1
|
PrACTiC: A Predictive Algorithm for Chemoradiotherapy-Induced Cytopenia in Glioblastoma Patients. JOURNAL OF ONCOLOGY 2022; 2022:1438190. [PMID: 35111223 PMCID: PMC8803420 DOI: 10.1155/2022/1438190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/06/2022] [Indexed: 11/18/2022]
Abstract
Background Chemotherapy-induced cytopenia is the most frequent side effect of chemoradiotherapy in glioblastoma patients which may lead to reduced delivery of treatment. This study aims to develop a predictive model that is able to forecast the cytopenia induced by temozolomide (TMZ) during concomitant chemoradiotherapy. Methods Medical records of 128 patients with newly diagnosed glioblastoma were evaluated to extract the baseline complete blood test before and during the six weeks of chemoradiotherapy to create a dataset for the development of ML models. Using the constructed dataset, different ML algorithms were trained and tested. Results Our proposed algorithm achieved accuracies of 85.6%, 88.7%, and 89.3% in predicting thrombocytopenia, lymphopenia, and neutropenia, respectively. Conclusions The algorithm designed and developed in this study, called PrACTiC, showed promising results in the accurate prediction of thrombocytopenia, neutropenia, and lymphopenia induced by TMZ in glioblastoma patients. PrACTiC can provide valuable insight for physicians and help them to make the necessary treatment modifications and prevent the toxicities.
Collapse
|
2
|
Scheurer ME, Zhou R, Gilbert MR, Bondy ML, Sulman EP, Yuan Y, Liu Y, Vera E, Wendland MM, Youssef EF, Stieber VW, Komaki RR, Flickinger JC, Kenyon LC, Robins HI, Hunter GK, Crocker IR, Chao ST, Pugh SL, Armstrong TS. Germline polymorphisms in MGMT associated with temozolomide-related myelotoxicity risk in patients with glioblastoma treated on NRG Oncology/RTOG 0825. Neurooncol Adv 2022; 4:vdac152. [PMID: 36299794 PMCID: PMC9587696 DOI: 10.1093/noajnl/vdac152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background We sought to identify clinical and genetic predictors of temozolomide-related myelotoxicity among patients receiving therapy for glioblastoma. Methods Patients (n = 591) receiving therapy on NRG Oncology/RTOG 0825 were included in the analysis. Cases were patients with severe myelotoxicity (grade 3 and higher leukopenia, neutropenia, and/or thrombocytopenia); controls were patients without such toxicity. A risk-prediction model was built and cross-validated by logistic regression using only clinical variables and extended using polymorphisms associated with myelotoxicity. Results 23% of patients developed myelotoxicity (n = 134). This toxicity was first reported during the concurrent phase of therapy for 56 patients; 30 stopped treatment due to toxicity. Among those who continued therapy (n = 26), 11 experienced myelotoxicity again. The final multivariable clinical factor model included treatment arm, gender, and anticonvulsant status and had low prediction accuracy (area under the curve [AUC] = 0.672). The final extended risk prediction model including four polymorphisms in MGMT had better prediction (AUC = 0.827). Receiving combination chemotherapy (OR, 1.82; 95% CI, 1.02-3.27) and being female (OR, 4.45; 95% CI, 2.45-8.08) significantly increased myelotoxicity risk. For each additional minor allele in the polymorphisms, the risk increased by 64% (OR, 1.64; 95% CI, 1.43-1.89). Conclusions Myelotoxicity during concurrent chemoradiation with temozolomide is an uncommon but serious event, often leading to treatment cessation. Successful prediction of toxicity may lead to more cost-effective individualized monitoring of at-risk subjects. The addition of genetic factors greatly enhanced our ability to predict toxicity among a group of similarly treated glioblastoma patients.
Collapse
Affiliation(s)
- Michael E Scheurer
- Baylor College of Medicine, Departments of Pediatrics and Medicine, Houston, Texas, USA
| | - Renke Zhou
- Baylor College of Medicine, Departments of Pediatrics and Medicine, Houston, Texas, USA
| | - Mark R Gilbert
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Melissa L Bondy
- Baylor College of Medicine, Departments of Pediatrics and Medicine, Houston, Texas, USA
| | - Erik P Sulman
- M D Anderson Cancer Center, Brain and Spine Center, Houston, TX, USA
- Laura and Isaac Perlmutter Cancer Center at NYU Langone, New York, NY, USA
| | - Ying Yuan
- M D Anderson Cancer Center, Brain and Spine Center, Houston, TX, USA
| | - Yanhong Liu
- Baylor College of Medicine, Departments of Pediatrics and Medicine, Houston, Texas, USA
| | - Elizabeth Vera
- National Institutes of Health Clinical Center, Bethesda, MD, USA
- M D Anderson Cancer Center, Brain and Spine Center, Houston, TX, USA
| | - Merideth M Wendland
- National Cancer Institute, Bethesda, MD, USA
- Texas Oncology Cancer Center Sugar Land, Sugar Land, TX, USA
| | | | | | - Ritsuko R Komaki
- M D Anderson Cancer Center, Brain and Spine Center, Houston, TX, USA
| | | | | | - H Ian Robins
- University of Wisconsin Hospital, Madison, WI, USA
| | | | - Ian R Crocker
- Emory University, Winship Cancer Institute, Atlanta, GA, USA
| | | | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | | |
Collapse
|
3
|
Park AK, Waheed A, Forst DA, Al-Samkari H. Characterization and Prognosis of Temozolomide-Induced Aplastic Anemia in Patients with Central Nervous System Malignancies. Neuro Oncol 2021; 24:964-973. [PMID: 34647594 DOI: 10.1093/neuonc/noab240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Temozolomide-induced aplastic anemia (TIAA) is a rare but highly challenging complication of temozolomide (TMZ) therapy. Evidence describing prognosis, clinical characteristics, and treatment of this entity is very limited. METHODS We performed a multicenter, 22-year observational cohort study of patients with central nervous system (CNS) malignancies treated with temozolomide who developed TIAA, retrospectively analyzing prognosis, complications, and recovery. TIAA was defined using adapted evidence-based severe aplastic anemia criteria incorporating profound cytopenias and a minimum duration (4 weeks) without hematologic recovery. RESULTS Of 3,821 patients with CNS malignancies receiving TMZ, 34 patients (0.89%) met criteria for TIAA. Onset was rapid, with 29 patients (85.3%) developing TIAA before completing a second TMZ cycle. 23 patients (67.6%) ultimately achieved a hematologic recovery. Patients without recovery were more likely to develop febrile neutropenia (72.7% vs. 30.4%, P=0.03), infectious complications (45.5% vs. 8.7%, P=0.02), require hospitalization (81.8% vs. 43.5%, P=0.04), and die (100.0% vs. 60.9%, P=0.02). Median overall survival from TIAA diagnosis was 752 days in patients achieving a partial hematologic recovery versus 28 days in those who did not (P<0.0001). 29 patients (85.3%) received one or more hematopoietic growth factors; hematologic recovery rates were higher in patients receiving thrombopoietin receptor agonists (81.8% vs. 60.9%) but were not higher in patients receiving granulocyte colony stimulating factors. CONCLUSIONS TIAA occurs in <1% of patients receiving TMZ for CNS malignancies, but is highly morbid when it occurs and frequently fatal in the one-third of patients not achieving hematologic recovery. Thrombopoietin receptor agonists may improve the likelihood of a hematologic recovery.
Collapse
Affiliation(s)
- Albert K Park
- Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Anem Waheed
- Harvard Medical School, Boston, MA.,Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA
| | - Deborah A Forst
- Harvard Medical School, Boston, MA.,Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA.,Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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
| |
Collapse
|
6
|
Khaddour K, Harrison N, Govindan A, Campian JL. Development of Aplastic Anemia during Treatment of Anaplastic Astrocytoma with Temozolomide. Case Rep Oncol 2020; 13:1244-1251. [PMID: 33250738 PMCID: PMC7670352 DOI: 10.1159/000509744] [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: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 01/10/2023] Open
Abstract
Temozolomide (TMZ) is an oral alkylating agent that is considered the standard therapy in primary intracranial malignancies. The medication is well tolerated with a most common side effect of bone marrow suppression that is encountered in a small proportion of patients, often reversible with medication discontinuation and supportive treatment. Rarely, aplastic anemia can develop during treatment with TMZ. Here, we present a case of a patient who developed aplastic anemia following treatment with TMZ. We offer a review of the existing literature to have a better understanding of the causative effect and to examine the characteristics and outcomes when aplastic anemia develops during treatment with TMZ.
Collapse
Affiliation(s)
- Karam Khaddour
- Division of Oncology, Washington University at Saint Louis, Saint Louis, Missouri, USA
| | - Nigel Harrison
- Division of Neurology, Washington University at Saint Louis, Saint Louis, Missouri, USA
| | - Ashwin Govindan
- Division of Oncology, Washington University at Saint Louis, Saint Louis, Missouri, USA
| | - Jian L Campian
- Division of Oncology, Washington University at Saint Louis, Saint Louis, Missouri, USA
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Batalini F, Kaufmann MR, Aleixo GF, Drews R. Temozolomide-induced aplastic anaemia and incidental low-grade B-cell non-Hodgkin lymphoma in a geriatric patient with glioblastoma multiforme. BMJ Case Rep 2019; 12:12/6/e228803. [PMID: 31256047 DOI: 10.1136/bcr-2018-228803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Glioblastoma multiforme is an astrocyte-derived tumour representing the most aggressive primary brain malignancy. The median overall survival is 10-12 months, but it drops to 3-8.5 months for the cohort with more than 65 years old, which account to half of all patients. Initial management in this patient population aims to balance overall patient survival and quality of life with the inherent risks of treatment intervention, which include maximal safe tumour resection, radiation and temozolomide (TMZ) chemotherapy. This is accomplished through risk stratification as a function of patient age, functional status, comorbidities, tumour location and methylguanine methyltransferase promoter methylation status. We describe the care of a patient with prolonged febrile neutropaenia, with a rare but fatal complication from TMZ-induced idiosyncratic reaction, leading to aplastic anaemia and a provoking diagnosis of low-grade B-cell non-Hodgkin's lymphoma.
Collapse
Affiliation(s)
- Felipe Batalini
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew R Kaufmann
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Gabriel Francisco Aleixo
- Department of Medicine, Universidade do Oeste Paulista Faculdade de Medicina, Presidente Prudente, São Paulo, Brazil
| | - Reed Drews
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Chatzellis E, Angelousi A, Daskalakis K, Tsoli M, Alexandraki KI, Wachuła E, Meirovitz A, Maimon O, Grozinsky-Glasberg S, Gross D, Kos-Kudła B, Koumarianou A, Kaltsas G. Activity and Safety of Standard and Prolonged Capecitabine/Temozolomide Administration in Patients with Advanced Neuroendocrine Neoplasms. Neuroendocrinology 2019; 109:333-345. [PMID: 31167197 DOI: 10.1159/000500135] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Capecitabine and temozolomide combination (CAPTEM) is associated with high response rates in patients with advanced neuroendocrine neoplasms (NENs). We evaluated the real-world activity and safety of CAPTEM from 3 NEN centers. METHODS Clinicopathological characteristics and outcomes of patients treated with CAPTEM for bulky or progressive disease (PD) were retrospectively analyzed. -Results: Seventy-nine patients with gastroenteropancreatic (grades 1-2 [n = 38], grade 3 [n = 24]) and lung/thymic (n = 17) NENs were included. Median treatment duration was 12.1 months (range 0.6-55.6). Overall, partial responses (PRs) occurred in 23 (29.1%), stable (SD) in 24 (30.4%), and PD in 28 (35.4%) patients. Median progression-free survival (PFS) and overall survival (OS) were 10.1 (6-14.2) and 102.9 months (43.3-162.5), respectively. On univariate analysis, NENs naive to chemotherapy and low Ki67 were associated with favorable responses (partial response [PR] + SD; p = 0.011 and 0.045), PFS (p < 0.0001 and 0.002) and OS (p = 0.005 and 0.001). Primary site (pancreas and lung/thymus) was also a significant prognostic factor for PFS (p < 0.0001) and OS (p < 0.0001). On multivariate analysis, gastrointestinal and unknown primary NENs (hazard ratio [HR] 0.3, 95% CI 0.1-0.8, p = 0.009 and p = 0.018) and prior surgery (HR 2.4, 95% CI 11-4.9, p = 0.021) were independent prognostic factors for PFS. Ki-67 was a poor predictor for favorable response in receiver operating characteristic analysis (area under the curve 0.678). Safety analysis of CAPTEM indicated rare events of serious (grades 3-4) toxicities (n = 4) and low discontinuation rates (n = 8) even in patients with prolonged administration (>12 months). CONCLUSIONS CAPTEM treatment can be an effective and safe treatment even after prolonged administration for patients with NENs of various sites and Ki67 labeling index, associated with significant favorable responses and PFS.
Collapse
Affiliation(s)
- Eleftherios Chatzellis
- 1st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece,
- 251 HAF and VA Hospital, Athens, Greece,
| | - Anna Angelousi
- 1st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kosmas Daskalakis
- 1st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Marina Tsoli
- 1st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Krystallenia I Alexandraki
- 1st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ewa Wachuła
- Department of Clinical Oncology and Radiotherapy, Medical University of Silesia, Katowice, Poland
| | - Amichay Meirovitz
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ofra Maimon
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumour Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - David Gross
- Neuroendocrine Tumour Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Beata Kos-Kudła
- Department of Endocrinology and Neuroendocrine Neoplasms, Department of Endocrinology and Pathophysiology, Medical University of Silesia, Katowice, Poland
| | - Anna Koumarianou
- Fourth Department of Internal Medicine, Hematology-Oncology Unit, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- 1st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
|
12
|
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.
Collapse
Affiliation(s)
- Claudia Scaringi
- Department of Radiation Oncology, St Andrea Hospital, University Sapienza, Rome, Italy
| | | | | | | |
Collapse
|
13
|
Temozolomide-related idiosyncratic and other uncommon toxicities: a systematic review. Anticancer Drugs 2013; 23:1099-106. [PMID: 22850321 DOI: 10.1097/cad.0b013e328356f5b0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Temozolomide (TMZ)-related idiosyncratic and other uncommon toxicities have been reported. To better characterize these toxicities and to identify any associated risk factors, we performed a systematic review. We searched the PubMed database, limited to the English language, published between 1999 and December 2011. We selected only those articles in which TMZ was temporally related and was the sole or main contributing chemotherapeutic drug to idiosyncratic drug reactions (IDRs) and other uncommon toxicities. Hematological IDRs are biopsy-proven aplastic anemia or grade V toxicity or grade IV toxicity with slow and incomplete hematological recovery. Seventy-three cases were identified, including 21 hematological IDRs, 31 nonhematological IDRs and uncommon infections, and 21 second primary cancers. With a caveat of publication and reporting bias, the following observations could be made. The hematological IDRs predominantly occurred in female patients (exact binomial two-tailed, P=0.0041) and most patients were receiving TMZ concomitantly with radiotherapy for glioma. The median duration of exposure to TMZ was 30 days and the median cumulative TMZ exposure was 2250 mg/m (range, 500-6900 mg/m). The sex predilection was not evident in nonhematological IDRs and other uncommon toxicities. TMZ-induced pneumonitis and cholestatic hepatitis are emerging as a nonhematological hypersensitive reaction and IDR, respectively. For TMZ-related myelodysplasia or leukemia, the cumulative dose of TMZ ranged from 1400 to 30 000 mg/m. The cumulative dose of TMZ was lower and latency was shorter with a previous exposure to other leukemogenic drugs, suggesting that TMZ may have augmented the leukemogenic potential of other drugs. Early appearance of profound myelosuppression during the course of TMZ and concurrent radiotherapy could be a hematological IDR, which warrants prompt investigations to exclude aplastic anemia. Myelodysplasia or leukemia developed after a median TMZ exposure of 15 g/m.
Collapse
|
14
|
OTTY Z, SABESAN S. Non-Hodgkin's lymphoma in a patient on treatment with temozolomide. Asia Pac J Clin Oncol 2012; 8:e53-4. [DOI: 10.1111/j.1743-7563.2011.01500.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
15
|
Groves MD, Plummer AB. Helping patients make the best decision regarding duration of temozolomide chemotherapy treatment. Continuum (Minneap Minn) 2012; 18:421-5. [PMID: 22810137 DOI: 10.1212/01.con.0000413668.65668.4a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Outcomes for patients with glioblastoma have improved with the addition of temozolomide (TMZ) chemotherapy to radiation therapy followed by adjuvant TMZ for up to 1 year. Patients often wish to continue chemotherapy after the standard 1-year course. Whether to continue or to stop TMZ is a complex and stressful decision for the patient and family, and the decision should be based on a discussion of the known risks and benefits of each choice.
Collapse
|
16
|
9-Amino acridine pharmacokinetics, brain distribution, and in vitro/in vivo efficacy against malignant glioma. Cancer Chemother Pharmacol 2012; 69:1519-27. [DOI: 10.1007/s00280-012-1855-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
|
17
|
Niewald M, Berdel C, Fleckenstein J, Licht N, Ketter R, Rübe C. Toxicity after radiochemotherapy for glioblastoma using temozolomide--a retrospective evaluation. Radiat Oncol 2011; 6:141. [PMID: 22017800 PMCID: PMC3213071 DOI: 10.1186/1748-717x-6-141] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 10/21/2011] [Indexed: 11/10/2022] Open
Abstract
Purpose Retrospective evaluation of toxicity and results after radiochemotherapy for glioblastoma. Methods 46 patients with histopathologically proven glioblastoma received simultaneous radiochemotherapy (RCT). The mean age at the beginning of therapy was 59 years, the mean Karnofsky performance index 80%. 44 patients had been operated on before radiotherapy, two had not. A total dose of 60 Gy was applied in daily single fractions of 2.0 Gy within six weeks, 75 mg/m2/day Temozolomide were given orally during the whole radiotherapy period. Results A local progression could be diagnosed in 34/46 patients (70%). The median survival time amounted to 13.6 months resulting in one-year and two-year survival probabilities of 48% and 8%, respectively. Radiotherapy could be applied completely in 89% of the patients. Chemotherapy could be completed according to schedule only in 56.5%, the main reason being blood toxicity (50% of the interruptions). Most of those patients suffered from leucopenia and/or thrombopenia grade III and IV CTC (Common toxicity criteria). Further reasons were an unfavourable general health status or a rise of liver enzymes. The mean duration of thrombopenia and leucopenia amounted to 64 and 20 days. In two patients, blood cell counts remained abnormal until death. In two patients we noticed a rise of liver enzymes. In one of these in the healing phase of hepatitis a rise of ASAT and ALAT CTC grade IV was diagnosed. These values normalized after termination of temozolomide medication. One patient died of pneumonia during therapy. Conclusion Our survival data were well within the range taken from the literature. However, we noticed a considerable frequency and intensity of side effects to bone marrow and liver. These lead to the recommendations that regular examinations of blood cell count and liver enzymes should be performed during therapy and temozolomide should not be applied or application should be terminated according to the criteria given by the manufacturer.
Collapse
Affiliation(s)
- Marcus Niewald
- Department of Radiotherapy, Saarland University Hospital, Kirrberger Strasse, D-66421 Homburg, Germany.
| | | | | | | | | | | |
Collapse
|
18
|
La Rocca RV, Rezazadeh A. Carmustine-impregnated wafers and their impact in the management of high-grade glioma. Expert Opin Pharmacother 2011; 12:1325-1332. [PMID: 21548723 DOI: 10.1517/14656566.2011.580737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
19
|
Oh J, Kutas GJ, Davey P, Morrison M, Perry JR. Aplastic anemia with concurrent temozolomide treatment in a patient with glioblastoma multiforme. ACTA ACUST UNITED AC 2011; 17:124-6. [PMID: 20697524 DOI: 10.3747/co.v17i4.526] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Temozolomide (TMZ) is an oral alkylating agent used during concurrent and adjuvant chemotherapy for newly diagnosed glioblastoma multiforme. Temozolomide is generally well tolerated and improves survival; however, severe adverse events have occasionally been reported. Here, we report the case of a patient who developed aplastic anemia with related complications in the setting of concurrent TMZ treatment with radiotherapy. This case illustrates that aplastic anemia is a rare side effect of TMZ that can occur relatively early in the course of concurrent chemotherapy, and underscores the importance of clinician awareness of this potentially devastating side effect.
Collapse
Affiliation(s)
- J Oh
- Division of Neurology, Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON.
| | | | | | | | | |
Collapse
|
20
|
Reardon DA, Perry JR, Brandes AA, Jalali R, Wick W. Advances in malignant glioma drug discovery. Expert Opin Drug Discov 2011; 6:739-53. [DOI: 10.1517/17460441.2011.584530] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
21
|
Hematologic adverse events associated with temozolomide. Cancer Chemother Pharmacol 2011; 69:107-13. [DOI: 10.1007/s00280-011-1679-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 05/08/2011] [Indexed: 10/18/2022]
|
22
|
Neyns B, Tosoni A, Hwu WJ, Reardon DA. Dose-dense temozolomide regimens: antitumor activity, toxicity, and immunomodulatory effects. Cancer 2010; 116:2868-77. [PMID: 20564393 DOI: 10.1002/cncr.25035] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Temozolomide is an oral alkylating agent with established antitumor activity in patients with primary brain tumors and melanoma. The originally approved temozolomide dosing regimen is 150 to 200 mg/m(2) per day (Days 1 to 5 every 28-day cycle [5 of 28 days]). However, extended dosing regimens (eg, 7 of 14 days, 21 of 28 days, 6 of 8 weeks, or continuously daily) allow for administration of a higher cumulative dose per cycle and have been shown to deplete O(6)-methylguanine-DNA methyltransferase, which may enhance cytotoxic activity. This article reviews efficacy and safety data from studies that investigated dose-dense temozolomide regimens in patients with recurrent glioma and advanced metastatic melanoma. The clinical benefits of these dose-dense regimens compared with the standard 5 of 28-day regimen have yet to be established. Although the toxicity profile of dose-dense temozolomide is generally similar to that of the standard 5 of 28-day regimen, it is associated with an increased incidence and severity of lymphocytopenia. The clinical management of temozolomide-associated lymphodepletion and the potential risks and benefits of extended dosing with temozolomide are discussed. Preclinical and clinical evidence suggests that temozolomide-associated lymphodepletion may enhance the host immune response to tumor-associated antigens and/or immunotherapy and may overcome tumor-mediated immunosuppression. Further studies exploring the clinical implications of lymphodepletion are warranted.
Collapse
Affiliation(s)
- Bart Neyns
- Department of Medical Oncology, Oncology Center, UZ Brussel, Brussels, Belgium.
| | | | | | | |
Collapse
|
23
|
Armstrong TS, Cao Y, Scheurer ME, Vera-Bolaños E, Manning R, Okcu MF, Bondy M, Zhou R, Gilbert MR. Risk analysis of severe myelotoxicity with temozolomide: the effects of clinical and genetic factors. Neuro Oncol 2010; 11:825-32. [PMID: 19179423 DOI: 10.1215/15228517-2008-120] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A benefit of temozolomide (TMZ) is that myelotoxicity is uncommon. Recently, several small series have reported significant myelotoxicity resulting in treatment delays or death. The ability to predict risk of myelotoxicity may influence patient care. We retrospectively reviewed 680 malignant glioma patients and developed a clinical risk formula for myelotoxicity for each gender by logistic regression. The variables that remained were assigned a score of 1 and added together for a final risk score. Women experienced more myelotoxicity than did men (p = 0.015). For males, risk factors included body surface area (BSA) > or = 2 m(2) (odds ratio [OR] = 2.712, p = 0.04), not on steroids (OR = 2.214, p = 0.06), and on bowel medication (OR = 3.955, p = 0.008). For females, final factors included no prior chemotherapy (OR = 3.727, p = 0.001), creatinine > or = 1 mg/dl (OR = 6.08, p = 0.002), platelets < 270,000/mm(3) (OR = 2.438, p = 0.03), BSA < 2 m(2) (OR = 4.178, p = 0.04), not on medication for gastroesophageal reflux disease (OR = 2.942, p = 0.01), and on analgesics (OR = 2.169, p = 0.05). Age was included because of observable trends. Risk of developing myelotoxicity ranged from 0% to 33% (male) and from 0% to 100% (females). Polymorphisms in NQO1 (NAD(P)H dehydrogenase, quinone 1), MGMT (O(6)-methylguanine-DNA methyltransferase), and GSTP1 (glutathione S-transferase pi 1) were related to risk of developing myelotoxicity in a subset of patients. Myelotoxicity with TMZ is a significant clinical issue for those at risk. Use of a clinical model to predict risk and evaluation of identified genetic polymorphisms related to myelotoxicity may allow for individualized dosing, optimizing patient management.
Collapse
Affiliation(s)
- Terri S Armstrong
- Department of Integrative Nursing Care, University of Texas Health Science Center at Houston, School of Nursing, Baylor College of Medicine; Houston, TX, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
|
25
|
Villano JL, Seery TE, Bressler LR. Temozolomide in malignant gliomas: current use and future targets. Cancer Chemother Pharmacol 2009; 64:647-55. [DOI: 10.1007/s00280-009-1050-5] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 06/02/2009] [Indexed: 12/29/2022]
|
26
|
Binello E, Germano IM. Tonsillary carcinoma after temozolomide treatment for glioblastoma multiforme: treatment-related or dual-pathology? J Neurooncol 2009; 94:145-8. [DOI: 10.1007/s11060-009-9806-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 01/26/2009] [Indexed: 10/21/2022]
|
27
|
Nagane M, Nozue K, Shimizu S, Waha A, Miyazaki H, Kurita H, Homori M, Fujioka Y, Shiokawa Y. Prolonged and severe thrombocytopenia with pancytopenia induced by radiation-combined temozolomide therapy in a patient with newly diagnosed glioblastoma--analysis of O6-methylguanine-DNA methyltransferase status. J Neurooncol 2008; 92:227-32. [PMID: 19037596 DOI: 10.1007/s11060-008-9754-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 11/17/2008] [Indexed: 11/25/2022]
Abstract
We report a case of a 51-year-old woman with newly diagnosed glioblastoma multiforme (GBM) who was treated with surgery followed by the standard concomitant temozolomide (TMZ) and radiotherapy (RT). Although TMZ is generally safe and well-tolerated, she developed a sudden onset of prolonged and severe thrombocytopenia as the most prominent event of pancytopenia during the combined treatment, leading to discontinuation of the combined therapy. Thrombocytopenia lasted for more than 2 months with intensive, intermittent platelet transfusions. A bone marrow aspiration and biopsy performed after recovery of severe suppression still revealed reduced number of megakaryocytes. O(6)-methylguanine-DNA methyltransferase (MGMT) analyses showed methylated MGMT promoter in GBM, but unmethylated promoters in both peripheral blood leukocytes and bone marrow cells. This is the first report suggesting the irrelevance of MGMT status of normal hematopoietic cells to TMZ-induced severe thrombocytopenia and pancytopenia.
Collapse
Affiliation(s)
- Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
de Paiva TF, de Barros e Silva MJ, Rinck JA, Fanelli MF, Gimenes DL. Tuberculosis in a patient on temozolomide: a case report. J Neurooncol 2008; 92:33-5. [PMID: 18974931 DOI: 10.1007/s11060-008-9724-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 10/13/2008] [Indexed: 10/21/2022]
Abstract
Temozolomide (TMZ) is a cytotoxic agent of the imidazotetrazine class, chemically related to dacarbazine. Its use poses higher risks of lymphopenia and opportunistic infections. Prophylaxis for Pneumocystis jiroveci must be considered up to 12 months after treatment discontinuation. The due literature (MEDLINE) makes no mention of a possible connection between the use of TMZ and tuberculosis (TB). A female patient, aged 59, featuring glioblastoma multiforme and having undergone solely a brain biopsy, was submitted to TMZ along with radiotherapy. After the first TMZ maintenance cycle, the referred patient was admitted displaying a background of a 40-day afternoon fever and productive coughing. She was thus submitted to a bronchoscopy and LBA, which resulted BAAR 1+/4+. TMZ was then suspended, and rifampicin, isoniazid, and pyrazinamide introduced. Considerations on prophylaxis with isoniazide in cancer patients are long-lived and scarce. Some subgroups are likely to benefit from the prophylactic administration of isoniazide during TMZ treatment, such as those patients under high doses of corticoids, patients with past medical history of TB, the malnourished, patients from endemic regions, and patients with highly reactive tuberculinic tests. That, nevertheless, must not restrict the administration of TMZ, but, rather, stand for a warning about its possible toxicity, and thus mitigate complications.
Collapse
Affiliation(s)
- Tadeu Ferreira de Paiva
- Department of Oncology, Treatment and Research Center, Hospital A. C. Camargo, Rua Prof. Antônio Prudente, 211, CEP 01509-900, Liberdade, SP, Brazil
| | | | | | | | | |
Collapse
|
29
|
Bone marrow transplantation for severe aplastic anemia secondary to temozolomide. J Neurooncol 2008; 91:237-9. [PMID: 18818880 DOI: 10.1007/s11060-008-9704-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 09/15/2008] [Indexed: 10/21/2022]
Abstract
Radiotherapy (RT) and concomitant/adjuvant therapy with temozolomide (Temodar) is a common treatment regimen for children and adults with glioma. Although temozolomide is generally well tolerated with temporary myelosuppression as the primary dose-limiting toxicity, irreversible bone-marrow aplasia after treatment with temozolomide has been reported. We report the case of an adolescent patient with a high-grade glioma who, after >2 years of event-free survival, underwent successful bone marrow transplantation for treatment of temozolomide-induced severe aplastic anemia (SAA).
Collapse
|
30
|
Neyns B, Cordera S, Joosens E, Nader P. Non-Hodgkin's Lymphoma in Patients With Glioma Treated With Temozolomide. J Clin Oncol 2008; 26:4518-9. [DOI: 10.1200/jco.2008.18.8177] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bart Neyns
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Eric Joosens
- ZiekenhuisNetwerk Antwerpen Middelheim, Antwerp, Belgium
| | | |
Collapse
|