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Xue T, Kong X, Ma L. Trends in the Epidemiology of Pneumocystis Pneumonia in Immunocompromised Patients without HIV Infection. J Fungi (Basel) 2023; 9:812. [PMID: 37623583 PMCID: PMC10455156 DOI: 10.3390/jof9080812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/19/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
The increasing morbidity and mortality of life-threatening Pneumocystis pneumonia (PCP) in immunocompromised people poses a global concern, prompting the World Health Organization to list it as one of the 19 priority invasive fungal diseases, calling for increased research and public health action. In response to this initiative, we provide this review on the epidemiology of PCP in non-HIV patients with various immunodeficient conditions, including the use of immunosuppressive agents, cancer therapies, solid organ and stem cell transplantation, autoimmune and inflammatory diseases, inherited or primary immunodeficiencies, and COVID-19. Special attention is given to the molecular epidemiology of PCP outbreaks in solid organ transplant recipients; the risk of PCP associated with the increasing use of immunodepleting monoclonal antibodies and a wide range of genetic defects causing primary immunodeficiency; the trend of concurrent infection of PCP in COVID-19; the prevalence of colonization; and the rising evidence supporting de novo infection rather than reactivation of latent infection in the pathogenesis of PCP. Additionally, we provide a concise discussion of the varying effects of different immunodeficient conditions on distinct components of the immune system. The objective of this review is to increase awareness and knowledge of PCP in non-HIV patients, thereby improving the early identification and treatment of patients susceptible to PCP.
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Affiliation(s)
- Ting Xue
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xiaomei Kong
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD 20892, USA
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Climans SA, Grunfeld E, Mason WP, Chan KKW. Effectiveness and safety of pneumocystis pneumonia prophylaxis for patients receiving temozolomide chemoradiotherapy. Neuro Oncol 2022; 24:1738-1748. [PMID: 35312784 PMCID: PMC9527509 DOI: 10.1093/neuonc/noac072] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Malignant gliomas are treated with temozolomide chemoradiotherapy. Because pneumocystis pneumonia (PCP) can occur in patients receiving temozolomide, the product monograph recommends PCP prophylaxis during temozolomide chemoradiotherapy. Not all neuro-oncologists follow these recommendations, though. METHODS We performed a population-based retrospective cohort study of glioma patients undergoing temozolomide chemoradiotherapy 2005 to 2019 in Ontario, Canada. A propensity score model was used to predict the use of PCP prophylaxis. We compared the risk of PCP within 90 days of starting radiotherapy with versus without PCP prophylaxis using inverse probability of treatment weighting (IPTW). We also examined overall survival, hospitalizations, and myelosuppression. RESULTS There were 3,225 patients included in the cohort (648 received antibiotics and 2,434 did not). Only 18 patients developed PCP within 90 days of therapy. The IPTW-adjusted absolute risk reduction in PCP with antibiotics was 0.0035 (95% CI, -0.0013 to 0.0083), number needed to treat: 288. Neither overall survival nor hospitalization count differed between the groups. The number needed to harm by causing grade 3/4 neutropenia was 39. CONCLUSIONS In regions (like Ontario) where PCP is rare, routine PCP prophylaxis with trimethoprim-sulfamethoxazole should not be offered, since the harms may outweigh the benefits.
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Affiliation(s)
- Seth A Climans
- Corresponding Author: Seth A. Climans, MD, Department of Oncology, London Health Sciences Centre, 800 Commissioners Rd E, London, ON N6A 5W9, Canada ()
| | - Eva Grunfeld
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Warren P Mason
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Oncology and Hematology, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Climans SA, Mason WP, Grunfeld E, Chan K. Clinical features of glioma patients who develop pneumocystis pneumonia with temozolomide chemoradiotherapy. J Neurooncol 2022; 159:665-674. [PMID: 35932358 DOI: 10.1007/s11060-022-04109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The treatment of glioma with temozolomide chemoradiotherapy predisposes patients to pneumocystis pneumonia (PCP). Because PCP is a rare outcome, very little is known about specific clinical risk factors for its development in patients with glioma. METHODS We performed a population-based retrospective cohort study of glioma patients undergoing temozolomide chemoradiotherapy 2005 to 2019 in Ontario, Canada. We compared clinical features of patients who did not versus did develop PCP within one year of chemoradiotherapy. We examined the overall survival of patients by PCP status. RESULTS There were 5130 patients with glioma treated with temozolomide chemoradiotherapy. Ultimately, 38 patients (0.74%) were diagnosed with PCP within 1 year of chemoradiotherapy. Most (71%) infections occurred between 0-90 days and 29% occurred between 91-365 days. Median survival was 12.3 months in patients who did not develop PCP and 8.6 months in those who did develop PCP (P < 0.001). Trough 90-day lymphocyte counts were lower in the PCP group. When the lymphocytes fell below 0.19 × 109/L (or 0.25 × 109/L among patients without PCP prophylaxis), the risk of PCP was > 3.5%. CONCLUSIONS Pneumocystis pneumonia is rare in glioma patients who receive temozolomide chemoradiotherapy. Infection is associated with shorter survival and the development of lymphopenia. Reserving PCP prophylaxis for patients whose lymphocyte counts drop below 0.25 × 109/L may be a reasonable strategy.
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Affiliation(s)
- Seth A Climans
- Department of Oncology, Western University, London, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,London Regional Cancer Program, 800 Commissioners Rd E, London, ON, N6A5W9, Canada.
| | - Warren P Mason
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Eva Grunfeld
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kelvin Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Pansu N, Le Moing V, Poizot-Martin I, Joly V, Allavena C, Hocqueloux L, Duvivier C, Lourenco J, Jovelin T, Reynes J, Makinson A. Pneumocystis jirovecii Pneumonia and Toxoplasmosis in PWH with HIV-Controlled Disease Treated for Solid Malignancies: a DAT’AIDS study. Open Forum Infect Dis 2022; 9:ofac109. [PMID: 35392457 PMCID: PMC8982778 DOI: 10.1093/ofid/ofac109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/01/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- N Pansu
- Département des Maladies Infectieuses, CHU La Colombière, Montpellier, France
| | - V Le Moing
- Département des Maladies Infectieuses, CHU La Colombière, Montpellier, France
| | - I Poizot-Martin
- Département d’immunologie et hématologie clinique, APHM Sainte-Marguerite, Marseille, France
| | - V Joly
- Département des Maladies Infectieuses, Hôpital Bichat, APHP, Paris, France
| | - C Allavena
- Département des Maladies Infectieuses, CHU Hôtel Dieu, Nantes, France
| | - L Hocqueloux
- Département des Maladies Infectieuses, CHR d'Orléans-La Source, Orléans, France
| | - C Duvivier
- Département des Maladies Infectieuses, APHP - Hôpital Necker, Centre d’infectiologie Necker-Pasteur, Paris, France
| | - J Lourenco
- Département des Maladies Infectieuses, APHP - Hôpital Necker, Centre d’infectiologie Necker-Pasteur, Paris, France
| | - T Jovelin
- Département des Maladies Infectieuses, CHU Hôtel Dieu, Nantes, France
| | - J Reynes
- Département des Maladies Infectieuses, CHU La Colombière, Montpellier, France
| | - A Makinson
- Département des Maladies Infectieuses, CHU La Colombière, Montpellier, France
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Al-Toubah T, Pelle E, Valone T, Haider M, Strosberg JR. Efficacy and Toxicity Analysis of Capecitabine and Temozolomide in Neuroendocrine Neoplasms. J Natl Compr Canc Netw 2021; 20:29-36. [PMID: 34433130 DOI: 10.6004/jnccn.2021.7017] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/27/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The capecitabine/temozolomide (CAPTEM) regimen has significant activity in advanced neuroendocrine tumors (NETs). Questions exist regarding activity in pancreatic versus nonpancreatic NETs, risk of opportunistic infections, long-term myelotoxicity, and safety of prolonged treatment duration. Analysis of large patient cohorts is needed for the evaluation of rare toxicities and assessment of risk factors. METHODS We conducted a retrospective study of all patients with advanced NETs seen at Moffitt Cancer Center between January 2008 and June 2019 who received treatment with CAPTEM. RESULTS A total of 462 patients were eligible. The objective radiographic response rate was 46%, and the disease control rate was 81%. Median progression-free survival (PFS) was 18 months (95% CI, 14.0-21.9 months) and median overall survival was 51 months (95% CI, 42.8-59.2 months): 62 months in well-differentiated NETs versus 14 months in poorly differentiated neuroendocrine carcinomas (P<.0001). Patients with primary pancreatic tumors had the highest partial response rates and longest median PFS. Incidences of grade 4 thrombocytopenia and neutropenia were 7% and 3%, respectively, and substantially higher in women than men (P=.02 and P=.004, respectively). Only 1 case (0.2%) of suspected Pneumocystis pneumonia (PCP) was observed in a patient receiving corticosteroids. Three patients developed myelodysplastic disease, all of whom had received prior peptide receptor radiotherapy (PRRT). There were no acute treatment-related deaths; 1 patient died 2 months after a thrombocytopenic bleed. CONCLUSIONS The CAPTEM regimen is exceptionally safe. Efficacy is particularly robust in well-differentiated pancreatic NETs. Severe myelotoxicity is rare; the risk of grade 4 cytopenias is significantly increased in women, and therefore sex-based dosing should be considered. There were no cases of myelodysplastic syndromes, except among patients who had received PRRT, a known risk factor. The risk of PCP is negligible.
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Affiliation(s)
- Taymeyah Al-Toubah
- 1Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Eleonora Pelle
- 1Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Tiffany Valone
- 1Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Mintallah Haider
- 1Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jonathan R Strosberg
- 1Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Abstract
OPINION STATEMENT Corticosteroids have been essential in the management of brain tumor patients for decades, primarily for the treatment of peritumoral cerebral edema and its associated neurologic deficits. Dexamethasone is the drug of choice with standard practice being administration up to four times per day, however, because of its long biologic half-life and high potency, once or twice a day dosing is likely adequate in patients without elevated intracranial pressure. The length of corticosteroid treatment should be limited to the shortest period of time to minimize the risk of potential toxicities that can significantly affect quality of life, as well as to avoid a possible detrimental impact on survival in high-grade glioma patients and abrogation of the effect of immunotherapy. Agents such as bevacizumab should be considered in patients who are unable to wean completely off of steroids as well as those who have symptomatic edema and are on immunotherapy. Several other agents have been studied without much success. An increased understanding of the complex pathophysiology of peritumoral vasogenic edema is critically needed to discover new agents that are safer and more effective.
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Doello K, Amezcua V, García J, Valdivia J. Pneumocystis jirovecii Pneumonia in a Non-small Cell Lung Cancer Patient on Chemoradiotherapy: A Case Report. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 8:53-55. [PMID: 31929779 PMCID: PMC6945310 DOI: 10.4103/sjmms.sjmms_255_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 11/29/2022]
Abstract
Pneumocystis jirovecii pneumonia is a very uncommon complication in lung cancer patients. We report the case of a 59-year-old, Stage IIIB non-small cell lung cancer (epidermoid) patient who was receiving concurrent chemotherapy scheme (cisplatin + vinorelbine) and radiotherapy and developed fever and dyspnea not controlled with classical antibiotics. The patient developed respiratory distress. A high-resolution computed tomography showed a crazy-paving pattern, and a bronchoalveolar lavage confirmed the diagnosis of Pneumocystis jirovecii pneumonia. The patient was successfully managed with intravenous trimethoprim/sulfamethoxazole and voriconazole. Few such cases have been reported in the literature, and in most cases, the infection has been found to be associated with aggressive oncological treatments. Therefore, Pneumocystis jirovecii pneumonia should be considered in lung cancer patients with its presenting symptoms, especially if the patient is undergoing aggressive chemotherapy and/or radiotherapy.
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Affiliation(s)
- Kevin Doello
- Service of Medical Oncology, Virgen De Las Nieves Hospital, Granada, Spain
| | - Víctor Amezcua
- Service of Medical Oncology, Virgen De Las Nieves Hospital, Granada, Spain
| | - Javier García
- Service of Medical Oncology, Virgen De Las Nieves Hospital, Granada, Spain
| | - Javier Valdivia
- Service of Medical Oncology, Virgen De Las Nieves Hospital, Granada, Spain
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Liu SA, Sullivan T, Bryce C, Chan AM, Cilmi S. Cerebral aspergillosis within new tumour site presents as incidental new brain lesion in patient receiving temozolomide for glioblastoma multiforme. BMJ Case Rep 2019; 12:12/5/e227500. [PMID: 31154345 DOI: 10.1136/bcr-2018-227500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Glioblastoma multiforme (GBM) is an aggressive tumour that can lead to lymphopaenia. Its standard treatment involves temozolomide (TMZ) chemotherapy with radiation, often with addition of corticosteroids for symptomatic management. Although TMZ is also immunosuppressive, patients receiving TMZ rarely develop disseminated opportunistic infections. Here, we report the case of a patient with GBM receiving TMZ, radiotherapy and corticosteroids, who develops an incidental new brain lesion that is found to be disseminated Aspergillus within a new GBM tumour site. The patient received successful early treatment of her central nervous system aspergillosis. This case illustrates the profound immunosuppressive potential of GBM in conjunction with TMZ and corticosteroids, which can lead to high-morbidity opportunistic infections concurrently with tumour progression. Future research is needed to elucidate GBM, TMZ and corticosteroids' compound immune effects and guide management that strikes a balance between treating high-morbidity infections and continuing with immunosuppressive chemotherapy.
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Affiliation(s)
- Shiyuan Anabeth Liu
- Internal Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Timothy Sullivan
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Clare Bryce
- Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy M Chan
- Internal Medicine, Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Salvatore Cilmi
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lu G, Rao M, Zhu P, Liang B, El-Nazer RT, Fonkem E, Bhattacharjee MB, Zhu JJ. Triple-drug Therapy With Bevacizumab, Irinotecan, and Temozolomide Plus Tumor Treating Fields for Recurrent Glioblastoma: A Retrospective Study. Front Neurol 2019; 10:42. [PMID: 30766509 PMCID: PMC6366009 DOI: 10.3389/fneur.2019.00042] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
Clinical studies treating pediatric and adult solid tumors, such as glioblastoma (GBM), with a triple-drug regimen of temozolomide (TMZ), bevacizumab (BEV), and irinotecan (IRI) [TBI] have demonstrated various efficacies, but with no unexpected toxicities. The TBI regimen has never been studied in recurrent GBM (rGBM) patients. In this retrospective study, we investigated the outcomes and side effects of rGBM patients who had received the TBI regimen. We identified 48 adult rGBM patients with a median age of 56 years (range: 26-76), who received Tumor Treating Fields (TTFields) treatment for 30 days or longer, and concurrent salvage chemotherapies. The patients were classified into two groups based on chemotherapies received: TBI with TTFields (TBI+T, N = 18) vs. bevacizumab (BEV)-based chemotherapies with TTFields (BBC+T, N = 30). BBC regimens were either BEV monotherapy, BEV+IRI or BEV+CCNU. Patients in TBI+T group received on average 19 cycles of TMZ, 26 and 21 times infusions with BEV and IRI, respectively. Median overall survival (OS) and progression-free survival (PFS) for rGBM (OS-R and PFS-R) patients who received TBI+T were 18.9 and 10.7 months, respectively. In comparison, patients who received BBC+T treatment had OS-R and PFS-R of 11.8 (P > 0.05) and 4.7 (P < 0.05) months, respectively. Although the median PFS results were significantly different by 1.5 months (6.6 vs. 5.1) between TBI+T and BBC+T groups, the median OS difference of 14.7 months (32.5 vs. 17.8) was more pronounced, P < 0.05. Patients tolerated TBI+T or BBC+T treatments well and there were no unexpected toxicities. The most common side effects from TBI+T treatment included grade III hypertension (38.9%) and leukopenia (22.2%). In conclusion, the TBI regimen might play a role in the improvement of PFS-R and OS-R among rGBM patients. Prospective studies with a larger sample size are warranted to study the efficacy and toxicity of TBI+T regimen for rGBM.
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Affiliation(s)
- Guangrong Lu
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
| | - Mayank Rao
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
| | - Ping Zhu
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
- Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, UTHealth School of Public Health, Houston, TX, United States
| | - Buqing Liang
- Baylor Scott and White Health, Temple, TX, United States
| | | | - Ekokobe Fonkem
- Baylor Scott and White Health, Temple, TX, United States
| | - Meenakshi B. Bhattacharjee
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
| | - Jay-Jiguang Zhu
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
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Stepanenko AA, Chekhonin VP. Recent Advances in Oncolytic Virotherapy and Immunotherapy for Glioblastoma: A Glimmer of Hope in the Search for an Effective Therapy? Cancers (Basel) 2018; 10:E492. [PMID: 30563098 PMCID: PMC6316815 DOI: 10.3390/cancers10120492] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 11/19/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
To date, no targeted drugs, antibodies or combinations of chemotherapeutics have been demonstrated to be more efficient than temozolomide, or to increase efficacy of standard therapy (surgery, radiotherapy, temozolomide, steroid dexamethasone). According to recent phase III trials, standard therapy may ensure a median overall survival of up to 18⁻20 months for adult patients with newly diagnosed glioblastoma. These data explain a failure of positive non-controlled phase II trials to predict positive phase III trials and should result in revision of the landmark Stupp trial as a historical control for median overall survival in non-controlled trials. A high rate of failures in clinical trials and a lack of effective chemotherapy on the horizon fostered the development of conceptually distinct therapeutic approaches: dendritic cell/peptide immunotherapy, chimeric antigen receptor (CAR) T-cell therapy and oncolytic virotherapy. Recent early phase trials with the recombinant adenovirus DNX-2401 (Ad5-delta24-RGD), polio-rhinovirus chimera (PVSRIPO), parvovirus H-1 (ParvOryx), Toca 511 retroviral vector with 5-fluorocytosine, heat shock protein-peptide complex-96 (HSPPC-96) and dendritic cell vaccines, including DCVax-L vaccine, demonstrated that subsets of patients with glioblastoma/glioma may benefit from oncolytic virotherapy/immunotherapy (>3 years of survival after treatment). However, large controlled trials are required to prove efficacy of next-generation immunotherapeutics and oncolytic vectors.
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Affiliation(s)
- Aleksei A Stepanenko
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center for Psychiatry and Narcology, the Ministry of Health of the Russian Federation, Kropotkinsky lane 23, 119034 Moscow, Russia.
| | - Vladimir P Chekhonin
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center for Psychiatry and Narcology, the Ministry of Health of the Russian Federation, Kropotkinsky lane 23, 119034 Moscow, Russia.
- Department of Medical Nanobiotechnologies, Medico-Biological Faculty, N. I. Pirogov Russian National Research Medical University, the Ministry of Health of the Russian Federation, Ostrovitianov str. 1, 117997 Moscow, Russia.
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Skorupan N, Ranjan S, Mehta S, Yankulina O, Nenortas N, Grossman S, Ye X, Holdhoff M. Pneumocystis jirovecii prophylaxis in patients treated for high-grade gliomas: a survey among neuro-oncologists. Neurooncol Pract 2018; 6:321-326. [PMID: 31386039 DOI: 10.1093/nop/npy049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) is a known complication in patients with high-grade gliomas (HGGs) who are treated with radiation and chemotherapy. PJP prophylaxis is commonly recommended, but there are currently no clear guidelines regarding duration of treatment and choice of drugs. This study aimed to assess current practice patterns of PJP prophylaxis among neuro-oncologists. Methods An online survey of 14 multiple choice questions was sent to 207 neuro-oncologists and medical oncologists treating brain cancers at all National Cancer Institute-designated cancer centers in the United States. Recipients were identified via a search of the cancer centers' websites. Results Sixty-one invited experts completed the survey (response rate 29%; of these, 72% were neuro-oncologists, 18% were medical oncologists, and 10% were pediatric neuro- or medical oncologists). Seventy percent of respondents stated that they routinely prescribe PJP prophylaxis, while 7% do not provide prophylaxis. Eighty-one percent of respondents use absolute lymphocyte count (ALC) to assess lymphopenia and 13% also monitor CD4 lymphocyte counts during prophylaxis. The most commonly used first-line agent is trimethoprim-sulfamethoxazole (88% of respondents), followed by pentamidine (6%). Discontinuation of PJP prophylaxis is determined by the following: count recovery (33% by ALC; 18% by CD4 lymphocyte counts), radiation completion (23%), and chemotherapy completion (7%). Glucose-6-phosphate dehydrogenase levels were routinely checked by only 13% of respondents. Conclusions PJP prophylaxis is commonly used in HGG patients, but there are large variations in practice patterns, including the duration of prophylaxis. As consideration for PJP prophylaxis affects all patients with HGG, standardization of prophylaxis should be formally addressed.
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Affiliation(s)
- Nebojša Skorupan
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Surabhi Ranjan
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Seema Mehta
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olga Yankulina
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nathan Nenortas
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stuart Grossman
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaobu Ye
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthias Holdhoff
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Pneumocystis jirovecii pneumonia (PJP) is a common infection among susceptible patients with compromised immune function and can lead to life-threatening complications without prompt recognition and appropriate treatment. Clinicians should be aware that patients can develop severe infection even while receiving approved prophylactic medications for PJP. Furthermore, atypical radiographic findings, such as the cavitary lung lesions found in the patient in this case report, can make the diagnosis even more challenging.
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Abstract
Patients with brain tumor encounter a wide spectrum of tumor and treatment-related complications during their disease course. Tumors may serve as seizure substrates, are associated with a hypercoagulable state that results in thromboembolic complications, and may influence mood and cognition. Antitumor and supportive therapies may also have deleterious effects. Herein, we discuss major aspects of supportive care for patients with brain tumors, with attention to benefit and complications derived from the management of seizures, brain edema, venous thromboembolism, fatigue, mood alterations, and cognitive dysfunction.
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Affiliation(s)
- Kester A Phillips
- Department of Neuroscience, Inova Health System, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Camilo E Fadul
- Division of Neuro-Oncology, University of Virginia Health System, 1300 Jefferson Park Avenue, West Complex, Room 6228, Charlottesville, VA 22903-0156, USA
| | - David Schiff
- Division of Neuro-Oncology, University of Virginia Health System, 1300 Jefferson Park Avenue, West Complex, Room 6225, Charlottesville, VA 22903-0156, USA.
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Leoni D, Encina B, Rello J. Managing the oncologic patient with suspected pneumonia in the intensive care unit. Expert Rev Anti Infect Ther 2017; 14:943-60. [PMID: 27573637 DOI: 10.1080/14787210.2016.1228453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research. AREAS COVERED This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.
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Affiliation(s)
- D Leoni
- a Infectious Disease Department , Tor Vergata University Hospital, University of 'La Sapienza' , Rome , Italy.,b Clinical Research & Innovation in Pneumonia & Sepsis (CRIPS) , Vall d'Hebron Institute of Research , Barcelona , Spain
| | - B Encina
- b Clinical Research & Innovation in Pneumonia & Sepsis (CRIPS) , Vall d'Hebron Institute of Research , Barcelona , Spain
| | - J Rello
- b Clinical Research & Innovation in Pneumonia & Sepsis (CRIPS) , Vall d'Hebron Institute of Research , Barcelona , Spain.,c Centro de Investigación Biomédica En Red - Enfermedades Respiratorias (CIBERES) , Vall d'Hebron Institute of Research , Barcelona , Spain.,d Department of Medicine , Universitat Autònoma de Barcelona , Barcelona , Spain
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15
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Khan BA, Khan S, White B, Eranki A. Severe pneumocystis jiroveci pneumonia in a patient on temozolomide therapy: A case report and review of literature. Respir Med Case Rep 2017; 22:179-182. [PMID: 28861334 PMCID: PMC5568882 DOI: 10.1016/j.rmcr.2017.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/31/2017] [Accepted: 08/11/2017] [Indexed: 11/17/2022] Open
Abstract
A 66 year old man was diagnosed with CNS diffuse large B-cell lymphoma, and underwent treatment with Temozolomide, Dexamethasone, Rituximab, and radiation therapy, and prolonged steroid taper with Dexamethasone. Approximately one month after this, he presented with severe acute hypoxemic respiratory failure, and was admitted to the Medical Intensive Care Unit. Imaging showed diffuse ground glass opacities. Patient underwent diagnostic bronchoalveolar lavage which was positive for Pneumocystis jiroveci. He did not respond well to appropriate therapy and was transitioned to comfort care per his family's wishes, and expired. Pneumocystis jiroveci should always be included in the differential diagnosis of pneumonia in patients treated with Temozolomide, especially when this agent is used in combination with long term, high dose corticosteroids and radiation therapy.
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Abstract
Glioblastoma is the most common primary brain tumor in adults. Despite current multimodality treatment including surgical resection and temozolomide-based chemoradiotherapy, median survival is only 14-16 months. Characterization of molecular alterations in glioblastoma has identified prognostic subgroups and therapeutic opportunities for clinical trials across glioblastoma subsets. Following a number of negative Phase III trials testing temozolomide dose intensification and angiogenesis inhibition, recent interim analysis data indicate survival prolongation with use of a device (Optune™) delivering alternating electrical field therapy in newly diagnosed glioblastoma patients. In this review, we present an overview of the data supporting the current standard of care and discuss novel experimental therapies in early and late phase clinical testing including devices, small molecule drugs, angiogenesis inhibitors, oncolytic virotherapy and immunotherapy.
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Affiliation(s)
- Evidio Domingo-Musibay
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Evanthia Galanis
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.,Department of Molecular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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17
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Cooley L, Dendle C, Wolf J, Teh BW, Chen SC, Boutlis C, Thursky KA. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J 2015; 44:1350-63. [PMID: 25482745 DOI: 10.1111/imj.12599] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pneumocystis jirovecii infection (PJP) is a common cause of pneumonia in patients with cancer-related immunosuppression. There are well-defined patients who are at risk of PJP due to the status of their underlying malignancy, treatment-related immunosuppression and/or concomitant use of corticosteroids. Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP. Trimethoprim-sulfamethoxazole is the drug of choice for prophylaxis and treatment, although several alternative agents are available.
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Affiliation(s)
- L Cooley
- Department of Microbiology and Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania
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18
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Neuwelt AJ, Nguyen TM, Fu R, Bubalo J, Tyson RM, Lacy C, Gahramanov S, Nasseri M, Barnes PD, Neuwelt EA. Incidence of Pneumocystis jirovecii pneumonia after temozolomide for CNS malignancies without prophylaxis. CNS Oncol 2015; 3:267-73. [PMID: 25286038 DOI: 10.2217/cns.14.24] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
AIMS Prophylaxis against Pneumocystis jiroveci pneumonia (PJP) is currently recommended for patients receiving chemoradiation with temozolomide for newly diagnosed glioblastoma multiforme. At our institution, PJP prophylaxis during temozolomide treatment has not been routinely given because of the paucity of supporting data. We investigated the rate of PJP infections in our patients. PATIENTS & METHODS We conducted a retrospective chart review of 240 brain tumor patients treated between 1999 and 2012 with temozolomide and no PJP prophylaxis, 127 of which received concurrent chemoradiation. RESULTS One in 240 patients (0.4%; 95% CI: 0.01-2.00; median total dose: 7375 mg/m(2); interquartile range: 1300) were diagnosed with PJP. CONCLUSION There was a <1% rate of PJP for brain tumor patients treated with temozolomide until progression without PJP prophylaxis.
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Affiliation(s)
- Alexander J Neuwelt
- Department of Internal Medicine, University of New Mexico, 1 University of NM, Albuquerque, New Mexico 87131, USA
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19
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Schiff D, Lee EQ, Nayak L, Norden AD, Reardon DA, Wen PY. Medical management of brain tumors and the sequelae of treatment. Neuro Oncol 2015; 17:488-504. [PMID: 25358508 PMCID: PMC4483077 DOI: 10.1093/neuonc/nou304] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/28/2014] [Indexed: 12/11/2022] Open
Abstract
Patients with malignant brain tumors are prone to complications that negatively impact their quality of life and sometimes their overall survival as well. Tumors may directly provoke seizures, hypercoagulable states with resultant venous thromboembolism, and mood and cognitive disorders. Antitumor treatments and supportive therapies also produce side effects. In this review, we discuss major aspects of supportive care for patients with malignant brain tumors, with particular attention to management of seizures, venous thromboembolism, corticosteroids and their complications, chemotherapy including bevacizumab, and fatigue, mood, and cognitive dysfunction.
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Affiliation(s)
| | - Eudocia Q. Lee
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Lakshmi Nayak
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Andrew D. Norden
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - David A. Reardon
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
| | - Patrick Y. Wen
- Neuro-Oncology Center, University of Virginia Medical Center, Charlottesville, Virginia (D.S.); Center for Neuro-Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (E.Q.L., L.N., A.D.N., D.A.R., P.Y.W.)
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21
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Thomas RP, Recht L, Nagpal S. Advances in the management of glioblastoma: the role of temozolomide and MGMT testing. Clin Pharmacol 2012; 5:1-9. [PMID: 23293540 PMCID: PMC3534290 DOI: 10.2147/cpaa.s26586] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Glioblastoma (GB) is one of the most lethal forms of cancer, with an invasive growth pattern that requires the use of adjuvant therapies, including chemotherapy and radiation, to prolong survival. Temozolomide (TMZ) is an oral chemotherapy with a limited side effect profile that has become the standard of care in GB treatment. While TMZ has made an impact on survival, tumor recurrence and TMZ resistance remain major challenges. Molecular markers, such as O6-methylguanine-DNA methyltransferase methylation status, can be helpful in predicting tumor response to TMZ, and therefore guides clinical decision making. This review will discuss the epidemiology and possible genetic underpinnings of GB, how TMZ became the standard of care for GB patients, the pharmacology of TMZ, the practical aspects of using TMZ in clinic, and how molecular diagnostics – particularly the use of O6-methylguanine-DNA methyltransferase status – affect clinical management.
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Affiliation(s)
- Reena P Thomas
- Department of Neurological Sciences, Stanford University Hospital, Stanford, CA, USA
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