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Benedetti E, Traverso G, Pucci G, Morganti R, Bramanti E, Cavallo F, Capochiani E, De Maria M, Ricchiuto V, Stella MS, Galimberti S. Prospective study on the impact of BEAM versus FEAM conditioning on occurrence of neutropenic enterocolitis and on transplant outcome in lymphoma patients. Front Oncol 2024; 14:1369601. [PMID: 38803538 PMCID: PMC11128601 DOI: 10.3389/fonc.2024.1369601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Carmustine (BCNU), etoposide, cytarabine, and melphalan (BEAM) are a widely used high-dose chemotherapy regimen for autologous stem cell transplantation transplant (ASCT) in lymphoid malignancies. During BCNU shortages, some centers switched to fotemustine-substituted BEAM (FEAM). Neutropenic enterocolitis (NEC) is a life-threatening complication occurring after intestinal mucosa damage related to intensive chemotherapy. NEC mortality may be up to 30%-50%. In our study, we compared NEC incidence, symptoms, mortality, and transplant outcome in terms of overall survival (OS) and progression-free survival (PFS) in the BEAM vs. FEAM groups. Furthermore, we compared the cost of hospitalization of patients who did vs. patients who did not experience a NEC episode (NECe). Methods A total of 191 patients were enrolled in this study (N = 129 and N = 62 were conditioned with BEAM and FEAM, respectively). All patients received bed-side high-resolution ultrasound (US) for NEC diagnosis. Results and discussion NEC incidence and NEC-related mortality were similar in the BEAM and FEAM groups (31% and 40.3%, p = 0.653, and 5% and 8%, p = 0.627, respectively). At a median follow-up of 116 months, no difference was noted between BEAM vs. FEAM groups in terms of OS and PFS (p = 0.181 and p = 0.978, respectively). BEAM appeared equivalent to FEAM in terms of NEC incidence and efficacy. The high incidence of NEC and the low mortality is related to a timely US diagnosis and prompt treatment. US knowledge in NEC diagnosis allows to have comparable days of hospitalization of patients NECpos vs. patients NECneg. The cost analysis of NECpos vs. NECneg has been also performed.
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Affiliation(s)
- Edoardo Benedetti
- Operational Unit Hematology, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
- Viale delle Milizie 9 00195 Roma, Italian School of Basic and Emergency Ultrasound Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Pisa, Italy
| | - Ginevra Traverso
- Operational Unit Hematology, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giulia Pucci
- Operational Unit Hematology, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Morganti
- Section of Statistics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Emilia Bramanti
- Institute of Chemistry of Organo Metallic Compounds (ICCOM), Consiglio Nazionale delle Ricerche (CNR), Pisa, Italy
| | - Federica Cavallo
- Division of Hematology U, University Hospital Azienda Ospedaliero Universitaria (AOU) “Città della Salute e della Scienza”, Turin, Italy
- Division of Hematology U, Department of Molecular Biotechnologies and Health Sciences, University of Turin, Torino, Italy
| | - Enrico Capochiani
- Hematology Unit, Azienda Unità Sanitaria Locale (USL) Toscana Nord Ovest, Livorno, Italy
| | - Maurizio De Maria
- Hematology Unit, Azienda Unità Sanitaria Locale (USL) Toscana Nord Ovest, Livorno, Italy
| | - Vittorio Ricchiuto
- Dipartimento di Tecnologie Sanitarie Ente di Supporto Tecnico Amministrativo Regionale (ESTAR), Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Massimo Salvatore Stella
- Viale delle Milizie 9 00195 Roma, Italian School of Basic and Emergency Ultrasound Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Pisa, Italy
| | - Sara Galimberti
- Hematology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Benedetti E, Traverso G, Pucci G, Morganti R, Bramanti E, Lippolis P, Susini MC, Mazzantini E, Giubbolini R, Mavilia F, Capochiani E, Neri E, Arena C, Cerri F, De Simone L, Valentini K, Stella SM, Ricchiuto V, Bruno B, Galimberti S. Impact of different chemotherapy regimens on intestinal mucosal injury assessed with bedside ultrasound: a study in 213 AML patients. Front Oncol 2023; 13:1272072. [PMID: 38023169 PMCID: PMC10646482 DOI: 10.3389/fonc.2023.1272072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Neutropenic enterocolitis (NEC) is a life-threatening complication reported in patients with acute myeloid leukemia (AML) following chemotherapy (CHT). Intensive induction and consolidation CHT may damage intestinal mucosa leading to a NEC episode (NECe). NEC reported mortality may be up to 30-60%. Early US-guided bed-side diagnosis and prompt treatment may substantially improve the survival. An emerging worldwide concern is the intestinal colonization by multi-drug-resistant bacteria especially when patients are exposed to chemotherapy regimens potentially correlated to mucosal damage. Methods In our study we prospectively enrolled all AML patients admitted in our leukemia unit to receive intensive induction and consolidation chemotherapy and experiencing chemotherapy-induced-neutropenia (CHTN). Results and discussion Overall, we enrolled N=213 patients from 2007 to March 2023. We recorded N=465 CHTN, and N=42 NECe (9.0% incidence). The aim of our study was to assess which chemotherapy regimens are more associated with NEC. We found that ALM1310, followed by 7 + 3 (daunorubicin), 7 + 3 (idarubicin), 5 + 3 + 3 (cytarabine, etoposide, idarubicin), and AML1310 (consolidation) were associated with a statistically higher incidence of NEC. We did not detect NEC episodes in patients treated with CPX-351, 5 + 2 (cytarabine, idarubicine), and high-dose cytarabine. Thus, we found that cytarabine could determine mucosal damage when associated with an anthracycline but not if delivered either alone or as dual-drug liposomal encapsulation of daunorubicin/cytarabine. We also describe NEC mortality, symptoms at diagnosis, intestinal sites involvement, and prognostic significance of bowel wall thickening.
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Affiliation(s)
- Edoardo Benedetti
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ginevra Traverso
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giulia Pucci
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Morganti
- Section of Statistics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Emilia Bramanti
- Institute of Chemistry of Organo Metallic Compounds (ICCOM), Consiglio Nazionale delle Ricerche (CNR), Pisa, Italy
| | - Piero Lippolis
- General and Peritoneal Surgery Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maria Chiara Susini
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Elisa Mazzantini
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Fabrizio Mavilia
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Emanuele Neri
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Chiara Arena
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesca Cerri
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Luigi De Simone
- Anesthesia and Maternal-Infantile Resuscitation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Katia Valentini
- Anesthesia and Maternal-Infantile Resuscitation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Vittorio Ricchiuto
- Dipartimento di Tecnologie Sanitarie ESTAR, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Sara Galimberti
- Hematology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Babakhanlou R, Ravandi-Kashani F, Kontoyiannis DP. Neutropenic Enterocolitis: An Uncommon, but Fearsome Complication of Leukemia. J Hematol 2023; 12:59-65. [PMID: 37187499 PMCID: PMC10181327 DOI: 10.14740/jh1105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/29/2023] [Indexed: 05/17/2023] Open
Abstract
Neutropenic enterocolitis (NEC) is a life-threatening condition occurring in severely neutropenic patients, following intensive chemotherapy for leukemia. Its pathogenesis is not entirely understood and believed to be multifactorial, including mucosal injury as a result of cytotoxic drugs, profound neutropenia, impaired host defense and possibly microbiota changes. Establishing an early diagnosis is key. The management of NEC remains undefined due to lack of high-quality clinical data. With a better understanding of the disease, a more conservative approach is preferred over surgical intervention. The involvement of a multi-disciplinary team, consisting of the oncologist, infectious diseases specialists and surgeons is highly recommended. This review aims to delineate insights into the pathophysiology and clinical presentation of NEC and to emphasize the diagnostic and therapeutic approach to this condition.
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Affiliation(s)
- Rodrick Babakhanlou
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
- Corresponding Author: Rodrick Babakhanlou, Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Farhad Ravandi-Kashani
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Dimitrios P. Kontoyiannis
- Division of Internal Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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BAL T, YAQOOBİ H, ÇABALAK M, ÖNLEN Y, OCAK S. Duodenal Bölge Tutulumu İle Seyreden Mortal Nötropenik Enterokolit Olgusu. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.983805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Nötropenik enterokolit çoğunlukla akut lösemili hastalar gibi mukozal hasarı indükleme potansiyeli yüksek hastalığı olanları ve yoğun kemoterapötik rejimleri alan hastaları etkilemektedir. Burada kemoterapi devamında ateş, karın ağrısı, bulantı, kusma, karında şişkinlik, ishal, ağız içinde yara şikayetleri ile başvuran, batın BT' de diffüz duodenum duvar kalınlaşması saptanan 34 yaşında akut lenfoblastik lösemi tanılı nötropenik enterokolit olgusu sunulmuştur. Olgumuzu sunmaya değer kılan duodenal bölge tutulumu ile seyreden nötropenik enterokolit olmasıdır.
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Affiliation(s)
| | - Hasibullah YAQOOBİ
- Hatay Mustafa Kemal Üniversitesi Tayfur Ata Sökmen Tıp Fakültesi Hastanesi
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Torres US, Caiado AH, Tiferes DA, Bretas EA, Ueda SK, Chamié LP, Fong MS, Silva LL, Ottaiano AC, D'Ippolito G. The Cecum Revisited: A Multimodality Imaging Case-based Review of Common and Uncommon Cecal Diseases. Semin Ultrasound CT MR 2022; 43:455-465. [DOI: 10.1053/j.sult.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Early Diagnosis of Neutropenic Enterocolitis by Bedside Ultrasound in Hematological Malignancies: A Prospective Study. J Clin Med 2021; 10:jcm10184277. [PMID: 34575387 PMCID: PMC8468879 DOI: 10.3390/jcm10184277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Neutropenic enterocolitis (NEC) is a life-threatening complication following chemotherapy with high mortality rates. Early diagnosis is crucial to improve outcomes. We designed a large prospective study employing bedside ultrasonography (US) as a novel approach to allow early diagnosis and prompt treatment to reduce mortality. (2) Methods: NEC was defined as US or computed tomography (CT)-proven bowel wall thickness ≥ 4 mm at the onset of at least one of the following symptoms: fever and/or abdominal pain and/or diarrhea during neutropenia. From 2007 to 2018, 1754 consecutive patients underwent baseline bedside US that was invariably repeated within 12 h from the onset of symptom(s) suggestive of NEC. (3) Results: Overall, 117 episodes of NEC were observed, and overall mortality was 9.4%. Bowel wall thickening was invariably absent in the negative control group. Abdominal pain associated with one or more symptoms correlated with the highest relative risk (17.33), sensitivity (89.7%), specificity (100%), and accuracy (96.2%) for diagnosis. The combination of abdominal pain and fever at onset significantly correlated with worse survival (p < 0.0001, OR 13.85). BWT (p = 0.046), type of therapy (p = 0.049) and blood culture positivity (p = 0.003) correlated with worse survival. (4) Conclusions: Bedside ultrasound is a non-invasive and radiation free imaging technique for early diagnosis of NEC and its prompt treatment significantly reduced mortality.
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Resende LSR, Yamashita S, Niéro-Melo L. Uncommon trans-iliac bone faecal fistula in a leukaemic patient. BJR Case Rep 2020; 6:20190056. [PMID: 32201607 PMCID: PMC7068086 DOI: 10.1259/bjrcr.20190056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 11/05/2022] Open
Abstract
This is a rare case of an elderly woman diagnosed with acute myeloid leukaemia secondary to myelodysplastic syndrome who presented a spontaneous trans-iliac bone faecal fistula probably related to an incarcerated inguinal hernia and neutropaenia. As far as we know, this is the first described case of a trans-iliac bone faecal fistula.
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Affiliation(s)
- Lucilene Silva Ruiz Resende
- Haematology Service of Internal Medicine Department, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, Brazil
| | - Seizo Yamashita
- Radiology Service of Tropical Diseases and Imaging Diagnosis Department, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, Brazil
| | - Ligia Niéro-Melo
- Haematology Service of Internal Medicine Department, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, Brazil
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Radiologische Diagnostik von Thorax und Abdomen bei immunkompromittierten Patienten. Med Klin Intensivmed Notfmed 2019; 114:526-532. [DOI: 10.1007/s00063-017-0331-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 11/25/2022]
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9
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Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract. Adv Anat Pathol 2019; 26:151-170. [PMID: 30870181 DOI: 10.1097/pap.0000000000000230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.
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Mourad N, Michel RP, Marcus VA. Pathology of Gastrointestinal and Liver Complications of Hematopoietic Stem Cell Transplantation. Arch Pathol Lab Med 2019; 143:1131-1143. [PMID: 30838881 DOI: 10.5858/arpa.2018-0282-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT.— Despite advances in therapeutic and preventive measures, hematopoietic stem cell transplant recipients remain at risk for a variety of gastrointestinal and liver complications. OBJECTIVE.— To detail the pathologic features of the various gastrointestinal and liver complications occurring after hematopoietic stem cell transplantation in relation to their clinical context. The specific complications covered include graft-versus-host disease, mycophenolate mofetil-induced injury, timeline of infections, neutropenic enterocolitis, gastrointestinal thrombotic microangiopathy, sinusoidal obstruction syndrome, hepatic iron overload, and the controversy around cord colitis syndrome. DATA SOURCES.— The content of this article is based on pertinent peer-reviewed articles in PubMed, relevant textbooks, and on the authors' personal experiences. CONCLUSIONS.— The final histopathologic diagnosis requires the integration of clinical and histologic findings and the exclusion of other competing causes of injury. Review of the clinical data, including the original disease pretransplant, the type of transplant, the timing of the gastrointestinal and/or liver manifestations, the timing of the biopsy after transplant, the presence of graft-versus-host disease in other organs and sites, the list of drug regimens, and the clinical and laboratory evidence of infection, is the key to reaching the proper histologic diagnosis.
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Affiliation(s)
- Nathalie Mourad
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - René P Michel
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - Victoria A Marcus
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
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Seddon AN, Chaim J, Akin O, Drill E, Michael AG, Adel N, Tallman MS. Similar incidence of typhlitis in patients receiving various doses of daunorubicin or idarubicin as induction for acute myeloid leukemia. Leuk Res 2018; 68:48-50. [DOI: 10.1016/j.leukres.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 10/17/2022]
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12
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Tessier JM. Infections in the Non-Transplanted Immunocompromised Host. Surg Infect (Larchmt) 2017; 17:323-8. [PMID: 27206239 DOI: 10.1089/sur.2016.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Discoveries regarding the basic mechanisms underlying malignant disease, rheumatologic disorders, and autoimmune diseases have led to the development of many new therapeutic modalities that target components of the immune system. Most of these are antibodies or fusion proteins that interfere with components of the immune response that are playing both pathological and protective roles, resulting in variable degrees of immune suppression and a higher risk of infectious complications. METHODS Review of the English-language literature. RESULTS As these modalities are often used in combination with more traditional methods of immune suppression (e.g., corticosteroids), an increasing spectrum of infection is being encountered by clinicians. Febrile neutropenia requires rapid assessment and initiation of empiric broad-spectrum antimicrobial therapy. Persistence despite this therapy should prompt further investigation for drug-resistant bacteria and invasive fungal disease. Important pathogens to consider in patients with neutropenia, chronic steroid exposure, or underlying gastrointestinal malignant diseases include fungi (Candida, Aspergillus) and atypical bacteria (Nocardia, Clostridium septicum). CONCLUSIONS This review focuses on observations regarding the greater risk of infections associated with many of these new biological modalities, as well as some specific infectious complications that may be encountered more commonly by the surgical consultant.
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Affiliation(s)
- Jeffrey M Tessier
- Department of Infectious Diseases, John Peter Smith Hospital , Fort Worth, Texas
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Marginean EC. The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. Arch Pathol Lab Med 2017; 140:748-58. [PMID: 27472233 DOI: 10.5858/arpa.2015-0451-ra] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT -There is an ever-growing armamentarium of pharmacologic agents that can cause gastrointestinal (GI) mucosal injury, the most common symptoms being diarrhea, constipation, nausea, and vomiting. These are often self-limiting and without serious sequelae, but some symptoms are of greater concern, like drug-induced mucosal ulceration that can manifest as GI hemorrhage, stricture formation, and even perforation. Histologically, there is significant overlap between drug-induced injuries and various disease entities. A single type of medication may cause multiple patterns of injury, which can involve the entire GI tract or just some parts of it. OBJECTIVE -To review the most common drug-induced injury patterns affecting the colon, which may be recognized by the surgical pathologist on colonic mucosal biopsies. This review does not address the injuries occurring in the upper GI tract. DATA SOURCES -A PubMed review of English-language literature, up to December 2015, on drug-induced injury of GI tract was performed. CONCLUSIONS -There are numerous drugs that damage the colonic mucosa. The most common drugs are included in this review according to their histologic pattern of injury. It is important for the pathologist to keep in mind that a single drug type can induce many histologic patterns of mucosal injury that can mimic many disease entities. Although there are some histologic clues helpful in the diagnosis of drug-induced colonic injury, correlation with clinical history and especially medication history is essential to improve diagnostic accuracy.
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Affiliation(s)
- Esmeralda Celia Marginean
- From the Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Badar T, Handisides DR, Benito JM, Richie MA, Borthakur G, Jabbour E, Harutyunyan K, Konoplev S, Faderl S, Kroll S, Andreeff M, Pearce T, Kantarjian HM, Cortes JE, Thomas DA, Konopleva M. Phase I study of evofosfamide, an investigational hypoxia-activated prodrug, in patients with advanced leukemia. Am J Hematol 2016; 91:800-5. [PMID: 27169385 DOI: 10.1002/ajh.24415] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/23/2016] [Accepted: 05/09/2016] [Indexed: 12/20/2022]
Abstract
Tumor hypoxia causes resistance to radiation and chemotherapy. Evofosfamide (TH-302) has exhibited specific hypoxia-dependent cytotoxicity against primary acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) samples in vitro. Based on these findings, a Phase I study of evofosfamide was designed for patients with relapsed/refractory leukemia (NCT01149915). In this open-label study, patients were treated with evofosfamide as a 30-60 min/day infusion on Days 1-5 of a 21-day cycle (Arm A, n = 38) or as a continuous infusion over 120 hr over Days 1-5 of a 21-day cycle (Arm B, n = 11). Forty-nine patients were treated including 39 (80%) with AML and 9 (18%) with ALL. Patients had received a median of five prior therapies. In Arm A, the dose-limiting toxicities (DLTs) were grade 3 esophagitis, observed at a dose of 550 mg/m(2) . The maximum tolerated dose (MTD) was a daily dose of 460 mg/m(2) . In Arm B, the DLTs were grade 3 stomatitis and hyperbilirubinemia, observed at a daily dose of 460 mg/m(2) . The continuous infusion MTD was a daily dose of 330 mg/m(2) . Hypoxia markers HIF-1α and CAIX were highly expressed in leukemic bone marrow and were significantly reduced after evofosfamide therapy. The combined overall response rate in Arms A and B was 6% (2 CR/CRi and 1 PR), with all responses seen in Arm A. Evofosfamide has shown limited activity in heavily pretreated leukemia patients. Further evaluation investigating evofosfamide in combination with cytotoxic or demethylating agents is warranted. Am. J. Hematol. 91:800-805, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Talha Badar
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | | | - Juliana M. Benito
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Mary Ann Richie
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Gautam Borthakur
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Elias Jabbour
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Karine Harutyunyan
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Sergej Konoplev
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Stefan Faderl
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Stew Kroll
- Threshold Pharmaceuticals; South San Francisco California
| | - Michael Andreeff
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
- Department of Stem Cell Transplantation and Cellular Therapy; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Tillman Pearce
- Threshold Pharmaceuticals; South San Francisco California
| | - Hagop M. Kantarjian
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jorge E. Cortes
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Deborah A. Thomas
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Marina Konopleva
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
- Department of Stem Cell Transplantation and Cellular Therapy; The University of Texas MD Anderson Cancer Center; Houston Texas
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Antibiotic use before chemotherapy: a risk factor for developing neutropenic colitis in children with leukemia. J Pediatr Hematol Oncol 2015; 37:121-7. [PMID: 25089604 DOI: 10.1097/mph.0000000000000227] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It has been shown that the use of antimicrobials is a determinant that favors intestinal dysbiosis. The objective of this study is to establish the association between the previous use of antimicrobials and the development of neutropenic colitis (NC). METHODS A case-control study was carried out with subjects diagnosed with acute lymphoblastic leukemia from 2004 to July 2013. They were identified by cross-referencing the databases from the computing area and the records from the pediatric hematology section. Cases were children with neutropenia and fever, abdominal distension and pain, diarrhea or constipation, and ultrasonography or computed tomography showing an intestinal wall thickness of ≥4 mm. Controls were children with acute lymphoblastic leukemia with neutropenia and fever, with or without gastrointestinal symptomatology, but without images of NC. RESULTS Thirty-eight cases and 75 controls were included. The factors associated with the development of NC were severe neutropenia (odds ratio [OR], 12.4; 95% confidence interval [CI], 3-51; P=0.00001), the use of antimicrobials for >10 days, within the month previous to the appearance of NC (OR, 12.4; 95% CI, 3-51; P=0.00001), and use of doxorubicin (OR, 5.43, 95% CI, 2.1-13.8, P=0.00004). In particular, the risk of developing CN was 3.46 (95% CI, 0.88-14; P=0.04) when ceftriaxone was used. CONCLUSIONS The use of antimicrobials during >10 days before the administration of chemotherapy is a risk factor for developing NC, along with other factors previously studied.
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16
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Konopleva M, Thall PF, Yi CA, Borthakur G, Coveler A, Bueso-Ramos C, Benito J, Konoplev S, Gu Y, Ravandi F, Jabbour E, Faderl S, Thomas D, Cortes J, Kadia T, Kornblau S, Daver N, Pemmaraju N, Nguyen HQ, Feliu J, Lu H, Wei C, Wilson WR, Melink TJ, Gutheil JC, Andreeff M, Estey EH, Kantarjian H. Phase I/II study of the hypoxia-activated prodrug PR104 in refractory/relapsed acute myeloid leukemia and acute lymphoblastic leukemia. Haematologica 2015; 100:927-34. [PMID: 25682597 DOI: 10.3324/haematol.2014.118455] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 02/06/2015] [Indexed: 12/19/2022] Open
Abstract
We previously demonstrated vast expansion of hypoxic areas in the leukemic microenvironment and provided a rationale for using hypoxia-activated prodrugs. PR104 is a phosphate ester that is rapidly hydrolyzed in vivo to the corresponding alcohol PR-104A and further reduced to the amine and hydroxyl-amine nitrogen mustards that induce DNA cross-linking in hypoxic cells under low oxygen concentrations. In this phase I/II study, patients with relapsed/refractory acute myeloid leukemia (n=40) after 1 or 2 prior treatments or acute lymphoblastic leukemia (n=10) after any number of prior treatments received PR104; dose ranged from 1.1 to 4 g/m(2). The most common treatment-related grade 3/4 adverse events were myelosuppression (anemia 62%, neutropenia 50%, thrombocytopenia 46%), febrile neutropenia (40%), infection (24%), and enterocolitis (14%). Ten of 31 patients with acute myeloid leukemia (32%) and 2 of 10 patients with acute lymphoblastic leukemia (20%) who received 3 g/m(2) or 4 g/m(2) had a response (complete response, n=1; complete response without platelet recovery, n=5; morphological leukemia-free state, n=6). The extent of hypoxia was evaluated by the hypoxia tracer pimonidazole administered prior to a bone marrow biopsy and by immunohistochemical assessments of hypoxia-inducible factor alpha and carbonic anhydrase IX. A high fraction of leukemic cells expressed these markers, and PR104 administration resulted in measurable decrease of the proportions of hypoxic cells. These findings indicate that hypoxia is a prevalent feature of the leukemic microenvironment and that targeting hypoxia with hypoxia-activated prodrugs warrants further evaluation in acute leukemia. The trial is registered at clinicaltrials.gov identifier: 01037556.
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Affiliation(s)
- Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cecilia Arana Yi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Coveler
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juliana Benito
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sergej Konoplev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yongchuan Gu
- Auckland Cancer Society Research Centre, University of Auckland, NZ, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Faderl
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deborah Thomas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven Kornblau
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hoang Q Nguyen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennie Feliu
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hongbo Lu
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caimiao Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William R Wilson
- Auckland Cancer Society Research Centre, University of Auckland, NZ, USA
| | | | | | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elihu H Estey
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Freeman HJ. Spontaneous free perforation of the small intestine in adults. World J Gastroenterol 2014; 20:9990-9997. [PMID: 25110427 PMCID: PMC4123378 DOI: 10.3748/wjg.v20.i29.9990] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/21/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Spontaneous free perforation of the small intestine is uncommon, especially if there is no prior history of visceral trauma. However, free, even recurrent, perforation may complicate a defined and established clinical disorder, such as Crohn’s disease. In addition, free perforation may be the initial clinical presentation of an occult intestinal disorder, such as a lymphoma complicating celiac disease, causing diffuse peritonitis and an acute abdomen. Initial diagnosis of the precise cause may be difficult, but now has been aided by computerized tomographic imaging. The site of perforation may be helpful in defining a cause (e.g., ileal perforation in Crohn’s disease, jejunal perforation in celiac disease, complicated by lymphoma or collagenous sprue). Urgent surgical intervention, however, is usually required for precise diagnosis and treatment. During evaluation, an expanding list of other possible causes should be considered, even after surgery, as subsequent management may be affected. Free perforation may not only complicate an established intestinal disorder, but also a new acute process (e.g., caused by different infectious agents) or a longstanding and unrecognized disorder (e.g., congenital, metabolic and vascular causes). Moreover, new endoscopic therapeutic and medical therapies, including use of emerging novel biological agents, have been complicated by intestinal perforation. Recent studies also support the hypothesis that perforation of the small intestine may be genetically-based with different mutations causing altered connective tissue structure, synthesis and repair.
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18
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Kontoyiannis DP, Mathur M, Chen YB, Shellito PC, Tse JY. Case records of the Massachusetts General Hospital. Case 13-2014. A 41-year-old man with fever and abdominal pain after stem-cell transplantation. N Engl J Med 2014; 370:1637-46. [PMID: 24758620 DOI: 10.1056/nejmcpc1305994] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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19
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Castagnola E, Faraci M. Management of bacteremia in patients undergoing hematopoietic stem cell transplantation. Expert Rev Anti Infect Ther 2014; 7:607-21. [DOI: 10.1586/eri.09.35] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Acute myeloid leukemia and acute lymphoblastic leukemia remain devastating diseases. Only approximately 40% of younger and 10% of older adults are long-term survivors. Although curing the leukemia is always the most formidable challenge, complications from the disease itself and its treatment are associated with significant morbidity and mortality. Such complications, discussed herein, include tumor lysis, hyperleukocytosis, cytarabine-induced cellebellar toxicity, acute promyelocytic leukemia differentiation syndrome, thrombohemorrhagic syndrome in acute promyelocytic leukemia, L-asparaginase-associated thrombosis, leukemic meningitis, neutropenic fever, neutropenic enterocolitis, and transfussion-associated GVHD. Whereas clinical trials form the backbone for the management of acute leukemia, emergent clinical situations, predictable or not, are common and do not readily lend themselves to clinical trial evaluation. Furthermore, practice guidelines are often lacking. Not only are prospective trials impractical because of the emergent nature of the issue at hand, but clinicians are often reluctant to randomize such patients. Extensive practical experience is crucial and, even if there is no consensus, management of such emergencies should be guided by an understanding of the underlying pathophysiologic mechanisms.
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Gray TLV, Ooi CY, Tran D, Traubici J, Gerstle JT, Sung L. Gastrointestinal complications in children with acute myeloid leukemia. Leuk Lymphoma 2010; 51:768-77. [PMID: 20350277 DOI: 10.3109/10428191003695652] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Gastrointestinal complications in pediatric acute myeloid leukemia (AML) have not been systematically described in the literature. Our objective was to describe complications related to the small and large bowel in children with AML. Literature searches were conducted of Ovid Medline from 1950 to November 2009 and EMBASE from 1980 to November 2009. We included any study design that described gastrointestinal complications in children and/or adults with AML. Common gastrointestinal complications were typhlitis and enterocolitis. Less common complications included appendicitis, pneumatosis intestinalis, and perianal infections. Both leukemia infiltration and intensive chemotherapy likely play a role in the etiology of these conditions. There is a paucity of carefully conducted studies that describe the natural history of typhlitis and enterocolitis and evidence is needed to help guide the management of gastrointestinal complications. Gastrointestinal complications are relatively common in children with AML. Conduction of carefully performed cohort studies is needed to better understand the spectrum of symptoms and expected consequences of gastrointestinal complications. Randomized trials are required to develop evidence-based guidelines for the management of gastrointestinal complications in pediatric AML.
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Affiliation(s)
- Tyler L V Gray
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G1X8
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Thirumala R, Ramaswamy M, Chawla S. Diagnosis and management of infectious complications in critically ill patients with cancer. Crit Care Clin 2010; 26:59-91. [PMID: 19944276 DOI: 10.1016/j.ccc.2009.09.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cancer and its treatments lead to profound suppression of innate and acquired immune function. In this population, bacterial infections are common and may rapidly lead to overwhelming sepsis and death. Furthermore, infections caused by viral and fungal pathogens should be considered in patients who have specific immune defects. As cancer therapies have become more aggressive the risk for infection has increased and many patients require intensive care support. Despite improvements in long-term survival, infections remain a common complication of cancer therapy and accounts for the majority of chemotherapy-associated deaths. By understanding the host defense impairments and likely pathogens clinicians will be better able to guide diagnosis and management of this unique population.
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Affiliation(s)
- Raghukumar Thirumala
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, C1179, New York, NY 10021, USA
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Typhlitis during second-line chemotherapy with pemetrexed in non-small cell lung cancer (NSCLC): A case report. Lung Cancer 2009; 65:251-3. [DOI: 10.1016/j.lungcan.2009.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Revised: 02/21/2009] [Accepted: 02/25/2009] [Indexed: 11/18/2022]
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24
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Dumitra S, Sideris L, Leclerc Y, Leblanc G, Dubé P. Neutropenic enterocolitis and docetaxel neoadjuvant chemotherapy. Ann Oncol 2009; 20:795-6. [DOI: 10.1093/annonc/mdp035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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25
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Worth LJ, Slavin MA. Bloodstream infections in haematology: risks and new challenges for prevention. Blood Rev 2008; 23:113-22. [PMID: 19046796 DOI: 10.1016/j.blre.2008.10.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Bloodstream infections are an important cause of morbidity and mortality in the haematology population, and may contribute to delayed administration of chemotherapy, increased length of hospitalisation, and increased healthcare expenditure. For gram-positive, gram-negative, anaerobic and fungal infections, specific risk factors are recognised. Unique host and environmental factors contributing to pathogenesis are acknowledged in this population. Trends in spectrum and antimicrobial susceptibility of pathogens are examined, and potential contributing factors are discussed. These include the widespread use of empiric antimicrobial therapy, increasingly intensive chemotherapeutic regimens, frequent use of central venous catheters, and local infection control practices. In addition, the risks and benefits of prophylaxis, and spectrum of endemic flora are identified as relevant factors within individual centres. Finally, challenges are presented regarding prevention, early detection, surveillance and prophylaxis. To reduce the rate and impact of bloodstream infections multifaceted and customised strategies are required within individual haematology units.
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Affiliation(s)
- Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia.
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27
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Lee JM, Choi KH, Hah JO. Outcome of typhlitis in children with cancer. KOREAN JOURNAL OF PEDIATRICS 2008. [DOI: 10.3345/kjp.2008.51.2.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Kwang Hae Choi
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jeong Ok Hah
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
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