TMZ for relapse following first-line multiagent chemotherapy experienced SHM (20% at 10 years; p = 0.041). SHMs occurred in two out of 162 patients who underwent multiagent chemotherapy without TMZ (4.1% at 10 years). Gender, patient age and acute haematological toxicity during treatment did not affect the incidence of SHMs. CONCLUSION Data of our cohort do not indicate an increased risk of SHM following TMZ treatment when compared to previous chemotherapy regimen. However, if TMZ is administered as a second-line treatment following conventional chemotherapy regimen, the risk might be disproportionately increasing.
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Affiliation(s)
- Michael Karremann
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Nadja Krämer
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marion Hoffmann
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Göttingen, Göttingen, Germany
| | - Maria Wiese
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Beilken
- Department of Pediatric Hematology and Oncology, Medical School Hannover, Hannover, Germany
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Children's Hospital Regensburg, Regensburg, Germany
| | - Dagmar Dilloo
- Department of Pediatric Hematology and Oncology, Center for Child and Adolescent Medicine, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Pablo Hernáiz Driever
- Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfram Scheurlen
- Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany
| | - Andreas Kulozik
- Department of Pediatric Hematology, Oncology and Immunology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gerrit H Gielen
- Department of Neuropathology, University Hospital Bonn, 53105 Bonn, Germany
| | - André O von Bueren
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Matthias Dürken
- Department of Pediatric and Adolescent Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christof M Kramm
- Division of Pediatric Hematology and Oncology, Department of Child and Adolescent Health, University Medical Center Göttingen, Göttingen, Germany
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Mao Y, Yao Y, Zhang LW, Lu YC, Chen ZP, Zhang JM, Qi ST, You C, Wang RZ, Yang SY, Zhang X, Wang JS, Chen JX, Yang QY, Shen H, Li ZY, Wang X, Ma WB, Yang XJ, Zhen HN, Zhou LF. Does Early Postsurgical Temozolomide Plus Concomitant Radiochemotherapy Regimen Have Any Benefit in Newly-diagnosed Glioblastoma Patients? A Multi-center, Randomized, Parallel, Open-label, Phase II Clinical Trial. Chin Med J (Engl) 2016; 128:2751-8. [PMID: 26481741 PMCID: PMC4736883 DOI: 10.4103/0366-6999.167313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The radiochemotherapy regimen concomitantly employing temozolomide (TMZ) chemotherapy and radiotherapy (RT) 4 weeks after surgery, followed by 6 cycles of TMZ is a common treatment for glioblastoma (GBM). However, its median overall survival (OS) is only 14.6 months. This study was to explore the effectiveness and safety of early TMZ chemotherapy between surgery and chemoradiotherapy plus the standard concomitant radiochemotherapy regimen. Methods: A randomized, parallel group, open-label study of 99 newly diagnosed GBM patients was conducted at 10 independent Chinese neurosurgical departments from June 2008 to June 2012. Patients were treated with concomitant radiochemotherapy regimen plus early postsurgical temozolomide (early TMZ group) or standard concomitant radiochemotherapy regimen (control group). Overall response was assessed based on objective tumor assessments, administration of corticosteroid and neurological status test. Hematological, biochemical, laboratory, adverse event (AE), and neurological condition were measured for 24 months of follow-up. The primary efficacy endpoint of this study was overall survival (OS). The secondary endpoint was progression free survival (PFS). Results: The median OS time in the early TMZ group was 17.6 months, compared with 13.2 months in the control group (log-rank test P = 0.021). In addition, the OS rate in the early TMZ group was higher at 6, 12, and 18 months than in the control group, respectively (P < 0.05). The median PFS time was 8.7 months in the early TMZ group and 10.4 months in the control group (log-rank test P = 0.695). AEs occurred in 29 (55.8%) and 31(73.8%) patients respectively in early and control groups, including nausea (15.4% vs. 33.3%), vomiting (7.7% vs. 28.6%), fever (7.7% vs. 11.9%), and headache (3.8% vs. 23.8%). Only 30.8% and 33.3% were drug-related, respectively. Conclusions: Addition of TMZ chemotherapy in the early break of the standard concomitant radiochemotherapy regimen was well tolerated and significantly improved the OS of the GBM patients, compared with standard concomitant radiochemotherapy regimen. However, a larger randomized trial is warranted to verify these results.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Liang-Fu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China
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Affiliation(s)
- Enrico Franceschi
- Department of Medical Oncology, Bellaria Hospital, AUSL – IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Alba A Brandes
- Department of Medical Oncology, Bellaria Hospital, AUSL – IRCCS Institute of Neurological Sciences, Bologna, Italy
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Vandraas K, Tjønnfjord GE, Johannesen TB, Brandal P. Persistent bone marrow depression following short-term treatment with temozolomide. BMJ Case Rep 2016; 2016:bcr-2016-215797. [PMID: 27130558 DOI: 10.1136/bcr-2016-215797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Temozolomide (TMZ) is, in combination with radiotherapy (RT), the treatment of choice for glioblastoma multiforme. Although generally well tolerated, haematological side effects are observed in approximately 1-10% of patients receiving TMZ. We report a case of a patient who developed severe bone marrow failure (BMF) after only 3 weeks of concomitant TMZ. The BMF was grave with no signs of improvement for 12 months, resulting in more than 100 transfusions of blood cells.
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Schiff D, Lee EQ, Nayak L, Norden AD, Reardon DA, Wen PY. Medical management of brain tumors and the sequelae of treatment. Neuro Oncol 2015; 17:488-504. [PMID: 25358508 PMCID: PMC4483077 DOI: 10.1093/neuonc/nou304] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/28/2014] [Indexed: 12/11/2022] Open
Abstract
Patients with malignant brain tumors are prone to complications that negatively impact their quality of life and sometimes their overall survival as well. Tumors may directly provoke seizures, hypercoagulable states with resultant venous thromboembolism, and mood and cognitive disorders. Antitumor treatments and supportive therapies also produce side effects. In this review, we discuss major aspects of supportive care for patients with malignant brain tumors, with particular attention to management of seizures, venous thromboembolism, corticosteroids and their complications, chemotherapy including bevacizumab, and fatigue, mood, and cognitive dysfunction.
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Affiliation(s)
| | - Eudocia Q. Lee
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Lakshmi Nayak
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Andrew D. Norden
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - David A. Reardon
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Patrick Y. Wen
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
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26
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Goyal S, Singh RR, Balukrishna S, Bindra M, Backianathan S. An early and rare second malignancy in a treated glioblastoma multiforme: is it radiation or temozolomide? J Clin Diagn Res 2015; 9:TD05-7. [PMID: 26023622 PMCID: PMC4437138 DOI: 10.7860/jcdr/2015/13588.5833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/23/2015] [Indexed: 11/24/2022]
Abstract
Glioblastoma Multiforme (GBM) is a high-grade brain tumour with the most dismal prognosis. There are very few reports on second malignancies occurring in GBM patients, as the survival has been short. Second malignancies have been reported after treatment of malignancies with radiation therapy and chemotherapy especially after 5 to 10 y of treatment. Here in, we present a very unique case where a patient succumbed to sinonasal carcinoma occurring one and half years after treatment of GBM. A 17-year-old boy was diagnosed to have GBM and underwent surgery followed by chemoradiation and adjuvant chemotherapy with Temozolamide. He presented with undifferentiated sinonasal carcinoma, in the sinonasal region outside the radiation field within two years of treatment. Here we discuss the histology and possible chances of it being a second malignancy.
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Affiliation(s)
- Shina Goyal
- PG Registrar, Department of Radiation Oncology, Christian Medical College, Vellore, India
| | - Rabi Raja Singh
- Associate Professor, Medical Physics, Department of Radiation Oncology, Christian Medical College, Vellore, India
| | - Sasidharan Balukrishna
- Associate Professor, Department of Radiation Oncology, Christian Medical College, Vellore, India
| | - Mandeep Bindra
- Assistant Professor, Department of Pathology, Christian Medical College, Vellore, India
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27
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Rhun EL, Taillibert S, Chamberlain MC. The future of high-grade glioma: Where we are and where are we going. Surg Neurol Int 2015; 6:S9-S44. [PMID: 25722939 PMCID: PMC4338495 DOI: 10.4103/2152-7806.151331] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023] Open
Abstract
High-grade glioma (HGG) are optimally treated with maximum safe surgery, followed by radiotherapy (RT) and/or systemic chemotherapy (CT). Recently, the treatment of newly diagnosed anaplastic glioma (AG) has changed, particularly in patients with 1p19q codeleted tumors. Results of trials currenlty ongoing are likely to determine the best standard of care for patients with noncodeleted AG tumors. Trials in AG illustrate the importance of molecular characterization, which are germane to both prognosis and treatment. In contrast, efforts to improve the current standard of care of newly diagnosed glioblastoma (GB) with, for example, the addition of bevacizumab (BEV), have been largely disappointing and furthermore molecular characterization has not changed therapy except in elderly patients. Novel approaches, such as vaccine-based immunotherapy, for newly diagnosed GB are currently being pursued in multiple clinical trials. Recurrent disease, an event inevitable in nearly all patients with HGG, continues to be a challenge. Both recurrent GB and AG are managed in similar manner and when feasible re-resection is often suggested notwithstanding limited data to suggest benefit from repeat surgery. Occassional patients may be candidates for re-irradiation but again there is a paucity of data to commend this therapy and only a minority of selected patients are eligible for this approach. Consequently systemic therapy continues to be the most often utilized treatment in recurrent HGG. Choice of therapy, however, varies and revolves around re-challenge with temozolomide (TMZ), use of a nitrosourea (most often lomustine; CCNU) or BEV, the most frequently used angiogenic inhibitor. Nevertheless, no clear standard recommendation regarding the prefered agent or combination of agents is avaliable. Prognosis after progression of a HGG remains poor, with an unmet need to improve therapy.
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Affiliation(s)
- Emilie Le Rhun
- Department of Neuro-oncology, Roger Salengro Hospital, University Hospital, Lille, and Neurology, Department of Medical Oncology, Oscar Lambret Center, Lille, France, Inserm U-1192, Laboratoire de Protéomique, Réponse Inflammatoire, Spectrométrie de Masse (PRISM), Lille 1 University, Villeneuve D’Ascq, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Department of Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Tuccori M, Montagnani S, Capogrosso-Sansone A, Mantarro S, Antonioli L, Fornai M, Blandizzi C. Adverse reactions to oncologic drugs: spontaneous reporting and signal detection. Expert Rev Clin Pharmacol 2014; 8:61-75. [PMID: 25363790 DOI: 10.1586/17512433.2015.974555] [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] [Indexed: 12/14/2022]
Abstract
Oncology is one of the areas of medicine with the most active research being conducted on new drugs. New pharmacological entities frequently enter the clinical arena, and therefore, the safety profile of anticancer products deserves continuous monitoring. However, only very severe and (unusual) suspected adverse drug reactions (ADRs) are usually reported, since cancer patients develop ADRs very frequently and some practical selectivity must be used. Notably, a recent study was able to identify 76 serious ADRs reported in updated drug labels of oncologic drugs and 50% of them (n = 38) were potentially fatal. Of these, 49 and 58%, respectively, were not described in initial drug labels. The aims of this article are to provide an overview about spontaneous reporting of ADRs of oncologic drugs and to discuss the available methods to analyze the safety of anticancer drugs using databases of spontaneous ADR reporting.
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Affiliation(s)
- Marco Tuccori
- Tuscan Regional Centre of Pharmacovigilance, Pisa, Italy
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Haematological toxicity of Valproic acid compared to Levetiracetam in patients with glioblastoma multiforme undergoing concomitant radio-chemotherapy: a retrospective cohort study. J Neurol 2014; 262:179-86. [PMID: 25359262 DOI: 10.1007/s00415-014-7552-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 10/16/2014] [Accepted: 10/18/2014] [Indexed: 12/16/2022]
Abstract
Patients with glioblastoma multiforme (GBM) and symptomatic seizures are in need of a sufficient antiepileptic treatment. Haematological toxicity is a limiting side effect of both, first line radio-chemotherapy with temozolomide (TMZ) and co-medication with antiepileptic drugs. Valproic acid (VPA) and levetiracetam (LEV) are considered favourable agents in brain tumor patients with seizures, but are commonly reported to induce haematological side effects on their own. We hypothesized, that antiepileptic treatment with these agents has no increased impact on haematological side effects during radio-chemotherapy in the first line setting. We included 104 patients from two neuro-oncologic centres with GBM and standard radio-chemotherapy in a retrospective cohort study. Patients were divided according to their antiepileptic treatment with either VPA, LEV or without antiepileptic drug therapy (control group). Declines in haemoglobin levels and absolute blood cell counts for neutrophil granulocytes, lymphocytes and thrombocytes were analyzed twice during concomitant and once during adjuvant phase. A comparison between the examined groups was performed, using a linear mixed model. Neutrophil granulocytes, lymphocytes and thrombocytes significantly decreased over time in all three groups (all p < 0.012), but there was no significant difference between the compared groups. A significant decline in haemoglobin was observed in the LEV treated group (p = 0.044), but did not differ between the compared groups. As a novel finding, this study demonstrates that co-medication either with VPA or LEV in GBM patients undergoing first line radio-chemotherapy with TMZ has no additional impact on medium-term haematological toxicity.
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30
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Letarte N, Gabay MP, Bressler LR, Long KE, Stachnik JM, Villano JL. Analyzing temozolomide medication errors: potentially fatal. J Neurooncol 2014; 120:111-5. [PMID: 25026995 DOI: 10.1007/s11060-014-1523-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 06/28/2014] [Indexed: 11/27/2022]
Abstract
The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.
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Affiliation(s)
- Nathalie Letarte
- Faculte de pharmacie, Université de Montreal, Montreal, QC, Canada
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31
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Tzankov A, Medinger M. Aplastic anemia: possible associations with lymphoproliferative neoplasms. Int J Lab Hematol 2014; 36:382-7. [DOI: 10.1111/ijlh.12224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/28/2014] [Indexed: 01/20/2023]
Affiliation(s)
- A. Tzankov
- Pathology; University Hospital Basel; Basel Switzerland
| | - M. Medinger
- Hematology; University Hospital Basel; Basel Switzerland
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32
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Temozolomide-related acute lymphoblastic leukemia with translocation (4;11)(q21;q23) in a glioblastoma patient. J Clin Neurosci 2014; 21:701-4. [DOI: 10.1016/j.jocn.2013.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/06/2013] [Accepted: 07/12/2013] [Indexed: 12/26/2022]
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An Analysis of Temozolomide-related Adverse Drug Reactions Reported to the Medicines and Healthcare Products Regulatory Agency Through the Yellow Card Scheme Aiming to Characterise Idiosyncratic Profound Bone marrow Suppression Tantamount to Aplastic Anaemia. Clin Oncol (R Coll Radiol) 2014; 26:120-1. [DOI: 10.1016/j.clon.2013.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 10/10/2013] [Indexed: 11/18/2022]
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Momota H, Narita Y, Miyakita Y, Shibui S. Secondary hematological malignancies associated with temozolomide in patients with glioma. Neuro Oncol 2013; 15:1445-50. [PMID: 23519741 PMCID: PMC3779032 DOI: 10.1093/neuonc/not036] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 02/15/2013] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The alkylating agent temozolomide (TMZ) is widely used for the treatment of gliomas. Although reports of treatment-related myelodysplastic syndrome (MDS), acute myeloid leukemia (AML), and acute lymphoblastic leukemia (ALL) associated with TMZ are accumulating, it remains unclear whether TMZ has the same leukemogenic potential as other alkylating agents. METHODS We performed a single-institution retrospective analysis using a database of 359 glioma patients given nimustine (ACNU)-based therapy, TMZ-based therapy, or combination therapy, who were followed up for a minimum of 2 months, between January 1990 and December 2009, at the National Cancer Center Hospital in Japan. RESULTS Of the 359 patients, 225 received ACNU alone or ACNU plus other chemotherapeutic drugs (ACNU-based group; median follow-up period, 31.4 mo), 63 patients received ACNU-based therapy followed by TMZ therapy (ACNU-TMZ group; median follow-up period, 19.1 mo), and 71 patients received TMZ alone or TMZ plus other chemotherapeutic drugs (TMZ-based group; median follow-up period, 16.9 mo). Three patients in the ACNU-based group developed MDS/AML (incidence rate: 2.9 cases per 1000 person-years), 2 patients in the ACNU-TMZ group developed MDS/AML (13.0 cases per 1000 person-years), and 1 patient in the TMZ-based group developed ALL (9.9 cases per 1000 person-years). CONCLUSIONS Despite the limitations of this study, published reports and our results suggest that TMZ induces secondary hematological malignancies, particularly ALL, and might shorten the latency period when used in combination with other chemotherapeutic agents.
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Affiliation(s)
- Hiroyuki Momota
- Corresponding Author: Yoshitaka Narita, PhD, MD, Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
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Scaringi C, De Sanctis V, Minniti G, Enrici RM. Temozolomide-related hematologic toxicity. ACTA ACUST UNITED AC 2013; 36:444-9. [PMID: 23921765 DOI: 10.1159/000353752] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Temozolomide (TMZ) is an oral alkylating agent used for the treatment of recurrent or newly diagnosed malignant gliomas with significant survival benefit. TMZ is generally well tolerated and safe. The most common side effects are mild to moderate, and are represented by fatigue, nausea, vomiting, thrombocytopenia, and neutropenia. However severe hematologic adverse events (HAEs), including myelodysplastic syndrome and aplastic anemia, have also been reported. In this review we present an overview of the available literature of HAEs after exposure to TMZ.
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Affiliation(s)
- Claudia Scaringi
- Department of Radiation Oncology, St Andrea Hospital, University Sapienza, Rome, Italy
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36
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Gupta T, Mohanty S, Moiyadi A, Jalali R. Factors predicting temozolomide induced clinically significant acute hematologic toxicity in patients with high-grade gliomas: a clinical audit. Clin Neurol Neurosurg 2013; 115:1814-9. [PMID: 23764039 DOI: 10.1016/j.clineuro.2013.05.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 04/30/2013] [Accepted: 05/15/2013] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Myelo-suppression, the dose-limiting toxicity of alkylating cytotoxic agents is generally perceived to be uncommon with temozolomide (TMZ), a novel oral second generation imidazotetrazinone prodrug, with a reported incidence of 5-10% of grade 3-4 acute hematologic toxicity. We were observing a higher incidence of clinically significant myelo-toxicity with the standard schedule of TMZ, particularly in females, prompting us to do a clinical audit in our patient population. METHODS One hundred two adults (>18 years of age) treated with TMZ either for newly diagnosed or recurrent/progressive high-grade glioma constituted the study cohort. Clinically significant acute hematologic toxicity was defined as any one or more of the following: any grade 3-4 hematologic toxicity; omission of daily TMZ dose for ≥ 3 consecutive days during concurrent phase; deferral of subsequently due TMZ cycle by ≥ 7 days during adjuvant phase; dose reduction or permanent discontinuation of TMZ; use of growth factors, platelets or packed-cell transfusions during the course of TMZ. Uni-variate and multi-variate analysis was performed to correlate incidence of acute hematologic toxicity with baseline patient, disease, and treatment characteristics. RESULTS The incidence of clinically significant neutropenia and thrombocytopenia was 7% and 12% respectively. Seven (7%) patients needed packed-cells, growth factors, and/or platelet transfusions. Grade 3-4 lymphopenia though common (32%) was self-limiting and largely asymptomatic. Two (2%) patients, both women succumbed to community acquired pneumonia during adjuvant TMZ. Multi-variate logistic regression analysis identified female gender, grade IV histology, baseline total leukocyte count <7700/mm(3) and baseline serum creatinine ≥1mg/dl as factors associated with significantly increased risk of clinically significant acute hematologic toxicity. CONCLUSION The incidence of TMZ induced clinically significant neutropenia and thrombocytopenia was low in our patient population. Severe lymphopenia though high was largely asymptomatic and self-limiting. Gender, grade, leukocyte count, and serum creatinine were significant independent predictors of severe acute myelo-toxicity.
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Affiliation(s)
- Tejpal Gupta
- Department of Radiation Oncology, Advanced Centre for Treatment Research & Education in Cancer and Tata Memorial Hospital Tata Memorial Centre, Mumbai, India.
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PCV for anaplastic oligodendrogliomas: back to the future or a step backwards? A point/counterpoint discussion. J Neurooncol 2013; 113:143-7. [PMID: 23479035 DOI: 10.1007/s11060-013-1100-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 02/22/2013] [Indexed: 10/27/2022]
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Van Ginderachter L, Cox T, Drijkoningen R, Achten R, Joosens E, Maes A, Theunissen K, Mebis J. Non-hodgkin lymphoma after treatment with extended dosing temozolomide and radiotherapy for a glioblastoma: a case report. Case Rep Oncol 2013; 6:45-9. [PMID: 23466981 PMCID: PMC3573799 DOI: 10.1159/000346614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Temozolomide (TMZ) is an alkylating agent, used for the treatment of high-grade gliomas. This case report describes the development of a non-Hodgkin lymphoma in a patient treated with extended-dose temozolomide and radiotherapy. In addition to the possible mutagenic effect of temozolomide – as described for all alkylating agents – there might have been an immunosuppressive effect of TMZ. The pathological appearance of the lymphoma as well as the presence of a grade 3 lymphopenia early in treatment supports this hypothesis. As the use of TMZ increases, the awareness that TMZ may induce secondary malignancies should increase as well.
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Pietanza MC, Kadota K, Huberman K, Sima CS, Fiore JJ, Sumner DK, Travis WD, Heguy A, Ginsberg MS, Holodny AI, Chan TA, Rizvi NA, Azzoli CG, Riely GJ, Kris MG, Krug LM. Phase II Trial of Temozolomide in Patients with Relapsed Sensitive or Refractory Small Cell Lung Cancer, with Assessment of Methylguanine-DNA Methyltransferase as a Potential Biomarker. Clin Cancer Res 2012; 18:1138-45. [DOI: 10.1158/1078-0432.ccr-11-2059] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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40
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Going past the data for temozolomide. Cancer Chemother Pharmacol 2011; 69:1113-5. [DOI: 10.1007/s00280-011-1796-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 11/28/2011] [Indexed: 11/27/2022]
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