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Zhou Y, Li K, Adelson DL. An unmet need for pharmacology: Treatments for radiation-induced gastrointestinal mucositis. Biomed Pharmacother 2024; 175:116767. [PMID: 38781863 DOI: 10.1016/j.biopha.2024.116767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Gastrointestinal mucositis (GIM) continues to be a significant issue in the management of abdominal cancer radiation treatments and chemotherapy, causing significant patient discomfort and therapy interruption or even cessation. This review will first focus on radiotherapy induced GIM, providing an understanding of its clinical landscape. Subsequently, the aetiology of GIM will be reviewed, highlighting diverse contributing factors. The cellular and tissue damage and associated molecular responses in GIM will be summarised in the context of the underlying complex biological processes. Finally, available drugs and pharmaceutical therapies will be evaluated, underscoring their insufficiency, and highlighting the need for further research and innovation. This review will emphasize the urgent need for improved pharmacologic therapeutics for GIM, which is a key research priority in oncology.
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Affiliation(s)
- Yan Zhou
- Department of Molecular and Biomedical Science, School of Biological Sciences, The University of Adelaide, Adelaide, South Australia 5005, Australia; Zhendong Australia China Centre for Molecular Chinese Medicine, The University of Adelaide, Adelaide, South Australia 5005, Australia.
| | - Kun Li
- Beijing Zhendong Guangming Pharmaceutical Research Institute, Beijing 100120, China.
| | - David L Adelson
- Department of Molecular and Biomedical Science, School of Biological Sciences, The University of Adelaide, Adelaide, South Australia 5005, Australia; Zhendong Australia China Centre for Molecular Chinese Medicine, The University of Adelaide, Adelaide, South Australia 5005, Australia.
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Shah G, Giralt S, Dahi P. Optimizing high dose melphalan. Blood Rev 2024; 64:101162. [PMID: 38097487 DOI: 10.1016/j.blre.2023.101162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 03/12/2024]
Abstract
Melphalan, has been a major component of myeloma therapy since the 1950s. In the context of hematopoietic cell transplantation (HCT), high dose melphalan (HDM) is the most common conditioning regimen used due to its potent anti-myeloma effects and manageable toxicities. Common toxicities associated with HDM include myelosuppression, gastrointestinal issues, and mucositis. Established approaches to reduce these toxicities encompass dose modification, nausea prophylaxis with 5HT3 receptor antagonists, cryotherapy, amifostine use, and growth factors. Optimization of melphalan exposure through personalized dosing and its combination with other agents like busulfan, or bendamustine show promise. Propylene glycol-free melphalan (Evomela) represents a novel formulation aiming to enhance drug stability and reduce adverse effects. This review explores strategies to enhance the efficacy and mitigate the toxicity of HDM in multiple myeloma. Future directions involve exploring these strategies in clinical trials to improve the safety and efficacy of HDM, thereby enhancing outcomes for multiple myeloma patients undergoing autologous HCT.
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Affiliation(s)
- Gunjan Shah
- Adult BMT Service Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, United States of America.
| | - Sergio Giralt
- Adult BMT Service Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, United States of America.
| | - Parastoo Dahi
- Adult BMT Service Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, United States of America.
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Socioeconomic Factors and Survival of Multiple Myeloma Patients. Cancers (Basel) 2021; 13:cancers13040590. [PMID: 33546206 PMCID: PMC7913279 DOI: 10.3390/cancers13040590] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/11/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Outcome of Multiple Myeloma (MM) patients has improved as the result of the introduction of novel medications and use of autologous hematopoietic cell transplantation. However, this improvement comes at the expense of increased financial burden. It is largely unknown if socioeconomic factors influence MM survival. METHODS We used the National Cancer Database, a database that houses data on 70% of cancer patients in the US, to evaluate the effect of socioeconomic factors on the survival of 117,926 MM patients diagnosed between 2005 and 2014. RESULTS Patients aged ≥65 years who were privately insured lived longer than patients with Medicare (42 months vs. 31 months, respectively, p < 0.0001). Treatment in academic institutions led to better survival (HR: 1.49, 95% CI: 1.39, 1.59). Younger age, fewer comorbidities, treatment in academic centers, and living in a higher median income area were significantly associated with improved survival. After adjusting for confounders, survival of Medicare patients was similar to those with private insurance. However, the hazard of death remained higher for patients with Medicaid (HR: 1.59, 95% CI: 1.36, 1.87) or without insurance (HR: 1.62, 95% CI: 1.32, 1.99), compared to privately insured patients. CONCLUSION Economic factors and treatment facility type play an important role in the survival of MM patients.
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Gastrointestinal toxicity of high-dose melphalan in autologous hematopoietic stem cell transplantation: identification of risk factors and a benchmark for experimental therapies. Ann Hematol 2021; 100:1863-1870. [PMID: 33388856 DOI: 10.1007/s00277-020-04378-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
Gastrointestinal side effects are the dose-limiting toxicity of high-dose melphalan (HDM) in autologous hematopoietic stem-cell transplantation, but there are limited contemporary data on the incidence and severity of gastrointestinal toxicity associated with this regimen. We retrospectively studied 100 consecutive patients who received HDM alone or in combination with other conditioning agents. Patients had a median age of 56 (range 20-73); underlying diseases were myeloma (42%), lymphoma (42%), or amyloidosis (16%) and melphalan dosages were 200 (40%), 140 (59%), or 100 mg/m2 (1%). Ninety-seven percent of patients experienced diarrhea with a range of 1-18 bowel movements per day, 88% developed nausea, and 60% experienced vomiting. Abdominal CT scans rarely altered patient management, but stool studies were useful in identifying a treatable infectious source. Grade ≥ 2 diarrhea was associated with longer duration of diarrhea, longer length of stay, worse hypoalbuminemia, higher use of antibiotics, abdominal imaging, electrolyte repletions, and anti-diarrheal agents. Risk factors for severe diarrhea were female sex, melphalan dose, age > 50, creatinine clearance < 60 ml/min, and having a plasma cell neoplasm as opposed to lymphoma. Female sex was also associated with more severe nausea and vomiting. In summary, diarrhea remains an important toxicity of HDM and novel therapies for chemotherapy-induced diarrhea for patients undergoing stem-cell transplantation are needed. Grade 2 or higher diarrhea is associated with significant clinical consequences and should be used as the primary endpoint in prospective clinical trials.
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Anandan A, Kolk M, Ferrari N, Copley M, Driscoll J, Caimi P, Rashidi A, de Lima M, Malek E. Serum electrolyte dynamics in multiple myeloma patients undergoing autologous haematopoietic stem cell transplantation. Nephrology (Carlton) 2020; 25:450-456. [PMID: 32167620 DOI: 10.1111/nep.13712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/24/2020] [Accepted: 02/10/2020] [Indexed: 11/30/2022]
Abstract
AIM High-dose melphalan followed by autologous haematopoietic cell transplantation remains the standard-of-care therapy for multiple myeloma (MM). Gastrointestinal toxicity concomitant with electrolyte derangement is a primary cause of morbidity from transplant. Here, we assessed the dynamics of electrolyte imbalances and its role in hematologic counts and engraftment. Ω Patients and Methods One hundred and eighteen MM patients that received transplant were studied. RESULTS Engraftment speed (ES) was calculated as the period between the first rise in the absolute neutrophil count (ANC) and full engraftment defined as the first of three consecutive days with ANC > 500 × 106 /L. The defined median ES was 2 days (range 0-5 days) and 40 patients had ES ≤2 days. Engraftment occurred at a median of 10 days. The median time-to-nadir for phosphorus and potassium was 10 and 4.28 days, respectively. The drop in phosphorus and potassium serum level was statistically greater in patients with an ES ≤2 days compared to patients with ES ≥2 days. Magnesium level were not significantly affected and there was no significant difference between the drop in serum phosphorus and potassium based on severity of nausea or oral mucositis. CONCLUSION Our results indicate that there is a significant correlation between the magnitude of drop in potassium and phosphorous levels and a steep rise in neutrophil counts around the engraftment period following stem cell transplant. These events indicate a "genesis syndrome" characterized by a rapid, massive transfer of electrolytes into proliferating cells as has been previously described after HCT for certain high-grade lymphomas and leukemias.
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Affiliation(s)
- Apoorva Anandan
- Internal Medicine Department, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Merle Kolk
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Nicole Ferrari
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Melissa Copley
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - James Driscoll
- Division of Hematology & Oncology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Paolo Caimi
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Arash Rashidi
- Nephrology division, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Marcos de Lima
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Ehsan Malek
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
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Gastrointestinal Microbiome and Mycobiome Changes during Autologous Transplantation for Multiple Myeloma: Results of a Prospective Pilot Study. Biol Blood Marrow Transplant 2019; 25:1511-1519. [DOI: 10.1016/j.bbmt.2019.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/06/2019] [Accepted: 04/02/2019] [Indexed: 12/15/2022]
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Abstract
PURPOSE OF REVIEW Gastrointestinal mucositis is a frequent side effect of systemic anticancer treatment and radiotherapy. The occurrence endangers body resources by decreasing food intake and absorption. This review highlights new developments in treatment and prevention. RECENT FINDINGS Recent clinical practice guidelines recommend supplying adequate amounts of energy and nutrients to cancer patients undergoing anticancer treatments. This requires repeated screening for risk of malnutrition and in at-risk patients, assessment of food intake and nutritional status, followed by nutritional interventions targeted at individual deficiencies and tolerance to oral, enteral or parenteral feeding. Recent preclinical data report beneficial effects of stimulating the sensor for cell damage signals TRPA1, blocking histamine H2 receptors or supplying probiotics. In a recent clinical trial, amifostine reduced gastrointestinal symptoms and was well tolerated. Probiotics are studied in ongoing clinical trials and glucagon-like peptide 2 analogues are considered for future trials. Due to limited options available today, it has been suggested to also consider several plant-based complementary therapies. SUMMARY Although options for prevention and treatment of chemotherapy or radiotherapy-induced gastrointestinal mucositis today are still limited, inadequate energy and nutrient intake should trigger nutritional interventions, including counselling, oral nutritional supplements, tube feeding and parenteral nutrition. To prevent gastrointestinal mucositis, several new agents have shown promising results in preclinical trials.
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Ye R, Kundrapu S, Gerson SL, Driscoll JJ, Beck R, Ali N, Landgren O, VanHeeckeren W, Luo G, Kroger N, Caimi P, De Lima M, Malek E. Immune Signatures Associated With Clonal Isotype Switch After Autologous Stem Cell Transplantation for Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2019; 19:e213-e220. [PMID: 30878316 PMCID: PMC7444684 DOI: 10.1016/j.clml.2018.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/19/2018] [Accepted: 12/28/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND High-dose chemotherapy and autologous stem cell transplantation (ASCT) are integral components of the overall treatment for patients with multiple myeloma (MM) aged ≤ 65 years. The emergence of oligoclonal immunoglobulin bands (ie, immunoglobulins differing from those originally identified at diagnosis [termed clonal isotype switch (CIS)]) has been reported in patients with MM after high-dose chemotherapy followed by autologous stem cell transplantation. However, the clinical relevance and the correlation with immune reconstitution remains unclear. PATIENTS AND METHODS Patients with MM who had undergone ASCT from 2007 to 2016 were included in the present study. The percentage of natural killer cells, B-cells, and T-cells was measured using flow cytometry in pre- and post-ASCT bone marrow samples. CIS was defined as the appearance of a new serum monoclonal spike on serum protein electrophoresis and immunofixation that differed from original heavy or light chain detected at diagnosis. RESULTS A retrospective analysis of 177 patients with MM who had undergone ASCT detected CIS in 39 (22%). CIS after ASCT correlated with improved progression-free survival (52.2 vs. 36.6 months; P = .21) and overall survival (75.1 vs. 65.4 months; P = .021). Patients with a relapse had an isotype that differed from a CIS, confirming the benign nature of this phenomenon. CIS was also associated with lower CD8 T-cell percentages and a greater CD4/CD8 ratio (2.8 vs. 0.2; P = .001) compared with patients who did not demonstrate a CIS, suggestive of more profound T-cell immune reconstitution in this group. CONCLUSION Taken together, our data have demonstrated that a CIS is a benign phenomenon and correlates with a reduced disease burden and enriched immune repertoire beyond the B-cell compartment.
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Affiliation(s)
- Rebecca Ye
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Sirisha Kundrapu
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Stanton L Gerson
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - James J Driscoll
- Division of Hematology and Oncology, The Vontz Center for Molecular Studies, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rose Beck
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Naveed Ali
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Willem VanHeeckeren
- Division of Hematology and Oncology, University Hospital Cleveland Medical Center, Cleveland, OH
| | - George Luo
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicolaus Kroger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paolo Caimi
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Marcos De Lima
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ehsan Malek
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
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