Chemotherapy-induced neutropenia and febrile neutropenia in patients with gynecologic malignancy

Oral manifestations associated with neutropenia in Syrian patients diagnosed with hematological malignancies and undergoing chemotherapy: A cross-sectional study

Neutropenia can be caused by a variety of congenital and acquired factors, with Chemotherapy-induced myelosuppression being the most common cause. Neutropenia significantly affects oral health, leading to the manifestation of oral lesions such as ulcers, fungal and viral infections, and mucositis. This study aims to investigate oral lesions in patients with hematological malignancies who developed neutropenia after chemotherapy. This cross-sectional study included 50 patients with hematological malignancies. The participants were divided into 2 groups: the first group consisted of 25 patients with hematological malignancies who developed chemotherapy-induced neutropenia and the second group consisted of 25 patients with hematological malignancies who did not develop chemotherapy-induced neutropenia. Patients were assigned to one of the groups based on the absolute neutrophil count (ANC). Full oral clinical examination was performed to determine the presence of oral lesions. In the Chemotherapy-Induced Neutropenia group, the most common lesion was ulceration, observed in 12 patients (48%). Fungal infections were the second most common, present in 5 patients (20%), followed by viral infections in 4 patients (15%), and mucositis, which occurred in a single patient (4%). A statistically significant association was found between neutropenia and the presence of oral ulcers (P value = .015). In contrast, in the Chemotherapy group, oral changes were less frequent. Fungal infections were the most common, occurring in 4 patients (15%), followed by oral mucositis in 3 patients (12%). Ulceration and viral infections were the least common, each observed in 1 patient (4%). The frequency of various forms of oral ulcers increases with the severity of neutropenia. However, there was no significant increase in other oral lesions in patients with neutropenia.

Automated, high-throughput quantification of EGFP-expressing neutrophils in zebrafish by machine learning and a highly-parallelized microscope

Normal development of the immune system is essential for overall health and disease resistance. Bony fish, such as the zebrafish (Danio rerio), possess all the major immune cell lineages as mammals and can be employed to model human host response to immune challenge. Zebrafish neutrophils, for example, are present in the transparent larvae as early as 48 hours post fertilization and have been examined in numerous infection and immunotoxicology reports. One significant advantage of the zebrafish model is the ability to affordably generate high numbers of individual larvae that can be arrayed in multi-well plates for high throughput genetic and chemical exposure screens. However, traditional workflows for imaging individual larvae have been limited to low-throughput studies using traditional microscopes and manual analyses. Using a newly developed, parallelized microscope, the Multi-Camera Array Microscope (MCAM™), we have optimized a rapid, high-resolution algorithmic method to count fluorescently labeled cells in zebrafish larvae in vivo. Using transgenic zebrafish larvae, in which neutrophils express EGFP, we captured 18 gigapixels of images across a full 96-well plate, in 75 seconds, and processed the resulting datastream, counting individual fluorescent neutrophils in all individual larvae in 5 minutes. This automation is facilitated by a machine learning segmentation algorithm that defines the most in-focus view of each larva in each well after which pixel intensity thresholding and blob detection are employed to locate and count fluorescent cells. We validated this method by comparing algorithmic neutrophil counts to manual counts in larvae subjected to changes in neutrophil numbers, demonstrating the utility of this approach for high-throughput genetic and chemical screens where a change in neutrophil number is an endpoint metric. Using the MCAM™ we have been able to, within minutes, acquire both enough data to create an automated algorithm and execute a biological experiment with statistical significance. Finally, we present this open-source software package which allows the user to train and evaluate a custom machine learning segmentation model and use it to localize zebrafish and analyze cell counts within the segmented region of interest. This software can be modified as needed for studies involving other zebrafish cell lineages using different transgenic reporter lines and can also be adapted for studies using other amenable model species.

The occurrence and risk factors of chemotherapy-induced neutropenia in patients with breast cancer not receiving primary G-CSF prophylaxis

Background

Chemotherapy-induced neutropenia (CIN) is a substantial side effect in chemotherapy of breast cancer patients. Administration of granulocyte colony stimulating factor (G-CSF) that may reduce CIN occurrence is not commonly available to many local cases.

Objectives

To investigate the occurrence of grade 4 CIN and the influencing factors in breast cancer patients not receiving G-CSF prophylaxis.

Methods

One-hundred and eighty-six newly diagnosed breast cancer patients who received a 3-weekly (neo)adjuvant or palliative chemotherapy without primary G-CSF prophylaxis were included. Grade 4 CIN was defined as absolute neutrophil count (ANC) <0.5 × 103/mm3 during any chemotherapy cycle. We used logistic regression to explore the association of clinical, pathological and treatment factors with the risk of grade 4 CIN in the first cycle and in any given cycle.

Results

Fifty-seven (30.6%) patients experienced grade 4 CIN in the first cycle and 145 (78%) had it at least once during chemotherapy. In the first cycle, haemoglobin, ANC, and albumin levels were associated with grade 4 CIN (OR = 1.48, p = 0.031; OR = 0.68, p = 0.006; and OR = 2.07, p = 0.042). In any cycle, pre-treatment ANC levels and anthracycline-taxane combination regimen were associated with grade 4 CIN (OR = 0.78, p = 0.032 and OR = 3.64, p = 0.012).

Conclusions

A significant proportion of the local breast cancer cases undergoing chemotherapy without primary G-CSF prophylaxis experienced grade 4 CIN. Haemoglobin, ANC, and albumin levels are the risk factors for first cycle CIN, while pre-treatment ANC levels and anthracycline-taxane chemotherapy regimen are associated with CIN in any given cycle. These risk factors may be used to direct a recommendation of G-CSF prophylaxis to the most at-risk individuals in the local setting or other settings in similar situations.

Relacorilant + Nab-Paclitaxel in Patients With Recurrent, Platinum-Resistant Ovarian Cancer: A Three-Arm, Randomized, Controlled, Open-Label Phase II Study

PURPOSE

Despite therapeutic advances, outcomes for patients with platinum-resistant/refractory ovarian cancer remain poor. Selective glucocorticoid receptor modulation with relacorilant may restore chemosensitivity and enhance chemotherapy efficacy.

METHODS

This three-arm, randomized, controlled, open-label phase II study (ClinicalTrials.gov identifier: NCT03776812) enrolled women with recurrent, platinum-resistant/refractory, high-grade serous or endometrioid epithelial ovarian, primary peritoneal, or fallopian tube cancer, or ovarian carcinosarcoma treated with ≤4 prior chemotherapeutic regimens. Patients were randomly assigned 1:1:1 to (1) nab-paclitaxel (80 mg/m2) + intermittent relacorilant (150 mg the day before, of, and after nab-paclitaxel); (2) nab-paclitaxel (80 mg/m2) + continuous relacorilant (100 mg once daily); or (3) nab-paclitaxel monotherapy (100 mg/m2). Nab-paclitaxel was administered on days 1, 8, and 15 of each 28-day cycle. The primary end point was progression-free survival (PFS) by investigator assessment; objective response rate (ORR), duration of response (DOR), overall survival (OS), and safety were secondary end points.

RESULTS

A total of 178 women were randomly assigned. Intermittent relacorilant + nab-paclitaxel improved PFS (hazard ratio [HR], 0.66; log-rank test P = .038; median follow-up, 11.1 months) and DOR (HR, 0.36; P = .006) versus nab-paclitaxel monotherapy, while ORR was similar across arms. At the preplanned OS analysis (median follow-up, 22.5 months), the OS HR was 0.67 (P = .066) for the intermittent arm versus nab-paclitaxel monotherapy. Continuous relacorilant + nab-paclitaxel showed numerically improved median PFS but did not result in significant improvement over nab-paclitaxel monotherapy. Adverse events were comparable across study arms, with neutropenia, anemia, peripheral neuropathy, and fatigue/asthenia being the most common grade ≥3 adverse events.

CONCLUSION

Intermittent relacorilant + nab-paclitaxel improved PFS, DOR, and OS compared with nab-paclitaxel monotherapy. On the basis of protocol-prespecified Hochberg step-up multiplicity adjustment, the primary end point did not reach statistical significance (P < .025). A phase III evaluation of this regimen is underway (ClinicalTrials.gov identifier: NCT05257408).

Prevalence of blood stream infections and associated factors among febrile neutropenic cancer patients on chemotherapy at Ocean Road Cancer Institute, Tanzania

BACKGROUND

Febrile Neutropenia (FN) caused by bacteria in cancer patients is associated with poor prognosis. The aim of this study was to determine the prevalence of FN and associated factors among cancer patients on chemotherapy at Ocean Road Cancer Institute (ORCI), Tanzania.

METHODS

A cross-sectional study was conducted from June to September 2019. Study participants were conveniently recruited. A desk review of participants medical records was performed. Standard microbiological procedures used to culture and identify the bacterial isolates from the positive blood cultures of participants that presented with FN. Kirby-Bauer disc diffusion was used to perform the antibiotics susceptibility testing. SPSS version 20.0 and MS Excel were used in data entry and analysis. Chi-Square was used as a measure of association between various factors and neutropenia. P-value less than 0.05 was considered statistically significant.

RESULTS

A total 213 participants were enrolled. Of these 76.1% were female. Most of the participants came from the Coast region. Majority of participants presented with breast Cancer (36.2%) and GIT (20.2%). The prevalence of FN and bacteremia was 5.6% and 35.3% respectively. Staphylococcus Aureus (60%) and Coagulase-Negative Staphylococci (40%) were the main isolates. Of the 6 isolates tested most were resistant to Co-Trimoxazole 4/6 (66.7%) and Doxycycline 3/6 (50%). FN was positively associated with chemotherapy regimen (P = 0.0001), platelets count (P = 0.0001) and use of G-CSF (P = 0.0001).

CONCLUSION

The prevalence of FN among the cancer patients on chemotherapy in Tanzania is low but associated with drug-resistant bacteria.

Enhanced binding at fever temperatures of HER2 in complex with trastuzumab and pertuzumab

Aim: Fever follows the administration of trastuzumab and pertuzumab used in HER2-relevant immunotherapy, but is often eliminated in clinical practice. This work explores the role of temperature (37-39°C) in the formation of immune complexes between HER2 with either trastuzumab or pertuzumab or with both antibodies. Materials & methods: Using molecular dynamics simulations and free energy calculations, the binding between HER2 and these immunotherapeutic monoclonal antibodies was investigated at different temperatures. Results: Trastuzumab and pertuzumab present the highest binding free energy to HER2 at febrile temperatures (39°C), or when HER2 is in complex with both antibodies. Conclusion: Performing molecular dynamics simulations under fever temperatures may be important for delineating their role in enhancing the binding affinity of mature antibodies used in immunotherapy.

Automated, high-throughput quantification of EGFP-expressing neutrophils in zebrafish by machine learning and a highly-parallelized microscope

Normal development of the immune system is essential for overall health and disease resistance. Bony fish, such as the zebrafish (Danio rerio), possess all the major immune cell lineages as mammals and can be employed to model human host response to immune challenge. Zebrafish neutrophils, for example, are present in the transparent larvae as early as 48 hours post fertilization and have been examined in numerous infection and immunotoxicology reports. One significant advantage of the zebrafish model is the ability to affordably generate high numbers of individual larvae that can be arrayed in multi-well plates for high throughput genetic and chemical exposure screens. However, traditional workflows for imaging individual larvae have been limited to low-throughput studies using traditional microscopes and manual analyses. Using a newly developed, parallelized microscope, the Multi-Camera Array Microscope (MCAM™), we have optimized a rapid, high-resolution algorithmic method to count fluorescently labeled cells in zebrafish larvae in vivo. Using transgenic zebrafish larvae, in which neutrophils express EGFP, we captured 18 gigapixels of images across a full 96-well plate, in 75 seconds, and processed the resulting datastream, counting individual fluorescent neutrophils in all individual larvae in 5 minutes. This automation is facilitated by a machine learning segmentation algorithm that defines the most in-focus view of each larva in each well after which pixel intensity thresholding and blob detection are employed to locate and count fluorescent cells. We validated this method by comparing algorithmic neutrophil counts to manual counts in larvae subjected to changes in neutrophil numbers, demonstrating the utility of this approach for high-throughput genetic and chemical screens where a change in neutrophil number is an endpoint metric. Using the MCAM™ we have been able to, within minutes, acquire both enough data to create an automated algorithm and execute a biological experiment with statistical significance. Finally, we present this open-source software package which allows the user to train and evaluate a custom machine learning segmentation model and use it to localize zebrafish and analyze cell counts within the segmented region of interest. This software can be modified as needed for studies involving other zebrafish cell lineages using different transgenic reporter lines and can also be adapted for studies using other amenable model species.

Trends in the Epidemiology of Pneumocystis Pneumonia in Immunocompromised Patients without HIV Infection

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.

Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know

As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.

Toxicity of Nab-Paclitaxel Compared to Paclitaxel in a Tertiary Hospital in Jeddah, Saudi Arabia: A Retrospective Cohort Study

Background Nanoparticle albumin-bound paclitaxel has been developed to avoid the toxicities associated with Cremophor-solved paclitaxel. Although many studies confirm this hypothesis, there is recent evidence showing no difference between paclitaxel and nab-paclitaxel in their efficacy and safety profile. This study further assesses the toxicity of both paclitaxel and nab-paclitaxel in adult patients with breast and pancreatic cancer in a tertiary hospital in Jeddah, Saudi Arabia. These toxicities include neutropenia, anaemia, and effects on kidney and liver functions. Methods The study is a retrospective cohort study done at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 2018 to December 2021, conducted on patients diagnosed with breast or pancreatic cancer treated with paclitaxel or nab-paclitaxel. Results There is a statistically significant difference between the two groups in developing anaemia, renal, and liver toxicity (P<0.05). On the other hand, there are no statistically significant differences in developing neutropenia between the two groups (P=0.084). Conclusions Nab-paclitaxel might not be better than paclitaxel in reducing the risk of neutropenia, anaemia, and liver toxicity, as predicted. Nevertheless, both medications require that the patient's renal functions be monitored during the treatment. Further studies conducted in multiple oncology centres with a larger sample are needed to evaluate the toxicity of paclitaxel and nab-paclitaxel in adult patients with breast and pancreatic cancer.

Chemotherapy Induced Neutropenia, Febrile-Neutropenia and Determinants Among Solid Cancer Patients Attending Oncology Unit of a Tertiary Care Teaching Hospital in Ethiopia

Background

Globally the incidence of cancer is about 19.3 million new cases per year. Chemotherapy is among the standard treatments for cancer but neutropenia and febrile neutropenia are the most common side effects.

Objective

To assess the incidences of chemotherapy-induced neutropenia, febrile-neutropenia and associated factors in solid cancer patients attending Oncology unit of St. Paul Hospital Millennium Medical College in Addis Ababa, Ethiopia.

Methods

In this institution-based longitudinal study conducted from February to September, 2020 at one of the largest teaching and referral hospitals of Ethiopia, 101 patients who were diagnosed with any type of solid cancer were recruited using convenience sampling method. Patients were followed-up until they completed five cycles of chemotherapy. Data were analyzed using SPSS version 23 software. Paired sample t-test was used to compare the pre- and post-treatment results. Chi-squared test was employed to determine associated factors of neutropenia, and p-values less than 0.05 were taken as statistically significant.

Results

Of the total 101 participants, 98 were eligible per inclusion criteria and 6 (6.1%) of them died during the study period. The age of the participants ranged from 16-84 years with a mean age of 45. Of them, 48 (49.0%) were in the age group of 16-44 years, 73 (74.5%) were female, 66 (67.3%) were married, and 42.9% attained primary education. Among 92 patients, the incidence of neutropenia was 65 (70.7%) and the incidence of febrile neutropenia was 46 (50.0%). Adriamycin + cyclophosphamide and Adriamycin + cyclophosphamide + paclitaxel were the most commonly used anti-cancer treatments in this study. None of the tested factors were associated with chemo-induced neutropenia.

Conclusion

More than two thirds of the patients had chemotherapy associated neutropenia while half of the patients had febrile neutropenia; close monitoring of such patients is warranted.

Maximum daily dose of G-CSF is critical for preventing recurrence of febrile neutropenia in patients with gynecologic cancer: A case-control study

No study has evaluated the effect of therapeutic granulocyte colony-stimulating factor (G-CSF) in preventing recurrence of febrile neutropenia (FN) and survival outcomes in gynecologic cancer patients. Objective of this study is to optimize and to identify the use of G-CSF and identify the critical factors for preventing the recurrence of FN in women undergoing chemotherapy for the treatment of gynecologic cancer. The medical records of consecutive patients who underwent chemotherapy for the treatment of gynecologic cancer and experienced FN at least once were retrospectively reviewed. Clinico-laboratory variables were compared between those with and without recurrence of FN to identify risk factors for the recurrence and the most optimal usage of G-CSF that can prevent FN. Student t test, χ2 test, and multivariate Cox regression analysis were used. A total of 157 patients who met the inclusion criteria were included. Of 157, 49 (31.2%) experienced recurrence of FN. Age ≥55 years (P = .043), previous lines of chemotherapy ≤1 (P = .002), thrombocytopenia (P = .025), total dose (P = .003), and maximum daily dose (P = .009) of G-CSF were significantly associated with recurrence of FN. Multiple regression analysis showed that age ≥55 years (HR, 2.42; 95% CI, 1.14-5.14; P = .022), previous chemotherapy ≤1 (HR, 4.01; 95% CI, 1.40-11.55; P = .010), and maximum daily dose of G-CSF ≤600 μg (HR, 5.18; 95% CI, 1.12-24.02; P = .036) were independent risk factors for recurrent FN. Multivariate Cox regression analysis showed that a maximum daily dose of G-CSF ≤600 μg was the only independent risk factor for short recurrence-free survival of FN (HR, 4.75; 95% CI, 1.15-19.56; P = .031). Dose-dense administration of G-CSF >600 μg/day could prevent recurrence of FN in women who undergo chemotherapy for the treatment of gynecologic cancer and FN. Old age and FN at early lines of chemotherapy seem to be associated with FN recurrence.

Overcoming Taxane Resistance: Preclinical and Phase 1 Studies of Relacorilant, a Selective Glucocorticoid Receptor Modulator, with Nab-Paclitaxel in Solid Tumors

PURPOSE

Chemotherapy resistance remains a major problem in many solid tumors, including breast, ovarian, and pancreatic cancer. Glucocorticoids are one potential driver of chemotherapy resistance as they can mediate tumor progression via induction of cell-survival pathways. We investigated whether combining the selective glucocorticoid receptor (GR) modulator relacorilant with taxanes can enhance antitumor activity.

PATIENTS AND METHODS

The effect of relacorilant on paclitaxel efficacy was assessed in OVCAR5 cells in vitro and in the MIA PaCa-2 xenograft. A phase 1 study of patients with advanced solid tumors was conducted to determine the recommended phase 2 dose of relacorilant + nab-paclitaxel.

RESULTS

In OVCAR5 cells, relacorilant reversed the deleterious effects of glucocorticoids on paclitaxel efficacy (P < 0.001). Compared with paclitaxel alone, relacorilant + paclitaxel reduced tumor growth and slowed time to progression in xenograft models (both P < 0.0001). In the heavily pretreated phase 1 population [median (range) of prior regimens: 3 (1-8), prior taxane in 75.3% (55/73)], 33% (19/57) of response-evaluable patients achieved durable disease control (≥16 weeks) with relacorilant + nab-paclitaxel and 28.6% (12/42) experienced longer duration of benefit than on prior taxane (up to 6.4×). The most common dose-limiting toxicity of the combination was neutropenia, which was manageable with prophylactic G-CSF. Clinical benefit with relacorilant + nab-paclitaxel was also associated with GR-regulated transcript-level changes in a panel of GR-controlled genes.

CONCLUSIONS

The observed preclinical, clinical, and GR-specific pharmacodynamic responses demonstrate that selective GR modulation with relacorilant combined with nab-paclitaxel may promote chemotherapy response and is tolerable. Further evaluation of this combination in tumor types responsive to taxanes is ongoing.

Taxane monotherapy regimens for the treatment of recurrent epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the seventh most frequent cancer diagnosis worldwide, and the eighth leading cause of cancer mortality. Epithelial ovarian cancer is the most common kind, accounting for 90% of cases. First-line therapy for women with epithelial ovarian cancer consists of a combination of cytoreductive surgery and platinum and taxane-based chemotherapy. However, more than 50% of women with epithelial ovarian cancer will experience a relapse and require further chemotherapy and at some point develop resistance to platinum-based drugs. Currently, guidance on the use of most chemotherapy drugs, including taxanes, is unclear for women whose epithelial ovarian cancer has recurred. Paclitaxel, topotecan, pegylated liposomal doxorubicin hydrochloride, trabectedin and gemcitabine are all licensed for use in the UK at the discretion of clinicians, following discussion with the women as to potential adverse effects. Taxanes can be given in once-weekly regimens (at a lower dose) or three-weekly regimens (at a higher dose), which may have differences in the severity of side effects and effectiveness. As relapsed disease suggests incurable disease, it is all the more important to consider side effects and the impact of treatment schedules, as well as quality of life, and not only the life-prolonging effects of treatment.

OBJECTIVES

To assess the efficacy and toxicity of different taxane monotherapy regimens for women with recurrent epithelial ovarian, tubal or primary peritoneal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase, up to 22 March 2022. Other related databases and trial registries were searched as well as grey literature and no additional studies were identified. A total of 1500 records were identified.

SELECTION CRITERIA

We included randomised controlled trials of taxane monotherapy for adult women diagnosed with recurrent epithelial ovarian, tubal or primary peritoneal cancer, previously treated with platinum-based chemotherapy. We included trials comparing two or more taxane monotherapy regimens. Participants could be experiencing their first recurrence of disease or any line of recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors screened, independently assessed studies, and extracted data from the included studies. The clinical outcomes we examined were overall survival, response rate, progression-free survival, neurotoxicity, neutropenia, alopecia, and quality of life. We performed statistical analyses using fixed-effect and random-effects models following standard Cochrane methodology. We rated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

Our literature search yielded 1500 records of 1466 studies; no additional studies were identified by searching grey literature or handsearching. We uploaded the search results into Covidence. After the exclusion of 92 duplicates, we screened titles and abstracts of 1374 records. Of these, we identified 24 studies for full-text screening. We included four parallel-group randomised controlled trials (RCTs). All trials were multicentred and conducted in a hospital setting. The studies included 981 eligible participants with recurrent epithelial ovarian cancer, tubal or primary peritoneal cancer with a median age ranging between 56 to 62 years of age. All participants had a WHO (World Health Organization) performance status of between 0 to 2. The proportion of participants with serous histology ranged between 56% to 85%. Participants included women who had platinum-sensitive (71%) and platinum-resistant (29%) relapse. Some participants were taxane pre-treated (5.6%), whilst the majority were taxane-naive (94.4%). No studies were classified as having a high risk of bias for any of the domains in the Cochrane risk of bias tool. We found that there may be little or no difference in overall survival (OS) between weekly paclitaxel and three-weekly paclitaxel, but the evidence is very uncertain (risk ratio (RR) of 0.94, 95% confidence interval (CI) 0.66 to 1.33, two studies, 263 participants, very low-certainty evidence). Similarly, there may be little or no difference in response rate (RR of 1.07, 95% CI 0.78 to 1.48, two studies, 263 participants, very low-certainty evidence) and progression-free survival (PFS) (RR of 0.83, 95% CI 0.46 to 1.52, two studies, 263 participants, very low-certainty evidence) between weekly and three-weekly paclitaxel, but the evidence is very uncertain. We found differences in the chemotherapy-associated adverse events between the weekly and three-weekly paclitaxel regimens. The weekly paclitaxel regimen may result in a reduction in neutropenia (RR 0.51, 95% 0.27 to 0.95, two studies, 260 participants, low-certainty evidence) and alopecia (RR 0.58, 95% CI 0.46 to 0.73, one study, 205 participants, low-certainty evidence). There may be little or no difference in neurotoxicity, but the evidence was very low-certainty and we cannot exclude an effect (RR 0.53, 95% CI 0.19 to 1.45, two studies, 260 participants). When examining the effect of paclitaxel dosage in the three-weekly regimen, the 250 mg/m² paclitaxel regimen probably causes more neurotoxicity compared to the 175 mg/m² regimen (RR 0.41, 95% CI 0.21 to 0.80, one study, 330 participants, moderate-certainty evidence). Quality-of-life data were not extractable from any of the included studies.

AUTHORS' CONCLUSIONS

Fewer people may experience neutropenia when given weekly rather than three-weekly paclitaxel (low-certainty evidence), although it may make little or no difference to the risk of developing neurotoxicity (very low-certainty evidence). This is based on the participants receiving lower doses of drug more often. However, our confidence in this result is low and the true effect may be substantially different from the estimate of the effect. Weekly paclitaxel probably reduces the risk of alopecia, although the rates in both arms were high (46% versus 79%) (low-certainty evidence). A change to weekly from three-weekly chemotherapy could be considered to reduce the likelihood of toxicity, as it may have little or no negative impact on response rate (very low-certainty evidence), PFS (very low-certainty evidence) or OS (very low-certainty evidence). Three-weekly paclitaxel, given at a dose of 175 mg/m² compared to a higher dose,probably reduces the risk of neurotoxicity.We are moderately confident in this result; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. A change to 175 mg/m² paclitaxel (from a higher dose), if a three-weekly regimen is used, probably has little or no negative impact on PFS or OS (very low-certainty evidence).

Burden, risk factors, and management of neutropenic fever among solid cancer patients in Ethiopia

Objectives:

Although neutropenic fever is one of the most well-known oncologic emergencies and the common causes of death, a few studies have been conducted in resource-limited countries, particularly in Ethiopia. This study aimed to assess the burden, risk factors, and management of neutropenic fever among solid cancer patients in Ethiopia.

Methods:

A hospital-based retrospective follow-up study was conducted from January 2017 to February 2021. Data were collected from patient’s medical charts using a structured data abstraction format and analyzed using STATA version 14.2. Logistic regression analyses were used to identify independent predictors of neutropenic fever, and a p-value of < 0.05 was considered statistically significant.

Results:

A total of 416 patients were included, with a mean age of 51 ± 14 years. The cumulative incidence of neutropenic fever was 13%. Advanced age, low baseline white blood cell, prolonged duration of neutropenia, and presence of two or more comorbidities were factors significantly associated with neutropenic fever (p < 0.05). Among patients who need primary prophylaxis, 68% of patients did not get appropriate primary prophylaxis, and 30%, 71%, and 93% of prescribed anti-bacterial, anti-fungal, and anti-viral agents were inappropriate according to Infectious Disease Society of America Guideline, respectively.

Conclusion:

Neutropenic fever was common among solid cancer patients and it is multifactorial. The rate of guideline adherence during prophylaxis and treatment of neutropenic fever was poor. Health care professionals should be aware of these risk factors, and greater effort is needed to reduce the risk of neutropenic fever.

Chemotherapy-induced neutropenia among breast Cancer patients in a tertiary care hospital: Risk and consequences

STUDY OBJECTIVE

To identify the risk factors that may predispose breast cancer patients to Chemotherapy-induced neutropenia (CIN) and its associated complications for the years 2018 and 2020. CIN is an established complication of breast cancer treatment. Clinical Pharmacists can play an important role in the treatment of CIN through involvement in risk assessment to identify patients for oral antimicrobial therapy, drug therapy monitoring, and development of suitable guidelines or policies.

METHODOLOGY

A retrospective study was performed by collecting data of 72 breast cancer patients for the last two years from department of Medical Oncology in a tertiary care hospital.

RESULTS

The overall occurrence of CIN was 59.7% in our study population. Out of 72 patients studied, 43 patients were found to be neutropenic. Using Pearson Chi square test, chemotherapy-induced neutropenia was associated with older age (over 60 y) (p < 0.038), diabetes mellitus (p < 0.050), tumour stage IIIa (p < 0.024), AC (p < 0.051) and taxane chemotherapy regimens (p < 0.041). Febrile neutropenia occurred in 37.28% of patients and the incidence of infection-related mortality [severe septicaemia] was 3.38%.

CONCLUSION

The incorporation of clinical pharmacist must be brought into practice in our country for providing proper guidance to the patient on CIN and its complications. By identifying risk factors for neutropenia, the safe management of CIN may be possible in patients with breast cancer.

Racial disparity in taxane-induced neutropenia among cancer patients

BACKGROUND

Large interindividual variations have been reported in chemotherapy-induced toxicities. Little is known whether racial disparities exist in neutropenia associated with taxanes.

METHODS

Patients with a diagnosis of primary cancer who underwent chemotherapy with taxanes were identified from Vanderbilt University Medical Center's Synthetic Derivative. Multinomial regression models were applied to evaluate odds ratios (ORs) and 95% confidence intervals (CIs) of neutropenia associated with race, with adjustments for demographic variables, baseline neutrophil count, chemotherapy-related information, prior treatments, and cancer site.

RESULTS

A total of 3492 patients were included in the study. Compared with White patients, grade 2 or higher neutropenia was more frequently recorded among Black patients who received taxanes overall (42.2% vs. 32.7%, p < 0.001) or paclitaxel (43.0% vs. 36.7%, p < 0.001) but not among those who received docetaxel (32.0% vs. 30.2%, p = 0.821). After adjustments for multiple covariates, Black patients who received chemotherapy with any taxanes had significantly higher risk of grade 2 (OR = 1.53; 95% CI = 1.09-2.14) and grade 3 (OR = 1.91; 95% CI = 1.36-2.67) neutropenia but comparable risk of grade 4 neutropenia (OR = 1.19; 95% CI = 0.79-1.79). Similar association patterns were observed for Black patients who specifically received paclitaxel, but a null association was found for those treated with docetaxel.

CONCLUSION

Black cancer patients treated with taxanes for any cancer had a higher risk of neutropenia compared with their White counterparts, especially those who received paclitaxel. More research is needed to understand the mechanism(s) underlying this racial disparity in order to enhance the delivery of patient-centered oncology.

Evaluation of the clinical Index of Stable febrile neutropenia risk stratification system for management of febrile neutropenia in gynecologic oncology patients

OBJECTIVE

Scoring systems have been developed to identify low risk patients with febrile neutropenia (FN) who may be candidates for outpatient management. We sought to validate the predictive accuracy of the Clinical Index of Stable Febrile Neutropenia (CISNE) score alone and in conjunction with alternative scoring systems for risk of complications among gynecologic oncology patients.

METHODS

We conducted a single institution retrospective cohort study of patients admitted to an academic gynecologic oncology service for FN. We examined the performance characteristics (sensitivity, specificity, positive and negative predictive value) of three scoring systems (Multinational Association of Supportive Care in Cancer (MASCC), CISNE cut-off 1 (Low risk = 0), CISNE cut-off 2 (Low risk = <3)), and the combination of MASCC and CISNE to predict complications: inpatient death, ICU admission, hypotension, respiratory/renal failure, mental status change, cardiac failure, bleeding, and arrhythmia.

RESULTS

Fifty patients were identified for study inclusion. No low-risk CISNE patients died during hospitalization. Fewer CISNE low-risk patients experienced complications compared to high-risk patients, regardless of cut-off. Sensitivity, specificity, positive and negative predictive values of the scoring systems were: CISNE 1-37.1%, 86.7%, 86.7%, 37.1%; CISNE 2-85.7%, 46.7%, 78.9%, 58.3%; MASCC-82.9%, 66.7%, 85.3%, 62.5%; MASCC + CISNE 1-37.1%, 93.3%, 92.9%, 38.9%; MASCC + CISNE 2-80%, 73.3%, 87.5%, 61.1%.

CONCLUSIONS

The CISNE scoring system is an appropriate tool for the identification of patients with gynecologic cancers and FN who may benefit from close outpatient management. CISNE cut-off 2 performed comparably to the MASCC, but CISNE cut-off 1 had a higher specificity and positive predictive value.

Antibiotics modulate neoadjuvant therapy efficiency in patients with breast cancer: a pilot analysis

Mounting evidence suggests that microbiota dysbiosis caused by antibiotic administration is a risk factor for cancer, but few research reports focus on the relationships between antibiotics and chemotherapy efficiency. We evaluated the influence of antibiotic administration on neoadjuvant therapy efficacy in patients with breast cancer (BC) in the present study. BC patients were stratified into two groups: antibiotic-treated and control based on antibiotic administration within 30 days after neoadjuvant therapy initiation. Disease-free survival (DFS) and overall survival (OS) were assessed using the Kaplan-Meier method, and the Cox proportional hazards model was used for multivariate analyses. The pathologic complete response rate of the control group was significantly higher than that of the antibiotic-treated group (29.09% vs. 10.20%, p = 0.017). Further univariate analysis with Kaplan-Meier calculations demonstrated that antibiotic administration was strongly linked with both reduced DFS (p = 0.04) at significant statistical levels and OS (p = 0.088) at borderline statistical levels. Antibiotic administration was identified as a significant independent prognostic factor for DFS [hazard ratio (HR) 3.026, 95%, confidence interval (CI) 1.314-6.969, p = 0.009] and OS (HR 2.836, 95% CI 1.016-7.858, p = 0.047) by Cox proportional hazards model analysis. Antibiotics that initiated reduced efficiency of chemotherapy were more noticeable in the HER2-positive subgroup for both DFS (HR 5.51, 95% CI 1.77-17.2, p = 0.003) and OS (HR 7.0395% CI 1.94-25.53, p = 0.003), as well as in the T3-4 subgroup for both DFS (HR 20.36, 95% CI 2.41-172.07, p = 0.006) and OS (HR 13.45, 95% CI 1.39-130.08, p = 0.025) by stratified analysis. Antibiotic administration might be associated with reduced efficacy of neoadjuvant therapy and poor prognosis in BC patients. As a preliminary study, our research made preparations for further understanding and large-scale analyses of the impact of antibiotics on the efficacy of neoadjuvant therapy.

History of whole pelvis plus para-aortic radiation is a risk factor associated with febrile neutropenia during chemotherapy for recurrent cervical cancer

BACKGROUND

Radiation-based therapy is widely used for advanced cervical cancer. Prior radiation-based therapy is a potential risk factor for febrile neutropenia (FN). However, the effect of irradiation field size on the incidence of FN during recurrent cervical cancer treatment is unclear. This study aimed to investigate the relationship between prior irradiation field size and FN development during recurrent chemotherapy.

METHODS

This retrospective, observational study included cervical cancer patients who received recurrent chemotherapy between November 2006 and June 2020. The patients were classified into two groups based on the area of irradiation fields. The first group included patients with a history of whole pelvis (WP) irradiation (WP group). The second group had patients who underwent WP plus para-aortic lymph node (PAN) irradiation (WP + PAN group). The incidences of hematological toxicities and FN during the recurrent chemoradiotherapy were compared between the two groups.

RESULTS

The FN incidence was significantly higher in the WP + PAN group than in the WP group (32.1% vs. 0%, P < 0.001). The incidence of Grade 4 neutropenia was not significantly different between the WP + PAN and WP groups. The nadir absolute neutrophil counts were significantly lower and the dose reduction or discontinuation rate of chemotherapy was significantly higher in the WP + PAN group than in the WP group.

CONCLUSION

History of WP plus PAN radiation is a risk factor for developing FN during recurrent cervical cancer chemotherapy.

Assessment of Chemotherapy-Induced Febrile Neutropenia in Cancer Patients

Purpose: Chemotherapy-induced febrile neutropenia (CIFN) is an adverse drug reaction which needs medical attention. The treatment options for the CIFN are mandatory to improve treatment outcomes and quality of life. Methods: A prospective observational study was conducted in the in-patients and out-patients of oncology department who received chemotherapy from October 2016 to March 2017. The information such as demographics (age, gender, and comorbidities), complaints on admission, hematological investigations (neutrophil counts, platelet counts, hemoglobin levels, erythrocyte sedimentation rate, and white blood cells), type of tumor, stage of cancer, prophylaxis, cycle of antineoplastic chemotherapy that cause febrile neutropenia, treatment history, and outcome data were obtained from the patient's clinical record. The Multinational Association for Supportive Care in Cancer score and Absolute Neutrophil Count grading was used to predict the patient's risk of developing CIFN. Results: Out of 200 patients, 19 patients developed 22 episodes of CIFN. The overall occurrence of CIFN during the study was 9.5%. The higher incidence of CIFN has been observed among male gender (57.89%), stage III patients (42.10%), solid tumor (73.68%), and double chemotherapy regimen (59.1%). The higher incidence of CIFN was developed in I cycle (36.36%) followed by II cycle (22.72%) and VI cycle (18.18%). Conclusions: The incidence of CIFN during the study was 9.5%. In the 19 chemotherapy-induced FN patients, there has no significant effect of prophylaxis to prevent the febrile neutropenia.

Ziyuglycoside II alleviates cyclophosphamide-induced leukopenia in mice via regulation of HSPC proliferation and differentiation

Ziyuglycoside II (ZGS II) is a major bioactive ingredient of Sanguisorbae officinalis L., which has been widely used for managing myelosuppression or leukopenia induced by chemotherapy or radiotherapy. In the current study, we investigated the pro-hematopoietic effects and underlying mechanisms of ZGS II in cyclophosphamide-induced leukopenia in mice. The results showed that ZGS II significantly increased the number of total white blood cells and neutrophils in the peripheral blood. Flow cytometry analysis also showed a significant increase in the number of nucleated cells and hematopoietic stem and progenitor cells (HSPCs) including ST-HSCs, MPPs, and GMPs, and enhanced HSPC proliferation in ZGS II treated mice. The RNA-sequencing analysis demonstrated that ZGS II effectively regulated cell differentiation, immune system processes, and hematopoietic system-related pathways related to extracellular matrix (ECM)-receptor interaction, focal adhesion, hematopoietic cell lineage, cytokine-cytokine receptor interaction, the NOD-like receptor signaling pathway, and the osteoclast differentiation pathway. Moreover, ZGS II treatment altered the differentially expressed genes (DEGs) with known functions in HSPC differentiation and mobilization (Cxcl12, Col1a2, and Sparc) and the surface markers of neutrophilic precursors or neutrophils (Ngp and CD177). Collectively, these data suggest that ZGS II protected against chemotherapy-induced leukopenia by regulating HSPC proliferation and differentiation.

The timing of cyclic cytotoxic chemotherapy can worsen neutropenia and neutrophilia

Despite recent advances in immunotherapies, cytotoxic chemotherapy continues to be a first-line treatment option for the majority of cancers. Unfortunately, a common side effect in patients undergoing chemotherapy treatment is neutropenia. To mitigate the risk of neutropenia and febrile neutropenia, prophylactic treatment with granulocyte-colony stimulating factor (G-CSF) is administered. Extensive pharmacokinetic/pharmacodynamic modelling of myelosuppression during chemotherapy has suggested avenues for therapy optimization to mitigate this neutropenia. However, the issue of resonance, whereby neutrophil oscillations are induced by the periodic administration of cytotoxic chemotherapy and the coadministration of G-CSF, potentially aggravating a patient's neutropenic/neutrophilic status, is not well-characterized in the clinical literature. Here, through analysis of neutrophil data from young acute lymphoblastic leukaemia patients, we find that resonance is occurring during cyclic chemotherapy treatment in 26% of these patients. Motivated by these data and our previous modelling studies on adult lymphoma patients, we examined resonance during treatment with or without G-CSF. Using our quantitative systems pharmacology model of granulopoiesis, we show that the timing of cyclic chemotherapy can worsen neutropenia or neutrophilia, and suggest clinically-actionable schedules to reduce the resonant effect. We emphasize that delaying supportive G-CSF therapy to 6-7 days after chemotherapy can mitigate myelosuppressive effects. This study therefore highlights the importance of quantitative systems pharmacology for the clinical practice for developing rational therapeutic strategies.

Validation of Risk of Chemotherapy-Induced Neutropenia: Experience from Oncology Hospital of Nepal

Background

The majority of cancer patients undergoing chemotherapy show neutropenic condition which is a common side effect of myelosuppressive chemotherapy diagnosed as the reduced complete blood cell count. Such cancer patients have a higher risk of febrile neutropenia. The present study aimed to validate whether there was a risk of neutropenia in cancer patients receiving chemotherapy at Bhaktapur Cancer Hospital, Nepal.

Methods

Cross-sectional study was performed among 203 cancer patients of all age groups who attended Bhaktapur Cancer Hospital from May 2018 to January 2019 and who received a chemotherapy course. Patients receiving at least one cycle of chemotherapy as the first-line treatment were included. Statistical analysis was performed using SPSS 25. Loglinear analysis was used to analyze more than 2×2 categories among the grades and outcome of neutropenia. Multinomial logistic regression was applied to analyze the impact of various predictor variables such as chemotherapy cycles, grades of neutropenia, and gender on the outcome of neutropenia. Variation in the absolute neutrophil count (ANC) level at various days of chemotherapy cycles was assessed with the multivariate analysis of variance (MANOVA). The p-value <0.05 was considered significant at each condition.

Results

The main cancer type during the study period was breast cancer (41, 20.2%). Out of 163 neutropenic patients, 149 had severe neutropenia and 14 had mild neutropenia. Most patients were continued up to the 6th cycle of chemotherapy. There was significant association between the grade of neutropenia and the outcome of the condition (p-value 0.017). There were significant relations of the grade of neutropenia and smoking habit with the recovering status (p values 0.033 and 0.001, respectively). The absolute neutrophil count (ANC) level increased and decreased inconsistently (statistically non-significantly) in between treatment period of day 1 to 52.

Conclusion

Chemotherapy-induced neutropenia was a common occurrence. Majority (133, 66.5%) grade 4 neutropenic patients were recovering after the chemotherapy cycles. The physicians are warranted that they be ready for any unpredictable situation during chemotherapy treatment.

In vivo antitumoral effect of 4-nerolidylcatechol (4-NC) in NRAS-mutant human melanoma

NRAS-mutations arise in 15-20% of all melanomas and are associated with aggressive disease and poor prognosis. Besides, the treatment for NRAS-mutant melanoma are not very efficient and is currently limited to immune checkpoints inhibitors or aggressive chemotherapy. 4-nerolidylcathecol (4-NC), a natural product extracted from Pothomorphe umbellata, induces apoptosis in melanoma cells by ROS production, DNA damage and increased p53 expression, in addition to inhibiting invasion in reconstructed skin. Moreover, 4-NC showed cytotoxicity in BRAF/MEKi-resistant and naive melanoma cells by Endoplasmic Reticulum (ER) stress induction in vitro. We evaluated the in vivo efficacy and the systemic toxicity of 4-NC in a NRAS-mutant melanoma model. 4-NC was able to significantly suppress tumor growth 4-fold compared to controls. Cleaved PARP and p53 expression were increased indicating cell death. As a proof of concept, MMP-2 and MMP-14 gene expression were decreased, demonstrating a possible role of 4-NC in melanoma invasion inhibition. Toxicological analysis indicated minor changes in the liver and bone marrow, but this toxicity was very mild when compared to other proteasome inhibitors and ER stress inductors already described. Our data indicate that 4-NC can counteract melanoma growth in vivo with minor adverse effects, suggesting further investigation as a potential NRAS-mutant melanoma treatment.

Post-treatment Hematological Variations and the Role of Hemoglobin as a Predictor of Disease-free Survival in Stage 2 Breast Cancer Patients

Objectives

The primary objective of this study was to determine post-treatment variations in the hematological profile of stage 2 breast cancer patients and investigate the influence of disease stage and treatment pattern on these changes. The secondary objective was to evaluate the role of post-treatment hemoglobin as a predictor of disease-free survival.

Methods

This prospective, observational study included 177 stage 2, female, breast cancer patients. Treatment included surgery, chemotherapy, radiotherapy, and hormonal (anti-estrogen) therapy. Patients were divided into treatment groups based on their histopathological features. Laboratory investigations, including hemoglobin and complete blood count, were carried out twice, first, at the initial cancer diagnosis and, second, eight weeks after completion of radiotherapy. The patients were followed for a period of four years and their disease-free survival was calculated.

Results

A significant post-treatment decrease in hemoglobin levels and red blood cell (RBC) count was observed in all patients except hormone receptor-positive disease stage 2A patients treated without chemotherapy. Total leukocyte counts were significantly decreased in all hormone receptor-negative patients, and significant neutropenia was observed in all stage 2 patients who received chemotherapy. The severity of anemia was observed to be significantly lower in stage 2A patients (without lymph node metastasis) as compared to stage 2B patients (with lymph node metastasis). Furthermore, no anemia was observed in hormone receptor-positive patients treated without chemotherapy, while moderate anemia was observed in hormone receptor-negative patients who received both pre and post-surgical chemotherapy. The post-treatment hemoglobin levels were found to be a significant predictor of disease-free survival in hormone receptor-positive patients (HR = 0.140, p= 0.000) and in patients of all disease stages except stage 2B (T3 N1 M0).

Conclusion 

The incidence and severity of post-treatment anemia are low in patients treated with hormonal therapy and high in patients with lymph node metastasis. Higher post-treatment hemoglobin levels predict a longer duration of disease-free survival in hormone receptor-positive patients of disease stages 2A and 2B (T2).

Risk factors for bloodstream infections in gynecological cancer

OBJECTIVE

Infections are a threat to frail patients as they have a higher risk of developing serious complications from bloodstream pathogens. The aim of this study was to determine which factors can predict or diagnose bloodstream infections in patients with an underlying gynecologic malignancy.

MATERIALS AND METHODS

Between July 2016 and December 2017, 68 patients visiting the emergency room with an underlying gynecologic malignancy were evaluated. Variables concerning underlying disease, invasive procedures, and laboratory and clinical parameters were analyzed. Patients were divided into three groups based on their blood and urine specimens (positive blood specimens, positive urine specimens, and no positive specimens; patients who had both positive blood and urine specimens were included in the group of positive blood specimens). Risk factors for surgical site infections, recent (<30 days) surgery, and chemotherapy were studied separately.

RESULTS

68 patients were included in the analysis. Mean age was 55.6 years (standard deviation 14.1). 44% of patients had ovarian cancer, 35% cervical cancer, 12% endometrial cancer, and 9% had other cancer types. In total, 96% of all patients had undergone surgery. Patients who had been treated with chemotherapy were at a higher risk of developing bloodstream infection (P=0.04; odds ratio (OR)=7.9). C reactive protein, bilirubin, and oxygen saturation (SO₂) were significantly different between patients with an underlying infection and those who had none. Only C reactive protein maintained its significance in a linear model, with a cut-off of 180 mg/L (linear regression, P=0.03; OR=4).

CONCLUSIONS

Chemotherapy is a risk factor for the development of bloodstream infections in patients with an underlying gynecologic malignancy; C reactive protein could be a useful tool in making this diagnosis.

Timing and Outcomes of Abdominal Surgery in Neutropenic Patients

BACKGROUND

Surgery in neutropenic patients is challenging due to both atypical manifestations of common conditions and higher perioperative risk. We sought to describe the outcomes of neutropenic patients undergoing abdominal surgery and to identify factors contributing to morbidity and mortality.

METHODS

A retrospective chart review was performed for all patients neutropenic in the 24-hours prior to an abdominal operation at our institution between 1998 and 2017. The primary and secondary outcomes were 30-day mortality and morbidity, respectively. The chi-square test and two-tailed Student's t test were used for univariable comparisons (non-parametric tests used when appropriate). To determine the optimal threshold of absolute neutrophil count (ANC) to discriminate 30-day mortality, we maximized the Youden index (J).

RESULTS

Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/μL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality.

CONCLUSIONS

Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.

Chemotherapy-Induced Neutropenia as a Prognostic and Predictive Marker of Outcomes in Solid-Tumor Patients

Chemotherapy-induced neutropenia (CIN) is one of the most common side effects seen in cancer patients. As an adverse event, it is deemed undesirable since it often constitutes a dose-limiting toxicity for cytotoxic agents leading to treatment delays and/or dose reductions. It is also associated with a financial cost component from diagnostic work-up and treatment of patients with chemotherapy-induced febrile neutropenia (CIFN). Neutropenia is commonly accompanied by a decrease in other hematopoietic lineages (anemia and/or thrombocytopenia). Dosing of chemotherapeutic agents is based on the severity of adverse effects seen. Depending on the degree of neutropenia, chemotherapeutic agents may be put on hold until count recovery and growth factor support might be added to allow for dosing as scheduled. However, neutropenia appears to be more than just an adverse event. While CIFN by itself constitutes an adverse event, the appearance of just CIN is not necessarily a marker of poor outcome. In fact, it rather appears to be a surrogate marker of response and/or survival in patients treated with cytotoxic regimens. Here we present evidence in different tumor types treated with different regimens on the role CIN plays as a marker for improved outcomes. If CIN is a surrogate prognostic and/or potentially predictive marker of response, chemotherapy doses may need to be escalated to achieve neutropenia. In addition, instead of reducing treatment doses for safety concerns, the addition of growth factor support and alternative dosing schemes may be strategies to consider.

Neutrophils facilitate ovarian cancer premetastatic niche formation in the omentum

Metastasis of ovarian cancer frequently involves the omentum and has been described as a passive process that is governed by peritoneal fluid dynamics. Lee et al. show that metastatic tropism of ovarian cancer is actively orchestrated through the induction, by early-stage tumors, of neutrophil influx and chromatin extrusion in the premetastatic omental niche.

Ovarian cancer preferentially metastasizes to the omentum, a fatty tissue characterized by immune structures called milky spots, but the cellular dynamics that direct this tropism are unknown. Here, we identified that neutrophil influx into the omentum is a prerequisite premetastatic step in orthotopic ovarian cancer models. Ovarian tumor–derived inflammatory factors stimulated neutrophils to mobilize and extrude chromatin webs called neutrophil extracellular traps (NETs). NETs were detected in the omentum of ovarian tumor–bearing mice before metastasis and of women with early-stage ovarian cancer. NETs, in turn, bound ovarian cancer cells and promoted metastasis. Omental metastasis was decreased in mice with neutrophil-specific deficiency of peptidylarginine deiminase 4 (PAD4), an enzyme that is essential for NET formation. Blockade of NET formation using a PAD4 pharmacologic inhibitor also decreased omental colonization. Our findings implicate NET formation in rendering the premetastatic omental niche conducive for implantation of ovarian cancer cells and raise the possibility that blockade of NET formation prevents omental metastasis.

Appraising of the Clinical Practice Guidelines Quality in the Non-Pharmacological Management of Chemotherapy-Induced Febrile Neutropenia; A Review

Background:

Febrile neutropenia is a common and serious chemotherapy side effect, is associated with increased mortality, morbidity, and treatment expenditures. Several CPGs (Clinical practice guidelines) have been released for managing chemotherapy-induced febrile neutropenia. The aim of this study is Appraisal of the clinical practice Guidelines quality in the management of chemotherapy-induced febrile neutropenia.

Methods:

A review study with a systematic search of the present CPGs for the management of chemotherapy-induced febrile neutropenia. After screening the CPGs based on eligibility criteria, three CPGs were selected and 5 independent reviewers appraised them for methodological quality by using the AGREE II Instrument.

Results:

Three CPGs were included; all of them were evidence-based guidelines. The clarity of presentation domain scored the highest and the applicability domain has the lowest score among all domains of AGREE instrument and the rest of domains scored as descending respectively; Scope and purpose, stakeholder involvement, editorial independence, rigor of development. In general, the intra-class correlation coefficient (ICC) scores of all domains were very good according to the Landis and Koch’s scale, except the Applicability domain scored as substantial.

Conclusions:

This study showed the quality of appraised CPGs. Three domains of these CPGs based on the AGREE instrument scored less than other domains and were in relatively unfavorable status: applicability, rigor of development, editorial independence. Given the importance of these domains in guideline implementation, it is necessary to take actions for reducing these defects.

Utilization of G-CSF and GM-CSF as an alternative to discontinuation in clozapine-induced neutropenia or leukopenia: A case report and discussion

Clozapine remains the definitive gold standard for treatment-resistant schizophrenia despite limitations in use because of hematological abnormalities. Neutropenia or leukopenia are often treated with interruption of clozapine treatment, frequently resulting in clinical decompensation, hospitalization, increased burden to patient care, and increased risk of suicide. Colony-stimulating factors, including granulocyte colony-stimulating factors and granulocyte-macrophage colony-stimulating factors, are cytokines that stimulate proliferation and differentiation of myeloid precursor cells. Their use in the prevention and treatment of clozapine-associated neutropenia presents an alternative to clozapine discontinuation in certain cases. We present a case report of successful periodic granulocyte-macrophage colony-stimulating factor use with clozapine in a patient with treatment-resistant schizophrenia, as well as discussion of a practical approach to patients with possible clozapine-induced neutropenia or leukopenia.

Cancer-induced systemic myeloid dysfunction: Implications for treatment and a novel nanoparticle approach for its correction

Unlike other regulatory circuits, cancer-induced myeloid dysfunction involves more than an accumulation of impaired dendritic cells, protumoral macrophages, and myeloid derived suppressor cells in the tumor microenvironment. It is also characterized by "aberrant" myelopoiesis that results in the accumulation and expansion of immature myeloid precursors with a suppressive phenotype in the systemic circulation. The first part of this review briefly describes the evidence for and consequences of this systemic dysfunctional myelopoiesis and the possible reinforcement of this phenomenon by conventional treatments used in patients with cancer, in particular chemotherapy and granulocyte-colony stimulating factor. The second half of this review describes very small size particles, a novel immune-modulatory nanoparticle, and the evidence indicating a possible role of this agent in correcting or re-programming the dysfunctional myelopoiesis in different scenarios.

The Practical Consideration of Poliovirus as an Oncolytic Virotherapy

The inauguration of novel treatment strategies into the clinical setting faces a number of hurdles. In addition to treatment efficacy and safety, acceptance by doctors and patients is paramount to the success of novel therapies. Although viruses are the cause of numerous infectious diseases, these acellular entities have been harnessed over the years to benefit mankind. Recently, a recombinant Poliovirus-Rhinovirus Chimera (PVSRIPO) has shown promise for the treatment of glioblastoma in clinical trials as well as other cancer types in animal models. In this literature review, we discuss the use of PVSRIPO as an oncolytic virotherapy. In addition to being a potential treatment for glioblastoma, this recombinant virus could possibly be used against other cancers because many tumor cells express the PVSRIPO receptor antigens (CD155) and have a limited ability to control viral replication. Moreover, virus-induced immune responses contribute to the efficacy of PVSRIPO. Given the current trajectory of this experimental therapy, the possibility exists that PVSRIPO will soon be a viable treatment option for various cancer types. While many healthcare providers and cancer patients likely welcome this new viral based treatment, history has taught us that some may be skeptical and avoid its use because of the viral composition of this therapy.